Centro Escolar UniversityMendiola Manila

College of Nursing

NCM 106-RLE

Lecture Notes in MS Concept

HYPERTENSION

Definition: a systolic blood pressure above 140 mmhg or a diastolic pressure above 90 mmhg based on two or more measurements.

Classification:1. Optimal- systolic 120 mmhg diastolic 80 mmhg2. Normal- systolic 130 mmhg diastolic 85 mmhg3. High normal- systolic 130 to 139 mmhg diastolic 85 to 89 mmhg4. Stage 1- systolic 140 to 159 mmhg diastolic 90 to 99 mmhg5. Stage 2- systolic 160 to 179 mmhg diastolic 100 to 109 mmhg6. Stage 3- systolic 180 mmhg or higher diastolic 110 mmhg or higher

Hypertension is a major RISK FACTOR for atherosclerotic cardiovascular disease, heart failure, stroke and kidney failure

I. ESSENTIAL (PRIMARY) HYPERTENSION

It accounts to 90-95% in the adult population have essential HPN Affects more women than men, African- American men

Pathophysiology:

There is increased in peripheral resistance and or cardiac output secondary to increased sympathetic stimulation, increased renal sodium reabsorption, increased rennin angiotensin aldosterone system activity, decreased vasodilation of the arterioles or resistance to insulin action.

RISK FACTORS:

Obesity, excessive alcohol intake, overstimulation with coffee, smoking and drug intake.

II. SECONDARY HYPERTENSION

Characterized by elevation in BP with a specific cause such as arterial disease, renal disease, certain medications, tumors and pregnancy hypertension.

DIAGNOSTIC PROCEDURE:

- History and physical examination- Retinal examination- Laboratory studies:urinalysis, blood chemistry (sodium, potassium, creatinine, FBS, total and high density lipoprotein), ECG and echocardiography to assess left ventricular hypertrophy- Special studies: intravenous pyelography, renal arteriography, split renal function studies, rennin levels, 24 hour urine protein, creatinine clearance.

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COMPLICATIONS:

Renal Hemorrhage Heart failure Renal insufficiency and Failure Cardiovascular Accident (CVA) Transient Ischemic Attack (TIA) Myocardial Infarction (MI) Left Ventricular Hypertrophy

Medical management:

Goal- to prevent death and complications by achieving and maintaining an arterial BP below 140/90 mmhg (130/85 mmhg for people with DM or proteinuria> 1 g/24 hrs. whenever possible.

NURSING MANAGEMENT:

I. ASSESSMENT Assess BP at frequent intervals , know baseline and note changes in pressure Note the apical and peripheral pulse rate , rhythm and character Assess symptoms such as nose bleeds, angina pain, shortness of breath,

alterations in vision, speech or balance (vertigo), headache or nocturia Assess extent to which HPN has affected patient personally, socially and

financially

II. NURSING DIAGNOSIS1. Deficient knowledge regarding the relationship between the treatment regimen

and control of the disease process2. Noncompliance related to side effects of prescribed therapy

III. PLANNING AND GOALS

The major goal of the patient include understanding the disease process and its treatment, compliance with the self care program and absence of complications.

IV. INTERVENTIONS

1. Increasing Knowledge Emphasize the concept of controlling HPN ( with lifestyle changes and

medications) rather than curing it Arrange a consultation with a dietitian to help patient plan a weight loss Obtain patient education materials Advise patient to limit alcohol intake and avoid use of tobacco (smoking)

2. Monitoring and Managing Complications Assess all body systems when patient returns for follow up care Question patient about blurred vision, spots or diminished visual acuity Report any significant findings promptly to determine whether additional

studies or changes in medications are required.

V. EVALUATION

Expected Patient outcomes: Maintains adequate tissue perfusion Complies with self-care program

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Experiences no complications

RHEUMATIC HEART DISEASE

DEFINITION: Endocarditis associated with rheumatic fever caused by group A beta-hemolytic streptococcal infection.

