MEDICAL-SURGICAL NURSING

Overview of structures and functions:

NERVOUS SYSTEM
The functional unit of the nervous system is the nerve cells or neurons
The nervous system is composed of the ff:
Central Nervous System
Brain
Spinal Cord serves as a connecting link between the brain & the
periphery.
Peripheral Nervous System
Cranial Nerves 12 pairs; carry impulses to & from the brain.
Spinal Nerves 31 pairs; carry impulses to & from spinal cord.
Autonomic Nervous System
subdivision of the PNS that automatically controls body function such as
breathing & heart beat.
Special senses of vision and hearing are also covered in this section

Sympathetic nervous system generally accelerate some body functions in

response to stress.
Parasympathetic nervous system controls normal body functioning.

CELLS
A. NEURONS
Primary component of nervous system
Composed of cell body (gray matter), axon, and dendrites
Basic cells for nerve impulse and conduction.
Axon
Elongated process or fiber extending from the cell body
Transmits impulses (messages) away from the cell body to dendrites or
directly to the cell bodies of other neurons
Neurons usually has only one axon
Dendrites
Short, blanching fibers that receives impulses and conducts them toward
the nerve cell body.
Neurons may have many dendrites.
Synapse
Junction between neurons where an impulse is transmitted
Neurotransmitter
Chemical agent (ex. Acetylcholine, norepinephrine) involved in the
transmission of impulse across synapse.

Myelin Sheath
A wrapping of myelin (whitish, fatty material) that protects and insulates
nerve fibers and enhances the speed of impulse conduction.
o Both axons and dendrites may or may not have a myelin sheath
(myelinated/unmyelinated)
o Most axons leaving the CNS are heavily myelinated by schwann
cells
Functional Classification
1. Afferent (sensory) neurons
Transmit impulses from peripheral receptors to the CNS
2. Efferent (motor) neurons
Conduct impulses from CNS to muscle and glands
3. Internuncial neurons (interneurons)
Connecting links between afferent and efferent neurons
Properties
1. Excitability ability of neuron to be affected by changes in external
environment.
2. Conductility ability of neuron to transmit a wave of excitetation from one
cell to another.
3. Permanent Cell once destroyed not capable of regeneration.
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY
1. Labile
Capable of regeneration.
Epidermal cells, GIT cells, GUT cells, cells of lungs.
2. Stable
Capable of regeneration with limited time, survival period.
Kidney cells, Liver cells, Salivary cells, pancreas.
3. Permanent
Not capable of regeneration.
Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
B. NEUROGLIA
Support and protection of neurons.
TYPES
1. Astrocytes
maintains blood brain barrier semi-permiable.
majority of brain tumors (90%) arises from called astrocytoma.
integrity of blood brain barrier.
2. Oligodendria

3.

4.

produces myelin sheath in CNS.

act as insulator and facilitates rapid nerve impulse transmission.
Microglia
stationary cells that carry on phagocytosis (engulfing of bacteria or
cellular debris, eating), pinocytosis (cell drinking).
Epindymal
secretes a glue called chemo attractants that concentrate the bacteria.
MACROPHAGE
Microglia
Monocytes
Kupffers
Histiocytes
Alveolar Macrophage

ORGAN
Brain
Blood
Kidney
Skin
Lung

Central Nervous System

Composition Of Brain
80% brain mass
10% blood
10% CSF
Brain Mass
Parts Of The Brain
1. Cerebrum
largest part of the brain
outermost area (cerebral cortex) is gray matter
deeper area is composed of white matter
function of cerebrum: integration, sensory, motor
composed of two hemisphere the Right Cerebral Hemisphere and Left
Cerebral Hemisphere enclosed in the Corpus Callosum.
Each hemisphere divided into four lobes; many of the functional areas
of the cerebrum have been located in these lobes:
Lobes of Cerebrum
1. Frontal Lobe
controls personality, behavior
higher cortical thinking, intellectual functioning
precentral gyrus: controls motor function
Brocas Area: specialized motor speech area - when damaged results
to garbled speech.
2. Temporal Lobe

3.

4.

2.

hearing, taste, smell

short term memory
Wernickes area: sensory speech area (understanding/formulation of
language)
Pareital Lobe
for appreciation
integrates sensory information
discrimination of sensory impulses to pain, touch, pressure, heat, cold,
numbness.
Postcentral gyrus: registered general sensation (ex. Touch, pressure)
Occipital Lobe
for vision
Insula (Island of Reil)
visceral function activities of internal organ like gastric motility.
Limbic System (Rhinencephalon)
controls smell - if damaged results to anosmia (absence of smell).
controls libido
controls long term memory
Corpus Callosum
large fiber tract that connects the two cerebral hemisphere
Basal Ganglia
island of gray matter within white matter of cerebrum
regulate & integrate motor activity originating in the cerebral cortex
part of extrapyramidal system
area of gray matter located deep within each cerebral hemisphere.
release dopamine (controls gross voluntary movement).
Diencephalon/interbrain
Connecting part of the brain, between the cerebrum & the brain stem
Contains several small structures: the thalamus & hypothalamus are
most important
Thalamus
acts as relay station for discrimination of sensory signals (ex. Pain,
temperature, touch)
controls primitive emotional responses (ex. Rage, fear)
Hypothalamus
found immediately beneath the thalamus
plays a major role in regulation/controls of vital function: blood
pressure, thirst, appetite, sleep & wakefulness, temperature
(thermoregulatory center)

3.

4.

acts as controls center for pituitary gland and affects both divisions of
the autonomic nervous system.
controls some emotional responses like fear, anxiety and excitement.
androgenic hormones promotes secondary sex characteristics.
early sign for males are testicular and penile enlargement
late sign is deepening of voice.
early sign for females telarch and late sign is menarch.

Mesencephalon/Midbrain
acts as relay station for sight and hearing.
size of pupil is 2 3 mm.
equal size of pupil is isocoria.
unequal size of pupil is anisocoria.
hearing acuity is 30 40 dB.
positive PERRLA
Brain Stem
located at lowest part of brain.
contains midbrain, pons, medulla oblongata.
extends from the cerebral hemispheres to the foramen magnum at
the base of the skull.
contains nuclei of the cranial nerves and the long ascending and
descending tracts connecting the cerebrum and the spinal cord.
contains vital center of respiratory, vasomotor, and cardiac functions.
Pons
pneumotaxic center controls the rate, rhythm and depth of
respiration.
Medulla Oblongata
controls respiration, heart rate, swallowing, vomiting, hiccup,
vasomotor center (dilation and constriction of bronchioles).

5.

Cerebellum
smallest part of the brain, lesser brain.
coordinates muscle tone and movements and maintains position in
space (equilibrium)
controls balance, equilibrium, posture and gait.

Spinal Cord
serves as a connecting link between the brain and periphery
extends from foramen magnum to second lumbar vertebra

H-shaped gray matter in the center (cell bodies) surrounded by white

matter (nerve tract and fibers)

Gray Matter
1. Anterior Horns
Contains cell bodies giving rise to efferent (motor) fibers
2. Posterior Horns
Contains cell bodies connecting with afferent (sensory) fibers
from dorsal root ganglion
3. Lateral Horns
In thoracic region, contain cells giving rise to autonomic fibers of
sympathetic nervous system
White Matter
1. Ascending Tracts (sensory pathways)
a. Posterior Column
Carry impulses concerned with touch, pressure,
vibration, & position sense
b. Spinocerebellar
Carry impulses concerned with muscle tension &
position sense to cerebellum
c.

2.

Lateral Spinothalamic
Carry impulses resulting in pain & temperature
sensations
d. Anterior Spinothlamic
Carry impulses concerned with crude touch &
pressure
Descending Tracts (motor pathways)
a. Corticospinal (pyramidal, upper motor neurons)
Conduct motor impulses from motor cortex to
anterior horn cells (cross in the medulla)
b. Extrapyramidal
Help to maintain muscle tone & to control body
movement, especially gross automatic movements
such as walking

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

Components
a. Sensory Receptors
Receives/reacts to stimulus
b. Afferent Pathways
Transmits impulses to spinal cord
c. Interneurons
Synapses with a motor neuron (anterior horn cell)
d. Efferent Pathways
Transmits impulses from motor neuron to effector
e. Effectors
Muscle or organ that responds to stimulus
Supporting Structures
1. Skull
Rigid; numerous bones fused together
Protects & support the brain
2. Spinal Column
Consists of 7 cervical, 12 thoracic, & 5 lumbar vertebrae as well as
sacrum & coccyx
Supports the head & protect the spinal cord
3. Meninges
Membranes between the skull & brain & the vertebral column &
spinal cord
3 fold membrane that covers brain and spinal cord.
For support and protection; for nourishment; blood supply
Area between arachnoid & pia mater is called subarachnoid space:
CSF aspiration is done
Subdural space between the dura and arachnoid
Layers:
Dura Mater
outermost layer, tough, leathery
Arachnoid Mater
middle layer, weblike
Pia Mater
innermost layer, delicate, clings to surface of brain
4. Ventricles
Four fluid-filled cavities connecting with one another & spinal
canal
Produce & circulate cerebrospinal fluid
5. Cerebrospinal Fluid (CSF)

6.

7.

Surrounds brain & spinal cord

Offer protection by functioning as a shock absorber
Allows fluid shifts from the cranial cavity to the spinal cavity
Carries nutrient to & waste product away from nerve cells
Component of CSF: CHON, WBC, Glucose
Vascular Supply
Two internal carotid arteries anteriorly
Two vertebral arteries leading to basilar artery posteriorly
These arteries communicate at the base of the brain through the circle
of willis
Anterior, middle, & posterior cerebral arteries are the main arteries
for distributing blood to each hemisphere of the brain
Brain stem & cerebellum are supplied by branches of the vertebral &
basilar arteries
Venous blood drains into dural sinuses & then into jugular veins
Blood-Brain-Barrier (BBB)
Protective barrier preventing harmful agents from entering the
capillaries of the CNS; protect brain & spinal cord

Substance That Can Pass Blood-Brain Barrier

1. Amonia
Cerebral toxin
Hepatic Encephalopathy (Liver Cirrhosis)
Ascites
Esophageal Varices
Early Signs of Hepatic Encephalopathy
Asterexis (flapping hand tremors).
Late Signs of Hepatic Encephalopathy
Headache
Dizziness
Confusion
Fetor hepaticus (amonia like breath)
decrease LOC
2. Carbon Monoxide and Lead Poisoning
Can lead to Parkinsons Disease.
Epilepsy
Treated with calcium EDTA.
3. Type 1 DM (IDDM)
Causes diabetic ketoacidosis.
And increases breakdown of fats.
And free fatty acids

4.

5.

Resulting to cholesterol and positive to ketones (CNS depressant).

Resulting to acetone breath odor/fruity odor.
And kusshmauls respiration a rapid shallow respiration.
Which may lead to diabetic coma.
Hepatitis
Signs of jaundice (icteric sclerae).
Caused by bilirubin (yellow pigment)
Bilirubin
Increase bilirubin in brain (kernicterus).
Causing irreversible brain damage.

Peripheral Nervous System

Spinal Nerves
31 pairs: carry impulses to & from spinal cord
Each segment of the spinal cord contains a pair of spinal nerves (one of
each side of the body)
Each nerve is attached to the spinal by two roots:
1. Dorsal (posterior) roots
contains afferent (sensory) nerve whose cell body is in the
dorsal roots ganglion
2. Ventral (anterior) roots
Contains efferent (motor) nerve whose nerve fibers originate
in the anterior horn cell of the spinal cord (lower motor
neuron)
Cranial Nerves
12 pairs: carry impulses to & from the brain.
May have sensory, motor, or mixed functions.
Name & Number
Olfactory
: CN I
smell.
Optic
: CN II
Oculomotor
: CN III
constriction, elevation of upper eyelid;
Trochlear
: CN IV
movement of the eye
Trigeminal
: CN V
eyes (corneal reflex); muscle

Function
Sensory: carries impulses for sense of
Sensory: carries impulses for vision.
Motor: muscles for papillary
4 out of 6 extraocular movement.
Motor: muscles for downward, inward,
Mixed: impulses from face, surface of

Abducens
: CN VI
eye
Facial
: CN VII
tongue; muscles for facial
Acoustic

: CN VIII
division) & balance (vestibular

Controlling mastication.
Motor: muscles for lateral deviation of
Mixed: impulses for taste from anterior
Movement.
Sensory: impulses for hearing (cochlear

Division).
Glossopharyngeal
: CN IX
Mixed: impulses for sensation to
posterior tongue & pharynx; muscle
For movement of pharynx (elevation) &
swallowing.
Vagus
: CN X
Mixed: impulses for sensation to lower
pharynx & larynx; muscle for
Movement of soft palate, pharynx, &
larynx.
Spinal Accessory
: CN XI
Motor: movement of sternomastoid
muscles & upper part of trapezius
Muscles.
Hypoglossal
: CN XII
Motor: movement of tongue.
Autonomic Nervous System
Part of the peripheral nervous system
Include those peripheral nerves (both cranial & spinal) that regulates
smooth muscles, cardiac muscles, & glands.
Component:
1. Sympathetic Nervous System
Generally accelerates some body function in response to stress.
2. Parasympathetic Nervous System
Controls normal body functioning
Sympathetic Nervous System
(Adrenergic) Effect
- Involved in fight or aggression
response.
- Release of Norepinephrine
(cathecolamines) from adrenal glands
and causes vasoconstriction.
- Increase all bodily activity except GIT

Parasympathetic Nervous System

(Cholinergic) Effect, Vagal, Sympatholytic
- Involved in flight or withdrawal
response.
- Release of Acetylcholine.
- Decreases all bodily activities except
GIT.

EFFECTS OF SNS

EFFECTS OF PNS

- Dilation of pupils (mydriasis) in order

to be aware.
- Dry mouth (thickened saliva).
- Increase BP and Heart Rate.
- Bronchodilation, Increase RR
- Constipation.
- Urinary Retention.
- Increase blood supply to brain, heart
and skeletal muscles.
- SNS
I. Adrenergic Agents
- Give Epinephrine.
SE:
- SNS effect
Contraindication:
- Contraindicated to patients suffering
from COPD (Broncholitis,
Bronchoectasis, Emphysema, Asthma).
II. Beta-adrenergic Blocking Agents
- Also called Beta-blockers.
- all ending with lol
- Propranolol, Atenelol, Metoprolol.
Effect of Beta-blockers
B broncho spasm
E elicits a decrease in myocardial
contraction.
T treats hypertension.
A AV conduction slows down.
- Should be given to patients with
Angina, Myocardial Infarction,
Hypertension
ANTI- HYPERTENSIVE AGENTS
1. Beta-blockers lol
2. Ace Inhibitors Angiotensin pril
(Captopril, Enalapril)
3. Calcium Antagonist Nifedipine
(Calcibloc)
- In chronic cases of arrhythmia give
Lidocane, Xylocane.

- Constriction of pupils (miosis).

- Increase salivation.
- Decrease BP and Heart Rate.
- Bronchoconstriction, Decrease RR.
- Diarrhea
- Urinary frequency.

I. Cholinergic Agents
- Mestinon, Neostignin.
SE:
- PNS effect

Effectors
Sympathetic (Adrenergic) Effect
Parasympathetic (Cholinergic) Effect
Eye

dilate pupil (mydriasis)

constrict pupil (miosis)

Gland of Head
Lacrimal
no effect
stimulate secretions
Salivary
scanty thick, viscous secretions
copious thin, watery secretions
Dry mouth
Heart

increase rate & force of contraction

decrease rate

II. Anti-cholinergic Agents

- To counter cholinergic agents.
- Atrophine Sulfate

Blood Vessel
effect

constrict smooth muscles of the skin,

no

Abdominal blood vessels, and

Cutaneous blood vessels
Dilates smooth muscles of bronchioles,
Blood vessels of the heart & skeletal muscles

SE:
- SNS effect
Lungs

bronchodilation
bronchoconstriction

GI Tract
motility

decrease motility

Constrict sphincters
relaxed sphincters
Possibly inhibits secretions
stimulate secretions
Inhibits activity of gallbladder & ducts
activity of gallbladder & ducts
Inhibits glycogenolysis in liver
Adrenal Gland

stimulates secretion of epinephrine &

Norepinephrine

increase

stimulate

no effect

Urinary Tract
detrusor muscles

relaxes detrusor muscles

contract

GCS Grading / Scoring

1. Conscious 15 14
2. Lethargy
13 11
3. Stupor
10 8
4. Coma
7
5. Deep Coma 3

Contract trigone sphincter (prevent voiding) relaxes

trigone sphincter (allows voiding)
NEURO TRANSMITTER
Acethylcholine
Dopamine

Decrease
Myesthenia Gravis
Parkinsons Disease

Increase
Bi-polar Disorder
Schizophrenia

Physical Examination
Comprehensive Neuro Exam
Neuro Check
1. Level of Consciousness (LOC)
a. Orientation to time, place, person
b. Speech: clear, garbled, rambling
c. Ability to follow command
d. If does not respond to verbal stimuli, apply a painful stimulus (ex.
Pressure on the nailbeds, squeeze trapezius muscle); note response to
pain
Appropriate: withdrawal, moaning
Inappropriate: non-purposeful
e. Abnormal posturing (may occur spontaneously or in response to
stimulus)
Decorticate Posturing: extension of leg, internal rotation &
abduction of arms with flexion of elbows, wrist, & finger: (damage
to corticospinal tract; cerebral hemisphere)
Decerebrate Posturing: back arched, rigid extension of all four
extremities with hyperpronation of arms & plantar flexion of feet:
(damage to upper brain stem, midbrain, or pons)
2.

Glasgow Coma Scale

Objective measurement of LOC sometimes called as the quick neuro
check
Objective evaluation of LOC, motor / verbal response
A standardized system for assessing the degree of neurologic
impairment in critically ill client
Components
1. Eye opening
2. Verbal response
3. Motor response

3.

4.

5.

Pupillary Reaction & Eye Movement

a. Observe size, shape, & equality of pupil (note size in millimeter)
b. Reaction to light: pupillary constriction
c. Corneal reflex: blink reflex in response to light stroking of cornea
d. Oculocephalic reflex (dolls eyes): present in unconscious client with
intact brainstem
Motor Function
a. Movement of extremities (paralysis)
b. Muscle strength
Vital Signs: respiratory patterns (may help localize possible lesion)
a. Cheyne-Stokes Respiration: regular rhythmic alternating between
hyperventilation & apnea; may be caused by structural cerebral
dysfunction or by metabolic problems such as diabetic coma
b. Central Neurogenic Hyperventilation: sustained, rapid, regular
respiration (rate of 25/min) with normal O2 level; usually due to
brainstem dysfunction
c. Apneustic Breathing: prolonged inspiratory phase, followed by a 2-to3 sec pause; usually indicates dysfunction respiratory center in pons
d. Cluster Breathing: cluster of irregular breathing, irregularly followed
by periods of apnea; usually caused by a lesion in upper medulla &
lower pons
e. Ataxic Breathing: breathing pattern completely irregular; indicates
damage to respiratory center of the medulla

Neurologic Exam
1. Mental status and speech (Cerebral Function)
a. General appearance & behavior
b. LOC
c. Intellectual Function: memory (recent & remote), attention span,
cognitive skills
d. Emotional status
e. Thought content
f. Language / speech
2. Cranial nerve assessment
3. Cerebellar Function: posture, gait, balance, coordination

a.
b.
4.
5.
6.

Rombergs Test: 2 nurses, positive for ataxia

Finger to Nose Test: positive result mean dimetria (inability of body to
stop movement at desired point)
Sensory Function: light touch, superficial pain, temperature, vibration &
position sense
Motor Function: muscle size, tone, strength; abnormal or involuntary
movements
Reflexes
a. Deep tendon reflex: grade from 0 (no response); to 4 (hyperactive); 2
(normal)
b. Superficial
c. Pathologic: babinski reflex (dorsiflexion of the great toe with fanning
of toes): indicates damage to corticospinal tracts

Level Of Consciouness (LOC)

1. Conscious: awake
2. Lethargy: lethargic (drowsy, sleepy, obtunded)
3. Stupor
Stuporous: (awakened by vigorous stimulation)
Generalized body weakness
Decrease body reflex
4. Coma
Comatose
light coma: positive to all forms of painful stimulus
deep coma: negative to all forms of painful stimulus
Different Painful Stimulation
1. Deep sternal stimulation / deep sternal pressure
2. Orbital pressure
3. Pressure on great toes
4. Corneal or blinking reflex
Conscious Client: use a wisp of cotton
Unconscious Client: place 1 drop of saline solution
Test of Memory
1. Short term memory
Ask most recent activity
Positive result mean anterograde amnesia and damage to temporal
lobe
2. Long term memory
Ask for birthday and validate on profile sheet
Positive result mean retrograde amnesia and damage to limbic system

Consider educational background

Level of Orientation
1. Time: first asked
2. Person: second asked
3. Place: third asked
Cranial Nerves
Cranial Nerves
1. Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abducens
7. Facial
8. Acoustic
9. Glossopharengeal
10. Vagus
11. Spinal Accessory
12. Hypoglossal

Function
S
S
M
M (smallest)
B (largest)
M
B
S
B
B (longest)
M
M

CRANIAL NERVE I: OLFACTORY

Sensory function for smell
Material Used
Dont use alcohol, ammonia, perfume because it is irritating and highly
diffusible.
Use coffee granules, vinegar, bar of soap, cigarette
Procedure
Test each nostril by occluding each nostril
Abnormal Findings
1. Hyposnia: decrease sensitivity to smell
2. Dysosmia: distorted sense of smell
3. Anosmia: absence of smell
Either of the 3 may indicate head injury damaging the cribriform plate of ethmoid
bone where olfactory cells are located may indicate inflammatory conditions
(sinusitis)
CRANIAL NERVE II: OPTIC
Sensory function for vision or sight
Functions
1. Test visual acuity or central vision or distance

2.

Use Snellens Chart

Snellens Alphabet chart: for literate client
Snellens E chart: for illiterate client
Snellens Animal chart: for pediatric client
Normal visual acuity 20/20
Numerator: is constant, it is the distance of person from the chart (6-7
m, 20 feet)
Denominator: changes, indicates distance by which the person
normally can see letter in the chart.
20/200 indicates blindness
20/20 visual acuity if client is able to read letters above the red line.
Test of visual field or peripheral vision
a. Superiorly
b. Bitemporaly
c. Nasally
d. Inferiorly

CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

Controls or innervates the movement of extrinsic ocular muscle (EOM)
6 muscles:
Superior Rectus
Superior Oblique

Lateral Rectus

Inferior Oblique
Trochlear: controls superior oblique
Abducens: controls lateral rectus
Oculomotor: controls the 4 remaining EOM

Medial Rectus

Inferior Rectus

CRANIAL NERVE V: TRIGEMINAL

Largest cranial nerve
Consists of ophthalmic, maxillary, mandibular
Sensory: controls sensation of face, mucous membrane, teeth, soft palate
and corneal reflex
Motor: controls the muscle of mastication or chewing
Damage to CN V leads to Trigeminal Neuralgia / Tic Douloureux
Medication: Carbamezapine (Tegretol)
CRANIAL NERVE VII: FACIAL
Sensory: controls taste, anterior 2/3 of tongue
Pinch of sugar and cotton applicator placed on tip of tongue
Motor: controls muscle of facial expression
Instruct client to smile, frown and if results are negative there is facial
paralysis or Bells Palsy and the primary cause is forcep delivery.
CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR
Controls balance particularly kinesthesia or position sense, refers to
movement and orientation of the body in space.
CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS
Glosopharenageal: controls taste, posterior 1/3 of tongue
Vagus: controls gag reflex
Uvula should be midline and if not indicative of damage to cerebral
hemisphere
Effects of vagal stimulation is PNS
CRANIAL NERVE XI: SPINAL ACCESSORY
Innervates with sternocleidomastoid (neck) and trapezius (shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL
Controls the movement of tongue
Let client protrude tongue and it should be midline and if unable to do
indicative of damage to cerebral hemisphere and/or has short frenulum.
Pathognomonic Signs:

Oculomotor
Controls the size and response of pupil
Normal pupil size is 2 3 mm
Equal size of pupil: Isocoria
Unequal size of pupil: Anisocoria
Normal response: positive PERRLA

1.
2.
3.
4.
5.
6.

PTB low grade afternoon fever

PNEUMONIA rusty sputum.
ASTHMA wheezing on expiration.
EMPHYSEMA barrel chest.
KAWASAKI SYNDROME strawberry tongue
PERNICIOUS ANEMIA red beefy tongue

7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.

DOWN SYNDROME protruding tongue

CHOLERA rice watery stool.
MALARIA step ladder like fever with chills.
TYPHOID rose spots in abdomen.
DIPTHERIA pseudo membrane.
MEASLES koplicks spots
SLE butterfly rashes.
LIVER CIRRHOSIS spider like varices
LEPROSY lioning face
BOLIMIA chipmunk face.
APPENDICITIS rebound tenderness
DENGUE petichae or positive hermans sign.
MENINGITIS kernigs sign (leg pain), brudzinski sign (neck pain).
TETANY hypocalcemia (+) trousseus sign or carpopedal spasm/ (+)
chvostek sign (facial spasm).
TETANUS risus sardonicus
PANCREATITIS cullens sign (echymosis of umbilicus) / (+) grey turners
spots.
PYLORIC STENOSIS olive like mass.
PDA machine like murmur
ADDISONS DISEASE bronze like skin pigmentation.
CUSHINGS SYNDROME moon face appearance and buffalo hump.
HYPERTHYROIDSM/GRAVES DISEASE exopthalmus.

DEMYELINATING DISORDERS
Alzheimers disease
Atrophy of brain tissue due to deficiency of acetylcholine.
S/sx
4 As of Alzheimer
a. Amnesia loss of memory.
b. Agnosia unable to recognized inanimate/familiar objects.
c. Apraxia unable to determine purpose/ function of objects.
d. Aphasia no speech (nodding).
*Expressive aphasia
motor speech center unable to speak
Brocas Aphasia
*Receptive aphasia
inability to understand spoken words.
Common to Alzheimers

Wernikes Aphasia
General Knowing Gnostic Area or General Interpretative Area.

DOC
Aricept (taken at bedtime)
Cognex
Management
1. Palliative & supportive
Multiple Sclerosis (MS)
Chronic intermittently progressive disorder of CNS characterized
by scattered white patches of demyelination in brain and spinal
cord.
Characterized by remission and exacerbation.
S/sx are varied & multiple, reflecting the location of
demyelination within the CNS.
Cause unknown: maybe a slow growing virus or possibly
autoimmune disorders.
Incident: Affects women more than men ages 20-40 are prone &
more frequent in cool or temperate climate.

Ig G - only antibody that pass placental circulation causing passive

immunity, short term protection
Ig A - present in all bodily secretions (tears, saliva, colostrums).
Ig M - acute in inflammation.
Ig E - for allergic reaction
Ig D - for chronic inflammation.
* Give palliative or supportive care.

1.

2.

3.
4.

S/sx
Visual disturbances
blurring of vision (primary)
diplopia (double vision)
scotomas (blind spots)
Impaired sensation
touch, pain, pressure, temperature, or position sense
paresthesia such as tingling sensation, numbness
Mood swings or euphoria (sense of elation)
Impaired motor function
weakness

5.

6.
7.
8.

spasticity
paralysis
Impaired cerebral function
scanning speech
ataxic gait
nystagmus
dysarthria
intentional tremor
Bladder
Urinary retention or incontinence
Constipation
Sexual impotence in male / decrease sexual capacity
TRIAD SIGNS OF MS

a.

4.
5.
6.
7.
8.

9.
10.

ATAXIA
(unsteady gait, positive
rombergs test)
NYSTAGMUS
CHARCOTS
TRIAD

1.
2.
3.
4.
5.

1.
2.

3.

INTENTIONAL TREMORS

Dx
CSF Analysis: increase in IgG and Protein.
MRI: reveals site and extent of demyelination.
CT Scan: increase density of white matter.
Visual Evoked Response (VER) determine by EEG: maybe delayed
Positive Lhermittes Sign: a continuous and increase contraction of spinal
column.
Nursing Intervention
Assess the client for specific deficit related to location of demyelination
Promote optimum mobility
a. Muscles stretching & strengthening exercises
b. Walking exercises to improve gait: use wide-base gait
c. Assistive devices: canes, walker, rails, wheelchair as necessary
Administer medications as ordered

11.

12.
13.

ACTH (adreno chorticotropic hormone), Corticosteroids (prednisone)

for acute exacerbations: to reduce edema at site of demyelination to
prevent paralysis.
b. Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam (Valium) muscle relaxants: for spacity
c. Beta Interferons - Immunosuppresants: alter immune response.
Encourage independence in self-care activities
Prevent complications of immobility
Institute bowel program
Maintain side rails to prevent injury related to falls.
Institute stress management techniques.
a. Deep breathing exercises
b. Yoga
Increase fluid intake and increase fiber to prevent constipation.
Maintain urinary elimination
1. Urinary Retention
a. perform intermittent catheterization as ordered: to prevent
retention.
b. Bethanecol Chloride (Urecholine) as ordered
Nursing Management
only given subcutaneous.
monitor side effects bronchospasm and wheezing.
monitor breath sounds 1 hour after subcutaneous administration.
2. Urinary Incontinence
a. Establish voiding schedule
b. Anti spasmodic agent Prophantheline Bromide (Pro-banthine) if
ordered
3. Force fluid to 3000 ml/day.
4. Promote use of acid ash diet like cranberry juice, plums, prunes,
pineapple, vitamin C and orange: to acidify urine and prevent bacterial
multiplication.
Prevent injury related to sensory problems.
a. Test bath water with thermometer.
b. Avoid heating pads, hot water bottles.
c. Inspect body parts frequently for injury.
d. Make frequent position changes.
Prepare client for plasma exchange if indicated: to remove antibodies
Provide psychologic support to client/significant others.
a. Encourage positive attitude & assist client in setting realistic goals.
b. Provide compassion in helping client adapt to changes in body image
& self-concept.
c. Do not encourage false hope during remission.

d. Refer to MS societies & community agencies.

14. Provide client teaching & discharge planning concerning:
a. General measures to ensure optimum health.
Balance between activity & rest
Regular exercise such as walking, swimming, biking in mild
case.
Use energy conservation techniques
Well-balance diet
Fresh air & sunshine
Avoiding fatigue, overheating or chilling, stress, infection.
b. Use of medication & side effects.
c. Alternative methods for sexual counseling if indicated.
COMMON CAUSE OF UTI
Female
- short urethra (3-5 cm, 1-1 inches)
- poor perineal hygiene
- vaginal environment is moist
Nursing Management
- avoid bubble bath (can alter Ph of vagina).
- avoid use of tissue papers
- avoid using talcum powder and perfume.
Male
- urethra (20 cm, 8 inches)
- do not urinate after intercourse
INTRACRANIAL PRESSURE ICP
Monroe Kelly Hypothesis

Medulla Oblongata
Brain Herniation
Increase intra cranial pressure
Nursing Intervention
1. alternate hot and cold compress to prevent hematoma
CSF cushions brain (shock absorber)
Obstruction of flow of CSF will lead to enlargement of skull posteriorly
called hydrocephalus.
Early closure of posterior fontanels causes posterior enlargement of skull
in hydrocephalus.
DISORDERS
Increase Intracranial Pressure (IICP)
Increase in intracranial bulk brought due to an increase in any of the 3
major intracranial components: Brain Tissue, CSF, Blood.
Untreated increase ICP can lead to displacement of brain tissue
(herniation).
Present life threatening situation because of pressure on vital structures in
the brain stem, nerve tracts & cranial nerve.
Increase ICP may be caused:
head trauma/injury
localized abscess
cerebral edema
hemorrhage
inflammatory condition (stroke)
hydrocephalus
tumor (rarely)

Skull is a closed container

Any alteration or increase in one of the intracranial components
Increase intracranial pressure
(normal ICP is 0 15 mmHg)

1.
2.
3.

Cervical 1 also known as atlas.

Cervical 2 also known as axis.
1.
Foramen Magnum

S/sx
(Early signs)
Decrease LOC
Irritability / agitation
Progresses from restlessness to confusion & disorientation to lethargy &
coma
(Late signs)
Changes in Vital Signs (may be a late signs)
a. Systolic blood pressure increases while diastolic pressure remains
the same (widening pulse pressure)

2.

3.

4.
5.
6.
7.

1.

b. Pulse rate decrease

c. Abnormal respiratory patterns (cheyne-stokes respiration)
d. temperature increase directly proportional to blood pressure.
Pupillary Changes
a. Ipsilateral (same side) dilatation of pupil with sluggish
reaction to light from compression of cranial nerve III
b. unilateral dilation of pupils called uncal herniation
c. bilateral dilation of pupils called tentorial herniation
d. Pupil eventually becomes fixed & dilated
Motor Abnormalities
a. Contralateral (opposite side) hemiparesis from compression
of corticospinal tract
b. abnormal posturing
c. decorticate posturing (damage to cortex and spinal cord).
d. decerebrate posturing (damage to upper brain stem that
includes pons, cerebellum and midbrain).
Headache
Projective Vomiting
Papilledema (edema of optic disc)
Possible seizure activity
Nursing Intervention
Maintain patent airway and adequate ventilation by:
a. Prevention of hypoxia (decrease O2) and hypercarbia (increase
CO2) important:
Hypoxia may cause brain swelling which increase ICP
Early signs of hypoxia:
Restlessness
Tachycardia
Agitation
Late signs of hypoxia:
Extreme restlessness
Bradycardia
Dyspnea
Cyanosis
Hypercarbia may cause cerebral vasodilation which increase
ICP
Hypercabia
Increase CO2 (most powerful respiratory stimulant)
retention.
In chronic respiratory distress syndrome decrease O2
stimulates respiration.

b.

2.
3.
4.

5.

6.
7.

Before and after suctioning hyperventilate the client with

resuscitator bag connected to 100% O2 & limit suctioning to 10
15 seconds only.
c. Assist with mechanical hyperventilation as indicated: produces
hypocarbia (decease CO2) causing cerebral constriction &
decrease ICP.
Monitor V/S, input and output & neuro check frequently to detect increase
in ICP
Maintain fluid balance: fluid restriction to 1200-1500 ml/day may be
ordered
o
Position the client with head of bed elevated to 30-45 angle with neck in
neutral position unless contraindicated to improve venous drainage from
brain.
Prevent further increase ICP by:
a. Provide comfortable and quite environment.
b. Avoid use of restraints.
c. Maintain side rails.
d. Instruct client to avoid forms of valsalva maneuver like:
Straining stool: administer stool softener & mild laxatives as
ordered (Dulcolax, Duphalac)
Excessive vomiting: administer anti-emetics as ordered (Plasil
- Phil only, Phenergan)
Excessive coughing: administer anti-tussive
(dextromethorphan)
Avoid stooping/bending
Avoid lifting heavy objects
e. Avoid clustering of nursing care activity together.
Prevent complications of immobility.
Administer medications as ordered:
a. Hyperosmotic agent / Osmotic Diuretic [Mannitol (Osmitrol)]: to
reduce cerebral edema
Nursing Management
Monitor V/S especially BP: SE hypotension.
Monitor strictly input and output every hour: (output should
increase): notify physician if output is less 30 cc/hr.
Administered via side drip
Regulate fast drip to prevent crystal formation.
b. Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral edema
drug of choice for CHF (pulmonary edema)
loop of henle in kidneys.
Nursing Management

8.

9.

Monitor V/S especially BP: SE hypotension.

