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MEDICAL-SURGICAL NURSING By: Anthony T. Villegas R.N. O e! ie" o# st!$%t$!es an& #$n%tions: NERVOUS S'STEM 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

!eripheral Nervous System Cranial Nerves "# pairs$ carry impulses to & from the brain Spinal Nerves %" pairs$ carry impulses to & from spinal cord

&utonomic Nervous System subdivision of the !NS that automatically controls body function such as breathing & heart beat Special senses of vision and hearing are also covered in this section

CELLS &

Sympathetic nervous system generally accelerate some body functions in response to stress !arasympathetic nervous system controls normal body functioning

N'()*NS !rimary component of nervous system Composed of cell body +gray matter,- a.on- and dendrites Basic cells for nerve impulse and conduction

&.on 'longated process or fiber e.tending 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 a.on

/endrites Short- blanching fibers that receives impulses and conducts them toward the nerve cell body Neurons may have many dendrites

Synapse 0unction between neurons where an impulse is transmitted

Neurotransmitter

Chemical agent +e. &cetylcholine- norepinephrine, involved in the transmission of impulse across synapse

1yelin Sheath & wrapping of myelin +whitish- fatty material, that protects and insulates nerve fibers and enhances the speed of impulse conduction

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Both a.ons and dendrites may or may not have a myelin sheath +myelinated2unmyelinated, 1ost a.ons leaving the CNS are heavily myelinated by schwann cells

3unctional Classification " &fferent +sensory, neurons # % Transmit impulses from peripheral receptors to the CNS

'fferent +motor, neurons Conduct impulses from CNS to muscle and glands

4nternuncial neurons +interneurons, Connecting links between afferent and efferent neurons

!roperties

" # %

'.citability ability of neuron to be affected by changes in e.ternal environment Conductility ability of neuron to transmit a wave of e.citetation from one cell to another !ermanent Cell once destroyed not capable of regeneration

T5!'S *3 C'66S B&S'/ *N )'7'N')&T48' C&!&C4T5 " 6abile # % B Capable of regeneration 'pidermal cells- 74T cells- 7(T cells- cells of lungs

Stable Capable of regeneration with limited time- survival period 9idney cells- 6iver cells- Salivary cells- pancreas

!ermanent Not capable of regeneration 1yocardial cells- Neurons- Bone cells- *steocytes- )etinal Cells

N'()*764& Support and protection of neurons

T5!'S " &strocytes maintains blood brain barrier semi:permiable ma;ority of brain tumors +<=>, arises from called astrocytoma integrity of blood brain barrier

*ligodendria

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% ?

produces myelin sheath in CNS act as insulator and facilitates rapid nerve impulse transmission

1icroglia stationary cells that carry on phagocytosis +engulfing of bacteria or cellular debris- eating,- pinocytosis +cell drinking,

'pindymal

secretes a glue called chemo attractants that concentrate the bacteria

1&C)*!@&7' 1icroglia 1onocytes 9upffers @istiocytes &lveolar 1acrophage

*)7&N Brain Blood 9idney Skin 6ung

Cent!al Ne! o$s Syste( Composition *f Brain Brain 1ass !arts *f The Brain " Cerebrum largest part of the brain outermost area +cerebral corte., is gray matter deeper area is composed of white matter function of cerebrum: integration- sensory- motor composed of two hemisphere the )ight Cerebral @emisphere and 6eft Cerebral @emisphere enclosed in the Corpus Callosum 'ach hemisphere divided into four lobes$ many of the functional areas of the cerebrum have been located in these lobes: A=> brain mass "=> blood "=> CS3

6obes of Cerebrum " 3rontal 6obe controls personality- behavior higher cortical thinking- intellectual functioning precentral gyrus: controls motor function BrocaBs &rea: specialiCed motor speech area : when damaged results to garbled speech

Temporal 6obe hearing- taste- smell short term memory DernickeBs area: sensory speech area +understanding2formulation of language,

!areital 6obe for appreciation integrates sensory information discrimination of sensory impulses to pain- touch- pressure- heat- cold- numbness !ostcentral gyrus: registered general sensation +e. Touch- pressure,

*ccipital 6obe for vision

4nsula +4sland of )eil, visceral function activities of internal organ like gastric motility

6imbic System +)hinencephalon,

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 7anglia island of gray matter within white matter of cerebrum regulate & integrate motor activity originating in the cerebral corte. part of e.trapyramidal system area of gray matter located deep within each cerebral hemisphere release dopamine +controls gross voluntary movement,

/iencephalon2interbrain 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 +e. !ain- temperature- touch, controls primitive emotional responses +e. )age- fear,

@ypothalamus found immediately beneath the thalamus

plays a ma;or role in regulation2controls 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- an.iety and e.citement androgenic hormones promotes secondary se. 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

1esencephalon21idbrain acts as relay station for sight and hearing siCe of pupil is # % mm eEual siCe of pupil is isocoria uneEual siCe of pupil is anisocoria hearing acuity is %= ?= dB positive !'))6&

Brain Stem located at lowest part of brain contains midbrain- pons- medulla oblongata e.tends 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

!ons F pneumota.ic center controls the rate- rhythm and depth of respiration

1edulla *blongata controls respiration- heart rate- swallowing- vomiting- hiccup- vasomotor center +dilation and constriction of bronchioles,

Cerebellum smallest part of the brain- lesser brain coordinates muscle tone and movements and maintains position in space +eEuilibrium, controls balance- eEuilibrium- posture and gait

Spinal Cord serves as a connecting link between the brain and periphery e.tends from foramen magnum to second lumbar vertebra @:shaped gray matter in the center +cell bodies, surrounded by white matter +nerve tract and fibers,

7ray 1atter " &nterior @orns

Contains cell bodies giving rise to efferent +motor, fibers

!osterior @orns

Contains cell bodies connecting with afferent +sensory, fibers from dorsal root ganglion

6ateral @orns 4n thoracic region- contain cells giving rise to autonomic fibers of sympathetic nervous system

Dhite 1atter

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&scending Tracts +sensory pathways, a !osterior Column b c Carry impulses concerned with touch- pressure- vibration- & position sense

Spinocerebellar Carry impulses concerned with muscle tension & position sense to cerebellum

6ateral Spinothalamic Carry impulses resulting in pain & temperature sensations

&nterior Spinothlamic Carry impulses concerned with crude touch & pressure

/escending Tracts +motor pathways,

a
b

Corticospinal +pyramidal- upper motor neurons, Conduct motor impulses from motor corte. to anterior horn cells +cross in the medulla,

'.trapyramidal @elp to maintain muscle tone & to control body movement- especially gross automatic movements such as walking

)efle. &rc

)efle. consists of an involuntary response to a stimulus occurring over a neural pathway called a refle. arc Not relayed to & from brain: take place at cord levels

Components a Sensory )eceptors b )eceives2reacts to stimulus

&fferent !athways Transmits impulses to spinal cord

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c 4nterneurons

d e

Synapses with a motor neuron +anterior horn cell,

'fferent !athways Transmits impulses from motor neuron to effector

'ffectors 1uscle or organ that responds to stimulus

Supporting Structures " Skull # % )igid$ numerous bones fused together !rotects & support the brain

Spinal Column Consists of G cervical- "# thoracic- & F lumbar vertebrae as well as sacrum & coccy. Supports the head & protect the spinal cord

1eninges 1embranes between the skull & brain & the vertebral column & spinal cord % fold membrane that covers brain and spinal cord 3or support and protection$ for nourishment$ blood supply &rea between arachnoid & pia mater is called subarachnoid space: CS3 aspiration is done Subdural space between the dura and arachnoid 6ayers: /ura 1ater outermost layer- tough- leathery

&rachnoid 1ater middle layer- weblike

!ia 1ater innermost layer- delicate- clings to surface of brain

8entricles 3our fluid:filled cavities connecting with one another & spinal canal !roduce & circulate cerebrospinal fluid

Cerebrospinal 3luid +CS3, Surrounds brain & spinal cord *ffer protection by functioning as a shock absorber &llows fluid shifts from the cranial cavity to the spinal cavity Carries nutrient to & waste product away from nerve cells Component of CS3: C@*N- DBC- 7lucose

8ascular 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 &nterior- 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 8enous blood drains into dural sinuses & then into ;ugular veins

Blood:Brain:Barrier +BBB, !rotective barrier preventing harmful agents from entering the capillaries of the CNS$ protect brain & spinal cord

Substance That Can !ass Blood:Brain Barrier " &monia Cerebral to.in @epatic 'ncephalopathy +6iver Cirrhosis, &scites 'sophageal 8arices

'arly Signs of @epatic 'ncephalopathy

&stere.is +flapping hand tremors,

6ate Signs of @epatic 'ncephalopathy @eadache /iCCiness Confusion 3etor hepaticus +amonia like breath, decrease 6*C

Carbon 1ono.ide and 6ead !oisoning

Can lead to !arkinsonBs /isease. 'pilepsy Treated with calcium '/T&.

Type " /1 +4//1, Causes diabetic ketoacidosis &nd increases breakdown of fats &nd free fatty acids )esulting to cholesterol and positive to ketones +CNS depressant, )esulting to acetone breath odor2fruity odor &nd kusshmauls respiration a rapid shallow respiration

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? Dhich may lead to diabetic coma

@epatitis

Signs of ;aundice +icteric sclerae, Caused by bilirubin +yellow pigment,

Bilirubin

4ncrease bilirubin in brain +kernicterus, Causing irreversible brain damage

)e!i*he!al Ne! o$s Syste( Spinal Nerves %" pairs: carry impulses to & from spinal cord 'ach segment of the spinal cord contains a pair of spinal nerves +one of each side of the body, 'ach nerve is attached to the spinal by two roots:

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/orsal +posterior, roots

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Cranial Nerves

contains afferent +sensory, nerve whose cell body is in the dorsal roots ganglion

8entral +anterior, roots Contains efferent +motor, nerve whose nerve fibers originate in the anterior horn cell of the spinal cord +lower motor neuron,

"# pairs: carry impulses to & from the brain 1ay have sensory- motor- or mi.ed functions Name & Number *lfactory *ptic *culomotor Trochlear Trigeminal &bducens 3acial &coustic 7lossopharyngeal 8agus : CN I : CN I4 : CN 44 : CN 444 : CN 48 : CN 8 : CN 84 : CN 844 : CN 8444 : CN 4I : CN 4 3unction Sensory: carries impulses for sense of smell Sensory: carries impulses for vision 1otor: muscles for papillary constriction- elevation of upper eyelid$ ? out of H e.traocular movement 1otor: muscles for downward- inward- movement of the eye 1i.ed: impulses from face- surface of eyes +corneal refle.,$ muscle Controlling mastication 1otor: muscles for lateral deviation of eye 1i.ed: impulses for taste from anterior tongue$ muscles for facial 1ovement Sensory: impulses for hearing +cochlear division, & balance +vestibular /ivision, 1i.ed: impulses for sensation to posterior tongue & pharyn.$ muscle 3or movement of pharyn. +elevation, & swallowing 1i.ed: impulses for sensation to lower pharyn. & laryn.$ muscle for 1ovement of soft palate- pharyn.- & laryn. Spinal &ccessory @ypoglossal : CN I44 1otor: movement of sternomastoid muscles & upper part of trapeCius 1uscles 1otor: movement of tongue

A$tono(i% Ne! o$s Syste( !art of the peripheral nervous system 4nclude those peripheral nerves +both cranial & spinal, that regulates smooth muscles- cardiac muscles- & glands Component: " # Sympathetic Nervous System 7enerally accelerates some body function in response to stress !arasympathetic Nervous System Controls normal body functioning

Sympathetic Nervous System +&drenergic, 'ffect - 4nvolved in fight or aggression response : )elease of Norepinephrine +cathecolamines, from adrenal glands and causes vasoconstriction : 4ncrease all bodily activity e.cept 74T

!arasympathetic Nervous System +Cholinergic, 'ffect- 8agal- Sympatholytic - 4nvolved in flight or withdrawal response : )elease of &cetylcholine : /ecreases all bodily activities e.cept 74T

'33'CTS *3 !NS '33'CTS *3 SNS : /ilation of pupils +mydriasis, in order to be aware : /ry mouth +thickened saliva, : 4ncrease B! and @eart )ate : Bronchodilation- 4ncrease )) : Constipation : (rinary )etention : 4ncrease blood supply to brain- heart and skeletal muscles : SNS I. Cholinergic &gents : 1estinon- Neostignin : Constriction of pupils +miosis, : 4ncrease salivation : /ecrease B! and @eart )ate : Bronchoconstriction- /ecrease )) : /iarrhea : (rinary freEuency

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I. &drenergic &gents : 7ive 'pinephrine S': : SNS effect Contraindication: : Contraindicated to patients suffering from C*!/ +Broncholitis- Bronchoectasis'mphysema- &sthma, 44 Beta:adrenergic Blocking &gents : &lso called Beta:blockers : all ending with JlolK : !ropranolol- &tenelol- 1etoprolol 'ffect of Beta:blockers B broncho spasm ' elicits a decrease in myocardial contraction T treats hypertension & &8 conduction slows down : Should be given to patients with &ngina1yocardial 4nfarction- @ypertension &NT4: @5!')T'NS48' &7'NTS " Beta:blockers JlolK # &ce 4nhibitors &ngiotensin JprilK +Captopril- 'nalapril, % Calcium &ntagonist Nifedipine +Calcibloc, : 4n chronic cases of arrhythmia give 6idocaneIylocane 'ffectors 'ye 7land of @ead 6acrimal Salivary no effect scanty thick- viscous secretions /ry mouth @eart increase rate & force of contraction decrease rate stimulate secretions copious thin- watery secretions Sympathetic +&drenergic, 'ffect dilate pupil +mydriasis, !arasympathetic +Cholinergic, 'ffect S': : SNS effect 44 &nti:cholinergic &gents - To counter cholinergic agents : &trophine Sulfate S': : !NS effect

constrict pupil +miosis,

Blood 8essel

constrict smooth muscles of the skin&bdominal blood vessels- and Cutaneous blood vessels /ilates smooth muscles of bronchioles-

no effect

Blood vessels of the heart & skeletal muscles 6ungs bronchodilation bronchoconstriction

74 Tract

decrease motility Constrict sphincters !ossibly inhibits secretions 4nhibits glycogenolysis in liver

increase motility rela.ed sphincters stimulate secretions

4nhibits activity of gallbladder & ducts stimulate activity of gallbladder & ducts

&drenal 7land stimulates secretion of epinephrine & Norepinephrine (rinary Tract rela.es detrusor muscles

no effect

contract detrusor muscles rela.es trigone sphincter +allows voiding, 4ncrease Bi:polar /isorder SchiCophrenia

Contract trigone sphincter +prevent voiding, N'()* T)&NS14TT') &cethylcholine /opamine !hysical '.amination Comprehensive Neuro '.am Neuro Check /ecrease 1yesthenia 7ravis !arkinsonBs /isease

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6evel of Consciousness +6*C, a *rientation to time- place- person Speech: clear- garbled- rambling &bility to follow command 4f does not respond to verbal stimuli- apply a painful stimulus +e. !ressure on the nailbeds- sEueeCe trapeCius muscle,$ note response to pain &ppropriate: withdrawal- moaning 4nappropriate: non:purposeful

b
c

&bnormal posturing +may occur spontaneously or in response to stimulus,

/ecorticate !osturing: e.tension of leg- internal rotation & abduction of arms with fle.ion of elbows- wrist- & finger: +damage to corticospinal tract$ cerebral hemisphere, /ecerebrate !osturing: back arched- rigid e.tension of all four e.tremities with hyperpronation of arms & plantar fle.ion of feet: +damage to upper brain stem- midbrain- or pons, # 7lasgow Coma Scale *b;ective measurement of 6*C sometimes called as the Euick neuro check *b;ective evaluation of 6*C- motor 2 verbal response & standardiCed system for assessing the degree of neurologic impairment in critically ill client Components " # % 'ye opening 8erbal response 1otor response

7CS 7rading 2 Scoring " # % ? F % Conscious 6ethargy Stupor Coma /eep Coma "F "? "% "" "= A G %

!upillary )eaction & 'ye 1ovement

a b c d
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*bserve siCe- shape- & eEuality of pupil +note siCe in millimeter, )eaction to light: pupillary constriction Corneal refle.: blink refle. in response to light stroking of cornea *culocephalic refle. +dollBs eyes,: present in unconscious client with intact brainstem

1otor 3unction

a
b

1ovement of e.tremities +paralysis, 1uscle strength

8ital Signs: respiratory patterns +may help localiCe possible lesion,

a b c d e

Cheyne:Stokes )espiration: regular rhythmic alternating between hyperventilation & apnea$ may be caused by structural cerebral dysfunction or by metabolic problems such as diabetic coma Central Neurogenic @yperventilation: sustained- rapid- regular respiration +rate of #F2min, with normal *# level$ usually due to brainstem dysfunction &pneustic Breathing: prolonged inspiratory phase- followed by a #:to:% sec pause$ usually indicates dysfunction respiratory center in pons Cluster Breathing: cluster of irregular breathing- irregularly followed by periods of apnea$ usually caused by a lesion in upper medulla & lower pons &ta.ic Breathing: breathing pattern completely irregular$ indicates damage to respiratory center of the medulla

Neurologic '.am

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1ental status and speech +Cerebral 3unction, a b 7eneral appearance & behavior 6*C 4ntellectual 3unction: memory +recent & remote,- attention span- cognitive skills 'motional status Thought content 6anguage 2 speech

c
d e f #

Cranial nerve assessment Cerebellar 3unction: posture- gait- balance- coordination

a b ? F
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)ombergBs Test: # nurses- positive for ata.ia 3inger to Nose Test: positive result mean dimetria +inability of body to stop movement at desired point,

Sensory 3unction: light touch- superficial pain- temperature- vibration & position sense 1otor 3unction: muscle siCe- tone- strength$ abnormal or involuntary movements )efle.es

a
b

/eep tendon refle.: grade from = +no response,$ to ? +hyperactive,$ # +normal, Superficial !athologic: babinski refle. +dorsifle.ion of the great toe with fanning of toes,: indicates damage to corticospinal tracts

6evel *f Consciouness +6*C,

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Conscious: awake 6ethargy: lethargic +drowsy- sleepy- obtunded, Stupor Stuporous: +awakened by vigorous stimulation, 7eneraliCed body weakness /ecrease body refle.

Coma Comatose light coma: positive to all forms of painful stimulus deep coma: negative to all forms of painful stimulus

/ifferent !ainful Stimulation " # /eep sternal stimulation 2 deep sternal pressure *rbital pressure

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% ? !ressure on great toes Corneal or blinking refle. Conscious Client: use a wisp of cotton (nconscious Client: place " drop of saline solution Test of 1emory " Short term memory &sk most recent activity !ositive result mean anterograde amnesia and damage to temporal lobe # 6ong term memory &sk for birthday and validate on profile sheet !ositive result mean retrograde amnesia and damage to limbic system Consider educational background 6evel of *rientation

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Time: first asked !erson: second asked !lace: third asked

Cranial Nerves " # % ? F H G A < Cranial Nerves *lfactory *ptic *culomotor Trochlear Trigeminal &bducens 3acial &coustic 7lossophareng 3unction S S 1 1 +smallest, B +largest, 1 B S B B +longest, 1 1

eal "= 8agus "" Spinal &ccessory "# @ypoglossal

C)&N4&6 N')8' 4: *63&CT*)5 Sensory function for smell 1aterial (sed /onBt use alcohol- ammonia- perfume because it is irritating and highly diffusible (se coffee granules- vinegar- bar of soap- cigarette !rocedure Test each nostril by occluding each nostril &bnormal 3indings

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@yposnia: decrease sensitivity to smell /ysosmia: distorted sense of smell &nosmia: absence of smell

'ither of the % may indicate head in;ury damaging the cribriform plate of ethmoid bone where olfactory cells are located may indicate inflammatory conditions +sinusitis, C)&N4&6 N')8' 44: *!T4C Sensory function for vision or sight 3unctions " Test visual acuity or central vision or distance (se SnellenBs Chart SnellenBs &lphabet chart: for literate client SnellenBs ' chart: for illiterate client SnellenBs &nimal chart: for pediatric client Normal visual acuity #=2#= Numerator: is constant- it is the distance of person from the chart +H:G m- #= feet, /enominator: changes- indicates distance by which the person normally can see letter in the chart #=2#== indicates blindness #=2#= visual acuity if client is able to read letters above the red line # Test of visual field or peripheral vision a b c d Superiorly Bitemporaly Nasally 4nferiorly

C)&N4&6 N')8' 444- 48- 84: *C(6*1*T*)- T)*C@6'&)- &B/(C'NS Controls or innervates the movement of e.trinsic ocular muscle +'*1, H muscles: Superior )ectus Superior *bliEue

6ateral )ectus

1edial )ectus

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4nferior *bliEue Trochlear: controls superior obliEue &bducens: controls lateral rectus *culomotor: controls the ? remaining '*1 *culomotor Controls the siCe and response of pupil Normal pupil siCe is # % mm 'Eual siCe of pupil: 4socoria (neEual siCe of pupil: &nisocoria Normal response: positive !'))6& C)&N4&6 N')8' 8: T)47'14N&6 6argest cranial nerve Consists of ophthalmic- ma.illary- mandibular

4nferior )ectus

Sensory: controls sensation of face- mucous membrane- teeth- soft palate and corneal refle. 1otor: controls the muscle of mastication or chewing /amage to CN 8 leads to Trigeminal Neuralgia 2 Tic /ouloureu. 1edication: CarbameCapine +Tegretol, C)&N4&6 N')8' 844: 3&C4&6 Sensory: controls taste- anterior #2% of tongue !inch of sugar and cotton applicator placed on tip of tongue 1otor: controls muscle of facial e.pression 4nstruct client to smile- frown and if results are negative there is facial paralysis or BellBs !alsy and the primary cause is forcep delivery C)&N4&6 N')8' 8444: &C*(ST4C- 8'ST4B(6*C*C@6'&) Controls balance particularly kinesthesia or position sense- refers to movement and orientation of the body in space C)&N4&6 N')8' 4I- I: 76*S*!@&)'N7'&6- 8&7(S 7losopharenageal: controls taste- posterior "2% of tongue 8agus: controls gag refle. (vula should be midline and if not indicative of damage to cerebral hemisphere 'ffects of vagal stimulation is !NS C)&N4&6 N')8' I4: S!4N&6 &CC'SS*)5 4nnervates with sternocleidomastoid +neck, and trapeCius +shoulder, C)&N4&6 N')8' I44: @5!*76*SS&6 Controls the movement of tongue 6et client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral hemisphere and2or has short frenulum !athognomonic Signs:

" # % ? F H G A <

!TB + low grade afternoon fever !N'(1*N4& + rusty sputum &ST@1& + wheeCing on e.piration '1!@5S'1& barrel chest 9&D&S&94 S5N/)*1' + strawberry tongue !')N4C4*(S &N'14& + red beefy tongue /*DN S5N/)*1' + protruding tongue C@*6')& + rice watery stool 1&6&)4& + step ladder like fever with chills

"= T5!@*4/ + rose spots in abdomen "" /4!T@')4& + pseudo membrane "# 1'&S6'S + koplickBs spots "% S6' + butterfly rashes "? 648') C4))@*S4S + spider like varices "F 6'!)*S5 + lioning face "H B*6414& + chipmunk face "G &!!'N/4C4T4S + rebound tenderness "A /'N7(' + petichae or positive hermanBs sign "< 1'N4N74T4S + kernigBs sign +leg pain,- brudCinski sign +neck pain, #= T'T&N5 + hypocalcemia +L, trousseuBs sign or carpopedal spasm, +L, chvostek sign +facial spasm, #" T'T&N(S + risus sardonicus ## !&NC)'&T4T4S + cullenBs sign +echymosis of umbilicus, 2 +L, grey turners spots #% !56*)4C ST'N*S4S + olive like mass #? !/& + machine like murmur #F &//4S*NBS /4S'&S' + bronCe like skin pigmentation #H C(S@4N7BS S5N/)*1' + moon face appearance and buffalo hump

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"= #G @5!')T@5)*4/S127)&8'S /4S'&S' + e.opthalmus

DEM'ELINATING DISORDERS Al-hei(e!.s &isease &trophy of brain tissue due to deficiency of acetylcholine S2s. ? &Bs of &lCheimer

a b c d

&mnesia loss of memory &gnosia unable to recogniCed inanimate2familiar ob;ects &pra.ia unable to determine purpose2 function of ob;ects &phasia no speech +nodding,

M'.pressive aphasia Jmotor speech centerK unable to speak BrocaBs &phasia M)eceptive aphasia inability to understand spoken words Common to &lCheimerBs DernikeBs &phasia 7eneral 9nowing 7nostic &rea or 7eneral 4nterpretative &rea /*C &ricept +taken at bedtime, Cogne. 1anagement " !alliative & supportive

M$lti*le S%le!osis /MS0 Chronic intermittently progressive disorder of CNS characteriCed by scattered white patches of demyelination in brain and spinal cord CharacteriCed by remission and e.acerbation S2s. are varied & multiple- reflecting the location of demyelination within the CNS Cause unknown: maybe a slow growing virus or possibly autoimmune disorders 4ncident: &ffects women more than men ages #=:?= are prone & more freEuent in cool or temperate climate

4g 7 : only antibody that pass placental circulation causing passive immunity- short term protection 4g & : present in all bodily secretions +tears- saliva- colostrums, 4g 1 : acute in inflammation 4g ' : for allergic reaction 4g / : for chronic inflammation M 7ive palliative or supportive care S2s. " 8isual disturbances blurring of vision +primary, diplopia +double vision, scotomas +blind spots, # 4mpaired sensation touch- pain- pressure- temperature- or position sense paresthesia such as tingling sensation- numbness

%
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1ood swings or euphoria +sense of elation, 4mpaired motor function weakness spasticity paralysis

4mpaired cerebral function scanning speech ata.ic gait nystagmus dysarthria intentional tremor

H G A

Bladder (rinary retention or incontinence Constipation Se.ual impotence in male 2 decrease se.ual capacity T)4&/ S47NS *3 1S &ta.ia

C@&)C*TS T)4&/

"=

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+unsteady gait- positive rombergBs test,

4ntentional tremors /.

Nystagmus

" # % ? F

CS3 &nalysis: increase in 4g7 and !rotein 1)4: reveals site and e.tent of demyelination CT Scan: increase density of white matter 8isual 'voked )esponse +8'), determine by ''7: maybe delayed !ositive 6hermittes Sign: a continuous and increase contraction of spinal column Nursing 4ntervention

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&ssess the client for specific deficit related to location of demyelination !romote optimum mobility a 1uscles stretching & strengthening e.ercises Dalking e.ercises to improve gait: use wide:base gait &ssistive devices: canes- walker- rails- wheelchair as necessary

b c
%

&dminister medications as ordered

a b c
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&CT@ +adreno chorticotropic hormone,- Corticosteroids +prednisone, for acute e.acerbations: to reduce edema at site of demyelination to prevent paralysis Baclofen +6ioresal,- /antrolene +/antrium,- /iaCepam +8alium, : muscle rela.ants: for spacity Beta 4nterferons : 4mmunosuppresants: alter immune response

'ncourage independence in self:care activities !revent complications of immobility 4nstitute bowel program 1aintain side rails to prevent in;ury related to falls 4nstitute stress management techniEues a b /eep breathing e.ercises 5oga

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4ncrease fluid intake and increase fiber to prevent constipation " (rinary )etention a b perform intermittent catheteriCation as ordered: to prevent retention Bethanecol Chloride +(recholine, as ordered

"= 1aintain urinary elimination

Nursing 1anagement only given subcutaneous monitor side effects bronchospasm and wheeCing monitor breath sounds " hour after subcutaneous administration # (rinary 4ncontinence a 'stablish voiding schedule &nti spasmodic agent !rophantheline Bromide +!ro:banthine, if ordered

b
%

3orce fluid to %=== ml2day !romote use of acid ash diet like cranberry ;uice- plums- prunes- pineapple- vitamin C and orange: to acidify urine and prevent bacterial multiplication

"" !revent in;ury related to sensory problems a b c d Test bath water with thermometer &void heating pads- hot water bottles 4nspect body parts freEuently for in;ury 1ake freEuent position changes

"# !repare client for plasma e.change if indicated: to remove antibodies

"% !rovide psychologic support to client2significant others a b c d a 'ncourage positive attitude & assist client in setting realistic goals !rovide compassion in helping client adapt to changes in body image & self:concept /o not encourage false hope during remission )efer to 1S societies & community agencies 7eneral measures to ensure optimum health Balance between activity & rest )egular e.ercise such as walking- swimming- biking in mild case (se energy conservation techniEues Dell:balance diet 3resh air & sunshine &voiding fatigue- overheating or chilling- stress- infection b c (se of medication & side effects &lternative methods for se.ual counseling if indicated

"? !rovide client teaching & discharge planning concerning:

COMMON CAUSE O1 UTI 1e(ale : short urethra +%:F cm- ":" N inches, : poor perineal hygiene

""

"#
: vaginal environment is moist N$!sing Manage(ent : avoid bubble bath +can alter !h of vagina, : avoid use of tissue papers : avoid using talcum powder and perfume Male - urethra +#= cm- A inches, : do not urinate after intercourse 4NT)&C)&N4&6 !)'SS()' 4C! 1onroe 9elly @ypothesis Skull is a closed container &ny alteration or increase in one of the intracranial components 4ncrease intracranial pressure +normal 4C! is = "F mm@g, Cervical " also known as atlas Cervical # also known as a.is 3oramen 1agnum 1edulla *blongata Brain @erniation 4ncrease intra cranial pressure Nursing 4ntervention " alternate hot and cold compress to prevent hematoma

CS3 cushions brain +shock absorber, *bstruction of flow of CS3 will lead to enlargement of skull posteriorly called hydrocephalus 'arly closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus DISORDERS 4ncrease 4ntracranial !ressure +44C!, 4ncrease in intracranial bulk brought due to an increase in any of the % ma;or intracranial components: Brain Tissue- CS3- Blood (ntreated increase 4C! can lead to displacement of brain tissue +herniation, !resent life threatening situation because of pressure on vital structures in the brain stem- nerve tracts & cranial nerve 4ncrease 4C! may be caused: head trauma2in;ury localiCed abscess cerebral edema hemorrhage inflammatory condition +stroke, hydrocephalus tumor +rarely, S2s. +'arly signs, " # % /ecrease 6*C 4rritability 2 agitation !rogresses from restlessness to confusion & disorientation to lethargy & coma +6ate signs,

"

Changes in 8ital Signs +may be a late signs,

a
b

Systolic blood pressure increases while diastolic pressure remains the same +widening pulse pressure, !ulse rate decrease &bnormal respiratory patterns +cheyne:stokes respiration, temperature increase directly proportional to blood pressure

c
d #

!upillary Changes

a b c
d %

4psilateral +same side, dilatation of pupil with sluggish reaction to light from compression of cranial nerve 444 unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation !upil eventually becomes fi.ed & dilated Contralateral +opposite side, hemiparesis from compression of corticospinal tract abnormal posturing decorticate posturing +damage to corte. and spinal cord, decerebrate posturing +damage to upper brain stem that includes pons- cerebellum and midbrain,

1otor &bnormalities

a
b

c d
? F @eadache

!ro;ective 8omiting !apilledema +edema of optic disc,

"#

"%
G !ossible seiCure activity Nursing 4ntervention " 1aintain patent airway and adeEuate ventilation by:

!revention of hypo.ia +decrease *#, and hypercarbia +increase C*#, important: @ypo.ia may cause brain swelling which increase 4C! 'arly signs of hypo.ia: )estlessness Tachycardia &gitation 6ate signs of hypo.ia: '.treme restlessness Bradycardia /yspnea Cyanosis @ypercarbia may cause cerebral vasodilation which increase 4C! @ypercabia 4ncrease C*# +most powerful respiratory stimulant, retention 4n chronic respiratory distress syndrome decrease *# stimulates respiration

Before and after suctioning hyperventilate the client with resuscitator bag connected to "==> *# & limit suctioning to "= "F seconds only &ssist with mechanical hyperventilation as indicated: produces hypocarbia +decease C*#, causing cerebral constriction & decrease 4C!

c # % ?
F

1onitor 82S- input and output & neuro check freEuently to detect increase in 4C! 1aintain fluid balance: fluid restriction to "#==:"F== ml2day may be ordered !osition the client with head of bed elevated to %=:?Fo angle with neck in neutral position unless contraindicated to improve venous drainage from brain !revent further increase 4C! by: a b c d !rovide comfortable and Euite environment &void use of restraints 1aintain side rails 4nstruct client to avoid forms of valsalva maneuver like: Straining stool: administer stool softener & mild la.atives as ordered +/ulcola.- /uphalac, '.cessive vomiting: administer anti:emetics as ordered +!lasil : !hil only- !henergan, '.cessive coughing: administer anti:tussive +de.tromethorphan, &void stooping2bending &void lifting heavy ob;ects e &void clustering of nursing care activity together

H G

!revent complications of immobility &dminister medications as ordered:

@yperosmotic agent 2 *smotic /iuretic O1annitol +*smitrol,P: to reduce cerebral edema Nursing 1anagement 1onitor 82S especially B!: S' hypotension 1onitor strictly input and output every hour: +output should increase,: notify physician if output is less %= cc2hr &dministered via side drip )egulate fast drip to prevent crystal formation

6oop /iuretics O3urosemide- +6asi.,P: to reduce cerebral edema drug of choice for C@3 +pulmonary edema, loop of henle in kidneys Nursing 1anagement 1onitor 82S especially B!: S' hypotension 1onitor strictly input and output every hour: +output should increase,: notify physician if output is less %= cc2hr &dministered 48 push or oral 7iven early morning 4mmediate effect of "=:"F minutes 1a.imum effect of H hours

c d

Corticosteroids O/e.amethasone +/ecadron,P: anti:inflammatory effect reduces cerebral edema &nalgesics for headache as needed: Small dose of Codein S*? Strong opiates may be contraindicated since they potentiate respiratory depression- alter 6*C- & cause papillary changes

e
A a b

&nti:convulsants O!henytoin +/ilantin,P: to prevent seiCures 4C! monitoring records the pressure e.erted within the cranial cavity by the brain- cerebral blood- & CS3 Types of monitoring devices: 4ntraventricular Catheter: inserted in lateral ventricle to give direct measurement of 4C!$ also allows for drainage of CS3 if needed Subarachnoid screw +bolt,: inserted through the skull & dura matter into subarachnoid space 'pidural Sensor: least invasive method$ placed in space between skull & dura matter for indirect measurement of 4C!

&ssist with 4C! monitoring when indicated:

1onitor 4C! pressure readings freEuently & prevent complications: Normal 4C! reading is =:"F mm@g$ a sustained increase above "F mm@g is considered abnormal (se strict aseptic techniEue when handling any part of the monitoring system Check insertion site for signs of infection$ monitor temperature

"%

"?

&ssess system for CS3 leakage- loose connections- air bubbles in he line- & occluded tubing

<

!rovide intensive nursing care for clients treated with barbiturates therapy or administration of paralyCing agents

a b
c d e f

4ntravenous administration of barbiturates may be ordered: to induce coma artificially in the client who has not responded to conventional treatment !aralytic agents such as Overcuronium bromide +Norcuron,P: may be administered to paralyCed the client )educes metabolic demand that may protect the brain from further in;ury Constant monitoring of the clientBs 4C!- arterial blood gas- serum barbiturates level- & 'C7 is necessary ''7 monitoring as necessary !rovide appropriate nursing care for the client on a ventilator

"= *bserve for hyperthermia secondary to hypothalamus damage

2CONGESTIVE 3EART 1AILURE Signs an& Sy(*to(s : : : : : : : : : : : : : dyspnea orthopnea paro.ysmal nocturnal dyspnea productive cough frothy salivation cyanosis rales2crackles bronchial wheeCing *$ls$s alte!nans anore.ia and general body malaise !14 +point of ma.imum impulse2apical pulse rate, is displaced laterally S% +ventricular gallop, !redisposing 3actors21itral 8alve o o T!eat(ent Morphine Sulfate Aminophelline Digo.in Diuretics O.ygen Gases- blood monitor RIG3T CONGESTIVE 3EART 1AILURE / eno$s %ongestion0 Signs an& Sy(*to(s : ;ugular vein distention +neck, : ascites : pitting edema : weight gain : hepatosplenomegaly : ;aundice : pruritus : esophageal varices : anore.ia and general body malaise )@/ &ging

Signs an& Sy(*to(s o# Lasi4 in te!(s o# ele%t!olyte i(5alan%es " 3y*o6ale(ia : decrease *otassi$( le el : no!(al al$e is 7.8 + 9.9 (e:,L Sign an& Sy(*to(s : weakness and fatigue : constipation : positive ( wave on 'C7 tracing N$!sing Manage(ent : administer potassium supplements as ordered +;ali$( D$!$le< O!al )otassi$( Chlo!i&e, : increase intake of foods rich in potassium

"?