CLINICAL MANIFESTATIONS

Heart murmurs characteristic of valvular stenosis, egurgitation or both become audible on auscultation

Cardiac symptoms defend on which side of the heart is involved. Severity of symptoms depends on size and location of the lesion

The mitral valve is mostly affected, producing symptoms of left sided heart failure, shortness of breath, crackles and wheezes

DIAGNOSTIC PROCEDURES

Throat culture for accurate diagnosis of streptococcal infection of the throat

MEDICAL MANAGEMENT Eradication of causative organism and prevention of additional complications

such as thromboembolitic event Long term antibiotic therapy-Penicillin

NURSING MANAGEMENT Teaching patient about the disease its treatme nt and the steps needed to avoid

complications Educate patient and community regarding recognition of streptococcal infections

and the need to treat them Teach susceptible patients that may require long term oral antibiotic therapy and

may be required to take prophylactic antibiotics Emphasize that less common diagnostic procedures such as cystoscopy, also

require prophylactic antibiotic therapy

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

DEFINITION: Is a disease state in which airflow is obstructed by emphysema, chronic bronchitis or both. The airflow obstruction is usually progressive, irreversible, and associated with airway hyperactivity, resulting in narrowing of peripheral airways, airflow limitation and changes in the pulmonary vasculature.

RISK FACTORS: cigarette smoking, air pollution and occupational exposure(coal, cotton and grain)

CLINICAL MANIFESTATIONS: Dyspnea, cough and increased work of breathing Dyspnea on mild exertion advancing to dyspnea at rest Weight loss Symptoms are specific to disease: Bronchitis and Emphysema

SYMPTOMS:

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BRONCHITIS-

Chronic cough and production of copious purulent sputum which has a quality of layering out into three layers on stranding, a frothy top layer, a middle clear layer and a dense particular layer,

hemoptysis, clubbing of the fingers and repeated episodes of pulmonary infection.

EMPHYSEMA- Dyspnea with insidious onset progressing to severe dyspnea with slight exertion. Chronic cough, wheezing, dyspnea, fatigue, and tachypnea On inspection “barrel chest” due to air traping, muscle wasting and pursed lip

breathing On auscultation, diminished breath sounds with crackles, wheezes, rhonchi and

prolonged expiration Hyperresonance with percussion and a decrease in fremitus Anorexia, weight loss, weakness and inactivity Hypoxemia and Hypercapnia, morning headache in advance stages Inflammatory reactions and infections from pooled secretions.

COMPLICATIONS: Respiratory insufficiency or failure Atelectasis Pneumonia Pneumothorax Pulmonary HPN

Medical management: Bronchodilators Oxygen Therapy including nighttime oxygen Varied treatment specific to disease

NURSING MANAGEMENT:

I.ASSESSMENT

Assess risk factors Obtain health history such as duration of respiratory difficulty, dyspnea,

shortness of breath, wheezing, exercise, tolerance, fatigue, effects on eating and sleeping habits

Perform physical examination to obtain baseline data:- Pulse, RR, and rhythm- Contraction of abdominal muscles during inspiration- Use of accessory muscles to breathe, prolonged expiration- Cyanosis, neck vein engorgement- Peripheral edema- Cough, color, amount and consistency of sputum- Status of sensorium, increasing stupor, apprehension

II. NURSING DIAGNOSIS Impaired gas exchange related to ventilation perfusion inequality

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Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough and bronchopulmonary infection.

Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstiction and airway irritants

Self- care deficit related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation.

Activity intolerance due to fatigue, hypoxemia and ineffective breathing pattern Ineffective coping related to less socialization, anxiety, depression, lower activity

level and inability to work Deficient knowledge related to risk of smoking as evidenced by continuing at risk

behaviors.