Monitor strictly input and output every hour: (output should
increase): notify physician if output is less 30 cc/hr.
Administered IV push or oral.
Given early morning
Immediate effect of 10-15 minutes.
Maximum effect of 6 hours.
c. Corticosteroids [Dexamethasone (Decadron)]: anti-inflammatory
effect reduces cerebral edema
d. Analgesics for headache as needed:
Small dose of Codein SO4
Strong opiates may be contraindicated since they potentiate
respiratory depression, alter LOC, & cause papillary changes.
e. Anti-convulsants [Phenytoin (Dilantin)]: to prevent seizures.
Assist with ICP monitoring when indicated:
a. ICP monitoring records the pressure exerted within the cranial cavity
by the brain, cerebral blood, & CSF
b. Types of monitoring devices:
Intraventricular Catheter: inserted in lateral ventricle to give
direct measurement of ICP; also allows for drainage of CSF if
needed.
Subarachnoid screw (bolt): inserted through the skull & dura
matter into subarachnoid space.
Epidural Sensor: least invasive method; placed in space between
skull & dura matter for indirect measurement of ICP.
c. Monitor ICP pressure readings frequently & prevent complications:
Normal ICP reading is 0-15 mmHg; a sustained increase above 15
mmHg is considered abnormal.
Use strict aseptic technique when handling any part of the
monitoring system.
Check insertion site for signs of infection; monitor temperature.
Assess system for CSF leakage, loose connections, air bubbles in
he line, & occluded tubing.
Provide intensive nursing care for clients treated with barbiturates therapy
or administration of paralyzing agents.
a. Intravenous administration of barbiturates may be ordered: to induce
coma artificially in the client who has not responded to conventional
treatment.
b. Paralytic agents such as [vercuronium bromide (Norcuron)]: may be
administered to paralyzed the client
c. Reduces metabolic demand that may protect the brain from further
injury.

d.

Constant monitoring of the clients ICP, arterial blood gas, serum

barbiturates level, & ECG is necessary.
e. EEG monitoring as necessary
f. Provide appropriate nursing care for the client on a ventilator
10. Observe for hyperthermia secondary to hypothalamus damage.
*CONGESTIVE HEART FAILURE
Signs and Symptoms
- dyspnea
- orthopnea
- paroxysmal nocturnal dyspnea
- productive cough
- frothy salivation
- cyanosis
- rales/crackles
- bronchial wheezing
- pulsus alternans
- anorexia and general body malaise
- PMI (point of maximum impulse/apical pulse rate) is displaced
laterally
- S3 (ventricular gallop)
- Predisposing Factors/Mitral Valve
o RHD
o Aging
Treatment
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (venous congestion)
Signs and Symptoms
- jugular vein distention (neck)
- ascites
- pitting edema
- weight gain
- hepatosplenomegaly
- jaundice

- pruritus
- esophageal varices
- anorexia and general body malaise
Signs and Symptoms of Lasix in terms of electrolyte imbalances
1. Hypokalemia
- decrease potassium level
- normal value is 3.4 5.5 meq/L
Sign and Symptoms
- weakness and fatigue
- constipation
- positive U wave on ECG tracing
Nursing Management
- administer potassium supplements as ordered (Kalium Durule, Oral Potassium
Chloride)
- increase intake of foods rich in potassium
FRUITS
Apple
Banana
Cantalope
Oranges

VEGETABLES
Asparagus
Brocolli
Carrots
Spinach

2. Hypocalcemia/Tetany
- decrease calcium level
- normal value is 8.5 11 mg/100 ml
Signs and Symptoms
- tingling sensation
- paresthesia
- numbness
- (+) Trousseus sign/Carpopedal spasm
- (+) Chvosteks sign
Complications
- arrythmia
- seizures
Nursing Management
- Calcium Glutamate per IV slowly as ordered
* Calcium Glutamate toxicity results to seizure
Magnesium Sulfate
Magnesium Sulfate toxicity

S/S
BP
Urine output
DECREASE
Respiratory rate
Patellar relfex absent
3. Hyponatremia
- decrease sodium level
- normal value is 135 145 meq/L
Signs and Symptoms
- hypotension
- dehydration signs (initial sign in adult is thirst, in infant tachycardia)
- agitation
- dry mucous membrane
- poor skin turgor
- weakness and fatigue
Nursing Management
- force fluids
- administer isotonic fluid solution as ordered
4. Hyperglycemia
- normal FBS is 80 100 mg/dl
Signs and Symptoms
- polyuria
- polydypsia
- polyphagia
Nursing Management
- monitor FBS
5. Hyperuricemia
- increase uric acid (purine metabolism)
- foods high in uric acid (sardines, organ meats and anchovies)
*Increase in tophi deposit leads to gouty arthritis.
Signs and Symptoms
- joint pain (great toes)
- swelling
Nursing Management
- force fluids
- administer medications as ordered
a. Allopurinol (Zylopril)

- drug of choice for gout.

- mechanism of action: inhibits synthesis of uric acid.
b. Colchesine
- acute gout
- mechanism of action: promotes excretion of uric acid.
* Kidney stones
Signs and Symptoms
- renal cholic
- cool moist skin
Nursing Management
- force fluids
- administer medications as ordered
a. Narcotic Analgesic
- Morphine Sulfate
- antidote: Naloxone (Narcan) toxicity leads to tremors.
b. Allopurinol (Zylopril)
Side Effects
- respiratory depression (check for RR)
Parkinsons Disease/ Parkinsonism
Chronic progressive disorder of CNS characterized by degeneration of
dopamine producing cells in the substantia nigra of the midbrain and basal
ganglia.
Progressive disorder with degeneration of the nerve cell in the basal
ganglia resulting in generalized decline in muscular function
Disorder of the extrapyramidal system
Usually occurs in the older population
Cause Unknown: predominantly idiopathic, but sometimes disorder is
postencephalitic, toxic, arteriosclerotic, traumatic, or drug induced
(reserpine, methyldopa (aldomet) haloperidol (haldol), phenothiazines).
Pathophysiology
Disorder causes degeneration of dopamine producing neurons in the
substantia nigra in the midbrain
Dopamine: influences purposeful movement
Depletion of dopamine results in degeneration of the basal ganglia
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
2. Arteriosclerosis
3. Hypoxia

4.
5.

Encephalitis
Increase dosage of the following drugs:
a. Reserpine (Serpasil)
b. Methyldopa (Aldomet)
Antihypertensive
c. Haloperidol (Haldol)
_______
d. Phenothiazine ___________________ Antipsychotic
Side Effects Reserpine: Major depression lead to suicide
Aloneness

Multiple
loss
causes
suicide

Loss of spouse
Loss of Job
Nursing Intervention for Suicide
direct approach towards the client
close surveillance is a nursing priority
time to commit suicide is on weekends early morning

S/sx
1. Tremor: mainly of the upper limbs pill rolling tremors of extremities
especially the hands; resting tremor: most common initial symptoms
2. Bradykinesia: slowness of movement
3. Rigidity: cogwheel type
4. Stooped posture: shuffling, propulsive gait
5. Fatigue
6. Mask like facial expression with decrease blinking of the eyes.
7. Difficulty rising from sitting position.
8. Quite, monotone speech
9. Emotional lability: state of depression
10. Increase salivation: drooling type
11. Cramped, small handwriting
12. Autonomic Symptoms
a. excessive sweating
b. increase lacrimation
c. seborrhea
d. constipation
e. decrease sexual capacity
Nursing Intervention

1.

Administer medications as ordered

Anti-Parkinson Drug
a. Levodopa (L-dopa) short acting
MOA: Increase level of dopamine in the brain; relieves tremors;
rigidity; bradykinesia
SE: GIT irritation (should be taken with meal); anorexia; N/V;
postural hypotension; mental changes: confusion, agitation,
hallucination; cardiac arrhythmias; dyskinesias.
CI: narrow-angled glaucoma; client taking MAOI inhibitor;
reserpine; guanethidine; methyldopa; antipsychotic; acute
psychoses
Avoid multi-vitamins preparation containing vitamin B6 & food
rich in vitamin B6 (Pyridoxine): reverses the therapeutic effects of
Levodopa
Urine and stool may be darkened
Be aware of any worsening of symptoms with prolonged highdose therapy: on-off syndrome.
b. Carbidopa-levodopa (Sinemet)
Prevents breakdown of dopamine in the periphery & causes fewer
side effects.
c. Amantadine Hydrochloride (Symmetrel)
Used in mild cases or in combination with L-dopa to reduce
rigidity, tremors, & bradykinesia
Anti-Cholinergic Drug
a. Benztropine Mesylate (Cogentin)
b. Procyclidine (Kemadrine)
c. Trihexyphenidyl (Artane)
MOA: inhinit the action of acetylcholine; used in mild cases or in
combination with L-dopa; relived tremors & rigidity
SE: dry mouth; blurred vision; constipation; urinary retention;
confusion; hallucination; tachycardia
Anti-Histamines Drug
a. Diphenhydramine (benadryl)
MOA: decrease tremors & anxiety
SE: Adult: drowsiness Children: CNS excitement (hyperactivity)
because blood brain barrier is not yet fully developed.
b. Bromocriptine (Parlodel)
MOA: stimulate release of dopamine in the substantia nigra
Often employed when L-dopa loses effectiveness
MAOI Inhibitor

a.

Eldepryl (Selegilene)
MOA: inhibit dopamine breakdown & slow progression of disease

Anti-Depressant Drug
a. Tricyclic
MOA: given to treat depression commonly seen in Parkinsons
disease
2. Provide safe environment
Side rails on bed
Rails & handlebars in the toilet, bathtub, & hallways
No scattered rugs
Hard-back or spring-loaded chair to make getting up easier
3. Provide measures to increase mobility
Physical Therapy: active & passive ROM exercise; stretching exercise;
warm baths
Assistive devices
If client freezes suggest thinking of something to walk over
4. Encourage independence in self-care activities:
alter clothing for ease in dressing
use assistive device
do not rush the client
5. Improve communication abilities:
Instruct the client to practice reading a loud
Listen to own voice & enunciate each syllable clearly
6. Refer for speech therapy when indicated.
7. Maintain adequate nutrition.
Cut food into bite-size pieces
Provide small frequent feeding
Allow sufficient time for meals, use warming tray
8. Avoid constipation & maintain adequate bowel elimination
9. Provide significant support to client/ significant others:
Depression is common due to changes in body image & self-concept
10. Provide client teaching & discharge planning concerning:
a. Nature of the disease
b. Use prescribed medications & side effects
c. Importance of daily exercise as tolerated: balanced activity & rest
walking
swimming
gardening
d. Activities/ methods to limit postural deformities:
Firm mattress with small pillow
Keep head & neck as erected as possible

 Use broad-based gait

Raise feet while walking
e. Promotion of active participation in self-care activities.
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide
* Dopamine Agonist relieves tremor rigidity
MAGIC 2s IN DRUG MONITORING
DRUG
NORMAL RANGE

Digoxin/Lanoxin
(increase force of
cardiac output)
Lithium/Lithane
(decrease level of
Ach/NE/Serotonin)
Aminophelline
(dilates bronchial
tree)
Dilantin/Phenytoin
Acetaminophen/Tyl
enol

INDICATIO
N

.5 1.5 meq/L

TOXI
CITY
LEVE
L
2

.6 1.2 meq/L

Bipolar

10 19 mg/100 ml

20

COPD

10 19 mg/100 ml
10 30 mg/100 ml

20
200

Seizures
Osteo
Arthritis

1. Digitalis Toxicity
Signs and Symptoms
- nausea and vomiting
- diarrhea
- confusion
- photophobia
- changes in color perception (yellowish spots)
Antidote: Digibind
2. Lithium Toxicity
Signs and Symptoms
- anorexia
- nausea and vomiting
- diarrhea
- dehydration causing fine tremors
- hypothyroidism
Nursing Management

CHF

- force fluids
- increase sodium intake to 4 10 g% daily
3. Aminophelline Toxicity
Signs and Symptoms
- tachycardia
- palpitations
- CNS excitement (tremors, irritability, agitation and restlessness)
Nursing Management
CLASSIFICATION
- only mixed with plain NSS or 0.9 NaCl to prevent development of crystals of
precipitate.
- administered sandwich method
- avoid taking alcohol because it can lead to severe CNS depression
Cardiac Glycoside
- avoid caffeine
4. Dilantin Toxicity
Signs and Symptoms
Anti-Manic Agents
- gingival hyperplasia (swollen gums)
- hairy tongue
- ataxia
Bronchodilators
- nystagmus
Nursing Management
- provide oral care
Anti-Convulsant
Non-narcotic Analgesic- massage gums
5. Acetaminophen Toxicity
Signs and Symptoms
- hepatotoxicity (monitor for liver enzymes)
- SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
- SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
- nephrotoxicity monitor BUN (10 20) and Creatinine (.8 1)
- hypoglycemia
Tremors, tachycardia
Irritability
Restlessness
Extreme fatigue
Diaphoresis, depression
Antidote: Acetylceisteine (mucomyst) prepare suction apparatus as bedside.
MYASTHENIA GRAVIS (MG)
neuromuscular disorder characterized by a disturbance in the transmission
of impulses from nerve to muscle cells at the neuromuscular junction
leading to descending muscle weakness.
Incidence rate:
highest between 15 & 35 years old for women, over 40 for men.

1.
2.
3.
4.
5.
6.
7.

1.

2.
3.
1.

Affects women more than men

Cause:
Unknown/ idiopathic
Thought to be autoimmune disorder whereby antibodies destroy
acetylcholine receptor sites on the postsynaptic membrane of the
neuromuscular junction.
Voluntary muscles are affected, especially those muscles innervated by the
cranial nerve.
Pathophysiology
Autoimmune = Release of Cholinesterase Enzymes = Cholinesterase
destroy Acetylcholine (ACH) = Decrease of Acetylcholine (ACH)
Acetylcholine: activate muscle contraction
Autoimmune: it involves release of cholinesterase an enzyme that destroys
Ach
Cholinesterase: an enzyme that destroys ACH
S/sx
Initial sign is ptosis a clinical parameter to determine ptosis is palpebral
fissure: cracked or cleft in the lining or membrane of the eyelids
Diplopia
Dysphagia
Mask like facial expression
Hoarseness of voice, weakness of voice
Respiratory muscle weakness that may lead to respiratory arrest
Extreme muscle weakness especially during exertion and morning;
increase activity & reduced with rest.
Dx
Tensilon Test (Edrophonium Hydrochloride): IV injection of tensilon
provides temporary relief of S/sx for about 5-10 minutes and a maximum
of 15 minutes.
If there is no effect there is no damage to occipital lobe and midbrain
and is negative for M.G.
Electromyography (EMG): amplitudes of evoked potentials decrease
rapidly.
Presence of anti-acetlycholine receptors antibodies in the serum.
Medical Management
Drug Therapy
a. Anti-cholinesterase Drugs: [Ambenonium (Mytelase), Neostigmine
(Prostigmin), Pyridostigmine (Mestinon)]

2.

3.

1.

2.

3.
4.
5.

MOA: block the action of cholinesterase & increase the level of

acetylcholine at the neuromuscular junction.
SE: excessive salivation & sweating, abdominal cramps, N/V,
diarrhea, fasciculations (muscle twitching).
b. Corticosteroids: Prednisone
MOA: suppress autoimmune response
Used if other drugs are not effective
Surgery (Thymectomy)
a. Surgical removal of thymus gland: thought to be involve in the
production of acetylcholine receptor antibodies.
b. May cause remission in some clients especially if performed early in
the disease.
Plasma Exchange (Plasmapheresis)
a. Removes circulating acetylcholine receptor antibodies.
b. Use in clients who do not respond to other types of therapy.
Nursing Interventions
Administer anti-cholinesterase drugs as ordered:
a. Give medication exactly on time.
b. Give with milk & crackers to decrease GI upset
c. Monitor effectiveness of drugs: assess muscle strength & vital capacity
before & after medication.
d. Avoid use of the ff drugs:
Morphine SO4 & Strong Sedatives: respiratory depressant
effects
Quinine, Curare, Procainamide, Neomycin, Streptomycine,
Kanamycine & other aminoglycosides: skeletal muscle
blocking effect
e. Observe for side effects
Promote optimal nutrition:
a. Mealtime should coincide with the peak effect of the drugs: give
medication 30 minutes before meals.
b. Check gag reflex & swallowing ability before feeding.
c. Provide mechanical soft diet.
d. If the client has difficulty in chewing & swallowing, do not leave alone
at mealtime; keep emergency airway & suctioning equipment nearby.
Monitor respiratory status frequently: Rate, Depth, Vital Capacity; ability to
deep breathe & cough
Assess muscle strength frequently; plan activity to take advantage of
energy peaks & provide frequent rest periods.
Observe for signs of myasthenic or cholinergic crisis.

c.
d.
MYASTHENIC CRISIS
Abrupt onset of severe,
generalized muscle weakness
with inability to swallow, speak,
or maintain respirations.
Symptoms will improve
temporarily with tensilon test.

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

6.
7.

CHOLINERGIC CRISIS
Symptoms similar to myasthenic
crisis & in addition the side effect
of anti-cholinesterase drugs
(excessive salivation & sweating,
abdominal carmp, N/V, diarrhea,
fasciculation)
Symptoms worsen with tensilon
test: keep Atropine Sulfate &
emergency equipment on hand.
Cause:
over medication with the
cholinergic drugs (anticholinesterase)
Signs and Symptoms
PNS
Treatment
administer anti-cholinergic agents
(Atrophine Sulfate)

Nursing Care in Crisis:

a. Maintain tracheostomy set or endotracheal tube with mechanical
ventilation as indicated.
b. Monitor ABG & Vital Capacity
c. Administer medication as ordered:
Myasthenic Crisis: increase doses of anti-cholinesterase drug
as ordered.
Cholinergic Crisis: discontinue anti-cholinesterase drugs as
ordered until the client recovers.
d. Established method of communication
e. Provide support & reassurance.
Provide nursing care for the client with thymectomy.
Provide client teaching & discharge planning concerning:
a. Nature of the disease
b. Use of prescribe medications their side effects & sign of toxicity

e.
f.
g.
h.

Importance of checking with physician before taking any new

medication including OTC drugs
Importance of planning activities to take advantage of energy peaks &
of scheduling frequent rest period
Need o avoid fatigue, stress, people with upper respiratory infection
Use of eye patch for diplopia (alternate eyes)
Need to wear medic-alert bracelet
Myasthenia Gravis foundation & other community agencies

Guillain-Barre Syndrome
a disorder of the CNS characterized by bilateral, symmetrical, peripheral
polyneuritis characterized by ascending muscle paralysis.
Can occur at any age; affects women and men equally
Progression of disease is highly individual; 90% of clients stop progression
in 4 weeks; recovery is usually from 3-6 months; may have residual deficits.
Causes:
1. Unknown / idiopathic
2. May be autoimmune process

1.
2.

Predisposing Factors
Immunization
Antecedent viral infections such as LRT infections

S/sx
Mild Sensory Changes: in some clients severe misinterpretation of sensory
stimuli resulting to extreme discomfort
2. Clumsiness (initial sign)
3. Progressive motor weakness in more than one limb (classically is ascending
& symmetrical)
4. Dysphagia: cranial nerve involvement
5. Ascending muscle weakness leading to paralysis
6. Ventilatory insufficiency if paralysis ascends to respiratory muscles
7. Absence or decreased deep tendon reflex
8. Alternate hypotension to hypertension
9. Arrythmia (most feared complication)
10. Autonomic disfunction: symptoms that includes
a. increase salivation
b. increase sweating
c. constipation
1.

1.

Dx
CSF analysis: reveals increased in IgG and protein

2.

EMG: slowed nerve conduction

1.
2.
3.
4.
5.

Medical Management
Mechanical Ventilation: if respiratory problems present
Plasmapheresis: to reduce circulating antibodies
Continuous ECG monitoring to detect alteration in heart rate & rhythm
Propranolol: to prevent tachycardia
Atropine SO4: may be given to prevent episodes of bradycardia during
endotracheal suctioning & physical therapy

1.

2.
3.

4.

5.
6.
7.
8.

9.

Nursing Intervention
Maintain patent airway & adequate ventilation:
a. Monitor rate & depth of respiration; serial vital capacity
b. Observe for ventilatory insufficiency
c. Maintain mechanical ventilation as needed
d. Keep airway free of secretions & prevent pneumonia
Check individual muscle groups every 2 hrs in acute phase to check
progression of muscle weakness
Assess cranial nerve function:
a. Check gag reflex
b. Swallowing ability
c. Ability to handle secretion
d. Voice
Monitor strictly the following:
a. Vital signs
b. Input and output
c. Neuro check
d. ECG: due to arrhythmia
e. Observe signs of autonomic dysfunction: acute period of hypertension
fluctuating with hypotension
f. Tachycardia
g. Arrhythmias
Maintain side rails to prevent injury related to fall
Prevent complications of immobility: turning the client every 2 hrs
Assist in passive ROM exercise
Promote comfort (especially in clients with sensory changes):
a. Foot cradle
b. Sheepskin
c. Guided imagery
d. Relaxation techniques
Promote optimum nutrition:
a. Check gag reflex before feeding

b.
c.
10.

11.
12.

13.
14.

Start with pureed food

Assess need for NGT feeding: if unable to swallow; to prevent
aspiration
Administer medications as ordered
a. Corticosteroids: suppress immune response
b. Anti Cholinergic Agents:
Atrophine Sulfate
c. Anti Arrythmic Agents:
Lidocaine (Xylocaine)
Bretylium: blocks release of norepinephrine; to prevent increase
of BP
Assist in plasmapheresis (filtering of blood to remove autoimmune antibodies)
Prevent complications:
a. Arrythmia
b. Paralysis of respiratory muscles / respiratory arrest
Provide psychologic support & encouragement to client / significant others
Refer for rehabilitation to regain strength & treat any residual deficits.

INFLAMMATORY CONDITIONS OF THE BRAIN

Meningitis
Inflammation of the meninges of the brain & spinal cord.
Cause by bacteria, viruses, & other M.O.

1.
2.
3.
4.

Etiology / Most Common M.O.

Meningococcus: most dangerous
Pneumococcus
Streptococcus: cause of adult meningitis
Hemophilus Influenzae: cause of pediatric meningitis

4.

Mode of transmission
Airborne transmission (droplet nuclei)
Via blood, CSF, lymph
By direct extension from adjacent cranial structures (nasal, sinuses,
mastoid bone, ear, skull fracture)
By oral or nasopharyngeal route

2.
3.
4.

Signs and Symptoms

Headache, photophobia, general body malaise, irritability,
Projectile vomiting: due to increase ICP
Fever & chills

1.
2.
3.

5.
6.
7.
8.

1.

Anorexia & weight loss

Possible seizure activity & decrease LOC
Abnormal posturing: (decorticate and decerebrate)
Signs of Meningeal Irritation:
a. Nuchal rigidity or stiff neck: initial sign
b. Opisthotonos (arching of back): head & heels bent backward & body
arched forward
c. PS: Kernigs sign (leg pain): contraction or pain in the hamstring
muscles when attempting to extend the leg when the hip is flexed
d. PS: Brudzinski sign (neck pain): flexion at the hip & knee in response to
forward flexion of the neck
Dx
Lumbar Puncture:
Measurement & analysis of CSF shows increased pressure, elevated
WBC & CHON, decrease glucose & culture positive for specific M.O.
A hollow spinal needle is inserted in the subarachnoid space between
the L3-L4 or L4-L5.

1.
2.
3.

4.

Nursing Management Post Lumbar Puncture

Place flat on bed 12 24 o
Force fluids
Check punctured site for any discoloration, drainage and leakage to
tissues.
Assess for movement and sensation of extremities.

1.
2.
3.
4.

CSF analysis reveals

Increase CHON and WBC
Decrease glucose
Increase CSF opening pressure (normal pressure is 50 100 mmHg)
(+) cultured microorganism (confirms meningitis)

1.

CBC reveals
Increase WBC

1.
2.
3.

1.

Nursing Management Before Lumbar Puncture

Secure informed consent and explain procedure.
Empty bladder and bowel to promote comfort.
Encourage to arch back to clearly visualize L3-L4.

Nursing Management
Administer large doses of antibiotic IV as ordered:

a. Broad spectrum antibiotics (Penicillin, Tetracycline)

b. Mild analgesics: for headaches
c. Antipyretics: for fever
2. Enforced strict respiratory isolation 24 hours after initiation of anti biotic
therapy (for some type of meningitis)
3. Provide nursing care for increase ICP, seizure & hyperthermia if they occur
4. Provide nursing care for delirious or unconscious client as needed
5. Enforce complete bed rest
6. Keep room quiet & dark: if the client has headache & photophobia
7. Monitor strictly V/S, I & O & neuro check
8. Maintain fluid & electrolyte balance
9. Prevent complication of immobility
10. Provide client teaching & discharge planning concerning:
a. Importance of good diet: high CHON, high calories with small frequent
feedings.
b. Rehabilitation program for residual deficit
mental retardation
delayed psychomotor development
c. Prevent complications
most feared is hydrocephalus
hearing loss/nerve deafness is second complication
consult audiologist
Cerebrovascular Accident (CVA) (Stroke/Brain Attack/Apoplexy/Cerebral
Thrombosis)
Destruction (infarction) of brain cells caused by a reduction in cerebral
blood flow and oxygen
A partial or complete disruption in the brains blood supply.
2 largest & most common cerebral artery affected by stroke:
a. Mid Cerebral Artery
b. Internal Cerebral Artery
Incidence Rate:
a. Affects men more than women; Men are 2-3 times high risk; Incidence
increase with age
Causes:
a. Thrombosis (attached)
b. Embolism (detached): most dangerous because it can go to the lungs
& cause pulmonary embolism or the brain & cause cerebral embolism.
c. Hemorrhage
d. Compartment Syndrome: compression of nerves & arteries
S/sx Pulmonary Embolism

1.
2.
3.
4.
5.
6.
7.

Sudden sharp chest pain

Unexplained dyspnea
SOB
Tachycardia
Palpitations
Diaphoresis
Mild restlessness

6.
7.
8.

1.

1.
2.
3.
4.

S/sx of Cerebral Embolism

Headache
disorientation
Confusion
Decrease LOC

1.

2.

S/sx Compartment syndrome

Fat embolism is the most feared complications w/in 24 hrs after a
femur fracture.
Yellow bone marrow are produced from the medullary cavity
of the long bones and produces fat cells.
If there is bone fracture there is hemorrhage and there would
be escape of the fat cells in the circulation.
1.

1.
2.
3.
4.
5.
6.
7.
8.

1.
2.
3.
4.
5.

Risk Factors
Disease:
Hypertension
Diabetes Mellitus
Atherosclerosis / Arteriosclerosis
Myocardial Infarction
Mitral valve replacement
Valvular Disease / replacement
Chronic atrial Fibrillation
Post Cardiac Surgery
Lifestyle:
Smoking
Sedentary lifestyle
Obesity (increase 20% ideal body weight)
Hyperlipidemia more on genetics/genes that binds to cholesterol
Type A personality
a. Deadline driven
b. Can do multiple tasks
c. Usually fells guilty when not doing anything

2.

3.

Related to diet: increase intake of saturated fats like whole milk

Related stress physical and emotional
Prolong use of oral contraceptives: promotes lypolysis (breakdown of
lipids) leading to atherosclerosis that will lead to hypertension &
eventually CVA.

Pathophysiology
Interruption of cerebral blood flow for 5 min or more causes death of
neurons in affected area with irreversible loss of function.
Modifying Factors:
a. Cerebral Edema:
Develops around affected area causing further impairment
b. Vasospasm:
Constriction of cerebral blood vessel may occur, causing further
decrease in blood flow
c. Collateral Circulation:
May help to maintain cerebral blood flow when there is
compromise of main blood supply
Stages of Development
Transient Ischemic Attack (TIA)
a. Initial / warning signs of impending CVA / stroke
b. Brief period of neurologic deficit:
Visual loss / Visual disturbance
Hemiparesis
Slurred Speech / Speech disturbance
Vertigo
Aphasia
Headache: initial sign
Dizziness
Tinnitus
Possible Increase ICP
c. May last less than 30 sec, but no more than 24 hrs with complete
resolution of symptoms
Stroke in Evolution
Progressive development of stroke symptoms over a period of hours
to days
Complete Stroke
Neurologic deficit remains unchanged for 2-3-days period
S/sx

1.
2.

3.

1.
2.
3.

Headache
Generalized Signs:
Vomiting
Seizure
Confusion
Disorientation
Decrease LOC
Nuchal Rigidity
Fever
Hypertension
Slow Bounding Pulse
Cheyne-Strokes Respiration
(+) Kernigs & Brudzinski sign: may lead to hemorrhagic stroke
Focal Signs (related to site of infarction):
Hemiplegia
Homonymous hemianopsia: loss of half of visual field
Sensory loss
Aphasia
Dysarthia: inability to articulate words
Alexia: difficulty reading
Agraphia: difficulty writing
Dx
CT & Brain Scan: reveals brain lesions
EEG: abnormal changes
Cerebral Arteriography: invasive procedure due to injection of dye (iodine
based); Uses dye for visualization
May show occlusion or malformation of blood vessels
Reveals the site and extent of malocclusion

1.

2.

Nursing Management Post Cerebral Arteriography

Allergy Test (shellfish)
Force fluids to release dye because it is nephro toxic
Check for peripheral pulse: distal (femoral)
Check for hematoma formation

Nursing Intervention: Acute Stage

Maintain patent airway and adequate ventilation by:
a. Assist in mechanical ventilation
b. Administer O2 inhalation
Monitor strictly V/S, I & O, neuro check & observe signs of increase ICP,
shock, hyperthermia, & seizure

3.
4.

Provide CBR as ordered

Maintain fluid & electrolyte balance & ensure adequate nutrition:
a. IV therapy for the first few days
b. NGT for feeding the client who is unable to swallow
c. Fluid restriction as ordered: to decrease cerebral edema & might also
increase ICP
5. Maintain proper positioning & body alignment:
a. Elevate head 30-45 degree to decrease ICP
b. Turn & reposition every 2 hrs (20 min only on the affected side)
c. Passive ROM exercise every 4 hrs: prevent contractures; promote
body alignment
6. Promote optimum skin integrity: turn client & apply lotion every 2 hrs
7. Prevent complications of immobility by:
a. Turn client to side
b. Provide egg crate mattresses or water bed
c. Provide sand bag or food board.
8. Maintain adequate elimination:
a. Offer bed pan or urinal every 2 hrs; catheterized only if necessary
b. Administer stool softener & suppositories as ordered: to prevent
constipation & fecal impaction
9. Provide quiet, restful environment
10. Provide alternative means of communication to the client:
a. Non verbal cues
b. Magic slate: not paper & pen tiring for client
c. If positive to hemianopsia: approach client on unaffected side
11. Administer medications as ordered:
a. Hyperosmotic agent: to decrease cerebral edema
Osmotic Diuretics (Mannitol)
Loop Diuretics Furosemide (Lasix)
Corticosteroids (Dexamethazone)
b. Anti-convulsants: to prevent or treat seizures
c. Thrombolytic / Fibrinolytic Agents: given to dissolve clot (hemorrhage
must be ruled out)
Tissue Plasminogen Activating Factor (tPA, Alteplase): SE: allergic
Reaction
Streptokinase, Urokinase: SE: chest pain
d. Anticoagulants: for stroke in evolution or embolic stroke (hemorrhage
must be ruled out)
Heparin: short acting
Check for Partial Thromboplastin Time (PTT): if prolonged
there is a risk for bleeding
Antidote: Protamine SO4

Warfarin (Comadin): long acting / long term therapy

Give simultaneously with Heparin cause Warfarin (Coumadin)
will take effect after 3 days
Check for Prothrombin Time (PT): if prolonged there is a risk
for bleeding
Antidote: Vitamin K (Aqua Mephyton)
Anti Platelet: to inhibit platelet aggregation in treating TIAs
PASA (Aspirin)
Contraindicated for dengue, ulcer and unknown cause of
headache because it may potentiate bleeding
e. Antihypertensive: if indicated for elevated BP
f. Mild Analgesics: for pain
12. Provide client health teachings and discharge planning concerning
a. Avoid modifiable risk factors (diet, exercise, smoking)
b. Prevent complication (subarachnoid hemorrhage is the most
feared complication)
c. Dietary modification (decrease salt, saturated fats and caffeine)
d. Importance of follow up care

1.

2.

3.

Nursing Intervention: Rehabiltation

Hemiplegia: results from injury to cell in the cerebral motor cortex or to
corticospinal tract (causes contralateral hemiplegia since tracts crosses
medulla)
a. Turn every 2 hrs (20 min only on affected side)
b. Use proper positioning & repositioning to prevent deformities (foot
drop, external rotation of hips, flexion of fingers, wrist drop, abduction
of shoulder & arms)
c. Support paralyzed arm on pillow or use sling while out of bed to
prevent subluxation of shoulders
d. Elevate extremities to prevent dependent edema
e. Provide active & passive ROM exercises every 4 hrs
Susceptibility to hazard
a. Keep side rails up at all times
b. Institute safety measures
c. Inspect body parts frequently for signs of injury
Dysphagia: difficulty of swallowing
a. Check for gag reflex before feeding client
b. Maintain a calm, unhurried approach
c. Place client in upright position
d. Place food in unaffected side of the mouth
e. Offer soft foods
f. Give mouth care before & after meals

4.

5.

6.

7.

8.

9.

Homonymous Hemianopsia: loss of right or left half of each visual field

a. Approach the client on unaffected side
b. Place personal belongings, food etc., on unaffected side
c. Gradually teach the client to compensate by scanning (ex. Turning the
head to see things on affected side)
Emotional Lability: mood swings, frustrations
a. Create a quiet, restful environment with a reduction in excessive
sensory stimuli
b. Maintain a calm, non-threatening manner
c. Explain to family that clients behavior is not purposeful
Aphasia: most common in right hemiplegics; may be receptive / expressive
a. Receptive Aphasia
Give simple, slow directions
Give one command at a time; gradually shift topics
Use non-verbal techniques of communication (ex. Pantomime,
demonstration)
b. Expressive Aphasia
Listen & watch very carefully when the client attempts to speak
Anticipate clients needs to decrease frustrations & feeling of
helplessness
Allow sufficient time for client to answer
Sensory / Perceptual Deficit: more common in left hemiplegics;
characterized by impulsiveness unawareness of disabilities, visual neglect
(neglect of affected side & visual space on affected side)
a. Assist with self-care
b. Provide safety measures
c. Initially arrange objects in environment on unaffected side
d. Gradually teach client to take care of the affected & turn frequently &
look at affected side
Apraxia: loss of ability to perform purposeful, skilled acts
a. Guide client through intended movement (ex. Take object such as
wash cloth & guide client through movement of washing)
b. Keep repeating the movement
Generalizations about the clients with left hemiplegia vs. right hemiplegia
& nursing care
a. Left Hemiplegia
Perceptual, sensory deficits: quick & impulsive behavior
Use safety measures, verbal cues, simplicity in all area of care
b. Right Hemiplegia
Speech-language deficits: slow & cautious behavior
Use pantomime & demonstration

CONVULSIVE DISORDER/CONVULSION
disorder of CNS characterized by paroxysmal seizure with or without loss
of consciousness abnormal motor activity alternation in sensation and
perception and changes in behavior.
Seizure: first convulsive attack
Epilepsy: second or series of attacks
Febrile seizure: normal in children age below 5 years

1.
2.
3.
4.

5.
6.
7.

1.

Predisposing Factors
Head injury due to birth trauma
Genetics
Presence of brain tumor
Toxicity from the ff:
a. Lead
b. Carbon monoxide
Nutritional and Metabolic deficiencies
Physical and emotional stress
Sudden withdrawal to anti-convulsant drug: is predisposing factor for
status epilepticus: DOC: Diazepam (Valium) & Glucose
S/sx
Dependent on stages of development or types of seizure
Generalized Seizure
Initial onset in both hemisphere, usually involves loss of consciousness
& bilateral motor activity.
a. Major Motor Seizure (Grand mal Seizure): tonic-clonic seizure
Signs or aura with auditory, olfactory, visual, tactile, sensory
experience
Epileptic cry: is characterized by fall and loss of consciousness for
3-5 minutes
Tonic Phase:
Limbs contract or stiffens
Pupils dilated & eye roll up to one side
Glottis closes: causing noise on exhalation
May be incontinent
Occurs at same time as loss of consciousness last 20-40 sec
Tonic contractions: direct symmetrical extension of extremities
Clonic Phase:
repetitive movement
increase mucus production
slowly tapers

b.