"F

1RUITS Apple Banana Cantalop e Oranges

VEGETABLE S Asparagus Brocolli Carrots Spinach

# 3y*o%al%e(ia,Tetany : decrease %al%i$( le el : no!(al al$e is =.9 + >> (g,>?? (l Signs an& Sy(*to(s : tingling sensation : paresthesia : numbness : /@0 T!o$sse$s sign,Ca!*o*e&al s*as( : /@0 Ch oste6.s sign Co(*li%ations : arrythmia : seiCures N$!sing Manage(ent : Calcium 7lutamate per 48 slowly as ordered M Calcium 7lutamate to.icity results to seiCure 1agnesium Sulfate 1agnesium Sulfate to.icity S,S B! Urine output Respiratory rate )atellar relfe. absent % 3y*onat!e(ia : decrease so&i$( le el : no!(al al$e is >79 + >89 (e:,L Signs an& Sy(*to(s : hypotension : dehydration signs +initial sign in adult is thi!st- in infant ta%hy%a!&ia, : agitation : dry mucous membrane : poor skin turgor : weakness and fatigue N$!sing Manage(ent : force fluids : administer isotoni% #l$i& sol$tion as ordered ? 3y*e!gly%e(ia : no!(al 1BS is =? + >?? (g,&l Signs an& Sy(*to(s : polyuria : polydypsia : polyphagia N$!sing Manage(ent : monitor 3BS F 3y*e!$!i%e(ia : increase uric acid +purine metabolism, : foods high in uric acid +sardines- organ meats and anchovies, 2In%!ease in to*hi &e*osit lea&s to go$ty a!th!itis. Signs an& Sy(*to(s : ;oint pain +great toes, : swelling N$!sing Manage(ent : force fluids : administer medications as ordered a &llopurinol +Qylopril, : drug of choice for gout : mechanism of action: inhi5its synthesis o# $!i% a%i& b Colchesine : acute gout : mechanism of action: *!o(otes e4%!etion o# $!i% a%i& 2 ;i&ney stones Signs an& Sy(*to(s : renal cholic DECREASE

"F

"H
: cool moist skin N$!sing Manage(ent : force fluids : administer medications as ordered a Narcotic &nalgesic : 1orphine Sulfate : antidote: Nalo4one /Na!%an0 to.icity leads to tremors b &llopurinol +Qylopril, Si&e E##e%ts : respiratory depression +check for )), )a!6inson.s Disease, )a!6insonis( Chronic progressive disorder of CNS characteriCed by degeneration of dopamine producing cells in the substantia nigra of the midbrain and basal ganglia !rogressive disorder with degeneration of the nerve cell in the basal ganglia resulting in generaliCed decline in muscular function /isorder of the e.trapyramidal system (sually occurs in the older population Cause (nknown: predominantly idiopathic- but sometimes disorder is postencephalitic- to.ic- arteriosclerotic- traumatic- or drug induced +reserpine- methyldopa +aldomet, haloperidol +haldol,- phenothiaCines, !athophysiology /isorder causes degeneration of dopamine producing neurons in the substantia nigra in the midbrain /opamine: influences purposeful movement /epletion of dopamine results in degeneration of the basal ganglia !redisposing 3actors " # % ? F !oisoning +lead and carbon mono.ide, &rteriosclerosis @ypo.ia 'ncephalitis 4ncrease dosage of the following drugs: a )eserpine +Serpasil, b 1ethyldopa +&ldomet, c @aloperidol +@aldol, &ntihypertensive RRRRRRR

d !henothiaCine RRRRRRRRRRRRRRRRRRR &ntipsychotic Side 'ffects )eserpine: 1a;or depression lead to suicide Aloneness

M$lti*le loss %a$ses s$i%i&e

Loss o# s*o$se Nursing 4ntervention for Suicide direct approach towards the client close surveillance is a nursing priority time to commit suicide is on weekends early morning S2s.

Loss o# Ao5

"
# %

Tremor: mainly of the upper limbs Jpill rolling tremorsK of e.tremities especially the hands$ resting tremor: most common initial symptoms Bradykinesia: slowness of movement )igidity: cogwheel type Stooped posture: shuffling- propulsive gait 3atigue 1ask like facial e.pression with decrease blinking of the eyes /ifficulty rising from sitting position Suite- monotone speech 'motional lability: state of depression

?
F

H
G

A <

"= 4ncrease salivation: drooling type

"" Cramped- small handwriting "# &utonomic Symptoms a b c d e e.cessive sweating increase lacrimation seborrhea constipation decrease se.ual capacity

Nursing 4ntervention " &dminister medications as ordered &nti:!arkinson /rug

6evodopa +6:dopa, short acting 1*&: 4ncrease level of dopamine in the brain$ relieves tremors$ rigidity$ bradykinesia

"H

"G

S': 74T irritation +should be taken with meal,$ anore.ia$ N28$ postural hypotension$ mental changes: confusion- agitationhallucination$ cardiac arrhythmias$ dyskinesias C4: narrow:angled glaucoma$ client taking 1&*4 inhibitor$ reserpine$ guanethidine$ methyldopa$ antipsychotic$ acute psychoses &void multi:vitamins preparation containing vitamin BH & food rich in vitamin BH +!yrido.ine,: reverses the therapeutic effects of 6evodopa (rine and stool may be darkened Be aware of any worsening of symptoms with prolonged high:dose therapy: Jon:offK syndrome

b
c

Carbidopa:levodopa +Sinemet, !revents breakdown of dopamine in the periphery & causes fewer side effects &mantadine @ydrochloride +Symmetrel, (sed in mild cases or in combination with 6:dopa to reduce rigidity- tremors- & bradykinesia

&nti:Cholinergic /rug a b c BenCtropine 1esylate +Cogentin, !rocyclidine +9emadrine, Trihe.yphenidyl +&rtane, 1*&: inhinit the action of acetylcholine$ used in mild cases or in combination with 6:dopa$ relived tremors & rigidity S': dry mouth$ blurred vision$ constipation$ urinary retention$ confusion$ hallucination$ tachycardia &nti:@istamines /rug a /iphenhydramine +benadryl, 1*&: decrease tremors & an.iety S': &dult: drowsiness Children: CNS e.citement +hyperactivity, because blood brain barrier is not yet fully developed b Bromocriptine +!arlodel, 1*&: stimulate release of dopamine in the substantia nigra *ften employed when 6:dopa loses effectiveness 1&*4 4nhibitor a 'ldepryl +Selegilene, 1*&: inhibit dopamine breakdown & slow progression of disease &nti:/epressant /rug a # Tricyclic 1*&: given to treat depression commonly seen in !arkinsonBs disease !rovide safe environment Side rails on bed )ails & handlebars in the toilet- bathtub- & hallways No scattered rugs @ard:back or spring:loaded chair to make getting up easier % !rovide measures to increase mobility !hysical Therapy: active & passive )*1 e.ercise$ stretching e.ercise$ warm baths &ssistive devices 4f client JfreeCesK suggest thinking of something to walk over ? 'ncourage independence in self:care activities: alter clothing for ease in dressing use assistive device do not rush the client F 4mprove communication abilities: 4nstruct the client to practice reading a loud 6isten to own voice & enunciate each syllable clearly H G )efer for speech therapy when indicated 1aintain adeEuate nutrition Cut food into bite:siCe pieces !rovide small freEuent feeding &llow sufficient time for meals- use warming tray A < &void constipation & maintain adeEuate bowel elimination !rovide significant support to client2 significant others: /epression is common due to changes in body image & self:concept "= !rovide client teaching & discharge planning concerning: a b c Nature of the disease (se prescribed medications & side effects 4mportance of daily e.ercise as tolerated: balanced activity & rest walking swimming gardening d &ctivities2 methods to limit postural deformities: 3irm mattress with small pillow 9eep head & neck as erected as possible (se broad:based gait )aise feet while walking e !romotion of active participation in self:care activities M 4ncrease 8itamin B when taking 4N@ +4soniaCid,- 4sonicotinic &cid @ydraCide M /opamine &gonist relieves tremor rigidity MAGIC B.s IN DRUG MONITORING DRUG NORMAL RANGE TOCICIT' INDICATION CLASSI1ICATION

"G

"A
LEVEL B

Digo4in,Lano4in +increase force of cardiac output, Lithi$(,Lithane +decrease level of &ch2N'2Serotonin, A(ino*helline +dilates bronchial tree, Dilantin,)henytoin A%eta(ino*hen,Tylen ol " Digitalis To4i%ity Signs an& Sy(*to(s : nausea and vomiting : diarrhea : confusion : photophobia

.9 + >.9 (e:,L

C31

Ca!&ia% Gly%osi&e

.D + >.B (e:,L

Bi*ola!

Anti-Mani% Agents

>? + >E (g,>?? (l >? + >E (g,>?? (l >? + 7? (g,>?? (l

B? B? B??

CO)D Sei-$!es Osteo A!th!itis

B!on%ho&ilato!s Anti-Con $lsant Non-na!%oti% Analgesi%

: changes in color perception +yellowish spots, Anti&ote: /igibind # Lithi$( To4i%ity Signs an& Sy(*to(s : anore.ia : nausea and vomiting : diarrhea : dehydration causing fine tremors : hypothyroidism N$!sing Manage(ent : force fluids : increase sodium intake to ? "= g> daily % A(ino*helline To4i%ity Signs an& Sy(*to(s : tachycardia : palpitations : CNS e.citement +tremors- irritability- agitation and restlessness, N$!sing Manage(ent : only mi.ed with plain NSS or = < NaCl to prevent development of crystals of precipitate : administered sandwich method : avoid taking alcohol because it can lead to severe CNS depression : avoid caffeine ? Dilantin To4i%ity Signs an& Sy(*to(s : gingival hyperplasia +swollen gums, : hairy tongue : ata.ia : nystag($s N$!sing Manage(ent : provide oral care : massage gums F A%eta(ino*hen To4i%ity Signs an& Sy(*to(s : hepatoto.icity +monitor for liver enCymes, : S7!T2&6T +Serum 7lutamic !yruvate Transaminace, : S7*T2&ST +Serum 7lutamic *.alo:&cetil Transaminace, : nephroto.icity monitor B(N +"= #=, and Creatinine + A ", : hypoglycemia Tremors- tachycardia Irritability Restlessness E.treme fatigue Diaphoresis- depression Anti&ote: &cetylceisteine +mucomyst, prepare suction apparatus as bedside M'AST3ENIA GRAVIS /MG0 neuromuscular disorder characteriCed by a disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular ;unction leading to descending muscle weakness 4ncidence rate: highest between "F & %F years old for women- over ?= for men &ffects women more than men Cause: (nknown2 idiopathic Thought to be autoimmune disorder whereby antibodies destroy acetylcholine receptor sites on the postsynaptic membrane of the neuromuscular ;unction 8oluntary muscles are affected- especially those muscles innervated by the cranial nerve !athophysiology &utoimmune T )elease of Cholinesterase 'nCymes T Cholinesterase destroy &cetylcholine +&C@, T /ecrease of &cetylcholine +&C@,

"A

"<

&cetylcholine: activate muscle contraction &utoimmune: it involves release of cholinesterase an enCyme that destroys &ch Cholinesterase: an enCyme that destroys &C@

S2s.

"
# % ? F

4nitial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure: cracked or cleft in the lining or membrane of the eyelids /iplopia /ysphagia 1ask like facial e.pression @oarseness of voice- weakness of voice )espiratory muscle weakness that may lead to respiratory arrest '.treme muscle weakness especially during e.ertion and morning$ increase activity & reduced with rest /.

H G

"

Tensilon Test +'drophonium @ydrochloride,: 48 in;ection of tensilon provides temporary relief of S2s. for about F:"= minutes and a ma.imum of "F minutes 4f there is no effect there is no damage to occipital lobe and midbrain and is negative for 1 7

# %
"

'lectromyography +'17,: amplitudes of evoked potentials decrease rapidly !resence of anti:acetlycholine receptors antibodies in the serum 1edical 1anagement /rug Therapy

&nti:cholinesterase /rugs: O&mbenonium +1ytelase,- Neostigmine +!rostigmin,- !yridostigmine +1estinon,P 1*&: block the action of cholinesterase & increase the level of acetylcholine at the neuromuscular ;unction S': e.cessive salivation & sweating- abdominal cramps- N28- diarrhea- fasciculations +muscle twitching,

Corticosteroids: !rednisone 1*&: suppress autoimmune response (sed if other drugs are not effective

Surgery +Thymectomy,

a
b

Surgical removal of thymus gland: thought to be involve in the production of acetylcholine receptor antibodies 1ay cause remission in some clients especially if performed early in the disease

!lasma '.change +!lasmapheresis, a b )emoves circulating acetylcholine receptor antibodies (se in clients who do not respond to other types of therapy

Nursing 4nterventions

"

&dminister anti:cholinesterase drugs as ordered: a b 7ive medication e.actly on time 7ive with milk & crackers to decrease 74 upset 1onitor effectiveness of drugs: assess muscle strength & vital capacity before & after medication &void use of the ff drugs: 1orphine S*? & Strong Sedatives: respiratory depressant effects Suinine- Curare- !rocainamide- Neomycin- Streptomycine- 9anamycine & other aminoglycosides: skeletal muscle blocking effect e *bserve for side effects

c
d

!romote optimal nutrition:

a b
c

1ealtime should coincide with the peak effect of the drugs: give medication %= minutes before meals Check gag refle. & swallowing ability before feeding !rovide mechanical soft diet 4f the client has difficulty in chewing & swallowing- do not leave alone at mealtime$ keep emergency airway & suctioning eEuipment nearby

d % ? F

1onitor respiratory status freEuently: )ate- /epth- 8ital Capacity$ ability to deep breathe & cough &ssess muscle strength freEuently$ plan activity to take advantage of energy peaks & provide freEuent rest periods *bserve for signs of myasthenic or cholinergic crisis 15&ST@'N4C C)4S4S &brupt onset of severe- generaliCed muscle weakness with inability to swallow- speak- or maintain respirations Symptoms will improve temporarily with tensilon test C@*64N')74C C)4S4S Symptoms similar to myasthenic crisis & in addition the side effect of anti: cholinesterase drugs +e.cessive salivation & sweating- abdominal carmpN28- diarrhea- fasciculation, Symptoms worsen with tensilon test: keep &tropine Sulfate & emergency

Causes: under medication physical or emotional stress infection Signs and Symptoms the client is unable to see- swallowspeak- breathe Treatment administer cholinergic agents as ordered Cause:

eEuipment on hand

over medication with the cholinergic drugs +anti:cholinesterase, Signs and Symptoms !NS Treatment administer anti:cholinergic agents +&trophine Sulfate,

Nursing Care in Crisis: a 1aintain tracheostomy set or endotracheal tube with mechanical ventilation as indicated

"<

#=
b 1onitor &B7 & 8ital Capacity &dminister medication as ordered: 1yasthenic Crisis: increase doses of anti:cholinesterase drug as ordered Cholinergic Crisis: discontinue anti:cholinesterase drugs as ordered until the client recovers d e H 'stablished method of communication !rovide support & reassurance

!rovide nursing care for the client with thymectomy !rovide client teaching & discharge planning concerning: a b c d e f g h Nature of the disease (se of prescribe medications their side effects & sign of to.icity 4mportance of checking with physician before taking any new medication including *TC drugs 4mportance of planning activities to take advantage of energy peaks & of scheduling freEuent rest period Need o avoid fatigue- stress- people with upper respiratory infection (se of eye patch for diplopia +alternate eyes, Need to wear medic:alert bracelet 1yasthenia 7ravis foundation & other community agencies

7uillain:Barre Syndrome a disorder of the CNS characteriCed by bilateral- symmetrical- peripheral polyneuritis characteriCed by ascending muscle paralysis Can occur at any age$ affects women and men eEually !rogression of disease is highly individual$ <=> of clients stop progression in ? weeks$ recovery is usually from %:H months$ may have residual deficits Causes: " # (nknown 2 idiopathic 1ay be autoimmune process !redisposing 3actors " # 4mmuniCation &ntecedent viral infections such as 6)T infections S2s.

" # % ? F H
G A

1ild Sensory Changes: in some clients severe misinterpretation of sensory stimuli resulting to e.treme discomfort Clumsiness +initial sign, !rogressive motor weakness in more than one limb +classically is ascending & symmetrical, /ysphagia: cranial nerve involvement &scending muscle weakness leading to paralysis 8entilatory insufficiency if paralysis ascends to respiratory muscles &bsence or decreased deep tendon refle. &lternate hypotension to hypertension &rrythmia +most feared complication,

<

"= &utonomic disfunction: symptoms that includes

a b c /. increase salivation increase sweating constipation

" #

CS3 analysis: reveals increased in 4g7 and protein '17: slowed nerve conduction 1edical 1anagement

" # % ? F

1echanical 8entilation: if respiratory problems present !lasmapheresis: to reduce circulating antibodies Continuous 'C7 monitoring to detect alteration in heart rate & rhythm !ropranolol: to prevent tachycardia &tropine S*?: may be given to prevent episodes of bradycardia during endotracheal suctioning & physical therapy Nursing 4ntervention

"

1aintain patent airway & adeEuate ventilation: a b c d 1onitor rate & depth of respiration$ serial vital capacity *bserve for ventilatory insufficiency 1aintain mechanical ventilation as needed 9eep airway free of secretions & prevent pneumonia

# %

Check individual muscle groups every # hrs in acute phase to check progression of muscle weakness &ssess cranial nerve function: a b c d Check gag refle. Swallowing ability &bility to handle secretion 8oice 8ital signs 4nput and output Neuro check 'C7: due to arrhythmia *bserve signs of autonomic dysfunction: acute period of hypertension fluctuating with hypotension Tachycardia &rrhythmias

1onitor strictly the following: a b c

d e
f g

#=

#"
F 1aintain side rails to prevent in;ury related to fall !revent complications of immobility: turning the client every # hrs &ssist in passive )*1 e.ercise !romote comfort +especially in clients with sensory changes,: a b c d 3oot cradle Sheepskin 7uided imagery )ela.ation techniEues

H
G

<

!romote optimum nutrition: a b Check gag refle. before feeding Start with pureed food &ssess need for N7T feeding: if unable to swallow$ to prevent aspiration

c a b c

"= &dminister medications as ordered Corticosteroids: suppress immune response &nti Cholinergic &gents: &trophine Sulfate &nti &rrythmic &gents: 6idocaine +Iylocaine, Bretylium: blocks release of norepinephrine$ to prevent increase of B!

"" &ssist in plasmapheresis +filtering of blood to remove autoimmune anti:bodies, "# !revent complications:
a b &rrythmia !aralysis of respiratory muscles 2 respiratory arrest

"% !rovide psychologic support & encouragement to client 2 significant others "? )efer for rehabilitation to regain strength & treat any residual deficits IN1LAMMATOR' CONDITIONS O1 T3E BRAIN 1eningitis 4nflammation of the meninges of the brain & spinal cord Cause by bacteria- viruses- & other 1 * 'tiology 2 1ost Common 1 *

"
#

1eningococcus: most dangerous !neumococcus Streptococcus: cause of adult meningitis @emophilus 4nfluenCae: cause of pediatric meningitis 1ode of transmission

% ?

"
#

&irborne transmission +droplet nuclei, 8ia blood- CS3- lymph By direct e.tension from ad;acent cranial structures +nasal- sinuses- mastoid bone- ear- skull fracture, By oral or nasopharyngeal route Signs and Symptoms

%
?

@eadache- photophobia- general body malaise- irritability!ro;ectile vomiting: due to increase 4C! 3ever & chills &nore.ia & weight loss !ossible seiCure activity & decrease 6*C &bnormal posturing: +decorticate and decerebrate, Signs of 1eningeal 4rritation:

%
? F H

G
A

a b c d

Nuchal rigidity or stiff neck: initial sign *pisthotonos +arching of back,: head & heels bent backward & body arched forward !S: 9ernigBs sign +leg pain,: contraction or pain in the hamstring muscles when attempting to e.tend the leg when the hip is fle.ed !S: BrudCinski sign +neck pain,: fle.ion at the hip & knee in response to forward fle.ion of the neck

/.

"

6umbar !uncture: 1easurement & analysis of CS3 shows increased pressure- elevated DBC & C@*N- decrease glucose & culture positive for specific 1* & hollow spinal needle is inserted in the subarachnoid space between the 6%:6? or 6?:6F Nursing 1anagement Before 6umbar !uncture " # % Secure informed consent and e.plain procedure 'mpty bladder and bowel to promote comfort 'ncourage to arch back to clearly visualiCe 6%:6? Nursing 1anagement !ost 6umbar !uncture

"
# % ?

!lace flat on bed "# #? 3orce fluids

Check punctured site for any discoloration- drainage and leakage to tissues &ssess for movement and sensation of e.tremities

#"

##
CS3 analysis reveals " # 4ncrease C@*N and DBC /ecrease glucose 4ncrease CS3 opening pressure +normal pressure is F= "== mm@g, +L, cultured microorganism +confirms meningitis, CBC reveals " 4ncrease DBC

% ?

Nursing 1anagement " &dminister large doses of antibiotic 48 as ordered:

a b c #
% ? F

Broad spectrum antibiotics +!enicillin- Tetracycline, 1ild analgesics: for headaches &ntipyretics: for fever

'nforced strict respiratory isolation #? hours after initiation of anti biotic therapy +for some type of meningitis, !rovide nursing care for increase 4C!- seiCure & hyperthermia if they occur !rovide nursing care for delirious or unconscious client as needed 'nforce complete bed rest 9eep room Euiet & dark: if the client has headache & photophobia 1onitor strictly 82S- 4 & * & neuro check 1aintain fluid & electrolyte balance !revent complication of immobility

H
G A <

"= !rovide client teaching & discharge planning concerning:

a
b

4mportance of good diet: high C@*N- high calories with small freEuent feedings )ehabilitation program for residual deficit mental retardation delayed psychomotor development

!revent complications most feared is hydrocephalus hearing loss2nerve deafness is second complication consult audiologist

Cerebrovascular &ccident +C8&, +Stroke2Brain &ttack2&pople.y2Cerebral Thrombosis, /estruction +infarction, of brain cells caused by a reduction in cerebral blood flow and o.ygen & partial or complete disruption in the brains blood supply # largest & most common cerebral artery affected by stroke: a b 1id Cerebral &rtery 4nternal Cerebral &rtery

4ncidence )ate: a &ffects men more than women$ 1en are #:% times high risk$ 4ncidence increase with age

Causes:

a b
c

Thrombosis +attached, 'mbolism +detached,: most dangerous because it can go to the lungs & cause pulmonary embolism or the brain & cause cerebral embolism @emorrhage Compartment Syndrome: compression of nerves & arteries S2s. !ulmonary 'mbolism " # % ? F H G Sudden sharp chest pain (ne.plained dyspnea S*B Tachycardia !alpitations /iaphoresis 1ild restlessness S2s. of Cerebral 'mbolism " # % ? @eadache disorientation Confusion /ecrease 6*C S2s. Compartment syndrome

"

3at embolism is the most feared complications w2in #? hrs after a femur fracture 5ellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells 4f there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation

)isk 3actors /isease: " # % ? F H G @ypertension /iabetes 1ellitus &therosclerosis 2 &rteriosclerosis 1yocardial 4nfarction 1itral valve replacement 8alvular /isease 2 replacement Chronic atrial 3ibrillation

##

#%
A !ost Cardiac Surgery 6ifestyle: " # % ? F Smoking Sedentary lifestyle *besity +increase #=> ideal body weight, @yperlipidemia more on genetics2genes that binds to cholesterol Type & personality a b c /eadline driven Can do multiple tasks (sually fells guilty when not doing anything

H
G

)elated to diet: increase intake of saturated fats like whole milk )elated stress physical and emotional !rolong use of oral contraceptives: promotes lypolysis +breakdown of lipids, leading to atherosclerosis that will lead to hypertension & eventually C8& !athophysiology

"
#

4nterruption of cerebral blood flow for F min or more causes death of neurons in affected area with irreversible loss of function 1odifying 3actors: a b c Cerebral 'dema: /evelops around affected area causing further impairment 8asospasm: Constriction of cerebral blood vessel may occur- causing further decrease in blood flow Collateral Circulation: 1ay help to maintain cerebral blood flow when there is compromise of main blood supply Stages of /evelopment

"

Transient 4schemic &ttack +T4&, a b 4nitial 2 warning signs of impending C8& 2 stroke Brief period of neurologic deficit: 8isual loss 2 8isual disturbance @emiparesis Slurred Speech 2 Speech disturbance 8ertigo &phasia @eadache: initial sign /iCCiness Tinnitus !ossible 4ncrease 4C! c 1ay last less than %= sec- but no more than #? hrs with complete resolution of symptoms !rogressive development of stroke symptoms over a period of hours to days

# %

Stroke in 'volution Complete Stroke Neurologic deficit remains unchanged for #:%:days period S2s.

" #

@eadache 7eneraliCed Signs: 8omiting SeiCure Confusion /isorientation /ecrease 6*C Nuchal )igidity 3ever @ypertension Slow Bounding !ulse Cheyne:Strokes )espiration +L, 9ernigBs & BrudCinski sign: may lead to hemorrhagic stroke

3ocal Signs +related to site of infarction,: @emiplegia @omonymous hemianopsia: loss of half of visual field Sensory loss &phasia /ysarthia: inability to articulate words &le.ia: difficulty reading &graphia: difficulty writing /.

" # %

CT & Brain Scan: reveals brain lesions ''7: abnormal changes Cerebral &rteriography: invasive procedure due to in;ection of dye +iodine based,$ (ses dye for visualiCation 1ay show occlusion or malformation of blood vessels )eveals the site and e.tent of malocclusion

#%

#?

Nursing 1anagement !ost Cerebral &rteriography &llergy Test +shellfish, 3orce fluids to release dye because it is nephro to.ic Check for peripheral pulse: distal +femoral, Check for hematoma formation Nursing 4ntervention: &cute Stage " 1aintain patent airway and adeEuate ventilation by: a b # % ? &ssist in mechanical ventilation &dminister *# inhalation

1onitor strictly 82S- 4 & *- neuro check & observe signs of increase 4C!- shock- hyperthermia- & seiCure !rovide CB) as ordered 1aintain fluid & electrolyte balance & ensure adeEuate nutrition: a b 48 therapy for the first few days N7T for feeding the client who is unable to swallow 3luid restriction as ordered: to decrease cerebral edema & might also increase 4C! 'levate head %=:?F degree to decrease 4C! Turn & reposition every # hrs +#= min only on the affected side, !assive )*1 e.ercise every ? hrs: prevent contractures$ promote body alignment

c
F a b

1aintain proper positioning & body alignment:

c H
G

!romote optimum skin integrity: turn client & apply lotion every # hrs !revent complications of immobility by: a b c Turn client to side !rovide egg crate mattresses or water bed !rovide sand bag or food board *ffer bed pan or urinal every # hrs$ catheteriCed only if necessary &dminister stool softener & suppositories as ordered: to prevent constipation & fecal impaction

1aintain adeEuate elimination:

a b
<

!rovide Euiet- restful environment

"= !rovide alternative means of communication to the client:

a Non verbal cues 1agic slate: not paper & pen tiring for client 4f positive to hemianopsia: approach client on unaffected side

b c a

"" &dminister medications as ordered: @yperosmotic agent: to decrease cerebral edema *smotic /iuretics +1annitol, 6oop /iuretics 3urosemide +6asi., Corticosteroids +/e.amethaCone,

b c

&nti:convulsants: to prevent or treat seiCures Thrombolytic 2 3ibrinolytic &gents: given to dissolve clot +hemorrhage must be ruled out, Tissue !lasminogen &ctivating 3actor +t!&- &lteplase,: S': allergic )eaction Streptokinase- (rokinase: S': chest pain

&nticoagulants: for stroke in evolution or embolic stroke +hemorrhage must be ruled out, @eparin: short acting Check for !artial Thromboplastin Time +!TT,: if prolonged there is a risk for bleeding &ntidote: !rotamine S*? Darfarin +Comadin,: long acting 2 long term therapy 7ive simultaneously with @eparin cause Darfarin +Coumadin, will take effect after % days Check for !rothrombin Time +!T,: if prolonged there is a risk for bleeding &ntidote: 8itamin 9 +&Eua 1ephyton, &nti !latelet: to inhibit platelet aggregation in treating T4&Bs !&S& +&spirin, Contraindicated for dengue- ulcer and unknown cause of headache because it may potentiate bleeding

e f

&ntihypertensive: if indicated for elevated B! 1ild &nalgesics: for pain

"# !rovide client health teachings and discharge planning concerning

a b c
d

&void modifiable risk factors +diet- e.ercise- smoking, !revent complication +subarachnoid hemorrhage is the most feared complication, /ietary modification +decrease salt- saturated fats and caffeine, 4mportance of follow up care

Nursing 4ntervention: )ehabiltation

"

@emiplegia: results from in;ury to cell in the cerebral motor corte. or to corticospinal tract +causes contralateral hemiplegia since tracts crosses medulla,

a b c d
e # a

Turn every # hrs +#= min only on affected side, (se proper positioning & repositioning to prevent deformities +foot drop- e.ternal rotation of hips- fle.ion of fingers- wrist dropabduction of shoulder & arms, Support paralyCed arm on pillow or use sling while out of bed to prevent sublu.ation of shoulders 'levate e.tremities to prevent dependent edema !rovide active & passive )*1 e.ercises every ? hrs 9eep side rails up at all times

Susceptibility to haCard

#?

#F
b c 4nstitute safety measures 4nspect body parts freEuently for signs of in;ury

/ysphagia: difficulty of swallowing a b c d e f Check for gag refle. before feeding client 1aintain a calm- unhurried approach !lace client in upright position !lace food in unaffected side of the mouth *ffer soft foods 7ive mouth care before & after meals

@omonymous @emianopsia: loss of right or left half of each visual field a b &pproach the client on unaffected side !lace personal belongings- food etc - on unaffected side 7radually teach the client to compensate by scanning +e. Turning the head to see things on affected side,

c F
a b c

'motional 6ability: mood swings- frustrations Create a Euiet- restful environment with a reduction in e.cessive sensory stimuli 1aintain a calm- non:threatening manner '.plain to family that clientBs behavior is not purposeful

&phasia: most common in right hemiplegics$ may be receptive 2 e.pressive a )eceptive &phasia 7ive simple- slow directions 7ive one command at a time$ gradually shift topics (se non:verbal techniEues of communication +e. !antomime- demonstration, b '.pressive &phasia 6isten & watch very carefully when the client attempts to speak &nticipate clientBs needs to decrease frustrations & feeling of helplessness &llow sufficient time for client to answer

Sensory 2 !erceptual /eficit: more common in left hemiplegics$ characteriCed by impulsiveness unawareness of disabilities- visual neglect +neglect of affected side & visual space on affected side, a b c d &ssist with self:care !rovide safety measures 4nitially arrange ob;ects in environment on unaffected side 7radually teach client to take care of the affected & turn freEuently & look at affected side

&pra.ia: loss of ability to perform purposeful- skilled acts

a
b

7uide client through intended movement +e. Take ob;ect such as wash cloth & guide client through movement of washing, 9eep repeating the movement

<

7eneraliCations about the clients with left hemiplegia vs right hemiplegia & nursing care a 6eft @emiplegia !erceptual- sensory deficits: Euick & impulsive behavior (se safety measures- verbal cues- simplicity in all area of care b )ight @emiplegia Speech:language deficits: slow & cautious behavior (se pantomime & demonstration

C*N8(6S48' /4S*)/')2C*N8(6S4*N disorder of CNS characteriCed by paro.ysmal seiCure with or without loss of consciousness abnormal motor activity alternation in sensation and perception and changes in behavior SeiCure: first convulsive attack 'pilepsy: second or series of attacks 3ebrile seiCure: normal in children age below F years !redisposing 3actors " # % ? @ead in;ury due to birth trauma 7enetics !resence of brain tumor To.icity from the ff: a b F H 6ead Carbon mono.ide

Nutritional and 1etabolic deficiencies !hysical and emotional stress Sudden withdrawal to anti:convulsant drug: is predisposing factor for status epilepticus: /*C: /iaCepam +8alium, & 7lucose S2s. /ependent on stages of development or types of seiCure

"

7eneraliCed SeiCure 4nitial onset in both hemisphere- usually involves loss of consciousness & bilateral motor activity

1a;or 1otor SeiCure +7rand mal SeiCure,: tonic:clonic seiCure Signs or aura with auditory- olfactory- visual- tactile- sensory e.perience 'pileptic cry: is characteriCed by fall and loss of consciousness for %:F minutes Tonic !hase: 6imbs contract or stiffens !upils dilated & eye roll up to one side 7lottis closes: causing noise on e.halation 1ay be incontinent *ccurs at same time as loss of consciousness last #=:?= sec Tonic contractions: direct symmetrical e.tension of e.tremities

#F

#H

Clonic !hase: repetitive movement increase mucus production slowly tapers Clonic contractions: contraction of e.tremities !ostictal sleep: unresponsive sleep SeiCure ends with postictal period of confusion- drowsiness

&bsence SeiCure +!etit mal SeiCure,: (sually non:organic brain damage present 1ust be differentiated from daydreaming Sudden onset with twitching & rolling of eyes that last #=:?= sec Common among pediatric clients characteriCed by: Blank stare /ecrease blinking of eyes Twitching of mouth 6oss of consciousness +F "= seconds,

!artial or 6ocaliCed SeiCure Begins in focal area of brain & symptoms are related to a dysfunction of that area 1ay progress into a generaliCed seiCure

a b

0acksonian SeiCure +focal seiCure, characteriCed by tingling and ;erky movement of inde. finger and thumb that spreads to the shoulder and other side of the body !sychomotor SeiCure +focal motor seiCure, 1ay follow trauma- hypo.ia- drug use !urposeful but inappropriate repetitive motor acts &ura is present: daydreaming like &utomatism: stereotype repetitive and non propulsive behavior Clouding of consciousness: not in contact with environment 1ild hallucinatory sensory e.perience

Status 'pilepticus (sually refers to generaliCed grand mal seiCure SeiCure is prolong +or there are repeated seiCures without regaining consciousness, & unresponsive to treatment Can result in decrease in *# supply & possible cardiac arrest & continuous uninterrupted seiCure activity 4f left untreated can lead to hyperpyre.ia and lead to coma and eventually death /*C: /iaCepam +8alium, & 7lucose

C. Diagnosti% )!o%e&$!es " CT Scan reveals brain lesions # ''7 reveals hyper activity of electrical brain waves D. N$!sing Manage(ent " 1aintain patent airway and promote safety before seiCure activity a clear the site of blunt or sharp ob;ects 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 # &void precipitating stimulus such as bright2glaring lights and noise % &dminister medications as ordered a &nti convulsants +/ilantin- !henytoin, b /iaCepam- 8alium c CarbamaCepine +Tegnetol, trigeminal neuralgia d !henobarbital- 6uminal ? 4nstitute seiCure and safety precaution post seiCure attack a administer *# inhalation b provide suction apparatus F /ocument and monitor the following a onset and duration b types of seiCures c duration of post ictal sleep may lead to status epilepticus d assist in surgical procedure cortical resection *verview &natomy & !hysiology of the 'ye '.ternal Structure of 'ye

a b

'yelids +!alpebrae, & 'yelashes: protect the eye from foreign particles Con;unctiva: !alpebral Con;unctiva: pink$ lines inner surface of eyelids Bulbar Con;unctiva: white with small blood vessels- covers anterior sclera

6acrimal &pparatus +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

#H

#G d

The movement of the eye is controlled by H e.traocular muscles +'*1,

4nternal Structure of 'ye & % layers of the eyeball " *uter 6ayer

a b
#

Sclera: tough- white connective tissue +Jwhite of the eyeK,$ located anteriorly & posteriorly Cornea: transparent tissue through which light enters the eye$ located anteriorly

1iddle 6ayer

a b c d
%

Choroid: highly vascular layer- nourishes retina$ located posteriorly Ciliary Body: anterior to choroid- secrets aEueous humor$ muscle change shape of lens 4ris: pigmented membrane behind cornea- gives color to eye$ located anteriorly !upil: is circular opening in the middle of the iris that constrict or dilates to regulate amount of light entering the eye

4nner 6ayer

6ight:sensitive layer composed of rods & cones +visual cell, Cones: specialiCed for fine discrimination & color vision$ +daylight 2 colored vision, )ods: more sensitive to light than cones- aid in peripheral vision$ +night twilight vision,

b B
C

*ptic /isk: area in retina for entrance of optic nerve- has no photoreceptors

6ens: transparent body that focuses image on retina 3luid of the eye

" # a
b

&Eueous @umor: 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 8itreous @umor: clear- gelatinous material that fills posterior cavity of eye$ maintains transparency & form of eye

8isual !athways )etina +rods & cones, translates light waves into neural impulses that travel over the optic nerves *ptic nerves for each eye meet at the optic chiasm 3ibers from median halves of the retinas cross here & travel to the opposite side of the brain 3ibers from lateral halves of retinas remain uncrossed

*ptic 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 aEueous humor drainage 1eibomian gland: secrets a lubricating fluid inside the eyelid 1aculla lutea: yellow spot center of retina 3ovea centralis: area with highest visual acuity or acute vision # muscles of iris: Circular smooth muscle fiber: Constricts the pupil )adial smooth muscle fiber: /ilates the pupil !hysiology of vision ? !hysiological processes for vision to occur:

"
# % ?