III. PLANNING Improved gas exchange Smoking cessation Improved breathing pattern Maximal self- management Improved activity tolerance Achievement of airway clearance Impaired coping ability Improved health related quality of life Adherence to the therapeutic programs and home care

IV NURSING INTERVENTIONS:

Improving Gas Exchange Monitor Dyspnea and Hypoxia Administer Medications and be alert for potential side effects Assess relief of bronchospasm through patient report of less dyspnea Monitor prescribed oxygen effectiveness with pulse oximetry or arterial blood

gas (ABG ) analysisAchieving Airway Clearance

Encourage high fluid intake to liquefy secretions Instruct patient in directed or controlled coughing Provide chest physiotherapy with potential drainage and intermittent passive

pressure (IPPB) when ordered Instruct patient in effective breathing techniques Measure expiratory flow rates

Preventing Bronchopulmonary Infections

Instruct patient to report signs of infection and report any worsening of symptoms Advise patient to avoid outdoor exposure during high pollen counts or significant

air pollution because there may increase bronchospasm Encourage immunization against hemophilus Influenzae and streptococcus

pneumonia and pneumococcal vaccine every 5 to 7 yrs.

IV. EVALUATION:

Expected patient outcomes: Demonstrates improved gas exchange Achieves maximal airway clearance Improves breathing pattern Maintains maximal level of self-care and physical functioning Achieves activity tolerance and exercises and performs activities with less

shortness of breath

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Develops effective coping mechanisms and participates in a pulmonary rehabilitation program

Adheres to the therapeutic program

ASTHMA

DEFINITION: Is a chronic inflammatory disease of the airways characterized by hyperresponsiveness, mucosal edema and mucus production. Inflammation leads to obstruction from mucosal edema, reducing airway diameter and contraction of bronchial smooth muscle> Acute exacerbations last from minutes to hours to days and are interspersed with symptom- free period.

RISK FACTORS: Allergy Chronic exposure to airway irritants or allergens(e.g. grass, weed, pollens, mold,

dust or animals) Common triggers for asthma symptoms and exacerbations includes airway

irritants (pollutants, cold, heat, strong odors, smoke, perfumes)

CLINICAL MANIFESTATIONS:

Most common symptom is cough frequently occur at night and early morning (with or without mucus production), dyspnea, and wheezing

Chest tightness An asthma exacerbation is frequently preceded by increasing symptoms over

days, but it may begin abruptly Expiration requires effort and becomes prolonged As exacerbation progresses, central cyanosis secondary to severe hypoxia may

occur Additional symptoms: diaphoresis, tachychardia, and a widened pulse pressure

may occur

DIAGNOSTIC PROCEDURES; Sputum and blood test Pulse oximetry, ABG Pulmonary function tests (FEV &FVC)

MEDICAL MANAGEMENT: Leukotrine modifiers inhibitors/antileukotrines block receptors to prevent

bronchoconnstrictors Beta-adrenergic agonists Methylxanthines Anticholenergics Corticosteroids: metered dose inhales (MDI) Mast cell inhibitors

NURSING MANAGEMENT:

I. ASSESSMENT:

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Evaluate and Identify substances that precipitate attacks (obtain history of exacerbations, family environment and health history)

Monitor respiratory status for progression or resolution of asthma attack (e.g. breath sounds, pulse oximetry, vital signs, peak flow)

Obtain medical history and history of medications allergy

II. NURSING DIAGNOSIS Ineffective airway clearance related to airway obstruction related to

airway constriction and excess mucus production Anxiety related to fear of death Risk for ineffective management of treatment regimen

III. PLANNING Goals may include the ff:

Unlabored breathing Clear breath sounds Pulmonary studies within normal limits Knowledge of self-care regimen for prevention and treatment

IV. NURSING INTERVENTIONPromoting airway clearance

Administer prescribed therapy and monitor patient responses Administer fluids and antibiotics (if infection present) Assist with intubation and respiratory support if needed

Minimizing Anxiety Provide nursing care using a calm approach Keep patient and family informed about procedures

V. EVALUATIONExpected patient outcomes:

Breathes freely and clearly Experiences no respiratory failure or other complications Carries out self-care measures effectively

PANCREATITIS

DEFINITION: Inflammation of the pancreas an dis a serious disorder that can range in severity from a relatively mild self limiting disorder to a rapidly fatal disease that dose not respond to any treatment.