Clonic contractions: contraction of extremities

Postictal sleep: unresponsive sleep
Seizure ends with postictal period of confusion, drowsiness
Absence Seizure (Petit mal Seizure):
Usually non-organic brain damage present
Must be differentiated from daydreaming
Sudden onset with twitching & rolling of eyes that last 20-40 sec
Common among pediatric clients characterized by:
Blank stare
Decrease blinking of eyes
Twitching of mouth
Loss of consciousness (5 10 seconds)

2.

Partial or Localized Seizure

Begins in focal area of brain & symptoms are related to a dysfunction
of that area
May progress into a generalized seizure
a. Jacksonian Seizure (focal seizure)
characterized by tingling and jerky movement of index finger and
thumb that spreads to the shoulder and other side of the body.
b. Psychomotor Seizure (focal motor seizure)
May follow trauma, hypoxia, drug use
Purposeful but inappropriate repetitive motor acts
Aura is present: daydreaming like
Automatism: stereotype repetitive and non propulsive behavior
Clouding of consciousness: not in contact with environment
Mild hallucinatory sensory experience

3.

Status Epilepticus
Usually refers to generalized grand mal seizure
Seizure is prolong (or there are repeated seizures without regaining
consciousness) & unresponsive to treatment
Can result in decrease in O2 supply & possible cardiac arrest
A continuous uninterrupted seizure activity
If left untreated can lead to hyperpyrexia and lead to coma and
eventually death.
DOC: Diazepam (Valium) & Glucose

C. Diagnostic Procedures
1. CT Scan reveals brain lesions
2. EEG reveals hyper activity of electrical brain waves

D. Nursing Management
1. Maintain patent airway and promote safety before seizure activity
a. clear the site of blunt or sharp objects
b. loosen clothing of client
c. maintain side rails
d. avoid use of restrains
e. turn clients head to side to prevent aspiration
f. place mouth piece of tongue guard to prevent biting or tongue
2. Avoid precipitating stimulus such as bright/glaring lights and noise
3. Administer medications as ordered
a. Anti convulsants (Dilantin, Phenytoin)
b. Diazepam, Valium
c. Carbamazepine (Tegnetol) trigeminal neuralgia
d. Phenobarbital, Luminal
4. Institute seizure and safety precaution post seizure attack
a. administer O2 inhalation
b. provide suction apparatus
5. Document and monitor the following
a. onset and duration
b. types of seizures
c. duration of post ictal sleep may lead to status epilepticus
d. assist in surgical procedure cortical resection
Overview Anatomy & Physiology of the Eye
External Structure of Eye
a. Eyelids (Palpebrae) & Eyelashes: protect the eye from foreign particles
b. Conjunctiva:
Palpebral Conjunctiva: pink; lines inner surface of eyelids
Bulbar Conjunctiva: white with small blood vessels, covers
anterior sclera
c. Lacrimal Apparatus (lacrimal gland & its ducts & passage): produces tears
to lubricate the eye & moisten the cornea; tears drain into the
nasolacrimal duct, which empties into nasal cavity
d. The movement of the eye is controlled by 6 extraocular muscles (EOM)
Internal Structure of Eye
A. 3 layers of the eyeball
1. Outer Layer
a. Sclera: tough, white connective tissue (white of the eye);
located anteriorly & posteriorly

b.
2.

3.

Cornea: transparent tissue through which light enters the eye;

located anteriorly
Middle Layer
a. Choroid: highly vascular layer, nourishes retina; located
posteriorly
b. Ciliary Body: anterior to choroid, secrets aqueous humor; muscle
change shape of lens
c. Iris: pigmented membrane behind cornea, gives color to eye;
located anteriorly
d. Pupil: is circular opening in the middle of the iris that constrict or
dilates to regulate amount of light entering the eye
Inner Layer
a. Light-sensitive layer composed of rods & cones (visual cell)
Cones: specialized for fine discrimination & color vision;
(daylight / colored vision)
Rods: more sensitive to light than cones, aid in peripheral
vision; (night twilight vision)
b. Optic Disk: area in retina for entrance of optic nerve, has no
photoreceptors

B. Lens: transparent body that focuses image on retina

C. Fluid of the eye
1. Aqueous Humor: clear, watery fluid in anterior & posterior chambers
in anterior part of eye; serves as refracting medium & provides
nutrients to lens & cornea; contribute to maintenance of intraocular
pressure
2. Vitreous Humor: clear, gelatinous material that fills posterior cavity of
eye; maintains transparency & form of eye
Visual Pathways
a. Retina (rods & cones) translates light waves into neural impulses that
travel over the optic nerves
b. Optic nerves for each eye meet at the optic chiasm
Fibers from median halves of the retinas cross here & travel to the
opposite side of the brain
Fibers from lateral halves of retinas remain uncrossed
c. Optic nerves continue from optic chiasm as optic tracts & travels to the
cerebrum (occipital lobe) where visual impulses are perceived &
interpreted
Canal of schlemm: site of aqueous humor drainage
Meibomian gland: secrets a lubricating fluid inside the eyelid
Maculla lutea: yellow spot center of retina

 Characterized by increase intraocular pressure resulting in progressive loss

of vision
May cause blindness if not recognized & treated
Early detection is very important
preventable but not curable
Regular eye exam including tonometry for person over age 40 is
recommended

Fovea centralis: area with highest visual acuity or acute vision

2 muscles of iris:
Circular smooth muscle fiber: Constricts the pupil
Radial smooth muscle fiber: Dilates the pupil
Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays: bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes

1.
2.
3.
4.
5.

Unit of measurements of refraction: diopters

Normal eye refraction: emmetropia
Normal IOP: 12-21 mmHg

1.
Error of Refraction
1. Myopia: nearsightedness: Treatment: biconcave lens
2. Hyperopia: farsightedness: Treatment: biconvex lens
3. Astigmatisim: distorted vision: Treatment: cylindrical
4. Presbyopia: old sight inelasticity of lens due to aging: Treatment: bifocal
lens or double vista
Accommodation of lenses: based on thelmholtz theory of accommodation
Near Vision: Ciliary muscle contracts: Lens bulges

2.

3.

Far Vision: ciliary muscle dilates / relaxes: lens is flat

Convergence of the eye:

Error:
1. Exotropia:1 eye normal
2. Esophoria:
corrective eye surgery
3. Strabismus: squint eye
4. Amblyopia: prolong squinting

Common Visual Disorder

Glaucoma

1.

corrected by
2.

Predisposing Factors
Common among 40 years old and above
Hereditary
Hypertension
Obesity
History of previous eye surgery, trauma, inflammation
Types of Glaucoma:
Chronic (open-angle) Glaucoma:
Most common form
Due to obstruction of the outflow of aqueous humor, in trabecular
meshwork or canal of schlemm
Acute (close-angle) Glaucoma:
Due to forward displacement of the iris against the cornea,
obstructing the outflow of the aqueous humor
Occurs suddenly & is an emergency situation
If untreated it will result to blindness
Chronic (close-angle) Glaucoma:
similar to acute (close-angle) glaucoma, with the potential for an acute
attack
S/sx
Chronic (open-angle) Glaucoma: symptoms develops slowly
Impaired peripheral vision (PS: tunnel vision)
Halos around light
Mild discomfort in the eye
Loss of central vision if unarrested
Acute (close-angle) Glaucoma
Severe eye pain
Blurred cloudy vision
Halos around light
N/V
Steamy cornea
Moderate pupillary dilation

3.

Chronic (close-angle) Glaucoma

Transient blurred vision
Slight eye pain
Halos around lights
3.

1.
2.
3.
4.
5.

1.

2.

Dx
Visual Acuity: reduced
Tonometry: reading of 24-32 mmHg suggest glaucoma; may be 50 mmHg
of more in acute (close-angle) glaucoma
Ophthalmoscopic exam: reveals narrowing of small vessels of optic disk,
cupping of optic disk
Perimetry: reveals defects in visual field
Gonioscopy: examine angle of anterior chamber
Medical Management
Chronic (open-angle) Glaucoma
a. Drug Therapy: one or a combination of the following
Miotics eye drops (Pilocarpine): to increase outflow of aqueous
humor
Epinephrine eye drops: to decrease aqueous humor production &
increase outflow
Carbonic Anhydrase Inhibitor: Acetazolamide (Diamox): to
decrease aqueous humor production
Timolol Maleate (Timoptic): topical beta-adrenergic blocker: to
decrease intraocular pressure (IOP)
b. Surgery (if no improvement with drug)
Filtering procedure (Trabeculectomy / Trephining): to create
artificial openings for the outflow of aqueous humor
Laser Trabeculoplasty: non-invasive procedure performed with
argon laser that can be done on an out-client basis; procedure
similar result as trabeculectomy
Acute (close-angle) Glaucoma
a. Drug Therapy: before surgery
Miotics eye drops (Pilocarpine): to cause pupil to contract & draw
iris away from cornea
Osmotic Agent (Glycerin oral, Mannitol IV): to decrease
intraocular pressure (IOP)
Narcotic Analgesic: for pain
b. Surgery
Peripheral Iridectomy: portion of the iris is excised to facilitate
outflow of aqueous humor

1.
2.
3.
4.
5.
6.

Argon Laser Beam Surgery: non-invasive procedure using laser

produces same effect as iridectomy; done in out-client basis
Iridectomy: usually performed on second eye later since a large
number of client have an acute acute attack in the other eye
Chronic (close-angle) Glaucoma
a. Drug Therapy:
miotics (pilocarpine)
b. Surgery:
bilateral peripheral iridectomy: to prevent acute attacks
Nursing Intervention
Administer medication as ordered
Provide quite, dark environment
Maintain accurate I & O with the use of osmotic agent
Prepare client for surgery if indicated
Provide post-op care
Provide client teaching & discharge planning
a. Self-administration of eye drops
b. Need to avoid stooping, heavy lifting or pushing, emotional upsets,
excessive fluid intake, constrictive clothing around the neck
c. Need to avoid the use antihistamines or sympathomimetic drugs
(found in cold preparation) in close-angle glaucoma since they may
cause mydriasis
d. Importance of follow-up care
e. Need to wear medic-alert tag

Cataract
Decrease opacity of ocular lens
Incidence increases with age

5.
6.

Predisposing Factor
Aging 65 years and above
May caused by changes associated with aging (senile cataract)
Related to congenital
May develop secondary to trauma, radiation, infection, certain drugs
(corticosteroids)
Diabetes Mellitus
Prolonged exposure to UV rays

1.
2.

S/sx
Loss of central vision
Blurring or hazy vision

1.
2.
3.
4.

3.
4.
5.
6.

Progressive decrease of vision

Glare in bright lights
Milky white appearance at center of pupils
Decrease perception to colors

1.

Diagnostic Procedure
Ophthalmoscopic exam: confirms presence of cataract

1.

2.

3.

Nursing Intervention
Prepare client for cataract surgery:
a. Performed when client can no longer remain independent because of
reduced vision
b. Surgery performed on one eye at a time; usually in a same day surgery
unit
c. Local anesthesia & intravenous sedation usually used
d. Types of cataract surgery:
Extracapsular Extraction: lens capsule is excised & the lens is
expressed; posterior capsule is left in place (may be used to
support new artificial lens implant); partial removal of lens
Phacoemulsification: type of extracapsular extraction; a hollow
needle capable of ultrasonic vibration is inserted into lens,
vibrations emulsify the lens, which is aspirated
Intracapsular Extraction: lens is totally removed within its
capsules, may be delivered from eye by cryoextraction (lens is
frozen with metal probe & removed); total removal of lens &
surrounding capsules
e. Peripheral Iridectomy: may be performed at the time of surgery; small
hole cut in iris to prevent development of secondary glaucoma
f. Intraocular Lens Implant: often performed at the time of surgery
Nursing Intervention Pre-op
a. Assess vision in the unaffected eye since the affected eye will be
patched post-op
b. Provide pre-op teaching regarding measures to prevent intraocular
pressure (IOP) post-op
c. Administer medication as ordered:
Topical Mydriatics (Mydriacyl) & Cyclopegics (Cyclogyl): to dilate
the pupil
Topical antibiotics: to prevent infection
Acetazolamide (Diamox) & osmotic agent (Oral Glycerin or
Mannitol IV): to decrease intraocular pressure to provide soft
eyeball for surgery
Nursing Intervention Post-op

a.
b.

4.

5.

6.

Reorient the client to surroundings

Provide safety measures:
Elevate side rails
Provide call bells
Assist with ambulation when fully recovered from anesthesia
c. Prevent intraocular pressure & stress on the suture line:
Elevate head of the bed 30-40 degree
Have the client lie on back or unaffected side
Avoid having the client cough, sneeze, bend over, or move head
too rapidly
Treat nausea with anti-emetics as ordered: to prevent vomiting
Give stool softener as ordered: to prevent straining
Observe for & report signs of intraocular pressure (IOP):
Severe eye pain
Restlessness
Increased pulse
Protect eye from injury:
a. Dressing usually removed the day after the surgery
b. Eyeglasses or eye shield used during the day
c. Always use eye shield during the night
Administer medication as ordered:
a. Topical mydriatics & cycloplegic: to decrease spasm of ciliary body &
relieve pain
b. Topical antibiotics & corticosteroids
c. Mild analgesic as needed
Provide client teaching & discharge planning concerning:
a. Technique of eyedrop administration
b. Use of eye shield at night
c. No bending, stooping, or lifting
d. Report signs & symptoms of complication immediately to physician:
Severe eye pain
Decrease vision
Excessive drainage
Swelling of eyelid
e. Cataract glasses / contact lenses
If a lens implant has not been performed the client will need
glasses or contact lenses
Temporary glasses are worn for 1-4 weeks then permanent
glasses fitted
Cataract glasses magnify object by 1/3 & distortion peripheral
vision

 Have the client practice manual coordination with assistance

until new spatial relationship becomes familiar
Have client practice walking, using stairs, reaching for articles
Contact lenses cause less distortion of vision; prescribe at one
month
Retinal Detachment
Separation of epithelial surface of retina
Detachment or the sensory retina from the pigment epithelium of the
retina

1.
2.
3.
4.
5.

Predisposing Factors
Trauma
Aging process
Severe diabetic retinopathy
Post-cataract extraction
Severe myopia (near sightedness)
Pathophysiology
Tear in the retina allows vitreous humor to seep behind the sensory retina
& separate it from the pigment epithelium

1.
2.
3.
4.
5.

S/sx
Curtain veil like vision coming across field of vision
Flashes of light
Visual field loss
Floaters
Gradual decrease of central vision

1.

Dx
Ophthalmoscopic exam: confirms diagnosis

1.
2.

Medical Management
Bed rest with eye patched & detached areas dependent to prevent further
detachment
Surgery: necessary to repair detachment
a. Photocoagulation: light beam (argon laser) through dilated pupil
creates an inflammatory reaction & scarring to heal the area
b. Cryosurgery or diathermy: application of extreme cold or heat to
external globe; inflammatory reaction causes scarring & healing of
area

c.

Scleral buckling: shortening of sclera to force pigment epithelium close

to retina

Nursing Intervention Pre-op

Maintain bed rest as ordered with head of bed flat & detached area in a
dependent position
2. Use bilateral eye patches as ordered; elevate side rails to prevent injury
3. Identify yourself when entering the room
4. Orient the client frequently to time of date & surroundings; explain
procedures
5. Provide diversional activities to provide sensory stimulation
Nursing Intervention Post-op
1. Check orders for positioning & activity level:
a. May be on bed rest for 1-2 days
b. May need to position client so that detached area is in dependent
position
2. Administer medication as ordered:
a. Topical mydriatics
b. Analgesic as needed
3. Provide client teaching & discharge planning concerning:
a. Techniques of eyedrop administration
b. Use eye shield at night
c. No bending from waist; no heavy work or lifting for 6 weeks
d. Restriction of reading for 3 weeks or more
e. May watch TV
f. Need to check to physician regarding combing & shampooing hair &
shaving
g. Need to report complications such as recurrence of detachment
1.

Overview of Anatomy & Physiology Of Ear (Hearing)

External Ear
1. Auricle (Pinna): outer projection of ear composed of cartilage & covered by
skin; collects sound waves
2. External Auditory Canal: lined with skin; glands secretes cerumen (wax),
providing protection; transmits sound waves to tympanic membrane
3. Tympanic Membrane (Eardrum): at end of external canal; vibrates in
response to sound & transmits vibrations to middle ear
Middle Ear
1. Ossicles
a. 3 small bones: malleus (Hammer) attached to tympanic membrane,
incus (anvil), stapes (stirrup)

b.
c.

2.

Ossicles 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)
Eustachian Tube: connects nasopharynx & middle ear; bring air into
middle ear, thus equalizing pressure on both sides of eardrum

Inner Ear
1. Cochlea
Controls hearing
Contains Organ of Corti (the true organ of hearing): the receptor
end-organ for hearing
Transmit sound waves from the oval window & initiates nerve
impulses carried by cranial nerve VIII (acoustic branch) to the
brain (temporal lobe of cerebrum)
2. Vestibular Apparatus
Organ of balance
Composed of three semicircular canals & the utricle
3. Endolymph & Perilymph
For static equilibrium
4. Mastoid air cells
Air filled spaces in temporal bone in skull

1.
2.

1.

1.
2.

1.
2.
3.

Disorder of the Ear

Otosclerosis
Formation of new spongy bone in the labyrinth of the ear causing
fixation of the stapes in the oval window
This prevent transmission of auditory vibration to the inner ear

1.

Predisposing Factor
Found more often in women

1.
2.
3.

Cause
Unknown / idiopathic
There is familial tendency
Ear trauma & surgery

1.
2.

S/sx
Progressive hearing loss
Tinnitus
Dx

4.

5.
6.

7.

8.

Audiometry: reveals conductive hearing loss

Webers & Rinnes Test: show bone conduction is greater than air
conduction
Medical Management
Stapedectomy: procedure of choice
Removal of diseased portion of stapes & replacement with
prosthesis to conduct vibrations from the middle ear to inner ear
Usually performed under local anesthesia
Used to treat otoscrlerosis
Nursing Intervention Pre-op
Provide general pre-op nursing care, including an explanation of postop expectation
Explain to the client that hearing may improve during surgery & then
decrease due to edema & packing
Nursing Intervention Post-op
Position the client according to the surgeons orders (possibly with
operative ear uppermost to prevent displacement of the graft)
Have the client deep breathe every 2 hours while in bed, but no
coughing
Elevate side rails; assist the client with ambulation & move slowly:
may have some vertigo
Administer medication as ordered:
Analgesic
Antibiotics
Anti-emetics
Anti-motion sickness drug: Meclesine Hcl (Bonamine)
Check for dressing frequently for excessive drainage or bleeding
Assess facial nerve function: Ask the client to do the ff:
Wrinkle forehead
Close eyelids
Puff out checks for any asymmetry
Question the client about the ff: report existence to physicians
Pain
Headaches
Vertigo
Unusual sensations in the ear
Provide client teaching & discharge planning concerning:
a. Warning against blowing nose or coughing; sneeze with mouth
open

b.
c.
d.

Need to keep ear dry in the shower; no shampooing until allowed

No flying for 6 mos. Especially if upper respiratory tract infection
is present
Placement of cotton balls in auditory meatus after packing is
removed; change twice daily

2.

Menieres Disease
Disease of the inner ear resulting from dilatation of the endolymphatic
system & increase volume of endolymph
Characterized by recurrent & usually progressive triad of symptoms:
vertigo, tinnitus, hearing loss
3.
1.

Predisposing Factor
Incidence highest between ages 30 & 60
Cause
Unknown / idiopathic
Theories include the ff:
a. Allergy
b. Toxicity
c. Localized ischemia
d. Hemorrhage
e. Viral infection
f. Edema

1.

2.
3.
4.
5.

S/sx
Sudden attacks of vertigo lasting hours or days; attacks occurs several
times a year
N/V
Tinnitus
Progressive hearing loss
Nystagmus

8.

1.
2.

Dx
Audiometry: reveals sensorineural hearing loss
Vestibular Test: reveals decrease function

2.
3.

1.

1.

Medical Management
Acute:
Atropine (decreases autonomic nervous system activity)
Diazepam (Valium)
Fentanyl & Droperidol (Innovar)

2.
3.
4.
5.
6.
7.

Chronic:
a. Drug Therapy:
Vasodilators (nicotinic Acid)
Diuretics
Mild sedative or tranquilizers: Diazepam (Valium)
Antihistamines: Diphenhydramine (Benadryl)
Meclizine (antivert)
b. Diet:
Low sodium diet
Restricted fluid intake
Restrict caffeine & nicotine
Surgery:
a. Surgical destruction of labyrinth causing loss of vestibular &
cochlear function (if disease is unilateral)
b. Intracranial division of vestibular portion of cranial nerve VIII
c. Endolymphatic sac decompression or shunt to equalize pressure
in endolymphatic space
Nursing Intervention
Maintain bed rest in a quiet, darkened room in position of choice;
elevate side rails as needed
Only move the client for essential care (bath may not be essential)
Provide emesis basin for vomiting
Monitor IV Therapy; maintain accurate I&O
Assist in ambulation when the attack is over
Administer medication as ordered
Prepare client for surgery as indicated (pot-op care includes using
above measures)
Provide client care & discharge planning concerning:
a. Use of medication & side effects
b. Low sodium diet & decrease fluid intake
c. Importance of eliminating smoking

Overview of Anatomy & Physiology of Endocrine System

Endocrine System
Is composed of an interrelated complex of glands (Pituitary G, Adrenal G,
Thyroid G, Parathyroid G, Islets of langerhans of the pancreas, Ovaries &
Testes) that secretes a variety of hormones directly into the bloodstream.
Its major function, together with the nervous system: is to regulate body
function

Hormones Regulation
1. Hormones: chemical substance that acts s messenger to specific cells &
organs (target organs), stimulating & inhibiting various processes
Two Major Categories
a. Local: hormones with specific effect in the area of secretion (ex.
Secretin, cholecystokinin, panceozymin [CCK-PZ])
b. General: hormones transported in the blood to distant sites where
they exert their effects (ex. Cortisol)
2. Negative Feedback Mechanisms: major means of regulating hormone
levels
a. Decreased concentration of a circulating hormones triggers
production of a stimulating hormones from pituitary gland; this
hormones in turn stimulates its target organ to produce hormones
b. Increased concentration of a hormones inhibits production of the
stimulating hormone, resulting in decreased secretion of the target
organ hormone
3. Some hormones are controlled by changing blood levels of specific
substances (ex. Calcium, glucose)
4. Certain hormones (ex. Cortisol or female reproductive hormones) follow
rhythmic patterns of secretion
5. Autonomic & CNS control (pituitary-hypothalamic axis): hypothalamus
controls release of the hormones of the anterior pituitary gland through
releasing & inhibiting factors that stimulate or inhibits hormone secretions
Hormone Function
Endocrine G
Pituitary G
Anterior lobe: TSH
thyroid hormones

Hormone

Functions
: stimulate thyroid G to release

: ACTH

: FSH, LH
maturation, & function of primary
: GH, Somatotropin

: stimulate adrenal cortex to

produce & release
adrenocoticoids
: stimulate growth,
& secondary sex organ
: stimulate growth of body

tissues & bones

: Prolactin or LTH
mammary gland &
Posterior lobe
: ADH
release during stress

: stimulate development of

: Oxytocin
contractions during delivery & the

Or in response to an increase
in plasma osmolality
To stimulate reabsorption of
H2O & decrease urine
Output
: stimulate uterine

Intermediate lobe

: MSH

Release of milk in lactation

: affects skin pigmentation

Adrenal G
Adrenal Cortex
balance; stimulate

: Mineralocorticoid

: regulate fluid & electrolyte

(ex. Aldosterone) reabsoption of sodium, chloride, &

H2O; stimulate
potassium excretion
: Glucocorticoids : increase blood glucose level by
increasing rate of
(ex. Cortisol,
glyconeogenesis; increase
CHON catabolism; increase
corticosterone) mobilization of fatty acid;
promote sodium & H2O
retention; anti-inflammatory effect; aid body in
coping
with stress
: Sex Hormones : influence development of secondary
sex
(androgens, estrogens characeristics
progesterones)
Adrenal Medulla
: Epinephrine,
: function in acute stress;
increase HR, BP; dilates
Norepinephrine bronchioles; convert glycogen to
glucose when
Needed by the muscles for
energy
Thyroid G
fats, & CHON

: T3, T4

: regulate metabolic rate; CHO,

Metabolism; aid in regulating

Lactation
: regulates H2O metabolism;

physical & mental

Growth & development

: Thyrocalcitonin

: lowers serum calcium &

: PTH

: regulates serum calcium &

phosphate levels
Parathyroid G
phosphate levels

Pancreas (islets of
Langerhans)
Beta Cells
: Insulin
across cell membrane;
Alpha Cells
: Glucagon
causing glyconeogenisis

: allows glucose to diffuse

Converts glucose to glycogen
: increase blood glucose by

2.

& glycogenolysis in the liver;

secreted in response to
low blood sugar
Ovaries : Estrogen, Progesterone : development of secondary sex characteristics
in the
Female, maturation of sex
organ, sexual functioning
Maintenance of pregnancy
Testes
: Testosterone
: development of secondary
sex characteristics in the
Male maturation of the sex
organs, sexual functioning

Pituitary Gland (Hypophysis)

Located in sella turcica at the base of brain
Master Gland or master clock
Controls all metabolic function of body
3 Lobes of Pituitary Gland
1. Anterior Lobe PG (Adenohypophysis)
a. Secretes tropic hormones (hormones that stimulate target glands to
produce their hormones): adrenocorticotropic H (ACTH), thyroidstimulating H (TSH), follicle-stimulating H (FSH), luteinizing H (LH)
ACTH: promotes development of adrenal cortex
LH: secretes estrogen
FSH: secretes progesterone
b. Also secretes hormones that have direct effects on tissues:
somatotropic or growth H, prolactin

3.

Somatotropic / GH: promotes elongation of long bones

Hyposecretion of GH: among children results to dwarfism
Hypersecretion of GH: among children results to gigantism
Hypersecretion of GH: among adults results to acromegaly
(square face)
DOC: Ocreotide (Sandostatin)
Prolactin: promotes development of mammary gland; with
help of oxytocin it initiates milk let down reflex
c. Regulated by hypothalamic releasing & inhibiting factors & by negative
feedback system
Posterior Lobe PG (Neurohypophysis)
Does not produce hormones
Store & release anti-diuretic hormones (ADH) & oxytocin produced by
hypothalamus
Secretes hormones oxytocin (promotes uterine contractions
preventing bleeding or hemorrhage)
Administer oxytocin immediately after delivery to prevent uterine
atony.
Initiates milk let down reflex with help of hormone prolactin
Intermediate Lobe PG
Secretes melanocytes stimulating H (MSH)
MSH: for skin pigmentation
Hyposecretion of MSH: results to albinism
Hypersecretion of MSH: results to vitiligo
2 feared complications of albinism:
1. Lead to blindness due to severe photophobia
2. Prone to skin cancer

Adrenal Glands
Two small glands, one above each kidney; Located at top of each
kidney
2 Sections of Adrenal Glands
1. Adrenal Cortex (outer portion): produces mineralocorticoids,
glucocorticoids, sex hormones
3 Zones/Layers
Zona Fasciculata: secretes glucocortocoids (cortisol): controls
glucose metabolism: Sugar
Zona Reticularis: secretes traces of glucocorticoids & androgenic
hormones: promotes secondary sex characteristics: Sex

2.

Zona Glumerulosa: secretes mineralocorticoids (aldosterone):

promotes sodium and water reabsorption and excretion of
potassium: Salt
Adrenal Medulla (inner portion): produces epinephrine, norepinephrine
(secretes catecholamines a power hormone): vasoconstrictor
2 Types of Catecholamines:
Epinephrine (vasoconstrictor)
Norepinephrine (vasoconstrictor)
o Pheochromocytoma (adrenal medulla): Increase secretion of
norepinephrine: Leading to hypertension which is resistant to
pharmacological agents leading to CVA: Use beta-blockers

Thyroid Gland
Located in anterior portion of the neck
Consist of 2 lobes connected by a narrow isthmus
Produces thyroxine (T4), triiodothyronine (T3), thyrocalcitonin
3 Hormones Secreted:
T3: 3 molecules of iodine (more potent)
T4: 4 molecule of iodine
T3 and T4 are metabolic hormone: increase brain activity;
promotes cerebration (thinking); increase V/S
Thyrocalcitonin: antagonizes the effects of parathormone to
promote calcium reabsorption.
Parathyroid Gland
4 small glands located in pairs behind the thyroid gland
Produce parathormone (PTH)
Promotes calcium reabsorption
Pancreas
Located behind the stomach
Has both endocrine & exocrine function (mixed gland)
Consist of Acinar Cells (exocrine gland): which secretes pancreatic juices:
that aids in digestion
Islets of langerhans (alpha & beta cells) involved in endocrine function:
Alpha Cell: produce glucagons: (function: hyperglycemia)
Beta Cell: produce insulin: (function: hypoglycemia)
Delta Cells: produce somatostatin: (function: antagonizes the effects
of growth hormones)
Gonads
Ovaries: located in pelvic cavity; produce estrogen & progesterone

Testes: located in scrotum; produces testosterone

Pineal Gland
Secretes melatonin
Inhibits LH secretion
It controls & regulates circadian rhythm (body clock)
Diabetes Incipidus (DI)
DI: dalas-ihi
Decrease of anti-diuretic hormone (ADH)
Hyposecretion of ADH
Hypofunction of the posterior pituitary gland (PPG) resulting in deficiency
of ADH
Characterized by excessive thirst & urination
Anti-diuretic Hormone: Pitressin (Vasopressin)
Function: prevents urination thereby conserving water
Note: Alcohol inhibits release of ADH

1.
2.
3.
4.

Predisposing Factor
Related to pituitary surgery
Trauma
Inflammation
Presence of tumor

S/sx
Severe polyuria with low specific gravity
Polydipsia (excessive thirst)
Fatigue
Muscle weakness
Irritability
Weight loss
Hypotension
Signs of dehydration
a. Adult: thirst; Children: tachycardia
b. Agitation
c. Poor Skin turgor
d. Dry mucous membrane
9. Tachycardia, eventually shock if fluids is not replaced
10. If left untreated results to hypovolemic shock (late sign anuria)
1.
2.
3.
4.
5.
6.
7.
8.

1.

Dx
Urine Specific Gravity (NV: 1.015 1.030): less than 1.004

2.
3.

1.

2.
3.

4.
5.

Serum Na: increase resulting to hypernatremia

H2O deprivation test: reveals inability to concentrate urine
Nursing Intervention
Maintain F&E balance / Force fluids 2000-3000 ml/day
a. Keep accurate I&O
b. Weigh daily
c. Administer IV/oral fluids as ordered to replace fluid loss
Monitor strictly V/S & observe for signs of dehydration & hypovolemia
Administer hormone replacement as ordered:
a. Vasopressin (Pitressin) & Vasopressin Tannate (Pitressin Tannate Oil):
administered by IM injection
Warm to body temperature before giving
Shake tannate suspension to ensure uniform dispersion
b. Lypressin (Diapid): nasal spray
Prevent complications: hypovolemic shock is the most feared complication
Provide client teaching & discharge planning concerning:
a. Lifelong hormone replacement: Lypressin (Diapid) as needed to
control polyuria & polydipsia
b. Need to wear medic-alert bracelet

Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH)

Hypersecretion of anti-diuretic hormone (ADH) from the PPG even when
the client has abnormal serum osmolality

1.
2.

3.

1.
2.

3.

Predisposing Factors
Head injury
Related to presence of bronchogenic cancer
Initial sign of lung cancer is non productive cough
Non invasive procedure is chest x-ray
Related to hyperplasia of pituitary gland (increase size of organ brought
about by increase of number of cells)
S/sx
Person with SIADH cannot excrete a dilute urine
Fluid retention & Na deficiency
a. Hypertension
b. Edema
c. Weight gain
Water intoxication: may lead to cerebral edema: lead to increase ICP; may
lead to seizure activity

1.
2.

Dx
Urine specific gravity: is increase
Serum Sodium: is decreased

1.
2.

Medical Management
Treat underlying cause if possible
Diuretics & fluid restriction

1.
2.

3.
4.
5.
6.
7.

Nursing Intervention
Restrict fluid: to promote fluid loss & gradual increase in serum Na
Administer medications as ordered:
a. Loop diuretics (Lasix)
b. Osmotic diuretics (Mannitol)
Monitor strictly V/S, I&O & neuro check
Weigh patient daily and assess for pitting edema
Monitor serum electrolytes & blood chemistries carefully
Provide meticulous skin care
Prevent complications

HYPOTHYROIDISM
- all are decrease except weight and menstruation
- memory impairment
Signs and Symptoms
- there is loss of appetite but there is weight gain
- menorrhagia
- cold intolerance
- constipation
HYPERTHYROIDISM
- all are increase except weight and menstruation
Signs and Symptoms
- increase appetite but there is weight loss
- amenorrhea
- exophthalmos
Thyroid Disorder
Simple Goiter
Enlargement of thyroid gland due to iodine deficiency
Enlargement of the thyroid gland not caused by inflammation of neoplasm

 Low level of thyroid hormones stimulate increased secretion of TSH by

pituitary; under TSH stimulation the thyroid increases in size to
compensate & produce more thyroid hormone

3.

Predisposing Factors
Endemic: caused by nutritional iodine deficiency, most common in the
goiter belt area, areas where soil & H2O are deficient in iodine; occurs
most frequently during adolescence & pregnancy
Goiter belt area:
a. Midwest, northwest & great lakes region
b. Places far from sea
c. Mountainous regions
Sporadic: caused by
Increase intake of goitrogenic foods (contains agent that decrease the
thyroxine production: pro-goitrin an anti-thyroid agent that has no
iodine). Ex. cabbage, turnips, radish, strawberry, carrots, sweet
potato, rutabagas, peaches, peas, spinach, broccoli, all nuts
Soil erosion washes away iodine
Goitrogenic drugs:
a. Anti-Thyroid Agent: Propylthiouracil (PTU)
b. Large doses of iodine
c. Phenylbutazone
d. Para-amino salicylic acid
e. Lithium Carbonate
f. PASA (Aspirin)
g. Cobalt
Genetic defects that prevents synthesis of thyroid hormones

1.
2.
3.
4.

S/sx
Enlarged thyroid gland
Dysphagia
Respiratory distress
Mild restlessness

1.

2.

1.
2.
3.
4.

Dx
Serum T4: reveals normal or below normal
Thyroid Scan: reveals enlarged thyroid gland.
Serum Thyroid Stimulating Hormone (TSH): is increased (confirmatory
diagnostic test)
RAIU (Radio Active Iodine Uptake): normal or increased
Medical Management

1.

2.
3.

1.

Drug Therapy:
Hormone replacement with levothyroxine (Synthroid) (T4), dessicated
thyroid, or liothyronine (Cytomel) (T3)
Small dose of iodine (Lugols or potassium iodide solution): for goiter
resulting from iodine deficiency
Avoidance of goitrogenic food or drugs in sporadic goiter
Surgery:
Subtotal thyroidectomy: (if goiter is large) to relieve pressure
symptoms & for cosmetic reasons
Nursing Intervention
Administer Replacement therapy as ordered:
a. Lugols Solution / SSKI (Saturated Solution of Potassium Iodine)
Color purple or violet and administered via straw to prevent
staining of teeth.
4 Medications to be taken via straw: Lugols, Iron, Tetracycline,
Nitrofurantoin (DOC: for pyelonephritis)
b. Thyroid Hormones:
Levothyroxine (Synthroid)
Liothyronine (Cytomel)
Thyroid Extracts
Nursing Intervention when giving Thyroid Hormones:
Instruct client to take in the morning to prevent insomnia
Monitor vital signs especially heart rate because drug causes
tachycardia and palpitations
3. Monitor side effects:
Insomnia
Tachycardia and palpitations
Hypertension
Heat intolerance
Increase dietary intake of foods rich in iodine:
Seaweeds
Seafoods like oyster, crabs, clams and lobster but not shrimps
because it contains lesser amount of iodine.
Iodized salt: best taken raw because it is easily destroyed by heat
Assist in surgical procedure of subtotal thyroidectomy
Provide client teaching & discharge planning concerning:
Used of iodized salt in preventing & treating endemic goiter
Thyroid hormone replacement
1.
2.

