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MEDICAL-SURGICAL NURSING
By: Anthony T. Villegas R.N.
Overview of structures and functions:
NERVOUS SYSTEM
The functional unit of the nervous system is the nerve cells
or neurons
The nervous system is composed of the ff:
Central Nervous System
Brain
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.
Spinal Nerves – 31 pairs; carry impulses to & from spinal
cord.
Autonomic Nervous System
subdivision of the PNS that automatically controls body
function such as breathing & heart beat.
Special senses of vision and hearing are also covered in this section
Sympathetic nervous system – generally accelerate some
body functions in response to stress.
Parasympathetic nervous system – controls normal body
functioning.
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
Neurons usually has only one axon
Dendrites
Short, blanching fibers that receives impulses and conducts
them toward the nerve cell body.
Neurons may have many dendrites.
Synapse
Junction between neurons where an impulse is transmitted
Neurotransmitter
Chemical agent (ex. Acetylcholine, norepinephrine) involved
in the transmission of impulse across synapse.
Myelin Sheath
A wrapping of myelin (whitish, fatty material) that protects
and insulates nerve fibers and enhances the speed of
impulse conduction.
o Both axons and dendrites may or may not have a
myelin sheath (myelinated/unmyelinated)
o Most axons leaving the CNS are heavily myelinated
by schwann cells
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.
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY
1. Labile
Capable of regeneration.
Epidermal cells, GIT cells, GUT cells, cells of lungs.
2. Stable
Capable of regeneration with limited time, survival
period.
Kidney cells, Liver cells, Salivary cells, pancreas.
3. Permanent
Not capable of regeneration.
Myocardial cells, Neurons, Bone cells, Osteocytes,
Retinal Cells.
B. NEUROGLIA
Support and protection of neurons.
TYPES
1. Astrocytes
maintains blood brain barrier semi-permiable.
majority of brain tumors (90%) arises from called
astrocytoma.
integrity of blood brain barrier.
2. Oligodendria
produces myelin sheath in CNS.
act as insulator and facilitates rapid nerve impulse
transmission.
3. Microglia
stationary cells that carry on phagocytosis (engulfing of
bacteria or cellular debris, eating), pinocytosis (cell
drinking).
4. Epindymal
secretes a glue called chemo attractants that
concentrate the bacteria.
MACROPHAGE ORGAN
Microglia
Monocytes
Kupffers
Histiocytes
Alveolar Macrophage
Brain
Blood
Kidney
Skin
Lung
Central Nervous System
Composition Of Brain
80% brain mass
10% blood
10% CSF
Brain Mass
Parts Of The Brain
1. Cerebrum
largest part of the brain
outermost area (cerebral cortex) is gray matter
deeper area is composed of white matter
function of cerebrum: integration, sensory, motor
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
precentral gyrus: controls motor function
Broca’s Area: specialized motor speech area - when
damaged results to garbled speech.
2. Temporal Lobe
hearing, taste, smell
short term memory
Wernicke’s area: sensory speech area
(understanding/formulation of language)
3. Pareital Lobe
for appreciation
integrates sensory information
discrimination of sensory impulses to pain, touch,
pressure, heat, cold, numbness.
Postcentral gyrus: registered general sensation (ex.
Touch, pressure)
4. Occipital Lobe
for vision
Insula (Island of Reil)
visceral function activities of internal organ like gastric
motility.
Limbic System (Rhinencephalon)
1
1
controls smell - if damaged results to anosmia (absence
of smell).
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.
release dopamine (controls gross voluntary movement).
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)
controls primitive emotional responses (ex. Rage, fear)
Hypothalamus
found immediately beneath the thalamus
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.
androgenic hormones promotes secondary sex
characteristics.
early sign for males are testicular and penile
enlargement
late sign is deepening of voice.
early sign for females telarch and late sign is menarch.
3. Mesencephalon/Midbrain
acts as relay station for sight and hearing.
size of pupil is 2 – 3 mm.
equal size of pupil is isocoria.
unequal size of pupil is anisocoria.
hearing acuity is 30 – 40 dB.
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.
Not relayed to & from brain: take place at cord levels
Components
a. Sensory Receptors
Receives/reacts to stimulus
b. Afferent Pathways
Transmits impulses to spinal cord
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
Subdural space between the dura and arachnoid
Layers:
Dura Mater
outermost layer, tough, leathery
Arachnoid Mater
middle layer, weblike
2
2
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
Offer protection by functioning as a shock absorber
Allows fluid shifts from the cranial cavity to the spinal
cavity
Carries nutrient to & waste product away from nerve
cells
Component of CSF: CHON, WBC, Glucose
6. Vascular Supply
Two internal carotid arteries anteriorly
Two vertebral arteries leading to basilar artery
posteriorly
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
Substance That Can Pass Blood-Brain Barrier
1. Amonia
Cerebral toxin
Hepatic Encephalopathy (Liver Cirrhosis)
Ascites
Esophageal Varices
Early Signs of Hepatic Encephalopathy
Asterexis (flapping hand tremors).
Late Signs of Hepatic Encephalopathy
Headache
Dizziness
Confusion
Fetor hepaticus (amonia like breath)
decrease LOC
2. Carbon Monoxide and Lead Poisoning
Can lead to Parkinson’s Disease.
Epilepsy
Treated with calcium EDTA.
3. Type 1 DM (IDDM)
Causes diabetic ketoacidosis.
And increases breakdown of fats.
And free fatty acids
Resulting to cholesterol and positive to ketones (CNS
depressant).
Resulting to acetone breath odor/fruity odor.
And kusshmauls respiration a rapid shallow respiration.
Which may lead to diabetic coma.
4. Hepatitis
Signs of jaundice (icteric sclerae).
Caused by bilirubin (yellow pigment)
5. Bilirubin
Increase bilirubin in brain (kernicterus).
Causing irreversible brain damage.
Peripheral Nervous System
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)
Each nerve is attached to the spinal by two roots:
1. Dorsal (posterior) roots
contains afferent (sensory) nerve whose cell
body is in the dorsal roots ganglion
2. Ventral (anterior) roots
Contains efferent (motor) nerve whose nerve
fibers originate in the anterior horn cell of the
spinal cord (lower motor neuron)
Cranial Nerves
12 pairs: carry impulses to & from the brain.
May have sensory, motor, or mixed functions.
Name & Number Function
Olfactory : CN I Sensory: carries impulses for
sense of smell.
Optic : CN II Sensory: carries impulses for vision.
Oculomotor : CN III Motor: muscles for papillary
constriction, elevation of upper eyelid;
4 out of 6 extraocular
movement.
Trochlear : CN IV Motor: muscles for downward,
inward, movement of the eye
Trigeminal : CN V Mixed: impulses from face, surface
of eyes (corneal reflex); muscle
Controlling mastication.
Abducens : CN VI Motor: muscles for lateral deviation
of eye
Facial : CN VII Mixed: impulses for taste from
anterior tongue; muscles for facial
Movement.
Acoustic : CN VIII Sensory: impulses for
hearing (cochlear division) & balance (vestibular
Division).
Glossopharyngeal : CN IX Mixed: impulses for
sensation to posterior tongue & pharynx; muscle
For movement of pharynx
(elevation) & swallowing.
Vagus : CN X Mixed: impulses for sensation to
lower pharynx & larynx; muscle for
Movement of soft palate,
pharynx, & larynx.
Spinal Accessory : CN XI Motor: movement of
sternomastoid muscles & upper part of trapezius
Muscles.
Hypoglossal : CN XII Motor: movement of tongue.
Autonomic Nervous System
Part of the peripheral nervous system
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
Sympathetic Nervous System
(Adrenergic) Effect
Parasympathetic Nervous System
(Cholinergic) Effect, Vagal,
Sympatholytic
- Involved in fight or aggression
response.
- Release of Norepinephrine
(cathecolamines) from adrenal
glands and causes
vasoconstriction.
- Increase all bodily activity
except GIT
EFFECTS OF SNS
- Dilation of pupils (mydriasis) in
order to be aware.
- Dry mouth (thickened saliva).
- Increase BP and Heart Rate.
- Bronchodilation, Increase RR
- Constipation.
- Urinary Retention.
- Increase blood supply to brain,
heart and skeletal muscles.
- SNS
I. Adrenergic Agents
- Involved in flight or withdrawal
response.
- Release of Acetylcholine.
- Decreases all bodily activities
except GIT.
EFFECTS OF PNS
- Constriction of pupils (miosis).
- Increase salivation.
- Decrease BP and Heart Rate.
- Bronchoconstriction, Decrease
RR.
- Diarrhea
- Urinary frequency.
I. Cholinergic Agents
- Mestinon, Neostignin.
SE:
3
3
- Give Epinephrine.
SE:
- SNS effect
Contraindication:
- Contraindicated to patients
suffering from COPD
(Broncholitis, Bronchoectasis,
Emphysema, Asthma).
II. Beta-adrenergic Blocking
Agents
- Also called Beta-blockers.
- all ending with “lol”
- Propranolol, Atenelol,
Metoprolol.
Effect of Beta-blockers
B – broncho spasm
E – elicits a decrease in
myocardial contraction.
T – treats hypertension.
A – AV conduction slows down.
- Should be given to patients
with Angina, Myocardial
Infarction, Hypertension
ANTI- HYPERTENSIVE AGENTS
1. Beta-blockers – “lol”
2. Ace Inhibitors – Angiotensin
“pril” (Captopril, Enalapril)
3. Calcium Antagonist –
Nifedipine (Calcibloc)
- In chronic cases of arrhythmia
give Lidocane, Xylocane.
- PNS effect
II. Anti-cholinergic Agents
- To counter cholinergic agents.
- Atrophine Sulfate
SE:
- SNS effect
Effectors Sympathetic (Adrenergic) Effect
Parasympathetic (Cholinergic) Effect
Eye dilate pupil (mydriasis) constrict
pupil (miosis)
Gland of Head
Lacrimal no effect
stimulate secretions
Salivary scanty thick, viscous secretions
copious thin, watery secretions
Dry mouth
Heart increase rate & force of contraction
decrease rate
Blood Vessel constrict smooth muscles of the skin, no effect
Abdominal blood vessels, and
Cutaneous blood vessels
Dilates smooth muscles of bronchioles,
Blood vessels of the heart & skeletal muscles
Lungs bronchodilation
bronchoconstriction
GI Tract decrease motility
increase motility
Constrict sphincters relaxed
sphincters
Possibly inhibits secretions
stimulate secretions
Inhibits activity of gallbladder & ducts stimulate
activity of gallbladder & ducts
Inhibits glycogenolysis in liver
Adrenal Gland stimulates secretion of epinephrine & no effect
Norepinephrine
Urinary Tract relaxes detrusor muscles
contract detrusor muscles
Contract trigone sphincter (prevent voiding)
relaxes trigone sphincter (allows voiding)
NEURO TRANSMITTER Decrease Increase
Acethylcholine Myesthenia Gravis Bi-polar Disorder
Dopamine Parkinson’s Disease Schizophrenia
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)
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)
2. Glasgow Coma Scale
Objective measurement of LOC sometimes called as the
quick neuro check
Objective evaluation of LOC, motor / verbal response
A standardized system for assessing the degree of
neurologic impairment in critically ill client
Components
1. Eye opening
2. Verbal response
3. Motor response
GCS Grading / Scoring
1. Conscious 15 – 14
2. Lethargy 13 – 11
3. Stupor 10 – 8
4. Coma 7
5. Deep Coma 3
3. Pupillary Reaction & Eye Movement
a. Observe size, shape, & equality of pupil (note size in
millimeter)
b. Reaction to light: pupillary constriction
c. Corneal reflex: blink reflex in response to light stroking
of cornea
d. Oculocephalic reflex (doll’s eyes): present in
unconscious client with intact brainstem
4. Motor Function
a. Movement of extremities (paralysis)
b. Muscle strength
5. Vital Signs: respiratory patterns (may help localize possible
lesion)
a. Cheyne-Stokes Respiration: regular rhythmic alternating
between hyperventilation & apnea; may be caused by
structural cerebral dysfunction or by metabolic
problems such as diabetic coma
b. Central Neurogenic Hyperventilation: sustained, rapid,
regular respiration (rate of 25/min) with normal O2
level; usually due to brainstem dysfunction
c. Apneustic Breathing: prolonged inspiratory phase,
followed by a 2-to-3 sec pause; usually indicates
dysfunction respiratory center in pons
d. Cluster Breathing: cluster of irregular breathing,
irregularly followed by periods of apnea; usually caused
by a lesion in upper medulla & lower pons
e. Ataxic Breathing: breathing pattern completely
irregular; indicates damage to respiratory center of the
medulla
Neurologic Exam
1. Mental status and speech (Cerebral Function)
a. General appearance & behavior
4
4
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
Level Of Consciouness (LOC)
1. Conscious: awake
2. Lethargy: lethargic (drowsy, sleepy, obtunded)
3. Stupor
Stuporous: (awakened by vigorous stimulation)
Generalized body weakness
Decrease body reflex
4. Coma
Comatose
light coma: positive to all forms of painful stimulus
deep coma: negative to all forms of painful stimulus
Different Painful Stimulation
1. Deep sternal stimulation / deep sternal pressure
2. Orbital pressure
3. Pressure on great toes
4. Corneal or blinking reflex
Conscious Client: use a wisp of cotton
Unconscious Client: place 1 drop of saline solution
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
eal
B
10. Vagus B (longest)
11. Spinal
Accessory
M
12. Hypoglossal M
CRANIAL NERVE I: OLFACTORY
Sensory function for smell
Material Used
Don’t use alcohol, ammonia, perfume because it is irritating
and highly diffusible.
Use coffee granules, vinegar, bar of soap, cigarette
Procedure
Test each nostril by occluding each nostril
Abnormal Findings
1. Hyposnia: decrease sensitivity to smell
2. Dysosmia: distorted sense of smell
3. Anosmia: absence of smell
Either of the 3 may indicate head injury damaging the cribriform
plate of ethmoid bone where olfactory cells are located may indicate
inflammatory conditions (sinusitis)
CRANIAL NERVE II: OPTIC
Sensory function for vision or sight
Functions
1. Test visual acuity or central vision or distance
Use Snellen’s Chart
Snellen’s Alphabet chart: for literate client
Snellen’s E chart: for illiterate client
Snellen’s Animal chart: for pediatric client
Normal visual acuity 20/20
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
CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS
Controls or innervates the movement of extrinsic ocular
muscle (EOM)
6 muscles:
Superior Rectus Superior Oblique
Lateral Rectus Medial
Rectus
Inferior Oblique Inferior
Rectus
Trochlear: controls superior oblique
Abducens: controls lateral rectus
Oculomotor: controls the 4 remaining EOM
Oculomotor
Controls the size and response of pupil
Normal pupil size is 2 – 3 mm
Equal size of pupil: Isocoria
Unequal size of pupil: Anisocoria
Normal response: positive PERRLA
CRANIAL NERVE V: TRIGEMINAL
Largest cranial nerve
Consists of ophthalmic, maxillary, mandibular
Sensory: controls sensation of face, mucous membrane,
teeth, soft palate and corneal reflex
Motor: controls the muscle of mastication or chewing
Damage to CN V leads to Trigeminal Neuralgia / Tic
Douloureux
Medication: Carbamezapine (Tegretol)
CRANIAL NERVE VII: FACIAL
Sensory: controls taste, anterior 2/3 of tongue
Pinch of sugar and cotton applicator placed on tip of tongue
Motor: controls muscle of facial expression
5
5
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.
CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR
Controls balance particularly kinesthesia or position sense,
refers to movement and orientation of the body in space.
CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS
Glosopharenageal: controls taste, posterior 1/3 of tongue
Vagus: controls gag reflex
Uvula should be midline and if not indicative of damage to
cerebral hemisphere
Effects of vagal stimulation is PNS
CRANIAL NERVE XI: SPINAL ACCESSORY
Innervates with sternocleidomastoid (neck) and trapezius
(shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL
Controls the movement of tongue
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:
1. PTB – low grade afternoon fever
2. PNEUMONIA – rusty sputum.
3. ASTHMA – wheezing on expiration.
4. EMPHYSEMA – barrel chest.
5. KAWASAKI SYNDROME – strawberry tongue
6. PERNICIOUS ANEMIA – red beefy tongue
7. DOWN SYNDROME – protruding tongue
8. CHOLERA – rice watery stool.
9. MALARIA – step ladder like fever with chills.
10. TYPHOID – rose spots in abdomen.
11. DIPTHERIA – pseudo membrane.
12. MEASLES – koplick’s spots
13. SLE – butterfly rashes.
14. LIVER CIRRHOSIS – spider like varices
15. LEPROSY – lioning face
16. BOLIMIA – chipmunk face.
17. APPENDICITIS – rebound tenderness
18. DENGUE – petichae or positive herman’s sign.
19. MENINGITIS – kernig’s sign (leg pain), brudzinski sign (neck
pain).
20. TETANY – hypocalcemia (+) trousseu’s sign or carpopedal
spasm/ (+) chvostek sign (facial spasm).
21. TETANUS – risus sardonicus
22. PANCREATITIS – cullen’s sign (echymosis of umbilicus) / (+)
grey turners spots.
23. PYLORIC STENOSIS – olive like mass.
24. PDA – machine like murmur
25. ADDISON’S DISEASE – bronze like skin pigmentation.
26. CUSHING’S SYNDROME – moon face appearance and buffalo
hump.
27. HYPERTHYROIDSM/GRAVES DISEASE – exopthalmus.
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
Multiple Sclerosis (MS)
Chronic intermittently progressive disorder of CNS
characterized by scattered white patches of
demyelination in brain and spinal cord.
Characterized by remission and exacerbation.
S/sx are varied & multiple, reflecting the location of
demyelination within the CNS.
Cause unknown: maybe a slow growing virus or
possibly autoimmune disorders.
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 A - present in all bodily secretions (tears, saliva,
colostrums).
Ig M - acute in inflammation.
Ig E - for allergic reaction
Ig D - for chronic inflammation.
* Give palliative or supportive care.
S/sx
1. Visual disturbances
blurring of vision (primary)
diplopia (double vision)
scotomas (blind spots)
2. Impaired sensation
touch, pain, pressure, temperature, or position sense
paresthesia such as tingling sensation, numbness
3. Mood swings or euphoria (sense of elation)
4. Impaired motor function
weakness
spasticity
paralysis
5. Impaired cerebral function
scanning speech
ataxic gait
nystagmus
dysarthria
intentional tremor
6. Bladder
Urinary retention or incontinence
7. Constipation
8. Sexual impotence in male / decrease sexual capacity
TRIAD SIGNS OF MS
Ataxia
(unsteady gait,
positive romberg’s test)
Intentional tremors
Nystagmus
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.
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CHARCOTS TRIAD
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
Regular exercise such as walking, swimming,
biking in mild case.
Use energy conservation techniques
Well-balance diet
Fresh air & sunshine
Avoiding fatigue, overheating or chilling, stress,
infection.
b. Use of medication & side effects.
c. Alternative methods for sexual counseling if indicated.
COMMON CAUSE OF UTI
Female
- short urethra (3-5 cm, 1-1 ½ inches)
- poor perineal hygiene
- vaginal environment is moist
Nursing Management
- avoid bubble bath (can alter Ph of vagina).
- avoid use of tissue papers
- avoid using talcum powder and perfume.
Male
- urethra (20 cm, 8 inches)
- do not urinate after intercourse
INTRACRANIAL PRESSURE ICP
Monroe Kelly Hypothesis
Skull is a closed container
Any alteration or increase in one of the intracranial components
Increase intracranial pressure
(normal ICP is 0 – 15 mmHg)
Cervical 1 – also known as atlas.
Cervical 2 – also known as axis.
Foramen Magnum
Medulla Oblongata
Brain Herniation
Increase intra cranial pressure
Nursing Intervention
1. alternate hot and cold compress to prevent hematoma
CSF cushions brain (shock absorber)
Obstruction of flow of CSF will lead to enlargement of skull
posteriorly called hydrocephalus.
Early closure of posterior fontanels causes posterior
enlargement of skull in 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.
Untreated increase ICP can lead to displacement of brain
tissue (herniation).
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
inflammatory condition (stroke)
hydrocephalus
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
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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)
7. Possible seizure activity
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
Hypercarbia may cause cerebral vasodilation
which increase ICP
Hypercabia
Increase CO2 (most powerful respiratory
stimulant) retention.
In chronic respiratory distress syndrome
decrease O2 stimulates respiration.
b. Before and after suctioning hyperventilate the client
with resuscitator bag connected to 100% O2 & limit
suctioning to 10 – 15 seconds only.
c. Assist with mechanical hyperventilation as
indicated: produces hypocarbia (decease CO2)
causing cerebral constriction & decrease ICP.
2. Monitor V/S, input and output & neuro check frequently to
detect increase in ICP
3. Maintain fluid balance: fluid restriction to 1200-1500 ml/day
may be ordered
4. Position the client with head of bed elevated to 30-45o angle
with neck in neutral position unless contraindicated to
improve venous drainage from brain.
5. Prevent further increase ICP by:
a. Provide comfortable and quite environment.
b. Avoid use of restraints.
c. Maintain side rails.
d. Instruct client to avoid forms of valsalva maneuver like:
Straining stool: administer stool softener & mild
laxatives as ordered (Dulcolax, Duphalac)
Excessive vomiting: administer anti-emetics as
ordered (Plasil - Phil only, Phenergan)
Excessive coughing: administer anti-tussive
(dextromethorphan)
Avoid stooping/bending
Avoid lifting heavy objects
e. Avoid clustering of nursing care activity together.
6. Prevent complications of immobility.
7. Administer medications as ordered:
a. Hyperosmotic agent / Osmotic Diuretic [Mannitol
(Osmitrol)]: to reduce cerebral edema
Nursing Management
Monitor V/S especially BP: SE hypotension.
Monitor strictly input and output every hour: (output
should increase): notify physician if output is less 30
cc/hr.
Administered via side drip
Regulate fast drip to prevent crystal formation.
b. Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral
edema
drug of choice for CHF (pulmonary edema)
loop of henle in kidneys.
Nursing Management
Monitor V/S especially BP: SE hypotension.
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.
Check insertion site for signs of infection; monitor
temperature.
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.
*CONGESTIVE HEART FAILURE
Signs and Symptoms
- dyspnea
- orthopnea
- paroxysmal nocturnal dyspnea
- productive cough
- frothy salivation
- cyanosis
- rales/crackles
- bronchial wheezing
- pulsus alternans
- anorexia and general body malaise
- PMI (point of maximum impulse/apical pulse rate) is
displaced laterally
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- S3 (ventricular gallop)
- Predisposing Factors/Mitral Valve
o RHD
o Aging
Treatment
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (venous congestion)
Signs and Symptoms
- jugular vein distention (neck)
- ascites
- pitting edema
- weight gain
- hepatosplenomegaly
- jaundice
- pruritus
- esophageal varices
- anorexia and general body malaise
Signs and Symptoms of Lasix in terms of electrolyte
imbalances
1. Hypokalemia
- decrease potassium level
- normal value is 3.4 – 5.5 meq/L
Sign and Symptoms
- weakness and fatigue
- constipation
- positive U wave on ECG tracing
Nursing Management
- administer potassium supplements as ordered (Kalium Durule,
Oral Potassium Chloride)
- increase intake of foods rich in potassium
FRUITS VEGETABL
ES
Apple
Banana
Cantalop
e
Oranges
Asparagus
Brocolli
Carrots
Spinach
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
Magnesium Sulfate toxicity
S/S
BP
Urine output DECREASE
Respiratory rate
Patellar relfex absent
3. Hyponatremia
- decrease sodium level
- normal value is 135 – 145 meq/L
Signs and Symptoms
- hypotension
- dehydration signs (initial sign in adult is thirst, in infant
tachycardia)
- agitation
- dry mucous membrane
- poor skin turgor
- weakness and fatigue
Nursing Management
- force fluids
- administer isotonic fluid solution as ordered
4. Hyperglycemia
- normal FBS is 80 – 100 mg/dl
Signs and Symptoms
- polyuria
- polydypsia
- polyphagia
Nursing Management
- monitor FBS
5. Hyperuricemia
- increase uric acid (purine metabolism)
- foods high in uric acid (sardines, organ meats and anchovies)
*Increase in tophi deposit leads to gouty arthritis.
Signs and Symptoms
- joint pain (great toes)
- swelling
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
- cool moist skin
Nursing Management
- force fluids
- administer medications as ordered
a. Narcotic Analgesic
- Morphine Sulfate
- antidote: Naloxone (Narcan) toxicity leads to tremors.
b. Allopurinol (Zylopril)
Side Effects
- respiratory depression (check for RR)
Parkinson’s Disease/ Parkinsonism
Chronic progressive disorder of CNS characterized by
degeneration of dopamine producing cells in the substantia
nigra of the midbrain and basal ganglia.
Progressive disorder with degeneration of the nerve cell in
the basal ganglia resulting in generalized decline in
muscular function
Disorder of the extrapyramidal system
Usually occurs in the older population
Cause Unknown: predominantly idiopathic, but sometimes
disorder is postencephalitic, toxic, arteriosclerotic,
traumatic, or drug induced (reserpine, methyldopa
(aldomet) haloperidol (haldol), phenothiazines).
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Multiple loss causes suicide
Pathophysiology
Disorder causes degeneration of dopamine producing
neurons in the substantia nigra in the midbrain
Dopamine: influences purposeful movement
Depletion of dopamine results in degeneration of the basal
ganglia
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
Side Effects Reserpine: Major depression lead to suicide
Aloneness
Loss of spouse Loss
of Job
Nursing Intervention for Suicide
direct approach towards the client
close surveillance is a nursing priority
time to commit suicide is on weekends early morning
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
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
MAGIC 2’s IN DRUG MONITORING
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DRUG NORMAL RANGE TOXICITY
LEVEL
INDICATION
Digoxin/Lanoxin
(increase force of
cardiac output)
.5 – 1.5 meq/L 2 CHF
Lithium/Lithane
(decrease level of
Ach/NE/Serotonin)
.6 – 1.2 meq/L 2 Bipolar
Aminophelline
(dilates bronchial tree)
10 – 19 mg/100 ml 20 COPD
Dilantin/Phenytoin 10 – 19 mg/100 ml 20 Seizures
Acetaminophen/
Tylenol
10 – 30 mg/100 ml 200 Osteo
Arthritis
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.
MYASTHENIA GRAVIS (MG)
neuromuscular disorder characterized by a disturbance in
the transmission of impulses from nerve to muscle cells at
the neuromuscular junction leading to descending muscle
weakness.
Incidence rate:
highest between 15 & 35 years old for women, over 40
for men.
Affects women more than men
Cause:
Unknown/ idiopathic
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)
Acetylcholine: activate muscle contraction
Autoimmune: it involves release of cholinesterase an
enzyme that destroys Ach
Cholinesterase: an enzyme that destroys ACH
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.
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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
muscle weakness with inability to
swallow, speak, or maintain respirations.
Symptoms will improve temporarily with
tensilon test.
Causes:
under medication
physical or emotional stress
infection
Signs and Symptoms
the client is unable to see, swallow,
speak, breathe
Treatment
administer cholinergic agents as ordered
Symptoms similar to myasthenic crisis &
in addition the side effect of anti-
cholinesterase drugs (excessive
salivation & sweating, abdominal carmp,
N/V, diarrhea, fasciculation)
Symptoms worsen with tensilon test:
keep Atropine Sulfate & emergency
equipment on hand.
Cause:
over medication with the
drugs (anti-cholinesterase)
Signs and Symptoms
PNS
Treatment
administer anti-cholinergic agents
(Atrophine Sulfate)
Nursing Care in Crisis:
a. Maintain tracheostomy set or endotracheal tube with
mechanical ventilation as indicated.
b. Monitor ABG & Vital Capacity
c. Administer medication as ordered:
Myasthenic Crisis: increase doses of anti-
cholinesterase drug as ordered.
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.
Can occur at any age; affects women and men equally
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
5. Maintain side rails to prevent injury related to fall
6. Prevent complications of immobility: turning the client every
2 hrs
7. Assist in passive ROM exercise
8. Promote comfort (especially in clients with sensory
changes):
a. Foot cradle
b. Sheepskin
c. Guided imagery
d. Relaxation techniques
9. Promote optimum nutrition:
a. Check gag reflex before feeding
b. Start with pureed food
c. Assess need for NGT feeding: if unable to swallow; to
prevent aspiration
10. Administer medications as ordered
a. Corticosteroids: suppress immune response
b. Anti Cholinergic Agents:
Atrophine Sulfate
c. Anti Arrythmic Agents:
Lidocaine (Xylocaine)
Bretylium: blocks release of norepinephrine; to
prevent increase of BP
11. Assist in plasmapheresis (filtering of blood to remove
autoimmune anti-bodies)
12. Prevent complications:
a. Arrythmia
b. Paralysis of respiratory muscles / respiratory arrest
13. Provide psychologic support & encouragement to client /
significant others
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14. Refer for rehabilitation to regain strength & treat any
residual deficits.
INFLAMMATORY CONDITIONS OF THE BRAIN
Meningitis
Inflammation of the meninges of the brain & spinal cord.
Cause by bacteria, viruses, & other M.O.
Etiology / Most Common M.O.
1. Meningococcus: most dangerous
2. Pneumococcus
3. Streptococcus: cause of adult meningitis
4. Hemophilus Influenzae: cause of pediatric meningitis
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
Signs and Symptoms
2. Headache, photophobia, general body malaise, irritability,
3. Projectile vomiting: due to increase ICP
4. Fever & chills
5. Anorexia & weight loss
6. Possible seizure activity & decrease LOC
7. Abnormal posturing: (decorticate and decerebrate)
8. Signs of Meningeal Irritation:
a. Nuchal rigidity or stiff neck: initial sign
b. Opisthotonos (arching of back): head & heels bent
backward & body arched forward
c. PS: Kernig’s sign (leg pain): contraction or pain in the
hamstring muscles when attempting to extend the leg
when the hip is flexed
d. PS: Brudzinski sign (neck pain): flexion at the hip & knee
in response to forward flexion of the neck
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.
Nursing Management Before Lumbar Puncture
1. Secure informed consent and explain procedure.
2. Empty bladder and bowel to promote comfort.
3. Encourage to arch back to clearly visualize L3-L4.
Nursing Management Post Lumbar Puncture
1. Place flat on bed 12 – 24 o
2. Force fluids
3. Check punctured site for any discoloration, drainage and
leakage to tissues.
4. Assess for movement and sensation of extremities.
CSF analysis reveals
1. Increase CHON and WBC
2. Decrease glucose
3. Increase CSF opening pressure (normal pressure is 50 –
100 mmHg)
4. (+) cultured microorganism (confirms meningitis)
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
Cerebrovascular Accident (CVA) (Stroke/Brain
Attack/Apoplexy/Cerebral Thrombosis)
Destruction (infarction) of brain cells caused by a reduction
in cerebral blood flow and oxygen
A partial or complete disruption in the brains blood supply.
2 largest & most common cerebral artery affected by stroke:
a. Mid Cerebral Artery
b. Internal Cerebral Artery
Incidence Rate:
a. Affects men more than women; Men are 2-3 times high
risk; Incidence increase with age
Causes:
a. Thrombosis (attached)
b. Embolism (detached): most dangerous because it can
go to the lungs & cause pulmonary embolism or the
brain & cause cerebral embolism.
c. Hemorrhage
d. Compartment Syndrome: compression of nerves &
arteries
S/sx Pulmonary Embolism
1. Sudden sharp chest pain
2. Unexplained dyspnea
3. SOB
4. Tachycardia
5. Palpitations
6. Diaphoresis
7. Mild restlessness
S/sx of Cerebral Embolism
1. Headache
2. disorientation
3. Confusion
4. Decrease LOC
S/sx Compartment syndrome
1. Fat embolism is the most feared complications w/in
24 hrs after a femur fracture.
Yellow bone marrow are produced from the
medullary cavity of the long bones and produces
fat cells.