CLINICAL MANIFESTATIONS Severe abdominal pain in the mid-epigastrium may be accompanied by

abdominal distention Poorly defined palpable abdominal mass and decreased peristalsis Frequently acute in onset (24 to 48 hrs after a heavy meal or alcohol ingestion)

maybe severe after meals and unrelieved by antacids Patient appears acutely ill Abdominal guarding rigid or board like abdomen Soft abdomen in the absence of peritonitis Ecchymosis in the flank or around the umbilicus which may indicate severe

hemorrhagic pancreatitis Hypotension related to hypovolemia and shock

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Acute renal failure Tachycardia, cyanosis and cold clammy skin Respiratory distress and hypoxia Dyspnea Tachypnea Abnormal blood gas values Diffuse pulmonary infiltrates Myocardial depression, hypocalcemia, hypercalcemia and DIC

Diagnostic procedures: Urine amylase level White blood cell count Hypocalcemia, transient hyperglycemia :glucosuria and increased serum bilirubin

levels in some patients X-rays of abdomen and chest Ultrasound and CT scan Serum amylase and serum lipase levels are most indicative (rises to more than

normal within 24 hrs. Amylase returns to normal elevated within 7 to 14 days Peritoneal fluid is evaluated for increase in pancreatic enzymes

MEDICAL MANAGEMENT: acute phase Oral intake is withheld to inhibit pancreatic stimulation and secretion of

pancreatic enzymes Parenteral nutrition (PN) Nasogastric suction is used to relive nausea and vomiting, decrease painful

abdominal distention and paralytic ileus Cimetidine (tagamet) is given to decrease hydrochloric acid secretion Pain medication (morphine) Correction of fluid and blood loss an dlow albumin levels Antibiotics for infection Insulin for hyperglycemia Aggressive respiratory care Biliary drainage (drain and stents) to decreased pain and increased weight gain Surgical intervention, drainage, resection or debridement

MEDICAL MANAGEMENT: POSTACUTE PHASE

Antacids Oral feedings low in fat and proteins Caffeine and alcohol are eliminated Medications: thiazide, diuretics, glucocorticoids or oral contraceptives are

discontinued

COMPLICATIONS: Fluid and electrolyte imbalances Necrosis of the pancreas Shock and multiple organ failure

NURSING MANAGEMENTI. ASSESSMENT

Assess presence and character of pain its relationship to eating and to alcohol consumption

Assess nutritional fluid status and history of gallbladder attack and alcohol use

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History of gastrointestinal problems: fatty stools, diarrhea, nausea and vomiting

Assess respiratory status including rate, pattern and breath sounds Assess abdomen for pain, tenderness, guarding and bowel sounds more

board like or soft abdomen

II. NURSING DIAGNOSIS Pain and discomfort related to edema, distention of the pancreas and

peritoneal irritation Imbalance nutrition: less than body requirements related to inadequate

dietary intake, impaired absorption, reduced food intake and increased metabolic demands

Ineffective breathing pattern related to severe pain, pulmonary infiltrates, pleural effusion and atelectasis

Impaired skin integrity resulting from poor nutritional status, bed rest, surgical wound

III. PLANNING Relief of pain and discomfort Improved fluid and nutritional status Improved respiratory function Absence of complications

IV. NURSING INTERVENTIONRelieving Pain and discomfort

Administer meperidine (demerol) Avoid morphine sulfate Withhold oral fluids to decrease formation and secretion of secretin Use nasogastric suctioning to remove gastric secretions and relieve

abdominal distention Maintain patient on bed rest to decrease metabolic rate and reduce

secretions of pancreatic enzymes Provide explanation about treatment

Improving nutritional status Monitor lab results, daily weights and anthropometric measures Assess nutritional status and increased metabolic requirement Provide mouth care, patient should receive nothing by mouth during attack Administer fluids, electrolytes and parenteral nutrition Monitor serum glucose levels and give insulin Introduce oral feedings gradually Avoid heavy meals, alcoholic beverages, excessive use of coffee and spicy

foodsProviding wound care

Assess the wound, drainage sites and skin carefully for signs of infection, inflammation and breakdown

Carry out wound care Turn patient every 2 hrs.