2.

3.
4.

Hypothyroidism (Myxedema)

 Slowing of metabolic processes caused by hypofunction of the thyroid

gland with decreased thyroid hormone secretion
Hyposecretion of thyroid hormone
Decrease in all V/S except wt & menses
Adults: myxedema non pitting edema
Children: cretinism the only endocrine disorder that can lead to mental
retardation
In severe or untreated cases myxedema coma may occur:
Characterized by intensification of S/sx of hypothyroidism &
neurologic impairment leading to coma
Mortality rate high; prompt recognition & treatment essential
Precipitating factors: failure to take prescribed medications; infection;
trauma; exposure to cold; use of sedatives, narcotics or anesthetics

1.
2.
3.

4.
5.
6.
7.

1.
2.
3.
4.
5.
6.
7.
8.
9.

Predisposing Factors
Primary hypothyroidism: atrophy of the gland possibly caused by an
autoimmune process
Secondary hypothyroidism: caused by decreased stimulation from
pituitary TSH
Iatrogenic: surgical removal of the gland or over treatment of
hyperthyroidism with drugs or radioactive iodine; disease caused by
medical intervention such as surgery
Related to atrophy of thyroid gland due to trauma, presence of tumor,
inflammation
Iodine deficiency
Autoimmune (Hashimotos Disease)
Occurs more often to women ages 30 & 60

S/sx
Loss of appetite: but there is wt gain
Anorexia
Weight gain: which promotes lipolysis leading to atherosclerosis and
MI
Constipation
Cold intolerance
Dry scaly skin
Spares hair
Brittleness of nails
Decrease in all V/S: except wt gain & menses
a. Hypotension
b. Bradycardia

10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

1.
2.
3.
1.

2.

1.

2.

c. Bradypnea
d. Hypothermia
Weakness and fatigue
Slowed mental processes
Dull look
Slow clumsy movement
Lethargy
Generalized interstitial non-pitting edema (Myxedema)
Hoarseness of voice
Decrease libido
Memory impairment
Psychosis
Menorrhagia
Dx
Serum T3 and T4: is decreased
Serum Cholesterol: is increased
RAIU (Radio Active Iodine Uptake): is decreased
Medical Management
Drug Therapy:
Levothyroxine (Synthroid)
Thyroglobulin (Proloid)
Dessicated thyroid
Liothyronine (Cytomel)
Myxedema coma is a medical emergency:
IV thyroid hormones
Correction of hypothermina
Maintenance of vital function
Treatment of precipitating cause
Nursing Intervention
Monitor strictly V/S & I&O, daily weights; observe for edema & signs
of cardiovascular complication & to determine presence of myxedema
coma
Administer thyroid hormone replacement therapy as ordered &
monitor effects:
a. Observe signs of thyrotoxicosis:
Tachycardia & palpitation
N/V
Diarrhea
Sweating
Tremors

 Agitation
Dyspnea
b. Increase dosage gradually, especially in clients with cardiac
complication
3. Provide comfortable and warm environment: due to cold intolerance
4. Provide a low calorie diet
5. Avoid the use of sedatives; reduce the dose of any sedatives,
narcotics, or anesthetic agent by half as ordered
6. Provide meticulous skin care: to prevent skin breakdown
7. Increase fluid & food high in fiber: to prevent constipation; administer
stool softener as ordered
8. Observe for signs of myxedema coma; provide appropriate nursing
care
a. Administer medication as ordered
b. Maintain vital functions:
Correct hypothermia
Maintain adequate ventilation
9. Myxedema coma:
A complication of hypothyroidism & an emergency case
A severe form of hypothyroidism is characterized by:
Severe hypotension
Bradycardia
Bradypnea
Hypoventilation
Hyponatremia
Hypoglycemia
Hypothermia
Leading to progressive stupor and coma
Nursing Management for Myxedema Coma
1. Assist in mechanical ventilation
2. Administer thyroid hormones as ordered
3. Administer IVF replacement isotonic fluid solution as ordered /
Force fluids
10. Provide client health teaching and discharge planning concerning:
a. Thyroid hormone replacement
b. Importance of regular follow-up care
c. Need in additional protection in cold weather
d. Measures to prevent constipation
e. Avoid precipitating factors leading to myxedema coma &
hypovolemic shock
f. Stress & infection
g. Use of anesthetics, narcotics, and sedatives

Hyperthyroidism
Secretion of excessive amounts of thyroid hormone in the blood causes an
increase in metabolic process
Increase in T3 and T4
Graves Disease or Thyrotoxicosis
Increase in all V/S except wt & menses

1.
2.

3.
4.

Predisposing Factors
More often seen in women between ages 30 & 50
Autoimmune: involves release of long acting thyroid stimulator
causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of
dehydration among infants)
Excessive iodine intake
Related to hyperplasia (increase size of TG)

S/sx
Increase appetite (hyperphagia): but there is weight loss
Heat intolerance
Weight loss
Diarrhea: increase motility
Increased in all V/S: except wt & menses
a. Tachycardia
b. Increase systolic BP
c. Palpitation
6. Warm smooth skin
7. Fine soft hair
8. Pliable nails
9. CNS involvement
a. Irritability & agitation
b. Restlessness
c. Tremors
d. Insomnia
e. Hallucinations
f. Sweating
g. Hyperactive movement
10. Goiter
11. PS: Exopthalmus (protrusion of eyeballs)
12. Amenorrhea
1.
2.
3.
4.
5.

1.

Dx
Serum T3 and T4: is increased

2.
3.

1.

2.

3.

RAIU (Radio Active Iodine Uptake): is increased

Thyroid Scan: reveals an enlarged thyroid gland
Medical Management
Drug Therap:
a. Anti-thyroid drugs: Propylthiouracil (PTU) & methimazole
(Tapazole): blocke synthesis of thyroid hormone; toxic effect
include agranulocytosis
b. Adrenergic Blocking Agent: Propranolol (Inderal): used to
decrease sympathetic activity & alleviate symptoms such as
tachycardia
Radioactive Iodine Therapy
a. Radioactive isotope of iodine (ex. 131I): given to destroy the
thyroid gland, thereby decreasing production of thyroid hormone
b. Used in middle-aged or older clients who are resistant to, or
develop toxicity from drug therapy
c. Hypothyroidism is a potential complication
Surgery: Thyroidectomy performed in younger client for whom drug
therapy has not been effective

Nursing Intervention
Monitor strictly V/s & I&O, daily weight
Administer anti-thyroid medications as ordered:
a. Propylthiouracil (PTU)
b. Methimazole (Tapazole)
3. Provide for period of uninterrupted rest:
a. Assign a private room away from excessive activity
b. Administer medication to promote sleep as ordered
4. Provide comfortable and cold environment
5. Minimized stress in the environment
6. Encourage quiet, relaxing diversional activities
7. Provide dietary intake that is high in CHO, CHON, calories, vitamin &
minerals with supplemental feeding between meals & at bedtime;
omit stimulant
8. Observe for & prevent complication
a. Exophthalmos: protects eyes with dark glasses & artificial tears as
ordered
b. Thyroid Storm
9. Provide meticulous skin care
10. Maintain side rails
11. Provide bilateral eye patch to prevent drying of the eyes
12. Assist in surgical procedures subtotal Thyroidectomy:
1.
2.

13. Provide client teaching & discharge planning concerning:

a. Need to recognized & report S/sx of agranulocytosis (fever, sore
throat, skin rash): if taking anti-thyroid drugs
b. S/sx of hyperthyroidism & hypothyroidism
Thyroid Storm
Uncontrolled & potentially life-threatening hyperthyroidism caused by
sudden & excessive release of thyroid hormone into the bloodstream

1.
2.
3.

Precipitating Factors
Stress
Infection
unprepared thyroid surgery

1.
2.
3.
4.
5.
6.
7.
8.

S/sx
Apprehension
Restlessness
Extremely high temp (up to 106 F / 40.7 C)
Tahchycardia
HF
Respiratory Distress
Delirium
Coma

1.
2.
3.

Nursing Intervention
Maintain patent airway & adequate ventilation; administer O2 as
ordered
Administer IV therapy as ordered
Administer medication as ordered:
a. Anti-thyroid drugs
b. Corticosteroids
c. Sedatives
d. Cardiac Drugs

Thyroidectomy
Partial or total removal of thyroid gland
Indication:
Subtotal Thyroidectomy: hyperthyroidism
Total Thyroidectomy: thyroid cancer
Nursing Intervention Pre-op

1.

2.
3.

Ensure that the client is adequately prepared for surgery

a. Cardiac status is normal
b. Weight & nutritional status is normal
Administer anti-thyroid drugs as ordered: to suppressed the
production of thyroid hormone & to prevent thyroid storm
Administer iodine preparation Lugols Solution (SSKI) or Potassium
Iodide Solution: to decrease vascularity of the thyroid gland & to
prevent hemorrhage.
8.

1.
2.
3.
4.

5.

6.

7.

Nursing Intervention Post-Op

Monitor V/S & I&O
Check dressing for signs of hemorrhage: check for wetness behind the
neck
Place client in semi-fowlers position & support head with pillow
Observe for respiratory distress secondary to hemorrhage, edema of
glottis, laryngeal nerve damage, or tetany: keep tracheostomy set, O2
& suction nearby
Assess for signs of tetany: due to hypocalcemia: due to secondary
accidental removal of parathyroid glands: keep Calcium Gluconate
available:
Watch out for accidental removal of parathyroid which may lead
to hypocalcemia (tetany)
Classic S/sx of Tetany
Positive trousseus sign
Positive chvostek sign
Observe for arrhythmia, seizure: give Calcium Gluconate IV slowly
as ordered
Ecourage clients voice to rest:
a. Some hoarseness is common
b. Check every 30-60 min for extreme hoarseness or any
accompanying respiratory distress
Observe for signs of thyroid storm / thyrotoxicosis: due to release of
excessive amount of thyroid hormone during surgery
Agitation

TRIAD SIGNS

9.
10.

11.
12.

13.
14.

15.

Hyperthermia
Tachycardia
Administer medications as ordered:
Anti Pyretics
Beta-blockers
Monitor strictly vital signs, input and output and neuro check.
Maintain side rails
Offer TSB
Administer IV fluids as ordered: until the client is tolerating fluids by
mouth
Administer analgesics as ordered: for incisional pain
Relieve discomfort from sore throat:
a. Cool mist humidifier to thin secretions
b. Administer analgesic throat lozenges before meals prn as ordered
Encourage coughing & deep breathing every hour
Assist the client with ambulation: instruct the client to place the hands
behind the neck: to decrease stress on suture line if added support is
necessary
Hormonal replacement therapy for lifetime
Watch out for accidental laryngeal damage which may lead to
hoarseness of voice: encourage client to talk/speak immediately after
operation and notify physician
Provide client teaching& discharge planning concerning:
a. S/sx of hyperthyroidism & hypothyroidism
b. Self administration of thyroid hormone: if total thyroidectomy is
performed
c. Application of lubricant to the incision once suture is removed
d. Perform ROM neck exercise 3-4 times a day
e. Importance of follow up care with periodic serum calcium level

Hypoparathyroidism
Disorder characterized by hypocalcemia resulting from a deficiency of
parathormone (PTH) production
Decrease secretion of parathormone: leading to hypocalcemia: resulting to
hyperphospatemia
If calcium decreases phosphate increases

1.
2.
3.

Predisposing Factors
May be hereditary
Idiopathic
Caused by accidental damage to or removal of parathyroid gland
during thyroidectomy surgery

4.

1.

2.

Oral calcium preparation: Calcium Gluconate, Calcium

Lactate, Calcium Carbonate (Os-Cal)
Large dose of vitamin D (Calciferol): to help absorption of
calcium

Atrophy of parathyroid gland due to: inflammation, tumor, trauma

S/sx
Acute hypocalcemia (tetany)
a. Paresthesia: tingling sensation of finger & around lip
b. Muscle spasm
c. laryngospasm/broncospasm
d. Dysphagia
e. Seizure: feared complications
f. Cardiac arrhythmia: feared complications
g. Numbness
h. Positive trousseus sign: carpopedal spasm
i. Positive chvostek sign
Chronic hypocalcemia (tetany)
a. Fatigue
b. Weakness
c. Muscle cramps
d. Personality changes
e. Irritability
f. Memory impairment
g. Agitation
h. Dry scaly skin
i. Hair loss
j. Loss of tooth enamel
k. Tremors
l. Cardiac arrhythmias
m. Cataract formation
n. Photophobia
o. Anorexia
p. N/V

CHOLECALCIFEROL ARE DERIVED FROM

Drug
Sunlight (Calcitriol)

Diet (Calcidiol)

Phosphate Binder: Aluminum Hydroxide Gel (Amphogel) or

aluminum carbonate gel, basic (basaljel): to decrease
phosphate levels
ANTACID
A.A.C
Aluminum
Magnesium
Containing
Antacids

MAD

Containing
Antacids

Aluminum
Hydroxide
Gel
Side Effect: Constipation

Side Effect:

Diarrhea
1.
2.
3.
4.

Diagnostic Procedures
Serum Calcium level: decreased (normal value: 8.5 11 mg/100 ml)
Serum Phosphate level: increased (normal value: 2.5 4.5 mg/100 ml)
Skeletal X-ray of long bones: reveals a increased in bone density
CT Scan: reveals degeneration of basal ganglia

2.
3.
4.
5.
6.

1.

Nursing Management
Administer medications as ordered such as:
a. Acute Tetany: Calcium Gluconate slow IV drip as ordered
b. Chronic Tetany:

7.

8.

Institute seizure & safety precaution

Provide quite environment free from excessive stimuli
Avoid precipitating stimulus such as glaring lights and noise
Monitor signs of hoarseness or stridor; check for signs for Chvosteks
& Trousseaus sign
Keep emergency equipment (tracheostomy set, injectable Calcium
Gluconate) at bedside: for presence of laryngospasm
For tetany or generalized muscle cramp: may use rebreathing bag or
paper bag to produce mild respiratory acidosis: to promote increase
ionized Ca levels
Monitor serum calcium & phosphate level

9. Provide high-calcium & low-phosphorus diet

10. Provide client teaching & discharge planning concerning:
a. Medication regimen: oral calcium preparation & vit D to be taken
with meal to increase absorption
b. Need to recognized & report S/sx of hypo/hypercalcemia
c. Importance of follow-up care with periodic serum calcium level
d. Prevent complications
e. Hormonal replacement therapy for lifetime
Hyperparathyroidism
Increase secretion of PTH that results in an altered state of calcium,
phosphate & bone metabolism
Decrease parathormone
Hypercalcemia: bone demineralization leading to bone fracture (calcium is
stored 99% in bone and 1% blood)
Kidney stones

1.
2.
3.

Predisposing Factors
Most commonly affects women between ages 35 & 65
Primary Hyperparathyroidism: caused by tumor & hyperplasia of
parathyroid gland
Secondary Hyperparathyroidism: cause by compensatory over
secretion of PTH in response to hypocalcemia from:
a. Children: Ricketts
b. Adults: Osteomalacia
c. Chronic renal disease
d. Malabsorption syndrome

6.

S/sx
Bone pain (especially at back); Bone demineralization; Pathologic
fracture
Kidney stones; Renal colic; Polyuria; Polydipsia; Cool moist skin
Anorexia; N/V; Gastric Ulcer; Constipation
Muscle weakness; Fatigue
Irritability / Agitation; Personality changes; Depression; Memory
impairment
Cardiac arrhythmias; HPN

1.
2.
3.

Dx
Serum Calcium: is increased
Serum Phosphate: is decreased
Skeletal X-ray of long bones: reveals bone demineralization

1.
2.
3.
4.
5.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Nursing Intervention
Administer IV infusions of normal saline solution & give diuretics as
ordered:
Monitor I&O & observe fluid overload & electrolytes imbalance
Assist client with self care: Provide careful handling, Moving,
Ambulation: to prevent pathologic fracture
Monitor V/S: report irregularities
Force fluids 2000-3000 L/day: to prevent kidney stones
Provide acid-ash juices (ex. Cranberry, orange juice): to acidify urine &
prevent bacterial growth
Strain urine: using gauze pad: for stone analysis
Provide low-calcium & high-phosphorus diet
Provide warm sitz bath: for comfort
Administer medications as ordered: Morphine Sulfate (Demerol)
Maintain side rails
Assist in surgical procedure: Parathyroidectomy
Provide client teaching & discharge planning concerning:
a. Need to engage in progressive ambulatory activities
b. Increase fluid intake
c. Use of calcium preparation & importance of high-calcium diet
following a parathyroidectomy
d. Prevent complications: renal failure
e. Hormonal replacement therapy for lifetime
f. Importance of follow up care

Addisons Disease
Primary adrenocortical insufficiency; hypofunction of the adrenal cortex
causes decrease secretion of the mineralcorticoids, glucocorticoids, & sex
hormones
Hyposecretion of adrenocortical hormone leading to:
Metabolic disturbance: Sugar
Fluid and electrolyte imbalance: Na, H2O, K
Deficiency of neuromascular function: Salt, Sex

1.

Predisposing Factors
Relatively rare disease caused by:
Idiopathic atrophy of the adrenal cortex: due to an autoimmune
process
Destruction of the gland secondary to TB or fungal infections
S/sx

1.
2.
3.

5.
6.
7.
8.
9.

Fatigue, Muscle weakness

Anorexia, N/V, abdominal pain, weight loss
History of hypoglycemic reaction / Hypoglycemia: tremors,
tachycardia, irritability, restlessness, extreme fatigue, diaphoresis,
depression
Hyponatremia: hypotension, signs of dehydration, weight loss, weak
pulse
Decrease tolerance to stress
Hyperkalemia: agitation, diarrhea, arrhythmia
Decrease libido
Loss of pubic and axillary hair
Bronze like skin pigmentation

1.
2.
3.
4.

Dx
FBS: is decreased (normal value: 80 100 mg/dl)
Plasma Cortisol: is decreased
Serum Sodium: is decrease (normal value: 135 145 meq/L)
Serum Potassium: is increased (normal value: 3.5 4.5 meq/L)

4.

1.

Nursing Intervention
Administer hormone replacement therapy as ordered:
a. Glucocorticoids: stimulate diurnal rhythm of cortisol release, give
2/3 of dose in early morning & 1/3 of dose in afternoon
Corticosteroids: Dexamethasone (Decadrone)
Hydrocortisone: Cortisone (Prednisone)
b. Mineralocorticoids:
Fludrocortisone Acetate (Florinef)
Nursing Management when giving steroids
Instruct client to take 2/3 dose in the morning and 1/3 dose in the
afternoon to mimic the normal diurnal rhythm
2. Taper dose (withdraw gradually from drug)
3. Monitor side effects:
Hypertension
Edema
Hirsutism
Increase susceptibility to infection
Moon face appearance
Monitor V/S
Decrease stress in the environment
Prevent exposure to infection
Provide rest period: prevent fatigue
1.

2.
3.
4.
5.

6.
7.

Weight daily
Provide small frequent feeding of diet: decrease in K, increase cal,
CHO, CHON, Na: to prevent hypoglycemia, & hyponatremia & provide
proper nutrition
8. Monitor I&O: to determine presence of addisonian crisis (complication
of addisons disease)
9. Provide meticulous skin care
10. Provide client teaching & discharge planning concerning:
a. Disease process: signs of adrenal insufficiency
b. Use of prescribe medication for lifelong replacement therapy:
never omit medication
c. Need to avoid stress, trauma & infection: notify the physician if
these occurs as medication dosage may need to be adjusted
d. Stress management technique
e. Diet modification
f. Use of salt tablet (if prescribe) or ingestion of salty foods (potato
chips): if experiencing increase sweating
g. Importance of alternating regular exercise with rest periods
h. Avoidance of strenuous exercise especially in hot weather
i. Avoid precipitating factor: leading to addisonian crisis: stress,
infection, sudden withdrawal to steroids
j. Prevent complications: addisonian crisis, hypovolemic shock
k. Importance of follow up care
Addisonian Crisis
Severe exacerbation of addisons diseasecaused by acute adrenal
insufficiency

1.
2.
3.
4.
5.
6.

1.
2.

Predisposing Factors
Strenuous activity
Stress
Trauma
Infection
Failure to take prescribe medicine
Iatrogenic:
Surgery of pituitary gland or adrenal gland
Rapid withdrawal of exogenous steroids in a client on longterm steroid therapy
S/sx
Generalized muscle weakness
Severe hypotension

3.
4.

Hypovolemic shock: vascular collapse

Hyponatremia: leading to progressive stupor and coma

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Nursing Intervention
Assist in mechanical ventilation
Administer IV fluids (5% dextrose in saline, plasma) as ordered: to
treat vascular collapse
3. Administer IV glucocorticoids: Hydrocortisone (Solu-Cortef) &
vasopressors as ordered
4. Force fluids
5. If crisis precipitate by infection: administer antibiotics as ordered
6. Maintain strict bed rest & eliminate all forms of stressful stimuli
7. Monitor V/S, I&O & daily weight
8. Protect client from infection
9. Provide client teaching & discharge planning concerning: same as
addisons disease
Muscle weakness
Fatigue
Obese trunk with thin arms & legs
Muscle wasting
Irritability
Depression
Frequent mood swings
Moon face
Buffalo hump
Pendulous abdomen
Purple striae on trunk
Acne
Thin skin

1.
2.
3.
4.

Dx
FBS: is increased
Plasma Cortisol: is increased
Serum Sodium: is increased
Serum Potassium: is decreased

Cushing Syndrome
Condition resulting from excessive secretion of corticosteroids, particularly
glucocorticoid cortisol
Hypersecretion of adrenocortical hormones

1.
2.

3.
4.
5.

Predisposing Factors
Primary Cushings Syndrome: caused by adrenocortical tumors or
hyperplasia
Secondary Cushings Syndrome (also called Cushings disease): caused
by functioning pituitary or nonpituitary neoplasm secreting ACTH,
causing increase secretion of glucocorticoids
Iatrogenic: cause by prolonged use of corticosteroids
Related to hyperplasia of adrenal gland
Increase susceptibility to infections

14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

S/sx
Signs of masculinization in women: menstrual dysfunction, decrease libido
Osteoporosis
Decrease resistance to infection
Hypertension
Edema
Hypernatremia
Weight gain
Hypokalemia
Constipation
U wave upon ECG (T wave hyperkalemia)
Hirsutis
Easy bruising

1.
2.

4.

1.

2.
3.

Nursing Intervention
Maintain muscle tone
a. Provide ROM exercise
b. Assist in ambulation
Prevent accidents fall & provide adequate rest
Protect client from exposure to infection

Maintain skin integrity

a. Provide meticulous skin care
b. Prevent tearing of the skin: use paper tape if necessary
5. Minimize stress in the environment
6. Monitor V/S: observe for hypertension & edema
7. Monitor I&O & daily weight: assess for pitting edema: Measure abdominal
girth: notify physician
8. Provide diet low in Calorie & Na & high in CHON, K, Ca, Vitamin D
9. Monitor urine: for glucose & acetone; administer insulin as ordered
10. Provide psychological support & acceptance
11. Prepare client for hypophysectomy or radiation: if condition is caused by a
pituitary tumor

12. Prepare client for Adrenalectomy: if condition is caused by an adrenal

tumor or hyperplasia
13. Restrict sodium intake
14. Administer medications as ordered: Spironolactone (Aldactone): potassium
sparring diuretics
15. Provide client teaching & discharge planning concerning:
a. Diet modification
b. Importance of adequate rest
c. Need to avoid stress & infection
d. Change in medication regimen (alternate day therapy or reduce
dosage): if caused of condition is prolonged corticosteroid therapy
e. Prevent complications (DM)
f. Hormonal replacement for lifetime: lifetime due to adrenal gland
removal: no more corticosteroid!
g. Importance of follow up care
Diabetes Mellitus (DM)
Represent a heterogenous group of chronic disorders characterized by
hyperglycemia
Hyperglycemia: due to total or partial insulin deficiency or insensitivity of the
cells to insulin
Characterized by disorder in the metabolism of CHO, fats, CHON, as well as
changes in the structure & function of blood vessels
Metabolic disorder characterized by non utilization of carbohydrates, protein
and fat metabolism
Pathophysiology
Lack of insulin causes hyperglycemia (insulin is necessary for the transport of glucose
across the cell membrane) = Hyperglycemia leads to osmitic diuresis as large amounts of
glucose pass through the kidney result polyuria & glycosuria = Diuresis leads to cellular
dehydration & F & E depletion causing polydipsia (excessive thirst) = Polyphagia (hunger
& increase appetite) result from cellular starvation = The body turns to fat & CHON for
energy but in the absence of glucose in the cell fat cannot be completely metabolized &
ketones (intermediate products of fat metabolism) are produced = This leads to
ketonemia, ketonuria (contributes to osmotic diuresis) & metabolic acidosis (ketones are
acid bodies) = Ketone sacts as CNS depressants & can cause coma = Excess loss of F & E

leads to hypovolemia, hypotension, renal failure & decease blood flow to the brain
resulting in coma & death unless treated.
MAIN FOODSTUFF
1. CHO
2. CHON
3. Fats

ANABOLISM
Glucose
Amino Acids
Fatty Acids

CATABOLISM
Glycogen
Nitrogen
Free Fatty Acids
: cholesterol
: ketones

HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria
Cellular starvation: weight loss
Stimulates the appetite / satiety center

Polyuria
Cellular dehydration
Stimulates the thirst

center
(Hypothalamus)
Polyphagia
* liver has glycogen that undergo glycogenesis/glycogenolysis
GLUCONEOGENESIS
Formation of glucose from non-CHO sources
Increase protein formation
Negative Nitrogen balance
Tissue wasting (Cachexia)
INCREASE FAT CATABOLISM

(Hypothalamus)
Polydypsia

Secondary to destruction of beta cells in the islets of langerhans in the

pancreas resulting in little of no insulin production
Non-obese adults
Requires insulin injection
Juvenile onset type (Brittle disease)

1.

Incidence Rate
10% general population has Type I DM

1.
2.
3.
4.
5.

Predisposing Factors
Autoimmune response
Genetics / Hereditary (total destruction of pancreatic cells)
Related to viruses
Drugs: diuretics (Lasix), Steroids, oral contraceptives
Related to carbon tetrachloride toxicity

Free fatty acids

Cholesterol
Atherosclerosis
Hypertension

Ketones
Diabetic Keto Acidosis
Acetone Breath

Kussmauls

Respiration
odor
MI

CVA

Death

1.

Diabetic Coma

Classification Of DM
Type I Insulin-dependent Diabetes Mellitus (IDDM)
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glucosuria
5. Weight loss
6. Fatigue

S/sx
7.
8.
9.
10.
11.

Dx
1.

2.
3.
4.

FBS:
a. A level of 140 mg/dl of greater on at two occasions confirms DM
b. May be normal in Type II DM
Postprandial Blood Sugar: elevated
Oral Glucose Tolerance Test (most sensitve test): elevated
Glycosolated Hemoglobin (hemoglobin A1c): elevated

1.
2.
3.

Medical Management
Insulin therapy
Exercise
Diet:

4.

Anorexia
N/V
Blurring of vision
Increase susceptibility to infection
Delayed / poor wound healing
a. Consistency is imperative to avoid hypoglycemia
b. High-fiber, low-fat diet also recommended
Drug therapy:
a. Insulin:
Short Acting: used in treating ketoacidosis; during surgery,
infection, trauma; management of poorly controlled diabetes; to
supplement long-acting insulins
Intermediate: used for maintenance therapy
Long Acting: used for maintenance therapy in clients who
experience hyperglycemia during the night with intermediateacting insulin

b.

5.

Insulin preparation can consist of mixture of pure pork, pure beef, or

human insulin. Human insulin is the purest insulin & has the lowest
antigenic effect
c. Human Insulin: is recommended for all newly diagnosed Type I & Type
II DM who need short-term insulin therapy; the pregnant client &
diabetic client with insulin allergy or severe insulin resistance
d. Insulin Pumps: externally worn device that closely mimic normal
pancreatic functioning
Exercise: helpful adjunct to therapy as exercise decrease the bodys need
for insulin

Characteristics of Insulin Preparation

Drug
Synonym
Appearance
Compatible Mixed
Rapid Acting
Insulin Injection Regular Ins
Clear
All insulin prep

Onset

Peak

Duration

-1

2-4

6-8

Insulin Zinc
Ultralente Ins
Regular Ins &
suspension,
semilente prep
extended

1.
2.

Intermediate Acting
Isophane Ins
NPH Ins
Regular Ins
injection
injection
Insulin Zinc
Lente Ins
Regular Ins &
Suspension
semilente prep

Cloudy

-1

4-6

12-16

Cloudy

1-1

8-12

18-24

Cloudy

1-1

8-12

18-24

16-20

30-36

Complication
Diabetic Ketoacidosis (DKA)

1.

Incidence Rate
90% of general population has Type II DM

1.
2.

Predisposing Factors
Genetics
Obesity: because obese persons lack insulin receptor binding sites

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

S/sx
Usually asymptomatic
Polyuria
Polydypsia
Polyphagia
Glycosuria
Weight gain / Obesity
Fatigue
Blurred Vision
Increase susceptibility to infection
Delayed / poor wound healing

5.
Long Acting

4-8

Type II Non-insulin-dependent Diabetes Mellitus (NIDDM)

May result to partial deficiency of insulin production &/or an insensitivity of
the cells to insulin
Obese adult over 40 years old
Maturity onset type

except lente
Insulin, Zinc
Semilente Ins
Lente prep
suspension,
prompt

Cloudy

Dx
FBS:
c. A level of 140 mg/dl of greater on at two occasions confirms DM

6.
7.
8.

d. May be normal in Type II DM

Postprandial Blood Sugar: elevated
Oral Glucose Tolerance Test (most sensitve test): elevated
Glycosolated Hemoglobin (hemoglobin A1c): elevated

:Decrease intestinal
absorption of glucose &
improves

1.
2.
3.
4.

5.

6.

Medical Management
Ideally manage by diet & exercise
Oral Hypoglycemic agents or occasionally insulin: if diet & exercise are not
effective in controlling hyperglycemia
Insulin is needed in acute stress: ex. Surgery, infection
Diet: CHO 50%, CHON 30% & Fats 20%
a. Weight loss is important since it decreases insulin resistance
b. High-fiber, low-fat diet also recommended
Drug therapy:
a. Occasional use of insulin
b. Oral hypoglycemic agent:
Used by client who are not controlled by diet & exercise
Increase the ability of islet cells of the pancreas to secret insulin;
may have some effect on cell receptors to decrease resistance to
insulin
Exercise: helpful adjunct to therapy as exercise decrease the bodys need
for insulin

insulin sensitivity
Oral Alpha-glucosidose Inhibitor
Acarbose (Precose)
glucose absorption

Unknown

Unknown

:Delay
&

digestion of CHO,
lowering
blood sugar
Miglitol (Glyset)
Troglitazone (Rezulin)
plasma glucose &

Rapid

2-3
2-3

Unknown

:Reduce
insulin

:Potetiates action of insulin

in
skeletal muscle &
decrease

Oral Hypoglycemic Agent

Drug
Comments
Oral Sulfonylureas
Acetohexamide (Dymelor)
Chlorpropamide (Diabinase)
Glyburide (Micronase, Diabeta)
Oral Biguanides
Metformin (Glucophage)
:Decrease glucose
production in liver

glucose
Onset

Peak

Duration
production in liver

1
1
15 min- 1 hr

4-6
4-6
2-8

12-24
40-60
10-24

1.

1.
2-2.5

10-16
2.

Complications
Hyper Osmolar Non-Ketotic Coma (HONKC)
Nursing Intervention
Administer insulin or oral hypoglycemic agent as ordered: monitor
hypoglycemia especially during period of drug peak action
Provide special diet as ordered:
a. Ensure that the client is eating all meals

If all food is not ingested: provide appropriate substitute according to

the exchange list or give measured amount of orange juice to
substitute for leftover food; provide snack later in the day
3. Monitor urine sugar & acetone (freshly voided specimen)
4. Perform finger sticks to monitor blood glucose level as ordered (more
accurate than urine test)
5. Observe signs of hypo/hyperglycemia
6. Provide meticulous skin care & prevent injury
7. Maintain I&O; weight daily
8. Provide emotional support: assist client in adapting change in lifestyle &
body image
9. Observe for chronic complications & plan of care accordingly:
a. Atherosclerosis: leads to CAD, MI, CVA & Peripheral Vascular Disease
b. Microangiopathy: most commonly affects eyes & kidneys
c. Kidney Disease
Recurrent Pyelonephritis
Diabetic Nephropathy
d. Ocular Disorder
Premature Cataracts
Diabetic Retinopathy
e. Peripheral Neuropathy
Affects PNS & ANS
Cause diarrhea, constipation, neurogenic bladder, impotence,
decrease sweating
10. Provide client teaching & discharge planning concerning:
a. Disease process
b. Diet
Client should be able to plan a meal using exchange lists before
discharge
Emphasize importance of regularity of meals; never skip meals
c. Insulin
How to draw up into syringe
Use insulin at room temp
Gently roll the vial between palms
Draw up insulin using sterile technique
If mixing insulin, draw up clear insulin, before cloudy insulin
Injection technique

b.

d.

e.

f.

g.

Systematically rotate the site: to prevent lipodystrophy:

(hypertrophy or atrophy of tissue)
Insert needle at a 45 (skinny clients) or 90 (fat or obese clients)
degree angle depending on amount of adipose tissue
May store current vial of insulin at room temperature; refrigerate
extra supplies
Somogyis phenomenon: hypoglycemia followed by periods of
hyperglycemia or rebound effect of insulin.
Provide many opportunities for return demonstration
Oral hypoglycemic agent
Stress importance of taking the drug regularly
Avoid alcohol intake while on medication: it can lead to severe
hypoglycemia reaction
Instruct the client to take it with meals: to lessen GIT irritation &
prevent hypoglycemia
Urine testing (not very accurate reflection of blood glucose level)
May be satisfactory for Type II diabetics since they are more stable
Use clinitest, tes-tape, diastix, for glucose testing
Perform test before meals & at bedtime
Use freshly voided specimen
Be consistent in brand of urine test used
Report results in percentage
Report result to physician if results are greater that 1%, especially
if experiencing symptoms of hyperglycemia
Urine testing for ketones should be done by Type I diabetic clients
when there is persistent glycosuria, increase blood glucose level or
if the client is not feeling well (acetest, ketostix)
Blood glucose monitoring
Use for Type I diabetic client: since it gives exact blood glucose
level & also detects hypoglycemia
Instruct client in finger stick technique: use of monitor device (if
used), & recording & utilization of test results
General care
Perform good oral hygiene & have regular dental exam
Have regular eye exam
Care for sick days (ex. Cold or flu)

h.

i.

j.

Do not omit insulin or oral hypoglycemic agent: since infection

causes increase blood sugar
Notify physician
Monitor urine or blood glucose level & urine ketones
frequently
If N/V occurs: sip on clear liquid with simple sugar
Foot care
Wash foot with mild soap & water & pat dry
Apply lanolin lotion to feet: to prevent drying & cracking
Cut toenail straight across
Avoid constrictive garments such as garters
Wear clean, absorbent socks (cotton or wool)
Purchase properly fitting shoes & break new shoes in gradually
Never go barefoot
Inspect foot daily & notify physician: if cut, blister, or break in skin
occurs
Exercise
Undertake regular exercise; avoid sporadic, vigorous exercise
Food intake may need to be increased before exercising
Exercise is best performed after meals when the blood sugar is
rising
Complication

1.
2.
3.
4.
5.
6.
7.
8.
9.