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
8. Post Cardiac Surgery
Lifestyle:
1. Smoking
2. Sedentary lifestyle
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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
Headache: initial sign
Dizziness
Tinnitus
Possible Increase ICP
c. May last less than 30 sec, but no more than 24 hrs with
complete resolution of symptoms
2. Stroke in Evolution
Progressive development of stroke symptoms over a
period of hours to days
3. Complete Stroke
Neurologic deficit remains unchanged for 2-3-days
period
S/sx
1. Headache
2. Generalized Signs:
Vomiting
Seizure
Confusion
Disorientation
Decrease LOC
Nuchal Rigidity
Fever
Hypertension
Slow Bounding Pulse
Cheyne-Strokes Respiration
(+) Kernig’s & Brudzinski sign: may lead to hemorrhagic
stroke
3. Focal Signs (related to site of infarction):
Hemiplegia
Homonymous hemianopsia: loss of half of visual field
Sensory loss
Aphasia
Dysarthia: inability to articulate words
Alexia: difficulty reading
Agraphia: difficulty writing
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
Nursing Management Post Cerebral Arteriography
Allergy Test (shellfish)
Force fluids to release dye because it is nephro toxic
Check for peripheral pulse: distal (femoral)
Check for hematoma formation
Nursing Intervention: Acute Stage
1. Maintain patent airway and adequate ventilation by:
a. Assist in mechanical ventilation
b. Administer O2 inhalation
2. Monitor strictly V/S, I & O, neuro check & observe signs of
increase ICP, shock, hyperthermia, & seizure
3. Provide CBR as ordered
4. Maintain fluid & electrolyte balance & ensure adequate
nutrition:
a. IV therapy for the first few days
b. NGT for feeding the client who is unable to swallow
c. Fluid restriction as ordered: to decrease cerebral edema
& might also increase ICP
5. Maintain proper positioning & body alignment:
a. Elevate head 30-45 degree to decrease ICP
b. Turn & reposition every 2 hrs (20 min only on the
affected side)
c. Passive ROM exercise every 4 hrs: prevent contractures;
promote body alignment
6. Promote optimum skin integrity: turn client & apply lotion
every 2 hrs
7. Prevent complications of immobility by:
a. Turn client to side
b. Provide egg crate mattresses or water bed
c. Provide sand bag or food board.
8. Maintain adequate elimination:
a. Offer bed pan or urinal every 2 hrs; catheterized only if
necessary
b. Administer stool softener & suppositories as ordered: to
prevent constipation & fecal impaction
9. Provide quiet, restful environment
10. Provide alternative means of communication to the client:
a. Non verbal cues
b. Magic slate: not paper & pen tiring for client
c. If positive to hemianopsia: approach client on
unaffected side
11. Administer medications as ordered:
a. Hyperosmotic agent: to decrease cerebral edema
Osmotic Diuretics (Mannitol)
Loop Diuretics Furosemide (Lasix)
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
Streptokinase, Urokinase: SE: chest pain
d. Anticoagulants: for stroke in evolution or embolic stroke
(hemorrhage must be ruled out)
Heparin: short acting
Check for Partial Thromboplastin Time (PTT): if
prolonged there is a risk for bleeding
Antidote: Protamine SO4
Warfarin (Comadin): long acting / long term therapy
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
Antidote: Vitamin K (Aqua Mephyton)
Anti Platelet: to inhibit platelet aggregation in
treating TIA’s
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
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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
Nursing Intervention: Rehabiltation
1. Hemiplegia: results from injury to cell in the cerebral motor
cortex or to corticospinal tract (causes contralateral
hemiplegia since tracts crosses medulla)
a. Turn every 2 hrs (20 min only on affected side)
b. Use proper positioning & repositioning to prevent
deformities (foot drop, external rotation of hips, flexion
of fingers, wrist drop, abduction of shoulder & arms)
c. Support paralyzed arm on pillow or use sling while out of
bed to prevent subluxation of shoulders
d. Elevate extremities to prevent dependent edema
e. Provide active & passive ROM exercises every 4 hrs
2. Susceptibility to hazard
a. Keep side rails up at all times
b. Institute safety measures
c. Inspect body parts frequently for signs of injury
3. Dysphagia: difficulty of swallowing
a. Check for gag reflex before feeding client
b. Maintain a calm, unhurried approach
c. Place client in upright position
d. Place food in unaffected side of the mouth
e. Offer soft foods
f. Give mouth care before & after meals
4. Homonymous Hemianopsia: loss of right or left half of each
visual field
a. Approach the client on unaffected side
b. Place personal belongings, food etc., on unaffected side
c. Gradually teach the client to compensate by scanning
(ex. Turning the head to see things on affected side)
5. Emotional Lability: mood swings, frustrations
a. Create a quiet, restful environment with a reduction in
excessive sensory stimuli
b. Maintain a calm, non-threatening manner
c. Explain to family that client’s behavior is not purposeful
6. Aphasia: most common in right hemiplegics; may be
receptive / expressive
a. Receptive Aphasia
Give simple, slow directions
Give one command at a time; gradually shift topics
Use non-verbal techniques of communication (ex.
Pantomime, demonstration)
b. Expressive Aphasia
Listen & watch very carefully when the client
attempts to speak
Anticipate client’s needs to decrease frustrations &
feeling of helplessness
Allow sufficient time for client to answer
7. Sensory / Perceptual Deficit: more common in left
hemiplegics; characterized by impulsiveness unawareness
of disabilities, visual neglect (neglect of affected side &
visual space on affected side)
a. Assist with self-care
b. Provide safety measures
c. Initially arrange objects in environment on unaffected
side
d. Gradually teach client to take care of the affected & turn
frequently & look at affected side
8. Apraxia: loss of ability to perform purposeful, skilled acts
a. Guide client through intended movement (ex. Take
object such as wash cloth & guide client through
movement of washing)
b. Keep repeating the movement
9. Generalizations about the clients with left hemiplegia vs.
right hemiplegia & nursing care
a. Left Hemiplegia
Perceptual, sensory deficits: quick & impulsive
behavior
Use safety measures, verbal cues, simplicity in all
area of care
b. Right Hemiplegia
Speech-language deficits: slow & cautious behavior
Use pantomime & demonstration
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
Epilepsy: second or series of attacks
Febrile seizure: normal in children age below 5 years
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
Glottis closes: causing noise on exhalation
May be incontinent
Occurs at same time as loss of consciousness
last 20-40 sec
Tonic contractions: direct symmetrical extension of
extremities
Clonic Phase:
repetitive movement
increase mucus production
slowly tapers
Clonic contractions: contraction of extremities
Postictal sleep: unresponsive sleep
Seizure ends with postictal period of confusion,
drowsiness
b. Absence Seizure (Petit mal Seizure):
Usually non-organic brain damage present
Must be differentiated from daydreaming
Sudden onset with twitching & rolling of eyes that last
20-40 sec
Common among pediatric clients characterized by:
Blank stare
Decrease blinking of eyes
Twitching of mouth
Loss of consciousness (5 – 10 seconds)
2. Partial or Localized Seizure
Begins in focal area of brain & symptoms are related to
a dysfunction of that area
May progress into a generalized seizure
a. Jacksonian Seizure (focal seizure)
characterized by tingling and jerky movement of
index finger and thumb that spreads to the shoulder
and other side of the body.
b. Psychomotor Seizure (focal motor seizure)
May follow trauma, hypoxia, drug use
Purposeful but inappropriate repetitive motor acts
Aura is present: daydreaming like
Automatism: stereotype repetitive and non
propulsive behavior
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Clouding of consciousness: not in contact with
environment
Mild hallucinatory sensory experience
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.
DOC: Diazepam (Valium) & Glucose
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
Overview Anatomy & Physiology of the Eye
External Structure of Eye
a. Eyelids (Palpebrae) & Eyelashes: protect the eye from
foreign particles
b. Conjunctiva:
Palpebral Conjunctiva: pink; lines inner surface of
eyelids
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
d. The movement of the eye is controlled by 6 extraocular
muscles (EOM)
Internal Structure of Eye
A. 3 layers of the eyeball
1. Outer Layer
a. Sclera: tough, white connective tissue (“white of the
eye”); located anteriorly & posteriorly
b. Cornea: transparent tissue through which light
enters the eye; located anteriorly
2. Middle Layer
a. Choroid: highly vascular layer, nourishes retina;
located posteriorly
b. Ciliary Body: anterior to choroid, secrets aqueous
humor; muscle change shape of lens
c. Iris: pigmented membrane behind cornea, gives
color to eye; located anteriorly
d. Pupil: is circular opening in the middle of the iris
that constrict or dilates to regulate amount of light
entering the eye
3. Inner Layer
a. Light-sensitive layer composed of rods & cones
(visual cell)
Cones: specialized for fine discrimination &
color vision; (daylight / colored vision)
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
B. Lens: transparent body that focuses image on retina
C. Fluid of the eye
1. Aqueous Humor: clear, watery fluid in anterior &
posterior chambers in anterior part of eye; serves as
refracting medium & provides nutrients to lens &
cornea; contribute to maintenance of intraocular
pressure
2. Vitreous Humor: clear, gelatinous material that fills
posterior cavity of eye; maintains transparency & form
of eye
Visual Pathways
a. Retina (rods & cones) translates light waves into neural
impulses that travel over the optic nerves
b. Optic nerves for each eye meet at the optic chiasm
Fibers from median halves of the retinas cross here
& travel to the opposite side of the brain
Fibers from lateral halves of retinas remain
uncrossed
c. Optic nerves continue from optic chiasm as optic tracts &
travels to the cerebrum (occipital lobe) where visual
impulses are perceived & interpreted
Canal of schlemm: site of aqueous humor drainage
Meibomian gland: secrets a lubricating fluid inside the eyelid
Maculla lutea: yellow spot center of retina
Fovea centralis: area with highest visual acuity or acute vision
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
Unit of measurements of refraction: diopters
Normal eye refraction: emmetropia
Normal IOP: 12-21 mmHg
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
Accommodation of lenses: based on thelmholtz theory of
accommodation
Near Vision: Ciliary muscle contracts: Lens bulges
Far Vision: ciliary muscle dilates / relaxes: lens is flat
Convergence of the eye:
Error:
1. Exotropia:1 eye normal
2. Esophoria: corrected by
corrective eye surgery
3. Strabismus: squint eye
4. Amblyopia: prolong squinting
Common Visual Disorder
Glaucoma
Characterized by increase intraocular pressure resulting in
progressive loss of vision
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May cause blindness if not recognized & treated
Early detection is very important
preventable but not curable
Regular eye exam including tonometry for person over age
40 is recommended
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
Loss of central vision if unarrested
2. Acute (close-angle) Glaucoma
Severe eye pain
Blurred cloudy vision
Halos around light
N/V
Steamy cornea
Moderate pupillary dilation
3. Chronic (close-angle) Glaucoma
Transient blurred vision
Slight eye pain
Halos around lights
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
Carbonic Anhydrase Inhibitor: Acetazolamide
(Diamox): to decrease aqueous humor production
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)
Narcotic Analgesic: for pain
b. Surgery
Peripheral Iridectomy: portion of the iris is excised
to facilitate outflow of aqueous humor
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
1. Administer medication as ordered
2. Provide quite, dark environment
3. Maintain accurate I & O with the use of osmotic agent
4. Prepare client for surgery if indicated
5. Provide post-op care
6. Provide client teaching & discharge planning
a. Self-administration of eye drops
b. Need to avoid stooping, heavy lifting or pushing,
emotional upsets, excessive fluid intake, constrictive
clothing around the neck
c. Need to avoid the use antihistamines or
sympathomimetic drugs (found in cold preparation) in
close-angle glaucoma since they may cause mydriasis
d. Importance of follow-up care
e. Need to wear medic-alert tag
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
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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
Topical antibiotics: to prevent infection
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
Treat nausea with anti-emetics as ordered: to
prevent vomiting
Give stool softener as ordered: to prevent straining
Observe for & report signs of intraocular pressure
(IOP):
Severe eye pain
Restlessness
Increased pulse
4. Protect eye from injury:
a. Dressing usually removed the day after the surgery
b. Eyeglasses or eye shield used during the day
c. Always use eye shield during the night
5. Administer medication as ordered:
a. Topical mydriatics & cycloplegic: to decrease spasm of
ciliary body & relieve pain
b. Topical antibiotics & corticosteroids
c. Mild analgesic as needed
6. Provide client teaching & discharge planning concerning:
a. Technique of eyedrop administration
b. Use of eye shield at night
c. No bending, stooping, or lifting
d. Report signs & symptoms of complication immediately
to physician:
Severe eye pain
Decrease vision
Excessive drainage
Swelling of eyelid
e. Cataract glasses / contact lenses
If a lens implant has not been performed the client
will need glasses or contact lenses
Temporary glasses are worn for 1-4 weeks then
permanent glasses fitted
Cataract glasses magnify object by 1/3 & distortion
peripheral vision
Have the client practice manual coordination
with assistance until new spatial relationship
becomes familiar
Have client practice walking, using stairs,
reaching for articles
Contact lenses cause less distortion of vision;
prescribe at one month
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
Nursing Intervention Pre-op
1. Maintain bed rest as ordered with head of bed flat &
detached area in a dependent position
2. Use bilateral eye patches as ordered; elevate side rails to
prevent injury
3. Identify yourself when entering the room
4. Orient the client frequently to time of date & surroundings;
explain procedures
5. Provide diversional activities to provide sensory stimulation
Nursing Intervention Post-op
1. Check orders for positioning & activity level:
a. May be on bed rest for 1-2 days
b. May need to position client so that detached area is in
dependent position
2. Administer medication as ordered:
a. Topical mydriatics
b. Analgesic as needed
3. Provide client teaching & discharge planning concerning:
a. Techniques of eyedrop administration
b. Use eye shield at night
c. No bending from waist; no heavy work or lifting for 6
weeks
d. Restriction of reading for 3 weeks or more
e. May watch TV
f. Need to check to physician regarding combing &
shampooing hair & shaving
g. Need to report complications such as recurrence of
detachment
Overview of Anatomy & Physiology Of Ear (Hearing)
External Ear
1. Auricle (Pinna): outer projection of ear composed of
cartilage & covered by skin; collects sound waves
2. External Auditory Canal: lined with skin; glands secretes
cerumen (wax), providing protection; transmits sound
waves to tympanic membrane
3. Tympanic Membrane (Eardrum): at end of external canal;
vibrates in response to sound & transmits vibrations to
middle ear
Middle Ear
1. Ossicles
a. 3 small bones: malleus (Hammer) attached to
tympanic membrane, incus (anvil), stapes (stirrup)
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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
Disorder of the Ear
Otosclerosis
Formation of new spongy bone in the labyrinth of the
ear causing fixation of the stapes in the oval window
This prevent transmission of auditory vibration to the
inner ear
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
Nursing Intervention Pre-op
1. Provide general pre-op nursing care, including an
explanation of post-op expectation
2. Explain to the client that hearing may improve during
surgery & then decrease due to edema & packing
Nursing Intervention Post-op
1. Position the client according to the surgeon’s orders
(possibly with operative ear uppermost to prevent
displacement of the graft)
2. Have the client deep breathe every 2 hours while in bed,
but no coughing
3. Elevate side rails; assist the client with ambulation &
move slowly: may have some vertigo
4. Administer medication as ordered:
Analgesic
Antibiotics
Anti-emetics
Anti-motion sickness drug: Meclesine Hcl
(Bonamine)
5. Check for dressing frequently for excessive drainage or
bleeding
6. Assess facial nerve function: Ask the client to do the ff:
Wrinkle forehead
Close eyelids
Puff out checks for any asymmetry
7. Question the client about the ff: report existence to
physicians
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)
Fentanyl & Droperidol (Innovar)
2. Chronic:
a. Drug Therapy:
Vasodilators (nicotinic Acid)
Diuretics
Mild sedative or tranquilizers: Diazepam
(Valium)
Antihistamines: Diphenhydramine (Benadryl)
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
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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
Overview of Anatomy & Physiology of Endocrine System
Endocrine System
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
Thyroid G : T3, T4 : regulate metabolic
rate; CHO, fats, & CHON
Metabolism; aid in
regulating physical & mental
Growth &
development
: Thyrocalcitonin : lowers
serum calcium & phosphate levels
Parathyroid G : PTH : regulates serum
calcium & phosphate levels
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
Ovaries : Estrogen, Progesterone :
development of secondary sex characteristics in the
Female, maturation
of sex organ, sexual functioning
Maintenance of
pregnancy
Testes : Testosterone : development of
secondary sex characteristics in the
Male maturation of
the sex organs, sexual functioning
Pituitary Gland (Hypophysis)
Located in sella turcica at the base of brain
“Master Gland” or master clock
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Controls all metabolic function of body
3 Lobes of Pituitary Gland
1. Anterior Lobe PG (Adenohypophysis)
a. Secretes tropic hormones (hormones that stimulate
target glands to produce their hormones):
adrenocorticotropic H (ACTH), thyroid-stimulating H
(TSH), follicle-stimulating H (FSH), luteinizing H (LH)
ACTH: promotes development of adrenal cortex
LH: secretes estrogen
FSH: secretes progesterone
b. Also secretes hormones that have direct effects on
tissues: somatotropic or growth H, prolactin
Somatotropic / GH: promotes elongation of long
bones
Hyposecretion of GH: among children results to
dwarfism
Hypersecretion of GH: among children results to
gigantism
Hypersecretion of GH: among adults results to
acromegaly (square face)
DOC: Ocreotide (Sandostatin)
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
Secretes hormones oxytocin (promotes uterine
contractions preventing bleeding or hemorrhage)
Administer oxytocin immediately after delivery to
prevent uterine atony.