)efraction of light rays: bending of light rays &ccommodation of lens Constriction & dilation of pupils Convergence of eyes

(nit of measurements of refraction: diopters Normal eye refraction: emmetropia Normal 4*!: "#:#" mm@g 'rror of )efraction

" # % ?

1yopia: nearsightedness: Treatment: biconcave lens @yperopia: farsightedness: Treatment: biconve. lens &stigmatisim: distorted vision: Treatment: cylindrical !resbyopia: Jold sightK inelasticity of lens due to aging: Treatment: bifocal lens or double vista

&ccommodation of lenses: based on thelmholtC theory of accommodation Near 8ision: Ciliary muscle contracts: 6ens bulges 3ar 8ision: ciliary muscle dilates 2 rela.es: lens is flat Convergence of the eye: 'rror:

" # % ?

'.otropia:" eye normal 'sophoria: Strabismus: sEuint eye &mblyopia: prolong sEuinting corrected by corrective eye surgery

Common 8isual /isorder 7laucoma CharacteriCed by increase intraocular pressure resulting in progressive loss of vision 1ay cause blindness if not recogniCed & treated 'arly detection is very important preventable but not curable )egular eye e.am including tonometry for person over age ?= is recommended

#G

#A

!redisposing 3actors " # % ? F Common among ?= years old and above @ereditary @ypertension *besity @istory of previous eye surgery- trauma- inflammation

Types of 7laucoma:

"

Chronic +open:angle, 7laucoma: 1ost common form /ue to obstruction of the outflow of aEueous humor- in trabecular meshwork or canal of schlemm

&cute +close:angle, 7laucoma: /ue to forward displacement of the iris against the cornea- obstructing the outflow of the aEueous humor *ccurs suddenly & is an emergency situation 4f untreated it will result to blindness

Chronic +close:angle, 7laucoma: similar to acute +close:angle, glaucoma- with the potential for an acute attack S2s.

"

Chronic +open:angle, 7laucoma: symptoms develops slowly 4mpaired peripheral vision +!S: tunnel vision, @alos around light 1ild discomfort in the eye 6oss of central vision if unarrested

&cute +close:angle, 7laucoma Severe eye pain Blurred cloudy vision @alos around light N28 Steamy cornea 1oderate pupillary dilation

Chronic +close:angle, 7laucoma Transient blurred vision Slight eye pain @alos around lights /.

" # % ? F

8isual &cuity: reduced Tonometry: reading of #?:%# mm@g suggest glaucoma$ may be F= mm@g of more in acute +close:angle, glaucoma *phthalmoscopic e.am: reveals narrowing of small vessels of optic disk- cupping of optic disk !erimetry: reveals defects in visual field 7onioscopy: e.amine angle of anterior chamber 1edical 1anagement

"

Chronic +open:angle, 7laucoma

/rug Therapy: one or a combination of the following 1iotics eye drops +!ilocarpine,: to increase outflow of aEueous humor 'pinephrine eye drops: to decrease aEueous humor production & increase outflow Carbonic &nhydrase 4nhibitor: &cetaColamide +/iamo.,: to decrease aEueous humor production Timolol 1aleate +Timoptic,: topical beta:adrenergic blocker: to decrease intraocular pressure +4*!,

Surgery +if no improvement with drug, 3iltering procedure +Trabeculectomy 2 Trephining,: to create artificial openings for the outflow of aEueous humor 6aser Trabeculoplasty: non:invasive procedure performed with argon laser that can be done on an out:client basis$ procedure similar result as trabeculectomy

&cute +close:angle, 7laucoma

/rug Therapy: before surgery 1iotics eye drops +!ilocarpine,: to cause pupil to contract & draw iris away from cornea *smotic &gent +7lycerin oral- 1annitol 48,: to decrease intraocular pressure +4*!, Narcotic &nalgesic: for pain

Surgery !eripheral 4ridectomy: portion of the iris is e.cised to facilitate outflow of aEueous humor &rgon 6aser Beam Surgery: non:invasive procedure using laser produces same effect as iridectomy$ done in out:client basis 4ridectomy: usually performed on second eye later since a large number of client have an acute acute attack in the other eye

Chronic +close:angle, 7laucoma

a
b

/rug Therapy: miotics +pilocarpine, Surgery: bilateral peripheral iridectomy: to prevent acute attacks

Nursing 4ntervention

#A

#<
" # % ? F H &dminister medication as ordered !rovide Euite- dark environment 1aintain accurate 4 & * with the use of osmotic agent !repare client for surgery if indicated !rovide post:op care !rovide client teaching & discharge planning a Self:administration of eye drops Need to avoid stooping- heavy lifting or pushing- emotional upsets- e.cessive fluid intake- constrictive clothing around the neck Need to avoid the use antihistamines or sympathomimetic drugs +found in cold preparation, in close:angle glaucoma since they may cause mydriasis d e Cataract /ecrease opacity of ocular lens 4ncidence increases with age !redisposing 3actor " &ging HF years and above 1ay caused by changes associated with aging +JsenileK cataract, )elated to congenital 1ay develop secondary to trauma- radiation- infection- certain drugs +corticosteroids, /iabetes 1ellitus !rolonged e.posure to (8 rays S2s. " # % ? F H 6oss of central vision Blurring or haCy vision !rogressive decrease of vision 7lare in bright lights 1ilky white appearance at center of pupils /ecrease perception to colors /iagnostic !rocedure 4mportance of follow:up care Need to wear medic:alert tag

b c

#
%

?
F H

"

*phthalmoscopic e.am: confirms presence of cataract Nursing 4ntervention

"

!repare client for cataract surgery: a b c d !erformed when client can no longer remain independent because of reduced vision Surgery performed on one eye at a time$ usually in a same day surgery unit 6ocal anesthesia & intravenous sedation usually used Types of cataract surgery: '.tracapsular '.traction: lens capsule is e.cised & the lens is e.pressed$ posterior capsule is left in place +may be used to support new artificial lens implant,$ partial removal of lens !hacoemulsification: type of e.tracapsular e.traction$ a hollow needle capable of ultrasonic vibration is inserted into lensvibrations emulsify the lens- which is aspirated 4ntracapsular '.traction: lens is totally removed within its capsules- may be delivered from eye by cryoe.traction +lens is froCen with metal probe & removed,$ total removal of lens & surrounding capsules

e f
# a

!eripheral 4ridectomy: may be performed at the time of surgery$ small hole cut in iris to prevent development of secondary glaucoma 4ntraocular 6ens 4mplant: often performed at the time of surgery &ssess vision in the unaffected eye since the affected eye will be patched post:op !rovide pre:op teaching regarding measures to prevent intraocular pressure +4*!, post:op &dminister medication as ordered: Topical 1ydriatics +1ydriacyl, & Cyclopegics +Cyclogyl,: to dilate the pupil Topical antibiotics: to prevent infection &cetaColamide +/iamo., & osmotic agent +*ral 7lycerin or 1annitol 48,: to decrease intraocular pressure to provide soft eyeball for surgery

Nursing 4ntervention !re:op

b
c

Nursing 4ntervention !ost:op a b )eorient the client to surroundings !rovide safety measures: 'levate side rails !rovide call bells &ssist with ambulation when fully recovered from anesthesia c !revent intraocular pressure & stress on the suture line: 'levate head of the bed %=:?= degree @ave the client lie on back or unaffected side &void having the client cough- sneeCe- bend over- or move head too rapidly Treat nausea with anti:emetics as ordered: to prevent vomiting 7ive stool softener as ordered: to prevent straining *bserve for & report signs of intraocular pressure +4*!,: Severe eye pain )estlessness 4ncreased pulse

!rotect eye from in;ury: a /ressing usually removed the day after the surgery

#<

%=
b c F 'yeglasses or eye shield used during the day &lways use eye shield during the night Topical mydriatics & cycloplegic: to decrease spasm of ciliary body & relieve pain Topical antibiotics & corticosteroids 1ild analgesic as needed TechniEue of eyedrop administration (se of eye shield at night No bending- stooping- or lifting )eport signs & symptoms of complication immediately to physician: Severe eye pain /ecrease vision '.cessive drainage Swelling of eyelid e Cataract glasses 2 contact lenses 4f a lens implant has not been performed the client will need glasses or contact lenses Temporary glasses are worn for ":? weeks then permanent glasses fitted Cataract glasses magnify ob;ect by "2% & distortion peripheral vision @ave the client practice manual coordination with assistance until new spatial relationship becomes familiar @ave client practice walking- using stairs- reaching for articles Contact lenses cause less distortion of vision$ prescribe at one month )etinal /etachment Separation of epithelial surface of retina /etachment or the sensory retina from the pigment epithelium of the retina !redisposing 3actors " # % ? Trauma &ging process Severe diabetic retinopathy !ost:cataract e.traction Severe myopia +near sightedness, !athophysiology Tear in the retina allows vitreous humor to seep behind the sensory retina & separate it from the pigment epithelium S2s. " # % ? F Curtain veil like vision coming across field of vision 3lashes of light 8isual field loss 3loaters 7radual decrease of central vision /.

&dminister medication as ordered:

a
b c H a b c d

!rovide client teaching & discharge planning concerning:

"

*phthalmoscopic e.am: confirms diagnosis 1edical 1anagement

" #

Bed rest with eye patched & detached areas dependent to prevent further detachment Surgery: necessary to repair detachment

a b c

!hotocoagulation: light beam +argon laser, through dilated pupil creates an inflammatory reaction & scarring to heal the area Cryosurgery or diathermy: application of e.treme cold or heat to e.ternal globe$ inflammatory reaction causes scarring & healing of area Scleral buckling: shortening of sclera to force pigment epithelium close to retina

Nursing 4ntervention !re:op " 1aintain bed rest as ordered with head of bed flat & detached area in a dependent position (se bilateral eye patches as ordered$ elevate side rails to prevent in;ury 4dentify yourself when entering the room *rient the client freEuently to time of date & surroundings$ e.plain procedures !rovide diversional activities to provide sensory stimulation Nursing 4ntervention !ost:op " Check orders for positioning & activity level: a b # a b % a b c d e f 1ay be on bed rest for ":# days 1ay need to position client so that detached area is in dependent position Topical mydriatics &nalgesic as needed TechniEues of eyedrop administration (se eye shield at night No bending from waist$ no heavy work or lifting for H weeks )estriction of reading for % weeks or more 1ay watch T8 Need to check to physician regarding combing & shampooing hair & shaving Need to report complications such as recurrence of detachment

#
% ?

&dminister medication as ordered:

!rovide client teaching & discharge planning concerning:

%=

%"

*verview of &natomy & !hysiology *f 'ar +@earing, '.ternal 'ar

" # %

&uricle +!inna,: outer pro;ection of ear composed of cartilage & covered by skin$ collects sound waves '.ternal &uditory Canal: lined with skin$ glands secretes cerumen +wa.,- providing protection$ transmits sound waves to tympanic membrane Tympanic 1embrane +'ardrum,: at end of e.ternal canal$ vibrates in response to sound & transmits vibrations to middle ear

1iddle 'ar " *ssicles

a
b

% small bones: malleus +@ammer, attached to tympanic membrane- incus +anvil,- stapes +stirrup, *ssicles are set in motion by sound waves from tympanic membrane 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,

c #
4nner 'ar "

'ustachian Tube: connects nasopharyn. & middle ear$ bring air into middle ear- thus eEualiCing pressure on both sides of eardrum

Cochlea Controls hearing Contains *rgan 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 8444 +acoustic branch, to the brain +temporal lobe of cerebrum,

8estibular &pparatus *rgan of balance Composed of three semicircular canals & the utricle

% ?

'ndolymph & !erilymph 3or static eEuilibrium 1astoid air cells &ir filled spaces in temporal bone in skull

/isorder of the 'ar *tosclerosis 3ormation of new spongy bone in the labyrinth of the ear causing fi.ation of the stapes in the oval window This prevent transmission of auditory vibration to the inner ear !redisposing 3actor " 3ound more often in women Cause " # % (nknown 2 idiopathic There is familial tendency 'ar trauma & surgery S2s. " # !rogressive hearing loss Tinnitus /.

" #

&udiometry: reveals conductive hearing loss DeberBs & )inneBs Test: show bone conduction is greater than air conduction 1edical 1anagement

"

Stapedectomy: procedure of choice )emoval of diseased portion of stapes & replacement with prosthesis to conduct vibrations from the middle ear to inner ear (sually performed under local anesthesia (sed to treat otoscrlerosis Nursing 4ntervention !re:op

"

!rovide general pre:op nursing care- including an e.planation of post:op e.pectation '.plain to the client that hearing may improve during surgery & then decrease due to edema & packing Nursing 4ntervention !ost:op

" # % ?

!osition the client according to the surgeonBs orders +possibly with operative ear uppermost to prevent displacement of the graft, @ave the client deep breathe every # hours while in bed- but no coughing 'levate side rails$ assist the client with ambulation & move slowly: may have some vertigo &dminister medication as ordered: &nalgesic &ntibiotics &nti:emetics &nti:motion sickness drug: 1eclesine @cl +Bonamine,

Check for dressing freEuently for e.cessive drainage or bleeding &ssess facial nerve function: &sk the client to do the ff: Drinkle forehead Close eyelids !uff out checks for any asymmetry

Suestion the client about the ff: report e.istence to physicians

%"

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!ain @eadaches 8ertigo (nusual sensations in the ear A !rovide client teaching & discharge planning concerning:

a b c d

Darning against blowing nose or coughing$ sneeCe with mouth open Need to keep ear dry in the shower$ no shampooing until allowed No flying for H mos 'specially if upper respiratory tract infection is present !lacement of cotton balls in auditory meatus after packing is removed$ change twice daily

1eniereBs /isease /isease of the inner ear resulting from dilatation of the endolymphatic system & increase volume of endolymph CharacteriCed by recurrent & usually progressive triad of symptoms: vertigo- tinnitus- hearing loss !redisposing 3actor " 4ncidence highest between ages %= & H= Cause # % (nknown 2 idiopathic Theories include the ff: a b c d e f &llergy To.icity 6ocaliCed ischemia @emorrhage 8iral infection 'dema

S2s. " # % ? F Sudden attacks of vertigo lasting hours or days$ attacks occurs several times a year N28 Tinnitus !rogressive hearing loss Nystagmus /.

" #

&udiometry: reveals sensorineural hearing loss 8estibular Test: reveals decrease function 1edical 1anagement

"

&cute: &tropine +decreases autonomic nervous system activity, /iaCepam +8alium, 3entanyl & /roperidol +4nnovar,

Chronic:

/rug Therapy: 8asodilators +nicotinic &cid, /iuretics 1ild sedative or tranEuiliCers: /iaCepam +8alium, &ntihistamines: /iphenhydramine +Benadryl, 1ecliCine +antivert,

/iet: 6ow sodium diet )estricted fluid intake )estrict caffeine & nicotine

Surgery:

a
b

Surgical destruction of labyrinth causing loss of vestibular & cochlear function +if disease is unilateral, 4ntracranial division of vestibular portion of cranial nerve 8444 'ndolymphatic sac decompression or shunt to eEualiCe pressure in endolymphatic space

Nursing 4ntervention " 1aintain bed rest in a Euiet- darkened room in position of choice$ elevate side rails as needed *nly move the client for essential care +bath may not be essential, !rovide emesis basin for vomiting 1onitor 48 Therapy$ maintain accurate 4&* &ssist in ambulation when the attack is over &dminister medication as ordered !repare client for surgery as indicated +pot:op care includes using above measures, !rovide client care & discharge planning concerning: a b c (se of medication & side effects 6ow sodium diet & decrease fluid intake 4mportance of eliminating smoking

# %
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G A

*verview of &natomy & !hysiology of 'ndocrine System 'ndocrine System

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4s composed of an interrelated comple. of glands +!ituitary 7- &drenal 7- Thyroid 7- !arathyroid 7- 4slets of langerhans of the pancreas*varies & Testes, that secretes a variety of hormones directly into the bloodstream 4ts ma;or function- together with the nervous system: is to regulate body function @ormones )egulation

"

@ormones: chemical substance that acts s messenger to specific cells & organs +target organs,- stimulating & inhibiting various processes Two 1a;or Categories

a b #
a b

6ocal: hormones with specific effect in the area of secretion +e. Secretin- cholecystokinin- panceoCymin OCC9:!QP, 7eneral: hormones transported in the blood to distant sites where they e.ert their effects +e. Cortisol,

Negative 3eedback 1echanisms: ma;or means of regulating hormone levels /ecreased 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 4ncreased concentration of a hormones inhibits production of the stimulating hormone- resulting in decreased secretion of the target organ hormone

% ? F

Some hormones are controlled by changing blood levels of specific substances +e. Calcium- glucose, Certain hormones +e. Cortisol or female reproductive hormones, follow rhythmic patterns of secretion &utonomic & CNS control +pituitary:hypothalamic a.is,: hypothalamus controls release of the hormones of the anterior pituitary gland through releasing & inhibiting factors that stimulate or inhibits hormone secretions

@ormone 3unction 'ndocrine 7 !ituitary 7 &nterior lobe : &CT@ : 3S@- 6@ : 7@- Somatotropin : !rolactin or 6T@ : TS@ : stimulate thyroid 7 to release thyroid hormones : stimulate adrenal corte. to produce & release adrenocoticoids : stimulate growth- maturation- & function of primary & secondary se. organ : stimulate growth of body tissues & bones : stimulate development of mammary gland & 6actation !osterior lobe : &/@ : regulates @#* metabolism$ release during stress *r in response to an increase in plasma osmolality To stimulate reabsorption of @#* & decrease urine *utput : *.ytocin : stimulate uterine contractions during delivery & the )elease of milk in lactation 4ntermediate lobe &drenal 7 &drenal Corte. : 1ineralocorticoid +e. &ldosterone, : 7lucocorticoids +e. Cortisolcorticosterone, : regulate fluid & electrolyte balance$ stimulate reabsoption of sodium- chloride- & @#*$ stimulate potassium e.cretion : increase blood glucose level by increasing rate of glyconeogenesis$ increase C@*N catabolism$ increase mobiliCation of fatty acid$ promote sodium & @#* with stress : Se. @ormones progesterones, &drenal 1edulla : 'pinephrineNorepinephrine : function in acute stress$ increase @)- B!$ dilates bronchioles$ convert glycogen to glucose when Needed by the muscles for energy Thyroid 7 : T%- T? : regulate metabolic rate$ C@*- fats- & C@*N 1etabolism$ aid in regulating physical & mental 7rowth & development : Thyrocalcitonin !arathyroid 7 !ancreas +islets of 6angerhans, Beta Cells : 4nsulin : allows glucose to diffuse across cell membrane$ Converts glucose to glycogen &lpha Cells : 7lucagon : increase blood glucose by causing glyconeogenisis & glycogenolysis in the liver$ secreted in response to low blood sugar *varies : 'strogen- !rogesterone : development of secondary se. characteristics in the : !T@ : lowers serum calcium & phosphate levels : regulates serum calcium & phosphate levels : influence development of secondary se. +androgens- estrogens characeristics : 1S@ : affects skin pigmentation @ormone 3unctions

retention$ anti:inflammatory effect$ aid body in coping

3emale- maturation of se. organ- se.ual functioning 1aintenance of pregnancy Testes : Testosterone : development of secondary se. characteristics in the 1ale maturation of the se. organs- se.ual functioning !ituitary 7land +@ypophysis,

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6ocated in sella turcica at the base of brain J1aster 7landK or master clock Controls all metabolic function of body % 6obes of !ituitary 7land

"

&nterior 6obe !7 +&denohypophysis,

Secretes tropic hormones +hormones that stimulate target glands to produce their hormones,: adrenocorticotropic @ +&CT@,- thyroid: stimulating @ +TS@,- follicle:stimulating @ +3S@,- luteiniCing @ +6@, &CT@: promotes development of adrenal corte. 6@: secretes estrogen 3S@: secretes progesterone

&lso secretes hormones that have direct effects on tissues: somatotropic or growth @- prolactin Somatotropic 2 7@: promotes elongation of long bones @yposecretion of 7@: among children results to dwarfism @ypersecretion of 7@: among children results to gigantism @ypersecretion of 7@: among adults results to acromegaly +sEuare face, /*C: *creotide +Sandostatin, !rolactin: promotes development of mammary gland$ with help of o.ytocin it initiates milk let down refle.

)egulated by hypothalamic releasing & inhibiting factors & by negative feedback system

!osterior 6obe !7 +Neurohypophysis, /oes not produce hormones Store & release anti:diuretic hormones +&/@, & o.ytocin produced by hypothalamus Secretes hormones o.ytocin +promotes uterine contractions preventing bleeding or hemorrhage, &dminister o.ytocin immediately after delivery to prevent uterine atony 4nitiates milk let down refle. with help of hormone prolactin

4ntermediate 6obe !7 Secretes melanocytes stimulating @ +1S@, 1S@: for skin pigmentation @yposecretion of 1S@: results to albinism @ypersecretion of 1S@: results to vitiligo # feared complications of albinism: " # 6ead to blindness due to severe photophobia !rone to skin cancer

&drenal 7lands Two small glands- one above each kidney$ 6ocated at top of each kidney # Sections of &drenal 7lands

"

&drenal Corte. +outer portion,: produces mineralocorticoids- glucocorticoids- se. hormones % Qones26ayers Qona 3asciculata: secretes glucocortocoids +cortisol,: controls glucose metabolism: Sugar Qona )eticularis: secretes traces of glucocorticoids & androgenic hormones: promotes secondary se. characteristics: Se. Qona 7lumerulosa: secretes mineralocorticoids +aldosterone,: promotes sodium and water reabsorption and e.cretion of potassium: Salt

&drenal 1edulla +inner portion,: produces epinephrine- norepinephrine +secretes catecholamines a power hormone,: vasoconstrictor # Types of Catecholamines: 'pinephrine +vasoconstrictor, Norepinephrine +vasoconstrictor,

!heochromocytoma +adrenal medulla,: 4ncrease secretion of norepinephrine: 6eading to hypertension which is resistant to pharmacological agents leading to C8&: (se beta:blockers

Thyroid 7land 6ocated in anterior portion of the neck Consist of # lobes connected by a narrow isthmus !roduces thyro.ine +T?,- triiodothyronine +T%,- thyrocalcitonin % @ormones Secreted: T%: % molecules of iodine +more potent, T?: ? molecule of iodine T% and T? are metabolic hormone: increase brain activity$ promotes cerebration +thinking,$ increase 82S Thyrocalcitonin: antagoniCes the effects of parathormone to promote calcium reabsorption !arathyroid 7land ? small glands located in pairs behind the thyroid gland !roduce parathormone +!T@, !romotes calcium reabsorption !ancreas 6ocated behind the stomach @as both endocrine & e.ocrine function +mi.ed gland, Consist of &cinar Cells +e.ocrine gland,: which secretes pancreatic ;uices: that aids in digestion 4slets of langerhans +alpha & beta cells, involved in endocrine function: &lpha Cell: produce glucagons: +function: hyperglycemia,

%?

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Beta Cell: produce insulin: +function: hypoglycemia, /elta Cells: produce somatostatin: +function: antagoniCes the effects of growth hormones, 7onads *varies: located in pelvic cavity$ produce estrogen & progesterone Testes: located in scrotum$ produces testosterone !ineal 7land Secretes melatonin 4nhibits 6@ secretion 4t controls & regulates circadian rhythm +body clock,

/iabetes 4ncipidus +/4, /4: dalas:ihi /ecrease of anti:diuretic hormone +&/@, @yposecretion of &/@ @ypofunction of the posterior pituitary gland +!!7, resulting in deficiency of &/@ CharacteriCed by e.cessive thirst & urination

&nti:diuretic @ormone: !itressin +8asopressin, 3unction: prevents urination thereby conserving water Note: &lcohol inhibits release of &/@ !redisposing 3actor " # % ? )elated to pituitary surgery Trauma 4nflammation !resence of tumor S2s. " Severe polyuria with low specific gravity !olydipsia +e.cessive thirst, 3atigue 1uscle weakness 4rritability Deight loss @ypotension Signs of dehydration

#
% ? F H G A

a
b c d

&dult: thirst$ Children: tachycardia &gitation !oor Skin turgor /ry mucous membrane

<

Tachycardia- eventually shock if fluids is not replaced

"= 4f left untreated results to hypovolemic shock +late sign anuria,

D4

" # %

(rine Specific 7ravity +N8: " ="F " =%=,: less than " ==? Serum Na: increase resulting to hypernatremia @#* deprivation test: reveals inability to concentrate urine Nursing 4ntervention

"

1aintain 3&' balance 2 3orce fluids #===:%=== ml2day a b c 9eep accurate 4&* Deigh daily &dminister 482oral fluids as ordered to replace fluid loss

1onitor strictly 82S & observe for signs of dehydration & hypovolemia &dminister hormone replacement as ordered:

8asopressin +!itressin, & 8asopressin Tannate +!itressin Tannate *il,: administered by 41 in;ection Darm to body temperature before giving Shake tannate suspension to ensure uniform dispersion

b ?
F

6ypressin +/iapid,: nasal spray

!revent complications: hypovolemic shock is the most feared complication !rovide client teaching & discharge planning concerning:

a
b

6ifelong hormone replacement: 6ypressin +/iapid, as needed to control polyuria & polydipsia Need to wear medic:alert bracelet

Syndrome of 4nappropriate &nti:diuretic @ormone Secretion +S4&/@, @ypersecretion of anti:diuretic hormone +&/@, from the !!7 even when the client has abnormal serum osmolality !redisposing 3actors " # @ead in;ury )elated to presence of bronchogenic cancer 4nitial sign of lung cancer is non productive cough

%F

%H

Non invasive procedure is chest .:ray

)elated to hyperplasia of pituitary gland +increase siCe of organ brought about by increase of number of cells, S2s.

" #

!erson with S4&/@ cannot e.crete a dilute urine 3luid retention & Na deficiency a b c @ypertension 'dema Deight gain

Dater into.ication: may lead to cerebral edema: lead to increase 4C!$ may lead to seiCure activity /.

" #

(rine specific gravity: is increase Serum Sodium: is decreased 1edical 1anagement

" #

Treat underlying cause if possible /iuretics & fluid restriction Nursing 4ntervention

" #

)estrict fluid: to promote fluid loss & gradual increase in serum Na &dminister medications as ordered:

a b
% ? F H G

6oop diuretics +6asi., *smotic diuretics +1annitol,

1onitor strictly 82S- 4&* & neuro check Deigh patient daily and assess for pitting edema 1onitor serum electrolytes & blood chemistries carefully !rovide meticulous skin care !revent complications

3')OT3'ROIDISM : all are &e%!ease e.cept "eight and (enst!$ation : memory impairment Signs an& Sy(*to(s : there is loss of appetite but there is weight gain : menorrhagia : cold intolerance : constipation 3')ERT3'ROIDISM : all are in%!ease e.cept "eight and (enst!$ation Signs an& Sy(*to(s : increase appetite but there is weight loss : amenorrhea : e.ophthalmos Thyroid /isorder Simple 7oiter 'nlargement of thyroid gland due to iodine deficiency 'nlargement of the thyroid gland not caused by inflammation of neoplasm 6ow level of thyroid hormones stimulate increased secretion of TS@ by pituitary$ under TS@ stimulation the thyroid increases in siCe to compensate & produce more thyroid hormone !redisposing 3actors

"

'ndemic: caused by nutritional iodine deficiency- most common in the Jgoiter beltK area- areas where soil & @#* are deficient in iodine$ occurs most freEuently during adolescence & pregnancy 7oiter belt area: a b c 1idwest- northwest & great lakes region !laces far from sea 1ountainous regions

Sporadic: caused by 4ncrease intake of goitrogenic foods +contains agent that decrease the thyro.ine production: pro:goitrin an anti:thyroid agent that has no iodine, '. cabbage- turnips- radish- strawberry- carrots- sweet potato- rutabagas- peaches- peas- spinach- broccoli- all nuts Soil erosion washes away iodine 7oitrogenic drugs:

a
b c d e

&nti:Thyroid &gent: !ropylthiouracil +!T(, 6arge doses of iodine !henylbutaCone !ara:amino salicylic acid 6ithium Carbonate !&S& +&spirin, Cobalt

f
g %

7enetic defects that prevents synthesis of thyroid hormones

%H

%G

S2s. " # % ? 'nlarged thyroid gland /ysphagia )espiratory distress 1ild restlessness /.

" # % ?

Serum T?: reveals normal or below normal Thyroid Scan: reveals enlarged thyroid gland Serum Thyroid Stimulating @ormone +TS@,: is increased +confirmatory diagnostic test, )&4( +)adio &ctive 4odine (ptake,: normal or increased 1edical 1anagement

"

/rug Therapy: @ormone replacement with levothyro.ine +Synthroid, +T?,- dessicated thyroid- or liothyronine +Cytomel, +T%, Small dose of iodine +6ugolBs or potassium iodide solution,: for goiter resulting from iodine deficiency

# %

&voidance of goitrogenic food or drugs in sporadic goiter Surgery: Subtotal thyroidectomy: +if goiter is large, to relieve pressure symptoms & for cosmetic reasons Nursing 4ntervention

"

&dminister )eplacement therapy as ordered:

6ugolBs Solution 2 SS94 +Saturated Solution of !otassium 4odine, Color purple or violet and administered via straw to prevent staining of teeth ? 1edications to be taken via straw: 6ugolBs- 4ron- Tetracycline- Nitrofurantoin +/*C: for pyelonephritis,

Thyroid @ormones: 6evothyro.ine +Synthroid, 6iothyronine +Cytomel, Thyroid '.tracts Nursing 4ntervention when giving Thyroid @ormones:

" #
%

4nstruct client to take in the morning to prevent insomnia 1onitor vital signs especially heart rate because drug causes tachycardia and palpitations 1onitor side effects: 4nsomnia Tachycardia and palpitations @ypertension @eat intolerance

4ncrease dietary intake of foods rich in iodine: Seaweeds SeafoodBs like oyster- crabs- clams and lobster but not shrimps because it contains lesser amount of iodine 4odiCed salt: best taken raw because it is easily destroyed by heat

% ?

&ssist in surgical procedure of subtotal thyroidectomy !rovide client teaching & discharge planning concerning: (sed of iodiCed salt in preventing & treating endemic goiter Thyroid hormone replacement

@ypothyroidism +1y.edema, Slowing of metabolic processes caused by hypofunction of the thyroid gland with decreased thyroid hormone secretion @yposecretion of thyroid hormone /ecrease in all 82S e.cept wt & menses &dults: my.edema non pitting edema Children: cretinism the only endocrine disorder that can lead to mental retardation 4n severe or untreated cases my.edema coma may occur: CharacteriCed by intensification of S2s. of hypothyroidism & neurologic impairment leading to coma 1ortality rate high$ prompt recognition & treatment essential !recipitating factors: failure to take prescribed medications$ infection$ trauma$ e.posure to cold$ use of sedatives- narcotics or anesthetics !redisposing 3actors

" # % ?
F

!rimary hypothyroidism: atrophy of the gland possibly caused by an autoimmune process Secondary hypothyroidism: caused by decreased stimulation from pituitary TS@ 4atrogenic: surgical removal of the gland or over treatment of hyperthyroidism with drugs or radioactive iodine$ disease caused by medical intervention such as surgery )elated to atrophy of thyroid gland due to trauma- presence of tumor- inflammation 4odine deficiency &utoimmune +@ashimotos /isease, *ccurs more often to women ages %= & H= S2s.

H
G

"
#

6oss of appetite: but there is wt gain &nore.ia Deight gain: which promotes lipolysis leading to atherosclerosis and 14

%G

%A
? F H G A Constipation Cold intolerance /ry scaly skin Spares hair Brittleness of nails /ecrease in all 82S: e.cept wt gain & menses a b c d @ypotension Bradycardia Bradypnea @ypothermia

<

"= Deakness and fatigue "" Slowed mental processes "# /ull look "% Slow clumsy movement "? 6ethargy

"F 7eneraliCed interstitial non:pitting edema +1y.edema,

"H @oarseness of voice "G /ecrease libido "A 1emory impairment "< !sychosis #= 1enorrhagia /.

" # % "

Serum T% and T?: is decreased Serum Cholesterol: is increased )&4( +)adio &ctive 4odine (ptake,: is decreased 1edical 1anagement /rug Therapy: 6evothyro.ine +Synthroid, Thyroglobulin +!roloid, /essicated thyroid 6iothyronine +Cytomel,

1y.edema coma is a medical emergency: 48 thyroid hormones Correction of hypothermina 1aintenance of vital function Treatment of precipitating cause Nursing 4ntervention

" #

1onitor strictly 82S & 4&*- daily weights$ observe for edema & signs of cardiovascular complication & to determine presence of my.edema coma &dminister thyroid hormone replacement therapy as ordered & monitor effects:

*bserve signs of thyroto.icosis: Tachycardia & palpitation N28 /iarrhea Sweating Tremors &gitation /yspnea

4ncrease dosage gradually- especially in clients with cardiac complication

%
? F

!rovide comfortable and warm environment: due to cold intolerance !rovide a low calorie diet &void the use of sedatives$ reduce the dose of any sedatives- narcotics- or anesthetic agent by half as ordered !rovide meticulous skin care: to prevent skin breakdown 4ncrease fluid & food high in fiber: to prevent constipation$ administer stool softener as ordered *bserve for signs of my.edema coma$ provide appropriate nursing care a &dminister medication as ordered 1aintain vital functions: Correct hypothermia 1aintain adeEuate ventilation

H G A

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1y.edema coma: & complication of hypothyroidism & an emergency case & severe form of hypothyroidism is characteriCed by: Severe hypotension Bradycardia Bradypnea @ypoventilation @yponatremia @ypoglycemia @ypothermia 6eading to progressive stupor and coma Nursing 1anagement for 1y.edema Coma

%A

%<
" # % a b c d e f g &ssist in mechanical ventilation &dminister thyroid hormones as ordered &dminister 483 replacement isotonic fluid solution as ordered 2 3orce fluids Thyroid hormone replacement 4mportance of regular follow:up care Need in additional protection in cold weather 1easures to prevent constipation &void precipitating factors leading to my.edema coma & hypovolemic shock Stress & infection (se of anesthetics- narcotics- and sedatives

"= !rovide client health teaching and discharge planning concerning:

@yperthyroidism Secretion of e.cessive amounts of thyroid hormone in the blood causes an increase in metabolic process 4ncrease in T% and T? 7raveBs /isease or Thyroto.icosis 4ncrease in all 82S e.cept wt & menses !redisposing 3actors " 1ore often seen in women between ages %= & F= &utoimmune: involves release of long acting thyroid stimulator causing e.opthalmus +protrusion of eyeballs, enopthalmus +late sign of dehydration among infants, % '.cessive iodine intake )elated to hyperplasia +increase siCe of T7, S2s.

"
# %

4ncrease appetite +hyperphagia,: but there is weight loss @eat intolerance Deight loss /iarrhea: increase motility 4ncreased in all 82S: e.cept wt & menses a b c Tachycardia 4ncrease systolic B! !alpitation

? F

H G A <

Darm smooth skin 3ine soft hair !liable nails CNS involvement a b c d e f g 4rritability & agitation )estlessness Tremors 4nsomnia @allucinations Sweating @yperactive movement

"= 7oiter

"" !S: '.opthalmus +protrusion of eyeballs,

"# &menorrhea /.