Polyuria
Polydipsia
Polyphagia
Glucosuria
Weight loss
Anorexia
N/V
Abdominal pain
Skin warm, dry & flushed

1.

Dx
FBS: is increased

k.

Learn to recognized S/sx of hypo/hyperglycemia: for hypoglycemia

(cold and clammy skin), for hyperglycemia (dry and warm skin):
administer simple sugars
Eat candy or drink orange juice with sugar added for insulin
reaction (hypoglycemia)
Monitor signs of DKA & HONKC
Need to wear a Medic-Alert bracelet

Diabetic Ketoacidosis (DKA)

Acute complication of DM characterized by hyperglycemia & accumulation of
ketones in the body: cause metabolic acidosis
Acute complication of Type I DM: due to severe hyperglycemia leading to severe
CNS depression
Occurs in insulin-dependent diabetic clients
Onset slow: maybe hours to days

1.
2.
3.
4.
5.
6.

Predisposing Factors
Undiagnosed DM
Neglect to treatment
Infection
cardiovascular disorder
Hyperglycemia
Physical & Emotional Stress: number one precipitating factor

10.
11.
12.
13.
14.
15.
16.
17.

S/sx
Dry mucous membrane; soft eyeballs
Blurring of vision
PS: Acetone breath odor
PS: Kussmauls Respiration (rapid shallow breathing) or tachypnea
Alteration in LOC
Hypotension
Tachycardia
CNS depression leading to coma

2.
3.
4.

Serum glucose & ketones level: elevated

BUN (normal value: 10 20): elevated: due to dehydration
Creatinine (normal value: .8 1): elevated: due to dehydration

5.
6.
7.
8.

Hct (normal value: female 36 42, male 42 48): elevated: due to

dehydration
Serum Na: decrease
Serum K: maybe normal or elevated at first
ABG: metabolic acidosis with compensatory respiratory alkalosis

1.
2.
3.
4.
5.
6.
7.
8.
9.

Nursing Intervention
Maintain patent airway
Assist in mechanical ventilation
Maintain F&E balance:
a. Administer IV therapy as ordered:
Normal saline (0.9% NaCl), followed by hypotonic solutions (.45%
NaCl) sodium chloride: to counteract dehydration & shock
When blood sugar drops to 250 mg/dl: may add 5% dextrose to IV
Potassium will be added: when the urine output is adequate
b. Observe for F&E imbalance, especially fluid overload, hyperkalemia &
hypokalemia
Administer insulin as ordered: regular acting insulin/rapid acting insulin
a. Regular insulin IV (drip or push) & / or subcutaneously (SC)
b. If given IV drip: give small amount of albumin since insulin adheres to
IV tubing
c. Monitor blood glucose level frequently
Administer medications as ordered:
a. Sodium Bicarbonate: to counteract acidosis
b. Antibiotics: to prevent infection
Polyuria
Polydipsia
Polyphagia
Glucosuria
Weight loss
Anorexia
N/V
Abdominal pain
Skin warm, dry & flushed

1.

Dx
Blood glucose level: extremely elevated

1.
2.
3.

4.

5.

6.
7.
8.
9.
10.

Check urine output every hour

Monitor V/S, I&O & blood sugar levels
Assist client with self-care
Provide care for unconscious client if in a coma
Discuss with client the reasons ketosis developed & provide additional
diabetic teaching if indicated

Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC)

Characterized by hyperglycemia & a hyperosmolar state without ketosis
Occurs in non-insulin-dependent diabetic or non-diabetic persons (typically
elderly clients)
Hyperosmolar: increase osmolarity (severe dehydration)
Non-ketotic: absence of lypolysis (no ketones)

1.
2.
3.
4.
5.
6.
7.

Predisposing Factors
Undiagnosed diabetes
Infection or other stress
Certain medications (ex. dilantin, thiazide, diuretics)
Dialysis
Hyperalimentation
Major burns
Pancreatic disease
S/sx

10.
11.
12.
13.
14.
15.
16.
17.

Dry mucous membrane; soft eyeballs

Blurring of vision
Hypotension
Tachycardia
Headache and dizziness
Restlessness
Seizure activity
Alteration / Decrease LOC: diabetic coma

2.
3.
4.

BUN: elevated: due to dehydration

Creatinine: elevted: due to dehydration
Hct: elevated: due to dehydration

5.

Urine: (+) for glucose

Nursing Intervention
Maintain patent airway
Assist in mechanical ventilation
Maintain F&E balance:
a. Administer IV therapy as ordered:
Normal saline (0.9% NaCl), followed by hypotonic solutions (.45%
NaCl) sodium chloride: to counteract dehydration & shock
When blood sugar drops to 250 mg/dl: may add 5% dextrose to IV
Potassium will be added: when the urine output is adequate
b. Observe for F&E imbalance, especially fluid overload, hyperkalemia &
hypokalemia
4. Administer insulin as ordered:
a. Regular insulin IV (drip or push) & / or subcutaneously (SC)
b. If given IV drip: give small amount of albumin since insulin adheres to
IV tubing
c. Monitor blood glucose level frequently
5. Administer medications as ordered:
a. Antibiotics: to prevent infection
6. Check urine output every hour
7. Monitor V/S, I&O & blood sugar levels
8. Assist client with self-care
9. Provide care for unconscious client if in a coma
10. Discuss with client the reasons ketosis developed & provide additional
diabetic teaching if indicated

HEMATOLOGICAL SYSTEM

1.
2.
3.

Overview of Anatomy & Physiology of Hematologic System

The structure of the hematological of hematopoietic system includes the blood,
blood vessels, & blood forming organs (bone marrow, spleen, liver, lymph
nodes, & thymus gland).
The major function of blood: is to carry necessary materials (O2, nutrients) to
cells & remove CO2 & metabolic waste products.
The hematologic system also plays an important role in hormone transport, the
inflammatory & immune responses, temperature regulation, F&E balance &
acid-base balance.

I. Blood

II. Blood Vessels

III. Blood Forming

1. Arteries
2. Veins
3. Capillaries

1. Liver
2. Thymus
3. Spleen
4. Lymphoid

Organs

55% Plasma
(Fluid)
Organ
Serum

45% Formed
cellular elements

Plasma CHON
(formed in liver)
1. Albumin
2. Globulins
3. Prothrombin and Fibrinogen

5. Lymph Nodes
6. Bone Marrow

Bone Marrow
Contained inside all bones, occupies interior of spongy bones & center of long
bones; collectively one of the largest organs in the body (4-5% of total body
weight)
Primary function is Hematopoiesis: the formation of blood cells
All blood cells start as stem cells in the bone marrow; these mature into
different, specific types of cells, collectively referred to as Formed Elements of
Blood or Blood Components:
1. Erythrocytes
2. Leukocytes
3. Thrombocytes
Two kinds of Bone Marrow:
1. Red Marrow
Carries out hematopoiesis; production site of erythroid, myeloid, &
thrombocytic component of blood; one source of lymphocytes &
macrophages
Found in the ribs, vertebral column, other flat bones

2.

Blood

Yellow Marrow
Red marrow that has changed to fats; found in long bone; does not
contribute to hematopoiesis

Composed of plasma (55%) & cellular components (45%)

Hematocrit
1. Reflects portion of blood composed of red blood cells
2. Centrifugation of blood results in separation into top layer of plasma,
middle layer of leukocytes & platelets, & bottom layer of erythrocytes
3. Majority of formed elements is erythrocytes; volume of leukocytes &
platelets is negligible
Distribution
1. 1300 ml in pulmonary circulation
a. 400 ml arterial
b. 60 ml capillary
c. 840 ml venous
2. 3000 ml in systemic circulation
a. 550 ml arterial
b. 300 ml capillary
c. 2150 ml venous

Plasma
Liquid part of the blood; yellow in color because of pigments
Consists of serum (liquid portion of plasma) & fibrinogen
Contains plasma CHON such as albumin, serum, globulins, fibrinogen,
prothrombin, plasminogen
1. Albumin
Largest & numerous plasma CHON
Involved in regulation of intravascular plasma volume
Maintains osmotic pressure: preventing edema
2. Serum Globulins
a. Alpha: role in transport steroids, lipids, bilirubin & hormones
b. Beta: role in transport of iron & copper
c. Gamma: role in immune response, function of antibodies
3. Fibrinogens, Prothrombin, Plasminogens: clotting factors to prevent
bleeding

Cellular Components or Formed Elements

1. Erythrocytes (RBC)
a. Normal value: 4 6 million/mm3
b. No nucleus, Biconcave shape discs, Chiefly sac of hemoglobin
c. Call membrane is highly diffusible to O2 & CO2
d. Responsible for O2 transport via hemoglobin (Hgb)
Two portion: iron carried on heme portion; second portion is CHON
Normal blood contains 12-18 g Hgb/100 ml blood; higher (14-18 g) in
men than in women (12-14 g)
e. Production
Start in bone marrow as stem cells, release as reticulocytes (immature
cells), mature into erythrocytes
Erythropoietin stimulates differentiation; produced by kidneys &
stimulated by hypoxia
Iron, vitamin B12, folic acid, pyridoxine vitamin B6, & other factors
required for erythropoiesis
f. Hemolysis (Destruction)
Normal life span of RBC is 80 120 days and is killed in red pulp of
spleen
Immature RBCs destroyed in either bone marrow or other
reticuloendothelial organs (blood, connective tissue, spleen, liver, lungs
and lymph nodes)
Mature cells remove chiefly by liver and spleen
Bilirubin (yellow pigment): by product of Hgb (red pigment) released
when RBCs destroyed, excreted in bile
Biliverdin (green pigment)
Hemosiderin (golden brown pigment)
Iron: feed from Hgb during bilirubin formation; transported to bone
marrow via transferring and and reclaimed for new Hgb production
Premature destruction: may be caused by RBC membrane
abnormalities, Hgb abnormalities, extrinsic physical factors (such as the
enzyme defects found in G6PD)
Normal age RBCs may be destroyed by gross damage as in trauma or
extravascular hemolysis (in spleen, liver, bone marrow)
g. Hemoglobin: normal value female 12 14 gms% male 14 16 gms%

h.
i.

2.

Hematocrit red cell percentage in wholeblood (normal value: female 36

42% male 42 48%)
Substances needed for maturation of RBC:
a. Folic acid
b. Iron
c. Vitamin c
d. Vitamin b12 (Cyanocobalamin)
e. Vitamin b6 (Pyridoxine)
f. Intrinsic factor

Leukocytes (WBC)
a. Normal value: 5000 10000/mm3
b. Granulocytes and mononuclear cells: involved in the protection from
bacteria and other foreign substances
c. Granulocytes:
Polymorphonuclear Neutrophils
- 60 70% of WBC
- Involved in short term phagocytosis for acute inflammation
- Mature neutrophils: polymorphonuclear leukocytes
- Immature neutrophils: band cells (bacterial infection usually
produces increased numbers of band cells)
Polymorphonuclear Basophils
- For parasite infections
- Responsible for the release of chemical mediation for
inflammation
- Involved in prevention of clotting in microcirculation and allergic
reactions
Polymorphonuclear Eosinophils
- Involved in phagocytosis and allergic reaction
Eosinophils & Basophils: are reservoirs of histamine, serotonin &
heparin
d. Non Granulocytes
Mononuclear cells: large nucleated cells
a. Monocytes:
Involved in long-term phagocytosis for chronic inflammation
Play a role in immune response

b.

Macrophage in blood
Largest WBC
Produced by bone marrow: give rise to histiocytes (kupffer
cells of liver), macrophages & other components of
reticuloendothelial system
Lymphocytes: immune cells; produce substances against foreign
cells; produced primarily in lymph tissue (B cells) & thymus (T cells)

Lymphocytes

B-cell
- bone marrow
for immunity

T-cell
- thymus

Natural killer cell

- anti-viral and anti-tumor property

HIV
c.

Thrombocytes (Platelets)
Normal value: 150,000 450,000/mm3
Normal life span of platelet is 9 12 days
Fragments of megakaryocytes formed in bone marrow
Production regulated by thrombopoietin
Essential factors in coagulation via adhesion, aggregation &
plug formation
Release substances involved in coagulation
Promotes hemostasis (prevention of blood loss)
Consist of immature or baby platelets or megakaryocytes
which is the target of dengue virus
Signs of Platelet Dysfunction
1. Petechiae
2. Echhymosis
3. Oozing of blood from venipunctured site

Blood Groups
Erythrocytes carry antigens, which determine the different blood group

1.

2.

Blood-typing system are based on the many possible antigens, but the most
important are the antigens of the ABO & Rh blood groups because they are
most likely to be involved in transfusion reactions
ABO Typing
a. Antigens of systems are labeled A & B
b. Absence of both antigens results in type O blood
c. Presence of both antigen is type AB
d. Presence of either type A or B results in type A & type B, respectively
e. Type O: universal donor
f. Antibodies are automatically formed against ABO antigens not on persons
own RBC
Rh Typing
a. Identifies presence or absence of Rh antigens (Rh + or Rh -)
b. Anti-Rh antibodies not automatically formed in Rh (-) persons, but if Rh (+)
blood is given, antibody formation starts & second exposure to Rh antigen
will trigger a transfusion reaction
c. Important for Rh (-) woman carrying Rh (+) baby; 1st pregnancy not
affected, but subsequent pregnancy with an Rh (+) baby, mothers
antibodies attack babys RBC

Complication of Blood Transfusion

Type
Causes
Mechanism
Intervention
Hemolytic
ABO
Antibodies in
Stop transfusion.
Incompatibility; recipient plasma
continue saline IV
Rh
react w/ antigen
send blood unit &
Incompatibility; in donor cells.
client blood
Use of dextrose Agglutinated cell
sample to lab.
solutions;
block capillary
Watch for

Occurrence

S/sx

Acute:

Headache,

first 5 min

lumbar or

after completion sternal pain,

of transfusion

diarrhea, fever,
chills, flushing,

Delayed:

heat along vein,

Wide temp
blood flow to
days to 2
hemoglobinuria.
fluctuation
organs.
weeks after
Treat or prevent
Hemolysis (Hgb
shock, DIC, &
into plasma &
renal shutdown
urine)

restlessness,
anemia, jaundice,
dyspnea, signs
of shock, renal
shutdown, DIC

Complication of Blood Transfusion

Type
Causes
Mechanism
Intervention

Occurrence

S/sx

Allergic

Immune

Within 30 min

Uticaria, larygeal

sensitivity to

start of

edema, wheezing

foreign serum

transfusion

dyspnea,

Transfer of an
Stop transfusion.
antigen &
Administer
antibody from
antihistamine &
donor to
or epinephrine.
recipient;
Treat
Allergic donor
life-threatening

CHON

bronchospasm,
headache,
anaphylaxis

reaction
_________________________________________________________________________
______________
Pyrogenic
Recipient
Leukocytes
Within 15-90
Fever, chills,
Stop transfusion.
possesses
agglutination
min after
flushing,
Treat temp.
antibodies
bacterial
initiation of
palpitation,
Transfuse with

directed against organism

transfusion
tachycardia,
leukocytes-poor
WBC; bacterial
occasional
blood of washed
contamination;
lumbar pain
RBC.
Multitransfused
Administer
client;
antibiotics prn
multiparous
client
_________________________________________________________________________
______________
Circulatory
Too rapid
Fluid volume
During & after Dyspnea,
Slow infusion rate
Overload
infusion in
overload
transfusion
increase BP,
Used packed cells
Susceptible
tachycardia,
instead of whole
Client
orthopnea,
blood.
cyanosis, anxiety
Monitor CVP
t
hrough a
separate line.
_________________________________________________________________________
______________
Air Embolism
Blood given
Bolus of air
Anytime
Dyspnea,
Clamp tubing.
under air
blocks pulmonary
increase pulse,
Turn client on
pressure
artery outflow
wheezing, chest
left side
following severe
pain, decrease BP,

blood loss
ThromboUsed of large
Assess for signs
cytopenia
amount of
of bleeding.
banked blood
Initiate bleeding

apprehension
Abnormal

Platelets

When large

deteriorate

amount of blood bleeding

rapidly in stored given over 24 hr

blood

precautions.
Use fresh blood.
_________________________________________________________________________
______________
Citrate
Large amount
Citrate binds
After large
Neuromascular
Monitor/treat
Intoxication
of citrated blood ionic calcium
amount of
irritability
hypocalcemia.
in client with
banked blood
Bleeding due to
Avoid large
decrease liver
decrease calcium
amounts of
function
citrated blood.
Monitor liver fxn
_________________________________________________________________________
______________
Hyperkalemia
Potassium level Release of
In client with
Nausea, colic,
Administer blood
increase in
potassium into renal
diarrhea, muscle
less than 5-7
stored blood
plasma with
insufficiency
spasm, ECG
days old in client
red cell lysis
changes (tall
with impaired
peaked T-waves,
potassium

short Q-T

excretion
segments)
Blood Coagulation
Conversion of fluid blood into a solid clot to reduce blood loss when blood
vessels are ruptured

System that Initiating Clotting

1. Intrinsic System: initiated by contact activation following endothelial injury
(intrinsic to vessel itself)
a. Factor XII: initiate as contact made between damaged vessel & plasma
CHON
b. Factors VIII, IX & XI activated
2. Extrinsic System:
a. Initiated by tissue thromboplastins released from injured vessels
(extrinsic to vessel)
b. Factor VII activated

Common Pathways: activated by either intrinsic or extrinsic pathways

1. Platelet factor 3 (PF3) & calcium react with factor X & V
2. Prothrombin converted to thrombin via thromboplastin
3. Thrombin acts on fibrinogens, forming soluble fibrin
4. Soluble fibrin polymerized by factor XIII to produce a stable, insoluble fibrin clot
Clot Resolution: takes place via fibrinolytic system by plasmin & proteolytic enzymes;
clots dissolves as tissue repairs.
Spleen
Largest Lymphatic Organ: functions as blood filtration system & reservoir
Vascular bean shape; lies beneath the diaphragm, behind & to the left of the
stomach; composed of fibrous tissue capsule surrounding a network of fiber
Contains two types of pulp:
a. Red Pulp: located between the fibrous strands, composed of RBC, WBC &
macrophages
b. White Pulp: scattered throughout the red pulp, produces lymphocytes &
sequesters lymphocytes, macrophages, & antigens

1%-2% of red cell mass or 200 ml blood/minute stored in the spleen; blood
comes via splenic artery to the pulp for cleansing, then passes into splenic
venules that are lined with phagocytic cells & finally to the splenic vein to the
liver.
Important hematopoietic site in fetus; postnatally procedures lymphocytes &
monocytes
Important in phagocytosis; removes misshapen erythrocytes, unwanted parts of
erythrocytes
Also involved in antibody production by plasma cells & iron metabolism (iron
released from Hgb portion of destroyed erythrocytes returned to bone marrow)
In the adult functions of the spleen can be taken over by the reticuloendothelial
system.

Liver

Involved in bile production (via erythrocyte destruction & bilirubin production)

& erythropoeisis (during fetal life & when bone marrow production is
insufficient).
Kupffer cells of liver have reticuloendothelial function as histiocytes; phagocytic
activity & iron storage.
Liver also involved in synthesis of clotting factors, synthesis of antithrombins.

Blood Tranfusion
Purpose
1. RBC: Improve O2 transport
2. Whole Blood, Plasma, Albumin: volume expansion
3. Fresh Frozen Plasma, Albumin, Plasma Protein Fraction: provision of
proteins
4. Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole Blood: provision of
coagulation factors
5. Platelet Concentration, Fresh Whole Blood: provision of platelets

1.

Blood & Blood Products

Whole Blood: provides all components
a. Large volume can cause difficulty: 12-24 hr for Hgb & Hct to rise
b. Complications: volume overload, transmission of hepatitis or AIDS,
transfusion reacion, infusion of excess potassium & sodium, infusion of

2.

3.

4.

5.
6.

7.

anticoagulant (citrate) used to keep stored blood from clotting, calcium

binding & depletion (citrate) in massive transfusion therapy
Red Blood Cell (RBC)
a. Provide twice amount of Hgb as an equivalent amount of whole blood
b. Indicate in cases of blood loss, pre-op & post-op client & those with
incipient congestive failure
c. Complication: transfusion reaction (less common than with whole
blood: due to removal of plasma protein)
Fresh Frozen Plasma
a. Contains all coagulation factors including V & VIII
b. Can be stored frozen for 12 months; takes 20 minutes to thaw
c. Hang immediately upon arrival to unit (loses its coagulation factor
rapidly)
Platelets
a. Will raise recipients platelet count by 10,000/mm 3
b. Pooled from 4-8 units of whole blood
c. Single-donor platelet transfusion may be necessary for clients who
have developed antibodies; compatibilities testing may be necessary
Factor VIII Fractions (Cryoprecipitate): contains factor VIII, fibrinogens & XIII
Granulocytes
a. Do not increase WBC: increase marginal pool (at tissue level) rather
than circulating pool
b. Premedication with steroids, antihistamine & acetaminophen
c. Respiratory distress with shortness of breath, cyanosis & chest pain
may occur; requires cessation of transfusion & immediate attention
d. Shaking chills or rigors common, require brief cessation of therapy,
administration of meperdine IV until rigors are diminished &
resumption of transfusion when symptoms relieved
Volume Expander: albumin; percentage concentration varies (50-100
ml/unit); hyperosmolar solution should not be used in dehydrated clients

1.

2.

3.

4.

5.

6.

7.
8.
9.

1.
2.
3.
4.

Goals / Objectives
Replace circulating blood volume
Increase the O2 carrying capacity of blood
Prevent infection: if there is a decrease in WBC
Prevent bleeding: if there is platelet deficiency

Principles of blood transfusion

Proper refrigeration
a. Expiration of packed RBC is 3-6 days
b. Expiration of platelet is 3-5 days
Proper typing and cross matching
a. Type O: universal donor
b. Type AB: universal recipient
c. 85% of population is RH positive
Aseptically assemble all materials needed for BT
a. Filter set
b. Gauge 18-19 needle
c. Isotonic solution (0.9 NaCl / plain NSS): to prevent hemolysis
Instruct another RN to re check the following
a. Client name
b. Blood typing & cross matching
c. Expiration date
d. Serial number
Check the blood unit for bubbles cloudiness, sediments and darkness in
color because it indicates bacterial contamination
a. Never warm blood: it may destroy vital factors in blood.
b. Warming is only done: during emergency situation & if you have the
warming device
c. Emergency rapid BT is given after 30 minutes & let natural room
temperature warm the blood.
BT should be completed less than 4 hours because blood that is exposed at
room temperature more than 2 hours: causes blood deterioration that can
lead to bacterial contamination
Avoid mixing or administering drugs at BT line: to prevent hemolysis
Regulate BT 10-15 gtts/min or KVO rate or equivalent to 100 cc/hr: to
prevent circulatory overload
Monitor strictly vital signs before, during & after BT especially every 15
minutes for first hour because majority of transfusion reaction occurs
during this period
a. Hemolytic reaction
b. Allergic reaction
c. Pyrogenic reaction
d. Circulatory overload

e.
f.
g.
h.

1.
2.
3.
4.
5.
6.
7.

Air embolism
Thrombocytopenia
Cytrate intoxication
Hyperkalemia (caused by expired blood)

S/sx of Hemolytic reaction

Headache and dizziness
Dyspnea
Diarrhea / Constipation
Hypotension
Flushed skin
Lumbasternal / Flank pain
Urine is color red / portwine urine

5.
6.
7.

Nursing Management
Stop BT
Notify physician
Flush with plain NSS
Administer isotonic fluid solution: to prevent shock and acute tubular
necrosis
Send the blood unit to blood bank for re-examination
Obtain urine & blood sample & send to laboratory for re-examination
Monitor vital signs & I&O

1.
2.
3.
4.
5.
6.

S/sx of Allergic reaction

Fever
Dyspnea
Broncial wheezing
Skin rashes
Urticaria
Laryngospasm & Broncospasm

1.
2.
3.
4.

Nursing Management
Stop BT
Notify physician
Flush with plain NSS
Administer medications as ordered

1.
2.
3.
4.

a.
5.
6.
7.

Anti Histamine (Benadryl): if positive to hypotension, anaphylactic

shock: treat with Epinephrine
Send the blood unit to blood bank for re examination
Obtain urine & blood sample & send to laboratory for re-examination
Monitor vital signs and intake and output

1.
2.
3.
4.
5.
6.

S/sx Pyrogenic reactions

Fever and chills
Headache
Tachycardia
Palpitations
Diaphoresis
Dyspnea

5.
6.
7.
8.

Nursing Management
Stop BT
Notify physician
Flush with plain NSS
Administer medications as ordered
a. Antipyretic
b. Antibiotic
Send the blood unit to blood bank for re examination
Obtain urine & blood sample & send to laboratory for re-examination
Monitor vital signs & I&O
Render TSB

1.
2.
3.
4.

S/sx of Circulatory reaction

Orthopnea
Dyspnea
Rales / Crackles upon auscultation
Exertional discomfort

1.
2.
3.
4.

1.
2.
3.

Nursing Management
Stop BT
Notify physician
Administer medications as ordered
a. Loop diuretic (Lasix)

2. Pneumocystic Carini Pneumonia

Nursing Care
1. Assess client for history of previous blood transfusions & any adverse
reaction
2. Ensure that the adult client has an 18-19 gauge IV catheter in place
3. Use 0.9% sodium chloride
4. At least two nurse should verify the ABO group, RH type, client & blood
numbers & expiration date
5. Take baseline V/S before initiating transfusion
6. Start transfusion slowly (2 ml/min)
7. Stay with the client during the first 15 min of the transfusion & take V/S
frequently
8. Maintain the prescribed transfusion rate:
a. Whole Blood: approximately 3-4 hr
b. RBC: approximately 2-4 hr
c. Fresh Frozen Plasma: as quickly as possible
d. Platelet: as quickly as possible
e. Cryoprecipitate: rapid infusion
f. Granulocytes: usually over 2 hr
g. Volume Expander: volume-dependent rate
9. Monitor for adverse reaction
10. Document the following:
a. Blood component unit number (apply sticker if available)
b. Date of infusion starts & end
c. Type of component & amount transfused
d. Client reaction & vital signs
e. Signature of transfusionist
HIV
- 6 months 5 years incubation period
- 6 months window period
- western blot opportunistic
- ELISA
- drug of choice AZT (Zidon Retrovir)
2 Common fungal opportunistic infection in AIDS
1. Kaposis Sarcoma

Blood Disorder
Iron Deficiency Anemia (Anemias)
A chronic microcytic anemia resulting from inadequate absorption of iron
leading to hypoxemic tissue injury
Chronic microcytic, hypochromic anemia caused by either inadequate
absorption or excessive loss of iron
Acute or chronic bleeding principal cause in adults (chiefly from trauma,
dysfunctional uterine bleeding & GI bleeding)
May also be caused by inadequate intake of iron-rich foods or by inadequate
absorption of iron
In iron-deficiency states, iron stores are depleted first, followed by a reduction
in Hgb formation

1.
2.
3.

1.

2.

3.

Incidence Rate
Common among developed countries & tropical zones (blood-sucking
parasites)
Common among women 15 & 45 years old & children affected more
frequently, as are the poor
Related to poor nutrition
Predisposing Factors
Chronic blood loss due to:
a. Trauma
b. Heavy menstruation
c. Related to GIT bleeding resulting to hematemasis and melena (sign for
upper GIT bleeding)
d. Fresh blood per rectum is called hematochezia
Inadequate intake or absorption of iron due to:
a. Chronic diarrhea
b. Related to malabsorption syndrome
c. High cereal intake with low animal CHON digestion
d. Partial or complete gastrectomy
e. Pica
Related to improper cooking of foods

9.

S/sx
Usually asymptomatic (mild cases)
Weakness & fatigue (initial signs)
Headache & dizziness
Pallor & cold sensitivity
Dyspnea
Palpitations
Brittleness of hair & nails, spoon shape nails (koilonychias)
Atrophic Glossitis (inflammation of tongue)
a. Stomatitis
PLUMBER VINSONS
SYNDROME
b. Dysphagia
PICA: abnormal appetite or craving for non edible foods

1.
2.
3.
4.
5.
6.
7.
8.

Dx
RBC: small (microcytic) & pale (hypochromic)
RBC: is decreased
Hgb: decreased
Hct: moderately decreased
Serum iron: decreased
Reticulocyte count: is decreased
Serum ferritin: is decreased
Hemosiderin: absent from bone marrow

1.
2.
3.
4.
5.
6.
7.
8.

1.
2.
3.
4.

Nursing Intervention
Monitor for s/sx of bleeding through hematest of all elimination including
urine, stool & gastrict content
Enforce CBR / Provide adequate rest: plan activities so as not to over tire
the client
Provide thorough explanation of all diagnostic exam used to determine
sources of possible bleeding: help allay anxiety & ensure cooperation
Instruct client to take foods rich in iron
a. Organ meat
b. Egg yolk
c. Raisin
d. Sweet potatoes

5.
6.

e. Dried fruits
f. Legumes
g. Nuts
Instruct the client to avoid taking tea and coffee: because it contains
tannates which impairs iron absorption
Administer iron preparation as ordered:
a. Oral Iron Preparations: route of choice
Ferrous Sulfate
Ferrous Fumarate
Ferrous Gluconate

b.

Nursing Management when taking oral iron preparations

Instruct client to take with meals: to lessen GIT irritation
Dilute in liquid preparations well & administer using a straw: to
prevent staining of teeth
When possible administer with orange juice as vitamin C (ascorbic
acid): to enhance iron absorption
Warn clients that iron preparations will change stool color &
consistency (dark & tarry) & may cause constipation
Antacid ingestion will decrease oral iron effectiveness

Parenteral: used in clients intolerant to oral preparations, who are

noncompliant with therapy or who have continuing blood losses

Nursing Management when giving parenteral iron preparation

Use one needle to withdraw & another to administer iron
preparation as tissue staining & irritation are a problem
Use Z-track injection technique: to prevent leakage into tissue
Do not massage injection site but encourage ambulation as this
will enhance absorption; advice against vigourous exercise &
constricting garments
Observe for local signs of complication:
Pain at the injection site
Development of sterile abscesses
Lymphadenitis
Fever & chills
Headache

Urticaria
Pruritus
Hypotension
Skin rashes
Anaphylactic shock

Medications administered via straw

Lugols Solution
Iron
Tetracycline
Nitrofurantoin (Macrodentin)
7. Administer with Vitamin C or orange juice for absorption
8. Monitor & inform client of side effects
a. Anorexia
b. N/V
c. Abdominal pain
d. Diarrhea / constipation
e. Melena
9. If client cant tolerate / no compliance administer parenteral iron
preparation
a. Iron Dextran (IM, IV)
b. Sorbitex (IM)
10. Provide dietary teaching regarding food high in iron
11. Encourage ingestion of roughage & increase fluid intake: to prevent
constipation if oral iron preparation are being taken
Pernicious Anemia
Chronic progressive, macrocytic anemia caused by a deficiency of intrinsic
factor; the result is abnormally large erythrocytes & hypochlorhydria (a
deficiency of hydrochloric acid in gastric secretion)
Chronic anemia characterized by a deficiency of intrinsic factor leading to
hypochlorhydria (decrease hydrochloric acid secretion)
Characterized by neurologic & GI symptoms; death usually resuls if untreated
Lack of intrinsic factor is caused by gastric mucosal atrophy (possibly due to
heredity, prolonged iron deficiency, or an autoimmune disorder); can also
results in clients who have had a total gastrctomy if vitamin B 12 is not administer

1.
2.

3.

Pathophysiology
Intrinsic factor is necessary for the absorbtion of vitamin B12 into small
intestines
B12 deficiency diminished DNA synthesis, which results in defective
maturation of cell (particularly rapidly dividing cells such as blood cells & GI
tract cells)
B12 deficiency can alter structure & function of peripheral nerves, spinal
cord, & the brain

STOMACH
Pareital cells/Argentaffin or Oxyntic cells

Produces intrinsic factors

Promotes reabsorption of Vit B12

Secretes hydrochloric acid

Aids in digestion

Promotes maturation of RBC

1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
5.
6.

Predisposing Factors
Usually occurs in men & women over age of 50 with an increase in blueeyed person of Scandinavian decent
Subtotal gastrectomy
Hereditary factors
Inflammatory disorders of the ileum
Autoimmune
Strictly vegetarian diet
S/sx
Anemia
Weakness & fatigue
Headache and dizziness
Pallor & cold sensitivity
Dyspnea & palpitations: as part of compensation
GIT S/sx:
a. Mouth sore
b. PS: Red beefy tongue

7.

1.
2.
3.
4.
5.

6.

c. Indigestion / dyspepsia
d. Weight loss
e. Constipation / diarrhea
f. Jaundice
CNS S/sx:
a. Tingling sensation
b. Numbness
c. Paresthesias of hands & feet
d. Paralysis
e. Depression
f. Psychosis
g. Positive to Rombergs test: damage to cerebellum resulting to ataxia
Dx
Erythrocytes count: decrease
Blood Smear: oval, macrocytic erythrocytes with a proportionate amount of
Hgb
Bilirubin (indirect): elevated unconjugated fraction
Serum LDH: elevated
Bone Marrow:
a. Increased megaloblasts (abnormal erythrocytes)
b. Few normoblasts or maturing erythrocytes
c. Defective leukocytes maturation
Positive Schillings Test: reveals inadequate / decrease absorption of
Vitamin B12
a. Measures absorption of radioactive vitamin B12 bothe before & after
parenteral administration of intrinsic factor
b. Definitive test for pernicious anemia
c. Used to detect lack of intrinsic factor
d. Fasting client is given radioactive vitamin B12 by mouth & nonradioactive vitamin B12 IM to permit some excretion of radioactive
vitamin B12 in the urine if it os absorbed
e. 24-48 hour urine collection is obtained: client is encourage to drink
fluids
f. If indicated, second stage schilling test performed 1 week after first
stage. Fasting client is given radioactive vitamin B12 combined with
human intrinsic factor & test is repeated

7.
8.

1.

2.
1.
2.

3.
4.
5.
6.
7.
8.

Gastric Analysis: decrease free hydrochloric acid

Large number of reticulocytes in the blood following parenteral vitamin B 12
administration
Medical Management
Drug Therapy:
a. Vitamin B12 injection: monthly maintenance
b. Iron preparation: (if Hgb level inadequate to meet increase numbers of
erythrocytes)
c. Folic Acid
Controversial
Reverses anemia & GI symptoms but may intensify neurologic
symptoms
May be safe if given in small amounts in addition to vitamin B 12
Transfusion Therapy
Nursing Intervention
Enforce CBR: necessary if anemia is severe
Adminster Vitamin B12 injections at monthly intervals for lifetime as ordered
Never given orally because there is possibility of developing tolerance
Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal
No side effects
Provide a dietary intake that is high in CHON, vitamin c and iron (fish, meat,
milk / milk product & eggs)
Avoid highly seasoned, coursed, or very hot foods: if client has mouth sore
Provide safety when ambulating (especially when carrying hot item)
Instruct client to avoid irritating mouth washes instead use soft bristled
toothbrush
Avoid heat application to prevent burns
Provide client teaching & discharge planning concerning:
a. Dietery instruction
b. Importance of lifelong vitamin B12 therapy
c. Rehabilitation & physical therapy for neurologic deficit, as well as
instruction regarding safety

Aplastic Anemia
Stem cell disorder leading to bone marrow depression leading to pancytopenia

Pancytopenia or depression of granulocytes, platelets & erythrocytes

production: due to fatty replacement of the bone marrow
Bone marrow destruction may be idiopathic or secondary

1.
2.
3.

PANCYTOPENIA

Decrease RBC
Decrease Platelet
(anemia)
(thrombocytopenia)

1.
2.
3.
4.

1.

2.
3.

Decrease WBC

1.

(leukopenia)

2.
3.
4.