Initiates milk let down reflex with help of hormone
prolactin
3. Intermediate Lobe PG
Secretes melanocytes stimulating H (MSH)
MSH: for skin pigmentation
Hyposecretion of MSH: results to albinism
Hypersecretion of MSH: results to vitiligo
2 feared complications of albinism:
1. Lead to blindness due to severe
photophobia
2. Prone to skin cancer
Adrenal Glands
Two small glands, one above each kidney; Located at
top of each kidney
2 Sections of Adrenal Glands
1. Adrenal Cortex (outer portion): produces mineralocorticoids,
glucocorticoids, sex hormones
3 Zones/Layers
Zona Fasciculata: secretes glucocortocoids
(cortisol): controls glucose metabolism: Sugar
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
Produces thyroxine (T4), triiodothyronine (T3),
thyrocalcitonin
3 Hormones Secreted:
T3: 3 molecules of iodine (more potent)
T4: 4 molecule of iodine
T3 and T4 are metabolic hormone: increase brain
activity; promotes cerebration (thinking); increase
V/S
Thyrocalcitonin: antagonizes the effects of
parathormone to promote calcium reabsorption.
Parathyroid Gland
4 small glands located in pairs behind the thyroid gland
Produce parathormone (PTH)
Promotes calcium reabsorption
Pancreas
Located behind the stomach
Has both endocrine & exocrine function (mixed gland)
Consist of Acinar Cells (exocrine gland): which secretes
pancreatic juices: that aids in digestion
Islets of langerhans (alpha & beta cells) involved in
endocrine function:
Alpha Cell: produce glucagons: (function:
hyperglycemia)
Beta Cell: produce insulin: (function: hypoglycemia)
Delta Cells: produce somatostatin: (function:
antagonizes the effects of growth hormones)
Gonads
Ovaries: located in pelvic cavity; produce estrogen &
progesterone
Testes: located in scrotum; produces testosterone
Pineal Gland
Secretes melatonin
Inhibits LH secretion
It controls & regulates circadian rhythm (body clock)
Diabetes Incipidus (DI)
DI: dalas-ihi
Decrease of anti-diuretic hormone (ADH)
Hyposecretion of ADH
Hypofunction of the posterior pituitary gland (PPG) resulting
in deficiency of ADH
Characterized by excessive thirst & urination
Anti-diuretic Hormone: Pitressin (Vasopressin)
Function: prevents urination thereby conserving water
Note: Alcohol inhibits release of ADH
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
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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
Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH)
Hypersecretion of anti-diuretic hormone (ADH) from the PPG
even when the client has abnormal serum osmolality
Predisposing Factors
1. Head injury
2. Related to presence of bronchogenic cancer
Initial sign of lung cancer is non productive cough
Non invasive procedure is chest x-ray
3. Related to hyperplasia of pituitary gland (increase size of
organ brought about by increase of number of cells)
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
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
Nursing Intervention when giving Thyroid Hormones:
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1. Instruct client to take in the morning to prevent
insomnia
2. Monitor vital signs especially heart rate because drug
causes tachycardia and palpitations
3. Monitor side effects:
Insomnia
Tachycardia and palpitations
Hypertension
Heat intolerance
2. Increase dietary intake of foods rich in iodine:
Seaweeds
Seafood’s like oyster, crabs, clams and lobster but
not shrimps because it contains lesser amount of
iodine.
Iodized salt: best taken raw because it is easily
destroyed by heat
3. Assist in surgical procedure of subtotal thyroidectomy
4. Provide client teaching & discharge planning concerning:
Used of iodized salt in preventing & treating endemic
goiter
Thyroid hormone replacement
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
Adults: myxedema non pitting edema
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
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
A severe form of hypothyroidism is characterized
by:
Severe hypotension
Bradycardia
Bradypnea
Hypoventilation
Hyponatremia
Hypoglycemia
Hypothermia
Leading to progressive stupor and coma
Nursing Management for Myxedema Coma
1. Assist in mechanical ventilation
2. Administer thyroid hormones as ordered
3. Administer IVF replacement isotonic fluid solution as
ordered / Force fluids
10. Provide client health teaching and discharge planning
concerning:
a. Thyroid hormone replacement
b. Importance of regular follow-up care
c. Need in additional protection in cold weather
d. Measures to prevent constipation
e. Avoid precipitating factors leading to myxedema
coma & hypovolemic shock
f. Stress & infection
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g. Use of anesthetics, narcotics, and sedatives
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
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:
Subtotal Thyroidectomy: hyperthyroidism
Total Thyroidectomy: thyroid cancer
Nursing Intervention Pre-op
1. Ensure that the client is adequately prepared for
surgery
a. Cardiac status is normal
b. Weight & nutritional status is normal
2. Administer anti-thyroid drugs as ordered: to suppressed
the production of thyroid hormone & to prevent thyroid
storm
3. Administer iodine preparation Lugol’s Solution (SSKI) or
Potassium Iodide Solution: to decrease vascularity of the
thyroid gland & to prevent hemorrhage.
Nursing Intervention Post-Op
1. Monitor V/S & I&O
2. Check dressing for signs of hemorrhage: check for
wetness behind the neck
3. Place client in semi-fowlers position & support head with
pillow
4. Observe for respiratory distress secondary to
hemorrhage, edema of glottis, laryngeal nerve damage,
or tetany: keep tracheostomy set, O2 & suction nearby
5. Assess for signs of tetany: due to hypocalcemia: due to
secondary accidental removal of parathyroid glands:
keep Calcium Gluconate available:
Watch out for accidental removal of parathyroid
which may lead to hypocalcemia (tetany)
Classic S/sx of Tetany
Positive trousseu’s sign
Positive chvostek sign
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TRIAD SIGNS
Observe for arrhythmia, seizure: give Calcium
Gluconate IV slowly as ordered
6. Ecourage clients voice to rest:
a. Some hoarseness is common
b. Check every 30-60 min for extreme hoarseness or
any accompanying respiratory distress
7. Observe for signs of thyroid storm / thyrotoxicosis: due
to release of excessive amount of thyroid hormone
during surgery
Agitation
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
Decrease secretion of parathormone: leading to
hypocalcemia: resulting to hyperphospatemia
If calcium decreases phosphate increases
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
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)
Large dose of vitamin D (Calciferol): to help
absorption of calcium
CHOLECALCIFEROL ARE DERIVED FROM
Drug Diet (Calcidiol)
Sunlight (Calcitriol)
Phosphate Binder: Aluminum Hydroxide Gel
(Amphogel) or aluminum carbonate gel, basic
(basaljel): to decrease phosphate levels
ANTACID
A.A.C
MAD
Aluminum
Magnesium Containing
Containing
Antacids
Antacids
Aluminum
Hydroxide
Gel
Side Effect: Constipation
Side Effect: Diarrhea
2. Institute seizure & safety precaution
3. Provide quite environment free from excessive stimuli
4. Avoid precipitating stimulus such as glaring lights and
noise
5. Monitor signs of hoarseness or stridor; check for signs
for Chvostek’s & Trousseau’s sign
6. Keep emergency equipment (tracheostomy set,
injectable Calcium Gluconate) at bedside: for presence
of laryngospasm
7. For tetany or generalized muscle cramp: may use
rebreathing bag or paper bag to produce mild
respiratory acidosis: to promote increase ionized Ca
levels
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8. Monitor serum calcium & phosphate level
9. Provide high-calcium & low-phosphorus diet
10. Provide client teaching & discharge planning
concerning:
a. Medication regimen: oral calcium preparation & vit
D to be taken with meal to increase absorption
b. Need to recognized & report S/sx of
hypo/hypercalcemia
c. Importance of follow-up care with periodic serum
calcium level
d. Prevent complications
e. Hormonal replacement therapy for lifetime
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
5. Force fluids 2000-3000 L/day: to prevent kidney stones
6. Provide acid-ash juices (ex. Cranberry, orange juice): to
acidify urine & prevent bacterial growth
7. Strain urine: using gauze pad: for stone analysis
8. Provide low-calcium & high-phosphorus diet
9. Provide warm sitz bath: for comfort
10. Administer medications as ordered: Morphine Sulfate
(Demerol)
11. Maintain side rails
12. Assist in surgical procedure: Parathyroidectomy
13. Provide client teaching & discharge planning
concerning:
a. Need to engage in progressive ambulatory activities
b. Increase fluid intake
c. Use of calcium preparation & importance of high-
calcium diet following a parathyroidectomy
d. Prevent complications: renal failure
e. Hormonal replacement therapy for lifetime
f. Importance of follow up care
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:
Metabolic disturbance: Sugar
Fluid and electrolyte imbalance: Na, H2O, K
Deficiency of neuromascular function: Salt, Sex
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)
Hydrocortisone: Cortisone (Prednisone)
b. Mineralocorticoids:
Fludrocortisone Acetate (Florinef)
Nursing Management when giving steroids
1. Instruct client to take 2/3 dose in the morning and
1/3 dose in the afternoon to mimic the normal
diurnal rhythm
2. Taper dose (withdraw gradually from drug)
3. Monitor side effects:
Hypertension
Edema
Hirsutism
Increase susceptibility to infection
Moon face appearance
2. Monitor V/S
3. Decrease stress in the environment
4. Prevent exposure to infection
5. Provide rest period: prevent fatigue
6. Weight daily
7. Provide small frequent feeding of diet: decrease in K,
increase cal, CHO, CHON, Na: to prevent hypoglycemia,
& hyponatremia & provide proper nutrition
8. Monitor I&O: to determine presence of addisonian crisis
(complication of addison’s disease)
9. Provide meticulous skin care
10. Provide client teaching & discharge planning
concerning:
a. Disease process: signs of adrenal insufficiency
b. Use of prescribe medication for lifelong replacement
therapy: never omit medication
c. Need to avoid stress, trauma & infection: notify the
physician if these occurs as medication dosage may
need to be adjusted
d. Stress management technique
e. Diet modification
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f. Use of salt tablet (if prescribe) or ingestion of salty
foods (potato chips): if experiencing increase
sweating
g. Importance of alternating regular exercise with rest
periods
h. Avoidance of strenuous exercise especially in hot
weather
i. Avoid precipitating factor: leading to addisonian
crisis: stress, infection, sudden withdrawal to
steroids
j. Prevent complications: addisonian crisis,
hypovolemic shock
k. Importance of follow up care
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
20. Weight gain
21. Hypokalemia
22. Constipation
23. U wave upon ECG (T wave hyperkalemia)
24. Hirsutis
25. Easy bruising
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
Diabetes Mellitus (DM)
Represent a heterogenous group of chronic disorders
characterized by hyperglycemia
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
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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.
MAIN FOODSTUFF ANABOLISM CATABOLISM
1. CHO
2. CHON
3. Fats
Glucose
Amino Acids
Fatty Acids
Glycogen
Nitrogen
Free Fatty Acids
: cholesterol
: ketones
HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria
Polyuria
Cellular starvation: weight loss Cellular dehydration
Stimulates the appetite / satiety center
Stimulates the thirst center
(Hypothalamus)
(Hypothalamus)
Polyphagia
Polydypsia
* liver has glycogen that undergo glycogenesis/glycogenolysis
GLUCONEOGENESIS
Formation of glucose from non-CHO sources
Increase protein formation
Negative Nitrogen balance
Tissue wasting (Cachexia)
INCREASE FAT CATABOLISM
Free fatty acids
Cholesterol
Ketones
Atherosclerosis Diabetic
Keto Acidosis
Hypertension Acetone Breath
Kussmaul’s Respiration odor
MI CVA
DeathDiabetic Coma
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
Juvenile onset type (Brittle disease)
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
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
Characteristics of Insulin Preparation
Drug Synonym Appearance Onset Peak
Duration Compatible Mixed
Rapid Acting
Insulin InjectionRegular Ins Clear ½-1 2-4 6-8
All insulin prep
except lente
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
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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)
2. Type II Non-insulin-dependent Diabetes Mellitus (NIDDM)
May result to partial deficiency of insulin production &/or
an insensitivity of the cells to insulin
Obese adult over 40 years old
Maturity onset type
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
Oral Hypoglycemic Agent
Drug Onset Peak Duration
Comments
Oral Sulfonylureas
Acetohexamide (Dymelor) 1 4-6 12-
24
Chlorpropamide (Diabinase) 1 4-6 40-60
Glyburide (Micronase, Diabeta) 15 min- 1 hr 2-8 10-24
Oral Biguanides
Metformin (Glucophage) 2-2.5 10-
16 :Decrease glucose
production in liver
:Decrease intestinal
absorption of glucose &
improves insulin sensitivity
Oral Alpha-glucosidose Inhibitor
Acarbose (Precose) Unknown 1 Unknown
:Delay glucose absorption
& digestion of CHO,
lowering blood sugar
Miglitol (Glyset) 2-3
Troglitazone (Rezulin) Rapid 2-3 Unknown
:Reduce plasma glucose &
insulin
:Potetiates action of insulin
in skeletal muscle &
decrease glucose
production in liver
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
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Emphasize importance of regularity of meals;
never skip meals
c. Insulin
How to draw up into syringe
Use insulin at room temp
Gently roll the vial between palms
Draw up insulin using sterile technique
If mixing insulin, draw up clear insulin,
before cloudy insulin
Injection technique
Systematically rotate the site: to prevent
lipodystrophy: (hypertrophy or atrophy of
tissue)
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
Somogyi’s phenomenon: hypoglycemia followed
by periods of hyperglycemia or rebound effect
of insulin.