" # %

Serum T% and T?: is increased )&4( +)adio &ctive 4odine (ptake,: is increased Thyroid Scan: reveals an enlarged thyroid gland 1edical 1anagement

"

/rug Therap:

a b
#

&nti:thyroid drugs: !ropylthiouracil +!T(, & methimaCole +TapaCole,: blocke synthesis of thyroid hormone$ to.ic effect include agranulocytosis &drenergic Blocking &gent: !ropranolol +4nderal,: used to decrease sympathetic activity & alleviate symptoms such as tachycardia

)adioactive 4odine Therapy

a
b c

)adioactive isotope of iodine +e. "%"4,: given to destroy the thyroid gland- thereby decreasing production of thyroid hormone (sed in middle:aged or older clients who are resistant to- or develop to.icity from drug therapy @ypothyroidism is a potential complication

Surgery: Thyroidectomy performed in younger client for whom drug therapy has not been effective Nursing 4ntervention

" #

1onitor strictly 82s & 4&*- daily weight &dminister anti:thyroid medications as ordered:

a b
% a b ? F H

!ropylthiouracil +!T(, 1ethimaCole +TapaCole, &ssign a private room away from e.cessive activity &dminister medication to promote sleep as ordered

!rovide for period of uninterrupted rest:

!rovide comfortable and cold environment 1inimiCed stress in the environment 'ncourage Euiet- rela.ing diversional activities

%<

?= G
A

!rovide dietary intake that is high in C@*- C@*N- calories- vitamin & minerals with supplemental feeding between meals & at bedtime$ omit stimulant *bserve for & prevent complication

a
b <

'.ophthalmos: protects eyes with dark glasses & artificial tears as ordered Thyroid Storm

!rovide meticulous skin care

"= 1aintain side rails "" !rovide bilateral eye patch to prevent drying of the eyes

"# &ssist in surgical procedures subtotal Thyroidectomy:

"% !rovide client teaching & discharge planning concerning:

a
b Thyroid Storm

Need to recogniCed & report S2s. of agranulocytosis +fever- sore throat- skin rash,: if taking anti:thyroid drugs S2s. of hyperthyroidism & hypothyroidism

(ncontrolled & potentially life:threatening hyperthyroidism caused by sudden & e.cessive release of thyroid hormone into the bloodstream !recipitating 3actors " # % Stress 4nfection unprepared thyroid surgery S2s. " # &pprehension )estlessness '.tremely high temp +up to "=H 3 2 ?= G C, Tahchycardia @3 )espiratory /istress /elirium Coma Nursing 4ntervention " # % 1aintain patent airway & adeEuate ventilation$ administer *# as ordered &dminister 48 therapy as ordered &dminister medication as ordered: a b c d Thyroidectomy !artial or total removal of thyroid gland 4ndication: Subtotal Thyroidectomy: hyperthyroidism Total Thyroidectomy: thyroid cancer Nursing 4ntervention !re:op " 'nsure that the client is adeEuately prepared for surgery a b # % Cardiac status is normal Deight & nutritional status is normal &nti:thyroid drugs Corticosteroids Sedatives Cardiac /rugs

%
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&dminister anti:thyroid drugs as ordered: to suppressed the production of thyroid hormone & to prevent thyroid storm &dminister iodine preparation 6ugolBs Solution +SS94, or !otassium 4odide Solution: to decrease vascularity of the thyroid gland & to prevent hemorrhage Nursing 4ntervention !ost:*p

"

1onitor 82S & 4&* Check dressing for signs of hemorrhage: check for wetness behind the neck !lace client in semi:fowlers position & support head with pillow *bserve for respiratory distress secondary to hemorrhage- edema of glottis- laryngeal nerve damage- or tetany: keep tracheostomy set- *# & suction nearby &ssess for signs of tetany: due to hypocalcemia: due to secondary accidental removal of parathyroid glands: keep Calcium 7luconate available: Datch out for accidental removal of parathyroid which may lead to hypocalcemia +tetany, Classic S2s. of Tetany !ositive trousseuBs sign !ositive chvostek sign *bserve for arrhythmia- seiCure: give Calcium 7luconate 48 slowly as ordered

#
%

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'courage clients voice to rest: a b Some hoarseness is common Check every %=:H= min for e.treme hoarseness or any accompanying respiratory distress

*bserve for signs of thyroid storm 2 thyroto.icosis: due to release of e.cessive amount of thyroid hormone during surgery &gitation

T)4&/ S47NS

?=

?"

@yperthermia &dminister medications as ordered: &nti !yretics Beta:blockers

Tachycardia

1onitor strictly vital signs- input and output and neuro check 1aintain side rails *ffer TSB

A <

&dminister 48 fluids as ordered: until the client is tolerating fluids by mouth &dminister analgesics as ordered: for incisional pain a b Cool mist humidifier to thin secretions &dminister analgesic throat loCenges before meals prn as ordered

"= )elieve discomfort from sore throat:

"" 'ncourage coughing & deep breathing every hour

"# &ssist 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 "% @ormonal replacement therapy for lifetime

"? Datch out for accidental laryngeal damage which may lead to hoarseness of voice: encourage client to talk2speak immediately after
operation and notify physician

"F !rovide client teaching& discharge planning concerning:

a b c d e S2s. of hyperthyroidism & hypothyroidism Self administration of thyroid hormone: if total thyroidectomy is performed &pplication of lubricant to the incision once suture is removed !erform )*1 neck e.ercise %:? times a day 4mportance of follow up care with periodic serum calcium level

@ypoparathyroidism /isorder characteriCed by hypocalcemia resulting from a deficiency of parathormone +!T@, production /ecrease secretion of parathormone: leading to hypocalcemia: resulting to hyperphospatemia 4f calcium decreases phosphate increases !redisposing 3actors " # % 1ay be hereditary 4diopathic Caused by accidental damage to or removal of parathyroid gland during thyroidectomy surgery &trophy of parathyroid gland due to: inflammation- tumor- trauma S2s.

"

&cute hypocalcemia +tetany,

a
b c d

!aresthesia: tingling sensation of finger & around lip 1uscle spasm laryngospasm2broncospasm /ysphagia SeiCure: feared complications Cardiac arrhythmia: feared complications Numbness !ositive trousseuBs sign: carpopedal spasm !ositive chvostek sign

e f
g

h
i

Chronic hypocalcemia +tetany, a b c d e f g h i ; k l m n o p 3atigue Deakness 1uscle cramps !ersonality changes 4rritability 1emory impairment &gitation /ry scaly skin @air loss 6oss of tooth enamel Tremors Cardiac arrhythmias Cataract formation !hotophobia &nore.ia N28 /iagnostic !rocedures

" # % ?

Serum Calcium level: decreased +normal value: A F "" mg2"== ml, Serum !hosphate level: increased +normal value: # F ? F mg2"== ml, Skeletal I:ray of long bones: reveals a increased in bone density CT Scan: reveals degeneration of basal ganglia

?"

?#

Nursing 1anagement

"

&dminister medications as ordered such as:

a b

&cute Tetany: Calcium 7luconate slow 48 drip as ordered Chronic Tetany: *ral calcium preparation: Calcium 7luconate- Calcium 6actate- Calcium Carbonate +*s:Cal, 6arge dose of vitamin / +Calciferol,: to help absorption of calcium C@*6'C&6C43')*6 &)' /')48'/ 3)*1

/rug

/iet +Calcidiol,

Sunlight +Calcitriol,

!hosphate Binder: &luminum @ydro.ide 7el +&mphogel, or aluminum carbonate gel- basic +basal;el,: to decrease phosphate levels &NT&C4/ &&C &luminum &ntacids &luminum @ydro.ide 7el Side 'ffect: Constipation # % ? F 4nstitute seiCure & safety precaution !rovide Euite environment free from e.cessive stimuli &void precipitating stimulus such as glaring lights and noise 1onitor signs of hoarseness or stridor$ check for signs for ChvostekBs & TrousseauBs sign 9eep emergency eEuipment +tracheostomy set- in;ectable Calcium 7luconate, at bedside: for presence of laryngospasm 3or tetany or generaliCed muscle cramp: may use rebreathing bag or paper bag to produce mild respiratory acidosis: to promote increase ioniCed Ca levels A < 1onitor serum calcium & phosphate level !rovide high:calcium & low:phosphorus diet a b c d e 1edication regimen: oral calcium preparation & vit / to be taken with meal to increase absorption Need to recogniCed & report S2s. of hypo2hypercalcemia 4mportance of follow:up care with periodic serum calcium level !revent complications @ormonal replacement therapy for lifetime Side 'ffect: /iarrhea 1&/ 1agnesium &ntacids Containing Containing

H G

"= !rovide client teaching & discharge planning concerning:

@yperparathyroidism 4ncrease secretion of !T@ that results in an altered state of calcium- phosphate & bone metabolism /ecrease parathormone @ypercalcemia: bone demineraliCation leading to bone fracture +calcium is stored <<> in bone and "> blood, 9idney stones !redisposing 3actors " 1ost commonly affects women between ages %F & HF !rimary @yperparathyroidism: caused by tumor & hyperplasia of parathyroid gland Secondary @yperparathyroidism: cause by compensatory over secretion of !T@ in response to hypocalcemia from:

# %

a b
c d

Children: )icketts &dults: *steomalacia Chronic renal disease 1alabsorption syndrome S2s.

" # % ? F H

Bone pain +especially at back,$ Bone demineraliCation$ !athologic fracture 9idney stones$ )enal colic$ !olyuria$ !olydipsia$ Cool moist skin &nore.ia$ N28$ 7astric (lcer$ Constipation 1uscle weakness$ 3atigue 4rritability 2 &gitation$ !ersonality changes$ /epression$ 1emory impairment Cardiac arrhythmias$ @!N /.

" # %

Serum Calcium: is increased Serum !hosphate: is decreased Skeletal I:ray of long bones: reveals bone demineraliCation Nursing 4ntervention

" #

&dminister 48 infusions of normal saline solution & give diuretics as ordered: 1onitor 4&* & observe fluid overload & electrolytes imbalance &ssist client with self care: !rovide careful handling- 1oving- &mbulation: to prevent pathologic fracture 1onitor 82S: report irregularities

% ?

?#

?% F H G
A

3orce fluids #===:%=== 62day: to prevent kidney stones !rovide acid:ash ;uices +e. Cranberry- orange ;uice,: to acidify urine & prevent bacterial growth Strain urine: using gauCe pad: for stone analysis !rovide low:calcium & high:phosphorus diet !rovide warm sitC bath: for comfort

<

"= &dminister medications as ordered: 1orphine Sulfate +/emerol,

"" 1aintain side rails

"# &ssist in surgical procedure: !arathyroidectomy "% !rovide client teaching & discharge planning concerning:
a b Need to engage in progressive ambulatory activities 4ncrease fluid intake (se of calcium preparation & importance of high:calcium diet following a parathyroidectomy !revent complications: renal failure @ormonal replacement therapy for lifetime 4mportance of follow up care

c d
e f

&ddisonBs /isease !rimary adrenocortical insufficiency$ hypofunction of the adrenal corte. causes decrease secretion of the mineralcorticoidsglucocorticoids- & se. hormones @yposecretion of adrenocortical hormone leading to: 1etabolic disturbance: Sugar 3luid and electrolyte imbalance: Na- @#*- 9 /eficiency of neuromascular function: Salt- Se. !redisposing 3actors

"

)elatively rare disease caused by: 4diopathic atrophy of the adrenal corte.: due to an autoimmune process /estruction of the gland secondary to TB or fungal infections S2s.

" #

3atigue- 1uscle weakness &nore.ia- N28- abdominal pain- weight loss @istory of hypoglycemic reaction 2 @ypoglycemia: tremors- tachycardia- irritability- restlessness- e.treme fatigue- diaphoresisdepression @yponatremia: hypotension- signs of dehydration- weight loss- weak pulse /ecrease tolerance to stress @yperkalemia: agitation- diarrhea- arrhythmia /ecrease libido 6oss of pubic and a.illary hair BronCe like skin pigmentation /.

% ?
F

H
G A <

" # % ?

3BS: is decreased +normal value: A= "== mg2dl, !lasma Cortisol: is decreased Serum Sodium: is decrease +normal value: "%F "?F meE26, Serum !otassium: is increased +normal value: % F ? F meE26, Nursing 4ntervention

"

&dminister hormone replacement therapy as ordered:

7lucocorticoids: stimulate diurnal rhythm of cortisol release- give #2% of dose in early morning & "2% of dose in afternoon Corticosteroids: /e.amethasone +/ecadrone, @ydrocortisone: Cortisone +!rednisone,

1ineralocorticoids: 3ludrocortisone &cetate +3lorinef, Nursing 1anagement when giving steroids

"

4nstruct client to take #2% dose in the morning and "2% dose in the afternoon to mimic the normal diurnal rhythm Taper dose +withdraw gradually from drug, 1onitor side effects: @ypertension 'dema @irsutism 4ncrease susceptibility to infection 1oon face appearance

#
%

# % ?

1onitor 82S /ecrease stress in the environment !revent e.posure to infection !rovide rest period: prevent fatigue Deight daily !rovide small freEuent feeding of diet: decrease in 9- increase cal- C@*- C@*N- Na: to prevent hypoglycemia- & hyponatremia & provide proper nutrition 1onitor 4&*: to determine presence of addisonian crisis +complication of addisonBs disease, !rovide meticulous skin care

F
H

G A
<

"= !rovide client teaching & discharge planning concerning:

?%

?? a b c
d e

/isease process: signs of adrenal insufficiency (se of prescribe medication for lifelong replacement therapy: never omit medication Need to avoid stress- trauma & infection: notify the physician if these occurs as medication dosage may need to be ad;usted Stress management techniEue /iet modification (se of salt tablet +if prescribe, or ingestion of salty foods +potato chips,: if e.periencing increase sweating 4mportance of alternating regular e.ercise with rest periods &voidance of strenuous e.ercise especially in hot weather &void precipitating factor: leading to addisonian crisis: stress- infection- sudden withdrawal to steroids !revent complications: addisonian crisis- hypovolemic shock 4mportance of follow up care

f
g h

i ;
k

&ddisonian Crisis Severe e.acerbation of addisonBs diseasecaused by acute adrenal insufficiency !redisposing 3actors " # % ? F Strenuous activity Stress Trauma 4nfection 3ailure to take prescribe medicine 4atrogenic: Surgery of pituitary gland or adrenal gland )apid withdrawal of e.ogenous steroids in a client on long:term steroid therapy S2s. " # 7eneraliCed muscle weakness Severe hypotension @ypovolemic shock: vascular collapse @yponatremia: leading to progressive stupor and coma Nursing 4ntervention " &ssist in mechanical ventilation &dminister 48 fluids +F> de.trose in saline- plasma, as ordered: to treat vascular collapse &dminister 48 glucocorticoids: @ydrocortisone +Solu:Cortef, & vasopressors as ordered 3orce fluids 4f crisis precipitate by infection: administer antibiotics as ordered 1aintain strict bed rest & eliminate all forms of stressful stimuli 1onitor 82S- 4&* & daily weight !rotect client from infection !rovide client teaching & discharge planning concerning: same as addisonBs disease

% ?

# %
?

F
H G A

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Cushing Syndrome Condition resulting from e.cessive secretion of corticosteroids- particularly glucocorticoid cortisol @ypersecretion of adrenocortical hormones !redisposing 3actors

" # %
? F

!rimary CushingBs Syndrome: caused by adrenocortical tumors or hyperplasia Secondary CushingBs Syndrome +also called CushingBs disease,: caused by functioning pituitary or nonpituitary neoplasm secreting &CT@- causing increase secretion of glucocorticoids 4atrogenic: cause by prolonged use of corticosteroids )elated to hyperplasia of adrenal gland 4ncrease susceptibility to infections S2s.

" # % ? F H G A <

1uscle weakness 3atigue *bese trunk with thin arms & legs 1uscle wasting 4rritability /epression 3reEuent mood swings 1oon face Buffalo hump

"= !endulous abdomen "" !urple striae on trunk "# &cne "% Thin skin

"? Signs of masculiniCation in women: menstrual dysfunction- decrease libido

"F *steoporosis "H /ecrease resistance to infection "G @ypertension "A 'dema "< @ypernatremia

??

?F
#= Deight gain #" @ypokalemia ## Constipation

#% ( wave upon 'C7 +T wave hyperkalemia,

#? @irsutis #F 'asy bruising /.

" # % ?

3BS: is increased !lasma Cortisol: is increased Serum Sodium: is increased Serum !otassium: is decreased Nursing 4ntervention

"

1aintain muscle tone a b !rovide )*1 e.ercise &ssist in ambulation

# % ?

!revent accidents fall & provide adeEuate rest !rotect client from e.posure to infection 1aintain skin integrity a !rovide meticulous skin care !revent tearing of the skin: use paper tape if necessary

b
F

1inimiCe stress in the environment 1onitor 82S: observe for hypertension & edema 1onitor 4&* & daily weight: assess for pitting edema: 1easure abdominal girth: notify physician !rovide diet low in Calorie & Na & high in C@*N- 9- Ca- 8itamin / 1onitor urine: for glucose & acetone$ administer insulin as ordered

H G
A

<

"= !rovide psychological support & acceptance

"" !repare client for hypophysectomy or radiation: if condition is caused by a pituitary tumor "# !repare client for &drenalectomy: if condition is caused by an adrenal tumor or hyperplasia
"% )estrict sodium intake

"? &dminister medications as ordered: Spironolactone +&ldactone,: potassium sparring diuretics

"F !rovide client teaching & discharge planning concerning: a b c /iet modification 4mportance of adeEuate rest Need to avoid stress & infection Change in medication regimen +alternate day therapy or reduce dosage,: if caused of condition is prolonged corticosteroid therapy !revent complications +/1, @ormonal replacement for lifetime: lifetime due to adrenal gland removal: no more corticosteroidU 4mportance of follow up care

d e f
g

/iabetes 1ellitus +/1, )epresent a heterogenous group of chronic disorders characteriCed by hyperglycemia @yperglycemia: due to total or partial insulin deficiency or insensitivity of the cells to insulin CharacteriCed by disorder in the metabolism of C@*- fats- C@*N- as well as changes in the structure & function of blood vessels 1etabolic disorder characteriCed by non utiliCation of carbohydrates- protein and fat metabolism !athophysiology 6ack of insulin causes hyperglycemia +insulin is necessary for the transport of glucose across the cell membrane, T @yperglycemia leads to osmitic diuresis as large amounts of glucose pass through the kidney result polyuria & glycosuria T /iuresis leads to cellular dehydration & 3 & ' depletion causing polydipsia +e.cessive thirst, T !olyphagia +hunger & increase appetite, result from cellular starvation T The body turns to fat & C@*N for energy but in the absence of glucose in the cell fat cannot be completely metaboliCed & ketones +intermediate products of fat metabolism, are produced T This leads to ketonemia- ketonuria +contributes to osmotic diuresis, & metabolic acidosis +ketones are acid bodies, T 9etone sacts as CNS depressants & can cause coma T '.cess loss of 3 & ' leads to hypovolemia- hypotension- renal failure & decease blood flow to the brain resulting in coma & death unless treated 1&4N 3**/ST(33 " C@* # C@*N % 3ats &N&B*64S1 7lucose &mino &cids 3atty &cids C&T&B*64S1 7lycogen Nitrogen 3ree 3atty &cids : cholesterol : ketones

@5!')765C'14& 4ncrease osmotic diuresis 7lycosuria Cellular starvation: weight loss Stimulates the appetite 2 satiety center +@ypothalamus, !olyphagia M liver has glycogen that undergo glycogenesis2glycogenolysis !olyuria Cellular dehydration Stimulates the thirst center +@ypothalamus, !olydypsia

?F

?H
76(C*N'*7'N'S4S 3ormation of glucose from non:C@* sources 4ncrease protein formation Negative Nitrogen balance Tissue wasting +Cache.ia, 4NC)'&S' 3&T C&T&B*64S1 3ree fatty acids Cholesterol &therosclerosis @ypertension &cetone Breath odor 14 C8& 9ussmaulBs )espiration 9etones /iabetic 9eto &cidosis

/eath

/iabetic Coma

Classification *f /1

"

Type 4 4nsulin:dependent /iabetes 1ellitus +4//1, Secondary to destruction of beta cells in the islets of langerhans in the pancreas resulting in little of no insulin production Non:obese adults )eEuires insulin in;ection 0uvenile onset type +Brittle disease, 4ncidence )ate " "=> general population has Type 4 /1 !redisposing 3actors " &utoimmune response 7enetics 2 @ereditary +total destruction of pancreatic cells, )elated to viruses /rugs: diuretics +6asi.,- Steroids- oral contraceptives )elated to carbon tetrachloride to.icity S2s. " # % ? F H G A < !olyuria !olydipsia !olyphagia 7lucosuria Deight loss 3atigue &nore.ia N28 Blurring of vision

#
%

?
F

"= 4ncrease susceptibility to infection "" /elayed 2 poor wound healing

/. " 3BS: a b & level of "?= mg2dl of greater on at two occasions confirms /1 1ay be normal in Type 44 /1

# % ?

!ostprandial Blood Sugar: elevated *ral 7lucose Tolerance Test +most sensitve test,: elevated 7lycosolated @emoglobin +hemoglobin &"c,: elevated 1edical 1anagement

" # %

4nsulin therapy '.ercise /iet: a b Consistency is imperative to avoid hypoglycemia @igh:fiber- low:fat diet also recommended 4nsulin: Short &cting: used in treating ketoacidosis$ during surgery- infection- trauma$ management of poorly controlled diabetes$ to supplement long:acting insulins 4ntermediate: used for maintenance therapy 6ong &cting: used for maintenance therapy in clients who e.perience hyperglycemia during the night with intermediate: acting insulin

/rug therapy: a

4nsulin preparation can consist of mi.ture of pure pork- pure beef- or human insulin @uman insulin is the purest insulin & has the lowest antigenic effect

?H

?G c d F

@uman 4nsulin: is recommended for all newly diagnosed Type 4 & Type 44 /1 who need short:term insulin therapy$ the pregnant client & diabetic client with insulin allergy or severe insulin resistance 4nsulin !umps: e.ternally worn device that closely mimic normal pancreatic functioning

'.ercise: helpful ad;unct to therapy as e.ercise decrease the bodyBs need for insulin Characteristics of 4nsulin !reparation

/rug )apid &cting

Synonym

&ppearance Clear

*nset N:"

!eak #:?

/uration H:A

Compatible 1i.ed &ll insulin prep e.cept lente

4nsulin 4n;ection )egular 4ns

4nsulin- Qinc suspensionprompt

Semilente 4ns

Cloudy

N:"

?:H

"#:"H

6ente prep

4ntermediate &cting 4sophane 4ns in;ection 4nsulin Qinc Suspension 6ong &cting 4nsulin Qinc suspensione.tended Complication (ltralente 4ns Cloudy ?:A "H:#= %=:%H )egular 4ns & semilente prep 6ente 4ns Cloudy ":" N A:"# "A:#? N!@ 4ns Cloudy ":" N A:"# "A:#? )egular 4ns in;ection )egular 4ns & semilente prep

" #

/iabetic 9etoacidosis +/9&,

Type 44 Non:insulin:dependent /iabetes 1ellitus +N4//1, 1ay result to partial deficiency of insulin production &2or an insensitivity of the cells to insulin *bese adult over ?= years old 1aturity onset type 4ncidence )ate " <=> of general population has Type 44 /1 !redisposing 3actors " 7enetics *besity: because obese persons lack insulin receptor binding sites S2s. " # % ? F H G A < (sually asymptomatic !olyuria !olydypsia !olyphagia 7lycosuria Deight gain 2 *besity 3atigue Blurred 8ision 4ncrease susceptibility to infection

"= /elayed 2 poor wound healing /.

3BS: c d & level of "?= mg2dl of greater on at two occasions confirms /1 1ay be normal in Type 44 /1

H G A

!ostprandial Blood Sugar: elevated *ral 7lucose Tolerance Test +most sensitve test,: elevated 7lycosolated @emoglobin +hemoglobin &"c,: elevated 1edical 1anagement

"

4deally manage by diet & e.ercise *ral @ypoglycemic agents or occasionally insulin: if diet & e.ercise are not effective in controlling hyperglycemia 4nsulin is needed in acute stress: e. Surgery- infection /iet: C@* F=>- C@*N %=> & 3ats #=> a b Deight loss is important since it decreases insulin resistance @igh:fiber- low:fat diet also recommended *ccasional use of insulin *ral hypoglycemic agent: (sed by client who are not controlled by diet & e.ercise 4ncrease the ability of islet cells of the pancreas to secret insulin$ may have some effect on cell receptors to decrease resistance to insulin

#
%

/rug therapy: a

'.ercise: helpful ad;unct to therapy as e.ercise decrease the bodyBs need for insulin

?G

?A
*ral @ypoglycemic &gent /rug *ral Sulfonylureas &cetohe.amide +/ymelor, Chlorpropamide +/iabinase, " " ?:H #:A ?:H ?=:H= "=:#? "#:#? *nset !eak /uration Comments

7lyburide +1icronase- /iabeta, "F min: " hr *ral Biguanides 1etformin +7lucophage, #:# F

"=:"H

:/ecrease glucose production in liver :/ecrease intestinal absorption of glucose & improves insulin sensitivity

*ral &lpha:glucosidose 4nhibitor &carbose +!recose, (nknown " (nknown :/elay glucose absorption & digestion of C@*lowering blood sugar 1iglitol +7lyset, TroglitaCone +)eCulin, )apid #:% #:% (nknown :)educe plasma glucose & insulin :!otetiates action of insulin in skeletal muscle & decrease glucose production in liver Complications

"

@yper *smolar Non:9etotic Coma +@*N9C, Nursing 4ntervention

" #

&dminister insulin or oral hypoglycemic agent as ordered: monitor hypoglycemia especially during period of drug peak action !rovide special diet as ordered: a 'nsure that the client is eating all meals 4f all food is not ingested: provide appropriate substitute according to the e.change list or give measured amount of orange ;uice to substitute for leftover food$ provide snack later in the day

b % ?
F H G

1onitor urine sugar & acetone +freshly voided specimen, !erform finger sticks to monitor blood glucose level as ordered +more accurate than urine test, *bserve signs of hypo2hyperglycemia !rovide meticulous skin care & prevent in;ury 1aintain 4&*$ weight daily !rovide emotional support: assist client in adapting change in lifestyle & body image *bserve for chronic complications & plan of care accordingly:

A
<

a b
c

&therosclerosis: leads to C&/- 14- C8& & !eripheral 8ascular /isease 1icroangiopathy: most commonly affects eyes & kidneys 9idney /isease )ecurrent !yelonephritis /iabetic Nephropathy

*cular /isorder !remature Cataracts /iabetic )etinopathy

!eripheral Neuropathy &ffects !NS & &NS Cause diarrhea- constipation- neurogenic bladder- impotence- decrease sweating

"= !rovide client teaching & discharge planning concerning: a b /isease process /iet Client should be able to plan a meal using e.change lists before discharge 'mphasiCe importance of regularity of meals$ never skip meals c 4nsulin @ow to draw up into syringe (se insulin at room temp 7ently roll the vial between palms /raw up insulin using sterile techniEue 4f mi.ing insulin- draw up clear insulin- before cloudy insulin 4n;ection techniEue Systematically rotate the site: to prevent lipodystrophy: +hypertrophy or atrophy of tissue, 4nsert needle at a ?F +skinny clients, or <= +fat or obese clients, degree angle depending on amount of adipose tissue 1ay store current vial of insulin at room temperature$ refrigerate e.tra supplies SomogyiBs phenomenon: hypoglycemia followed by periods of hyperglycemia or rebound effect of insulin !rovide many opportunities for return demonstration d *ral hypoglycemic agent Stress importance of taking the drug regularly &void alcohol intake while on medication: it can lead to severe hypoglycemia reaction 4nstruct the client to take it with meals: to lessen 74T irritation & prevent hypoglycemia

(rine testing +not very accurate reflection of blood glucose level,

?A

?<

1ay be satisfactory for Type 44 diabetics since they are more stable (se clinitest- tes:tape- diasti.- for glucose testing !erform test before meals & at bedtime (se freshly voided specimen Be consistent in brand of urine test used )eport results in percentage )eport result to physician if results are greater that ">- especially if e.periencing symptoms of hyperglycemia (rine testing for ketones should be done by Type 4 diabetic clients when there is persistent glycosuria- increase blood glucose level or if the client is not feeling well +acetest- ketosti., f Blood glucose monitoring (se for Type 4 diabetic client: since it gives e.act blood glucose level & also detects hypoglycemia 4nstruct client in finger stick techniEue: use of monitor device +if used,- & recording & utiliCation of test results g 7eneral care !erform good oral hygiene & have regular dental e.am @ave regular eye e.am Care for Jsick daysK +e. Cold or flu, /o not omit insulin or oral hypoglycemic agent: since infection causes increase blood sugar Notify physician 1onitor urine or blood glucose level & urine ketones freEuently 4f N28 occurs: sip on clear liEuid with simple sugar h 3oot care Dash foot with mild soap & water & pat dry &pply lanolin lotion to feet: to prevent drying & cracking Cut toenail straight across &void constrictive garments such as garters Dear clean- absorbent socks +cotton or wool, !urchase properly fitting shoes & break new shoes in gradually Never go barefoot 4nspect foot daily & notify physician: if cut- blister- or break in skin occurs i '.ercise (ndertake regular e.ercise$ avoid sporadic- vigorous e.ercise 3ood intake may need to be increased before e.ercising '.ercise is best performed after meals when the blood sugar is rising ; Complication 6earn to recogniCed S2s. of hypo2hyperglycemia: for hypoglycemia +cold and clammy skin,- for hyperglycemia +dry and warm skin,: administer simple sugars 'at candy or drink orange ;uice with sugar added for insulin reaction +hypoglycemia, 1onitor signs of /9& & @*N9C k Need to wear a 1edic:&lert bracelet

/iabetic 9etoacidosis +/9&, &cute complication of /1 characteriCed by hyperglycemia & accumulation of ketones in the body: cause metabolic acidosis &cute complication of Type 4 /1: due to severe hyperglycemia leading to severe CNS depression *ccurs in insulin:dependent diabetic clients *nset slow: maybe hours to days !redisposing 3actors " # % ? F (ndiagnosed /1 Neglect to treatment 4nfection cardiovascular disorder @yperglycemia !hysical & 'motional Stress: number one precipitating factor S2s. " # % ? F H G A < !olyuria !olydipsia !olyphagia 7lucosuria Deight loss &nore.ia N28 &bdominal pain Skin warm- dry & flushed

"= /ry mucous membrane$ soft eyeballs "" Blurring of vision

"# !S: &cetone breath odor "% !S: 9ussmaulBs )espiration +rapid shallow breathing, or tachypnea
"? &lteration in 6*C "F @ypotension "H Tachycardia "G CNS depression leading to coma

?<

F=
/.

" # % ? F H G A

3BS: is increased Serum glucose & ketones level: elevated B(N +normal value: "= #=,: elevated: due to dehydration Creatinine +normal value: A ",: elevated: due to dehydration @ct +normal value: female %H ?#- male ?# ?A,: elevated: due to dehydration Serum Na: decrease Serum 9: maybe normal or elevated at first &B7: metabolic acidosis with compensatory respiratory alkalosis Nursing 4ntervention

" #

1aintain patent airway &ssist in mechanical ventilation 1aintain 3&' balance:

&dminister 48 therapy as ordered: Normal saline += <> NaCl,- followed by hypotonic solutions + ?F> NaCl, sodium chloride: to counteract dehydration & shock Dhen blood sugar drops to #F= mg2dl: may add F> de.trose to 48 !otassium will be added: when the urine output is adeEuate

*bserve for 3&' imbalance- especially fluid overload- hyperkalemia & hypokalemia

&dminister insulin as ordered: regular acting insulin2rapid acting insulin

a b
c F

)egular insulin 48 +drip or push, & 2 or subcutaneously +SC, 4f given 48 drip: give small amount of albumin since insulin adheres to 48 tubing 1onitor blood glucose level freEuently Sodium Bicarbonate: to counteract acidosis &ntibiotics: to prevent infection

&dminister medications as ordered:

a b
H G A <

Check urine output every hour 1onitor 82S- 4&* & blood sugar levels &ssist client with self:care !rovide care for unconscious client if in a coma

"= /iscuss with client the reasons ketosis developed & provide additional diabetic teaching if indicated @yperglycemic @yperosmolar Non:9etotic Coma +@@N9C, CharacteriCed by hyperglycemia & a hyperosmolar state without ketosis *ccurs in non:insulin:dependent diabetic or non:diabetic persons +typically elderly clients, @yperosmolar: increase osmolarity +severe dehydration, Non:ketotic: absence of lypolysis +no ketones, !redisposing 3actors " # % ? F H G (ndiagnosed diabetes 4nfection or other stress Certain medications +e. dilantin- thiaCide- diuretics, /ialysis @yperalimentation 1a;or burns !ancreatic disease S2s. " # % ? F H G A < !olyuria !olydipsia !olyphagia 7lucosuria Deight loss &nore.ia N28 &bdominal pain Skin warm- dry & flushed

"= /ry mucous membrane$ soft eyeballs "" Blurring of vision "# @ypotension "% Tachycardia "? @eadache and diCCiness "F )estlessness "H SeiCure activity "G &lteration 2 /ecrease 6*C: diabetic coma /.