Predisposing Factors
Chemicals (Benzene and its derivatives)
Related to radiation / exposure to x-ray
Immunologic injury
Drugs:
a. Broad Spectrum Antibiotics: Chloramphenicol (Sulfonamides)
b. Cytotoxic agent / Chemotherapeutic Agents:
Methotrexate (Alkylating Agent)
Vincristine (Plant Alkaloid)
Nitrogen Mustard (Antimetabolite)
Phenylbutazones (NSAIDS)
S/sx
Anemia
a. Weakness & fatigue
b. Headache & dizziness
c. Pallor & cold sensitivity
d. Dyspnea & palpitations
Leukopenia
a. Increase susceptibility to infection
Thrombocytopenia
a. Petechiae (multiple petechiae is called purpura)
b. Ecchymosis
c. Oozing of blood from venipunctured sites
Dx

5.

1.
2.
3.
4.
5.
6.
7.

8.

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
Medical Management
Blood transfusion: key to therapy until clients own marrow begins to
produce blood cells
Aggressive treatment of infection
Bone marrow transplantation
Drug Therapy:
a. Corticosteroids & / or androgens: to stimulate bone marrow function &
to increase capillary resistance (effective in children but usually not in
adults)
b. Estrogen & / or progesterone: to prevent amenorrhea in female clients
Identification & withdrawal of offending agent or drug
Nursing Intervention
Removal of underlying cause
Administer Blood Transfusion as ordered
Administer O2 inhalation
Enforce CBR
Institute reverse isolation
Provide nursing care for client with bone marrow transplant
Administer medications as ordered:
a. Corticosteroids: caused by immunologic injury
b. Immunosuppressants: Anti Lymphocyte Globulin
Given via central venous catheter
Given 6 days to 3 weeks to achieve maximum therapeutic effect of drug
Monitor for signs of infection & provide care to minimize risk:
a. Monitor neuropenic precautions
b. Encourage high CHON, vitamin diet: to help reduce incidence of
infection
c. Provide mouth care before & after meals
d. Fever

e. Cough
Monitor signs of bleeding & provide measures to minimize risk:
a. Use soft toothbrush when brushing teeth & electric razor when
shaving: prevent bleeding
b. Avoid IM, subcutaneous, venipunctured sites: Instead provide heparin
lock
c. Hematest urine & stool
d. Observe for oozing from gums, petechiae or ecchymoses
10. Provide client teaching & discharge planning concerning:
a. Self-care regimen
b. Identification of offending agent & importance of avoiding it (if
possible) in future
9.

Disseminated Intravascular Coagulation (DIC)

Diffuse fibrin deposition within arterioles & capillaries with widespread
coagulation all over the body & subsequent depletion of clotting factors
Acute hemorrhagic syndrome characterized by wide spread bleeding and
thrombosis due to a deficiency of prothrombin and fibrinogen
Hemorrhage from kidneys, brain, adrenals, heart & other organs
May be linked with entry of thromboplasic substance into the blood
Mortality rate is high usually because underlying disease cannot be corrected

1.

2.
3.
4.
5.

Pathophysiology
Underlying disease (ex. toxemia of pregnancy, cancer) cause release of
thromboplastic substance that promote the deposition of fibrin throughout
the microcirculation
Microthrombi form in many organs, causing microinfarcts & tissue necrosis
RBC are trapped in fibrin strands & are hemolysed
Platelets, prothrombin & other clotting factors are destroyed, leading to
bleeding
Excessive clotting activates the fibrinolytic system, which inhibits platelet
function, causing futher bleeding.

4.
5.
6.
7.

3.
4.
5.
6.

S/sx
Petechiae & Ecchymosis on the skin, mucous membrane, heart, eyes, lungs
& other organs (widespread and systemic)
Prolonged bleeding from breaks in the skin: oozing of blood from punctured
sites
Severe & uncontrollable hemorrhage during childbirth or surgical procedure
Hemoptysis
Oliguria & acute renal failure (late sign)
Convulsion, coma, death

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Dx
PT: prolonged
PTT: usually prolonged
Thrombin Time: usually prolonged
Fibrinogen level: usually depressed
Fibrin splits products: elevated
Protamine Sulfate Test: strongly positive
Factor assay (II, V, VII): depressed
CBC: reveals decreased platelets
Stool occult blood: positive
ABG analysis: reveals metabolic acidosis
Opthamoscopic exam: reveals sub retinal hemorrhages

1.
2.

1.
2.
3.

1.
2.
3.

Predisposing Factors
Related to rapid blood transfusion
Massive burns
Massive trauma

Anaphylaxis
Septecemia
Neoplasia (new growth of tissue)
Pregnancy

Medical Management
Identification & control the underlying disease is key
Blood Tranfusions: include whole blood, packed RBC, platelets, plasma,
cryoprecipitites & volume expanders
Heparin administration
a. Somewhat controversial
b. Inhibits thrombin thus preventing further clot formation, allowing
coagulation factors to accumulate

1.
2.
3.
4.

5.
6.
7.
8.

9.
10.
11.
12.
13.
14.

Nursing Intervention
Monitor blood loss & attemp to quantify
Monitor for signs of additional bleeding or thrombus formation
Monitor all hema test / laboratory data including stool and GIT
Prevent further injury
a. Avoid IM injection
b. Apply pressure to bleeding site
c. Turn & position the client frequently & gently
d. Provide frequent nontraumatic mouth care (ex. soft toothbrush or
gauze sponge)
Administer isotonic fluid solution as ordered: to prevent shock
Administer oxygen inhalation
Force fluids
Administer medications as ordered:
a. Vitamin K
b. Pitressin / Vasopresin: to conserve fluids
c. Heparin / Comadin is ineffective
Provide heparin lock
Institute NGT decompression by performing gastric lavage: by using ice or
cold saline solution of 500-1000 ml
Monitor NGT output
Prevent complication
a. Hypovolemic shock: Anuria (late sign of hypovolemic shock)
Provide emotional support to client & significant other
Teach client the importance of avoiding aspirin or aspirin-containing
compounds

Overview of the Structure & Functions of the Heart

Heart

Cardiovascular system consists of the heart, arteries, veins & capillaries. The
major function are circulation of blood, delivery of O2 & other nutrients to the
tissues of the body & removal of CO2 & other cellular products metabolism
Muscular pumping organ that propel blood into the arerial system & receive
blood from the venous system of the body.
Located on the left mediastinum
Resemble like a close fist

Weighs approximately 300 400 grams

Covered by a serous membrane called the pericardium

Heart Wall / Layers of the Heart

Pericardium
Composed of fibrous (outermost layer) & serous pericardium (parietal &
visceral); a sac that function to protect the heart from friction
In between is the pericardial fluid which is 10 20 cc: Prevent pericardial friction
rub
2 layers of pericardium
Parietal: outer layer
Visceral: inner layer
Epicardium
Covers surface of the heart, becomes continuous with visceral layer of serous
pericardium
Outer layer
Myocardium
Middle muscular layer
Myocarditis can lead to cardiogenic shock and rheumatic heart disease
Endocardium
Thin, inner membrabous layer lining the chamber of the heart
Inner layer
Papillary Muscle
Arise from the endocardial & myocardial surface of the ventricles & attach to
the chordae tendinae
Chordae Tendinae
Attach to the tricuspid & mitral valves & prevent eversion during systole
Chambers of the Heart
Atria
2 chambers, function as receiving chambers, lies above the ventricles
Upper Chamber (connecting or receiving)
Right Atrium: receives systemic venous blood through the superior vena
cava, inferior vena cava & coronary sinus
Left Atrium: receives oxygenated blood returning to the heart from the
lungs trough the pulmonary veins

Ventricles
2 thick-walled chambers; major responsibility for forcing blood out of the heart;
lie below the atria
Lower Chamber (contracting or pumping)
Right Ventricle: contracts & propels deoxygenated blood into pulmonary
circulation via the aorta during ventricular systole; Right atrium has
decreased pressure which is 60 80 mmHg
Left Ventricle: propels blood into the systemic circulation via aortaduring
ventricular systole; Left ventricle has increased pressure which is 120 180
mmHg in order to propel blood to the systemic circulation
Valves
To promote unidimensional flow or prevent backflow
Atrioventricular Valve
Guards opening between
Mitral Valve: located between the left atrium & left ventricle; contains 2
leaflets attached to the chordae tandinae
Tricuspid Valve: located between the right atrium & right ventricle; contains
3 leaflets attached to the chordae tandinae
Functions
Permit unidirectional flow of blood from specific atrium to specific ventricle
during ventricular diastole
Prevent reflux flow during ventricular systole
Valve leaflets open during ventricular diastole; Closure of AV valves give rise to
first heart sound (S1 lub)
Semi-lunar Valve
Pulmonary Valve
Located between the left ventricle & pulmonary artery
Aortic Valve
Located between left ventricle & aorta
Function
Pemit unidirectional flow of the blood from specific ventricle to arterial vessel
during ventricular diastole
Prevent reflux blood flow during ventricular diastole

Valve open when ventricle contract & close during ventricular diastole; Closure
of SV valve produces second heart sound (S2 dub)

Extra Heart Sounds

S3: ventricular gallop usually seen in Left Congestive Heart Failure
S4: atrial gallop usually seen in Myocardial Infarction and Hypertension
Coronary Circulation
Coronary Arteries
Branch off at the base of the aorta & supply blood to the myocardium & the
conduction system
Arises from base of the aorta
Types of Coronary Arteries
Right Main Coronary Artery
Left Main Coronary Artery
Coronary Veins
Return blood from the myocardium back to the right atrium via the coronary
sinus
Conduction System
Sinoatrial Node (SA node or Keith Flack Node)
Located at the junction of superior vena cava and right atrium
Acts as primary pacemaker of the heart
Initiates the cardiac impulse which spreads across the atria & into AV node
Initiates electrical impulse of 60-100 bpm
Atrioventricular Node (AV node or Tawara Node)
Located at the inter atrial septum
Delays the impulse from the atria while the ventricles fill
Delay of electrical impulse for about .08 milliseconds to allow ventricular filling
Bundle of His
Arises from the AV node & conduct impulse to the bundle branch system

Located at the interventricular septum

Right Bundle Branch: divided into anterior lateral & posterior; transmits
impulses down the right side of the interventricular myocardium

Left Bundle Branch: divided into anterior & posterior

Anterior Portion: transmits impulses to the anterior endocardial
surface of the left ventricle
Posterior Portion: transmits impulse over the posterior & inferior
endocardial surface of the left ventricle

Purkinje Fibers
Transmit impulses to the ventricle & provide for depolarization after ventricular
contraction
Located at the walls of the ventricles for ventricular contraction

Most common pacemaker is the metal pacemaker and lasts up to 2 5 years

Abnormal ECG Tracing

Positive U wave: Hypokalemia
Peak T wave: Hyperkalemia
ST segment depression: Angina Pectoris
ST segment elevation: Myocardial Infarction
T wave inversion: Myocardial Infarction
Widening of QRS complexes: Arrythmia
Vascular System
Major function of the blood vessels isto supply the tissue with blood, remove
wastes, & carry unoxygenated blood back to the heart

SA NODE
AV NODE

BUNDLE OF HIS

PURKINJE FIBERS
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Electrical activity of heart can be visualize by attaching
electrodes to the skin & recording
activity by ECG
Electrocadiography (ECG) Tracing
P wave (atrail depolarization) contraction
QRS wave (ventricular depolarization)
T wave (ventricular repolarization)
Insert pacemaker if there is complete heart block

Types of Blood Vessels

Arteries
Elastic-walled vessels that can stretch during systole & recoil during diastole;
they carry blood away from the heart & distribute oxygenated blood throughout
the body
Arterioles
Small arteries that distribute blood to the capillaries & function in controlling
systemic vascular resistance & therefore arterial pressure
Capilliaries
The following exchanges occurs in the capilliaries
O2 & CO2
Solutes between the blood & tissue
Fluid volume transfer between the plasma & interstitial space
Venules
Small veins that receive blood from capillaries & function as collecting channels
between the capillaries & veins
Veins
Low-pressure vessels with thin small & less muscles than arteries; most contains
valves that prevent retrograde blood flow; they carry deoxygenated blood back
to the heart. When the skeletal surrounding veins contract, the veins are
compressed, promoting movement of blood back to the heart.

Cardiac Disorders
Coronary Arterial Disease / Ischemic Heart Disease
Stages of Development of Coronary Artery Disease
1. Myocardial Injury: Atherosclerosis
2. Myocardial Ischemia: Angina Pectoris
3. Myocardial Necrosis: Myocardial Infarction
ATHEROSCLEROSIS
ATHEROSCLEROSIS
Narrowing of artery
Lipid or fat deposits
Tunica intima
Predisposing Factors
1. Sex: male
2. Race: black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet: increased saturated fats
10. Type A personality
S/sx
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P - Percutaneous
T - Transluminal
C - Coronary

ARTERIOSCLEROSIS
Hardening of artery
Calcium and protein deposits
Tunica media

A Angioplasty
C - Coronary
A - Arterial
B - Bypass
A - And
G - Graft
S - Surgery
Objectives
1. Revascularize myocardium
2. To prevent angina
3. Increase survival rate
4. Done to single occluded vessels
5. If there is 2 or more occluded blood vessels CABG is done
3 Complications of CABG
1. Pneumonia: encourage to perform deep breathing, coughing exercise and use of
incentive spirometer
2. Shock
3. Thrombophlebitis
Angina Pectoris
Transient paroxysmal chest pain produced by insufficient blood flow to the
myocardium resulting to myocardial ischemia
Clinical syndrome characterized by paroxysmal chest pain that is usually relieved
by rest or nitroglycerine due to temporary myocardial ischemia
Predisposing Factors
1. Sex: male
2. Race: black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
7. Diabetes Mellitus
8. Hypertension

9.
10.
11.
12.
13.
14.
15.

CAD: Atherosclerosis
Thromboangiitis Obliterans
Severe Anemia
Aortic Insufficiency: heart valve that fails to open & close efficiently
Hypothyroidism
Diet: increased saturated fats
Type A personality

Precipitating Factors
4 Es of Angina Pectoris
1. Excessive physical exertion: heavy exercises, sexual activity
2. Exposure to cold environment: vasoconstriction
3. Extreme emotional response: fear, anxiety, excitement, strong emotions
4. Excessive intake of foods or heavy meal
S/sx
1. Levines Sign: initial sign that shows the hand clutching the chest
2. Chest pain: characterized by sharp stabbing pain located at sub sterna usually
radiates from neck, back, arms, shoulder and jaw muscles usually relieved by
rest or taking nitroglycerine (NTG)
3. Dyspnea
4. Tachycardia
5. Palpitations
6. Diaphoresis
Dx
1.
2.
3.
4.
5.

History taking and physical exam

ECG: may reveals ST segment depression & T wave inversion during chest pain
Stress test / treadmill test: reveal abnormal ECG during exercise
Increase serum lipid levels
Serum cholesterol & uric acid is increased

Medical Management
1. Drug Therapy: if cholesterol is elevated
Nitrates: Nitroglycerine (NTG)
Beta-adrenergic blocking agent: Propanolol
Calcium-blocking agent: nefedipine

2.
3.
4.

Ace Inhibitor: Enapril

Modification of diet & other risk factors
Surgery: Coronary artery bypass surgery
Percutaneuos Transluminal Coronary Angioplasty (PTCA)

Nursing Intervention
1. Enforce complete bed rest
2. Give prompt pain relievers with nitrates or narcotic analgesic as ordered
3. Administer medications as ordered:
a. Nitroglycerine (NTG): when given in small doses will act as venodilator, but
in large doses will act as vasodilator
Give 1st dose of NTG: sublingual 3-5 minutes
Give 2nd dose of NTG: if pain persist after giving 1st dose with interval of
3-5 minutes
Give 3rd & last dose of NTG: if pain still persist at 3-5 minutes interval
Nursing Management when giving NTG
1. NTG Tablets (sublingual)
Keep the drug in a dry place, avoid moisture and exposure to sunlight
as it may inactivate the drug
Relax for 15 minutes after taking a tablet: to prevent dizziness
Monitor side effects:
Orthostatic hypotension
Transient headache & dizziness: frequent side effect
Instruct the client to rise slowly from sitting position
Assist or supervise in ambulation
2. NTG Nitrol or Transdermal patch
Avoid placing near hairy areas as it may decrease drug absorption
Avoid rotating transdermal patches as it may decrease drug absorption
Avoid placing near microwave ovens or during defibrillation as it may
lead to burns (most important thing to remember)
b. Beta-blockers
Propanolol: side effects PNS
Not given to COPD cases: it causes bronchospasm
c. ACE Inhibitors
Enalapril

d.
4.
5.
6.
7.
8.

9.

Calcium Antagonist
Nefedipine
Administer oxygen inhalation
Place client on semi-to high fowlers position
Monitor strictly V/S, I&O, status of cardiopulmonary fuction & ECG tracing
Provide decrease saturated fats sodium and caffeine
Provide client health teachings and discharge planning
Avoidance of 4 Es
Prevent complication (myocardial infarction)
Instruct client to take medication before indulging into physical exertion to
achieve the maximum therapeutic effect of drug
Reduce stress & anxiety: relaxation techniques & guided imagery
Avoid overexertion & smoking
Avoid extremes of temperature
Dress warmly in cold weather
Participate in regular exercise program
Space exercise periods & allow for rest periods
The importance of follow up care
Instruct the client to notify the physician immediately if pain occurs & persists
despite rest & medication administration

Myocardial Infarction
Death of myocardial cells from inadequate oxygenation, often caused by sudden
complete blockage of a coronary artery
Characterized by localized formation of necrosis (tissue destruction) with
subsequent healing by scar formation & fibrosis
Heart attack
Terminal stage of coronary artery disease characterized by malocclusion,
necrosis & scarring.
Types
1. Transmural Myocardial Infarction: most dangerous type characterized by
occlusion of both right and left coronary artery
2. Subendocardial Myocardial Infarction: characterized by occlusion of either right
or left coronary artery
The Most Critical Period Following Diagnosis of Myocardial Infarction

6-8 hours because majority of death occurs due to arrhythmia leading to

premature ventricular contractions (PVC)

Predisposing Factors
1. Sex: male
2. Race: black
3. Smoking
4. Obesity
5. CAD: Atherosclerotic
6. Thrombus Formation
7. Genetic Predisposition
8. Hyperlipidemia
9. Sedentary lifestyle
10. Diabetes Mellitus
11. Hypothyroidism
12. Diet: increased saturated fats
13. Type A personality
S/sx
1. Chest pain
Excruciating visceral, viselike pain with sudden onset located at substernal
& rarely in precordial
Usually radiates from neck, back, shoulder, arms, jaw & abdominal muscles
(abdominal ischemia): severe crushing
Not usually relieved by rest or by nitroglycerine
2. N/V
3. Dyspnea
4. Increase in blood pressure & pulse, with gradual drop in blood pressure (initial
sign)
5. Hyperthermia: elevated temp
6. Skin: cool, clammy, ashen
7. Mild restlessness & apprehension
8. Occasional findings:
Pericardial friction rub
Split S1 & S2

Rales or Crackles upon auscultation

S4 or atrial gallop

Dx
1. Cardiac Enzymes
CPK-MB: elevated
Creatinine phosphokinase (CPK): elevated
Heart only, 12 24 hours
Lactic acid dehydrogenase (LDH): is increased
Serum glutamic pyruvate transaminase (SGPT): is increased
Serum glutamic oxal-acetic transaminase (SGOT): is increased
2. Troponin Test: is increased
3. ECG tracing reveals
ST segment elevation
T wave inversion
Widening of QRS complexes: indicates that there is arrhythmia in MI
4. Serum Cholesterol & uric acid: are both increased
5. CBC: increased WBC

7.
8.
9.
10.
11.
12.
13.

Nursing Intervention
Goal: Decrease myocardial oxygen demand
1.

2.
3.
4.
5.
6.

Decrease myocardial workload (rest heart)

Establish a patent IV line
Administer narcotic analgesic as ordered: Morphine Sulfate IV: provide pain
relief (given IV because after an infarction there is poor peripheral
perfusion & because serum enzyme would be affected by IM injection as
ordered)
Side Effects: Respiratory Depression
Antidote: Naloxone (Narcan)
Side Effects of Naloxone Toxicity: is tremors
Administer oxygen low flow 2-3 L / min: to prevent respiratory arrest or dyspnea
& prevent arrhythmias
Enforce CBR in semi-fowlers position without bathroom privileges (use bedside
commode): to decrease cardiac workload
Instruct client to avoid forms of valsalva maneuver
Place client on semi fowlers position
Monitor strictly V/S, I&O, ECG tracing & hemodynamic procedures

14.

Perform complete lung / cardiovascular assessment

Monitor urinary output & report output of less than 30 ml / hr: indicates
decrease cardiac output
Provide a full liquid diet with gradual increase to soft diet: low in saturated fats,
Na & caffeine
Maintain quiet environment
Administer stool softeners as ordered: to facilitate bowel evacuation & prevent
straining
Relieve anxiety associated with coronary care unit (CCU) environment
Administer medication as ordered:
a. Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate, Isodil (ISD):
sublingual
b. Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium
Side Effects: confusion and dizziness
c. Beta-blockers: Propanolol (Inderal)
d. ACE Inhibitors: Captopril (Enalapril)
e. Calcium Antagonist: Nefedipine
f. Thrombolytics / Fibrinolytic Agents: Streptokinase, Urokinase, Tissue
Plasminogen Activating Factor (TIPAF)
Side Effects: allergic reaction, urticaria, pruritus
Nursing Intervention: Monitor for bleeding time
g. Anti Coagulant
Heparin
Antidote: Protamine Sulfate
Nursing Intervention: Check for Partial Thrombin Time (PTT)
Caumadin (Warfarin)
Antidote: Vitamin K
Nursing Intervention: Check for Prothrombin Time (PT)
h. Anti Platelet: PASA (Aspirin): Anti thrombotic effect
Side Effects: Tinnitus, Heartburn, Indigestion / Dyspepsia
Contraindication: Dengue, Peptic Ulcer Disease, Unknown cause of
headache
Provide client health teaching & discharge planning concerning:
a. Effects of MI healing process & treatment regimen
b. Medication regimen including time name purpose, schedule, dosage, side
effects

c.
d.
e.
f.

g.
h.

i.

j.
k.

Dietary restrictions: low Na, low cholesterol, avoidance of caffeine

Encourage client to take 20 30 cc/week of wine, whisky and brandy: to
induce vasodilation
Avoidance of modifiable risk factors
Prevent Complication
Arrhythmia: caused by premature ventricular contraction
Cardiogenic shock: late sign is oliguria
Left Congestive Heart Failure
Thrombophlebitis: homans sign
Stroke / CVA
Dresslers Syndrome (Post MI Syndrome): client is resistant to
pharmacological agents: administer 150,000-450,000 units of
streptokinase as ordered
Importance of participation in a progressive activity program
Resumption of ADL particularly sexual intercourse: is 4-6 weeks post cardiac
rehab, post CABG & instruct to:
Make sex as an appetizer rather than dessert
Instruct client to assume a non weight bearing position
Client can resume sexual intercourse: if can climb or use the staircase
Need to report the ff s/sx:
Increased persistent chest pain
Dyspnea
Weakness
Fatigue
Persistent palpitation
Light headedness
Enrollment of client in a cardiac rehabilitation program
Strict compliance to mediation & importance of follow up care

2.
3.

Left Sided Heart Failure

Left ventricular damage causes blood to back up through the left atrium & into
the pulmonary veins: Increased pressure causes transudation into interstitial
tissues of the lungs which result pulmonary congestion.
Predisposing Factors
1. 90% is mitral valve stenosis due to RHD: inflammation of mitral valve due to
invasion of Group A beta-hemolytic streptococcus
2. Myocardial Infarction
3. Ischemic heart disease
4. Hypertension
5. Aortic valve stenosis
S/sx
1.
2.

Congestive Heart Failure

Inability of the heart to pump an adequate supply of blood to meet the
metabolic needs of the body
Inability of the heart to pump blood towards systemic circulation
Types of Heart Failure
1. Left Sided Heart Failure

Right Sided Heart Failure

High-Output Failure

3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Dyspnea
Paroxysmal nocturnal dyspnea (PND): client is awakened at night due to
difficulty of breathing
Orthopnea: use 2-3 pillows when sleeping or place in high fowlers
Tiredness
Muscle Weakness
Productive cough with blood tinged sputum
Tachycardia
Frothy salivation
Cyanosis
Pallor
Rales / Crackles
Bronchial wheezing
Pulsus Alternans: weak pulse followed by strong bounding pulse
PMI is displaced laterally: due to cardiomegaly
Possible S3: ventricular gallop

1.

Chest X-ray (CXR): reveals cardiomegaly

Dx

2.
3.
4.

5.
6.
7.

Pulmonary Arterial Pressure (PAP): measures pressure in right ventricle or

cardiac status: increased
Pulmonary Capillary Wedge Pressure (PCWP): measures end systolic and
dyastolic pressure: increased
Central Venous Pressure (CVP): indicates fluid or hydration status
Increase CVP: decreased flow rate of IV
Decrease CVP: increased flow rate of IV
Swan-Ganz catheterization: cardiac catheterization
Echocardiography: shows increased sized of cardiac chamber (cardiomyopathy):
dependent on extent of heart failure
ABG: reveals PO2 is decreased (hypoxemia), PCO2 is increased (respiratory
acidosis)

Right Sided Heart Failure

Weakened right ventricle is unable to pump blood into he pulmonary system:
systemic venous congestion occurs as pressure builds up
Predisposing Factors
1. Right ventricular infarction
2. Atherosclerotic heart disease
3. Tricuspid valve stenosis
4. Pulmonary embolism
5. Related to COPD
6. Pulmonic valve stenosis
7. Left sided heart failure
S/sx
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Anorexia
Nausea
Weight gain
Neck / jugular vein distension
Pitting edema
Bounding pulse
Hepatomegaly / Slenomegaly
Cool extremities
Ascites
Jaundice

11. Pruritus
12. Esophageal varices
Dx
1.
2.

3.
4.
5.

Chest X-ray (CXR): reveals cardiomegaly

Central Venous Pressure (CVP): measure fluid status: elevated
Measure pressure in right atrium: 4-10 cm of water
If CVP is less than 4 cm of water: Hypovolemic shock: increase IV flow rate
If CVP is more than 10 cm of water: Hypervolemic shock: Administer loop
diuretics as ordered
Nursing Intervention:
When reading CVP patient should be flat on bed
Upon insertion place client in trendelendberg position: to promote
ventricular filling and prevent pulmonary embolism
Echocardiography: reveals increased size of cardiac chambers (cardiomyopathy)
Liver enzymes: SGPT & SGOT: is increased
ABG: decreased pO2

Medical Management
1. Determination & elimination / control of underlying cause
2. Drug therapy: digitalis preparations, diuretics, vasodilators
3. Sodium-restricted diet: to decrease fluid retention
4. If medical therapies unsuccessful: mechanical assist devices (intra-aortic balloon
pump), cardiac transplantation, or mechanical heart may be employed
5. Treatment for Left Sided Heart Failure Only:
M Morphine SO4
A Aminophylline
D Digitalis
D Diuretics
O O2
G Gases
Nursing Intervention
Goal: Increase cardiac contractility thereby increasing cardiac output of 3-6 L / min
1.

Monitor respiratory status & provide adequate ventilation (when HF progress to

pulmonary edema)
a. Administer O2 therapy: high inflow 3-4 L / min delivered via nasal cannula

2.

3.

4.

5.

Maintain client in semi or high fowlers position: maximize oxygenation by

promoting lung expansion
c. Monitor ABG
d. Assess for breath sounds: noting any changes
Provide physical & emotional rest
a. Constantly assess level of anxiety
b. Maintain bed rest with limited activity
c. Maintain quiet & relaxed environment
d. Organized nursing care around rest periods
Increase cardiac output
a. Administer digitalis as ordered & monitor effects
Cardiac glycosides: Digoxin (Lanoxin)
Action: Increase force of cardiac contraction
Contraindication: If heart rate is decreased do not give
b. Monitor ECG & hemodynamic monitoring
c. Administer vasodilators as ordered
Vasodilators: Nitroglycerine (NTG)
d. Monitor V/S
Reduce / eliminate edema
a. Administer diuretics as ordered
Loop Diuretics: Lasix (Furosemide)
b. Daily weight
c. Maintain accurate I&O
d. Assess for peripheral edema
e. Measure abdominal girth daily
f. Monitor electrolyte levels
g. Monitor CVP & Swan-Ganz reading
h. Provide Na restricted diet as ordered
i. Provide meticulous skin care
If acute pulmonary edema occurs: For Left Sided Heart Failure only
a. Administer Narcotic Analgesic as ordered
Narcotic analgesic: Morphine SO4
Action: to allay anxiety & reduce preload & afterload
b. Administer Bronchodilator as ordered
Bronchodilators: Aminophylline IV

b.

6.
7.

Action: relieve bronchospasm, increase urinary output & increase

cardiac output
c. Administer Anti-arrythmic as ordered
Anti-arrythmic: Lidocaine (Xylocane)
Assist in bloodless phlebotomy: rotating tourniquet, rotated clockwise every 15
minutes: to promote decrease venous return or reducing preload
Provide client teaching & discharge planning concerning:
a. Need to monitor self daily for S/sx of Heart Failure (pedal edema, weight
gain, of 1-2 kg in a 2 day period, dyspnea, loss of appetite, cough)
b. Medication regimen including name, purpose, dosage, frequency & side
effects (digitalis, diuretics)
c. Prescribe diet plan (low Na, cholesterol, caffeine: small frequent meals)
d. Need to avoid fatigue & plan for rest periods
e. Prevent complications
Arrythmia
Shock
Right ventricular hypertrophy
MI
Thrombophlebitis
f. Importance of follow-up care

Peripheral Vascular Disorder

Arterial Ulcer
1. Thromboangiitis Obliterans (Buergers Disease)
2. Raynauds Phenomenon
Venous Ulcer
1. Varicose Veins
2. Thrombophlebitis (deep vein thrombosis)
Thromboangiitis Obliterans (Buergers Disease)
Acute inflammatory disorder affecting the small / medium sized arteries & veins
of the lower extremities
Occurs as focal, obstructive, process; result in occlusion of a vessel with a
subsequent development of collateral circulation

1.
Predisposing Factors
1. High risk groups - men 25-40 years old
2. High incident among smokers

2.

S/sx
1.
2.
3.
4.
5.

Intermittent claudication: leg pain upon walking

st
Cold sensitivity & changes in skin color 1 white (pallor) changing to blue
(cyanosis) then red (rubor)
Decreased or absent peripheral pulses (posterior tibial & dorsalis pedis)
Trophic changes
Ulceration & Gangrene formation (advanced)

1.
2.
3.

Oscillometry: may reveal decrease in peripheral pulse volume

Doppler (UTZ): reveals decrease blood flow to the affected extremity
Angiography: reveals location & extent of obstructive process

3.
4.
5.
6.
7.

Dx

Medical Management
1. Drug Therapy
a. Vasodilators: to improve arterial circulation (effectiveness ?)
Papaverine
Isoxsuprine HCL (Vasodilan)
Nylidrin HCL (Arlidin)
Nicotinyl Alcohol (Roniacol)
Cyclandelate (Cyclospasmol)
Tolazoline HCL (Priscoline)
b. Analgesic: to relieve ischemic pain
c. Anti-coagulant: to prevent thrombus formation
2. Surgery
a. Bypass Grafting
b. Endarterectomy
c. Balloon Catheter Dilation
d. Lumbar Sympathectomy: to increase blood flow
e. Amputation: may be necessary
Nursing Intervention

Encourage a slow progressive physical activity

Walking at least 2 times / day
Out of bed at least 3-4 times / day
Administer medications as ordered
Analgesics
Vasodilators
Anti-coagulants
Foot care management:
Need to avoid trauma to the affected extreminty
Importance of stop smoking
Need to maintain warmth especially in cold weather
Prepare client for surgery: below knee amputation (BKA)
Importance of follow-up care

Raynauds Phenomenon
Intermittent episodes of arterial spasm most frequently involving the fingers or
digits of the hands
Predisposing Factors
1. High risk group: female between the teenage years & age 40 years old & above
2. Smoking
3. Collagen diseases
a. Systemic Lupus Erythematosus (SLE): butterfly rash
b. Rheumatoid Arthritis
4. Direct hand trauma
a. Piano playing
b. Excessive typing
c. Operating chainsaw
S/sx
1.
2.
3.
4.
5.
6.

Coldness
Numbness
Tingling in one or more digits
Pain: usually precipitated by exposure to cold, Emotional upset & Tobacco use
Intermittent color changes: pallor (white), cyanosis (blue), rubor (red)
Small ulceration & gangrene a tips of digits (advance)

Dx
1.
2.

Doppler UTZ: decrease blood flow to the affected extremity

Angiography: reveals site & extent of malocclusion

Medical Management
1. Administer medications as ordered
a. Catecholamine-depliting antihypertinsive drugs:
Reserpine
Guanethidine Monosulfate (Ismelin)
b. Vasodilators
Nursing Intervention
1. Importance of stop smoking
2. Need to maintain warmth especially in cold weather
3. Need to wear gloves when handling cold object / opening a freezer or
refrigerator door
Varicose Veins
Dilated veins that occurs most often in the lower extremities & trunk. As the
vessel dilates the valves become stretched & incompetent with result venous
pooling / edema
Abnormal dilation of veins of lower extremities and trunks due to incompetent
valve resulting to increased venous pooling resulting to venous stasis causing
decrease venous return
Predisposing Factors
1. Hereditary
2. Congenital weakness of the veins
3. Thrombophlebitis
4. Cardiac disorder
5. Pregnancy
6. Obesity
7. Prolonged standing or sitting

4.

Heaviness in legs

1.
2.
3.

Venography
Trendelenburg Test: veins distends quickly in less than 35 seconds
Doppler Ultrasound: decreased or no blood flow heard after calf or thigh
compression

Dx

Medical Management
1. Vein Ligation: involves ligating the saphenous vein where it joins the femoral
vein & stripping the saphenous vein system fro groin to ankles
2. Sclerotherapy: can recur & only done in spider web varicosities & danger of
thrombosis (2-3 years for embolism)
Nursing Intervention
1. Elevate legs above heart level: to promote increased venous return by placing 23 pillows under the legs
2. Measure the circumference of ankle & calf muscle daily: to determine if swollen
3. Apply anti-embolic / knee-length stockings
4. Provide adequate rest
5. Administer medications as ordered
a. Analgesics: for pain
6. Prepare client for vein ligation if necessary
a. Provide routine pre-op care: usually OPD
b. In addition to routine post-op care:
Keep affected extremity elevated above the level of the heart: to
prevent edema
Apply elastic bandage & stockings which should be removed every 8
hours for short periods & reapplied
Assist out of bed within 24 hours ensuring the elastic stockings is
applied
Assess for increase of bleeding particularly in groin area
7. Provide client teaching & discharge planning

S/sx
1.
2.
3.

Pain after prolonged standing: relieved by elevation

Swollen dilated tortuous skin veins
Warm to touch

Thrombophlebitis (Deep vein thrombosis)

Inflammation of the vessel wall with formation of clot (thrombus), may affect
superficial or deep veins
Inflammation of the veins with thrombus formation
Most frequent veins affected are the saphenous, femoral & popliteal
Can result in damage to the surrounding tissue, ischemia & necrosis

Predisposing Factors
1. Obesity
2. Smoking
3. Related to pregnancy
4. Severe anemia
5. Prolong use of oral contraceptives: promotes lipolysis
6. Prolonged immobility
7. Trauma
8. Dehydration
9. Sepsis
10. Congestive heart failure
11. Myocardial infarction
12. Post-op complication: surgery
13. Venous cannulation: insertion of various cardiac catheter
14. Increase in saturated fats in the diet.
S/sx
1.
2.
3.

Pain in the affected extremity

Superficial vein: Tenderness, redness induration along course of the vein
Deep vein:
Swelling
Venous distention of limb
Tenderness over involved vein
Positive homans sign: pain at the calf or leg muscle upon dorsi flexion of
the foot
Cyanosis

1.
2.

Venography (Phlebography): increased uptake of radioactive material

Doppler ultrasonography: impairment of blood flow ahead of thrombus

Dx

3.