Provide many opportunities for return
demonstration
d. Oral hypoglycemic agent
Stress importance of taking the drug regularly
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)
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
Care for “sick days” (ex. Cold or flu)
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
If N/V occurs: sip on clear liquid with simple
sugar
h. Foot care
Wash foot with mild soap & water & pat dry
Apply lanolin lotion to feet: to prevent drying &
cracking
Cut toenail straight across
Avoid constrictive garments such as garters
Wear clean, absorbent socks (cotton or wool)
Purchase properly fitting shoes & break new
shoes in gradually
Never go barefoot
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
Diabetic Ketoacidosis (DKA)
Acute complication of DM characterized by hyperglycemia &
accumulation of ketones in the body: cause metabolic
acidosis
Acute complication of Type I DM: due to severe
hyperglycemia leading to severe CNS depression
Occurs in insulin-dependent diabetic clients
Onset slow: maybe hours to days
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
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
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30
When blood sugar drops to 250 mg/dl: may add
5% dextrose to IV
Potassium will be added: when the urine output
is adequate
b. Observe for F&E imbalance, especially fluid
overload, hyperkalemia & hypokalemia
4. Administer insulin as ordered: regular acting
insulin/rapid acting insulin
a. Regular insulin IV (drip or push) & / or
subcutaneously (SC)
b. If given IV drip: give small amount of albumin since
insulin adheres to IV tubing
c. Monitor blood glucose level frequently
5. Administer medications as ordered:
a. Sodium Bicarbonate: to counteract acidosis
b. Antibiotics: to prevent infection
6. Check urine output every hour
7. Monitor V/S, I&O & blood sugar levels
8. Assist client with self-care
9. Provide care for unconscious client if in a coma
10. Discuss with client the reasons ketosis developed &
provide additional diabetic teaching if indicated
Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC)
Characterized by hyperglycemia & a hyperosmolar state
without ketosis
Occurs in non-insulin-dependent diabetic or non-diabetic
persons (typically elderly clients)
Hyperosmolar: increase osmolarity (severe dehydration)
Non-ketotic: absence of lypolysis (no ketones)
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
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
When blood sugar drops to 250 mg/dl: may add
5% dextrose to IV
Potassium will be added: when the urine output
is adequate
b. Observe for F&E imbalance, especially fluid
overload, hyperkalemia & hypokalemia
4. Administer insulin as ordered:
a. Regular insulin IV (drip or push) & / or
subcutaneously (SC)
b. If given IV drip: give small amount of albumin since
insulin adheres to IV tubing
c. Monitor blood glucose level frequently
5. Administer medications as ordered:
a. Antibiotics: to prevent infection
6. Check urine output every hour
7. Monitor V/S, I&O & blood sugar levels
8. Assist client with self-care
9. Provide care for unconscious client if in a coma
10. Discuss with client the reasons ketosis developed &
provide additional diabetic teaching if indicated
Overview of Anatomy & Physiology of Hematologic System
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
I. Blood II. Blood VesselsIII. Blood Forming Organs
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. Albumin2. Globulins3. 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
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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
Consists of serum (liquid portion of plasma) & fibrinogen
Contains plasma CHON such as albumin, serum, globulins,
fibrinogen, prothrombin, plasminogen
1. Albumin
Largest & numerous plasma CHON
Involved in regulation of intravascular plasma
volume
Maintains osmotic pressure: preventing edema
2. Serum Globulins
a. Alpha: role in transport steroids, lipids, bilirubin &
hormones
b. Beta: role in transport of iron & copper
c. Gamma: role in immune response, function of
antibodies
3. Fibrinogens, Prothrombin, Plasminogens: clotting factors
to prevent bleeding
Cellular Components or Formed Elements
1. Erythrocytes (RBC)
a. Normal value: 4 – 6 million/mm3
b. No nucleus, Biconcave shape discs, Chiefly sac of
hemoglobin
c. Call membrane is highly diffusible to O2 & CO2
d. Responsible for O2 transport via hemoglobin (Hgb)
Two portion: iron carried on heme portion; second
portion is CHON
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
Biliverdin (green pigment)
Hemosiderin (golden brown pigment)
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
b. Lymphocytes: immune cells; produce
substances against foreign cells; produced
primarily in lymph tissue (B cells) & thymus (T
cells)
Lymphocytes
B-cell T-cell Natural killer cell- bone marrow - thymus - anti-viral and anti-tumor property
for immunity
HIV
c. Thrombocytes (Platelets)
Normal value: 150,000 – 450,000/mm3
Normal life span of platelet is 9 – 12 days
Fragments of megakaryocytes formed in
bone marrow
Production regulated by thrombopoietin
Essential factors in coagulation via
adhesion, aggregation & plug formation
Release substances involved in coagulation
Promotes hemostasis (prevention of blood
loss)
Consist of immature or baby platelets or
megakaryocytes which is the target of
dengue virus
Signs of Platelet Dysfunction
1. Petechiae
2. Echhymosis
3. Oozing of blood from venipunctured site
Blood Groups
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32
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
Complication of Blood Transfusion
Type Causes Mechanism Occurrence S/sx
Intervention
Hemolytic ABO Antibodies in Acute:
Headache, Stop transfusion.
Incompatibility; recipient plasma first 5 min
lumbar or continue saline IV
Rh react w/ antigen after
completion sternal pain, send blood unit &
Incompatibility; in donor cells. of transfusion
diarrhea, fever, client blood
Use of dextrose Agglutinated cell
chills, flushing, sample to lab.
solutions; block capillary Delayed:
heat along vein, Watch for
Wide temp blood flow to days to 2
restlessness, hemoglobinuria.
fluctuation organs. weeks after
anemia, jaundice, Treat or prevent
Hemolysis (Hgb
dyspnea, signs shock, DIC, &
into plasma & of
shock, renal renal shutdown
urine)
shutdown, DIC
Complication of Blood Transfusion
Type Causes Mechanism Occurrence S/sx
Intervention
Allergic Transfer of an Immune Within 30 min
Uticaria, larygeal Stop transfusion.
antigen & sensitivity to start of
edema, wheezing Administer
antibody from foreign serum transfusion
dyspnea, antihistamine &
donor to CHON
bronchospasm, or epinephrine.
recipient;
headache, Treat
Allergic donor
anaphylaxis life-threatening
reaction
_____________________________________________________________________
__________________
Pyrogenic Recipient Leukocytes Within 15-90
Fever, chills, Stop transfusion.
possesses agglutination min after
flushing, Treat temp.
antibodies bacterial initiation of
palpitation, Transfuse with
directed against organism transfusion
tachycardia, leukocytes-poor
WBC; bacterial
occasional blood of washed
contamination;
lumbar pain RBC.
Multitransfused
Administer
client;
antibiotics prn
multiparous
client
_____________________________________________________________________
__________________
Circulatory Too rapid Fluid volume During & after
Dyspnea, Slow infusion rate
Overload infusion in overload
transfusion increase BP, Used packed cells
Susceptible
tachycardia, instead of whole
Client
orthopnea, blood.
cyanosis, anxiety Monitor CVP
t
hro
ug
h a
separate line.
_____________________________________________________________________
__________________
Air Embolism Blood given Bolus of air Anytime
Dyspnea, Clamp tubing.
under air blocks pulmonary
increase pulse, Turn client on
pressure artery outflow
wheezing, chest left side
following severe
pain, decrease BP,
blood loss
apprehension
_____________________________________________________________________
__________________Thrombo- Used of large Platelets
When large Abnormal Assess for signs
cytopenia amount of deteriorate amount of blood
bleeding of bleeding.
banked blood rapidly in stored given over
24 hr Initiate bleeding
blood
precautions.
Use fresh blood.
_____________________________________________________________________
__________________
Citrate Large amount Citrate binds After large
Neuromascular Monitor/treat
Intoxication of citrated blood ionic calcium amount of
irritability hypocalcemia.
in client with banked blood
Bleeding due to Avoid large
decrease liver
decrease calcium amounts of
function
citrated blood.
Monitor liver fxn
_____________________________________________________________________
__________________
Hyperkalemia Potassium level Release of In client with
Nausea, colic, Administer blood
increase in potassium into renal
diarrhea, muscle less than 5-7
stored blood plasma with insufficiency
spasm, ECG days old in client
33
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red cell lysis
changes (tall with impaired
peaked T-waves, potassium
short Q-T excretion
seg
ments)
Blood Coagulation
Conversion of fluid blood into a solid clot to reduce blood
loss when blood vessels are ruptured
System that Initiating Clotting
1. Intrinsic System: initiated by contact activation following
endothelial injury (“intrinsic” to vessel itself)
a. Factor XII: initiate as contact made between damaged
vessel & plasma CHON
b. Factors VIII, IX & XI activated
2. Extrinsic System:
a. Initiated by tissue thromboplastins released from injured
vessels (“extrinsic” to vessel)
b. Factor VII activated
Common Pathways: activated by either intrinsic or extrinsic
pathways
1. Platelet factor 3 (PF3) & calcium react with factor X & V
2. Prothrombin converted to thrombin via thromboplastin
3. Thrombin acts on fibrinogens, forming soluble fibrin
4. Soluble fibrin polymerized by factor XIII to produce a stable,
insoluble fibrin clot
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
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
Blood & Blood Products
1. Whole Blood: provides all components
a. Large volume can cause difficulty: 12-24 hr for Hgb
& Hct to rise
b. Complications: volume overload, transmission of
hepatitis or AIDS, transfusion reacion, infusion of
excess potassium & sodium, infusion of
anticoagulant (citrate) used to keep stored blood
from clotting, calcium binding & depletion (citrate)
in massive transfusion therapy
2. Red Blood Cell (RBC)
a. Provide twice amount of Hgb as an equivalent
amount of whole blood
b. Indicate in cases of blood loss, pre-op & post-op
client & those with incipient congestive failure
c. Complication: transfusion reaction (less common
than with whole blood: due to removal of plasma
protein)
3. Fresh Frozen Plasma
a. Contains all coagulation factors including V & VIII
b. Can be stored frozen for 12 months; takes 20
minutes to thaw
c. Hang immediately upon arrival to unit (loses its
coagulation factor rapidly)
4. Platelets
a. Will raise recipient’s platelet count by 10,000/mm3
b. Pooled from 4-8 units of whole blood
c. Single-donor platelet transfusion may be necessary
for clients who have developed antibodies;
compatibilities testing may be necessary
5. Factor VIII Fractions (Cryoprecipitate): contains factor
VIII, fibrinogens & XIII
6. Granulocytes
a. Do not increase WBC: increase marginal pool (at
tissue level) rather than circulating pool
b. Premedication with steroids, antihistamine &
acetaminophen
c. Respiratory distress with shortness of breath,
cyanosis & chest pain may occur; requires cessation
of transfusion & immediate attention
d. Shaking chills or rigors common, require brief
cessation of therapy, administration of meperdine IV
until rigors are diminished & resumption of
transfusion when symptoms relieved
7. Volume Expander: albumin; percentage concentration
varies (50-100 ml/unit); hyperosmolar solution should
not be used in dehydrated clients
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
Principles of blood transfusion
1. Proper refrigeration
a. Expiration of packed RBC is 3-6 days
b. Expiration of platelet is 3-5 days
2. Proper typing and cross matching
a. Type O: universal donor
b. Type AB: universal recipient
c. 85% of population is RH positive
3. Aseptically assemble all materials needed for BT
a. Filter set
b. Gauge 18-19 needle
c. Isotonic solution (0.9 NaCl / plain NSS): to prevent
hemolysis
4. Instruct another RN to re check the following
a. Client name
b. Blood typing & cross matching
c. Expiration date
d. Serial number
5. Check the blood unit for bubbles cloudiness, sediments
and darkness in color because it indicates bacterial
contamination
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a. Never warm blood: it may destroy vital factors in
blood.
b. Warming is only done: during emergency situation &
if you have the warming device
c. Emergency rapid BT is given after 30 minutes & let
natural room temperature warm the blood.
6. BT should be completed less than 4 hours because
blood that is exposed at room temperature more than 2
hours: causes blood deterioration that can lead to
bacterial contamination
7. Avoid mixing or administering drugs at BT line: to
prevent hemolysis
8. Regulate BT 10-15 gtts/min or KVO rate or equivalent to
100 cc/hr: to prevent circulatory overload
9. Monitor strictly vital signs before, during & after BT
especially every 15 minutes for first hour because
majority of transfusion reaction occurs during this period
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)
S/sx of Hemolytic reaction
1. Headache and dizziness
2. Dyspnea
3. Diarrhea / Constipation
4. Hypotension
5. Flushed skin
6. Lumbasternal / Flank pain
7. Urine is color red / portwine urine
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
S/sx of Allergic reaction
1. Fever
2. Dyspnea
3. Broncial wheezing
4. Skin rashes
5. Urticaria
6. Laryngospasm & Broncospasm
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
S/sx Pyrogenic reactions
1. Fever and chills
2. Headache
3. Tachycardia
4. Palpitations
5. Diaphoresis
6. Dyspnea
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
S/sx of Circulatory reaction
1. Orthopnea
2. Dyspnea
3. Rales / Crackles upon auscultation
4. Exertional discomfort
Nursing Management
1. Stop BT
2. Notify physician
3. Administer medications as ordered
a. Loop diuretic (Lasix)
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)
2 Common fungal opportunistic infection in AIDS
1. Kaposis Sarcoma
2. Pneumocystic Carini Pneumonia
Blood Disorder
Iron Deficiency Anemia (Anemias)
A chronic microcytic anemia resulting from inadequate
absorption of iron leading to hypoxemic tissue injury
Chronic microcytic, hypochromic anemia caused by either
inadequate absorption or excessive loss of iron
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)
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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
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
Nursing Management when taking oral iron
preparations
Instruct client to take with meals: to lessen GIT
irritation
Dilute in liquid preparations well & administer
using a straw: to prevent staining of teeth
When possible administer with orange juice as
vitamin C (ascorbic acid): to enhance iron
absorption
Warn clients that iron preparations will change
stool color & consistency (dark & tarry) & may
cause constipation
Antacid ingestion will decrease oral iron
effectiveness
b. Parenteral: used in clients intolerant to oral
preparations, who are noncompliant with therapy or
who have continuing blood losses
Nursing Management when giving parenteral
iron preparation
Use one needle to withdraw & another to
administer iron preparation as tissue staining &
irritation are a problem
Use Z-track injection technique: to prevent
leakage into tissue
Do not massage injection site but encourage
ambulation as this will enhance absorption;
advice against vigourous exercise & constricting
garments
Observe for local signs of complication:
Pain at the injection site
Development of sterile abscesses
Lymphadenitis
Fever & chills
Headache
Urticaria
Pruritus
Hypotension
Skin rashes
Anaphylactic shock
Medications administered via straw
Lugol’s Solution
Iron
Tetracycline
Nitrofurantoin (Macrodentin)
7. Administer with Vitamin C or orange juice for absorption
8. Monitor & inform client of side effects
a. Anorexia
b. N/V
c. Abdominal pain
d. Diarrhea / constipation
e. Melena
9. If client can’t tolerate / no compliance administer
parenteral iron preparation
a. Iron Dextran (IM, IV)
b. Sorbitex (IM)
10. Provide dietary teaching regarding food high in iron
11. Encourage ingestion of roughage & increase fluid intake:
to prevent constipation if oral iron preparation are being
taken
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
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Pareital cells/Argentaffin or Oxyntic cells
Produces intrinsic factors
Secretes hydrochloric acid
Promotes reabsorption of Vit B12
Aids in digestion
Promotes maturation of RBC
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
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
Decrease RBC Decrease WBC Decrease Platelet
(anemia) (leukopenia)
(thrombocytopenia)
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
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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
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
Given via central venous catheter
Given 6 days to 3 weeks to achieve maximum
therapeutic effect of drug
8. Monitor for signs of infection & provide care to minimize
risk:
a. Monitor neuropenic precautions
b. Encourage high CHON, vitamin diet: to help reduce
incidence of infection
c. Provide mouth care before & after meals
d. Fever
e. Cough
9. Monitor signs of bleeding & provide measures to
minimize risk:
a. Use soft toothbrush when brushing teeth & electric
razor when shaving: prevent bleeding
b. Avoid IM, subcutaneous, venipunctured sites:
Instead provide heparin lock
c. Hematest urine & stool
d. Observe for oozing from gums, petechiae or
ecchymoses
10. Provide client teaching & discharge planning
concerning:
a. Self-care regimen
b. Identification of offending agent & importance of
avoiding it (if possible) in future
Disseminated Intravascular Coagulation (DIC)
Diffuse fibrin deposition within arterioles & capillaries with
widespread coagulation all over the body & subsequent
depletion of clotting factors
Acute hemorrhagic syndrome characterized by wide spread
bleeding and thrombosis due to a deficiency of prothrombin
and fibrinogen
Hemorrhage from kidneys, brain, adrenals, heart & other
organs
May be linked with entry of thromboplasic substance into
the blood
Mortality rate is high usually because underlying disease
cannot be corrected
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
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
Overview of the Structure & Functions of the Heart
Cardiovascular system consists of the heart, arteries, veins
& capillaries. The major function are circulation of blood,
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SA NODE
AV NODE
BUNDLE OF HIS
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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
Heart Wall / Layers of the Heart
Pericardium
Composed of fibrous (outermost layer) & serous pericardium
(parietal & visceral); a sac that function to protect the heart
from friction
In between is the pericardial fluid which is 10 – 20 cc:
Prevent pericardial friction rub
2 layers of pericardium
Parietal: outer layer
Visceral: inner layer
Epicardium
Covers surface of the heart, becomes continuous with
visceral layer of serous pericardium
Outer layer
Myocardium
Middle muscular layer
Myocarditis can lead to cardiogenic shock and rheumatic
heart disease
Endocardium
Thin, inner membrabous layer lining the chamber of the
heart
Inner layer
Papillary Muscle
Arise from the endocardial & myocardial surface of the
ventricles & attach to the chordae tendinae
Chordae Tendinae
Attach to the tricuspid & mitral valves & prevent eversion
during systole
Chambers of the Heart
Atria
2 chambers, function as receiving chambers, lies above the
ventricles
Upper Chamber (connecting or receiving)
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
Lower Chamber (contracting or pumping)
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
To promote unidimensional flow or prevent backflow
Atrioventricular Valve
Guards opening between
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
Located between the left ventricle & pulmonary artery
Aortic Valve
Located between left ventricle & aorta
Function
Pemit unidirectional flow of the blood from specific ventricle
to arterial vessel during ventricular diastole
Prevent reflux blood flow during ventricular diastole
Valve open when ventricle contract & close during
ventricular diastole; Closure of SV valve produces second
heart sound (S2 “dub”)
Extra Heart Sounds
S3: ventricular gallop usually seen in Left Congestive Heart
Failure
S4: atrial gallop usually seen in Myocardial Infarction and
Hypertension
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
Atrioventricular Node (AV node or Tawara Node)
Located at the inter atrial septum
Delays the impulse from the atria while the ventricles fill
Delay of electrical impulse for about .08 milliseconds to
allow ventricular filling
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
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39
PURKINJE FIBERS
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
QRS wave (ventricular depolarization)
T wave (ventricular repolarization)
Insert pacemaker if there is complete heart block
Most common pacemaker is the metal pacemaker and lasts
up to 2 – 5 years
Abnormal ECG Tracing
Positive U wave: Hypokalemia
Peak T wave: Hyperkalemia
ST segment depression: Angina Pectoris
ST segment elevation: Myocardial Infarction
T wave inversion: Myocardial Infarction
Widening of QRS complexes: Arrythmia
Vascular System
Major function of the blood vessels isto supply the tissue
with blood, remove wastes, & carry unoxygenated blood
back to the heart
Types of Blood Vessels
Arteries
Elastic-walled vessels that can stretch during systole &
recoil during diastole; they carry blood away from the heart
& distribute oxygenated blood throughout the body
Arterioles
Small arteries that distribute blood to the capillaries &
function in controlling systemic vascular resistance &
therefore arterial pressure
Capilliaries
The following exchanges occurs in the capilliaries
O2 & CO2
Solutes between the blood & tissue
Fluid volume transfer between the plasma & interstitial
space
Venules
Small veins that receive blood from capillaries & function as
collecting channels between the capillaries & veins
Veins
Low-pressure vessels with thin small & less muscles than
arteries; most contains valves that prevent retrograde blood
flow; they carry deoxygenated blood back to the heart.