" # % ? F

Blood glucose level: e.tremely elevated B(N: elevated: due to dehydration Creatinine: elevted: due to dehydration @ct: elevated: due to dehydration (rine: +L, for glucose Nursing 4ntervention

" #

1aintain patent airway &ssist in mechanical ventilation

F=

F" %

1aintain 3&' balance:

&dminister 48 therapy as ordered: Normal saline += <> NaCl,- followed by hypotonic solutions + ?F> NaCl, sodium chloride: to counteract dehydration & shock Dhen blood sugar drops to #F= mg2dl: may add F> de.trose to 48 !otassium will be added: when the urine output is adeEuate

*bserve for 3&' imbalance- especially fluid overload- hyperkalemia & hypokalemia

&dminister insulin as ordered:

a b
c F

)egular insulin 48 +drip or push, & 2 or subcutaneously +SC, 4f given 48 drip: give small amount of albumin since insulin adheres to 48 tubing 1onitor blood glucose level freEuently &ntibiotics: to prevent infection

&dminister medications as ordered:

a
H G A <

Check urine output every hour 1onitor 82S- 4&* & blood sugar levels &ssist client with self:care !rovide care for unconscious client if in a coma

"= /iscuss with client the reasons ketosis developed & provide additional diabetic teaching if indicated

*verview of &natomy & !hysiology of @ematologic System

The structure of the hematological of hematopoietic system includes the blood- blood vessels- & blood forming organs +bone marrowspleen- liver- lymph nodes- & thymus gland, The ma;or function of blood: is to carry necessary materials +*#- nutrients, to cells & remove C*# & metabolic waste products The hematologic system also plays an important role in hormone transport- the inflammatory & immune responses- temperature regulation- 3&' balance & acid:base balance

@'1&T*6*74C&6 S5ST'1

4 Blood FF> !lasma +3luid, Serum ?F> 3ormed cellular elements

44 Blood 8essels " &rteries # 8eins % Capillaries " # % ? F H

444 Blood 3orming *rgans 6iver Thymus Spleen 6ymphoid *rgan 6ymph Nodes Bone 1arrow

!lasma C@*N +formed in liver, " &lbumin # 7lobulins % !rothrombin and 3ibrinogen

Bone 1arrow Contained inside all bones- occupies interior of spongy bones & center of long bones$ collectively one of the largest organs in the body +?:F> of total body weight, !rimary function is @ematopoiesis: the formation of blood cells &ll blood cells start as stem cells in the bone marrow$ these mature into different- specific types of cells- collectively referred to as 3ormed 'lements of Blood or Blood Components: " # % Two kinds of Bone 1arrow: " )ed 1arrow Carries out hematopoiesis$ production site of erythroid- myeloid- & thrombocytic component of blood$ one source of lymphocytes & macrophages 3ound in the ribs- vertebral column- other flat bones # 5ellow 1arrow )ed marrow that has changed to fats$ found in long bone$ does not contribute to hematopoiesis Blood Composed of plasma +FF>, & cellular components +?F>, @ematocrit " # % " )eflects portion of blood composed of red blood cells Centrifugation of blood results in separation into top layer of plasma- middle layer of leukocytes & platelets- & bottom layer of erythrocytes 1a;ority of formed elements is erythrocytes$ volume of leukocytes & platelets is negligible "%== ml in pulmonary circulation a b c # a b c !lasma 6iEuid part of the blood$ yellow in color because of pigments ?== ml arterial H= ml capillary A?= ml venous FF= ml arterial %== ml capillary #"F= ml venous /istribution 'rythrocytes 6eukocytes Thrombocytes

%=== ml in systemic circulation

F"

F#

Consists of serum +liEuid portion of plasma, & fibrinogen Contains plasma C@*N such as albumin- serum- globulins- fibrinogen- prothrombin- plasminogen " &lbumin 6argest & numerous plasma C@*N 4nvolved in regulation of intravascular plasma volume 1aintains osmotic pressure: preventing edema # Serum 7lobulins

a b c %

&lpha: role in transport steroids- lipids- bilirubin & hormones Beta: role in transport of iron & copper 7amma: role in immune response- function of antibodies

3ibrinogens- !rothrombin- !lasminogens: clotting factors to prevent bleeding

Cellular Components or 3ormed 'lements

"

'rythrocytes +)BC, a Normal value: ? H million2mm% No nucleus- Biconcave shape discs- Chiefly sac of hemoglobin Call membrane is highly diffusible to *# & C*# )esponsible for *# transport via hemoglobin +@gb, Two portion: iron carried on heme portion$ second portion is C@*N Normal blood contains "#:"A g @gb2"== ml blood$ higher +"?:"A g, in men than in women +"#:"? g, e !roduction Start in bone marrow as stem cells- release as reticulocytes +immature cells,- mature into erythrocytes 'rythropoietin stimulates differentiation$ produced by kidneys & stimulated by hypo.ia 4ron- vitamin B"#- folic acid- pyrido.ine vitamin BH- & other factors reEuired for erythropoiesis

b
c

@emolysis +/estruction, Normal life span of )BC is A= "#= days and is killed in red pulp of spleen 4mmature )BCs destroyed in either bone marrow or other reticuloendothelial organs +blood- connective tissue- spleen- liverlungs and lymph nodes, 1ature cells remove chiefly by liver and spleen Bilirubin +yellow pigment,: by product of @gb +red pigment, released when )BCs destroyed- e.creted in bile Biliverdin +green pigment, @emosiderin +golden brown pigment, 4ron: feed from @gb during bilirubin formation$ transported to bone marrow via transferring and and reclaimed for new @gb production !remature destruction: may be caused by )BC membrane abnormalities- @gb abnormalities- e.trinsic physical factors +such as the enCyme defects found in 7H!/, Normal age )BCs may be destroyed by gross damage as in trauma or e.travascular hemolysis +in spleen- liver- bone marrow,

g h
i

@emoglobin: normal value female "# "? gms> male "? "H gms> @ematocrit red cell percentage in wholeblood +normal value: female %H ?#> male ?# ?A>, Substances needed for maturation of )BC: a b c 3olic acid 4ron 8itamin c 8itamin b"# +Cyanocobalamin, 8itamin bH +!yrido.ine, 4ntrinsic factor

d e
f

6eukocytes +DBC,

a b c

Normal value: F=== "====2mm% 7ranulocytes and mononuclear cells: involved in the protection from bacteria and other foreign substances 7ranulocytes: !olymorphonuclear Neutrophils : : H= G=> of DBC 4nvolved in short term phagocytosis for acute inflammation 1ature neutrophils: polymorphonuclear leukocytes 4mmature neutrophils: band cells +bacterial infection usually produces increased numbers of band cells,

: :
: : :

!olymorphonuclear Basophils 3or parasite infections )esponsible for the release of chemical mediation for inflammation 4nvolved in prevention of clotting in microcirculation and allergic reactions

!olymorphonuclear 'osinophils : 4nvolved in phagocytosis and allergic reaction

'osinophils & Basophils: are reservoirs of histamine- serotonin & heparin

Non 7ranulocytes

1ononuclear cells: large nucleated cells a 1onocytes: 4nvolved in long:term phagocytosis for chronic inflammation !lay a role in immune response 1acrophage in blood 6argest DBC !roduced by bone marrow: give rise to histiocytes +kupffer cells of liver,- macrophages & other components of reticuloendothelial system

F#

F% b
6ymphocytes

6ymphocytes: immune cells$ produce substances against foreign cells$ produced primarily in lymph tissue +B cells, & thymus +T cells,

B:cell T:cell : bone marrow : thymus for immunity

Natural killer cell : anti:viral and anti:tumor property

@48

Thrombocytes +!latelets,

Normal value: "F=-=== ?F=-===2mm% Normal life span of platelet is < "# days 3ragments of megakaryocytes formed in bone marrow !roduction regulated by thrombopoietin 'ssential factors in coagulation via adhesion- aggregation & plug formation )elease substances involved in coagulation !romotes hemostasis +prevention of blood loss, Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus Signs of !latelet /ysfunction " # % !etechiae 'chhymosis *oCing of blood from venipunctured site

Blood 7roups 'rythrocytes 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 &B* & )h blood groups because they are most likely to be involved in transfusion reactions " &B* Typing a b c d &ntigens of systems are labeled & & B &bsence of both antigens results in type * blood !resence of both antigen is type &B !resence of either type & or B results in type & & type B- respectively Type *: universal donor &ntibodies are automatically formed against &B* antigens not on persons own )BC 4dentifies presence or absence of )h antigens +)h L or )h :, &nti:)h antibodies not automatically formed in )h +:, persons- but if )h +L, blood is given- antibody formation starts & second e.posure to )h antigen will trigger a transfusion reaction 4mportant for )h +:, woman carrying )h +L, baby$ "st pregnancy not affected- but subseEuent pregnancy with an )h +L, babymotherBs antibodies attack babyBs )BC Complication of Blood Transfusion Type @emolytic Causes &B* )h (se of de.trose solutions$ Dide temp fluctuation 1echanism &ntibodies in *ccurrence &cute: S2s. @eadachefirst F min after completion diarrhea- fever4ntervention Stop transfusion continue saline 48 send blood unit & client blood chills- flushing- sample to lab heat along veinrestlessnessdyspnea- signs shutdown- /4C hemoglobinuria Treat or prevent shock- /4C- & anemia- ;aundiceDatch for sternal pain-

e
f #

)h Typing

a b c

4ncompatibility$ recipient plasma react w2 antigen 4ncompatibility$ in donor cells

lumbar or

of transfusion

&gglutinated cell block capillary /elayed: blood flow to organs @emolysis +@gb into plasma & urine, days to # weeks after

of shock- renal renal shutdown

Complication of Blood Transfusion Type &llergic Causes Transfer of an antigen & donor to recipient$ &llergic donor 1echanism 4mmune sensitivity to C@*N *ccurrence Dithin %= min start of transfusion S2s. 4ntervention Stop transfusion &dminister

(ticaria- larygeal edema- wheeCing dyspneaheadacheanaphyla.is

antibody from foreign serum

antihistamine & Treat life:threatening reaction

bronchospasm- or epinephrine

RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR !yrogenic )ecipient possesses antibodies DBC$ bacterial 6eukocytes agglutination bacterial Dithin "F:<= min after initiation of 3ever- chillsflushingpalpitationoccasional Stop transfusion Treat temp Transfuse with leukocytes:poor blood of washed

directed against

organism

transfusion

tachycardia-

F%

F?
contamination$ 1ultitransfused client$ multiparous client RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR Circulatory *verload Client Too rapid Susceptible 3luid volume /uring & after /yspneatransfusion tachycardiaorthopneaSlow infusion rate increase B!blood 1onitor C8! through a separate line RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR &ir 'mbolism Blood given under air pressure blood loss large &bnormal &ssess for signs deteriorate blood amount of blood bleeding precautions (se fresh blood RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR Citrate 4nto.ication 6arge amount in client with decrease liver function RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR @yperkalemia !otassium level )elease of increase in stored blood plasma with red cell lysis 4n client with insufficiency Nausea- colicspasm- 'C7 changes +tall short S:T segments, Blood Coagulation Conversion of fluid blood into a solid clot to reduce blood loss when blood vessels are ruptured System that 4nitiating Clotting &dminister blood less than F:G days old in client with impaired potassium e.cretion potassium into renal diarrhea- muscle Citrate binds &fter large banked blood Neuromascular 1onitor2treat irritability hypocalcemia &void large amounts of citrated blood 1onitor liver f.n Bleeding due to decrease calcium of citrated blood ionic calcium amount of of bleeding 4nitiate bleeding rapidly in stored given over #? hr Bolus of air artery outflow &nytime /yspneawheeCing- chest apprehension (sed of large !latelets Dhen Clamp tubing left side blocks pulmonary increase pulse- Turn client on pain- decrease B!(sed packed cells instead of whole infusion in overload lumbar pain )BC &dminister antibiotics prn

cyanosis- an.iety

following severe

RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRThrombo: cytopenia amount of banked blood

peaked T:waves-

"

4ntrinsic System: initiated by contact activation following endothelial in;ury +JintrinsicK to vessel itself,

a
b #

3actor I44: initiate as contact made between damaged vessel & plasma C@*N 3actors 8444- 4I & I4 activated 4nitiated by tissue thromboplastins released from in;ured vessels +Je.trinsicK to vessel, 3actor 844 activated

'.trinsic System:

a
b

Common !athways: activated by either intrinsic or e.trinsic pathways

"
# % ?

!latelet factor % +!3%, & calcium react with factor I & 8 !rothrombin converted to thrombin via thromboplastin Thrombin acts on fibrinogens- forming soluble fibrin Soluble fibrin polymeriCed by factor I444 to produce a stable- insoluble fibrin clot

Clot )esolution: takes place via fibrinolytic system by plasmin & proteolytic enCymes$ clots dissolves as tissue repairs

Spleen 6argest 6ymphatic *rgan: functions as blood filtration system & reservoir 8ascular 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 b

)ed !ulp: located between the fibrous strands- composed of )BC- DBC & macrophages Dhite !ulp: scattered throughout the red pulp- produces lymphocytes & seEuesters lymphocytes- macrophages- & antigens

">:#> of red cell mass or #== ml blood2minute 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 4mportant hematopoietic site in fetus$ postnatally procedures lymphocytes & monocytes 4mportant in phagocytosis$ removes misshapen erythrocytes- unwanted parts of erythrocytes &lso involved in antibody production by plasma cells & iron metabolism +iron released from @gb portion of destroyed erythrocytes returned to bone marrow, 4n the adult functions of the spleen can be taken over by the reticuloendothelial system 6iver

F?

FF

4nvolved in bile production +via erythrocyte destruction & bilirubin production, & erythropoeisis +during fetal life & when bone marrow production is insufficient, 9upffer cells of liver have reticuloendothelial function as histiocytes$ phagocytic activity & iron storage 6iver also involved in synthesis of clotting factors- synthesis of antithrombins Blood Tranfusion !urpose

" # % ? F

)BC: 4mprove *# transport Dhole Blood- !lasma- &lbumin: volume e.pansion 3resh 3roCen !lasma- &lbumin- !lasma !rotein 3raction: provision of proteins Cryoprecipitate- 3resh 3roCen !lasma- 3resh Dhole Blood: provision of coagulation factors !latelet Concentration- 3resh Dhole Blood: provision of platelets Blood & Blood !roducts

"

Dhole Blood: provides all components

a b

6arge volume can cause difficulty: "#:#? hr for @gb & @ct to rise Complications: volume overload- transmission of hepatitis or &4/S- transfusion reacion- infusion of e.cess potassium & sodiuminfusion of anticoagulant +citrate, used to keep stored blood from clotting- calcium binding & depletion +citrate, in massive transfusion therapy

)ed Blood Cell +)BC, a b !rovide twice amount of @gb as an eEuivalent amount of whole blood 4ndicate in cases of blood loss- pre:op & post:op client & those with incipient congestive failure Complication: transfusion reaction +less common than with whole blood: due to removal of plasma protein, Contains all coagulation factors including 8 & 8444 Can be stored froCen for "# months$ takes #= minutes to thaw @ang immediately upon arrival to unit +loses its coagulation factor rapidly,

c
% a b

3resh 3roCen !lasma

c
?

!latelets

a
b c

Dill raise recipientBs platelet count by "=-===2mm% !ooled from ?:A units of whole blood Single:donor platelet transfusion may be necessary for clients who have developed antibodies$ compatibilities testing may be necessary

F
H

3actor 8444 3ractions +Cryoprecipitate,: contains factor 8444- fibrinogens & I444 7ranulocytes

a
b c d

/o not increase DBC: increase marginal pool +at tissue level, rather than circulating pool !remedication with steroids- antihistamine & acetaminophen )espiratory distress with shortness of breath- cyanosis & chest pain may occur$ reEuires cessation of transfusion & immediate attention Shaking chills or rigors common- reEuire brief cessation of therapy- administration of meperdine 48 until rigors are diminished & resumption of transfusion when symptoms relieved

8olume '.pander: albumin$ percentage concentration varies +F=:"== ml2unit,$ hyperosmolar solution should not be used in dehydrated clients 7oals 2 *b;ectives

"

)eplace circulating blood volume 4ncrease the *# carrying capacity of blood !revent infection: if there is a decrease in DBC !revent bleeding: if there is platelet deficiency !rinciples of blood transfusion

# % ?

"

!roper refrigeration a b '.piration of packed )BC is %:H days '.piration of platelet is %:F days Type *: universal donor Type &B: universal recipient AF> of population is )@ positive 3ilter set 7auge "A:"< needle 4sotonic solution += < NaCl 2 plain NSS,: to prevent hemolysis Client name Blood typing & cross matching '.piration date Serial number Never warm blood: it may destroy vital factors in blood Darming is only done: during emergency situation & if you have the warming device 'mergency rapid BT is given after %= minutes & let natural room temperature warm the blood

!roper typing and cross matching

a b
c % a b

&septically assemble all materials needed for BT

c
? a b c d F

4nstruct another )N to re check the following

Check the blood unit for bubbles cloudiness- sediments and darkness in color because it indicates bacterial contamination

a b
c

H G A
<

BT should be completed less than ? hours because blood that is e.posed at room temperature more than # hours: causes blood deterioration that can lead to bacterial contamination &void mi.ing or administering drugs at BT line: to prevent hemolysis )egulate BT "=:"F gtts2min or 98* rate or eEuivalent to "== cc2hr: to prevent circulatory overload 1onitor strictly vital signs before- during & after BT especially every "F minutes for first hour because ma;ority of transfusion reaction occurs during this period

FF

FH
a b c d e f g @emolytic reaction &llergic reaction !yrogenic reaction Circulatory overload &ir embolism Thrombocytopenia Cytrate into.ication @yperkalemia +caused by e.pired blood,

S2s. of @emolytic reaction " # % ? F H @eadache and diCCiness /yspnea /iarrhea 2 Constipation @ypotension 3lushed skin 6umbasternal 2 3lank pain (rine is color red 2 portwine urine Nursing 1anagement " # % Stop BT Notify physician 3lush with plain NSS &dminister isotonic fluid solution: to prevent shock and acute tubular necrosis Send the blood unit to blood bank for re:e.amination *btain urine & blood sample & send to laboratory for re:e.amination 1onitor vital signs & 4&* S2s. of &llergic reaction " # % ? F H 3ever /yspnea Broncial wheeCing Skin rashes (rticaria 6aryngospasm & Broncospasm Nursing 1anagement " # % ? Stop BT Notify physician 3lush with plain NSS &dminister medications as ordered

?
F H G

a
F H G

&nti @istamine +Benadryl,: if positive to hypotension- anaphylactic shock: treat with 'pinephrine

Send the blood unit to blood bank for re e.amination *btain urine & blood sample & send to laboratory for re:e.amination 1onitor vital signs and intake and output S2s. !yrogenic reactions

" # % ? F H

3ever and chills @eadache Tachycardia !alpitations /iaphoresis /yspnea Nursing 1anagement

" # % ?

Stop BT Notify physician 3lush with plain NSS &dminister medications as ordered a b &ntipyretic &ntibiotic

F H G A

Send the blood unit to blood bank for re e.amination *btain urine & blood sample & send to laboratory for re:e.amination 1onitor vital signs & 4&* )ender TSB

S2s. of Circulatory reaction " # % ? *rthopnea /yspnea )ales 2 Crackles upon auscultation '.ertional discomfort Nursing 1anagement " # % Stop BT Notify physician &dminister medications as ordered

6oop diuretic +6asi.,

FH

FG
Nursing Care " # % &ssess client for history of previous blood transfusions & any adverse reaction 'nsure that the adult client has an "A:"< gauge 48 catheter in place (se = <> sodium chloride &t least two nurse should verify the &B* group- )@ type- client & blood numbers & e.piration date Take baseline 82S before initiating transfusion Start transfusion slowly +# ml2min, Stay with the client during the first "F min of the transfusion & take 82S freEuently 1aintain the prescribed transfusion rate:

?
F

H
G A

a b c d e f g
<

Dhole Blood: appro.imately %:? hr )BC: appro.imately #:? hr 3resh 3roCen !lasma: as Euickly as possible !latelet: as Euickly as possible Cryoprecipitate: rapid infusion 7ranulocytes: usually over # hr 8olume '.pander: volume:dependent rate

1onitor for adverse reaction

"= /ocument the following:

a
b c d e @48

Blood component unit number +apply sticker if available, /ate of infusion starts & end Type of component & amount transfused Client reaction & vital signs Signature of transfusionist

: H months F years incubation period : H months window period : western blot opportunistic : '64S& : drug of choice &QT +Qidon )etrovir, # Common fungal opportunistic infection in &4/S " 9aposis Sarcoma # !neumocystic Carini !neumonia Blood /isorder 4ron /eficiency &nemia +&nemias, & chronic microcytic anemia resulting from inadeEuate absorption of iron leading to hypo.emic tissue in;ury Chronic microcytic- hypochromic anemia caused by either inadeEuate absorption or e.cessive loss of iron &cute or chronic bleeding principal cause in adults +chiefly from trauma- dysfunctional uterine bleeding & 74 bleeding, 1ay also be caused by inadeEuate intake of iron:rich foods or by inadeEuate absorption of iron 4n iron:deficiency states- iron stores are depleted first- followed by a reduction in @gb formation 4ncidence )ate

"
# %

Common among developed countries & tropical Cones +blood:sucking parasites, Common among women "F & ?F years old & children affected more freEuently- as are the poor )elated to poor nutrition !redisposing 3actors

"

Chronic blood loss due to: a b Trauma @eavy menstruation )elated to 74T bleeding resulting to hematemasis and melena +sign for upper 74T bleeding, 3resh blood per rectum is called hematocheCia Chronic diarrhea )elated to malabsorption syndrome @igh cereal intake with low animal C@*N digestion !artial or complete gastrectomy !ica

c d
# a b c d e %

4nadeEuate intake or absorption of iron due to:

)elated to improper cooking of foods S2s.

" #
% ? F H

(sually asymptomatic +mild cases, Deakness & fatigue +initial signs, @eadache & diCCiness !allor & cold sensitivity /yspnea !alpitations Brittleness of hair & nails- spoon shape nails +koilonychias, &trophic 7lossitis +inflammation of tongue,

G A

a
b

Stomatitis /ysphagia

!6(1B') 84NS*NBS S5N/)*1'

<

!4C&: abnormal appetite or craving for non edible foods

FG

FA
/.

" # % ? F H G A

)BC: small +microcytic, & pale +hypochromic, )BC: is decreased @gb: decreased @ct: moderately decreased Serum iron: decreased )eticulocyte count: is decreased Serum ferritin: is decreased @emosiderin: absent from bone marrow Nursing 4ntervention

"

1onitor for s2s. of bleeding through hematest of all elimination including urine- stool & gastrict content 'nforce CB) 2 !rovide adeEuate rest: plan activities so as not to over tire the client !rovide thorough e.planation of all diagnostic e.am used to determine sources of possible bleeding: help allay an.iety & ensure cooperation 4nstruct client to take foods rich in iron a b c d e f g *rgan meat 'gg yolk )aisin Sweet potatoes /ried fruits 6egumes Nuts

# %
?

F
H

4nstruct the client to avoid taking tea and coffee: because it contains tannates which impairs iron absorption &dminister iron preparation as ordered: a *ral 4ron !reparations: route of choice 3errous Sulfate 3errous 3umarate 3errous 7luconate Nursing 1anagement when taking oral iron preparations 4nstruct client to take with meals: to lessen 74T irritation /ilute in liEuid preparations well & administer using a straw: to prevent staining of teeth Dhen possible administer with orange ;uice as vitamin C +ascorbic acid,: to enhance iron absorption Darn clients that iron preparations will change stool color & consistency +dark & tarry, & may cause constipation &ntacid ingestion will decrease oral iron effectiveness

!arenteral: used in clients intolerant to oral preparations- who are noncompliant with therapy or who have continuing blood losses Nursing 1anagement when giving parenteral iron preparation (se one needle to withdraw & another to administer iron preparation as tissue staining & irritation are a problem (se Q:track in;ection techniEue: to prevent leakage into tissue /o not massage in;ection site but encourage ambulation as this will enhance absorption$ advice against vigourous e.ercise & constricting garments *bserve for local signs of complication: !ain at the in;ection site /evelopment of sterile abscesses 6ymphadenitis 3ever & chills @eadache (rticaria !ruritus @ypotension Skin rashes &naphylactic shock 1edications administered via straw 6ugolBs Solution 4ron Tetracycline Nitrofurantoin +1acrodentin,

G A

&dminister with 8itamin C or orange ;uice for absorption 1onitor & inform client of side effects a b c d e &nore.ia N28 &bdominal pain /iarrhea 2 constipation 1elena 4ron /e.tran +41- 48, Sorbite. +41,

<

4f client canBt tolerate 2 no compliance administer parenteral iron preparation

a b

"= !rovide dietary teaching regarding food high in iron

"" 'ncourage ingestion of roughage & increase fluid intake: to prevent constipation if oral iron preparation are being taken

FA

F<
!ernicious &nemia 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 characteriCed by a deficiency of intrinsic factor leading to hypochlorhydria +decrease hydrochloric acid secretion, CharacteriCed by neurologic & 74 symptoms$ death usually resuls if untreated 6ack 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 B"# is not administer !athophysiology

" # %

4ntrinsic factor is necessary for the absorbtion of vitamin B"# into small intestines B"# deficiency diminished /N& synthesis- which results in defective maturation of cell +particularly rapidly dividing cells such as blood cells & 74 tract cells, B"# deficiency can alter structure & function of peripheral nerves- spinal cord- & the brain ST*1&C@ !areital cells2&rgentaffin or *.yntic cells !roduces intrinsic factors !romotes reabsorption of 8it B"# !romotes maturation of )BC !redisposing 3actors Secretes hydrochloric acid &ids in digestion

" # % ? F H " # % ?

(sually occurs in men & women over age of F= with an increase in blue:eyed person of Scandinavian decent Subtotal gastrectomy @ereditary factors 4nflammatory disorders of the ileum &utoimmune Strictly vegetarian diet S2s. &nemia Deakness & fatigue @eadache and diCCiness !allor & cold sensitivity /yspnea & palpitations: as part of compensation 74T S2s.: a 1outh sore !S: )ed beefy tongue 4ndigestion 2 dyspepsia Deight loss Constipation 2 diarrhea 0aundice

F
H

b
c d e f

CNS S2s.: a b c d e f Tingling sensation Numbness !aresthesias of hands & feet !aralysis /epression !sychosis !ositive to )ombergBs test: damage to cerebellum resulting to ata.ia

g
/.

" # % ?
F

'rythrocytes count: decrease Blood Smear: oval- macrocytic erythrocytes with a proportionate amount of @gb Bilirubin +indirect,: elevated uncon;ugated fraction Serum 6/@: elevated Bone 1arrow:

a
b c

4ncreased megaloblasts +abnormal erythrocytes, 3ew normoblasts or maturing erythrocytes /efective leukocytes maturation

!ositive SchillingBs Test: reveals inadeEuate 2 decrease absorption of 8itamin B"#

a
b c

1easures absorption of radioactive vitamin B"# bothe before & after parenteral administration of intrinsic factor /efinitive test for pernicious anemia (sed to detect lack of intrinsic factor 3asting client is given radioactive vitamin B"# by mouth & non:radioactive vitamin B"# 41 to permit some e.cretion of radioactive vitamin B"# in the urine if it os absorbed #?:?A hour urine collection is obtained: client is encourage to drink fluids 4f indicated- second stage schilling test performed " week after first stage 3asting client is given radioactive vitamin B"# combined with human intrinsic factor & test is repeated

d
e

f G A

7astric &nalysis: decrease free hydrochloric acid 6arge number of reticulocytes in the blood following parenteral vitamin B"# administration 1edical 1anagement

"

/rug Therapy:

8itamin B"# in;ection: monthly maintenance

F<

H= b
c

4ron preparation: +if @gb level inadeEuate to meet increase numbers of erythrocytes, 3olic &cid Controversial )everses anemia & 74 symptoms but may intensify neurologic symptoms 1ay be safe if given in small amounts in addition to vitamin B"#

Transfusion Therapy Nursing 4ntervention 'nforce CB): necessary if anemia is severe &dminster 8itamin B"# in;ections at monthly intervals for lifetime as ordered Never given orally because there is possibility of developing tolerance Site of in;ection for 8itamin B"# is dorsogluteal and ventrogluteal No side effects

" #

% ? F
H G A

!rovide a dietary intake that is high in C@*N- vitamin c and iron +fish- meat- milk 2 milk product & eggs, &void highly seasoned- coursed- or very hot foods: if client has mouth sore !rovide safety when ambulating +especially when carrying hot item, 4nstruct client to avoid irritating mouth washes instead use soft bristled toothbrush &void heat application to prevent burns !rovide client teaching & discharge planning concerning: a /ietery instruction 4mportance of lifelong vitamin B"# therapy )ehabilitation & physical therapy for neurologic deficit- as well as instruction regarding safety

b
c

&plastic &nemia Stem cell disorder leading to bone marrow depression leading to pancytopenia !ancytopenia or depression of granulocytes- platelets & erythrocytes production: due to fatty replacement of the bone marrow Bone marrow destruction may be idiopathic or secondary !&NC5T*!'N4& /ecrease )BC +anemia, !redisposing 3actors /ecrease DBC +leukopenia, /ecrease !latelet +thrombocytopenia,

"
# % ?

Chemicals +BenCene and its derivatives, )elated to radiation 2 e.posure to .:ray 4mmunologic in;ury /rugs:

a
b

Broad Spectrum &ntibiotics: Chloramphenicol +Sulfonamides, Cytoto.ic agent 2 Chemotherapeutic &gents: 1ethotre.ate +&lkylating &gent, 8incristine +!lant &lkaloid, Nitrogen 1ustard +&ntimetabolite, !henylbutaCones +NS&4/S,

S2s. " &nemia a b c d # % a Deakness & fatigue @eadache & diCCiness !allor & cold sensitivity /yspnea & palpitations 4ncrease susceptibility to infection !etechiae +multiple petechiae is called purpura, 'cchymosis *oCing of blood from venipunctured sites

6eukopenia Thrombocytopenia

a
b c /.

"
#

CBC: reveals pancytopenia Normocytic anemia- granulocytopenia- thrombocytopenia Bone marrow biopsy: aspiration +site is the posterior iliac crest,: marrow is fatty & contain very few developing cells$ reveals fat necrosis in bone marrow 1edical 1anagement

"
# % ?

Blood transfusion: key to therapy until clientBs own marrow begins to produce blood cells &ggressive treatment of infection Bone marrow transplantation /rug Therapy:

a b
F

Corticosteroids & 2 or androgens: to stimulate bone marrow function & to increase capillary resistance +effective in children but usually not in adults, 'strogen & 2 or progesterone: to prevent amenorrhea in female clients

4dentification & withdrawal of offending agent or drug Nursing 4ntervention

" #

)emoval of underlying cause &dminister Blood Transfusion as ordered &dminister *# inhalation

H=

H"
? F H G 'nforce CB) 4nstitute reverse isolation !rovide nursing care for client with bone marrow transplant &dminister medications as ordered:

a b

Corticosteroids: caused by immunologic in;ury 4mmunosuppressants: &nti 6ymphocyte 7lobulin 7iven via central venous catheter 7iven H days to % weeks to achieve ma.imum therapeutic effect of drug

1onitor for signs of infection & provide care to minimiCe risk: a 1onitor neuropenic precautions 'ncourage high C@*N- vitamin diet: to help reduce incidence of infection !rovide mouth care before & after meals 3ever Cough (se soft toothbrush when brushing teeth & electric raCor when shaving: prevent bleeding &void 41- subcutaneous- venipunctured sites: 4nstead provide heparin lock @ematest urine & stool *bserve for ooCing from gums- petechiae or ecchymoses Self:care regimen 4dentification of offending agent & importance of avoiding it +if possible, in future

b
c d e <

1onitor signs of bleeding & provide measures to minimiCe risk:

a b
c d a

"= !rovide client teaching & discharge planning concerning:

/isseminated 4ntravascular Coagulation +/4C, /iffuse fibrin deposition within arterioles & capillaries with widespread coagulation all over the body & subseEuent depletion of clotting factors &cute hemorrhagic syndrome characteriCed by wide spread bleeding and thrombosis due to a deficiency of prothrombin and fibrinogen @emorrhage from kidneys- brain- adrenals- heart & other organs 1ay be linked with entry of thromboplasic substance into the blood 1ortality rate is high usually because underlying disease cannot be corrected

!athophysiology

"
# % ? F

(nderlying disease +e. to.emia of pregnancy- cancer, cause release of thromboplastic substance that promote the deposition of fibrin throughout the microcirculation 1icrothrombi form in many organs- causing microinfarcts & tissue necrosis )BC are trapped in fibrin strands & are hemolysed !latelets- prothrombin & other clotting factors are destroyed- leading to bleeding '.cessive clotting activates the fibrinolytic system- which inhibits platelet function- causing futher bleeding !redisposing 3actors

" # % ? F

)elated to rapid blood transfusion 1assive burns 1assive trauma &naphyla.is Septecemia Neoplasia +new growth of tissue, !regnancy S2s.

H
G

"
# % ?

!etechiae & 'cchymosis on the skin- mucous membrane- heart- eyes- lungs & other organs +widespread and systemic, !rolonged bleeding from breaks in the skin: ooCing of blood from punctured sites Severe & uncontrollable hemorrhage during childbirth or surgical procedure @emoptysis *liguria & acute renal failure +late sign, Convulsion- coma- death /.

F
H

" # % ? F H G A <

!T: prolonged !TT: usually prolonged Thrombin Time: usually prolonged 3ibrinogen level: usually depressed 3ibrin splits products: elevated !rotamine Sulfate Test: strongly positive 3actor assay +44- 8- 844,: depressed CBC: reveals decreased platelets Stool occult blood: positive

"= &B7 analysis: reveals metabolic acidosis "" *pthamoscopic e.am: reveals sub retinal hemorrhages
1edical 1anagement " 4dentification & control the underlying disease is key Blood Tranfusions: include whole blood- packed )BC- platelets- plasma- cryoprecipitites & volume e.panders @eparin administration a Somewhat controversial

#
%

H"

H#
b 4nhibits thrombin thus preventing further clot formation- allowing coagulation factors to accumulate

Nursing 4ntervention " # % ? 1onitor blood loss & attemp to Euantify 1onitor for signs of additional bleeding or thrombus formation 1onitor all hema test 2 laboratory data including stool and 74T !revent further in;ury a b c &void 41 in;ection &pply pressure to bleeding site Turn & position the client freEuently & gently !rovide freEuent nontraumatic mouth care +e. soft toothbrush or gauCe sponge,

d F
H G A

&dminister isotonic fluid solution as ordered: to prevent shock &dminister o.ygen inhalation 3orce fluids &dminister medications as ordered: a 8itamin 9 !itressin 2 8asopresin: to conserve fluids @eparin 2 Comadin is ineffective

b
c <

!rovide heparin lock

"= 4nstitute N7T decompression by performing gastric lavage: by using ice or cold saline solution of F==:"=== ml
"" 1onitor N7T output "# !revent complication

@ypovolemic shock: &nuria +late sign of hypovolemic shock,

"% !rovide emotional support to client & significant other "? Teach client the importance of avoiding aspirin or aspirin:containing compounds

*verview of the Structure & 3unctions of the @eart @eart 1uscular pumping organ that propel blood into the arerial system & receive blood from the venous system of the body 6ocated on the left mediastinum )esemble like a close fist Deighs appro.imately %== ?== grams Covered by a serous membrane called the pericardium Cardiovascular system consists of the heart- arteries- veins & capillaries The ma;or function are circulation of blood- delivery of *# & other nutrients to the tissues of the body & removal of C*# & other cellular products metabolism

@eart Dall 2 6ayers of the @eart !ericardium

Composed of fibrous +outermost layer, & serous pericardium +parietal & visceral,$ a sac that function to protect the heart from friction 4n between is the pericardial fluid which is "= #= cc: !revent pericardial friction rub # layers of pericardium

'picardium

!arietal: outer layer 8isceral: inner layer

Covers surface of the heart- becomes continuous with visceral layer of serous pericardium *uter layer

1yocardium 1iddle muscular layer 1yocarditis can lead to cardiogenic shock and rheumatic heart disease

'ndocardium Thin- inner membrabous layer lining the chamber of the heart 4nner layer

!apillary 1uscle &rise from the endocardial & myocardial surface of the ventricles & attach to the chordae tendinae

Chordae Tendinae &ttach to the tricuspid & mitral valves & prevent eversion during systole

Chambers of the @eart &tria # chambers- function as receiving chambers- lies above the ventricles (pper Chamber +connecting or receiving,

8entricles

)ight &trium: receives systemic venous blood through the superior vena cava- inferior vena cava & coronary sinus 6eft &trium: receives o.ygenated blood returning to the heart from the lungs trough the pulmonary veins

# thick:walled chambers$ ma;or responsibility for forcing blood out of the heart$ lie below the atria 6ower Chamber +contracting or pumping,

)ight 8entricle: contracts & propels deo.ygenated blood into pulmonary circulation via the aorta during ventricular systole$ )ight atrium has decreased pressure which is H= A= mm@g 6eft 8entricle: propels blood into the systemic circulation via aortaduring ventricular systole$ 6eft ventricle has increased pressure which is "#= "A= mm@g in order to propel blood to the systemic circulation

8alves

H#

H%
To promote unidimensional flow or prevent backflow

&trioventricular 8alve 7uards opening between

3unctions

1itral 8alve: located between the left atrium & left ventricle$ contains # leaflets attached to the chordae tandinae Tricuspid 8alve: located between the right atrium & right ventricle$ contains % leaflets attached to the chordae tandinae

!ermit unidirectional flow of blood from specific atrium to specific ventricle during ventricular diastole !revent reflu. flow during ventricular systole 8alve leaflets open during ventricular diastole$ Closure of &8 valves give rise to first heart sound +S" JlubK,

Semi:lunar 8alve !ulmonary 8alve 6ocated between the left ventricle & pulmonary artery

&ortic 8alve 6ocated between left ventricle & aorta

3unction !emit unidirectional flow of the blood from specific ventricle to arterial vessel during ventricular diastole !revent reflu. blood flow during ventricular diastole 8alve open when ventricle contract & close during ventricular diastole$ Closure of S8 valve produces second heart sound +S# JdubK,

'.tra @eart Sounds

S%: ventricular gallop usually seen in 6eft Congestive @eart 3ailure S?: atrial gallop usually seen in 1yocardial 4nfarction and @ypertension

Coronary Circulation Coronary &rteries Branch off at the base of the aorta & supply blood to the myocardium & the conduction system &rises from base of the aorta Types of Coronary &rteries )ight 1ain Coronary &rtery 6eft 1ain Coronary &rtery

Coronary 8eins )eturn blood from the myocardium back to the right atrium via the coronary sinus

Conduction System Sinoatrial Node +S& node or 9eith 3lack Node, 6ocated at the ;unction of superior vena cava and right atrium &cts as primary pacemaker of the heart 4nitiates the cardiac impulse which spreads across the atria & into &8 node 4nitiates electrical impulse of H=:"== bpm

&trioventricular Node +&8 node or Tawara Node, 6ocated at the inter atrial septum /elays the impulse from the atria while the ventricles fill /elay of electrical impulse for about =A milliseconds to allow ventricular filling

Bundle of @is &rises from the &8 node & conduct impulse to the bundle branch system 6ocated at the interventricular septum

)ight Bundle Branch: divided into anterior lateral & posterior$ transmits impulses down the right side of the interventricular myocardium 6eft Bundle Branch: divided into anterior & posterior

!urkin;e 3ibers

&nterior !ortion: transmits impulses to the anterior endocardial surface of the left ventricle !osterior !ortion: transmits impulse over the posterior & inferior endocardial surface of the left ventricle

Transmit impulses to the ventricle & provide for depolariCation after ventricular contraction 6ocated at the walls of the ventricles for ventricular contraction

S& N*/' &8 N*/'

B(N/6' *3 @4S

!()94N0' 34B')S

H%

H?
'lectrical activity of heart can be visualiCe by attaching electrodes to the skin & recording activity by 'C7 'lectrocadiography +'C7, Tracing

! wave +atrail depolariCation, contraction S)S wave +ventricular depolariCation, T wave +ventricular repolariCation, 4nsert pacemaker if there is complete heart block 1ost common pacemaker is the metal pacemaker and lasts up to # F years

&bnormal 'C7 Tracing

!ositive ( wave: @ypokalemia !eak T wave: @yperkalemia ST segment depression: &ngina !ectoris ST segment elevation: 1yocardial 4nfarction T wave inversion: 1yocardial 4nfarction Didening of S)S comple.es: &rrythmia

8ascular System 1a;or function of the blood vessels isto supply the tissue with blood- remove wastes- & carry uno.ygenated blood back to the heart

Types of Blood 8essels &rteries 'lastic:walled vessels that can stretch during systole & recoil during diastole$ they carry blood away from the heart & distribute o.ygenated blood throughout the body &rterioles Small arteries that distribute blood to the capillaries & function in controlling systemic vascular resistance & therefore arterial pressure

Capilliaries The following e.changes occurs in the capilliaries 8enules 8eins 6ow:pressure vessels with thin small & less muscles than arteries$ most contains valves that prevent retrograde blood flow$ they carry deo.ygenated blood back to the heart Dhen the skeletal surrounding veins contract- the veins are compressed- promoting movement of blood back to the heart Small veins that receive blood from capillaries & function as collecting channels between the capillaries & veins *# & C*# Solutes between the blood & tissue 3luid volume transfer between the plasma & interstitial space

Cardiac /isorders Coronary &rterial /isease 2 4schemic @eart /isease Stages of /evelopment of Coronary &rtery /isease

" # %

1yocardial 4n;ury: &therosclerosis 1yocardial 4schemia: &ngina !ectoris 1yocardial Necrosis: 1yocardial 4nfarction

&T@')*SC6')*S4S &T@')*SC6')*S4S Narrowing of artery 6ipid or fat deposits Tunica intima &)T')4*SC6')*S4S @ardening of artery Calcium and protein deposits Tunica media

!redisposing 3actors

" #
% ? F H G A

Se.: male )ace: black Smoking *besity @yperlipidemia Sedentary lifestyle /iabetes 1ellitus @ypothyroidism /iet: increased saturated fats

<

"= Type & personality S2s. " # % ? F Chest pain /yspnea Tachycardia !alpitations /iaphoresis

Treatment ! - !ercutaneous T - Transluminal C - Coronary

H?