Improving respiratory function Maintain patient in semi-fowlers position to decrease pressure in diaphragm Change position frequently to prevent atelectasis and pooling of respiratory

secretions Administer anticholinergic medications to decrease gastric and pancreatic

secretions Assess respiratory status frequently and teach patients coughing techniques

and deep breathing

V. EVALUATION9

Expected patient outcomes: Report relief of pain and discomfort Experiences improved respiratory function Achieves nutritional and fluid and electrolyte balance Exhibits intact skin Remains free of complications

LIVER (HEPATIC) CIRRHOSIS

DEFINITION: Is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver.

Types:1. Alcoholic- most frequent due to alcoholism2. Late result of previous acute viral hepatitis3. Biliary- a result of chronic biliary obstruction and infection, less common type

Clinical Manifestations:

Compensated cirrhosis usually found secondary to routine physical examination Decompensated Cirrhosis: symptoms of decreased protein, clotting factors and

other substances and of portal hypertension. Liver enlargement early in the course ( fatty liver) later to course liver size

decreases from scar tissue Portal obstruction and ascites: chronic dyspepsia, constipation or diarrhea,

splenomegaly, spider telangiectasis Gastrointestinal varices, distended abdominal blood vessels, varices or

hemorrhoids, hematemesis, profuse hemorrhage from the stomach and esophageal varices

Edema Vitamin deficiency (Vit ACK) and anemia Mental deterioration with impending hepatic encephalopathy and hepatic coma

Diagnostic Procedures:

Liver function tests ( serum alkaline phosphatase, AST, SGOT, ALT, SGPT, GGT and Bilirubin, Prothrombin time, ABGs, Laparoscopy in conjunction with biopsy

Ultrasound scanning Computed tonography (CT) scan Magnetic Resonance Imaging (MRI) Radioscopic Liver scan

COMPLICATIONS: Bleeding and hemorrhage Hepatic encephalopathy Fluid volume excess

Medical Management

Treatment includes Antacids, vitamins, balanced diet, and nutritional supplements, potassium sparing diuretics (for ascites), avoidance of alcohol

Colchicine may increase the length of survival in patients with mild and moderate cirrhosis

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Nursing Management:I. ASSESSMENT

Focus on dietary intake, nutritional status, onset of symptoms, history of precipitating factors, including long term alcohol abuse, exposure to toxic agents, medications.

Assess mental status through interview and intervention with patients, note orientation to time, place and person

Note relationships with family and friends and co-workers regarding incapacitation secondary to alcohol abuse and cirrhosis

Note abdominal distention and bloating, gastrointestinal bleeding, bruising and weight changes

Document exposure to toxic agents such as hepatotoxic medicationsII. NURSING DIAGNOSIS

Activity intolerance related to fatigue, general debility muscle wasting and discomfort

Imbalanced nutrition: Less than body requirements, related to chronic gastritis, decreased gastrointestinal motility and anorexia

Impaired skin integrity related to compromised immunologic status, edema, and poor nutrition

Risk for injury related to altered clotting mechanismsIII. PLANNING

Goals may include: Independence in activities Improved nutritional status Improved skin integrity Decreased potential for injury Improved mental status Absence of complications

IV. NURSING INTERVENTIONS

Providing rest Position bed for maximal respiratory efficiency: provide oxygen if

needed Initiate efforts to prevent respiratory, circulatory and vascular

disturbances Encourage patient to increase activity gradually and plan rest with

activity and mild exercise

Improving Nutritional status Provide a nutritious high protein diet supplemented B-complex vitamins

and others, including AC and K and Folic acid if there is no indication of impending coma