When the skeletal surrounding veins contract, the veins are
compressed, promoting movement of blood back to the
heart.
Cardiac Disorders
Coronary Arterial Disease / Ischemic Heart Disease
Stages of Development of Coronary Artery Disease
1. Myocardial Injury: Atherosclerosis
2. Myocardial Ischemia: Angina Pectoris
3. Myocardial Necrosis: Myocardial Infarction
ATHEROSCLEROSIS
ATHEROSCLEROSIS ARTERIOSCLEROSIS
Narrowing of artery
Lipid or fat deposits
Tunica intima
Hardening of artery
Calcium and protein
deposits
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
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
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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)
Beta-adrenergic blocking agent: Propanolol
Calcium-blocking agent: nefedipine
Ace Inhibitor: Enapril
2. Modification of diet & other risk factors
3. Surgery: Coronary artery bypass surgery
4. Percutaneuos Transluminal Coronary Angioplasty (PTCA)
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
Nursing Management when giving NTG
1. NTG Tablets (sublingual)
Keep the drug in a dry place, avoid moisture and
exposure to sunlight as it may inactivate the drug
Relax for 15 minutes after taking a tablet: to
prevent dizziness
Monitor side effects:
Orthostatic hypotension
Transient headache & dizziness: frequent side
effect
Instruct the client to rise slowly from sitting position
Assist or supervise in ambulation
2. NTG Nitrol or Transdermal patch
Avoid placing near hairy areas as it may decrease
drug absorption
Avoid rotating transdermal patches as it may
decrease drug absorption
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
Not given to COPD cases: it causes bronchospasm
c. ACE Inhibitors
Enalapril
d. Calcium Antagonist
Nefedipine
4. Administer oxygen inhalation
5. Place client on semi-to high fowlers position
6. Monitor strictly V/S, I&O, status of cardiopulmonary fuction
& ECG tracing
7. Provide decrease saturated fats sodium and caffeine
8. Provide client health teachings and discharge planning
Avoidance of 4 E’s
Prevent complication (myocardial infarction)
Instruct client to take medication before indulging into
physical exertion to achieve the maximum therapeutic
effect of drug
Reduce stress & anxiety: relaxation techniques & guided
imagery
Avoid overexertion & smoking
Avoid extremes of temperature
Dress warmly in cold weather
Participate in regular exercise program
Space exercise periods & allow for rest periods
The importance of follow up care
9. Instruct the client to notify the physician immediately if pain
occurs & persists despite rest & medication administration
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
The Most Critical Period Following Diagnosis of Myocardial Infarction
6-8 hours because majority of death occurs due to
arrhythmia leading to premature ventricular contractions
(PVC)
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
12. Diet: increased saturated fats
13. Type A personality
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
Not usually relieved by rest or by nitroglycerine
2. N/V
3. Dyspnea
4. Increase in blood pressure & pulse, with gradual drop in
blood pressure (initial sign)
5. Hyperthermia: elevated temp
6. Skin: cool, clammy, ashen
7. Mild restlessness & apprehension
8. Occasional findings:
Pericardial friction rub
Split S1 & S2
Rales or Crackles upon auscultation
S4 or atrial gallop
Dx
1. Cardiac Enzymes
CPK-MB: elevated
Creatinine phosphokinase (CPK): elevated
Heart only, 12 – 24 hours
Lactic acid dehydrogenase (LDH): is increased
Serum glutamic pyruvate transaminase (SGPT): is
increased
Serum glutamic oxal-acetic transaminase (SGOT): is
increased
2. Troponin Test: is increased
3. ECG tracing reveals
ST segment elevation
T wave inversion
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Widening of QRS complexes: indicates that there is
arrhythmia in MI
4. Serum Cholesterol & uric acid: are both increased
5. CBC: increased WBC
Nursing Intervention
Goal: Decrease myocardial oxygen demand
1. Decrease myocardial workload (rest heart)
Establish a patent IV line
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
Antidote: Naloxone (Narcan)
Side Effects of Naloxone Toxicity: is tremors
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
c. Beta-blockers: Propanolol (Inderal)
d. ACE Inhibitors: Captopril (Enalapril)
e. Calcium Antagonist: Nefedipine
f. Thrombolytics / Fibrinolytic Agents: Streptokinase,
Urokinase, Tissue Plasminogen Activating Factor (TIPAF)
Side Effects: allergic reaction, urticaria, pruritus
Nursing Intervention: Monitor for bleeding time
g. Anti Coagulant
Heparin
Antidote: Protamine Sulfate
Nursing Intervention: Check for Partial Thrombin
Time (PTT)
Caumadin (Warfarin)
Antidote: Vitamin K
Nursing Intervention: Check for Prothrombin
Time (PT)
h. Anti Platelet: PASA (Aspirin): Anti thrombotic effect
Side Effects: Tinnitus, Heartburn, Indigestion /
Dyspepsia
Contraindication: Dengue, Peptic Ulcer Disease,
Unknown cause of headache
14. Provide client health teaching & discharge planning
concerning:
a. Effects of MI healing process & treatment regimen
b. Medication regimen including time name purpose,
schedule, dosage, side effects
c. Dietary restrictions: low Na, low cholesterol, avoidance
of caffeine
d. Encourage client to take 20 – 30 cc/week of wine,
whisky and brandy: to induce vasodilation
e. Avoidance of modifiable risk factors
f. Prevent Complication
Arrhythmia: caused by premature ventricular
contraction
Cardiogenic shock: late sign is oliguria
Left Congestive Heart Failure
Thrombophlebitis: homan’s sign
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
Congestive Heart Failure
Inability of the heart to pump an adequate supply of blood
to meet the metabolic needs of the body
Inability of the heart to pump blood towards systemic
circulation
Types of Heart Failure
1. Left Sided Heart Failure
2. Right Sided Heart Failure
3. High-Output Failure
Left Sided Heart Failure
Left ventricular damage causes blood to back up through
the left atrium & into the pulmonary veins: Increased
pressure causes transudation into interstitial tissues of the
lungs which result pulmonary congestion.
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
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
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Decrease CVP: increased flow rate of IV
5. Swan-Ganz catheterization: cardiac catheterization
6. Echocardiography: shows increased sized of cardiac
chamber (cardiomyopathy): dependent on extent of heart
failure
7. ABG: reveals PO2 is decreased (hypoxemia), PCO2 is
increased (respiratory acidosis)
Right Sided Heart Failure
Weakened right ventricle is unable to pump blood into he
pulmonary system: systemic venous congestion occurs as
pressure builds up
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 less than 4 cm of water: Hypovolemic shock:
increase IV flow rate
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
3. Echocardiography: reveals increased size of cardiac
chambers (cardiomyopathy)
4. Liver enzymes: SGPT & SGOT: is increased
5. ABG: decreased pO2
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
3. Increase cardiac output
a. Administer digitalis as ordered & monitor effects
Cardiac glycosides: Digoxin (Lanoxin)
Action: Increase force of cardiac contraction
Contraindication: If heart rate is decreased do not
give
b. Monitor ECG & hemodynamic monitoring
c. Administer vasodilators as ordered
Vasodilators: Nitroglycerine (NTG)
d. Monitor V/S
4. Reduce / eliminate edema
a. Administer diuretics as ordered
Loop Diuretics: Lasix (Furosemide)
b. Daily weight
c. Maintain accurate I&O
d. Assess for peripheral edema
e. Measure abdominal girth daily
f. Monitor electrolyte levels
g. Monitor CVP & Swan-Ganz reading
h. Provide Na restricted diet as ordered
i. Provide meticulous skin care
5. If acute pulmonary edema occurs: For Left Sided Heart
Failure only
a. Administer Narcotic Analgesic as ordered
Narcotic analgesic: Morphine SO4
Action: to allay anxiety & reduce preload & afterload
b. Administer Bronchodilator as ordered
Bronchodilators: Aminophylline IV
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
Peripheral Vascular Disorder
Arterial Ulcer
1. Thromboangiitis Obliterans (Buerger’s Disease)
2. Raynaud’s Phenomenon
Venous Ulcer
1. Varicose Veins
2. Thrombophlebitis (deep vein thrombosis)
Thromboangiitis Obliterans (Buerger’s Disease)
Acute inflammatory disorder affecting the small / medium
sized arteries & veins of the lower extremities
Occurs as focal, obstructive, process; result in occlusion of a
vessel with a subsequent development of collateral
circulation
Predisposing Factors
1. High risk groups - men 25-40 years old
2. High incident among smokers
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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
Medical Management
1. Drug Therapy
a. Vasodilators: to improve arterial circulation
(effectiveness ?)
Papaverine
Isoxsuprine HCL (Vasodilan)
Nylidrin HCL (Arlidin)
Nicotinyl Alcohol (Roniacol)
Cyclandelate (Cyclospasmol)
Tolazoline HCL (Priscoline)
b. Analgesic: to relieve ischemic pain
c. Anti-coagulant: to prevent thrombus formation
2. Surgery
a. Bypass Grafting
b. Endarterectomy
c. Balloon Catheter Dilation
d. Lumbar Sympathectomy: to increase blood flow
e. Amputation: may be necessary
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
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
Thrombophlebitis (Deep vein thrombosis)
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Inflammation of the vessel wall with formation of clot
(thrombus), may affect superficial or deep veins
Inflammation of the veins with thrombus formation
Most frequent veins affected are the saphenous, femoral &
popliteal
Can result in damage to the surrounding tissue, ischemia &
necrosis
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
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:
Transient hair loss
Burning sensation of feet
Bleeding complication
2. Surgery
a. Vein ligation & stripping
b. Venous thrombectomy: removal of cloth in the
iliofemoral region
c. Plication of the inferior vena cava: insertion of an
umbrella-like prosthesis into the lumen of the vena
cava: to filter incoming cloth
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
Use infusion pump to administer heparin
Ensure proper injection technique
Use 26 or 27 gauge syringe with ½-5/8 inch
needle, inject into fatty layer of abdomen above
iliac crest
Avoid injecting within 2 inches of umbilicus
Insert needle at 45-90o to skin
Do not withdraw plunger to assess blood return
Apply gentle pressure after removal of needle:
avoid massage
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
Obtain careful medication history (there are many
drug-drug interaction)
Advise client to withhold dose & notify MD
immediately if bleeding occur
Have antidote (Vitamin K) available
Alert client to factors that may affect the
anticoagulant response (high-fat diet or sudden
increased in vit. K-rich food)
Instruct the client to wear medic-alert bracelet
4. Assess V/S every 4 hours
5. Monitor chest pain or shortness of breath: possible
pulmonary embolism
6. Measure thigh, calves, ankles & instep every morning
7. Provide client teaching & discharge planning
a. Need to avoid standing, sitting for long period,
constrictive clothing, crossing legs at the knee, smoking,
oral contraceptives
b. Importance of adequate hydration: to prevent
hypercoagubility
c. Use elastic stockings when ambulatory
d. Importance of planned rest periods with elevation of the
feet
e. Drug regimen
f. Plan for exercise / activity
Begin with dorsiflexion of the feet while sitting or
lying down
Swim several times weekly
Gradually increased walking distance
g. Importance of weight reduction: if obese
h. Monitor for signs of complications
a. Pulmonary Embolism
Sudden sharp chest pain
Unexplained dyspnea
Tachycardia
Palpitations
Diaphoresis
Restlessness
Overview of Anatomy & Physiology of the Respiratory System
Upper Respiratory System
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Structure of the respiratory system, primarily an air
conduction system, include the nose, pharynx & larynx. Air
is filtered warmed & humidified in the upper airway before
passing to lower airway.