HF
& + &ngioplasty C - Coronary & - &rterial B - Bypass & - &nd 7 - 7raft S - Surgery

*b;ectives " # % ? F )evasculariCe myocardium To prevent angina 4ncrease survival rate /one to single occluded vessels 4f there is # or more occluded blood vessels C&B7 is done

% Complications of C&B7

"
# %

!neumonia: encourage to perform deep breathing- coughing e.ercise and use of incentive spirometer Shock Thrombophlebitis

&ngina !ectoris Transient paro.ysmal chest pain produced by insufficient blood flow to the myocardium resulting to myocardial ischemia Clinical syndrome characteriCed by paro.ysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial ischemia !redisposing 3actors " # % ? F H G A Se.: male )ace: black Smoking *besity @yperlipidemia Sedentary lifestyle /iabetes 1ellitus @ypertension C&/: &therosclerosis

<

"= Thromboangiitis *bliterans "" Severe &nemia

"# &ortic 4nsufficiency: heart valve that fails to open & close efficiently
"% @ypothyroidism

"? /iet: increased saturated fats

"F Type & personality !recipitating 3actors ? 'Bs of &ngina !ectoris

" # %
?

'.cessive physical e.ertion: heavy e.ercises- se.ual activity '.posure to cold environment: vasoconstriction '.treme emotional response: fear- an.iety- e.citement- strong emotions '.cessive intake of foods or heavy meal

S2s.

" #
% ? F H

6evineBs Sign: initial sign that shows the hand clutching the chest Chest pain: characteriCed by sharp stabbing pain located at sub sterna usually radiates from neck- back- arms- shoulder and ;aw muscles usually relieved by rest or taking nitroglycerine +NT7, /yspnea Tachycardia !alpitations /iaphoresis

/. " @istory taking and physical e.am 'C7: may reveals ST segment depression & T wave inversion during chest pain Stress test 2 treadmill test: reveal abnormal 'C7 during e.ercise 4ncrease serum lipid levels Serum cholesterol & uric acid is increased

# %
? F

1edical 1anagement

"

/rug Therapy: if cholesterol is elevated

Nitrates: Nitroglycerine +NT7, Beta:adrenergic blocking agent: !ropanolol Calcium:blocking agent: nefedipine &ce 4nhibitor: 'napril

1odification of diet & other risk factors Surgery: Coronary artery bypass surgery

HF

HH ?

!ercutaneuos Transluminal Coronary &ngioplasty +!TC&,

Nursing 4ntervention " # 'nforce complete bed rest 7ive prompt pain relievers with nitrates or narcotic analgesic as ordered &dminister medications as ordered:

Nitroglycerine +NT7,: when given in small doses will act as venodilator- but in large doses will act as vasodilator

7ive "st dose of NT7: sublingual %:F minutes 7ive #nd dose of NT7: if pain persist after giving "st dose with interval of %:F minutes 7ive %rd & last dose of NT7: if pain still persist at %:F minutes interval

Nursing 1anagement when giving NT7

"

NT7 Tablets +sublingual, 9eep the drug in a dry place- avoid moisture and e.posure to sunlight as it may inactivate the drug )ela. for "F minutes after taking a tablet: to prevent diCCiness 1onitor side effects: *rthostatic hypotension Transient headache & diCCiness: freEuent side effect

4nstruct the client to rise slowly from sitting position &ssist or supervise in ambulation

NT7 Nitrol or Transdermal patch &void placing near hairy areas as it may decrease drug absorption &void rotating transdermal patches as it may decrease drug absorption &void placing near microwave ovens or during defibrillation as it may lead to burns +most important thing to remember,

Beta:blockers !ropanolol: side effects !NS Not given to C*!/ cases: it causes bronchospasm

c d ? F H G A

&C' 4nhibitors 'nalapril

Calcium &ntagonist Nefedipine

&dminister o.ygen inhalation !lace client on semi:to high fowlers position 1onitor strictly 82S- 4&*- status of cardiopulmonary fuction & 'C7 tracing !rovide decrease saturated fats sodium and caffeine !rovide client health teachings and discharge planning &voidance of ? 'Bs !revent complication +myocardial infarction, 4nstruct client to take medication before indulging into physical e.ertion to achieve the ma.imum therapeutic effect of drug )educe stress & an.iety: rela.ation techniEues & guided imagery &void overe.ertion & smoking &void e.tremes of temperature /ress warmly in cold weather !articipate in regular e.ercise program Space e.ercise periods & allow for rest periods The importance of follow up care

<

4nstruct the client to notify the physician immediately if pain occurs & persists despite rest & medication administration

1yocardial 4nfarction /eath of myocardial cells from inadeEuate o.ygenation- often caused by sudden complete blockage of a coronary artery CharacteriCed by localiCed formation of necrosis +tissue destruction, with subseEuent healing by scar formation & fibrosis @eart attack Terminal stage of coronary artery disease characteriCed by malocclusion- necrosis & scarring

Types

" #

Transmural 1yocardial 4nfarction: most dangerous type characteriCed by occlusion of both right and left coronary artery Subendocardial 1yocardial 4nfarction: characteriCed by occlusion of either right or left coronary artery

The 1ost Critical !eriod 3ollowing /iagnosis of 1yocardial 4nfarction

H:A hours because ma;ority of death occurs due to arrhythmia leading to premature ventricular contractions +!8C,

!redisposing 3actors

" #
% ?

Se.: male )ace: black Smoking *besity C&/: &therosclerotic Thrombus 3ormation 7enetic !redisposition @yperlipidemia Sedentary lifestyle

F
H G A <

"= /iabetes 1ellitus "" @ypothyroidism

HH

HG "# /iet: increased saturated fats

"% Type & personality S2s. " Chest pain

# % N28

'.cruciating visceral- viselike pain with sudden onset located at substernal & rarely in precordial (sually radiates from neck- back- shoulder- arms- ;aw & abdominal muscles +abdominal ischemia,: severe crushing Not usually relieved by rest or by nitroglycerine

/yspnea 4ncrease in blood pressure & pulse- with gradual drop in blood pressure +initial sign, @yperthermia: elevated temp Skin: cool- clammy- ashen 1ild restlessness & apprehension *ccasional findings: !ericardial friction rub Split S" & S# )ales or Crackles upon auscultation S? or atrial gallop

? F
H G A

/. "

Cardiac 'nCymes

C!9:1B: elevated Creatinine phosphokinase +C!9,: elevated @eart only- "# #? hours 6actic acid dehydrogenase +6/@,: is increased Serum glutamic pyruvate transaminase +S7!T,: is increased Serum glutamic o.al:acetic transaminase +S7*T,: is increased

#
%

Troponin Test: is increased 'C7 tracing reveals ST segment elevation T wave inversion Didening of S)S comple.es: indicates that there is arrhythmia in 14

? F

Serum Cholesterol & uric acid: are both increased CBC: increased DBC

Nursing 4ntervention

"

7oal: /ecrease myocardial o.ygen demand

/ecrease myocardial workload +rest heart, 'stablish a patent 48 line &dminister narcotic analgesic as ordered: 1orphine Sulfate 48: provide pain relief +given 48 because after an infarction there is poor peripheral perfusion & because serum enCyme would be affected by 41 in;ection as ordered,

# %
? F H G

Side 'ffects: )espiratory /epression &ntidote: Nalo.one +Narcan, Side 'ffects of Nalo.one To.icity: is tremors

&dminister o.ygen low flow #:% 6 2 min: to prevent respiratory arrest or dyspnea & prevent arrhythmias 'nforce CB) in semi:fowlers position without bathroom privileges +use bedside commode,: to decrease cardiac workload 4nstruct client to avoid forms of valsalva maneuver !lace client on semi fowlers position 1onitor strictly 82S- 4&*- 'C7 tracing & hemodynamic procedures !erform complete lung 2 cardiovascular assessment 1onitor urinary output & report output of less than %= ml 2 hr: indicates decrease cardiac output !rovide a full liEuid diet with gradual increase to soft diet: low in saturated fats- Na & caffeine

A <

"= 1aintain Euiet environment

"" &dminister stool softeners as ordered: to facilitate bowel evacuation & prevent straining "# )elieve an.iety associated with coronary care unit +CC(, environment "% &dminister medication as ordered: a b
8asodilators: Nitroglycirine +NT7,- 4sosorbide /initrate- 4sodil +4S/,: sublingual &nti &rrythmic &gents: 6idocaine +Iylocane,- Brithylium

c d e f

Side 'ffects: confusion and diCCiness

Beta:blockers: !ropanolol +4nderal, &C' 4nhibitors: Captopril +'nalapril, Calcium &ntagonist: Nefedipine Thrombolytics 2 3ibrinolytic &gents: Streptokinase- (rokinase- Tissue !lasminogen &ctivating 3actor +T4!&3,

Side 'ffects: allergic reaction- urticaria- pruritus Nursing 4ntervention: 1onitor for bleeding time

&nti Coagulant @eparin

&ntidote: !rotamine Sulfate Nursing 4ntervention: Check for !artial Thrombin Time +!TT,

HG

HA

Caumadin +Darfarin,

h
a b

&ntidote: 8itamin 9 Nursing 4ntervention: Check for !rothrombin Time +!T,

&nti !latelet: !&S& +&spirin,: &nti thrombotic effect Side 'ffects: Tinnitus- @eartburn- 4ndigestion 2 /yspepsia Contraindication: /engue- !eptic (lcer /isease- (nknown cause of headache

"? !rovide client health teaching & discharge planning concerning:

'ffects of 14 healing process & treatment regimen 1edication regimen including time name purpose- schedule- dosage- side effects /ietary restrictions: low Na- low cholesterol- avoidance of caffeine 'ncourage client to take #= %= cc2week of wine- whisky and brandy: to induce vasodilation &voidance of modifiable risk factors !revent Complication

c d
e f

&rrhythmia: caused by premature ventricular contraction Cardiogenic shock: late sign is oliguria 6eft Congestive @eart 3ailure Thrombophlebitis: homanBs sign Stroke 2 C8& /resslerBs Syndrome +!ost 14 Syndrome,: client is resistant to pharmacological agents: administer "F=-===:?F=-=== units of streptokinase as ordered

4mportance of participation in a progressive activity program )esumption of &/6 particularly se.ual intercourse: is ?:H weeks post cardiac rehab- post C&B7 & instruct to: 1ake se. as an appetiCer rather than dessert 4nstruct client to assume a non weight bearing position Client can resume se.ual intercourse: if can climb or use the staircase

i ; k

Need to report the ff s2s.: 4ncreased persistent chest pain /yspnea Deakness 3atigue !ersistent palpitation 6ight headedness

'nrollment of client in a cardiac rehabilitation program Strict compliance to mediation & importance of follow up care

Congestive @eart 3ailure 4nability of the heart to pump an adeEuate supply of blood to meet the metabolic needs of the body 4nability of the heart to pump blood towards systemic circulation

Types of @eart 3ailure " # % 6eft Sided @eart 3ailure )ight Sided @eart 3ailure @igh:*utput 3ailure

6eft Sided @eart 3ailure

6eft ventricular damage causes blood to back up through the left atrium & into the pulmonary veins: 4ncreased pressure causes transudation into interstitial tissues of the lungs which result pulmonary congestion

!redisposing 3actors

"
# % ? F S2s. "

<=> is mitral valve stenosis due to )@/: inflammation of mitral valve due to invasion of 7roup & beta:hemolytic streptococcus 1yocardial 4nfarction 4schemic heart disease @ypertension &ortic valve stenosis

/yspnea !aro.ysmal nocturnal dyspnea +!N/,: client is awakened at night due to difficulty of breathing *rthopnea: use #:% pillows when sleeping or place in high fowlers Tiredness 1uscle Deakness !roductive cough with blood tinged sputum Tachycardia 3rothy salivation Cyanosis

# %
? F H G A <

"= !allor "" )ales 2 Crackles "# Bronchial wheeCing

"% !ulsus &lternans: weak pulse followed by strong bounding pulse "? !14 is displaced laterally: due to cardiomegaly "F !ossible S%: ventricular gallop
/.

"

Chest I:ray +CI),: reveals cardiomegaly

HA

H< # % ?

!ulmonary &rterial !ressure +!&!,: measures pressure in right ventricle or cardiac status: increased !ulmonary Capillary Dedge !ressure +!CD!,: measures end systolic and dyastolic pressure: increased Central 8enous !ressure +C8!,: indicates fluid or hydration status

F H G

4ncrease C8!: decreased flow rate of 48 /ecrease C8!: increased flow rate of 48

Swan:7anC catheteriCation: cardiac catheteriCation 'chocardiography: shows increased siCed of cardiac chamber +cardiomyopathy,: dependent on e.tent of heart failure &B7: reveals !*# is decreased +hypo.emia,- !C*# is increased +respiratory acidosis,

)ight Sided @eart 3ailure

Deakened right ventricle is unable to pump blood into he pulmonary system: systemic venous congestion occurs as pressure builds up

!redisposing 3actors " # % ? F H G S2s. " # % ? F H G A < &nore.ia Nausea Deight gain Neck 2 ;ugular vein distension !itting edema Bounding pulse @epatomegaly 2 Slenomegaly Cool e.tremities &scites )ight ventricular infarction &therosclerotic heart disease Tricuspid valve stenosis !ulmonary embolism )elated to C*!/ !ulmonic valve stenosis 6eft sided heart failure

"= 0aundice "" !ruritus "# 'sophageal varices /.

" #

Chest I:ray +CI),: reveals cardiomegaly Central 8enous !ressure +C8!,: measure fluid status: elevated

1easure pressure in right atrium: ?:"= cm of water 4f C8! is less than ? cm of water: @ypovolemic shock: increase 48 flow rate 4f C8! is more than "= cm of water: @ypervolemic shock: &dminister loop diuretics as ordered Nursing 4ntervention: Dhen reading C8! patient should be flat on bed (pon insertion place client in trendelendberg position: to promote ventricular filling and prevent pulmonary embolism

% ? F

'chocardiography: reveals increased siCe of cardiac chambers +cardiomyopathy, 6iver enCymes: S7!T & S7*T: is increased &B7: decreased p*#

1edical 1anagement " /etermination & elimination 2 control of underlying cause /rug therapy: digitalis preparations- diuretics- vasodilators Sodium:restricted diet: to decrease fluid retention 4f medical therapies unsuccessful: mechanical assist devices +intra:aortic balloon pump,- cardiac transplantation- or mechanical heart may be employed Treatment for 6eft Sided @eart 3ailure *nly: 1 1orphine S*? & &minophylline / /igitalis / /iuretics * *# 7 7ases Nursing 4ntervention 7oal: 4ncrease cardiac contractility thereby increasing cardiac output of %:H 6 2 min

# % ? F

"

1onitor respiratory status & provide adeEuate ventilation +when @3 progress to pulmonary edema,

a b
c

&dminister *# therapy: high inflow %:? 6 2 min delivered via nasal cannula 1aintain client in semi or high fowlers position: ma.imiCe o.ygenation by promoting lung e.pansion 1onitor &B7 &ssess for breath sounds: noting any changes Constantly assess level of an.iety 1aintain bed rest with limited activity 1aintain Euiet & rela.ed environment *rganiCed nursing care around rest periods

d
# a b c d

!rovide physical & emotional rest

H<

G=
% 4ncrease cardiac output a &dminister digitalis as ordered & monitor effects

b c

Cardiac glycosides: /igo.in +6ano.in, &ction: 4ncrease force of cardiac contraction Contraindication: 4f heart rate is decreased do not give

1onitor 'C7 & hemodynamic monitoring &dminister vasodilators as ordered

d ? a

8asodilators: Nitroglycerine +NT7,

1onitor 82S &dminister diuretics as ordered

)educe 2 eliminate edema

b c d e f g h i

6oop /iuretics: 6asi. +3urosemide,

/aily weight 1aintain accurate 4&* &ssess for peripheral edema 1easure abdominal girth daily 1onitor electrolyte levels 1onitor C8! & Swan:7anC reading !rovide Na restricted diet as ordered !rovide meticulous skin care

4f acute pulmonary edema occurs: 3or 6eft Sided @eart 3ailure only a &dminister Narcotic &nalgesic as ordered

Narcotic analgesic: 1orphine S*? &ction: to allay an.iety & reduce preload & afterload

&dminister Bronchodilator as ordered

Bronchodilators: &minophylline 48 &ction: relieve bronchospasm- increase urinary output & increase cardiac output

&dminister &nti:arrythmic as ordered

H
G preload

&nti:arrythmic: 6idocaine +Iylocane,

&ssist in bloodless phlebotomy: rotating tourniEuet- rotated clockwise every "F minutes: to promote decrease venous return or reducing !rovide client teaching & discharge planning concerning:

a b c
d e

Need to monitor self daily for S2s. of @eart 3ailure +pedal edema- weight gain- of ":# kg in a # day period- dyspnea- loss of appetitecough, 1edication regimen including name- purpose- dosage- freEuency & side effects +digitalis- diuretics, !rescribe diet plan +low Na- cholesterol- caffeine: small freEuent meals, Need to avoid fatigue & plan for rest periods !revent complications &rrythmia Shock )ight ventricular hypertrophy 14 Thrombophlebitis

4mportance of follow:up care

!eripheral 8ascular /isorder &rterial (lcer

"
#

Thromboangiitis *bliterans +BuergerBs /isease, )aynaudBs !henomenon

8enous (lcer " 8aricose 8eins Thrombophlebitis +deep vein thrombosis,

Thromboangiitis *bliterans +BuergerBs /isease, &cute inflammatory disorder affecting the small 2 medium siCed arteries & veins of the lower e.tremities *ccurs as focal- obstructive- process$ result in occlusion of a vessel with a subseEuent development of collateral circulation

!redisposing 3actors " # S2s. @igh risk groups : men #F:?= years old @igh incident among smokers

" # %
?

4ntermittent claudication: leg pain upon walking Cold sensitivity & changes in skin color "st white +pallor, changing to blue +cyanosis, then red +rubor, /ecreased or absent peripheral pulses +posterior tibial & dorsalis pedis, Trophic changes (lceration & 7angrene formation +advanced,

F
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" # %

*scillometry: may reveal decrease in peripheral pulse volume /oppler +(TQ,: reveals decrease blood flow to the affected e.tremity &ngiography: reveals location & e.tent of obstructive process

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G"

1edical 1anagement " /rug Therapy

8asodilators: to improve arterial circulation +effectiveness V, !apaverine 4so.suprine @C6 +8asodilan, Nylidrin @C6 +&rlidin, Nicotinyl &lcohol +)oniacol, Cyclandelate +Cyclospasmol, TolaColine @C6 +!riscoline,

b c
# a b c

&nalgesic: to relieve ischemic pain &nti:coagulant: to prevent thrombus formation Bypass 7rafting 'ndarterectomy Balloon Catheter /ilation 6umbar Sympathectomy: to increase blood flow &mputation: may be necessary

Surgery

d
e

Nursing 4ntervention " 'ncourage a slow progressive physical activity # % ? F Dalking at least # times 2 day *ut of bed at least %:? times 2 day

&dminister medications as ordered &nalgesics 8asodilators &nti:coagulants

3oot care management: Need to avoid trauma to the affected e.treminty

4mportance of stop smoking Need to maintain warmth especially in cold weather !repare client for surgery: below knee amputation +B9&, 4mportance of follow:up care

H
G

)aynaudBs !henomenon 4ntermittent episodes of arterial spasm most freEuently involving the fingers or digits of the hands !redisposing 3actors

"
# %

@igh risk group: female between the teenage years & age ?= years old & above Smoking Collagen diseases

a
b ? a b c S2s. " # %

Systemic 6upus 'rythematosus +S6',: butterfly rash )heumatoid &rthritis !iano playing '.cessive typing *perating chainsaw

/irect hand trauma

Coldness Numbness Tingling in one or more digits !ain: usually precipitated by e.posure to cold- 'motional upset & Tobacco use 4ntermittent color changes: pallor +white,- cyanosis +blue,- rubor +red, Small ulceration & gangrene a tips of digits +advance,

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" #

/oppler (TQ: decrease blood flow to the affected e.tremity &ngiography: reveals site & e.tent of malocclusion

1edical 1anagement " &dminister medications as ordered a Catecholamine:depliting antihypertinsive drugs: b " # % )eserpine 7uanethidine 1onosulfate +4smelin,

8asodilators

Nursing 4ntervention 4mportance of stop smoking Need to maintain warmth especially in cold weather Need to wear gloves when handling cold ob;ect 2 opening a freeCer or refrigerator door

8aricose 8eins

G"

G#
/ilated veins that occurs most often in the lower e.tremities & trunk &s the vessel dilates the valves become stretched & incompetent with result venous pooling 2 edema

&bnormal dilation of veins of lower e.tremities and trunks due to incompetent valve resulting to increased venous pooling resulting to venous stasis causing decrease venous return

!redisposing 3actors " # % ? F H G S2s. @ereditary Congenital weakness of the veins Thrombophlebitis Cardiac disorder !regnancy *besity !rolonged standing or sitting

"
# % ? /. "

!ain after prolonged standing: relieved by elevation Swollen dilated tortuous skin veins Darm to touch @eaviness in legs

8enography Trendelenburg Test: veins distends Euickly in less than %F seconds /oppler (ltrasound: decreased or no blood flow heard after calf or thigh compression

# %

1edical 1anagement

" #

8ein 6igation: involves ligating the saphenous vein where it ;oins the femoral vein & stripping the saphenous vein system fro groin to ankles Sclerotherapy: can recur & only done in spider web varicosities & danger of thrombosis +#:% years for embolism,

Nursing 4ntervention

"
# % ? F

'levate legs above heart level: to promote increased venous return by placing #:% pillows under the legs 1easure the circumference of ankle & calf muscle daily: to determine if swollen &pply anti:embolic 2 knee:length stockings !rovide adeEuate rest &dminister medications as ordered

a H
a

&nalgesics: for pain

!repare client for vein ligation if necessary !rovide routine pre:op care: usually *!/ 4n addition to routine post:op care:

9eep affected e.tremity elevated above the level of the heart: to prevent edema &pply elastic bandage & stockings which should be removed every A hours for short periods & reapplied &ssist out of bed within #? hours ensuring the elastic stockings is applied &ssess for increase of bleeding particularly in groin area

!rovide client teaching & discharge planning

Thrombophlebitis +/eep vein thrombosis,

4nflammation of the vessel wall with formation of clot +thrombus,- may affect superficial or deep veins 4nflammation of the veins with thrombus formation 1ost freEuent veins affected are the saphenous- femoral & popliteal Can result in damage to the surrounding tissue- ischemia & necrosis

!redisposing 3actors " # % ? *besity Smoking )elated to pregnancy Severe anemia !rolong use of oral contraceptives: promotes lipolysis !rolonged immobility Trauma /ehydration Sepsis

F
H G A <

"= Congestive heart failure "" 1yocardial infarction

"# !ost:op complication: surgery "% 8enous cannulation: insertion of various cardiac catheter
"? 4ncrease in saturated fats in the diet S2s. " !ain in the affected e.tremity Superficial vein: Tenderness- redness induration along course of the vein /eep vein: Swelling 8enous distention of limb Tenderness over involved vein

#
%

G#

G%
/.

!ositive homanBs sign: pain at the calf or leg muscle upon dorsi fle.ion of the foot Cyanosis

" # %

8enography +!hlebography,: increased uptake of radioactive material /oppler ultrasonography: impairment of blood flow ahead of thrombus 8enous pressure measurement: high in affected limb until collateral circulation is developed

1edical 1anagement " &nti:coagulant therapy a @eparin

&ction: block conversion of prothrombin to thrombin & reduces formation or e.tension of thrombus Side effects: Spontaneous bleeding 4n;ection site reaction 'cchymoses Tissue irritation & sloughing )eversible transient alopecia Cyanosis !an in the arms or legs Thrombocytopenia

Darfarin +Coumadin,

&ction: block prothrombin synthesis by interfering with vit 9 synthesis Side effects:

74: &nore.ia N28 /iarrhea Stomatitis

@ypersensitivity: /ermatitis (rticaria !ruritus 3ever

*ther: Transient hair loss Burning sensation of feet Bleeding complication

Surgery a 8ein ligation & stripping 8enous thrombectomy: removal of cloth in the iliofemoral region !lication of the inferior vena cava: insertion of an umbrella:like prosthesis into the lumen of the vena cava: to filter incoming cloth

b c

Nursing 4ntervention

" #
%

'levate legs above heart level: to promote increase venous return & decreased edema &pply warm moist pack: to reduce lymphatic congestion &dminister anti:coagulant as ordered: a @eparin

1onitor !TT: dosage should be ad;usted to keep !TT between " F:# F times normal control level (se infusion pump to administer heparin 'nsure proper in;ection techniEue (se #H or #G gauge syringe with N:F2A inch needle- in;ect into fatty layer of abdomen above iliac crest &void in;ecting within # inches of umbilicus 4nsert needle at ?F:<=o to skin /o not withdraw plunger to assess blood return &pply gentle pressure after removal of needle: avoid massage

&ssess for increased bleeding tendencies +hematuria- hematemesis- bleeding gums- petechiae of soft palate- con;unctiva retinaecchymoses- epista.is- bloody spumtum- melena, & instruct the client to observe for & report these @ave antidote +!rotamine Sulfate, available 4nstruct the client to avoid aspirin- antihistamines G cough preparations containing glyceryl guaiacolate & obtain 1/ permission before using other *TC drugs

Darfarin +Coumadin,

&ssess !T daily: dosage should be ad;usted to maintain !T at " F:# F times normal control level$ 4N) of # *btain careful medication history +there are many drug:drug interaction, &dvise client to withhold dose & notify 1/ immediately if bleeding occur @ave antidote +8itamin 9, available &lert client to factors that may affect the anticoagulant response +high:fat diet or sudden increased in vit 9:rich food, 4nstruct the client to wear medic:alert bracelet

&ssess 82S every ? hours 1onitor chest pain or shortness of breath: possible pulmonary embolism 1easure thigh- calves- ankles & instep every morning

F
H

G%

G?
G !rovide client teaching & discharge planning a Need to avoid standing- sitting for long period- constrictive clothing- crossing legs at the knee- smoking- oral contraceptives 4mportance of adeEuate hydration: to prevent hypercoagubility (se elastic stockings when ambulatory 4mportance of planned rest periods with elevation of the feet /rug regimen !lan for e.ercise 2 activity Begin with dorsifle.ion of the feet while sitting or lying down Swim several times weekly 7radually increased walking distance

b
c d e f

g
h

4mportance of weight reduction: if obese 1onitor for signs of complications a !ulmonary 'mbolism Sudden sharp chest pain (ne.plained dyspnea Tachycardia !alpitations /iaphoresis )estlessness

*verview of &natomy & !hysiology of the )espiratory System (pper )espiratory System Structure of the respiratory system- primarily an air conduction system- include the nose- pharyn. & laryn. &ir is filtered warmed & humidified in the upper airway before passing to lower airway Nose

" #
%

'.ternal 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 The septum is covered with mucous membrane- where the olfactory receptors are located Turbinates- located internally- assist in warming & moistening the air The ma;or function of the nose are warming- moistening & filtering air Consist of anastomosis of capillaries known as 9eissel )ach !le.us: the site of nose bleeding

!haryn. " # % & muscular passageway commonly called the throat &ir passes through the nose to the pharyn. Serves as a muscular passageway for both food and air

Composed of three section

" # %
6aryn.

Nasopharyn.: located above the soft palate of the mouth- contains the adenoids & opening to the eustachian tubes *ropharyn.: located directly behind the mouth & tongue- contains the palatine tonsils$ air & food enter the body through oropharyn. 6aryngopharyn.: e.tends from the epiglotitis to the si.th cervical level

"
# % ?

Sometimes called Jvoice Bo.K connects upper & lower airways 3ramework is formed by the hyoid bone- epiglotitis & thyroid- cricoid & arytenoids cartilages 6aryn. opens to allow respiration & closes to prevent aspiration when food passes through the pharyn. 8ocal cords of laryn. permit speech & are involved in the cough refle. 3or phonation +voice production, *pening of laryn. *pens to allow passage of air Closes to allow passage of food going to the esophagus The initial sign of complete airway obstruction is the inability to cough

F
7lottis " # % ?

6ower )espiratory System Consist of trachea- bronchi & branches- & the lungs & associated structures 3or gas e.change Trachea &9& JDindpipeK &ir move from the pharyn. to laryn. to trachea +length "":"% cm- diameter " F:# F cm in adult, '.tend from the laryn. to the second costal cartilage- where it bifurcates & is supported by "H:#= 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 )ight main bronchus 6arger & straighter than the left /ivided into three lobar branches +upper- middle & lower bronchi, to supply the three lobes of right lung 6eft main bronchus /ivides into the upper & lower lobar bronchi to supply the left lobes

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GF

Bronchioles 4n the bronchioles- airway patency is primarily dependent upon elastic recoil formed by network of smooth muscles The tracheobronchial tree ends at the terminal bronchials /istal to the terminal bronchioles the ma;or function is no longer air conduction but gas e.change between blood & alveolar air The respiratory bronchioles serves as the transition to the alveolar epithelium

6ungs )ight lung +consist of % lobes- "= segments, 6eft lung +consist of # lobes- A segments, 1ain 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 ape. !leura Serous membranes covering the lungs- continuous with the parietal pleura that lines the chest wall !arietal !leura 6ines 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 Dall 4ncludes the ribs cage- intercostal muscles & diaphragm Chest is a C shaped & supported by "# pairs of ribs & costal cartilages- the ribs have several attached muscles Contraction of the e.ternal intercostal muscles raises the ribs cage during inspiration & helps increase the siCe of the thoracic cavity The internal intercoastal muscles tends to pull ribs down & in & play a role in forced e.piration /iaphragm & ma;or muscle of ventilation +the e.change of air between the atmosphere & the alveoli, &lveoli &re functional cellular unit of the lungs$ about half arise directly from alveolar ducts & are responsible for about %F> of alveolar gas e.change !roduces surfactants Site of gas e.change +C*# and *#, /iffusion +/altonBs law of partial pressure of gases, Surfactant & phospholipids substance found in the fluid lining the alveolar epithelium )educes surface tension & increase stability of the alveoli & prevents their collapse &lveolar /ucts &rises from the respiratory bronchioles & lead to the alveoli &lveolar Sac 3orm the last part of the airway 3unctionally the same as the alveolar ducts they are surrounded by alveoli & are responsible for the HF> of the alveolar gas e.change Type 44 Cells of &lveoli Secretes surfactant /ecrease surface tension !revent collapse of alveoli Composed of lecithin and spingomyelin 6ecitin 2 Spingomyelin ratio: to determine lung maturity Normal 6ecitin 2 Spingomyelin ratio: is #:" 4n premature infants: ":# 7ive o.ygen of less ?=> in premature: to prevent atelectasis and retrolental fibroplasias )etinopathy & blindness: in premature !ulmonary Circulation !rovides for reo.ygenation of blood & release of C*# 7as transfers occurs in the pulmonary capillary bed )espiratory /istress Syndrome /ecrease o.ygen stimulates breathing 4ncrease carbon dio.ide is a powerful stimulant for breathing !neumonia 4nflammation of the alveolar spaces of the lungs- resulting in consolidation of lung tissue as the alveoli fill with e.udates 4nflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with e.udates 'tiologic &gents

" #
% ?

Streptococcus !neumonae: causing pneumococal pneumonia @emophylus 4nfluenCae: causing broncho pneumonia /iplococcus !neumoniae 9lebsella !neumoniae

GF

GH
F H 'scherichia !neumoniae !seudomonas

@igh )isk 7roups " # Children below F years old 'lderly

!redisposing 3actors " # % Smoking &ir pollution 4mmuno compromised )elated to prolonged immobility +C8& clients,: causing hypostatic pneumonia &spiration of food: causing aspiration pneumonia

? F
S2s. " # % ? F H G A

!roductive cough with greenish to rusty sputum )apid shallow respiration with e.piratory grunt Nasal flaring 4ntercostal rib retraction (se of accessory muscles of respiration /ullness to flatness upon auscultation !ossible pleural friction rub @igh:pitched bronchial breath sound )ales 2 crackles +early, progressing to coarse +later,

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"= 3ever "" Chills "# &nore.ia "% 7eneral body malaise "? Deight loss "F Bronchial wheeCing "H Cyanosis "G Chest pain

"A &bdominal distention leading to paralytic ileus +absence of peristalsis,

/.

" # % ?

Sputum 7ram Staining & Culture Sensitivity: positive to cultured microorganisms Chest .:ray: reveals pulmonary consolidation over affected area &B7 analysis: reveals decrease !*# CBC: reveals increase DBC- erythrocyte sedimentation rate is increased

Nursing 4ntervention " 3acilitate adeEuate ventilation &dminister *# as needed & assess its effectiveness: low inflow !lace client semi fowlers position Turn & reposition freEuently client who are immobiliCed &dminister analgesic as ordered: /*C: codeine: to relieve pain associated with breathing &uscultate breath sound every #:? hour 1onitor &B7 # 3acilitate removal of secretions 7eneral hydration /eep breathing & coughing e.ercise: tends to promote e.pectoration Tracheobronchial suctioning as needed &dminister 1ucolytic or '.pectorant as ordered &erosol treatment via nebuliCer @umidification of inhaled air Chest physiotherapy +!ostural /rainage,: tends to promote e.pectoration

%
?

*bserve color characteristics of sputum & report any changes: encourage client to perform good oral hygiene after e.pectoration !rovide adeEuate rest & relief control of pain 'nforce CB) with limited activity 6imit visits & minimiCed conversation !lan for uninterrupted rest periods 1aintain pleasant & restful environment

&dminister antibiotic as ordered: monitor effects & possible to.icity Broad Spectrum &ntibiotic !enicillin Tetracycline 1icrolides +Qethroma., &Cethromycin: Side 'ffect: *toto.icity

H
G

!revent transmission: respiratory isolation client with staphylococcal pneumonia Control fever & chills: 1onitor temperature & &dminister antipyretic as ordered 4ncreased fluid intake !rovide freEuent clothing & linen changing

&ssist in postural drainage: uses gravity & various position to stimulate the movement of secretions

GH

GG

Nursing 1anagement for !ostural /rainage

a
b c d e f g

Best done before meals or #:% hours: to prevent gastro esophageal reflu. 1onitor vital signs 'ncourage client deep breathing e.ercises &dminister bronchodilators #=:%= minutes before procedure Stop if client cannot tolerate procedure !rovide oral care after procedure Contraindicated with (nstable 82S @emoptysis Clients with increase intra ocular pressure +Normal 4*! "# #" mm@g, 4ncrease 4C!

<

!rovide increase C@*- calories- C@*N & vitamin C a b c d e 1edication regimen 2 antibiotic therapy Need for adeEuate rest- limited activity- good nutrition- with adeEuate fluid intake & good ventilation Need to continue deep breathing & coughing e.ercise for at least H:A weeks after discharge &vailability of vaccines Need to report S2s. of respiratory infection !ersistent or recurrent fever Changes in characteristics color of sputum Chills 4ncreased pain /ifficulty in breathing Deight loss !ersistent fatigue f g &void smoking !revent complications &telectasis 1eningitis h 4mportance of follow up care

"= !rovide client teaching & discharge planning

@istoplasmosis Systemic fungal disease caused by inhalation of dust contaminated by histoplasma capsulatum which is transmitted to bird manure &cute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure S2s. " # % ? F H G A /. Similar to !TB or !neumonia !roductive cough 3ever- chills- anore.ia- general body malaise Chest and ;oint pains /yspnea Cyanosis @emoptysis Sometimes asymptomatic

" # %

Chest I:ray: often appears similar to !TB @istoplasmin Skin Test: positive &B7 analysis: !*# decrease

1edical 1anagement

"

&nti:fungal &gent: &mphotericin B +3ungiCone, 8ery to.ic: to.icity includes anore.ia- chills- fever- headaches & renal failure &cetaminophen- Benadryl & Steroids is given with &mphotericin B: to prevent reaction

Nursing 4ntervention " # % ? 1onitor respiratory status 'nforce CB) &dminister o.ygen inhalation &dminister medications as ordered

&ntifungal: &mphotericin B +3ungiCone, *bserve severe side effects: 3ever: acetaminophen given prophylactically &naphylactic reaction: Benadryl & Steroids given prophylactically &bnormal renal function with hypokalemia & aCotemia: Nephroto.icity- check for B(N and Creatinine- @ypokalemia

F H

3orce fluids to liEuefy secretions NebuliCe & suction as needed !revent complications: bronchiectasis !revent the spread of infection by spraying of breeding places

G
A

Chronic *bstructive !ulmonary /isease +C*!/, Chronic Bronchitis

GG

GA

'.cessive production of mucus in the bronchi with accompanying persistent cough Characteristic include hypertrophy 2 hyperplasia of the mucus secreting gland in the bronchi- decreased ciliary activity- chronic inflammation & narrowing of the airway 4nflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways &9& JBlue BloatersK !redisposing 3actors " # S2s. Smoking &ir pollution

"
# % ? F H G A <

!roductive copious cough +consistent to all C*!/, /yspnea on e.ertion (se of accessory muscle of respiration Scattered rales 2 rhonchi 3eeling of gastric fullness Slight Cyanosis /istended neck veins &nkle edema !rolonged e.piratory grunt

"= &nore.ia and generaliCed body malaise "" !ulmonary hypertension a 6eading to peripheral edema Cor !ulmonale +right ventricular hypertrophy,

b
/.