Provide small, frequent meals, consider patient preferences and encourage patient to eat, provide protein supplements if indicated

Provide nutrients by feeding tube or total parenteral nutrition(TPN) Provide patients with fatty stools (steatorrhea) with water soluble forms of

fat- soluble vitamins AD and E and give folic acid and iron to prevent anemia

Provide a low-protein diet temporarily if patient shows signs of impending or advancing coma: restore protein intake to moderate (1-1.5 kg) when patient’s condition permits

Providing Skin Care Change position frequently Avoid using irritating soaps and adhesive tapes

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Provide lotion to soothe irritated skin< take measures to prevent patient from scratching the skin

Reducing Risk for Injury Use padded side rails if patient becomes agitated or restless Orient to time, place, and procedures to minimize agitation Instruct patient to ask for assistance to get out of bed Provide safety measures to prevent injury or cuts (electric razor, soft toothbrush) Apply pressure to venipuncture sites to minimize bleeding

V. EVALUATIONExpected patient outcomes:

Demonstrates ability to participate in activities Increases nutritional intake

DIABETES MELLITUS

DEFINITION: Is a group of metabolic disorders characterized by elevated levels of blood glucose. (hyperglycemia) resulting from defects in insulin production and secretion, decreased cellular response to insulin or both.

TYPES:TYPE I (FORMERLY INSULIN- DEPENDENT DM)

About 5 to 10% of diabetic patients Beta cells of the pancreas that normally produced insulin are destroyed by an

autoimmune process Insulin injections are needed to control blood glucose levels Has sudden onset, before the age of 30 yrs.

TYPE II (FORMERLY NON-INSULIN DEPENDENT DM) About 90-95% of diabetic patients It results from decreased sensitivity to insulin (insulin resistance) or from

decreased amount of insulin production Treated with diet and exercise, then oral hypoglycemic agents are needed Most frequent in patients older than 30 yrs of age and obese patients

GESTATIONAL DIABETES MELLITUS Characterized by any degree of glucose intolerance with onset during pregnancy

(2nd or 3rd trimester) It occurs in women 25 yrs of age or older, obese and with history of diabetes in

first degree relatives or members of certain ethnic groups

CLINICAL MANIFESTATIONS Polyuria, polydipsia, polyphagia Fatigue and weakness, sudden vision changes, tingling, numbness in hands or

feet, dry skin, sores that heal slowly and recurrent infection Onset may be associated with nausea, vomiting or stomach pains Results from a slow progressive glucose intolerance and results in long term

complications if diabetes goes undetected for many yrs.DIAGNOSTIC PROCEDURES

BLOOD GLUCOSE LEVELS Fasting blood glucose levels 126mg/dl or more Random plasma glucose levels more than 200 mg/dl or more than one occasion

COMPLICATIONS HYPOGLYCEMIA

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DKA HHNS Macrovascular disease (large vessel) Microvascular disease (small vessel e.g. eyes and kidneys) Neuropathic diseases: affects sensory, motor and autonomic nerves

MEDICAL MANAGEMENT Main goal of treatment is normalize insulin activity and glucose levels and to

reduce the development of vascular and neuropathic conditions Primary treatment of DM type I is insulin Primary treatment of DM type II is weight loss Exercise is important in enhancing the effectiveness of insulin Use of oral hypoglycemic agents if diet and exercise are not successful in

controlling blood glucose levels, insulin injections may be used in acute situations

NUTRITIONAL MANAGEMENT Meal plan should be based on patient’s usual eating habits and lifestyle and

should provide all essential food constituents Goals are to achieve and maintain ideal weight, meet energy needs, prevent

fluctuate of blood glucose level For patients with insulin to maintain blood glucose levels consistency is required

in maintaining calories and carbohydrates consumed at different meals. Consult dietitian for Diabetes management