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
Composed of three section
1. Nasopharynx: located above the soft palate of the mouth,
contains the adenoids & opening to the eustachian tubes
2. Oropharynx: located directly behind the mouth & tongue,
contains the palatine tonsils; air & food enter the body
through oropharynx
3. Laryngopharynx: extends from the epiglotitis to the sixth
cervical level
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
Lower Respiratory System
Consist of trachea, bronchi & branches, & the lungs &
associated structures
For gas exchange
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
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)
Left lung (consist of 2 lobes, 8 segments)
Main organ of respiration, lie within the thoracic cavity on
either side of the heart
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
Site of gas exchange (CO2 and O2)
Diffusion (Dalton’s law of partial pressure of gases)
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
Respiratory Distress Syndrome
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Decrease oxygen stimulates breathing
Increase carbon dioxide is a powerful stimulant for
breathing
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
5. Escherichia Pneumoniae
6. Pseudomonas
High Risk Groups
1. Children below 5 years old
2. Elderly
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
Deep breathing & coughing exercise: tends to promote
expectoration
Tracheobronchial suctioning as needed
Administer Mucolytic or Expectorant as ordered
Aerosol treatment via nebulizer
Humidification of inhaled air
Chest physiotherapy (Postural Drainage): tends to
promote expectoration
3. Observe color characteristics of sputum & report any
changes: encourage client to perform good oral hygiene
after expectoration
4. Provide adequate rest & relief control of pain
Enforce CBR with limited activity
Limit visits & minimized conversation
Plan for uninterrupted rest periods
Maintain pleasant & restful environment
5. Administer antibiotic as ordered: monitor effects & possible
toxicity
Broad Spectrum Antibiotic
Penicillin
Tetracycline
Microlides (Zethromax)
Azethromycin: Side Effect: Ototoxicity
6. Prevent transmission: respiratory isolation client with
staphylococcal pneumonia
7. Control fever & chills:
Monitor temperature A
Administer antipyretic as ordered
Increased fluid intake
Provide frequent clothing & linen changing
8. Assist in postural drainage: uses gravity & various position
to stimulate the movement of secretions
Nursing Management for Postural Drainage
a. Best done before meals or 2-3 hours: to prevent gastro
esophageal reflux
b. Monitor vital signs
c. Encourage client deep breathing exercises
d. Administer bronchodilators 20-30 minutes before
procedure
e. Stop if client cannot tolerate procedure
f. Provide oral care after procedure
g. Contraindicated with
Unstable V/S
Hemoptysis
Clients with increase intra ocular pressure (Normal
IOP 12 – 21 mmHg)
Increase ICP
9. Provide increase CHO, calories, CHON & vitamin C
10. Provide client teaching & discharge planning
a. Medication regimen / antibiotic therapy
b. Need for adequate rest, limited activity, good nutrition,
with adequate fluid intake & good ventilation
c. Need to continue deep breathing & coughing exercise
for at least 6-8 weeks after discharge
d. Availability of vaccines
e. Need to report S/sx of respiratory infection
Persistent or recurrent fever
Changes in characteristics color of sputum
Chills
Increased pain
Difficulty in breathing
Weight loss
Persistent fatigue
f. Avoid smoking
g. Prevent complications
Atelectasis
Meningitis
h. Importance of follow up care
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
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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
Acetaminophen, Benadryl & Steroids is given with
Amphotericin B: to prevent reaction
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:
Fever: acetaminophen given prophylactically
Anaphylactic reaction: Benadryl & Steroids
given prophylactically
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 Obstructive Pulmonary Disease (COPD)
Chronic Bronchitis
Excessive production of mucus in the bronchi with
accompanying persistent cough
Characteristic include hypertrophy / hyperplasia of the
mucus secreting gland in the bronchi, decreased ciliary
activity, chronic inflammation & narrowing of the airway
Inflammation of bronchus resulting to hypertrophy or
hyperplasia of goblet mucous producing cells leading to
narrowing of smaller airways
AKA “Blue Bloaters”
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
Predisposing Factors (Depending on Types)
1. Extrinsic Asthma (Atopic / Allergic)
Causes
Pollen
Dust
Fumes
Smoke
Gases
Danders
Furs
Lints
2. Intrinsic Asthma (Non atopic / Non allergic)
Causes
Hereditary
Drugs (aspirin, penicillin, beta blocker)
Foods (seafoods, eggs, milk, chocolates, chicken)
Food additives (nitrates)
Sudden change in temperature, air pressure and
humidity
Physical and emotional stress
3. Mixed Type: 90 – 95%
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
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
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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
Nursing Management before Bronchoscopy
1. Secure inform consent and explain procedure to client
2. Maintain NPO 6-8 hours prior to procedure
3. Monitor vital signs & breath sound
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
Segmental Wedge Lobectomy: promote re-expansion of
lungs
Unaffected lobectomy: facilitate drainage
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
Overdistention of thoracic cavity (barrel chest)
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
Decrease PO2 (hypoxemia leading to chronic
bronchitis, “Blue Bloaters”)
Decrease ph
Increase PCO2
Respiratory acidosis
Panacinar/centriacinar
Increase PO2 (hyperaxemia, “Pink Puffers”)
Decrease PCO2
Increase ph
Respiratory alkalosis
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
Received immunization for influenza & pneumonia
Report changes in characteristic & color of sputum
immediately
Report of worsening of symptoms (increased
tightness of chest, fatigue, increased dyspnea)
b. Control of environment
Use home humidifier at 30-50%
Wear scarf over nose & mouth in cold weather: to
prevent bronchospasm
Avoid smoking & contact with environmental smoke
Avoid abrupt change in temperature
c. Avoidance of inhaled irritants
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Stay indoor: if pollution level is high
Use air conditioner with efficiency particulate air
filter: to remove particles from air
d. Increase activity tolerance
Start with mild exercise: such as walking & gradual
increase in amount & duration
Used breathing techniques: (pursed lip,
diaphragmatic) during activities / exercise: to
control breathing
Have O2 available as needed to assist with activities
Plan activities that require low amount of energy
Plan rest period before & after activities
e. Prevent complications
Atelectasis
Cor Pulmonale: R ventricular hypertrophy
CO2 narcosis: may lead to coma
Pneumothorax: air in the pleural space
f. Strict compliance to medication
g. Importance of follow up care
Oncology Nursing
Pathophysiology & Etiology of Cancer
Evolution of Cancer Cells All cells constantly change through growth, degeneration,
repair, & adaptation. Normal cells must divide & multiply to
meet the needs of the organism as a whole, & this cycle of
cell growth & destruction is an integral part of life
processes. The activities of the normal cell in the human
body are all coordinated to meet the needs of the organism
as a whole, but when the regulatory control mechanisms of
normal fail, & growth continues in excess of the body needs,
neoplasia results.
The term neoplasia refers to both benign & malignant
growths, but malignant cells behave very differently from
normal cells & have special features characteristics of the
cancer process.
Since the growth control mechanism of normal cells is
not entirely understood, it is not clear what allows the
uncontrolled growth, therefore no definitive cure has
been found.
Characteristics of Malignant Cells
Cancer cells are mutated stem cells that have undergone
structural changes so that they are unable to perform the
normal functions of specialized tissues.
They may function is a disorderly way to crease normal
function completely, only functioning for their own survival
& growth.
The most undifferentiated cells are also called anaplastic.
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
Some cancers shows familial pattern
Maybe caused by inherited genetics defects
I – Immunologic
Failure of the immune system to respond & eradicate
cancer cells
Immunosuppressed individuals are more susceptible to
cancer
V – Viral
o Viruses have been shown to be the cause of certain
tumors in animals
o Viruses ( HTLV-I, Epstein Barr Virus, Human
Papilloma Virus) linked to human tumors
o Oncovirus (RNA – Type Viruses) thought to be culprit
E – Environmental
o Majority (over 80%) of human cancer related to
environmental carcinogens
o Types:
Physical
Radiation: X – ray, radium, nuclear
explosion & waste, UV
Trauma or chronic irritation
Chemical
Nitrates, & food additives, polycyclic
hydrocarbons, dyes, alkylating
agents
Drugs: arsenicals, stilbestol,
urethane
Cigarette smoke
hormones
Classification of Cancer
Tissue Typing:
Carcinoma – arises from surface, glandular, or parenchymal
epithelium
1. Squamous Cell Carcinoma – surface epithelium
2. Adenocarcinoma – glandular or parenchymal tissue
Sarcoma – arises from connective tissue
Leukemia – from blood
Lymphoma – from lymph glands
Multiple Myeloma – from bone marrow
Stages of Tumor Growth
A. Staging System:
TNM System: uses letters & numbers to designate the
extent of tumors
o T– stands for primary growth; 1-4 with increasing
size; T1S indicates carcinoma in situ
o N – stands for lymph nodes involvement: 0-4
indicates progressively advancing nodal disease
o M – stands for metastasis; 0 indicates no distant
metastases, 1 indicates presence of metastases
Stages 0 – IV: all cancers divided into five stages
incorporating size, nodal involvement & spread
B. Cytologic Diagnosis of Cancer
1. Involves in the study of shed cells (ex. Pap smear)
2. Classified by degree of cellular abnormality
Normal
Probably normal (slight changes)
Doubtful (more severe changes)
Probably cancer or precancerous
Definitely cancer
Client Factors
1. Seven warning signs of cancer
2. BSE – breast self – examination
3. Importance of retal exam for those over age 40
4. Hazards of smoking
5. Oral self – examination as well as annual exam of mouth
& teeth
6. Hazards of excess sun exposure
7. Importance of pap smear
8. P.E. with lab work – up: every 3 years ages 20-40; yearly
for age 40 & over
9. TSE – testicular self – examination
Testicular Cancer
i. Most common cancer in men between
the age of 15 & 34
Warning signs that men should look for:
i. Painless swelling
ii. Feeling of heaviness
iii. Hard lump (size of a pea)
iv. Sudden collection fluid in the scrotum
v. Dull ache in the lower abdomen or in the
groin
vi. Pain in the testicle or in the scrotum
vii. Enlargement or tenderness of the
breasts
7 Warning Signs of Cancer
C: change in bowel or bladder habits
A: a sore that doesn’t heal
U: unusual bleeding or discharge
T: thickening of lump in breast or elsewhere
I: indigestion or dysphagia
O: obvious change in wart or mole
N: nagging cough or hoarseness
Treatment of Cancer
Therapeutic Modality
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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.
Types of Chemotherapeutic Drugs
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.
Major Side Effects & Nursing Intervention
A. GI System
Nausea & Vomiting
o Administer antiemetics routinely q 4-6 hrs as well as
prophylactically before chemotherapy is initiated.
o Withhold food/fluid 4-6 hrs before chemotherapy
o Provide bland food in small amounts after treatment
Diarrhea
o Administer antidiarrheals.
o Maintain good perineal care.
o Give clear liquids as tolerated.
o Monitor K, Na, Cl levels.
Stomatitis (mouth sore)
o Provide & teach the client good oral hygiene,
including avoidance of commercial mouthwashes.
o Rinse with viscous lidocaine before meals to provide
analgesic effect.
o Perform a cleansing rinse with plain H2O or dilute a
H2O soluble lubricant such as hydrogen peroxide
after meal.
o Apply H2O lubricant such as K-Y jelly to lubricate
cracked lips.
o Advice client to suck on Popsicles or ice chips to
provide moisture.
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
Plant alkaloids (vincristine) cause neurologic damage with
repeated doses
Peripheral neuropathies, hearing loss, loss of deep tendon
reflex, & paralytic ileus may occur.
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.
Types of Energy Emitted
Alpha – particles cannot passed through skin, rarely used.
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.
Factors Controlling Exposure
Half-life – time required for half of radioactive atoms to
decay.
1. Each radioisotope has different half-life.
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2. At the end of half-life the danger from exposure
decreases.
Time – the shorter the duration the less the exposure.
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.
Side Effects of Radiation Therapy & Nursing Intervention
A. Skin - itching, redness, burning, oozing, sloughing.
Keep skin free from foreign substances.
Avoid use of medicated solution, ointment, or powders that
contain heavy metals such as zinc oxide.
Avoid pressure, trauma, infection to skin; use bed cradle.
Wash affected areas with plain H2O & pat dry; avoid soap.
Use cornstarch, olive oil for itching; avoid talcum powder.
If sloughing occurs, use sterile dressing with micropore tape
Avoid exposing skin to heat, cold, or sunlight & avoid
constricting irritating clothing.
B. Anorexia, N/V
Arrange meal time so they do not directly precede or
follow therapy.
Encourage bland foods.
Provide small attractive meals.
Avoid extreme temperature.
Administer antiemetics as ordered before meals.
C. Diarrhea
Encourage low residue, bland, high CHON food.
Administer antidiarrheal as ordered.
Provide good perineal care.
Monitor electrolytes particularly Na, K, Cl
D. Anemia, Leukopenia, Thrombocytopenia
Isolate from those with known infection.
Provide frequent rest period.
Encourage high CHON diet.
Avoid injury.
Assess for bleeding.
Monitor CBC, WBC, & platelets.
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
2. Causes: flames, chemicals, scalding, electric current
3. Sensation: little or no pain
4. Characteristics: wound is dry, white, leathery, or
hard
Overview Of Anatomy & Physiology Of Musculoskeletal System
Consist of bones, muscles, joints, cartilages, tendons,
ligaments, bursae
To provide a structural framework for the body
To provide a means for movement
Bones
Function of Bones
Provide support to skeletal framework
Assist in movement by acting as levers for muscles
Protect vital organ & soft tissue
Manufacture RBC in the red bone marrow
(hematopoiesis)
Provide site for storage of calcium & phosphorus
1. Types of Bones
Long Bones
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
Sizes and shapes vary (ex. Vertebrae & mandible)
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
Articular cartilage covers the ends of the bones
A fibrous capsule encloses the joint
Capsule is lined with synovial membrane that secretes
synovial fluid to lubricate the joint and reduce friction.
Muscles
Functions of Muscles
Provide shape to the body
Protect the bones
Maintain posture
Cause movement of body parts by contraction
Types of Muscles
Cardiac: involuntary; found only in heart
Smooth: involuntary; found in walls of hollow structures
(e.g. intestines)
Striated (skeletal): voluntary
1. Characteristics of skeletal muscles
Muscles are attached to the skeleton at the point of
origin and to bones at the point of insertion.
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
Tendons and Ligaments
Composed of dense, fibrous connective tissue
Functions
1. Ligaments attach bone to bone
2. Tendons attach muscle to bone
Rheumatoid Arthritis (RA)
Chronic systemic disease characterized by inflammatory
changes in joints and related structures.
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
1. Cause unknown or idiopathic
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2. Maybe an autoimmune process
3. Genetic factors
4. Play a role in society (work)
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)
Mefenamic acid (Ponstel)
Phenylbutazone (Butazolidin)
Piroxicam (Feldene)
Naproxen (Naprosyn)
Sulindac (Clinoril)
c. Gold compounds (Chrysotherapy)
Injectable form: given IM once a week; take 3-6
months to become effective
Sodium thiomalate (Myochrysine)
Aurothioglucose (Solganal)
SI: monitor blood studies & urinalysis
frequently
Proteinuria
Mouth ulcers
Skin rash
Aplastic anemia.
Oral form: smaller doses are effective; take 3-6
months to become effective
Auranofin (Ridaura)
SI: blood & urine studies should be
monitored.
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.
e. Methotrexate: given to suppress immune response
Cytoxan
SI: bone marrow suppression.
2. Physical therapy: to minimize joint deformities.
3. Surgery: to remove severely damaged joints (e.g. total hip
replacement; knee replacement).
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.
a. Ensure balance between activity & rest.
b. Provide 1-2 scheduled rest periods throughout day.
c. Rest & support inflamed joints: if splints used: remove
1-2 times/day for gentle ROM exercises.
5. Ensure bed rest if ordered for acute exacerbations.
a. Provide firm mattress.
b. Maintain proper body alignment.
c. Have client lie prone for ½ hour twice a day.
d. Avoid pillows under knees.
e. Keep joints mainly in extension, not flexion.
f. Prevent complications of immobility.
6. Provide heat treatments: warm bath, shower or whirlpool;
warm, moist compresses; paraffin dips as ordered.
a. May be more effective in chronic pain.
b. Reduce stiffness, pain & muscle spasm.
7. Provide cold treatments as ordered: most effective during
acute episodes.
8. Provide psychologic support and encourage client to
express feelings.
9. Assists clients in setting realistic goals; focus on client
strengths.
10. Provide client teaching & discharge planning & concerning.
a. Use of prescribed medications & side effects
b. Self-help devices to assist in ADL and to increase
independence
c. Importance of maintaining a balance between activity &
rest
d. Energy conservation methods
e. Performance of ROM, isometric & prescribed exercises
f. Maintenance of well-balanced diet
g. Application of resting splints as ordered
h. Avoidance of undue physical or emotional stress
i. Importance of follow-up care
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
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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
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
Systemic Lupus Erythematosus (SLE)
Chronic connective tissue disease involving multiple organ
systems
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
6. History of remissions & exacerbations
7. Joint pain
8. Morning stiffness
9. Skin lesions
Erythematous rash on face, neck or extremities may
occur
Butterfly rash over bridge of nose & cheeks
Photosensitivity with rash in areas exposed to sun
10. Oral or nasopharyngeal ulcerations
11. Alopecia
12. Renal system involvement
Proteinuria
Hematuria
Renal failure
13. CNS involvement
Peripheral neuritis
Seizures
Organic brain syndrome
Psychosis
14. Cardiopulmonary system involvement
Pericarditis
Pleurisy
15. Increase susceptibility to infection
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.
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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
1. CBC: WBC elevated
2. Blood cultures: may be positive
3. ESR: may be elevated
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
Sequestrectomy: removal of dead, infected bone &
cartilage
Bone grafting: after repeated infections
Leg amputation
7. Provide client teaching and discharge planning concerning
Use of prescribed oral antibiotic therapy & side effects
Importance of recognizing & reporting signs &
complications (deformity, fracture) or recurrence
FRACTURES
A. General information
1.