" &B7 analysis: reveals !*# decrease +hypo.emia,: causing cyanosis- !C*# increase Bronchial &sthma 4mmunologic 2 allergic reaction results in histamine release which produces three mainairway response: 'dema of mucus membraneSpasm of the smooth muscle of bronchi & bronchioles- &ccumulation of tenacious secretions )eversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways !redisposing 3actors +/epending on Types,

"

'.trinsic &sthma +&topic 2 &llergic, Causes !ollen /ust 3umes Smoke 7ases /anders 3urs 6ints

4ntrinsic &sthma +Non atopic 2 Non allergic, Causes @ereditary /rugs +aspirin- penicillin- beta blocker, 3oods +seafoods- eggs- milk- chocolates- chicken, 3ood additives +nitrates, Sudden change in temperature- air pressure and humidity !hysical and emotional stress

%
S2s. " # % ? F H G /. "

1i.ed Type: <= <F>

Cough that is non productive /yspnea DheeCing on e.piration Cyanosis 1ild Stress or apprehension Tachycardia- palpitations /iaphoresis

!ulmonary 3unction Test 4ncentive spirometer: reveals decrease vital lung capacity &B7 analysis: !*# decrease Before &B7 test for positive &llens Test- apply direct pressure to ulnar & radial artery to determine presence of collateral circulation

#
%

1edical 1anagement " /rug Therapy

a b c

Bronchodilators: given via inhalation or metered dose inhaler or 1/4 for F minutes Steroids: decrease inflammation: given "= min after bronchodilator 1ucomysts +acetylceisteine,: at bed side put suction machine

GA

G<
d e # % ? " 1ucolytics 2 e.pectorants &nti histamine

!hysical Therapy @yposensitiCation '.ecise 'nforce CB) *# inhalation: low flow #:% 62min: to prevent respiratory distress &dminister medications as ordered 3orce fluids #:% 62day Semi fowlers position: to promote lung e.pansion NebuliCe & suction when needed !rovide client health teachings and discharge planning concerning a b &voidance of precipitating factor !revent complications 'mphysema Status &sthmaticus: severe attack of asthma which cause poor controlled asthma /*C: 'pinephrine Steroids Bronchodilators

Nursing 4ntervention

#
% ? F H G

c
d

)egular adherence to medications: to prevent development of status asthmaticus 4mportance of follow up care

Bronchiectasis !ermanent abnormal dilation of the bronchi with destruction of muscular & elastic structure of the bronchial wall &bnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli !redisposing 3actors " # % Caused by bacterial infection )ecurrent lower respiratory tract infections Chest trauma Congenital defects +altered bronchial structure, )elated to presence of tumor +lung tumor, Thick tenacious secretion

? F
H S. " # % ?

!roductive cough with mucopurulent sputum /yspnea in e.ertion Cyanosis &nore.ia & generaliCed body malaise @emoptysis +only C*!/ with sign, DheeCing Deight loss

F
H G /.

" # %

CBC: elevation in DBC &B7: !*# decrease Bronchoscopy: reveals sources & sites of secretion: direct visualiCation of bronchus using fiberscope Nursing 1anagement before Bronchoscopy

" # %

Secure inform consent and e.plain procedure to client 1aintain N!* H:A hours prior to procedure 1onitor vital signs & breath sound !ost Bronchoscopy

" # %

3eeding initiated upon return of gag refle. &void talking- coughing and smoking- may cause irritation 1onitor for signs of gross 1onitor for signs of laryngeal spasm: prepare tracheostomy set

1edical 1anagement
" Surgery !neumonectomy: " lung is removed & position on affected side Segmental Dedge 6obectomy: promote re:e.pansion of lungs (naffected lobectomy: facilitate drainage 'mphysema 'nlargement & 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 C*# retention- hypo.ia & respiratory acidosis 4rreversible terminal stage of C*!/ characteriCed by 4nelasticity of alveoli &ir trapping 1aldistribution of gases *verdistention of thoracic cavity +barrel chest,

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A=
!redisposing 3actors " Smoking 4nhaled irritants: air pollution &llergy or allergic factor @igh risk: elderly @ereditary: it involves deficiency of &lpha " anti:trypsin: to release elastase for recoil of alveoli

#
% ?

F
S2s. " # % ?

!roductive cough Sputum production &nore.ia & generaliCed body malaise Deight loss 3laring of nostrils +alai nares, (se of accessory muscles /yspnea at rest 4ncreased rate & depth of breathing /ecrease respiratory e.cursion

F
H G A <

"= )esonance to hyper resonance "" /ecrease or diminished breath sounds with prolong e.piration "# /ecrease tactile fremitus "% !rolong e.piratory grunt "? )ales or rhonchi "F Bronchial wheeCing "H Barrel chest

"G !urse lip breathing: to eliminates e.cess C*# +compensatory mechanism,

/.

" #

!ulmonary 3unction Test: reveals decrease vital lung capacity &B7 analysis: reveals !anlobular2centrilobular /ecrease !*# +hypo.emia leading to chronic bronchitis- JBlue BloatersK, /ecrease ph 4ncrease !C*# )espiratory acidosis !anacinar2centriacinar 4ncrease !*# +hypera.emia- J!ink !uffersK, /ecrease !C*# 4ncrease ph )espiratory alkalosis

Nursing 4ntervention " # % 'nforce CB) &dminister o.ygen inhalation via low inflow &dminister medications as ordered

Bronchodilators: used to treat bronchospam &minophylline 4soproterenol +4suprel, Terbutalin +Brethine, 1etaproterenol +&lupent, Theophylline 4soetharine +Bronkosol,

Corticosteroids: !rednisone

&nti:microbial 2 &ntibiotics: to treat bacterial infection Tetracycline &mpicilline

1ucolytics 2 e.pectorants

3acilitate removal of secretions: a b c d 3orce fluids at least % 62day !rovide chest physiotherapy- coughing & deep breathing NebuliCe & suction when needed !rovide oral hygiene after e.pectoration of sputum !osition client to semi or high fowlers 4nstruct the client diaphragmatic muscles to breathe 'ncourage productive cough after all treatment +splint abdomen to help produce more e.pulsive cough, 'mploy pursed:lip breathing techniEues +prolonged slow rela.ed e.piration against pursed lips, 4nstitute pulmonary toilet

4mprove ventilation a b

c d
e

H
G A <

4nstitute !''! +positive end e.piratory pressure, in mechanical ventilation promotes ma.imum alveolar lung e.pansion !rovide comfortable & humid environment !rovide high carbohydrates- protein- calories- vitamins and minerals !rovide client teachings and discharge planning concerning a !revention of recurrent infection &void crowds & individual with known infection &dhere to high C@*N- C@* & increased vit C diet

A=

A"

)eceived immuniCation for influenCa & pneumonia )eport changes in characteristic & color of sputum immediately )eport of worsening of symptoms +increased tightness of chest- fatigue- increased dyspnea, b Control of environment (se home humidifier at %=:F=> Dear scarf over nose & mouth in cold weather: to prevent bronchospasm &void smoking & contact with environmental smoke &void abrupt change in temperature c &voidance of inhaled irritants Stay indoor: if pollution level is high (se air conditioner with efficiency particulate air filter: to remove particles from air d 4ncrease activity tolerance Start with mild e.ercise: such as walking & gradual increase in amount & duration (sed breathing techniEues: +pursed lip- diaphragmatic, during activities 2 e.ercise: to control breathing @ave *# available as needed to assist with activities !lan activities that reEuire low amount of energy !lan rest period before & after activities e !revent complications &telectasis Cor !ulmonale: ) ventricular hypertrophy C*# narcosis: may lead to coma !neumothora.: air in the pleural space f g Strict compliance to medication 4mportance of follow up care

*ncology Nursing !athophysiology & 'tiology of Cancer 'volution of Cancer Cells &ll 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 e.cess 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 1alignant Cells Cancer cells are mutated stem cells that have undergone structural changes so that they are unable to perform the normal functions of specialiCed 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

)ate of 7rowth Cancer cells have uncontrolled growth or cell division )ate at which a tumor grows involves both increased cell division & increased survival time of cells 1alignant cells do not form orderly layers- but pile on top of each other to eventually form tumors

!re:disposing 3actors

7 7enetics Some cancers shows familial pattern 1aybe caused by inherited genetics defects

4 4mmunologic 3ailure of the immune system to respond & eradicate cancer cells 4mmunosuppressed individuals are more susceptible to cancer

8 8iral o o o 8iruses have been shown to be the cause of certain tumors in animals 8iruses + @T68:4- 'pstein Barr 8irus- @uman !apilloma 8irus, linked to human tumors *ncovirus +)N& Type 8iruses, thought to be culprit

' 'nvironmental o o 1a;ority +over A=>, of human cancer related to environmental carcinogens Types: !hysical )adiation: I ray- radium- nuclear e.plosion & waste- (8 Trauma or chronic irritation

Chemical Classification of Cancer Tissue Typing: Nitrates- & food additives- polycyclic hydrocarbons- dyes- alkylating agents /rugs: arsenicals- stilbestol- urethane Cigarette smoke hormones

Carcinoma arises from surface- glandular- or parenchymal epithelium

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SEuamous Cell Carcinoma surface epithelium &denocarcinoma glandular or parenchymal tissue

Sarcoma arises from connective tissue 6eukemia from blood 6ymphoma from lymph glands 1ultiple 1yeloma from bone marrow

Stages of Tumor 7rowth & Staging System:

TN1 System: uses letters & numbers to designate the e.tent of tumors

o o o

T stands for primary growth$ ":? with increasing siCe$ T"S indicates carcinoma in situ N stands for lymph nodes involvement: =:? indicates progressively advancing nodal disease 1 stands for metastasis$ = indicates no distant metastases- " indicates presence of metastases

Stages = 48: all cancers divided into five stages incorporating siCe- nodal involvement & spread

B Cytologic /iagnosis of Cancer

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#

4nvolves in the study of shed cells +e. !ap smear, Classified by degree of cellular abnormality Normal !robably normal +slight changes, /oubtful +more severe changes, !robably cancer or precancerous /efinitely cancer

Client 3actors "

Seven warning signs of cancer BS' breast self e.amination 4mportance of retal e.am for those over age ?= @aCards of smoking *ral self e.amination as well as annual e.am of mouth & teeth @aCards of e.cess sun e.posure 4mportance of pap smear ! ' with lab work up: every % years ages #=:?=$ yearly for age ?= & over TS' testicular self e.amination

#
% ? F H G A

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Testicular Cancer i 1ost common cancer in men between the age of "F & %?

Darning signs that men should look for: i ii iii iv v vi vii !ainless swelling 3eeling of heaviness @ard lump +siCe of a pea, Sudden collection fluid in the scrotum /ull ache in the lower abdomen or in the groin !ain in the testicle or in the scrotum 'nlargement or tenderness of the breasts

G Darning Signs of Cancer C: change in bowel or bladder habits &: a sore that doesnBt heal (: unusual bleeding or discharge T: thickening of lump in breast or elsewhere 4: indigestion or dysphagia *: obvious change in wart or mole N: nagging cough or hoarseness Treatment of Cancer Therapeutic 1odality Chemotherapy &bility of the drug to kill cancer cells$ normal cells may also be damaged- producing side effects /ifferent drug act on tumor cell in different stages of the cell growth cycle

Types of Chemotherapeutic /rugs

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# %

&ntimetabolites o o o o 3oster cancer cell death by interfering with cellular metabolic process act with /N& to hinder cell growth & division obtained from periwinkle plant makes the hostBs body a less favorable environment for the growth of cancer cells affect )N& to make environment less favorable for cancer growth alter the endocrine environment to make it less conducive to growth of cancer cells

&lkylating &gent !lant &lkaloids

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&ntitumor &ntibiotics o o Steroids & Se. @ormones

1a;or Side 'ffects & Nursing 4ntervention

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& 74 System Nausea & 8omiting o o o &dminister antiemetics routinely E ?:H hrs as well as prophylactically before chemotherapy is initiated Dithhold food2fluid ?:H hrs before chemotherapy !rovide bland food in small amounts after treatment

/iarrhea o o o o &dminister antidiarrheals 1aintain good perineal care 7ive clear liEuids as tolerated 1onitor 9- Na- Cl levels

Stomatitis +mouth sore, o o o o o !rovide & teach the client good oral hygiene- including avoidance of commercial mouthwashes )inse with viscous lidocaine before meals to provide analgesic effect !erform a cleansing rinse with plain @#* or dilute a @#* soluble lubricant such as hydrogen pero.ide after meal &pply @#* lubricant such as 9:5 ;elly to lubricate cracked lips &dvice client to suck on !opsicles or ice chips to provide moisture

B @ematologic System Thrombocytopenia o o o o o o &void bumping or bruising the skin !rotect client from physical in;ury &void aspirin or aspirin products &void giving 41 in;ections 1onitor blood counts carefully &ssess for signs of increase bleeding tendencies +epista.is- petechiae- ecchymoses,

6eukopenia o o o o (se careful handwashing techniEue 1aintain reverse isolation if DBC count drops below "===2mm &ssess for signs of respiratory infection &void crowds2persons with known infection

&nemia o o o o !rovide adeEuate rest period 1onitor hemoglobin & hematocrit !rotect client from in;ury &dminister *# if needed

C 4ntegumentary System &lopecia o o o o '.plain that hair loss is not permanent *ffer support & encouragement Scalp tourniEuets or scalp hypothermia via ice pack may be ordered to minimiCe hair loss with some agent &dvice client to obtain wig before initiating treatment

/ )enal System

'ncourage fluid & freEuent voiding to prevent accumulation of metabolites in bladder$ ): may cause direct damage to kidney by e.cretion of metabolites 4ncreased e.cretion of uric acid may damage kidney &dminister allopurinol +Qyloprim, as ordered$ ): to prevent uric acid formation$ encourage fluids when administering allopurinol

' )eproductive System /amage may occur to both men & women resulting infertility &2or mutagenic damage to chromosomes Banking sperm often recommended for men before chemotherapy Clients & partners advised to use reliable methods of contraception during chemotherapy

3 Neurologic System !lant alkaloids +vincristine, cause neurologic damage with repeated doses !eripheral neuropathies- hearing loss- loss of deep tendon refle.- & paralytic ileus may occur

)adiation Therapy (ses ioniCing radiation to kill or limit the growth of cancer cells- maybe internal or e.ternal 4t not only in;ured cell membrane but destroy & alter /N& so that the cell cannot reproduce 'ffects cannot be limited to cancer cells only$ all e.posed cells including normal cells will be in;ured causing side effects 6ocaliCed effects are related to the area of the body being treated$ generaliCed effects maybe related to cellular breakdown products

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Types of 'nergy 'mitted

&lpha 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 7amma penetrate more deeper areas of the body- most common form of e.ternal radiotherapy +e. 'lectromagnetic or I:ray,

1ethods of /elivery

'.ternal )adiation Therapy beams high energy rays directly to the affected area '. Cobalt therapy 4nternal )adiation Therapy radioactive material is in;ected or implanted in the clientBs body for designated period of time

o o

Sealed 4mplants a radioisotope enclosed in a container so it does not circulate in the body$ clientBs body fluids should not be contaminated (nsealed source a radioisotope that is not encased in a container & does circulate in the body & contaminate body fluids

3actors Controlling '.posure

@alf:life time reEuired for half of radioactive atoms to decay " # 'ach radioisotope has different half:life &t the end of half:life the danger from e.posure decreases

Time the shorter the duration the less the e.posure /istance the greater the distance from the radiation source the less the e.posure Shielding all radiation can be blocked$ rubber gloves for alpha & usually beta rays$ thick lead or concrete stop gamma rays

Side 'ffects of )adiation Therapy & Nursing 4ntervention & Skin : itching- redness- burning- ooCing- sloughing 9eep skin free from foreign substances &void use of medicated solution- ointment- or powders that contain heavy metals such as Cinc o.ide &void pressure- trauma- infection to skin$ use bed cradle Dash affected areas with plain @#* & pat dry$ avoid soap (se cornstarch- olive oil for itching$ avoid talcum powder 4f sloughing occurs- use sterile dressing with micropore tape &void e.posing skin to heat- cold- or sunlight & avoid constricting irritating clothing

B &nore.ia- N28 &rrange meal time so they do not directly precede or follow therapy 'ncourage bland foods !rovide small attractive meals &void e.treme temperature &dminister antiemetics as ordered before meals

C /iarrhea 'ncourage low residue- bland- high C@*N food &dminister antidiarrheal as ordered !rovide good perineal care 1onitor electrolytes particularly Na- 9- Cl

/ &nemia- 6eukopenia- Thrombocytopenia 4solate from those with known infection !rovide freEuent rest period 'ncourage high C@*N diet &void in;ury &ssess for bleeding 1onitor CBC- DBC- & platelets

Burns Type: " # % ? Thermal Smoke 4nhalation Chemical 'lectrical direct tissue in;ury caused by thermal- electric- chemical & smoke inhaled +T'CS,

Classification !artial Thickness

"

Superficial partial thickness +"st degree, /epth: epidermis only Causes: sunburn- splashes of hot liEuid Sensation: painful Characteristics: erythema- blanching on pressure- no vesicles

/eep !artial Thickness +#nd degree, /epth: epidermis & dermis Causes: flash- scalding- or flame burn Sensation: very painful Characteristics: fluid filled vesicles$ red- shinny- wet after vesicles ruptures

3ull Thickness +%rd & ?th degree, " /epth: all skin layers & nerve endings$ may involve muscles- tendons & bones

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AF
# % ? Causes: flames- chemicals- scalding- electric current Sensation: little or no pain Characteristics: wound is dry- white- leathery- or hard

*verview *f &natomy & !hysiology *f 1usculoskeletal System Bones 3unction of Bones !rovide support to skeletal framework &ssist in movement by acting as levers for muscles !rotect vital organ & soft tissue 1anufacture )BC in the red bone marrow +hematopoiesis, !rovide site for storage of calcium & phosphorus Consist of bones- muscles- ;oints- cartilages- tendons- ligaments- bursae To provide a structural framework for the body To provide a means for movement

"

Types of Bones 6ong Bones

Central shaft +diaphysis, made of compact bone & two end +epiphyses, composed of cancellous bones +e. 3emur & humerus,

Short Bones Cancellous bones covered by thin layer of compact bone +e. Carpals & tarsals,

3lat Bones

Two layers of compact bone separated by a layer of cancellous bone +e. Skull & ribs,

4rregular Bones

0oints

SiCes and shapes vary +e. 8ertebrae & mandible,

&rticulation of bones occurs at ;oints 1ovable ;oints provide stabiliCation and permit a variety of movements

Classification

" # %

Synarthroses: immovable ;oints &mphiarthroses: partially movable ;oints /iarthroses +synovial,: freely movable ;oints

1uscles

@ave a ;oint cavity +synovial cavity, between the articulating bone surfaces &rticular cartilage covers the ends of the bones & fibrous capsule encloses the ;oint Capsule is lined with synovial membrane that secretes synovial fluid to lubricate the ;oint and reduce friction

3unctions of 1uscles !rovide shape to the body !rotect the bones 1aintain posture Cause movement of body parts by contraction

Types of 1uscles

"

Cardiac: involuntary$ found only in heart Smooth: involuntary$ found in walls of hollow structures +e g intestines, Striated +skeletal,: voluntary

Characteristics of skeletal muscles 1uscles are attached to the skeleton at the point of origin and to bones at the point of insertion @ave properties of contraction and e.tension- 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 & form of connective tissue 1a;or functions are to cushion bony prominences and offer protection where resiliency is reEuired

Tendons and 6igaments Composed of dense- fibrous connective tissue 3unctions " # 6igaments attach bone to bone Tendons attach muscle to bone

)heumatoid &rthritis +)&, Chronic systemic disease characteriCed by inflammatory changes in ;oints and related structures 0oint distribution is symmetric +bilateral,: most commonly affects smaller peripheral ;oints of hands & also commonly involves wristselbows- shoulders- knees- hips- ankles and ;aw

Cause

4f unarrested- affected ;oints progress through four stages of deterioration: synovitis- pannus formation- fibrous ankylosis- and bony ankylosis

AF

AH
" # % Cause unknown or idiopathic 1aybe an autoimmune process 7enetic factors !lay a role in society +work,

!redisposing factors

"
# % ? F S2s. " # % ?

*ccurs in women more often than men +%:", between the ages %F:?F 3atigue Cold 'motional stress 4nfection

3atigue &nore.ia & body malaise Deight loss Slight elevation in temperature 0oints are painful: warm- swollen- limited in motion- stiff in morning & after a period of inactivity & may show crippling deformity in long: standing disease 1uscle weakness secondary to inactivity @istory of remissions and e.acerbations Some clients have additional e.tra:articular manifestations: subcutaneous nodules$ eye- vascular- lung- or cardiac problems

F
H G

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" # %
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I:rays: shows various stages of ;oint disease CBC: anemia is common 'S): elevated )heumatoid factor positive &N&: may be positive C:reactive protein: elevated

F H

1edical 1anagement " /rug therapy

a b

&spirin: mainstay of treatment: has both analgesic and anti:inflammatory effect Nonsteroidal anti:inflammatory drugs +NS&4/s,: relieve pain and inflammation by inhibiting the synthesis of prostaglandins

4buprofen +1otrin, 4ndomethacin +4ndocin, 3enoprofen +Nalfon, 1efenamic acid +!onstel, !henylbutaCone +ButaColidin, !iro.icam +3eldene, Napro.en +Naprosyn, Sulindac +Clinoril,

7old compounds +Chrysotherapy, 4n;ectable form: given 41 once a week$ take %:H months to become effective

Sodium thiomalate +1yochrysine, &urothioglucose +Solganal,

S4: monitor blood studies & urinalysis freEuently !roteinuria 1outh ulcers Skin rash &plastic anemia

*ral form: smaller doses are effective$ take %:H months to become effective

&uranofin +)idaura,

S4: blood & urine studies should be monitored /iarrhea

Corticosteroids

4ntra:articular in;ections: temporarily suppress inflammation in specific ;oints Systemic administration: used only when client does not respond to less potent anti:inflammatory drugs

1ethotre.ate: given to suppress immune response Cyto.an

# %

S4: bone marrow suppression

!hysical therapy: to minimiCe ;oint deformities Surgery: to remove severely damaged ;oints +e g total hip replacement$ knee replacement,

Nursing 4nterventions " # &ssess ;oints for pain- swelling- tenderness & limitation of motion !romote maintenance of ;oint mobility and muscle strength

a
b

!erform )*1 e.ercises several times a day: use of heat prior to e.ercise may decrease discomfort$ stop e.ercise at the point of pain (se isometric or other e.ercise to strengthen muscles

% ?

Change position freEuently: alternate sitting- standing & lying !romote comfort & relief 2 control of pain

AH

AG
a b 'nsure balance between activity & rest !rovide ":# scheduled rest periods throughout day )est & support inflamed ;oints: if splints used: remove ":# times2day for gentle )*1 e.ercises !rovide firm mattress 1aintain proper body alignment @ave client lie prone for N hour twice a day &void pillows under knees 9eep ;oints mainly in e.tension- not fle.ion !revent complications of immobility

c
F a b c d e f

'nsure bed rest if ordered for acute e.acerbations

!rovide heat treatments: warm bath- shower or whirlpool$ warm- moist compresses$ paraffin dips as ordered a b 1ay be more effective in chronic pain )educe stiffness- pain & muscle spasm

G
A <

!rovide cold treatments as ordered: most effective during acute episodes !rovide psychologic support and encourage client to e.press feelings &ssists clients in setting realistic goals$ focus on client strengths

"= !rovide client teaching & discharge planning & concerning

a b c d e f g h i (se of prescribed medications & side effects Self:help devices to assist in &/6 and to increase independence 4mportance of maintaining a balance between activity & rest 'nergy conservation methods !erformance of )*1- isometric & prescribed e.ercises 1aintenance of well:balanced diet &pplication of resting splints as ordered &voidance of undue physical or emotional stress 4mportance of follow:up care

*steoarthritis Chronic non:systemic disorder of ;oints characteriCed by degeneration of articular cartilage Deight:bearing ;oints +spine- knees and hips, & terminal interphalangeal ;oints of fingers most commonly affected 4ncident )ate " # Domen & men affected eEually 4ncidence increases with age

!redisposing 3actors

"
# % S2s.

1ost important factor in development is aging +wear & tear on ;oints, *besity 0oint trauma

" # %
/.

!ain: +aggravated by use & relieved by rest, & stiffness of ;oints @eberdenBs nodes: bony overgrowths at terminal interphalangeal ;oints /ecreased )*1 with possible crepitation +grating sound when moving ;oints,

" #

I:rays: show ;oint deformity as disease progresses 'S): may be slightly elevated when disease is inflammatory

Nursing 4nterventions " # &ssess ;oints for pain & )*1 )elieve strain & prevent further trauma to ;oints a b c 'ncourage rest periods throughout day (se cane or walker when indicated 'nsure proper posture & body mechanics !romote weight reduction: if obese &void e.cessive weight:bearing activities & continuous standing

d
e

1aintain ;oint mobility and muscle strength a b c !rovide )*1 & isometric e.ercises 'nsure proper body alignment Change clientBs position freEuently &dminister medications as ordered: &spirin & NS&4/: most commonly used Corticosteroids +4ntra:articular in;ections,: to relieve pain & improve mobility

!romote comfort 2 relief of pain a

b
F H

&pply heat or ice as ordered +e g warm baths- compresses- hot packs,: to reduce pain

!repare client for ;oint replacement surgery if necessary !rovide client teaching and discharge planning concerning a b c d e f (sed of prescribed medications and side effects 4mportance of rest periods 1easures to relieve strain on ;oints )*1 and isometric e.ercises 1aintenance of a well:balanced diet (se of heat2ice as ordered

7out

AG

AA

& disorder of purine metabolism$ causes high levels of uric acid in the blood & the precipitation of urate crystals in the ;oints 4nflammation of the ;oints caused by deposition of urate crystals in articular tissue 4ncident )ate " # S2s. " # % ? 0oint pain )edness @eat Swelling 0oints of foot +especially great toe, & ankle most commonly affected +acute gouty arthritis stage, @eadache 1alaise &nore.ia Tachycardia *ccurs most often in males 3amilial tendency

F
H G A <

"= 3ever

"" Tophi in outer ear- hands & feet +chronic tophaceous stage,
/.

"

CBC: uric acid elevated

1edical 1anagement " /rug therapy a &cute attack: Colchicine 48 or !*: discontinue if diarrhea occurs NS&4/: 4ndomethacin +4ndocin, Napro.en +Naprosyn, !henylbutaCone +ButaColidin, b !revention of attacks (ricosuric agents: increase renal e.cretion of uric acid !robenecid +Benemid, SulfinpyraCone +&nturanel, &llopurinal +Qyloprim,: inhibits uric acid formation # % ? 6ow:purine diet may be recommended 0oint rest & protection @eat or cold therapy

Nursing 4nterventions " # % &ssess ;oints for pain- motion & appearance !rovide bed rest & ;oint immobiliCation as ordered &dminister anti:gout medications as ordered &dminister analgesics as ordered: for pain 4ncreased fluid intake to #===:%=== ml2day: to prevent formation of renal calculi &pply local heat or cold as ordered: to reduce pain &pply bed cradle: to keep pressure of sheets off ;oints !rovide client teaching and discharge planning concerning a 1edications & their side effects 1odifications for low:purine diet: avoidance of shellfish- liver- kidney- brains- sweetbreads- sardines- anchovies 6imitation of alcohol use 4ncreased in fluid intake Deight reduction if necessary 4mportance of regular e.ercise

? F H G
A

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c d e f

Systemic 6upus 'rythematosus +S6', Chronic connective tissue disease involving multiple organ systems 4ncident )ate " *ccurs most freEuently in young women

!redisposing 3actors " # % Cause unknown 4mmune 7enetic & viral factors have all been suggested

!athophysiology " # S2s. " # % ? F 3atigue 3ever &nore.ia Deight loss 1alaise & defect in bodyBs immunologic mechanisms produces autoantibodies in the serum directed against components of the clientBs own cell nuclei &ffects cells throughout the body resulting in involvement of many organs- including ;oints- skin- kidney- CNS & cardiopulmonary system

AA

A<
H G A < @istory of remissions & e.acerbations 0oint pain 1orning stiffness Skin lesions 'rythematous rash on face- neck or e.tremities may occur Butterfly rash over bridge of nose & cheeks !hotosensitivity with rash in areas e.posed to sun "= *ral or nasopharyngeal ulcerations "" &lopecia "# )enal system involvement !roteinuria @ematuria )enal failure "% CNS involvement !eripheral neuritis SeiCures *rganic brain syndrome !sychosis "? Cardiopulmonary system involvement !ericarditis !leurisy "F 4ncrease susceptibility to infection /.

" # % ? F
H

'S): elevated CBC: )BC anemia- DBC & platelet counts decreased &nti:nuclear antibody test +&N&,: positive 6upus 'rythematosus +6' prep,: positive &nti:/N&: positive Chronic false:positive test for syphilis

1edical 1anagement " /rug therapy

a b c

&spirin & NS&4/: to relieve mild symptoms such as fever & arthritis Corticosteroids: to suppress the inflammatory response in acute e.acerbations or severe disease 4mmunosuppressive agents: to suppress the immune response when client unresponsive to more conservative therapy &Cathioprine +4muran, Cyclophosphamide +Cyto.an,

# %

!lasma e.change: to provide temporary reduction in amount of circulating antibodies Supportive therapy: as organ systems become involved

Nursing 4nterventions " # % &ssess symptoms to determine systems involved 1onitor vital signs- 4&*- daily weights &dminister medications as ordered 4nstitute seiCure precautions & safety measures: with CNS involvement !rovide psychologic support to client 2 significant others !rovide client teaching & discharge planning concerning a b c /isease process & relationship to symptoms 1edication regimen & side effects 4mportance of adeEuate rest (se of daily heat & e.ercises as prescribed: for arthritis Need to avoid physical or emotional stress 1aintenance of a well:balanced diet Need to avoid direct e.posure to sunlight: wear hat & other protective clothing Need to avoid e.posure to persons with infections 4mportance of regular medical follow:up &vailability of community agencies

?
F H

d
e f

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h i ;

*steomyelitis 4nfection of the bone and surrounding soft tissues- most commonly caused by S. aureus. 4nfection may reach bone through open wound +compound fracture or surgery,- through the bloodstream- or by direct e.tension from infected ad;acent structures 4nfections can be acute or chronic$ both cause bone destruction S2s. " # % ? F H /. 1alaise 3ever !ain & tenderness of bone )edness & swelling over bone /ifficulty with weight:bearing /rainage from wound site may be present

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<= " # %

CBC: DBC elevated Blood cultures: may be positive 'S): may be elevated

Nursing 4nterventions " # &dminister analgesics & antibiotics as ordered (se sterile techniEues during dressing changes 1aintain proper body alignment & change position freEuently: to prevent deformities !rovide immobiliCation of affected part as ordered !rovide psychologic support & diversional activities +depression may result from prolonged hospitaliCation, !repare client for surgery if indicated 4ncision & drainage: of bone abscess SeEuestrectomy: removal of dead- infected bone & cartilage Bone grafting: after repeated infections 6eg amputation G !rovide client teaching and discharge planning concerning (se of prescribed oral antibiotic therapy & side effects 4mportance of recogniCing & reporting signs & complications +deformity- fracture, or recurrence 3)&CT()'S & B C / 7eneral information " 1edical management &ssessment findings Nursing interventions

%
?

F
H

*verview of &natomy & !hysiology 7astro 4ntestinal Track System The primary function of 74T are the movement of food- digestion- absorption- elimination & provision of a continuous supply of the nutrients electrolytes & @#* (pper alimentary canal: function for digestion 1outh Consist of lips & oral cavity !rovides entrance & initial processing for nutrients & sensory data such as taste- te.ture & temperature

'sophagus

*ral 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 !haryn.: aids in swallowing & functions in ingestion by providing a route for food to pass from the mouth to the esophagus

1uscular tube that receives foods from the pharyn. & propels it into the stomach by peristalsis

Stomach 6ocated on the left side of the abdominal cavity occupying the hypochondriac- epigastric & umbilical regions Stores & mi.es food with gastric ;uices & mucus producing chemical & mechanical changes in the bolus of food

The secretion of digestive ;uice 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 !NS & hormonal stimulation through secretion of gastrin by the gastric mucosa

&fter 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 !yloric Sphincter: located between the stomach & duodenum

Three anatomic division 3undus Body &ntrum

7astric Secretions:

!epsinogen: secreted by the chief cells located in the fundus aid in C@*N digestion @ydrocholoric &cid: secreted by parietal cells- function in C@*N digestion & released in response to gastrin 4ntrinsic 3actor: secreted by parietal cell- promotes absorption of 8it B"# 1ucoid Secretion: coat stomach wall & prevent auto digestion

"st half of duodenum 1iddle &limentary canal: 3unction for absorption$ Complete absorption: large intestine Small 4ntestines Composed of the duodenum- ;e;unum & ileum '.tends from the pylorus to the ileocecal valve which regulates flow into the large intestines to prevent reflu. to the into the small intestine

1a;or function: digestion & absorption of the end product of digestion Structural 3eatures:

8illi +functional unit of the small intestines,: finger like pro;ections located in the mucous membrane$ containing goblet cells that secrets mucus & absorptive cells that absorb digested food stuff

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Crypts of 6ieberkuhn: produce secretions containing digestive enCymes BrunnerBs 7land: found in the submucosaof the duodenum- secretes mucus

#nd half of duodenum 0e;unum 4leum "st half of ascending colon 6ower &limentary Canal: 3unction: elimination 6arge 4ntestine /ivided into four parts:

Cecum +with appendi., Colon +ascending- transverse- descending- sigmoid, )ectum &nus

Serves as a reservoir for fecal material until defecation occurs 3unction: to absorb water & electrolytes 1* present in the large intestine: are responsible for small amount of further breakdown & also make some vitamins

&mino &cids: 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 9 & some of the vitamin B groups

3eces +solid waste,: leave the body via rectum & anus

a
b c d e

&nus: contains internal sphincter +under involuntary control, & e.ternal sphincter +voluntary control, 3ecal matter: usually GF> water & #F> solid wastes +roughage- dead bacteria- fats- C@*N- inorganic matter,

#nd half of ascending colon Transverse /escending colon Sigmoid )ectum

&ccessory *rgan 6iver

6argest internal organ: located in the right hypochondriac & epigastric regions of the abdomen 6iver 6oobules: functional unit of the liver composed of hepatic cells @epatic Sinusoids +capillaries,: are lined with kupffer cells which carry out the process of phagocytosis !ortal circulation brings blood to the liver from the stomach- spleen- pancreas & intestines 3unction: 1etabolism of fats- C@* & C@*N: o.idiCes these nutrient for energy & produces compounds that can be stored !roduction of bile Con;ugation & e.cretion +in the form of glycogen- fatty acids- minerals- fat:soluble & water:soluble vitamins, of bilirubin Storage of vitamins &- /- B"# & iron Synthesis of coagulation factors /eto.ification of many drugs & con;ugation of se. hormones

Salivary gland 8erniform appendi. 6iver !ancreas: auto digestion 7allbladder: storage of bile Biliary System

Consist of the gallbladder & associated ductal system +bile ducts, 7allbladder: lies under the surface of the liver

3unction: to concentrate & store bile

/uctal System: provides a route for bile to reach the intestines

Bile: is formed in the liver & e.creted into hepatic duct @epatic /uct: ;oins with the cystic duct +which drains the gallbladder, to form the common bile duct

4f the sphincter of oddi is rela.ed: bile enters the duodenum- if contracted: bile is stored in gallbladder

!ancreas !ositioned transversely in the upper abdominal cavity Consist of head- body & tail along with a pancreatic duct which e.tends along the gland & enters the duodenum via the common bile duct @as both e.ocrine & endocrine function 3unction in 74 system: is e.ocrine '.ocrine cells in the pancreas secretes:

Trypsinogen & Chymotrypsin: for protein digestion &mylase: breakdown starch to disacchardes 6ipase: for fat digestion

'ndocrine function related to islets of langerhas

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!hysiology of /igestion & &bsorption

/igestion: physical & chemical breakdown of food into absorptive substance 4nitiate in the mouth where the food mi.es with saliva & starch is broken down 3ood then passes into the esophagus where it is propelled into the stomach 4n the stomach food is processed by gastric secretions into a substance called chyme 4n the small intestines C@* are hydrolyCed to monosaccharides- fats to glycerol & fatty acid & C@*N to amino acid to complete the digestive process

Dhen chymes enters the duodenum- mucus is secreted to neutraliCed hydrocholoric acid- in response to release secretinpancreas releases bicarbonate to neutraliCed acid chyme Cholecystokinin & !ancreoCymin +CC9!Q, &re produced by the duodenal mucosa Stimulate contraction of the gallbladder along with rela.ation of the sphincter of oddi +to allow bile flow from common bile duct into the duodenum, & stimulate release of the pancreatic enCymes

Salivary 7lands

" !arotid below & front of ear # Sublingual % Subma.illary !roduces saliva for mechanical digestion "#== :"F== ml2day : saliva produced

/isorder of the 74T !eptic (lcer /isease +!(/, 7astric (lcer (lceration of the mucosal lining of the stomach 1ost commonly found in the antrum '.coriation 2 erosion of submucosa & mucosal lining due to:

@ypersecretion of acid: pepsin /ecrease resistance to mucosal barrier

Caused by bacterial infection: @elicobacter !ylori

/oudenal (lcer 1ost commonly found in the first # cm of the duodenum CharacteriCed by gastric hyperacidity & a significant rate of gastric emptying

!redisposing factor

Smoking: vasoconstriction: effect 74T ischemia &lcohol &buse: stimulates release of histamine: !arietal cell release @cl acid T (lceration 'motional Stress /rugs:

S2s.