NURSING MANAGEMENTI. ASSESSMENT

Focus on signs and symptoms of prolonged hyperglycemia and physical, social and emotional factors

Assess for description of symptoms that preceded the diagnosis Assess for signs of DKA, including ketonuria, Kusmmaul respirations,

orthostatic hypotension and lethargy Monitor laboratory signs for metabolic acidosis Assess patients with type 2DM for signs of HHNS, hypotension, altered

sensorium, seizures, decreased skin turgor, hyperosmolarity and electrolyte imbalance

Assess physical factors that impair ability to learn or perform self care skills, visual defects. Motor coordination defects and neurologic defects

Assess emotional status through observation of general demeanor Assess coping skills by asking patient how patient dealt with difficult

situations in the past

II. NURSING DIAGNOSIS Risk for fluid volume deficit related to polyuria and dehydration Imbalanced nutrition related to imbalance of insulin, food and physical

activity Deficient knowledge about diabetes self-care skills and information Potential self-care deficit related to physical impairments or social factors Anxiety related to loss of control, fear, inability to manage diabetes,

misinformation related to diabetes and fear of diabetes complications Risk for complications

III. PLANNING Attainment of fluid and electrolyte balance Optimal control of blood glucose Regaining weight lost Ability to perform basic diabetes skills and self care activities

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Reduction of anxiety Absence of complications

IV. Nursing INTERVENTIONMaintaining fluid and electrolyte Balance

Measure I and O Administer IV and electrolytes as ordered Encourage fluid intake Measure serum electrolytes ( NA & K) Monitor VS to detect dehydration, tachycardia, and orthostatic

hypotensionImproving Nutritional Intake

Plan the diet with glucose control as the primary goal Take considerations in patients lifestyle, cultural background, activity

level and food preference Encourage patients to eat full meals and snacks as per diabetic diet Make arrangements for extra snacks before increased physical activity Ensure that insulin orders are altered as needed for delays in eating

due to diagnostic and other procedures Reducing Anxiety

Provide emotional support set aside time to talk with patient Clear up misconceptions patient or family may have regarding diabetes Assist patient and family to focus on learning self-care behaviors Encourage patient to perform the skills feared most-injection or finger

stick for blood glucose monitoring Give positive reinforcement for self-care behaviors attempted

Teaching Patients about Self- care Teach preventive behaviors for long term diabetic complications and

patient survival skills Provide special equipment for instruction on diabetic survival skills Tailor information according to patients ability to understand Instruct family so that they may assist in diabetes management Recommend follow-up education with out- patient diabetic specialist Assist in identifying community resources for education and supplies Health education on the ff:

1. Nutrition Eating habits Use of exchange system reading labels of foods

2. Exercise Monitoring blood glucose levels before, during and after exercise Eating complex carbohydrates before exercise Watch out for signs of hypoglycemia after exercise Encourage regular exercise

3. Self-Monitoring of blood glucose levels Provide initial training for SMBG Keep record of blood glucose levels

4. Testing urine for ketones Provide instruction in the urine testing procedure

5. Administering Insulin Therapy 3 categories of insulin, short acting ( regular)- onset 30 mins to 1 hr; peak 2-4 hrs,

duration:- 6-8 hrs. intermediate – onset- 3-4 hrs; peak- 4-12 hrs; duration 16-20 hrs and long acting insulin- onset- 6-8 hrs, peak 12 to 16 hrs,

duration- 20 to 30 hrs.6. Recognizing Problems with Insulin

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Local allergic reaction may occur- redness,, swelling, tenderness and induration of up to 1 to 2 hrs after injection

Systemic allergic reactions are rare Clinical insulin resistance may occur because immune antibodies

develop and bind the insulin Morning hyperglycemia may be noted

7. Teaching about Hypoglycemic agents Hypoglycemia may occur when excessive dose is taken Avoid ingestion of alcohol If hyperglycemia occur due to infection, trauma or surgery

hypoglycemic agent may be discontinued temporarily

V. EVALUATION fluid and electrolyte balance Optimal control of blood glucose Regaining weight lost Ability to perform basic diabetes skills and self care activities Reduction of anxiety Absence of complications