B. Medical management
C. Assessment findings
D. Nursing interventions
Overview of Anatomy & Physiology Gastro Intestinal Track System
The primary function of GIT are the movement of food,
digestion, absorption, elimination & provision of a
continuous supply of the nutrients electrolytes & H2O.
Upper alimentary canal: function for digestion
Mouth
Consist of lips & oral cavity
Provides entrance & initial processing for nutrients &
sensory data such as taste, texture & temperature
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
Two sphincters control the rate of food passage
Cardiac Sphincter: located at the opening between the
esophagus & stomach
Pyloric Sphincter: located between the stomach &
duodenum
Three anatomic division
Fundus
Body
Antrum
Gastric Secretions:
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
Intrinsic Factor: secreted by parietal cell, promotes
absorption of Vit B12
Mucoid Secretion: coat stomach wall & prevent auto
digestion
1st half of duodenum
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
Crypts of Lieberkuhn: produce secretions containing
digestive enzymes
Brunner’s Gland: found in the submucosaof the
duodenum, secretes mucus
2nd half of duodenum
Jejunum
Ileum
1st half of ascending colon
Lower Alimentary Canal: Function: elimination
Large Intestine
Divided into four parts:
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Cecum (with appendix)
Colon (ascending, transverse, descending, sigmoid)
Rectum
Anus
Serves as a reservoir for fecal material until defecation
occurs
Function: to absorb water & electrolytes
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)
a. 2nd half of ascending colon
b. Transverse
c. Descending colon
d. Sigmoid
e. Rectum
Accessory Organ
Liver
Largest internal organ: located in the right hypochondriac &
epigastric regions of the abdomen
Liver Loobules: functional unit of the liver composed of
hepatic cells
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
Storage of vitamins A, D, B12 & iron
Synthesis of coagulation factors
Detoxification of many drugs & conjugation of sex
hormones
Salivary gland
Verniform appendix
Liver
Pancreas: auto digestion
Gallbladder: storage of bile
Biliary System
Consist of the gallbladder & associated ductal system (bile
ducts)
Gallbladder: lies under the surface of the liver
Function: to concentrate & store bile
Ductal System: provides a route for bile to reach the
intestines
Bile: is formed in the liver & excreted into hepatic duct
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
Function in GI system: is exocrine
Exocrine cells in the pancreas secretes:
Trypsinogen & Chymotrypsin: for protein digestion
Amylase: breakdown starch to disacchardes
Lipase: for fat digestion
Endocrine function related to islets of langerhas
Physiology of Digestion & Absorption
Digestion: physical & chemical breakdown of food into
absorptive substance
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)
Are produced by the duodenal mucosa
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
- Produces saliva – for mechanical digestion
- 1200 -1500 ml/day - saliva produced
Disorder of the GIT
Peptic Ulcer Disease (PUD)
Gastric Ulcer
Ulceration of the mucosal lining of the stomach
Most commonly found in the antrum
Excoriation / erosion of submucosa & mucosal lining due to:
Hypersecretion of acid: pepsin
Decrease resistance to mucosal barrier
Caused by bacterial infection: Helicobacter Pylori
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
Left
epigastrium
Gaseous &
burning
Not usually
relieved by
food &
antacid
2-3 hrs after
eating
Mid
epigastrium
Cramping &
burning
Usually
relieved by
food &
antacid
12 MN –
3am pain
Hypersecreti
on
Normal
gastric acid
secretion
Increased
gastric acid
secretion
Vomiting Common Not
common
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Hemorrhage Hematemeis Melena
Weight Weight loss Weight gain
Complication
s
Stomach
cause
Hemorrhage
Perforation
High Risk 60 years old 20 years old
Dx
Hgb & Hct: decrease (if anemic)
Endoscopy: reveals ulceration & differentiate ulceration
from gastric cancer
Gastric Analysis: normal gastric acidity
Upper GI series: presence of ulcer confirm
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
Magnesium & aluminum salt: neutralized gastric
acid & inactivate pepsin if pH is raised to >=4
Aluminum containing Antacids Magnesium
containing Antacids
Ex. Aluminum OH gel (Amphojel) Ex. Milk of Magnesia
SE: Constipation SE: Diarrhea
Maalox
SE: fever
Histamines (H2) receptor antagonist: inhibits gastric
acid secretion of parietal cells
Ranitidine (Zantac): has some antibacterial action
against H. pylori
Cimetidine (Tagamet)
Famotidine (Pepcid)
Anticholinergic:
Atropine SO4: inhibit the action of acetylcholine at
post ganglionic site (secretory glands) results
decreases GI secretions
Propantheline: inhibit muscarinic action of
acetylcholine resulting decrease 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
Metronidazole & Amoxacillin: for ulcer caused by
Helicobacter Pylori
3. Surgery:
Gastric Resection
Anastomosis: joining of 2 or more hollow organ
Subtotal Gastrectomy: Partial removal of stomach
Before surgery for BI or BII
Do Vagotomy (severing or cutting of vagus
nerve) & Pyloroplasty (drainage) first
Billroth I (Gastroduodenostomy)
Removal of ½ of
stomach &
anastomoses of gastric
stump to the
duodenum.
Billroth II (Gastrojejunostomy)
Removal of ½ -3/4 of
stomach & duodenal bulb
& anastomostoses of
gastric stump to jejunum.
Nursing Intervention Post op
1. Monitor NGT output
Immediately post op should be bright red
Within 36-42 hrs: output is yellow green
After 42 hrs: output is dark red
2. Administer medication
Analgesic
Antibiotic
Antiemetics
3. Maintain patent IV line
4. Monitor V/S, I&O & bowel sounds
5. Complications:
Hemorrhage: Hypovolemic shock: Late signs: anuria
Peritonitis
Paralytic ileus: most feared
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
Avoid ulcerogenic drugs: salicylates, steroids
Know proper dosage, action & SE
b. Proper Diet
Bland diet consist of six meals / day
Eat slowly
Avoid acid producing substance: caffeine, alcohol,
highly seasoned food
Avoid stressfull situation at mealtime
Plan rest period after meal
Avoid late bedtime snacks
c. Avoidance of stress-producing situation & development
of stress production methods
Relaxation techniques
Exercise
Biofeedback
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
Disorders of the Gallbladder
Cholecystitis / Cholelithiasis
Cholecystitis:
Acute or chronic inflammation of the gallbladder
Most commonly associated with gallstones
Inflammation occurs within the walls of the gallbladder
& creates thickening accompanied by edema
Consequently there is impaired circulation, ischemia &
eventually necrosis
Cholelithiasis:
Formation of gallstones & cholesterol stones
Inflammation of gallbladder with gallstone formation.
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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
(Morpine SO4: is contraindicated because it causes
spasm of the Sphincter of Oddi)
Antocholinergic: (Atrophine SO4): for pain
(Anticholinergic: relax smooth muscles & open bile
ducts)
Antiemetics: Phenothiazide (Phenergan): with anti
emetic properties
4. Surgery: Cholecystectomy / Choledochostomy
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
Disorders of the Pancreas
Pancreatitis
An inflammatory process with varying degrees of pancreatic
edema, fat necrosis or hemorrhage
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
Bleeding of Pancreas: Cullen’s sign at umbilicus
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
Meperidine Hcl (Demerol)
Don’t give Morphine SO4: will cause spasm of
Sphincter of Oddi
Smooth muscle relaxant: to relieve pain
Papaverine Hcl
Anticholinergic: to decrease pancreatic stimulation
Atrophine SO4
Propantheline Bromide (Profanthene)
Antacids: to decrease pancreatic stimulation
Maalox
H2 Antagonist: to decrease pancreatic stimulation
Ranitidin (Zantac)
Vasodilators: to decrease pancreatic stimulation
Nitroglycerine (NTG)
Ca Gluconate: to decrease pancreatic stimulation
2. Diet Modification
3. NPO (usually)
4. Peritoneal Lavage
5. Dialysis
Nursing Intervention
1. Administer medication as ordered
2. Withhold food & fluid & eliminate odor: to decrease
pancreatic stimulation / aggravates pain
3. Assist in Total Parenteral Nutrition (TPN) or
hyperalimentation
Complication of TPN
Infection
Embolism
Hyperglycemia
4. Institute non-pharmacological measures: to decrease pain
Assist client to comfortable position: Knee chest or fetal
like position
Teach relaxation techniques & provide quiet, restful
environment
5. Provide client teaching & discharge planning
Dietary regimen when oral intake permitted
High CHO, CHON & decrease fats
Eat small frequent meal instead of three large ones
Avoid caffeine products
Eliminate alcohol consumption
Maintain relaxed atmosphere after meals
Report signs of complication
Continued N/V
Abdominal distension with feeling of fullness
Persistent weight loss
Severe epigastric or back pain
Frothy foul smelling bowel movement
Irritability, confusion, persistent elevation of
temperature (2 day)
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
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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
Avoid enema, cathartics: lead to rupture of appendix
3. Don’t give analgesic: will mask pain
Presence of pain means appendix has not ruptured
4. Avoid heat application: will rupture appendix
5. Monitor VS, I&O bowel sound
Nursing Intervention post op
1. If (+) Pendrose drain (rubber drain inserted at surgical
wound for drainage of blood, pus etc): indicates rupture of
appendix
2. Position the client semi-fowlers or side lying on right: to
facilitate drainage
3. Administer Meds:
Analgesic: due post op pain
Antibiotics: for infection
Antipyretics: for fever (PRN)
4. Monitor VS, I&O, bowel sound
5. Maintain patent IV line
6. Complications: Peritonitis, Septicemia
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
Administer diuretics as ordered
Provide client teaching & discharge planning
Avoidance of hepatotoxicity drug: sedative, opiates or OTC
drugs detoxified by liver
How to assess weight gain & increase abdominal girth
Avoid person with upper respiratory infection
Reporting signs of reccuring illness (liver tenderness, increase
jaundice, increase fatigue, anorexia)
Avoid all alcohol
Avoid straining stool vigorous blowing of nose & coughing: to
decrease incidence of bleeding
Complications:
Ascites: accumolation of free fluid in abdominal cavity
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
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Bleeding esophageal varices: Dilation of esophageal veins
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
Overview of Anatomy & Physiology Of GUT System
GUT: Genito-urinary tract
GUT includes the kidneys, ureters, urinary bladder, urethra & the
male & female genitalia
Function:
Promote excretion of nitrogenous waste products
Maintain F&E & acid base balance
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
Renal Sinus & Pelvis
Papillae
Projection of renal tissues located at the tip of the renal
pyramids
Calices
Minor Calyx: collects urine flow from collecting ducts
Major Calyx: directs urine from renal sinus to renal pelvis
Urine flows from renal pelvis to ureters
Nephron
Functional unit of the kidney
Basic living unit
Renal Corpuscle (vascular system of nephron)
Bowman’s Capsule:
Portion of the proximal tubule surrounds the glomerulus
Glomerulus:
Capillary network permeable to water, electrolytes,
nutrients & waste
Impermeable to large CHON molecules
Filters blood going to kidneys
Renal Tubule
Divided into proximal convoluted tubule, descending
loop of Henle, acending loop of Henle, distal
convoluted tubule & collecting ducts
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
Urine formation: 25 % of total cardiac output is received by kidneys
Glomerular Filtration
Ultrafiltration of blood by the glomerulus, beginning of urine
formation
Requires hydrostatic pressure & sufficient circulating volume
Pressure in bowman’s capsule opposes hydrostatic pressure &
filtration
If glomerular pressure insufficient to force substance out of the
blood into the tubules filtrate formation stops
Glomerular Filtration Rate (GFR)
Amount of blood filtered by the glomeruli in a given time
Normal: 125 ml / min
Filtrate formed has essentially same composition as blood
plasma without the CHON; blood cells & CHON are
usually too large to pass the glomerular membrane
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
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Phosphate concentration
Collecting Ducts
Received urine from distal convoluted tubules & reabsorb H2O
(regulated by ADH)
Normal Adult: produces 1 L /day of urine
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
When the BP drops the cells of the glomerulus release rennin
which then activates angiotensin to cause vasoconstriction.
Filtration – Normal GFR/ min is 125 ml of blood
Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes
is for reabsorption)
Tubular secretion – 1 ml is excreted in urine
Regulation of BP:
Predisposing factor:
Ex CS – hypovolemia – decrease BP going to kidneys
Activation of RAAS
Release of Renin (hydrolytic enzyme) at
juxtaglomerular apparatus
Angiotensin I mild vasoconstrictor
Angiotensin II vasoconstrictor
Adrenal cortex increase CO increase PR
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
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
Chronic Pyelonephritis: client usually not aware of
disease
Bladder irritability
Slight dull ache over the kidney
Chronic Fatigue
Weight loss
Polyuria
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Polydypsia
HPN
Atrophy of the kidney
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
Urinalysis: increase WBC, CHON & pus cells
Cystoscopic exam: urinary obstruction
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
Calcium Oxalate Uric Acid
Milk Cabbage Anchovies
Cranberries Organ meat
Nuts tea Nuts
Chocolates Sardines
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
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
Benign Prostatic Hypertrophy (BPH)
Mild to moderate glandular enlargement, hyperplsia & over
growth of the smooth muscles & connective tissue
As the gland enlarges it compresses the urethra: resulting to
urinary retention
Enlarged prostate gland leading to
Hydroureters: dilation of urethers
Hydronephrosis: dilation of renal pelvis
Kidney stones
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
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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
Acute Renal Failure
Sudden inability of the kidney to regulate fluid & electrolyte
balance & remove toxic products from the body
Sudden immobility of kidneys to excrete nitrogenous waste
products & maintain F&E balance due to a decrease in GFR
(N 125 ml/min)
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
Pre renal cause: decrease blood flow & glomerular filtrate
Ischemia & oliguria
Cardiogenic shock
Acute vasoconstriction
Septicemia
Hypovolemia Decrease
flow to kidneys
Hypotension
CHF
Hemorrhage
Dehydration
Intra-renal cause: involves renal pathology: kidney problem
Acute tubular necrosis
Endocarditis
DM
Tumors
Pyelonephritis
Malignant HPN
Acute Glomerulonephritis
Blood transfision reaction
Hypercalemia
Nephrotoxin (certain antibiotics, X-ray, dyes, pesticides,
anesthesia)
Post renal cause: involves mechanical obstruction
Tumors
Stricture
Blood cloths
Urolithiasis
BPH
Anatomic malformation
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
S/sx of recurrent renal disease
Importance of planned rest period
Use of prescribe drugs only
S/sx of UTI or respiratory infection: report to MD
Chronic Renal Failure
Progressive, irreversible destruction of the kidneys that
continues until nephrons are replaced by scar tissue
Loss of renal function gradual
Irreversible loss of kidney function
Predisposing factors:
DM
HPN
Recurrent UTI/ nephritis
Urinary Tract obstruction
Exposure to renal toxins
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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
Urinary System
Polyuria
Nocturia
Hematuria
Dysuria
Oliguria
Metabolic Disturbance
Azotemia (increase BUN
& Creatinine)
Hyperglycemia
Hyperinsulinemia
CNS
Headache
Lethargy
Disorientation
Restlessness
Memory impairment
GIT
N/V
Stomatitis
Uremic breath
Diarrhea /
constipation
Respiratory
Kassmaul’s resp
Decrease cough
reflex
Hematological
Normocytic anemia
Bleeding tendencies
Fluid & Electrolytes
Hyperkalemia
Hypernatermia
Hypermagnese
mia
Hyperposphate
mia
Hypocalcemia
Metabolic
acidosis
Integumentary
Itchiness /
pruritus
Uremic frost
Dx
Urinalysis: CHON, Na & WBC: elevated
Specific gravity: decrease
Platelets: decrease
Ca: decrease
Medical Management
Diet restriction
Multivitamins
Hematinics
Aluminum Hydroxide Gels
Antihypertensive
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!
Bedside- bulldog clip
- If with accidental removal of fistula to prevent
embolism.
- Infersole (diastole) – common dialisate used
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7. Complication
- Peritonitis
- Shock
8. Assist in surgery:
Renal transplantation : Complication – rejection.
Reverse isolation
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