Salicylates +&spirin, Steroids ButaColidin

7astric (lcer Site !ain &ntrum or lesser curvature %= min:" hr after eating 6eft epigastrium 7aseous & burning Not usually relieved by food & antacid /. @ypersecreti on 8omiting @emorrhage Deight Complication s @igh )isk Normal gastric acid secretion Common @ematemeis Deight loss Stomach cause @emorrhage H= years old

/uodenal (lcer /uodenal bulb #:% hrs after eating 1id epigastrium Cramping & burning (sually relieved by food & antacid "# 1N %am pain 4ncreased gastric acid secretion Not common 1elena Deight gain !erforation #= years old

@gb & @ct: decrease +if anemic, 'ndoscopy: reveals ulceration & differentiate ulceration from gastric cancer 7astric &nalysis: normal gastric acidity (pper 74 series: presence of ulcer confirm

1edical 1anagement " Supportive: # )est Bland diet Stress management

/rug Therapy:

&ntacids: neutraliCes gastric acid

&luminum hydro.ide: binds phosphate in the 74T & neutraliCed gastric acid & inactivates pepsin

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1agnesium & aluminum salt: neutraliCed gastric acid & inactivate pepsin if p@ is raised to WT?

&luminum containing &ntacids '. &luminum *@ gel +&mpho;el, S': Constipation

1agnesium containing &ntacids '. 1ilk of 1agnesia S': /iarrhea

1aalo. S': fever

@istamines +@#, receptor antagonist: inhibits gastric acid secretion of parietal cells

)anitidine +Qantac,: has some antibacterial action against @ pylori Cimetidine +Tagamet, 3amotidine +!epcid,

&nticholinergic:

&tropine S*?: inhibit the action of acetylcholine at post ganglionic site +secretory glands, results decreases 74 secretions !ropantheline: inhibit muscarinic action of acetylcholine resulting decrease 74 secretions

!roton !ump 4nhibitor: inhibit gastric acid secretion regardless of acetylcholine or histamine release

*mepraCole +!rilosec,: diminished the accumulation of acid in the gastric lumen & healing of duodenal ulcer

!epsin 4nhibitor: reacts with acid to form a paste that binds to ulcerated tissue to prevent further destruction by digestive enCyme pepsin

Sucralfate +Carafate,: provides a paste like subs that coats mucosal lining of stomach

1etronidaCole & &mo.acillin: for ulcer caused by @elicobacter !ylori

Surgery: 7astric )esection &nastomosis: ;oining of # or more hollow organ Subtotal 7astrectomy: !artial removal of stomach Before surgery for B4 or B44

/o 8agotomy +severing or cutting of vagus nerve, & !yloroplasty +drainage, first

Billroth 4 +7astroduodenostomy, )emoval of N of stomach & anastomoses of gastric stump to the duodenum Nursing 4ntervention !ost op " 1onitor N7T output 4mmediately post op should be bright red Dithin %H:?# hrs: output is yellow green &fter ?# hrs: output is dark red

Billroth 44 +7astro;e;unostomy, )emoval of N :%2? of stomach & duodenal bulb & anastomostoses of gastric stump to ;e;unum

# % ? F

&dminister medication &nalgesic &ntibiotic &ntiemetics

1aintain patent 48 line 1onitor 82S- 4&* & bowel sounds Complications:

@emorrhage: @ypovolemic shock: 6ate signs: anuria !eritonitis !aralytic ileus: most feared @ypokalemia Thromobphlebitis !ernicious anemia

Nursing 4ntervention " &dminister medication as ordered /iet: bland- non irritating- non spicy &void caffeine & milk 2 milk products: 4ncrease gastric acid secretion !rovide client teaching & discharge planning a 1edical )egimen Take medication at prescribe time @ave antacid available at all times )ecogniCed situation that would increase the need for antacids &void ulcerogenic drugs: salicylates- steroids 9now proper dosage- action & S'

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!roper /iet Bland diet consist of si. meals 2 day 'at slowly &void acid producing substance: caffeine- alcohol- highly seasoned food &void stressfull situation at mealtime !lan rest period after meal

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c &void late bedtime snacks

&voidance of stress:producing situation & development of stress production methods )ela.ation techniEues '.ercise Biofeedback

/umping syndrome &brupt emptying of stomach content into the intestine )apid gastric emptying of hypertonic food solutions Common complication of gastric surgery &ppears "F:#= min after meal & last for #=:H= min &ssociated with hyperosmolar C@51' in the ;e;unum which draws fluid by osmosis from the e.tracellular fluid into the bowel /ecreased plasma volume & distension of the bowel stimulates increased intestinal motility S2s. " # % ? F H G Deakness 3aintness 3eeling of fullness /iCCiness /iaphoresis /iarrhea !alpitations

Nursing 4ntervention " &void fluids in chilled solutions Small freEuent feeding: si. eEually divided feedings /iet: decrease C@*- moderate fats & C@*N 3lat on bed "F:%= min after E feeding

# %
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/isorders of the 7allbladder Cholecystitis 2 Cholelithiasis Cholecystitis: &cute or chronic inflammation of the gallbladder 1ost commonly associated with gallstones 4nflammation occurs within the walls of the gallbladder & creates thickening accompanied by edema ConseEuently there is impaired circulation- ischemia & eventually necrosis

Cholelithiasis: 3ormation of gallstones & cholesterol stones

4nflammation of gallbladder with gallstone formation

!redisposing 3actor:

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@igh risk: women ?= years old !ost menopausal women: undergoing estrogen therapy *besity Sedentary lifestyle @yperlipidemia Neoplasm

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Severe )ight abdominal pain +after eating fatty food,: *ccurring especially at night 4ntolerance of fatty food &nore.ia N28 0aundice !ruritus 'asy bruising Tea colored urine Steatorrhea

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/irect Bilirubin Transaminase: increase &lkaline !hosphatase: increase DBC: increase &mylase: increase 6ipase: increase *ral cholecystogram +or gallbladder series,: confirms presence of stones Supportive Treatment: N!* with N7T & 48 fluids /iet modification with administration of fat soluble vitamins /rug Therapy

1edical 1anagement

Narcotic analgesic: /*C: 1eperdipine @cl +/emerol,: for pain

+1orpine S*?: is contraindicated because it causes spasm of the Sphincter of *ddi,

&ntocholinergic: +&trophine S*?,: for pain

+&nticholinergic: rela. smooth muscles & open bile ducts,

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&ntiemetics: !henothiaCide +!henergan,: with anti emetic properties

Surgery: Cholecystectomy 2 Choledochostomy

Nursing 4ntervention " # &dminister pain medication as ordered & monitor effects &dminister 48 fluids as ordered /iet: increase C@*- moderate C@*N- decrease fats 1eticulous skin care: to relieved priritus

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/isorders of the !ancreas !ancreatitis &n inflammatory process with varying degrees of pancreatic edema- fat necrosis or hemorrhage !roteolytic & lipolytic pancreatic enCymes are activated in the pancreas rather than in the duodenum resulting in tissue damage & auto digestion of pancreas

&cute or chronic inflammation of pancreas leading to pancreatic edema- hemorrhage & necrosis due to auto digestion Bleeding of !ancreas: CullenBs sign at umbilicus

!redisposing factors: " # % ? F H G A < Chronic alcoholism @epatobilary disease Trauma 8iral infection !enetrating duodenal ulcer &bscesses *besity @yperlipidemia @yperparathyroidism

"= /rugs: ThiaCide- steroids- diuretics- oral contraceptives

S2S.:

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Severe left upper epigastric pain radiates from back & flank area: aggravated by eating with /*B N28 Tachycardia !alpitation: due to pain /yspepsia: indigestion /ecrease bowel sounds +L, CullenBs sign: ecchymosis of umbilicus +L, 7rey TurnerBs spots: ecchymosis of flank area @ypocalcemia @emorrhage

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Serum amylase & lipase: increase (rinary amylase: increase Blood Sugar: increase 6ipids 6evel: increase Serum Ca: decrease CT Scan: shows enlargement of the pancreas

1edical 1anagement " /rug Therapy

Narcotic &nalgesic: for pain

1eperidine @cl +/emerol, /onBt give 1orphine S*?: will cause spasm of Sphincter of *ddi

Smooth muscle rela.ant: to relieve pain !apaverine @cl

&nticholinergic: to decrease pancreatic stimulation &trophine S*? !ropantheline Bromide +!rofanthene,

&ntacids: to decrease pancreatic stimulation 1aalo.

@# &ntagonist: to decrease pancreatic stimulation

)anitidin +Qantac,

8asodilators: to decrease pancreatic stimulation

Nitroglycerine +NT7,

Ca 7luconate: to decrease pancreatic stimulation

/iet 1odification N!* +usually, !eritoneal 6avage /ialysis

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Nursing 4ntervention " &dminister medication as ordered Dithhold food & fluid & eliminate odor: to decrease pancreatic stimulation 2 aggravates pain

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&ssist in Total !arenteral Nutrition +T!N, or hyperalimentation Complication of T!N 4nfection 'mbolism @yperglycemia

4nstitute non:pharmacological measures: to decrease pain

&ssist client to comfortable position: 9nee chest or fetal like position Teach rela.ation techniEues & provide Euiet- restful environment

!rovide client teaching & discharge planning /ietary regimen when oral intake permitted @igh C@*- C@*N & decrease fats 'at small freEuent meal instead of three large ones &void caffeine products 'liminate alcohol consumption 1aintain rela.ed atmosphere after meals

)eport signs of complication Continued N28 &bdominal distension with feeling of fullness !ersistent weight loss Severe epigastric or back pain 3rothy foul smelling bowel movement 4rritability- confusion- persistent elevation of temperature +# day,

&pendicitis

4nflammation of the appendi. that prevents mucus from passing into the cecum 4nflammation of verniform appendi. 4f untreated: ischemia- gangrene- rupture & peritonitis 1ay cause by mechanical obstruction +fecalith- intestinal parasites, or anatomic defect 1ay be related to decrease fiber in the diet

!redisposing factor: " # % S2S.: 1icrobial infection 3eacalith: undigested food particles like tomato seeds- guava seeds etc 4ntestinal obstruction

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!athognomonic sign: +L, rebound tenderness 6ow grade fever N28 /ecrease bowel sound /iffuse pain at lower )ight iliac region 6ate sign: tachycardia: due to pain

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CBC: mild leukocytosis: increase DBC !': +L, rebound tenderness +fle. )ight leg- palpate )ight iliac area: rebound, (rinalysis: elevated acetone in urine

1edical 1anagement

Surgery: &ppendectomy #?:?F hrs

Nursing 4ntervention " # &dminister antibiotics 2 antipyretic as ordered )outinary pre:op nursing measures: Skin prep N!* &void enema- cathartics: lead to rupture of appendi.

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/onBt give analgesic: will mask pain !resence of pain means appendi. has not ruptured

&void heat application: will rupture appendi. 1onitor 8S- 4&* bowel sound

Nursing 4ntervention post op

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4f +L, !endrose drain +rubber drain inserted at surgical wound for drainage of blood- pus etc,: indicates rupture of appendi. !osition the client semi:fowlers or side lying on right: to facilitate drainage &dminister 1eds:

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&nalgesic: due post op pain &ntibiotics: for infection &ntipyretics: for fever +!)N,

1onitor 8S- 4&*- bowel sound 1aintain patent 48 line Complications: !eritonitis- Septicemia

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6iver Cirrhosis Chronic progressive disease characteriCed by inflammation- fibrosis & degeneration of the liver parenchymal cell /estroyed liver cell are replaced by scar tissue- resulting in architectural changes & malfunction of the liver 6ost of architectural design of liver leading to fat necrosis & scarring Types 6aennecBs Cirrhosis: &ssociated with alcohol abuse & malnutrition CharacteriCed by an accumulation of fat in the liver cell progressing to widespread scar formation !ostnecrotic Cirrhosis )esult in severe inflammation with massive necrosis as a complication of viral hepatitis Cardiac Cirrhosis *ccurs as a conseEuence of right sided heart failure 1anifested by hepatomegaly with some fibrosis Biliary Cirrhosis &ssociated with biliary obstruction usually in the common bile duct )esults in chronic impairment of bile e.cretion S2s. 3atigue &nore.ia N28 /yspepsia: 4ndigestion Deight loss 3latulence Change +4rregular, bowel habit &scites !eripheral edema @epatomegaly: pain located in the right upper Euadrant &trophy of the liver 3etor hepaticus: fruity- musty odor of chronic liver disease &teri.is: flapping of hands & tremores @ard nodular liver upon palpation 4ncreased abdominal girth Changes in moods &lertness & mental ability Sensory deficits 7ynecomastia /ecrease of pubic & a.illa hair in males &menorrhea in female 0aundice !ruritus or urticaria 'asy bruising Spider angiomas on nose- cheeks- upper thora. & shoulder !almar erythema 1uscle atrophy /. 6iver enCymes: increase S7!T +&6T, S7*T +&ST, 6/@ &lkaline !hosphate Serum cholesterol & ammonia: increase 4ndirect bilirubin: increase CBC: pancytopenia !T: prolonged @epatic (ltrasonogram: fat necrosis of liver lobules Nursing 4ntervention CB) with bathroom privileges 'ncourage gradual- progressive- increasing activity with planned rest period 4nstitute measure to relieve pruritus /o not use soap & detergent Bathe with tepid water followed by application of emollient lotion !rovide cool- light- non:constrictive clothing 9eep nail short: to avoid skin e.coriation from scratching &pply cool- moist compresses to pruritic area 1onitor 8S- 4 & * !revent 4nfection !revent skin breakdown: by turning & skin care !rovide reverse isolation for client with severe leukopenia: handwashing techniEue 1onitor DBC /iet: Small freEuent meals )estrict NaU @igh calorie- low to moderate C@*N- high C@*- low fats with supplemental 8it &- B:comple.- C- /- 9 & folic acid 1onitor 2 prevent bleeding 1easure abdominal girth daily: notify 1/ Dith pt daily & assess pitting edema

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&dminister diuretics as ordered !rovide client teaching & discharge planning &voidance of hepatoto.icity drug: sedative- opiates or *TC drugs deto.ified by liver @ow to assess weight gain & increase abdominal girth &void person with upper respiratory infection )eporting signs of reccuring illness +liver tenderness- increase ;aundice- increase fatigue- anore.ia, &void all alcohol &void straining stool vigorous blowing of nose & coughing: to decrease incidence of bleeding Complications: &scites: accumolation of free fluid in abdominal cavity Nursing 4ntervention 1eds: 6oop diuretics: "=:"F min effect &ssist in abdominal paracentesis: aspiration of fluid 8oid before paracentesis: to prevent accidental puncture of bladder as trochar is inserted Bleeding esophageal varices: /ilation of esophageal veins Nursing 4ntervention &dminister meds: 8it 9 !itrisin or 8asopresin +41, N7T decompression: lavage 7ive before lavage: ice or cold saline solution 1onitor N7T output &ssist in mechanical decompression 4nsertion of sengstaken:blackemore tube % lumen typed catheter Scissors at bedside to deflate balloon @epatic encephalopathy Nursing 4ntervention &ssist in mechanical ventilation: due coma 1onitor 8S- neuro check Siderails: due restless &dminister meds 6a.atives: to e.crete ammonia *verview of &natomy & !hysiology *f 7(T System 7(T: 7enito:urinary tract 7(T includes the kidneys- ureters- urinary bladder- urethra & the male & female genitalia 3unction: !romote e.cretion of nitrogenous waste products 1aintain 3&' & acid base balance 9idneys Two of bean shaped organ that lie in the retroperitonial space on either side of the vertebral column )etroperitonially +back of peritoneum, on either side of vertebral column &drenal gland is on top of each kidneys 'ncased in BowmansBs capsule )enal !arenchyma Corte. *utermost layer Site of glomeruli & pro.imal & distal tubules of nephron 1edulla 1iddle layer 3ormed by collecting tubules & ducts )enal Sinus & !elvis !apillae !ro;ection of renal tissues located at the tip of the renal pyramids Calices 1inor Caly.: collects urine flow from collecting ducts 1a;or Caly.: directs urine from renal sinus to renal pelvis (rine flows from renal pelvis to ureters Nephron 3unctional unit of the kidney Basic living unit )enal Corpuscle +vascular system of nephron, BowmanBs Capsule: !ortion of the pro.imal tubule surrounds the glomerulus 7lomerulus: Capillary network permeable to water- electrolytes- nutrients & waste 4mpermeable to large C@*N molecules

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3ilters blood going to kidneys )enal Tubule /ivided into pro.imal convoluted tubule- descending loop of @enle- acending loop of @enle- distal convoluted tubule & collecting ducts (reters Two tubes appro.imately #F:%F cm long '.tend from the renal pelvis to the pelvic cavity where they enter the bladder- convey urine from the kidney to the bladder !assageway of urine to bladder (reterovesical valve: prevent backflow of urine into ureters Bladder 6ocated behind the symphisis pubis Composed of muscular elastic tissue that makes it distensible Serve s as reservoir of urine +capable of holding "===:"A== ml & F== ml moderately full, 4nternal & e.ternal urethral sphincter controls the flow of urine (rge to void stimulated by passage of urine past the internal sphincter +involuntary, to the upper urethra )ela.ation of e.ternal sphincter +voluntary, produces emptying of the bladder +voiding, (rethra Small tube that e.tends from the bladder to the e.terior of the body !assage of urine- seminal & vaginal fluids 3emales: located behind the symphisis pubis & anterior vagina & appro.imately %:F cm 1ales: e.tend the entire length of the penis & appro.imately #= cm 3unction of kidneys 9idneys remove nitrogenous waste & regulates 3 & ' balance & acid base balance (rine is the end product (rine formation: #F > of total cardiac output is received by kidneys 7lomerular 3iltration (ltrafiltration of blood by the glomerulus- beginning of urine formation )eEuires hydrostatic pressure & sufficient circulating volume !ressure in bowmanBs capsule opposes hydrostatic pressure & filtration 4f glomerular pressure insufficient to force substance out of the blood into the tubules filtrate formation stops 7lomerular 3iltration )ate +73), &mount of blood filtered by the glomeruli in a given time Normal: "#F ml 2 min 3iltrate formed has essentially same composition as blood plasma without the C@*N$ blood cells & C@*N are usually too large to pass the glomerular membrane Tubular 3unction Tubules & collecting ducts carry out the function of reabsorption- secretion & e.cretion )eabsorption of @#* & electrolytes is controlled by anitdiuretics hormones +&/@, released by the pituitary & aldosterone secreted by the adrenal glands !ro.imal Convoluted Tubule )eabsorb the ff: A=> of 3 & ' @#* 7lucose &mino acids Bicarbonate Secretes the ff: *rganic substance Daste 6oop of @enli )eabsorb the ff: Na & Chloride in the ascending limb @#* in the descending limb Concentrate 2 dilutes urine /istal Convoluted Tubule Secretes the ff: !otassium @ydrogen ions &mmonia )eabsorb the ff: @#* Bicarbonate )egulate the ff: Ca !hosphate concentration Collecting /ucts )eceived urine from distal convoluted tubules & reabsorb @#* +regulated by &/@, Normal &dult: produces " 6 2day of urine )egulation of B! Through maintenance of volume +formation 2 e.cretion of urine, )ennin:angiotensin system is the kidneys controlled mechanism that can contribute to rise the B!

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Dhen the B! drops the cells of the glomerulus release rennin which then activates angiotensin to cause vasoconstriction

3iltration Normal 73)2 min is "#F ml of blood Tubular reabsorption "#?ml of ultra infiltrates +@#* & electrolytes is for reabsorption, Tubular secretion " ml is e.creted in urine )egulation of B!: !redisposing factor: '. CS hypovolemia decrease B! going to kidneys &ctivation of )&&S )elease of )enin +hydrolytic enCyme, at ;u.taglomerular apparatus &ngiotensin 4 mild vasoconstrictor &ngiotensin 44 vasoconstrictor

&drenal corte. &ldosterone

increase C*

increase !)

4ncrease B! 4ncrease Na & @#* reabsorption @ypervolemia

Color *dor Consistency p@ DBC2 )BC &lbumin ' coli

amber aromatic clear or slightly turbid ?FA +:, +:, +:,

Specific gravity " ="F " =%=

1ucus thread few &morphous urate +:,

(T4 C5ST4T4S 4nflammation of bladder due to bacterial infection !redisposing factors: 1icrobial invasion: ' coli @igh risk: women *bstruction (rinary retention 4ncrease estrogen levels Se.ual intercourse S2S.: !ain: flank area (rinary freEuency & urgency Burning pain upon urination /ysuria @ematuria Nocturia 3ever Chills &nore.ia 7en body malaise /. (rine culture & sensitivity: +L, to ' coli Nursing 4ntervention 3orce fluid: %=== ml Darm sitC bath: to promote comfort 1onitor & assess urine for gross odor- hematuria & sediments &cid &sh /iet: cranberry- vit C: *0: to acidify urine & prevent bacterial multiplication &dminister 1edication as ordered: Systemic &ntibiotics

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&mpicillin Cephalosporin &minoglycosides Sulfonamides Co:trima.aCole +Bactrim, 7antrism +7antanol, &ntibacterial Nitrofurantoin +1acrodantin, 1ethenamine 1andelate +1andelamine, Nali.idic &cid +Neg7ram, (rinary Tract &nagesic (rinary antiseptics: 1itropurantoin +1acrodantin, (rinary analgesic: !yridium !rovide client teachings & discharge planning 4mportance of @ydration 8oid after se.: to avoid stagnation 3emale: avoids cleaning back & front +should be front to back, Bubble bath- Tissue paper- !owder- perfume Complications: !yelonephritis !yelonephritis &cute 2 chronic inflammation of " or # renal pelvis of kidneys leading to tubular destruction & interstitial abscess formation &cute: infection usually ascends from lower urinary tract Chronic: a combination of structural alteration along with infection ma;or cause is ureterovesical reflu. with infected urine backing up into ureters & renal pelvis )ecurrent infection will lead to renal parenchymal deterioration & )enal 3ailure !redisposing factor: 1icrobial invasion ' Coli Streptococcus (rinary retention 2obstruction !regnancy /1 '.posure to renal to.ins S2s.: &cute !yelonephritis Severe flank pain or dull ache Costovertibral angle pain 2 tenderness 3ever Chills N28 &nore.ia 7en body malaise (rinary freEuency & urgency Nocturia /syuria @ematuria Burning sensation on urination Chronic !yelonephritis: client usually not aware of disease Bladder irritability Slight dull ache over the kidney Chronic 3atigue Deight loss !olyuria !olydypsia @!N &trophy of the kidney 1edical 1anagement (rinary analgesic: !eridium &cute &ntibiotics &ntispasmodic Surgery: removal of any obstruction Chronic &ntibiotics (rinary &ntiseptics Nitrofurantoin +macrodantin, S': peripheral neuropathy 74 irritation @emolytic anemia Staining of teeth Surgery: correction of structural abnormality if possible /. (rine culture & sensitivity: +L, ' coli & streptococcus

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(rinalysis: increase DBC- C@*N & pus cells Cystoscopic e.am: urinary obstruction Nursing 4ntervention !rovide CB): acute phase 1onitor 4 & * 3orce fluid &cid ash diet &dminister medication as ordered Chronic: possibility of dialysis & transplant if has renal deterioration Complication: )enal 3ailure Nephrolithiasis 2 (rolithiasis !resence of stone anywhere in the urinary tract 3ormation of stones at urinary tract 3reEuent composition of stones Calcium *.alate (ric acid Calcium 1ilk *.alate Cabbage Cranberries Nuts tea Chocolates !redisposing factors: /iet: increase Ca & o.alate 4ncrease uric acid level @ereditary: gout or calculi 4mmobility Sedentary lifestyle @yperparathyroidism S2s. &bdominal or flank pain )enal colic Cool moist skin +shock, Burning sensation upon urination @ematuria &nore.ia N28 /. 4ntravenous !yelography +48!,: identifies site of obstruction & presence of non:radiopaEue stones 9(B: reveals location- number & siCe of stone Cytoscopic '.am: urinary obstruction Stone &nalysis: composition & type of stone (rinalysis: indicates presence of bacteria- increase DBC- )BC & C@*N 1edical 1anagement Surgery !ercutaneous Nephrostomy: Tube is inserted through skin & underlying tissue into renal pelvis to remove calculi !ercutaneous Nephrostolithotomy /elivers ultrasound wave through a probe placed on the calculus '.tracorporeal Shockwave 6ithotripsy: Non:invasive /elivers shockwaves from outside of the body to the stone causing pulveriCation !ain management & diet modification Nursing 4ntervention 3orce fluid: %===:?=== ml 2 day Strain urine using gauCe pad: to detect stones & crush all cloths 'ncourage ambulation: to prevent stasis Darm sitC bath: for comfort &dminister narcotic analgesic as ordered: 1orphine S*?: to relieve pain &pplication warm compress at flank area: to relieve pain 1onitor 4 & * !rovide modified diet depending upon the stone consistency Calcium Stones 6imit milk & dairy products !rovide acid ash diet +cranberry or prune ;uice- meat- fish- eggs- poultry- grapes- whole grains,: to acidify urine Take vitamin C *.alate Stone &void e.cess intake of food 2 fluids high in o.alate +tea- chocolate- rhubarb- spinach, 1aintain alkaline:ash diet +milk- vegetable- fruits e.cept cranberry- plums & prune,: to alkaliniCe urine (ric &cid Stone Nuts Sardines (ric &cid &nchovies *rgan meat

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)educe food high in purine +liver- brain- kidney- venison- shellfish- meat soup- gravies- legumes, 1aintain alkaline urine &dminister &llopurinol +Qyloprim, as ordered: to decrease uric acid production: push fluids when giving allopurinol !rovide client teaching & discharge planning !revention of urinary stasis: increase fluid intake especially during hot weather & illness 1obility 8oiding whenever the urge is felt & at least twice during night &dherence to prescribe diet Complications: )enal 3ailure Benign !rostatic @ypertrophy +B!@, 1ild to moderate glandular enlargement- hyperplsia & over growth of the smooth muscles & connective tissue &s the gland enlarges it compresses the urethra: resulting to urinary retention 'nlarged prostate gland leading to @ydroureters: dilation of urethers @ydronephrosis: dilation of renal pelvis 9idney stones )enal failure !redisposing factor: @igh risk: F= years old & above & H=:G= +%:?. at risk, 4nfluence of male hormone S2s. (rgency- freEuency & hesitancy Nocturia 'nlargement of prostate gland upon palpation by digital rectal e.am /ecrease force & amount of urinary stream /ysuria @ematuria Burning sensation upon urination Terminal bubbling Backache Sciatica: severe pain in the lower back & down the back of thigh & leg /. /igital rectal e.am: enlarged prostate gland 9(B: urinary obstruction Cystoscopic '.am: reveals enlargement of prostate gland & obstruction of urine flow (rinalysis: alkalinity increase Specific 7ravity: normal or elevated B(N & Creatinine: elevated +if longstanding B!@, !rostate:specific &ntigen: elevated +normal is X ? ng 2ml, Nursing 4ntervention !rostate message: promotes evacuation of prostatic fluid 3orce fluid intake: #===:%=== ml unless contraindicated !rovide catheteriCation &dminister medication as ordered: TeraCosine +@ytrin,: rela.es bladder sphincter & make it easier to urinate 3inasteride +!roscar,: shrink enlarge prostate gland Surgery: !rostatectomy Transurethral )esection of !rostate +T()!,: insertion of a resectoscope into urethra to e.cise prostatic tissue &ssist in cystoclysis or continuous bladder irrigation Nursing 4ntervention 1onitor symptoms of infection 1onitor symptoms gross 2 flank bleeding Normal bleeding within #?h 1aintain irrigation or tube patent to flush out clots: to prevent bladder spasm & distention

&cute )enal 3ailure Sudden inability of the kidney to regulate fluid & electrolyte balance & remove to.ic products from the body Sudden immobility of kidneys to e.crete nitrogenous waste products & maintain 3&' balance due to a decrease in 73) +N "#F ml2min, Causes !re:renal cause: interfering with perfusion & resulting in decreased blood flow & glomerular filtrate 4nter:renal cause: condiion that cause damage to the nephrons !ost:renal cause: mechanical obstruction anywhere from the tubules to the urethra !re renal cause: decrease blood flow & glomerular filtrate 4schemia & oliguria Cardiogenic shock &cute vasoconstriction Septicemia @ypovolemia @ypotension C@3 @emorrhage /ecrease flow to kidneys

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/ehydration 4ntra:renal cause: involves renal pathology: kidney problem &cute tubular necrosis 'ndocarditis /1 Tumors !yelonephritis 1alignant @!N &cute 7lomerulonephritis Blood transfision reaction @ypercalemia Nephroto.in +certain antibiotics- I:ray- dyes- pesticides- anesthesia, !ost renal cause: involves mechanical obstruction Tumors Stricture Blood cloths (rolithiasis B!@ &natomic malformation S2s. *liguric !hase: caused by reduction in glomerular filtration rate (rine output less than ?== ml 2 #? hrs$ duration ":# weeks S2s. @ypernatremia @yperkalemia @yperphosphotemia @ypermagnesemia @ypocalcemia 1etabolic acidosis /. B(N & Creatinine: elevated /iuretic !hase: slow gradual increase in daily urine output /iuresis may occur +output %:F 6 2 day,: due to partially regenerated tubules inability to concentrate urine /uration: #:% weeks S2s. @yponatremia @ypokalemia @ypovolemia /. B(N & Creatinine: elevated )ecovery or Covalescent !hase: renal function stabiliCed with gradual improvement over ne.t %:"# mos Nursing 4ntervention 1onitor 2 maintain 3&' balance *btain baseline data on usual appearance & amount of clientBs urine 1easure 4&* every hour: note e.cessive losses &dminister 48 3&' supplements as ordered Deight daily 1onitor lab values: assess 2 treat 3&' & acid base imbalance as needed 1onitor alteration in fluid volume 1onitor 82S !&!- !CD!- C8! as needed 1onitor 4&* strictly &ssess every hour fro hypervolemia 1aintain ventilation /ecrease fluid intake as ordered &dminister diuretics- cardiac glycosides & hypertensive agent as ordered &ssess every hour for hypovolemia: replace fluid as ordered 1onitor 'C7 Check urine serum osmolality 2 osmolarity & urine specific gravity as ordered !romote optimal nutrition &dminister T!N as ordered )estrict C@*N intake !revent complication from impaired mobility !ulmonary 'mbolism Skin breakdown Contractures &telectesis !revent infection 2 fever &ssess sign of infection (se strict aseptic techniEue for wound & catheter care Take temperature via rectal &dminister antipyretics as ordered & cooling blankets Support clients 2 significant others: reduce level of an.iety !rovide care for client receiving dialysis !rovide client teaching & discharge planning &dherence to prescribed dietary regime

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S2s. of recurrent renal disease 4mportance of planned rest period (se of prescribe drugs only S2s. of (T4 or respiratory infection: report to 1/ Chronic )enal 3ailure !rogressive- irreversible destruction of the kidneys that continues until nephrons are replaced by scar tissue 6oss of renal function gradual 4rreversible loss of kidney function !redisposing factors: /1 @!N )ecurrent (T42 nephritis (rinary Tract obstruction '.posure to renal to.ins Stages of C)3 /iminished )eserve 8olume asymptomatic Normal B(N & Crea- 73) X "= %=> # )enal 4nsufficiency % 'nd Stage )enal disease

S2S.: N28 /iarrhea 2 constipation /ecreased urinary output /yspnea Stomatitis @ypotension +early, @ypertension +late, 6ethargy Convulsion 1emory impairment !ericardial 3riction )ub @3

(rinary System !olyuria Nocturia @ematuria /ysuria *liguria CNS @eadache 6ethargy /isorientation )estlessness 1emory impairment )espiratory 9assmaulBs resp /ecrease cough refle. 3luid & 'lectrolytes @yperkalemia @ypernatermia @ypermagnese mia @yperposphate mia @ypocalcemia 1etabolic acidosis

1etabolic /isturbance &Cotemia +increase B(N & Creatinine, @yperglycemia @yperinsulinemia 74T N28 Stomatitis (remic breath /iarrhea 2 constipation @ematological Normocytic anemia Bleeding tendencies 4ntegumentary 4tchiness 2 pruritus (remic frost

/. (rinalysis: C@*N- Na & DBC: elevated Specific gravity: decrease !latelets: decrease Ca: decrease 1edical 1anagement /iet restriction 1ultivitamins @ematinics &luminum @ydro.ide 7els &ntihypertensive

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Nursing 4ntervention !revent neurologic complication 1onitor for signs of uremia 3atigue 6oss of appetite /ecreased urine output &pathy Confusion 'levated B! 'dema of face & feet 4tchy skin )estlessness SeiCures 1onitor for changes in mental functioning *rient confused client to time- place- date & person 4nstitute safety measures to protect the client from falling out of bed 1onitor serum electrolytes- B(N & creatinine as ordered !romote optimal 74 function !rovide care for stomatitis 1onitor N28 & anore.ia: administer antiemetics as ordered 1onitor signs of 74 bleeding 1onitor & prevent alteration in 3&' balance 1onitor for hyperphosphatemia: administer aluminum hydro.ides gel +ampho;el- alternagel, as ordered !aresthesias 1uscle cramps SeiCures &bnormal refle. 1aintenance of skin integrity !rovide care for pruritus 1onitor uremic frost +urea crystalliCation on the skin,: bathe in plain water 1onitor for bleeding complication & prevent in;ury to client 1onitor @gb- @ct- platelets- )BC @ematest all secretions &dminister hematinics as ordered &void 41 in;ections 1aintain ma.imal cardiovascular function 1onitor B! &uscultate for pericardial friction rub !erform circulation check routinely &dminister diuretics as ordered & monitor 4&* 1odify digitalis dose as ordered +digitalis is e.creted in kidneys, !rovide care for client receiving dialysis /iseEuilibrium syndrome: from rapid removal of urea & nitrogenous waste prod leading to: N28 @!N 6eg cramps /isorientation !aresthes 'nforce CB) 1onitor 8S- 4&* 1eticulous skin care (remic frost assist in bathing pt ? 1eds: a , Na @C*% due @yperkalemia b , 9age.elate enema c , &nti @!N hydralaCine d , 8it & minerals e , !hosphate binder +&mphogel, &l *@ gel : S2' constipation f , /ecrease Ca Ca gluconate F &ssist in hemodialysis Consent2 e.plain procedure *btain baseline data & monitor 8S- 4&*- wt- blood e.am Strict aseptic techniEue 1onitor for signs of complications: B bleeding ' embolism / diseEuilibrium syndrome S septicemia S shock decrease in tissue perfusion /iseEuilibrium syndrome from rapid removal of urea & nitrogenous waste prod leading to: n2v @!N 6eg cramps /isorientation !aresthesia &void B! taking- blood e.traction- 48- at side of shunt or fistula Can lead to compression of fistula 1aintain patency of shunt by: !alpate for thrills & auscultate for bruits if +L, patent shuntU

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Bedside: bulldog clip : 4f with accidental removal of fistula to prevent embolism : 4nfersole +diastole, common dialisate used G Complication : !eritonitis : Shock A &ssist in surgery: )enal transplantation : Complication re;ection )everse isolation

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