MENINGITIS

DEFINITION: is an inflammation of the meninges, (membrane surrounding the brain and spinal cord)

TYPES: ASEPTIC- maybe viral or secondary to lymphoma, leukemia or brain abcess Septic-caused by bacteria such as Neisseria maningitides Tuberculosis

PATHOPHYSIOLOGY:Causative organism- Neiserria Meningitidis (meningococcal Meningitis), Streptococcus pneumonia (adults) and Haemophilus Influenzae (childrens and young adult)

Mode of transmission: direct contact including droplets and discharges from the nose and The causative organism enters into the bloodstream ---- causes the blood-brain barrier and triggers an inflammatory reaction in the meninges----- inflammation of of the subarachnoid and pia mater occurs----increased ICP.

Meningeal infections generally originate in 1 or 2 ways1. Through the bloodstream from other infections (cellulitis) or by direct

extension( after a traumatic injury to the facial bones)2. The cause is iatrogenic or secondary to invasive procedures (lumbar puncture) or

devices (ICP monitoring devices) or to opportunistic infections such as AIDS or Lyme disease

Clinical manifestations: Bacterial Meninigitis Nuchal rigidity ( stiff neck) is an early sign Positive kernig’s sign: when lying with thigh flexed on abdomen, patient cannot

completely extend leg Positive brudzinskis sign: flexing parient’s neck produces flexion of the knees

and hips: passive flexion of lower extremity of one side produces similar movement for opposite extremity

Photophobia (extreme sensitivity to light)

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Seizures and increased ICP signs include widened pulse pressure and bradycardia, respiratory irregularity, headache, vomiting and de;pressed level of consciousness

Clinical manifestations: Meningococcal Meninigitis Abrupt onset of high fever Extensive purpuric lesions (face and extrimities) Shock and signs of disseminated intravascular coagulopathy (DIC) Death is possible within a few hrs of onset of infection In AIDS patients there are few if any symptoms because of the blunted

inflammatory response occurring in the immunocompromised patients.

DIAGNOSTIC PROCEDURES: Culture and gram straining of cerebrospinal fluid and blood

PREVENTION

People with closed contact must have antimicrobial prophylaxis (rifampin) Meningococcal vaccination Polysaccharide vaccine (Haemophilus B polysaccharide vaccine)

MEDICAL MANAGEMENT Antimicrobial therapy (penicillin or amplicillin) Vancomycin hydrochloride alone or in combination with rifampin Dexamethasone may be beneficial as adjunct therapy for H influenza type B

meningitis Fluid volume expanders use to treat dehydration and shock Diazepam or phenytoin is used to control seizures An osmotic diuretic such as mannitol to treat cerebral edema

NURSING MANAGEMENT Monitor vital signs Determine oxygenation from ABG values and ;pulse oximeter Insert cuffed ET or Traecheostomy and placed patient on mechanical ventilator Give oxygen to maintain partial pressure of oxygen Monitor central venous pressure (CVP) for incipient shock which precedes

cardiac or respiratory failure Note generalized vasoconstriction, circumoral cyanosis and cold extrimities Reduce high fever to decrease load on heart and brain from oxygen demands Rapid IVF may be prescribed If syndrome of inappropriate anti diuretic hormone (SIADH) is suspected monitor

closely for body weight, serum electrolytes, urine volume, specific gravity and osmolarity

Assess clinical status continuously, evaluate skin and oral hygiene, promote comfort and protect patient during seizures and while comatose

Implement droplet precautions and respiratory isolation until 24 hrs after start of antibiotic therapy

Inform family about patients condition and permit family to see patients at appropriate intervals

Reference: Johnson, Joyce et al, Handbook for Brunner & Suddarth’s textbook of Medical Surgical Nursing 10th Edition,Lipincott William and Wilkins, 2004

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