Venous pressure measurement: high in affected limb until collateral circulation

is developed

Medical Management
1. Anti-coagulant therapy
a. Heparin
Action: block conversion of prothrombin to thrombin & reduces
formation or extension of thrombus
Side effects:
Spontaneous bleeding
Injection site reaction
Ecchymoses
Tissue irritation & sloughing
Reversible transient alopecia
Cyanosis
Pan in the arms or legs
Thrombocytopenia
b. Warfarin (Coumadin)
Action: block prothrombin synthesis by interfering with vit. K synthesis
Side effects:
GI:
Anorexia
N/V
Diarrhea
Stomatitis
Hypersensitivity:
Dermatitis
Urticaria
Pruritus
Fever
Other:
Transient hair loss
Burning sensation of feet
Bleeding complication
2. Surgery
a. Vein ligation & stripping

b.
c.

Venous thrombectomy: removal of cloth in the iliofemoral region

Plication of the inferior vena cava: insertion of an umbrella-like prosthesis
into the lumen of the vena cava: to filter incoming cloth

Nursing Intervention
1. Elevate legs above heart level: to promote increase venous return & decreased
edema
2. Apply warm moist pack: to reduce lymphatic congestion
3. Administer anti-coagulant as ordered:
a. Heparin
Monitor PTT: dosage should be adjusted to keep PTT between 1.5-2.5
times normal control level
Use infusion pump to administer heparin
Ensure proper injection technique
Use 26 or 27 gauge syringe with -5/8 inch needle, inject into fatty
layer of abdomen above iliac crest
Avoid injecting within 2 inches of umbilicus
o
Insert needle at 45-90 to skin
Do not withdraw plunger to assess blood return
Apply gentle pressure after removal of needle: avoid massage
Assess for increased bleeding tendencies (hematuria, hematemesis,
bleeding gums, petechiae of soft palate, conjunctiva retina,
ecchymoses, epistaxis, bloody spumtum, melena) & instruct the client
to observe for & report these
Have antidote (Protamine Sulfate) available
Instruct the client to avoid aspirin, antihistamines 7 cough preparations
containing glyceryl guaiacolate & obtain MD permission before using
other OTC drugs
b. Warfarin (Coumadin)
Assess PT daily: dosage should be adjusted to maintain PT at 1.5-2.5
times normal control level; INR of 2
Obtain careful medication history (there are many drug-drug
interaction)
Advise client to withhold dose & notify MD immediately if bleeding
occur
Have antidote (Vitamin K) available

4.
5.
6.
7.

Alert client to factors that may affect the anticoagulant response (highfat diet or sudden increased in vit. K-rich food)
Instruct the client to wear medic-alert bracelet
Assess V/S every 4 hours
Monitor chest pain or shortness of breath: possible pulmonary embolism
Measure thigh, calves, ankles & instep every morning
Provide client teaching & discharge planning
a. Need to avoid standing, sitting for long period, constrictive clothing,
crossing legs at the knee, smoking, oral contraceptives
b. Importance of adequate hydration: to prevent hypercoagubility
c. Use elastic stockings when ambulatory
d. Importance of planned rest periods with elevation of the feet
e. Drug regimen
f. Plan for exercise / activity
Begin with dorsiflexion of the feet while sitting or lying down
Swim several times weekly
Gradually increased walking distance
g. Importance of weight reduction: if obese
h. Monitor for signs of complications
a. Pulmonary Embolism
Sudden sharp chest pain
Unexplained dyspnea
Tachycardia
Palpitations
Diaphoresis
Restlessness

Overview of Anatomy & Physiology of the Respiratory System

Upper Respiratory System
Structure of the respiratory system, primarily an air conduction system, include
the nose, pharynx & larynx. Air is filtered warmed & humidified in the upper
airway before passing to lower airway.
Nose

1.

2.

3.
4.

External nose is a frame work of bone & cartilage , internally divided into two
passages or nares (nasal cavity) by the septum: air enters the system through
the nares
The septum is covered with mucous membrane, where the olfactory receptors
are located. Turbinates, located internally, assist in warming & moistening the
air
The major function of the nose are warming, moistening & filtering air.
Consist of anastomosis of capillaries known as Keissel Rach Plexus: the site of
nose bleeding

Pharynx
1. A muscular passageway commonly called the throat
2. Air passes through the nose to the pharynx
3. Serves as a muscular passageway for both food and air
Composed of three section
1. Nasopharynx: located above the soft palate of the mouth, contains the adenoids
& opening to the eustachian tubes
2. Oropharynx: located directly behind the mouth & tongue, contains the palatine
tonsils; air & food enter the body through oropharynx
3. Laryngopharynx: extends from the epiglotitis to the sixth cervical level
Larynx
1. Sometimes called voice Box connects upper & lower airways
2. Framework is formed by the hyoid bone, epiglotitis & thyroid, cricoid &
arytenoids cartilages
3. Larynx opens to allow respiration & closes to prevent aspiration when food
passes through the pharynx
4. Vocal cords of larynx permit speech & are involved in the cough reflex
5. For phonation (voice production)
Glottis
1. Opening of larynx
2. Opens to allow passage of air
3. Closes to allow passage of food going to the esophagus
4. The initial sign of complete airway obstruction is the inability to cough

Trachea
AKA Windpipe
Air move from the pharynx to larynx to trachea (length 11-13 cm, diameter 1.52.5 cm in adult)
Extend from the larynx to the second costal cartilage, where it bifurcates & is
supported by 16-20 C-shaped cartilage rings
The area where the trachea divides into two branches is called the carina
Consist of cartilaginous rings
Serves as passageway of air going to the lungs
Site of tracheostomy
Bronchi
Right main bronchus
Larger & straighter than the left
Divided into three lobar branches (upper, middle & lower bronchi) to supply
the three lobes of right lung
Left main bronchus
Divides into the upper & lower lobar bronchi to supply the left lobes
Bronchioles
In the bronchioles, airway patency is primarily dependent upon elastic recoil
formed by network of smooth muscles
The tracheobronchial tree ends at the terminal bronchials. Distal to the terminal
bronchioles the major function is no longer air conduction but gas exchange
between blood & alveolar air
The respiratory bronchioles serves as the transition to the alveolar epithelium
Lungs

Lower Respiratory System

Consist of trachea, bronchi & branches, & the lungs & associated structures
For gas exchange

Right lung (consist of 3 lobes, 10 segments)

Left lung (consist of 2 lobes, 8 segments)
Main organ of respiration, lie within the thoracic cavity on either side of the
heart
Broad area of lungs resting on diaphragm is called the base & the narrow
superior portion called the apex


Pleura
Serous membranes covering the lungs, continuous with the parietal pleura that
lines the chest wall
Parietal Pleura
Lines the chest walls & secretes small amounts of lubricating fluid into the
intrapleural space (space between the parietal pleura & visceral pleura) this
fluid holds the lungs & chest wall together as a single unit while allowing them
to move separately
Chest Wall
Includes the ribs cage, intercostal muscles & diaphragm
Chest is a C shaped & supported by 12 pairs of ribs & costal cartilages, the ribs
have several attached muscles
Contraction of the external intercostal muscles raises the ribs cage during
inspiration & helps increase the size of the thoracic cavity
The internal intercoastal muscles tends to pull ribs down & in & play a role
in forced expiration
Diaphragm
A major muscle of ventilation (the exchange of air between the atmosphere &
the alveoli).
Alveoli
Are functional cellular unit of the lungs; about half arise directly from alveolar
ducts & are responsible for about 35% of alveolar gas exchange
Produces surfactants
Site of gas exchange (CO2 and O2)
Diffusion (Daltons law of partial pressure of gases)
Surfactant
A phospholipids substance found in the fluid lining the alveolar epithelium
Reduces surface tension & increase stability of the alveoli & prevents their
collapse
Alveolar Ducts

Arises from the respiratory bronchioles & lead to the alveoli

Alveolar Sac
Form the last part of the airway
Functionally the same as the alveolar ducts they are surrounded by alveoli & are
responsible for the 65% of the alveolar gas exchange
Type II Cells of Alveoli
Secretes surfactant
Decrease surface tension
Prevent collapse of alveoli
Composed of lecithin and spingomyelin
Lecitin / Spingomyelin ratio: to determine lung maturity
Normal Lecitin / Spingomyelin ratio: is 2:1
In premature infants: 1:2
Give oxygen of less 40% in premature: to prevent atelectasis and retrolental
fibroplasias
Retinopathy & blindness: in premature
Pulmonary Circulation
Provides for reoxygenation of blood & release of CO2
Gas transfers occurs in the pulmonary capillary bed
Respiratory Distress Syndrome
Decrease oxygen stimulates breathing
Increase carbon dioxide is a powerful stimulant for breathing
Pneumonia
Inflammation of the alveolar spaces of the lungs, resulting in consolidation of
lung tissue as the alveoli fill with exudates
Inflammation of the lung parenchyma leading to pulmonary consolidation as the
alveoli is filled with exudates
Etiologic Agents
1. Streptococcus Pneumonae: causing pneumococal pneumonia
2. Hemophylus Influenzae: causing broncho pneumonia
3. Diplococcus Pneumoniae
4. Klebsella Pneumoniae

5.
6.

Escherichia Pneumoniae
Pseudomonas

High Risk Groups

1. Children below 5 years old
2. Elderly
Predisposing Factors
1. Smoking
2. Air pollution
3. Immuno compromised
4. Related to prolonged immobility (CVA clients): causing hypostatic pneumonia
5. Aspiration of food: causing aspiration pneumonia
S/sx
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Productive cough with greenish to rusty sputum

Rapid shallow respiration with expiratory grunt
Nasal flaring
Intercostal rib retraction
Use of accessory muscles of respiration
Dullness to flatness upon auscultation
Possible pleural friction rub
High-pitched bronchial breath sound
Rales / crackles (early) progressing to coarse (later)
Fever
Chills
Anorexia
General body malaise
Weight loss
Bronchial wheezing
Cyanosis
Chest pain
Abdominal distention leading to paralytic ileus (absence of peristalsis)

1.
2.

Sputum Gram Staining & Culture Sensitivity: positive to cultured microorganisms

Chest x-ray: reveals pulmonary consolidation over affected area

Dx

3.
4.

ABG analysis: reveals decrease PO2

CBC: reveals increase WBC, erythrocyte sedimentation rate is increased

Nursing Intervention
1. Facilitate adequate ventilation
Administer O2 as needed & assess its effectiveness: low inflow
Place client semi fowlers position
Turn & reposition frequently client who are immobilized
Administer analgesic as ordered: DOC: codeine: to relieve pain associated
with breathing
Auscultate breath sound every 2-4 hour
Monitor ABG
2. Facilitate removal of secretions
General hydration
Deep breathing & coughing exercise: tends to promote expectoration
Tracheobronchial suctioning as needed
Administer Mucolytic or Expectorant as ordered
Aerosol treatment via nebulizer
Humidification of inhaled air
Chest physiotherapy (Postural Drainage): tends to promote expectoration
3. Observe color characteristics of sputum & report any changes: encourage client
to perform good oral hygiene after expectoration
4. Provide adequate rest & relief control of pain
Enforce CBR with limited activity
Limit visits & minimized conversation
Plan for uninterrupted rest periods
Maintain pleasant & restful environment
5. Administer antibiotic as ordered: monitor effects & possible toxicity
Broad Spectrum Antibiotic
Penicillin
Tetracycline
Microlides (Zethromax)
Azethromycin: Side Effect: Ototoxicity
6. Prevent transmission: respiratory isolation client with staphylococcal
pneumonia
7. Control fever & chills:
Monitor temperature A

8.

Administer antipyretic as ordered

Increased fluid intake
Provide frequent clothing & linen changing
Assist in postural drainage: uses gravity & various position to stimulate the
movement of secretions

Nursing Management for Postural Drainage

a. Best done before meals or 2-3 hours: to prevent gastro esophageal reflux
b. Monitor vital signs
c. Encourage client deep breathing exercises
d. Administer bronchodilators 20-30 minutes before procedure
e. Stop if client cannot tolerate procedure
f. Provide oral care after procedure
g. Contraindicated with
Unstable V/S
Hemoptysis
Clients with increase intra ocular pressure (Normal IOP 12 21 mmHg)
Increase ICP
9. Provide increase CHO, calories, CHON & vitamin C
10. Provide client teaching & discharge planning
a. Medication regimen / antibiotic therapy
b. Need for adequate rest, limited activity, good nutrition, with adequate fluid
intake & good ventilation
c. Need to continue deep breathing & coughing exercise for at least 6-8 weeks
after discharge
d. Availability of vaccines
e. Need to report S/sx of respiratory infection
Persistent or recurrent fever
Changes in characteristics color of sputum
Chills
Increased pain
Difficulty in breathing
Weight loss
Persistent fatigue
f. Avoid smoking
g. Prevent complications
Atelectasis

h.

Meningitis
Importance of follow up care

Histoplasmosis
Systemic fungal disease caused by inhalation of dust contaminated by
histoplasma capsulatum which is transmitted to bird manure
Acute fungal infection caused by inhalation of contaminated dust or particles
with histoplasma capsulatum derived from birds manure
S/sx
1.
2.
3.
4.
5.
6.
7.
8.

Similar to PTB or Pneumonia

Productive cough
Fever, chills, anorexia, general body malaise
Chest and joint pains
Dyspnea
Cyanosis
Hemoptysis
Sometimes asymptomatic

1.
2.
3.

Chest X-ray: often appears similar to PTB

Histoplasmin Skin Test: positive
ABG analysis: PO2 decrease

Dx

Medical Management
1. Anti-fungal Agent: Amphotericin B (Fungizone)
Very toxic: toxicity includes anorexia, chills, fever, headaches & renal failure
Acetaminophen, Benadryl & Steroids is given with Amphotericin B: to
prevent reaction
Nursing Intervention
1. Monitor respiratory status
2. Enforce CBR
3. Administer oxygen inhalation
4. Administer medications as ordered
a. Antifungal: Amphotericin B (Fungizone)
Observe severe side effects:

5.
6.
7.
8.

Fever: acetaminophen given prophylactically

Anaphylactic reaction: Benadryl & Steroids given prophylactically
Abnormal renal function with hypokalemia & azotemia:
Nephrotoxicity, check for BUN and Creatinine, Hypokalemia
Force fluids to liquefy secretions
Nebulize & suction as needed
Prevent complications: bronchiectasis
Prevent the spread of infection by spraying of breeding places

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Bronchitis
Excessive production of mucus in the bronchi with accompanying persistent
cough
Characteristic include hypertrophy / hyperplasia of the mucus secreting gland in
the bronchi, decreased ciliary activity, chronic inflammation & narrowing of the
airway
Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet
mucous producing cells leading to narrowing of smaller airways
AKA Blue Bloaters
Predisposing Factors
1. Smoking
2. Air pollution

a.
b.

Dx
1. ABG analysis: reveals PO2 decrease (hypoxemia): causing cyanosis, PCO2 increase
Bronchial Asthma
Immunologic / allergic reaction results in histamine release which produces
three mainairway response: Edema of mucus membrane, Spasm of the smooth
muscle of bronchi & bronchioles, Accumulation of tenacious secretions
Reversible inflammatory lung condition due to hypersensitivity to allergens
leading to narrowing of smaller airways
Predisposing Factors (Depending on Types)
1. Extrinsic Asthma (Atopic / Allergic)
Causes
Pollen
Dust
Fumes
Smoke
Gases
Danders
Furs
Lints

S/sx
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Productive copious cough (consistent to all COPD)

Dyspnea on exertion
Use of accessory muscle of respiration
Scattered rales / rhonchi
Feeling of gastric fullness
Slight Cyanosis
Distended neck veins
Ankle edema
Prolonged expiratory grunt
Anorexia and generalized body malaise
Pulmonary hypertension

Leading to peripheral edema

Cor Pulmonale (right ventricular hypertrophy)

S/sx

2.

Intrinsic Asthma (Non atopic / Non allergic)

Causes
Hereditary
Drugs (aspirin, penicillin, beta blocker)
Foods (seafoods, eggs, milk, chocolates, chicken)
Food additives (nitrates)
Sudden change in temperature, air pressure and humidity
Physical and emotional stress

3.

Mixed Type: 90 95%

1.
2.
3.
4.
5.
6.
7.

Cough that is non productive

Dyspnea
Wheezing on expiration
Cyanosis
Mild Stress or apprehension
Tachycardia, palpitations
Diaphoresis

c.
d.

Status Asthmaticus: severe attack of asthma which cause poor

controlled asthma

DOC: Epinephrine

Steroids

Bronchodilators
Regular adherence to medications: to prevent development of status
asthmaticus
Importance of follow up care

Dx
1.
2.
3.

Pulmonary Function Test Incentive spirometer: reveals decrease vital lung

capacity
ABG analysis: PO2 decrease
Before ABG test for positive Allens Test, apply direct pressure to ulnar & radial
artery to determine presence of collateral circulation

Medical Management
1. Drug Therapy
a. Bronchodilators: given via inhalation or metered dose inhaler or MDI for 5
minutes
b. Steroids: decrease inflammation: given 10 min after bronchodilator
c. Mucomysts (acetylceisteine): at bed side put suction machine
d. Mucolytics / expectorants
e. Anti histamine
2. Physical Therapy
3. Hyposensitization
4. Execise
Nursing Intervention
1. Enforce CBR
2. O2 inhalation: low flow 2-3 L/min: to prevent respiratory distress
3. Administer medications as ordered
4. Force fluids 2-3 L/day
5. Semi fowlers position: to promote lung expansion
6. Nebulize & suction when needed
7. Provide client health teachings and discharge planning concerning
a. Avoidance of precipitating factor
b. Prevent complications

Emphysema

Bronchiectasis
Permanent abnormal dilation of the bronchi with destruction of muscular &
elastic structure of the bronchial wall
Abnormal permanent dilation of bronchus leading to destruction of muscular
and elastic tissues of alveoli
Predisposing Factors
1. Caused by bacterial infection
2. Recurrent lower respiratory tract infections
3. Chest trauma
4. Congenital defects (altered bronchial structure)
5. Related to presence of tumor (lung tumor)
6. Thick tenacious secretion
Sx
1.
2.
3.
4.
5.
6.
7.

Productive cough with mucopurulent sputum

Dyspnea in exertion
Cyanosis
Anorexia & generalized body malaise
Hemoptysis (only COPD with sign)
Wheezing
Weight loss

1.
2.
3.

CBC: elevation in WBC

ABG: PO2 decrease
Bronchoscopy: reveals sources & sites of secretion: direct visualization of
bronchus using fiberscope

Dx

S/sx
1.
2.
3.

Nursing Management before Bronchoscopy

Secure inform consent and explain procedure to client
Maintain NPO 6-8 hours prior to procedure
Monitor vital signs & breath sound

1.
2.
3.
4.

Post Bronchoscopy
Feeding initiated upon return of gag reflex
Avoid talking, coughing and smoking, may cause irritation
Monitor for signs of gross
Monitor for signs of laryngeal spasm: prepare tracheostomy set

Medical Management
1. Surgery
Pneumonectomy: 1 lung is removed & position on affected side
Segmental Wedge Lobectomy: promote re-expansion of lungs
Unaffected lobectomy: facilitate drainage
Emphysema
Enlargement & destruction of the alveolar, bronchial & bronchiolar tissue with
resultant loss of recoil, air tapping, thoracic overdistension, sputum
accumulation & loss of diaphragmatic muscle tone
These changes cause a state of CO2 retention, hypoxia & respiratory acidosis
Irreversible terminal stage of COPD characterized by
Inelasticity of alveoli
Air trapping
Maldistribution of gases
Overdistention of thoracic cavity (barrel chest)
Predisposing Factors
1. Smoking
2. Inhaled irritants: air pollution
3. Allergy or allergic factor
4. High risk: elderly
5. Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to release elastase for
recoil of alveoli

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Productive cough
Sputum production
Anorexia & generalized body malaise
Weight loss
Flaring of nostrils (alai nares)
Use of accessory muscles
Dyspnea at rest
Increased rate & depth of breathing
Decrease respiratory excursion
Resonance to hyper resonance
Decrease or diminished breath sounds with prolong expiration
Decrease tactile fremitus
Prolong expiratory grunt
Rales or rhonchi
Bronchial wheezing
Barrel chest
Purse lip breathing: to eliminates excess CO2 (compensatory mechanism)

1.
2.

Pulmonary Function Test: reveals decrease vital lung capacity

ABG analysis: reveals
Panlobular/centrilobular
Decrease PO2 (hypoxemia leading to chronic bronchitis, Blue
Bloaters)
Decrease ph

Increase PCO2

Respiratory acidosis
Panacinar/centriacinar

Increase PO2 (hyperaxemia, Pink Puffers)

Decrease PCO2

Increase ph

Respiratory alkalosis

Dx

Nursing Intervention
1. Enforce CBR
2. Administer oxygen inhalation via low inflow

3.

4.

5.

6.
7.
8.
9.

Administer medications as ordered

a. Bronchodilators: used to treat bronchospam

Aminophylline

Isoproterenol (Isuprel)

Terbutalin (Brethine)

Metaproterenol (Alupent)

Theophylline

Isoetharine (Bronkosol)
b. Corticosteroids:

Prednisone
c. Anti-microbial / Antibiotics: to treat bacterial infection

Tetracycline

Ampicilline
d. Mucolytics / expectorants
Facilitate removal of secretions:
a. Force fluids at least 3 L/day
b. Provide chest physiotherapy, coughing & deep breathing
c. Nebulize & suction when needed
d. Provide oral hygiene after expectoration of sputum
Improve ventilation
a. Position client to semi or high fowlers
b. Instruct the client diaphragmatic muscles to breathe
c. Encourage productive cough after all treatment (splint abdomen to help
produce more expulsive cough)
d. Employ pursed-lip breathing techniques (prolonged slow relaxed expiration
against pursed lips)
e. Institute pulmonary toilet
Institute PEEP (positive end expiratory pressure) in mechanical ventilation
promotes maximum alveolar lung expansion
Provide comfortable & humid environment
Provide high carbohydrates, protein, calories, vitamins and minerals
Provide client teachings and discharge planning concerning
a. Prevention of recurrent infection

Avoid crowds & individual with known infection

Adhere to high CHON, CHO & increased vit C diet

Received immunization for influenza & pneumonia

Report changes in characteristic & color of sputum immediately

b.

c.

d.

e.

f.
g.

Report of worsening of symptoms (increased tightness of chest,

fatigue, increased dyspnea)
Control of environment

Use home humidifier at 30-50%

Wear scarf over nose & mouth in cold weather: to prevent

bronchospasm

Avoid smoking & contact with environmental smoke

Avoid abrupt change in temperature

Avoidance of inhaled irritants

Stay indoor: if pollution level is high

Use air conditioner with efficiency particulate air filter: to remove

particles from air
Increase activity tolerance

Start with mild exercise: such as walking & gradual increase in amount
& duration

Used breathing techniques: (pursed lip, diaphragmatic) during activities

/ exercise: to control breathing

Have O2 available as needed to assist with activities

Plan activities that require low amount of energy

Plan rest period before & after activities

Prevent complications

Atelectasis

Cor Pulmonale: R ventricular hypertrophy

CO2 narcosis: may lead to coma

Pneumothorax: air in the pleural space

Strict compliance to medication
Importance of follow up care

Oncology Nursing
Pathophysiology & Etiology of Cancer
Evolution of Cancer Cells
All cells constantly change through growth, degeneration, repair, & adaptation.
Normal cells must divide & multiply to meet the needs of the organism as a
whole, & this cycle of cell growth & destruction is an integral part of life
processes. The activities of the normal cell in the human body are all
coordinated to meet the needs of the organism as a whole, but when the

regulatory control mechanisms of normal fail, & growth continues in excess of

the body needs, neoplasia results.
The term neoplasia refers to both benign & malignant growths, but malignant
cells behave very differently from normal cells & have special features
characteristics of the cancer process.
Since the growth control mechanism of normal cells is not entirely understood,
it is not clear what allows the uncontrolled growth, therefore no definitive cure
has been found.

Characteristics of Malignant Cells

Cancer cells are mutated stem cells that have undergone structural changes so
that they are unable to perform the normal functions of specialized tissues.
They may function is a disorderly way to crease normal function completely,
only functioning for their own survival & growth.
The most undifferentiated cells are also called anaplastic.
Rate of Growth
Cancer cells have uncontrolled growth or cell division
Rate at which a tumor grows involves both increased cell division & increased
survival time of cells.
Malignant cells do not form orderly layers, but pile on top of each other to
eventually form tumors.
Pre-disposing Factors
G Genetics
Some cancers shows familial pattern
Maybe caused by inherited genetics defects
I Immunologic
Failure of the immune system to respond & eradicate cancer cells
Immunosuppressed individuals are more susceptible to cancer
V Viral
o Viruses have been shown to be the cause of certain tumors in animals
o Viruses ( HTLV-I, Epstein Barr Virus, Human Papilloma Virus) linked to
human tumors
o Oncovirus (RNA Type Viruses) thought to be culprit
E Environmental

Majority (over 80%) of human cancer related to environmental

carcinogens
o Types:
Physical
Radiation: X ray, radium, nuclear explosion & waste,
UV
Trauma or chronic irritation
Chemical
Nitrates, & food additives, polycyclic hydrocarbons,
dyes, alkylating agents
Drugs: arsenicals, stilbestol, urethane
Cigarette smoke
hormones
Classification of Cancer
Tissue Typing:
Carcinoma arises from surface, glandular, or parenchymal epithelium
1. Squamous Cell Carcinoma surface epithelium
2. Adenocarcinoma glandular or parenchymal tissue
Sarcoma arises from connective tissue
Leukemia from blood
Lymphoma from lymph glands
Multiple Myeloma from bone marrow
Stages of Tumor Growth
A. Staging System:
TNM System: uses letters & numbers to designate the extent of tumors
o T stands for primary growth; 1-4 with increasing size; T1S indicates
carcinoma in situ
o N stands for lymph nodes involvement: 0-4 indicates progressively
advancing nodal disease
o M stands for metastasis; 0 indicates no distant metastases, 1
indicates presence of metastases
Stages 0 IV: all cancers divided into five stages incorporating size, nodal
involvement & spread
B. Cytologic Diagnosis of Cancer
1. Involves in the study of shed cells (ex. Pap smear)

2.

Classified by degree of cellular abnormality

Normal
Probably normal (slight changes)
Doubtful (more severe changes)
Probably cancer or precancerous
Definitely cancer
Client Factors
1. Seven warning signs of cancer
2. BSE breast self examination
3. Importance of retal exam for those over age 40
4. Hazards of smoking
5. Oral self examination as well as annual exam of mouth & teeth
6. Hazards of excess sun exposure
7. Importance of pap smear
8. P.E. with lab work up: every 3 years ages 20-40; yearly for age 40 & over
9. TSE testicular self examination
Testicular Cancer
i. Most common cancer in men between the age of 15 & 34
Warning signs that men should look for:
i. Painless swelling
ii. Feeling of heaviness
iii. Hard lump (size of a pea)
iv. Sudden collection fluid in the scrotum
v. Dull ache in the lower abdomen or in the groin
vi. Pain in the testicle or in the scrotum
vii. Enlargement or tenderness of the breasts

Treatment of Cancer
Therapeutic Modality

7 Warning Signs of Cancer

A. GI System

C: change in bowel or bladder habits

A: a sore that doesnt heal
U: unusual bleeding or discharge
T: thickening of lump in breast or elsewhere
I: indigestion or dysphagia
O: obvious change in wart or mole
N: nagging cough or hoarseness

Chemotherapy

Ability of the drug to kill cancer cells; normal cells may also be damaged,
producing side effects.
Different drug act on tumor cell in different stages of the cell growth cycle.

Types of Chemotherapeutic Drugs

1.
2.
3.

4.
5.

Antimetabolites
o Foster cancer cell death by interfering with cellular metabolic process.
Alkylating Agent
o act with DNA to hinder cell growth & division.
Plant Alkaloids
o obtained from periwinkle plant.
o makes the hosts body a less favorable environment for the growth of
cancer cells.
Antitumor Antibiotics
o affect RNA to make environment less favorable for cancer growth.
Steroids & Sex Hormones
o alter the endocrine environment to make it less conducive to growth of
cancer cells.

Major Side Effects & Nursing Intervention

Nausea & Vomiting

o Administer antiemetics routinely q 4-6 hrs as well as prophylactically
before chemotherapy is initiated.
o Withhold food/fluid 4-6 hrs before chemotherapy
o Provide bland food in small amounts after treatment

Diarrhea
o Administer antidiarrheals.

o
o
o

Maintain good perineal care.

Give clear liquids as tolerated.
Monitor K, Na, Cl levels.

Stomatitis (mouth sore)

o Provide & teach the client good oral hygiene, including avoidance of
commercial mouthwashes.
o Rinse with viscous lidocaine before meals to provide analgesic effect.
o Perform a cleansing rinse with plain H2O or dilute a H2O soluble
lubricant such as hydrogen peroxide after meal.
o Apply H2O lubricant such as K-Y jelly to lubricate cracked lips.
o Advice client to suck on Popsicles or ice chips to provide moisture.

B. Hematologic System

Thrombocytopenia
o Avoid bumping or bruising the skin.
o Protect client from physical injury.
o Avoid aspirin or aspirin products.
o Avoid giving IM injections.
o Monitor blood counts carefully.
o Assess for signs of increase bleeding tendencies (epistaxis, petechiae,
ecchymoses)
Leukopenia
o Use careful handwashing technique.
o Maintain reverse isolation if WBC count drops below 1000/mm
o Assess for signs of respiratory infection
o Avoid crowds/persons with known infection
Anemia
o
o
o
o

Provide adequate rest period

Monitor hemoglobin & hematocrit
Protect client from injury
Administer O2 if needed

C. Integumentary System

Alopecia
o Explain that hair loss is not permanent
o Offer support & encouragement
o Scalp tourniquets or scalp hypothermia via ice pack may be ordered to
minimize hair loss with some agent
o Advice client to obtain wig before initiating treatment

D. Renal System

Encourage fluid & frequent voiding to prevent accumulation of metabolites in

bladder; R: may cause direct damage to kidney by excretion of metabolites.
Increased excretion of uric acid may damage kidney
Administer allopurinol (Zyloprim) as ordered; R: to prevent uric acid formation;
encourage fluids when administering allopurinol

E. Reproductive System

Damage may occur to both men & women resulting infertility &/or mutagenic
damage to chromosomes
Banking sperm often recommended for men before chemotherapy
Clients & partners advised to use reliable methods of contraception during
chemotherapy

F. Neurologic System

Plant alkaloids (vincristine) cause neurologic damage with repeated doses

Peripheral neuropathies, hearing loss, loss of deep tendon reflex, & paralytic
ileus may occur.

Radiation Therapy
Uses ionizing radiation to kill or limit the growth of cancer cells, maybe internal
or external.
It not only injured cell membrane but destroy & alter DNA so that the cell
cannot reproduce.

Effects cannot be limited to cancer cells only; all exposed cells including normal
cells will be injured causing side effects.
Localized effects are related to the area of the body being treated; generalized
effects maybe related to cellular breakdown products.

Types of Energy Emitted

Alpha particles cannot passed through skin, rarely used.
Beta particle cannot passed through skin, more penetrating than alpha,
generally emitted from radioactive isotopes, used for internal source.
Gamma penetrate more deeper areas of the body, most common form of
external radiotherapy (ex. Electromagnetic or X-ray)
Methods of Delivery
External Radiation Therapy beams high energy rays directly to the affected
area. Ex. Cobalt therapy
Internal Radiation Therapy radioactive material is injected or implanted in the
clients body for designated period of time.
o Sealed Implants a radioisotope enclosed in a container so it does not
circulate in the body; clients body fluids should not be contaminated.
o Unsealed source a radioisotope that is not encased in a container &
does circulate in the body & contaminate body fluids.

Factors Controlling Exposure

Half-life time required for half of radioactive atoms to decay.
1. Each radioisotope has different half-life.
2. At the end of half-life the danger from exposure decreases.
Time the shorter the duration the less the exposure.
Distance the greater the distance from the radiation source the less the
exposure.
Shielding all radiation can be blocked; rubber gloves for alpha & usually beta
rays; thick lead or concrete stop gamma rays.
Side Effects of Radiation Therapy & Nursing Intervention
A. Skin - itching, redness, burning, oozing, sloughing.
Keep skin free from foreign substances.

Avoid use of medicated solution, ointment, or powders that contain heavy

metals such as zinc oxide.
Avoid pressure, trauma, infection to skin; use bed cradle.
Wash affected areas with plain H2O & pat dry; avoid soap.
Use cornstarch, olive oil for itching; avoid talcum powder.
If sloughing occurs, use sterile dressing with micropore tape
Avoid exposing skin to heat, cold, or sunlight & avoid constricting irritating
clothing.
B. Anorexia, N/V
Arrange meal time so they do not directly precede or follow therapy.
Encourage bland foods.
Provide small attractive meals.
Avoid extreme temperature.
Administer antiemetics as ordered before meals.
C. Diarrhea
Encourage low residue, bland, high CHON food.
Administer antidiarrheal as ordered.
Provide good perineal care.
Monitor electrolytes particularly Na, K, Cl
D. Anemia, Leukopenia, Thrombocytopenia
Isolate from those with known infection.
Provide frequent rest period.
Encourage high CHON diet.
Avoid injury.
Assess for bleeding.
Monitor CBC, WBC, & platelets.
Burns

Type:
1.
2.
3.
4.

direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Thermal
Smoke Inhalation
Chemical
Electrical

Classification

Partial Thickness
1. Superficial partial thickness (1st degree)
Depth: epidermis only
Causes: sunburn, splashes of hot liquid
Sensation: painful
Characteristics: erythema, blanching on pressure, no vesicles
2. Deep Partial Thickness (2nd degree)
Depth: epidermis & dermis
Causes: flash, scalding, or flame burn
Sensation: very painful
Characteristics: fluid filled vesicles; red, shinny, wet after
vesicles ruptures
Full Thickness (3rd & 4th degree)
1. Depth: all skin layers & nerve endings; may involve muscles, tendons &
bones
2. Causes: flames, chemicals, scalding, electric current
3. Sensation: little or no pain
4. Characteristics: wound is dry, white, leathery, or hard

Overview Of Anatomy & Physiology Of Musculoskeletal System

Consist of bones, muscles, joints, cartilages, tendons, ligaments, bursae
To provide a structural framework for the body
To provide a means for movement
Bones

1.

Function of Bones
Provide support to skeletal framework
Assist in movement by acting as levers for muscles
Protect vital organ & soft tissue
Manufacture RBC in the red bone marrow (hematopoiesis)
Provide site for storage of calcium & phosphorus
Types of Bones
Long Bones
Central shaft (diaphysis) made of compact bone & two end (epiphyses)
composed of cancellous bones (ex. Femur & humerus)
Short Bones

Joints

Cancellous bones covered by thin layer of compact bone (ex. Carpals &
tarsals)
Flat Bones
Two layers of compact bone separated by a layer of cancellous bone
(ex. Skull & ribs)
Irregular Bones
Sizes and shapes vary (ex. Vertebrae & mandible)

Articulation of bones occurs at joints

Movable joints provide stabilization and permit a variety of movements

Classification
1. Synarthroses: immovable joints
2. Amphiarthroses: partially movable joints
3. Diarthroses (synovial): freely movable joints
Have a joint cavity (synovial cavity) between the articulating bone surfaces
Articular cartilage covers the ends of the bones
A fibrous capsule encloses the joint
Capsule is lined with synovial membrane that secretes synovial fluid to
lubricate the joint and reduce friction.
Muscles
Functions of Muscles
Provide shape to the body
Protect the bones
Maintain posture
Cause movement of body parts by contraction
Types of Muscles
Cardiac: involuntary; found only in heart
Smooth: involuntary; found in walls of hollow structures (e.g. intestines)
Striated (skeletal): voluntary
1.

Characteristics of skeletal muscles

Muscles are attached to the skeleton at the point of origin and to
bones at the point of insertion.

Have properties of contraction and extension, as well as elasticity, to

permit isotonic (shortening and thickening of the muscle) and
isometric (increased muscle tension) movement.
Contraction is innervated by nerve stimulation.

Rheumatoid Arthritis (RA)

Chronic systemic disease characterized by inflammatory changes in joints and
related structures.
Joint distribution is symmetric (bilateral): most commonly affects smaller
peripheral joints of hands & also commonly involves wrists, elbows, shoulders,
knees, hips, ankles and jaw.
If unarrested, affected joints progress through four stages of deterioration:
synovitis, pannus formation, fibrous ankylosis, and bony ankylosis.
Cause
1. Cause unknown or idiopathic
2. Maybe an autoimmune process
3. Genetic factors
4. Play a role in society (work)
Predisposing factors
1. Occurs in women more often than men (3:1) between the ages 35-45.
2. Fatigue
3. Cold
4. Emotional stress

Infection

1.
2.
3.
4.
5.

Fatigue
Anorexia & body malaise
Weight loss
Slight elevation in temperature
Joints are painful: warm, swollen, limited in motion, stiff in morning & after a
period of inactivity & may show crippling deformity in long-standing disease.
Muscle weakness secondary to inactivity
History of remissions and exacerbations
Some clients have additional extra-articular manifestations: subcutaneous
nodules; eye, vascular, lung, or cardiac problems.

S/sx

Cartilage
A form of connective tissue
Major functions are to cushion bony prominences and offer protection where
resiliency is required
Tendons and Ligaments
Composed of dense, fibrous connective tissue
Functions
1. Ligaments attach bone to bone
2. Tendons attach muscle to bone

5.

6.
7.
8.

Dx
1.
2.
3.
4.
5.
6.

X-rays: shows various stages of joint disease

CBC: anemia is common
ESR: elevated
Rheumatoid factor positive
ANA: may be positive
C-reactive protein: elevated

Medical Management
1. Drug therapy
a. Aspirin: mainstay of treatment: has both analgesic and anti-inflammatory
effect.
b. Nonsteroidal anti-inflammatory drugs (NSAIDs): relieve pain and
inflammation by inhibiting the synthesis of prostaglandins.
Ibuprofen (Motrin)
Indomethacin (Indocin)
Fenoprofen (Nalfon)
Mefenamic acid (Ponstel)
Phenylbutazone (Butazolidin)
Piroxicam (Feldene)
Naproxen (Naprosyn)
Sulindac (Clinoril)
c. Gold compounds (Chrysotherapy)

2.
3.

Injectable form: given IM once a week; take 3-6 months to become

effective
Sodium thiomalate (Myochrysine)
Aurothioglucose (Solganal)
SI: monitor blood studies & urinalysis frequently
Proteinuria
Mouth ulcers
Skin rash
Aplastic anemia.
Oral form: smaller doses are effective; take 3-6 months to become
effective
Auranofin (Ridaura)
SI: blood & urine studies should be monitored.
Diarrhea
d. Corticosteroids
Intra-articular injections: temporarily suppress inflammation in specific
joints.
Systemic administration: used only when client does not respond to
less potent anti-inflammatory drugs.
e. Methotrexate: given to suppress immune response
Cytoxan
SI: bone marrow suppression.
Physical therapy: to minimize joint deformities.
Surgery: to remove severely damaged joints (e.g. total hip replacement; knee
replacement).

Nursing Interventions
1. Assess joints for pain, swelling, tenderness & limitation of motion.
2. Promote maintenance of joint mobility and muscle strength.
a. Perform ROM exercises several times a day: use of heat prior to exercise
may decrease discomfort; stop exercise at the point of pain.
b. Use isometric or other exercise to strengthen muscles.
3. Change position frequently: alternate sitting, standing & lying.
4. Promote comfort & relief / control of pain.
a. Ensure balance between activity & rest.
b. Provide 1-2 scheduled rest periods throughout day.

c.

Rest & support inflamed joints: if splints used: remove 1-2 times/day for
gentle ROM exercises.
5. Ensure bed rest if ordered for acute exacerbations.
a. Provide firm mattress.
b. Maintain proper body alignment.
c. Have client lie prone for hour twice a day.
d. Avoid pillows under knees.
e. Keep joints mainly in extension, not flexion.
f. Prevent complications of immobility.
6. Provide heat treatments: warm bath, shower or whirlpool; warm, moist
compresses; paraffin dips as ordered.
a. May be more effective in chronic pain.
b. Reduce stiffness, pain & muscle spasm.
7. Provide cold treatments as ordered: most effective during acute episodes.
8. Provide psychologic support and encourage client to express feelings.
9. Assists clients in setting realistic goals; focus on client strengths.
10. Provide client teaching & discharge planning & concerning.
a. Use of prescribed medications & side effects
b. Self-help devices to assist in ADL and to increase independence
c. Importance of maintaining a balance between activity & rest
d. Energy conservation methods
e. Performance of ROM, isometric & prescribed exercises
f. Maintenance of well-balanced diet
g. Application of resting splints as ordered
h. Avoidance of undue physical or emotional stress
i. Importance of follow-up care
Osteoarthritis
Chronic non-systemic disorder of joints characterized by degeneration of
articular cartilage
Weight-bearing joints (spine, knees and hips) & terminal interphalangeal joints
of fingers most commonly affected
Incident Rate
1. Women & men affected equally
2. Incidence increases with age

Predisposing Factors
1. Most important factor in development is aging (wear & tear on joints)
2. Obesity
3. Joint trauma

c.
d.
e.
f.

Measures to relieve strain on joints

ROM and isometric exercises
Maintenance of a well-balanced diet
Use of heat/ice as ordered.

S/sx
1.
2.
3.

Pain: (aggravated by use & relieved by rest) & stiffness of joints

Heberdens nodes: bony overgrowths at terminal interphalangeal joints
Decreased ROM with possible crepitation (grating sound when moving joints)

1.
2.

X-rays: show joint deformity as disease progresses

ESR: may be slightly elevated when disease is inflammatory

Dx

Nursing Interventions
1. Assess joints for pain & ROM.
2. Relieve strain & prevent further trauma to joints.
a. Encourage rest periods throughout day.
b. Use cane or walker when indicated.
c. Ensure proper posture & body mechanics.
d. Promote weight reduction: if obese
e. Avoid excessive weight-bearing activities & continuous standing.
3. Maintain joint mobility and muscle strength.
a. Provide ROM & isometric exercises.
b. Ensure proper body alignment.
c. Change clients position frequently.
4. Promote comfort / relief of pain.
a. Administer medications as ordered:

Aspirin & NSAID: most commonly used

Corticosteroids (Intra-articular injections): to relieve pain & improve

mobility.
b. Apply heat or ice as ordered (e.g. warm baths, compresses, hot packs): to
reduce pain.
5. Prepare client for joint replacement surgery if necessary.
6. Provide client teaching and discharge planning concerning
a. Used of prescribed medications and side effects
b. Importance of rest periods

Gout
A disorder of purine metabolism; causes high levels of uric acid in the blood &
the precipitation of urate crystals in the joints
Inflammation of the joints caused by deposition of urate crystals in articular
tissue
Incident Rate
1. Occurs most often in males
2. Familial tendency
S/sx
1.
2.
3.
4.
5.

Joint pain
Redness
Heat
Swelling
Joints of foot (especially great toe) & ankle most commonly affected (acute
gouty arthritis stage)
6. Headache
7. Malaise
8. Anorexia
9. Tachycardia
10. Fever
11. Tophi in outer ear, hands & feet (chronic tophaceous stage)
Dx
1.

CBC: uric acid elevated

Medical Management
1. Drug therapy
a. Acute attack:

Colchicine IV or PO: discontinue if diarrhea occurs

2.
3.
4.

NSAID: Indomethacin (Indocin)

Naproxen (Naprosyn)
Phenylbutazone (Butazolidin)
b. Prevention of attacks

Uricosuric agents: increase renal excretion of uric acid

Probenecid (Benemid)

Sulfinpyrazone (Anturanel)

Allopurinal (Zyloprim): inhibits uric acid formation

Low-purine diet may be recommended
Joint rest & protection
Heat or cold therapy

Nursing Interventions
1. Assess joints for pain, motion & appearance.
2. Provide bed rest & joint immobilization as ordered.
3. Administer anti-gout medications as ordered.
4. Administer analgesics as ordered: for pain
5. Increased fluid intake to 2000-3000 ml/day: to prevent formation of renal
calculi.
6. Apply local heat or cold as ordered: to reduce pain
7. Apply bed cradle: to keep pressure of sheets off joints.
8. Provide client teaching and discharge planning concerning
a. Medications & their side effects
b. Modifications for low-purine diet: avoidance of shellfish, liver, kidney,
brains, sweetbreads, sardines, anchovies
c. Limitation of alcohol use
d. Increased in fluid intake
e. Weight reduction if necessary
f. Importance of regular exercise

1.
2.
3.

Pathophysiology
1. A defect in bodys immunologic mechanisms produces autoantibodies in the
serum directed against components of the clients own cell nuclei.
2. Affects cells throughout the body resulting in involvement of many organs,
including joints, skin, kidney, CNS & cardiopulmonary system.
S/sx
1.
2.
3.
4.
5.
6.
7.
8.
9.

10.
11.
12.

13.
Systemic Lupus Erythematosus (SLE)
Chronic connective tissue disease involving multiple organ systems
Incident Rate
1. Occurs most frequently in young women
Predisposing Factors

Cause unknown
Immune
Genetic & viral factors have all been suggested

14.

Fatigue
Fever
Anorexia
Weight loss
Malaise
History of remissions & exacerbations
Joint pain
Morning stiffness
Skin lesions
Erythematous rash on face, neck or extremities may occur
Butterfly rash over bridge of nose & cheeks
Photosensitivity with rash in areas exposed to sun
Oral or nasopharyngeal ulcerations
Alopecia
Renal system involvement
Proteinuria
Hematuria
Renal failure
CNS involvement
Peripheral neuritis
Seizures
Organic brain syndrome
Psychosis
Cardiopulmonary system involvement
Pericarditis
Pleurisy

15. Increase susceptibility to infection

g.

Dx
1.
2.
3.
4.
5.
6.

ESR: elevated
CBC: RBC anemia, WBC & platelet counts decreased
Anti-nuclear antibody test (ANA): positive
Lupus Erythematosus (LE prep): positive
Anti-DNA: positive
Chronic false-positive test for syphilis

Medical Management
1. Drug therapy
a. Aspirin & NSAID: to relieve mild symptoms such as fever & arthritis
b. Corticosteroids: to suppress the inflammatory response in acute
exacerbations or severe disease
c. Immunosuppressive agents: to suppress the immune response when client
unresponsive to more conservative therapy
Azathioprine (Imuran)
Cyclophosphamide (Cytoxan)
2. Plasma exchange: to provide temporary reduction in amount of circulating
antibodies.
3. Supportive therapy: as organ systems become involved.

h.
i.
j.

Need to avoid direct exposure to sunlight: wear hat & other protective
clothing
Need to avoid exposure to persons with infections
Importance of regular medical follow-up
Availability of community agencies

Osteomyelitis
Infection of the bone and surrounding soft tissues, most commonly caused by S.
aureus.
Infection may reach bone through open wound (compound fracture or surgery),
through the bloodstream, or by direct extension from infected adjacent
structures.
Infections can be acute or chronic; both cause bone destruction.
S/sx
1.
2.
3.
4.
5.
6.

Malaise
Fever
Pain & tenderness of bone
Redness & swelling over bone
Difficulty with weight-bearing
Drainage from wound site may be present.

1.
2.
3.

CBC: WBC elevated

Blood cultures: may be positive
ESR: may be elevated

Dx
Nursing Interventions
1. Assess symptoms to determine systems involved.
2. Monitor vital signs, I&O, daily weights.
3. Administer medications as ordered.
4. Institute seizure precautions & safety measures: with CNS involvement.
5. Provide psychologic support to client / significant others.
6. Provide client teaching & discharge planning concerning
a. Disease process & relationship to symptoms
b. Medication regimen & side effects.
c. Importance of adequate rest.
d. Use of daily heat & exercises as prescribed: for arthritis.
e. Need to avoid physical or emotional stress
f. Maintenance of a well-balanced diet

Nursing Interventions
1. Administer analgesics & antibiotics as ordered.
2. Use sterile techniques during dressing changes.
3. Maintain proper body alignment & change position frequently: to prevent
deformities.
4. Provide immobilization of affected part as ordered.
5. Provide psychologic support & diversional activities (depression may result from
prolonged hospitalization)
6. Prepare client for surgery if indicated.
Incision & drainage: of bone abscess

7.

Sequestrectomy: removal of dead, infected bone & cartilage

Bone grafting: after repeated infections
Leg amputation
Provide client teaching and discharge planning concerning
Use of prescribed oral antibiotic therapy & side effects
Importance of recognizing & reporting signs & complications (deformity,
fracture) or recurrence

FRACTURES
A. General information
1.
B. Medical management
C. Assessment findings
D. Nursing interventions
Overview of Anatomy & Physiology Gastro Intestinal Track System
The primary function of GIT are the movement of food, digestion, absorption,
elimination & provision of a continuous supply of the nutrients electrolytes &
H2O.
Upper alimentary canal: function for digestion
Mouth
Consist of lips & oral cavity
Provides entrance & initial processing for nutrients & sensory data such as taste,
texture & temperature
Oral Cavity: contains the teeth used for mastication & the tongue which
assists in deglutition & the taste sensation & mastication
Salivary gland: located in the mouth produce secretion containing pyalin for
starch digestion & mucus for lubrication
Pharynx: aids in swallowing & functions in ingestion by providing a route for
food to pass from the mouth to the esophagus
Esophagus
Muscular tube that receives foods from the pharynx & propels it into the
stomach by peristalsis
Stomach

Located on the left side of the abdominal cavity occupying the hypochondriac,
epigastric & umbilical regions
Stores & mixes food with gastric juices & mucus producing chemical &
mechanical changes in the bolus of food
The secretion of digestive juice is stimulated by smelling, tasting & chewing
food which is known as cephalic phase of digestion
The gastric phase is stimulated by the presence of food in the stomach &
regulated by neural stimulation via PNS & hormonal stimulation through
secretion of gastrin by the gastric mucosa
After processing in the stomach the food bolus called chyme is released into
the small intestine through the duodenum
Two sphincters control the rate of food passage
Cardiac Sphincter: located at the opening between the esophagus &
stomach
Pyloric Sphincter: located between the stomach & duodenum
Three anatomic division
Fundus
Body
Antrum
Gastric Secretions:
Pepsinogen: secreted by the chief cells located in the fundus aid in CHON
digestion
Hydrocholoric Acid: secreted by parietal cells, function in CHON digestion &
released in response to gastrin
Intrinsic Factor: secreted by parietal cell, promotes absorption of Vit B12
Mucoid Secretion: coat stomach wall & prevent auto digestion

1st half of duodenum

Middle Alimentary canal: Function for absorption; Complete absorption: large intestine
Small Intestines
Composed of the duodenum, jejunum & ileum
Extends from the pylorus to the ileocecal valve which regulates flow into the
large intestines to prevent reflux to the into the small intestine
Major function: digestion & absorption of the end product of digestion
Structural Features:

Villi (functional unit of the small intestines): finger like projections located
in the mucous membrane; containing goblet cells that secrets mucus &
absorptive cells that absorb digested food stuff
Crypts of Lieberkuhn: produce secretions containing digestive enzymes
Brunners Gland: found in the submucosaof the duodenum, secretes mucus

2nd half of duodenum

Jejunum
Ileum
1st half of ascending colon
Lower Alimentary Canal: Function: elimination
Large Intestine
Divided into four parts:
Cecum (with appendix)
Colon (ascending, transverse, descending, sigmoid)
Rectum
Anus
Serves as a reservoir for fecal material until defecation occurs
Function: to absorb water & electrolytes
MO present in the large intestine: are responsible for small amount of further
breakdown & also make some vitamins
Amino Acids: deaminated by bacteria resulting in ammonia which is
converted to urea in the liver
Bacteria in the large intestine: aid in the synthesis of vitamin K & some of
the vitamin B groups
Feces (solid waste): leave the body via rectum & anus
Anus: contains internal sphincter (under involuntary control) & external
sphincter (voluntary control)
Fecal matter: usually 75% water & 25% solid wastes (roughage, dead
bacteria, fats, CHON, inorganic matter)
nd
a. 2 half of ascending colon
b. Transverse
c. Descending colon
d. Sigmoid
e. Rectum

Accessory Organ
Liver
Largest internal organ: located in the right hypochondriac & epigastric regions of
the abdomen
Liver Loobules: functional unit of the liver composed of hepatic cells
Hepatic Sinusoids (capillaries): are lined with kupffer cells which carry out the
process of phagocytosis
Portal circulation brings blood to the liver from the stomach, spleen, pancreas &
intestines
Function:
Metabolism of fats, CHO & CHON: oxidizes these nutrient for energy &
produces compounds that can be stored
Production of bile
Conjugation & excretion (in the form of glycogen, fatty acids, minerals, fatsoluble & water-soluble vitamins) of bilirubin
Storage of vitamins A, D, B12 & iron
Synthesis of coagulation factors
Detoxification of many drugs & conjugation of sex hormones
Salivary gland
Verniform appendix
Liver
Pancreas: auto digestion
Gallbladder: storage of bile
Biliary System
Consist of the gallbladder & associated ductal system (bile ducts)
Gallbladder: lies under the surface of the liver
Function: to concentrate & store bile
Ductal System: provides a route for bile to reach the intestines
Bile: is formed in the liver & excreted into hepatic duct
Hepatic Duct: joins with the cystic duct (which drains the gallbladder) to
form the common bile duct
If the sphincter of oddi is relaxed: bile enters the duodenum, if contracted: bile
is stored in gallbladder

Pancreas
Positioned transversely in the upper abdominal cavity
Consist of head, body & tail along with a pancreatic duct which extends along
the gland & enters the duodenum via the common bile duct
Has both exocrine & endocrine function
Function in GI system: is exocrine
Exocrine cells in the pancreas secretes:
Trypsinogen & Chymotrypsin: for protein digestion
Amylase: breakdown starch to disacchardes
Lipase: for fat digestion
Endocrine function related to islets of langerhas
Physiology of Digestion & Absorption
Digestion: physical & chemical breakdown of food into absorptive substance
Initiate in the mouth where the food mixes with saliva & starch is broken
down
Food then passes into the esophagus where it is propelled into the stomach
In the stomach food is processed by gastric secretions into a substance
called chyme
In the small intestines CHO are hydrolyzed to monosaccharides, fats to
glycerol & fatty acid & CHON to amino acid to complete the digestive
process
When chymes enters the duodenum, mucus is secreted to neutralized
hydrocholoric acid, in response to release secretin, pancreas releases
bicarbonate to neutralized acid chyme
Cholecystokinin & Pancreozymin (CCKPZ)
Are produced by the duodenal mucosa
Stimulate contraction of the gallbladder along with relaxation of
the sphincter of oddi (to allow bile flow from common bile duct
into the duodenum) & stimulate release of the pancreatic enzymes
Salivary Glands
1. Parotid below & front of ear
2. Sublingual
3. Submaxillary

Produces saliva for mechanical digestion

1200 -1500 ml/day - saliva produced

Disorder of the GIT

Peptic Ulcer Disease (PUD)
Gastric Ulcer
Ulceration of the mucosal lining of the stomach
Most commonly found in the antrum
Excoriation / erosion of submucosa & mucosal lining due to:
Hypersecretion of acid: pepsin
Decrease resistance to mucosal barrier
Caused by bacterial infection: Helicobacter Pylori
Doudenal Ulcer
Most commonly found in the first 2 cm of the duodenum
Characterized by gastric hyperacidity & a significant rate of gastric emptying
Predisposing factor
Smoking: vasoconstriction: effect GIT ischemia
Alcohol Abuse: stimulates release of histamine: Parietal cell release Hcl acid =
Ulceration
Emotional Stress
Drugs:
Salicylates (Aspirin)
Steroids
Butazolidin
S/sx

Site

Pain

Gastric Ulcer
Ulcer
Antrum or lesser curvature
30 min-1 hr after
eating
Left epigastrium
Gaseous & burning
Not usually

Duodenal
Duodenal bulb
2-3 hrs after
eating
Mid epigastrium
Cramping &
burning

relieved by food &

antacid

Usually relieved
by food & antacid
12 MN 3am
pain
Increased gastric
acid secretion
Not common
Melena
Weight gain
Perforation

20 years old

Hypersecretion

Vomiting
Hemorrhage
Weight
Complications

High Risk

Hgb & Hct: decrease (if anemic)

Endoscopy: reveals ulceration & differentiate ulceration from gastric cancer
Gastric Analysis: normal gastric acidity
Upper GI series: presence of ulcer confirm

Normal gastric acid

secretion
Common
Hematemeis
Weight loss
Stomach cause
Hemorrhage
60 years old

Maalox
SE: fever

Dx

Medical Management
1. Supportive:
Rest
Bland diet
Stress management
2. Drug Therapy:
Antacids: neutralizes gastric acid
Aluminum hydroxide: binds phosphate in the GIT & neutralized gastric
acid & inactivates pepsin
Magnesium & aluminum salt: neutralized gastric acid & inactivate
pepsin if pH is raised to >=4
Aluminum containing Antacids
Antacids
Ex. Aluminum OH gel (Amphojel)
SE: Constipation

3.

Histamines (H2) receptor antagonist: inhibits gastric acid secretion of

parietal cells
Ranitidine (Zantac): has some antibacterial action against H. pylori
Cimetidine (Tagamet)
Famotidine (Pepcid)
Anticholinergic:
Atropine SO4: inhibit the action of acetylcholine at post ganglionic site
(secretory glands) results decreases GI secretions
Propantheline: inhibit muscarinic action of acetylcholine resulting
decrease GI secretions
Proton Pump Inhibitor: inhibit gastric acid secretion regardless of
acetylcholine or histamine release
Omeprazole (Prilosec): diminished the accumulation of acid in the
gastric lumen & healing of duodenal ulcer
Pepsin Inhibitor: reacts with acid to form a paste that binds to ulcerated
tissue to prevent further destruction by digestive enzyme pepsin
Sucralfate (Carafate): provides a paste like subs that coats mucosal
lining of stomach
Metronidazole & Amoxacillin: for ulcer caused by Helicobacter Pylori
Surgery:
Gastric Resection
Anastomosis: joining of 2 or more hollow organ
Subtotal Gastrectomy: Partial removal of stomach
Before surgery for BI or BII
Do Vagotomy (severing or cutting of vagus nerve) & Pyloroplasty
(drainage) first

Magnesium containing
Ex. Milk of Magnesia
SE: Diarrhea

Billroth I (Gastroduodenostomy)
Removal of of stomach &
anastomoses of gastric stump to
the duodenum.

Billroth II (Gastrojejunostomy)
Removal of -3/4 of stomach &
duodenal bulb & anastomostoses of
gastric stump to jejunum.

Nursing Intervention Post op

1. Monitor NGT output
Immediately post op should be bright red
Within 36-42 hrs: output is yellow green
After 42 hrs: output is dark red
2. Administer medication
Analgesic
Antibiotic
Antiemetics
3. Maintain patent IV line
4. Monitor V/S, I&O & bowel sounds
5. Complications:
Hemorrhage: Hypovolemic shock: Late signs: anuria
Peritonitis
Paralytic ileus: most feared
Hypokalemia
Thromobphlebitis
Pernicious anemia
Nursing Intervention
1. Administer medication as ordered
2. Diet: bland, non irritating, non spicy
3. Avoid caffeine & milk / milk products: Increase gastric acid secretion
4. Provide client teaching & discharge planning
a. Medical Regimen
Take medication at prescribe time
Have antacid available at all times
Recognized situation that would increase the need for antacids
Avoid ulcerogenic drugs: salicylates, steroids
Know proper dosage, action & SE
b. Proper Diet
Bland diet consist of six meals / day
Eat slowly
Avoid acid producing substance: caffeine, alcohol, highly seasoned food
Avoid stressfull situation at mealtime
Plan rest period after meal

c.

Avoid late bedtime snacks

Avoidance of stress-producing situation & development of stress
production methods
Relaxation techniques
Exercise
Biofeedback

Dumping syndrome
Abrupt emptying of stomach content into the intestine
Rapid gastric emptying of hypertonic food solutions
Common complication of gastric surgery
Appears 15-20 min after meal & last for 20-60 min
Associated with hyperosmolar CHYME in the jejunum which draws fluid by
osmosis from the extracellular fluid into the bowel. Decreased plasma volume &
distension of the bowel stimulates increased intestinal motility
S/sx
1.
2.
3.
4.
5.
6.
7.

Weakness
Faintness
Feeling of fullness
Dizziness
Diaphoresis
Diarrhea
Palpitations

Nursing Intervention
1. Avoid fluids in chilled solutions
2. Small frequent feeding: six equally divided feedings
3. Diet: decrease CHO, moderate fats & CHON
4. Flat on bed 15-30 min after q feeding
Disorders of the Gallbladder
Cholecystitis / Cholelithiasis
Cholecystitis:
Acute or chronic inflammation of the gallbladder
Most commonly associated with gallstones

Inflammation occurs within the walls of the gallbladder & creates thickening
accompanied by edema
Consequently there is impaired circulation, ischemia & eventually necrosis
Cholelithiasis:
Formation of gallstones & cholesterol stones
Inflammation of gallbladder with gallstone formation.

Predisposing Factor:
1. High risk: women 40 years old
2. Post menopausal women: undergoing estrogen therapy
3. Obesity
4. Sedentary lifestyle
5. Hyperlipidemia
6. Neoplasm
S/sx:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Severe Right abdominal pain (after eating fatty food): Occurring especially at
night
Intolerance of fatty food
Anorexia
N/V
Jaundice
Pruritus
Easy bruising
Tea colored urine
Steatorrhea

Dx
1. Direct Bilirubin Transaminase: increase
2. Alkaline Phosphatase: increase
3. WBC: increase
4. Amylase: increase
5. Lipase: increase
6. Oral cholecystogram (or gallbladder series): confirms presence of stones
Medical Management
1. Supportive Treatment: NPO with NGT & IV fluids
2. Diet modification with administration of fat soluble vitamins

3.

4.

Drug Therapy
Narcotic analgesic: DOC: Meperdipine Hcl (Demerol): for pain
(Morpine SO4: is contraindicated because it causes spasm of the
Sphincter of Oddi)
Antocholinergic: (Atrophine SO4): for pain
(Anticholinergic: relax smooth muscles & open bile ducts)
Antiemetics: Phenothiazide (Phenergan): with anti emetic properties
Surgery: Cholecystectomy / Choledochostomy

Nursing Intervention
1. Administer pain medication as ordered & monitor effects
2. Administer IV fluids as ordered
3. Diet: increase CHO, moderate CHON, decrease fats
4. Meticulous skin care: to relieved priritus
Disorders of the Pancreas
Pancreatitis
An inflammatory process with varying degrees of pancreatic edema, fat necrosis
or hemorrhage
Proteolytic & lipolytic pancreatic enzymes are activated in the pancreas rather
than in the duodenum resulting in tissue damage & auto digestion of pancreas
Acute or chronic inflammation of pancreas leading to pancreatic edema,
hemorrhage & necrosis due to auto digestion
Bleeding of Pancreas: Cullens sign at umbilicus
Predisposing factors:
1. Chronic alcoholism
2. Hepatobilary disease
3. Trauma
4. Viral infection
5. Penetrating duodenal ulcer
6. Abscesses
7. Obesity
8. Hyperlipidemia
9. Hyperparathyroidism
10. Drugs: Thiazide, steroids, diuretics, oral contraceptives

S/Sx:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Severe left upper epigastric pain radiates from back & flank area: aggravated by
eating with DOB
N/V
Tachycardia
Palpitation: due to pain
Dyspepsia: indigestion
Decrease bowel sounds
(+) Cullens sign: ecchymosis of umbilicus
Hemorrhage
(+) Grey Turners spots: ecchymosis of flank area
Hypocalcemia

1.
2.
3.
4.
5.
6.

Serum amylase & lipase: increase

Urinary amylase: increase
Blood Sugar: increase
Lipids Level: increase
Serum Ca: decrease
CT Scan: shows enlargement of the pancreas

Dx

Medical Management
1. Drug Therapy
Narcotic Analgesic: for pain
Meperidine Hcl (Demerol)
Dont give Morphine SO4: will cause spasm of Sphincter of Oddi
Smooth muscle relaxant: to relieve pain
Papaverine Hcl
Anticholinergic: to decrease pancreatic stimulation
Atrophine SO4
Propantheline Bromide (Profanthene)
Antacids: to decrease pancreatic stimulation
Maalox
H2 Antagonist: to decrease pancreatic stimulation
Ranitidin (Zantac)
Vasodilators: to decrease pancreatic stimulation

2.
3.
4.
5.

Nitroglycerine (NTG)
Ca Gluconate: to decrease pancreatic stimulation
Diet Modification
NPO (usually)
Peritoneal Lavage
Dialysis

Nursing Intervention
1. Administer medication as ordered
2. Withhold food & fluid & eliminate odor: to decrease pancreatic stimulation /
aggravates pain
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
Complication of TPN
Infection
Embolism
Hyperglycemia
4. Institute non-pharmacological measures: to decrease pain
Assist client to comfortable position: Knee chest or fetal like position
Teach relaxation techniques & provide quiet, restful environment
5. Provide client teaching & discharge planning
Dietary regimen when oral intake permitted
High CHO, CHON & decrease fats
Eat small frequent meal instead of three large ones
Avoid caffeine products
Eliminate alcohol consumption
Maintain relaxed atmosphere after meals
Report signs of complication
Continued N/V
Abdominal distension with feeling of fullness
Persistent weight loss
Severe epigastric or back pain
Frothy foul smelling bowel movement
Irritability, confusion, persistent elevation of temperature (2 day)
Apendicitis
Inflammation of the appendix that prevents mucus from passing into the cecum

Inflammation of verniform appendix

If untreated: ischemia, gangrene, rupture & peritonitis
May cause by mechanical obstruction (fecalith, intestinal parasites) or anatomic
defect
May be related to decrease fiber in the diet

Predisposing factor:
1. Microbial infection
2. Feacalith: undigested food particles like tomato seeds, guava seeds etc.
3. Intestinal obstruction
S/Sx:
1.
2.
3.
4.
5.
6.

Pathognomonic sign: (+) rebound tenderness

Low grade fever
N/V
Decrease bowel sound
Diffuse pain at lower Right iliac region
Late sign: tachycardia: due to pain

Dx
1.
2.
3.

CBC: mild leukocytosis: increase WBC

PE: (+) rebound tenderness (flex Right leg, palpate Right iliac area: rebound)
Urinalysis: elevated acetone in urine

5.

Nursing Intervention post op

1. If (+) Pendrose drain (rubber drain inserted at surgical wound for drainage of
blood, pus etc): indicates rupture of appendix
2. Position the client semi-fowlers or side lying on right: to facilitate drainage
3. Administer Meds:
Analgesic: due post op pain
Antibiotics: for infection
Antipyretics: for fever (PRN)
4. Monitor VS, I&O, bowel sound
5. Maintain patent IV line
6. Complications: Peritonitis, Septicemia
Liver Cirrhosis
Chronic progressive disease characterized by inflammation, fibrosis & degeneration
of the liver parenchymal cell
Destroyed liver cell are replaced by scar tissue, resulting in architectural changes &
malfunction of the liver
Lost of architectural design of liver leading to fat necrosis & scarring
Types
Laennecs Cirrhosis:
Associated with alcohol abuse & malnutrition
Characterized by an accumulation of fat in the liver cell progressing to widespread
scar formation
Postnecrotic Cirrhosis
Result in severe inflammation with massive necrosis as a complication of viral
hepatitis
Cardiac Cirrhosis
Occurs as a consequence of right sided heart failure
Manifested by hepatomegaly with some fibrosis
Biliary Cirrhosis
Associated with biliary obstruction usually in the common bile duct
Results in chronic impairment of bile excretion

Medical Management
Surgery: Appendectomy 24-45 hrs
Nursing Intervention
1. Administer antibiotics / antipyretic as ordered
2. Routinary pre-op nursing measures:
Skin prep
NPO
Avoid enema, cathartics: lead to rupture of appendix
3. Dont give analgesic: will mask pain
Presence of pain means appendix has not ruptured
4. Avoid heat application: will rupture appendix

Monitor VS, I&O bowel sound

S/sx

Fatigue
Anorexia
N/V
Dyspepsia: Indigestion
Weight loss
Flatulence
Change (Irregular) bowel habit
Ascites
Peripheral edema
Hepatomegaly: pain located in the right upper quadrant
Atrophy of the liver
Fetor hepaticus: fruity, musty odor of chronic liver disease
Aterixis: flapping of hands & tremores
Hard nodular liver upon palpation
Increased abdominal girth
Changes in moods
Alertness & mental ability
Sensory deficits
Gynecomastia
Decrease of pubic & axilla hair in males
Amenorrhea in female
Jaundice
Pruritus or urticaria
Easy bruising
Spider angiomas on nose, cheeks, upper thorax & shoulder
Palmar erythema
Muscle atrophy

Dx
Liver enzymes: increase
SGPT (ALT)
SGOT (AST)
LDH Alkaline Phosphate
Serum cholesterol &
Indirect bilirubin: increase
CBC: pancytopenia

ammonia: increase

PT: prolonged
Hepatic Ultrasonogram: fat necrosis of liver lobules
Nursing Intervention
CBR with bathroom privileges
Encourage gradual, progressive, increasing activity with planned rest period
Institute measure to relieve pruritus
Do not use soap & detergent
Bathe with tepid water followed by application of emollient lotion
Provide cool, light, non-constrictive clothing
Keep nail short: to avoid skin excoriation from scratching
Apply cool, moist compresses to pruritic area
Monitor VS, I & O
Prevent Infection
Prevent skin breakdown: by turning & skin care
Provide reverse isolation for client with severe leukopenia: handwashing technique
Monitor WBC
Diet:
Small frequent meals
Restrict Na!
High calorie, low to moderate CHON, high CHO, low fats with supplemental Vit A, Bcomplex, C, D, K & folic acid
Monitor / prevent bleeding
Measure abdominal girth daily: notify MD
With pt daily & assess pitting edema
Administer diuretics as ordered
Provide client teaching & discharge planning
Avoidance of hepatotoxicity drug: sedative, opiates or OTC drugs detoxified by liver
How to assess weight gain & increase abdominal girth
Avoid person with upper respiratory infection
Reporting signs of reccuring illness (liver tenderness, increase jaundice, increase
fatigue, anorexia)
Avoid all alcohol
Avoid straining stool vigorous blowing of nose & coughing: to decrease incidence of
bleeding
Complications:
Ascites: accumolation of free fluid in abdominal cavity

Nursing Intervention
Meds: Loop diuretics: 10-15 min effect
Assist in abdominal paracentesis: aspiration of fluid
Void before paracentesis: to prevent accidental puncture of bladder as trochar
is inserted

Kidneys
Two of bean shaped organ that lie in the retroperitonial space on either
side of the vertebral column
Retroperitonially (back of peritoneum) on either side of vertebral column
Adrenal gland is on top of each kidneys
Encased in Bowmanss capsule

Bleeding esophageal varices: Dilation of esophageal veins

Nursing Intervention
Administer meds:
Vit K
Pitrisin or Vasopresin (IM)
NGT decompression: lavage
Give before lavage: ice or cold saline solution
Monitor NGT output
Assist in mechanical decompression
Insertion of sengstaken-blackemore tube
3 lumen typed catheter
Scissors at bedside to deflate balloon.
Hepatic encephalopathy
Nursing Intervention
Assist in mechanical ventilation: due coma
Monitor VS, neuro check
Siderails: due restless
Administer meds
Laxatives: to excrete ammonia
Overview of Anatomy & Physiology Of GUT System
GUT: Genito-urinary tract
GUT includes the kidneys, ureters, urinary bladder, urethra & the male & female genitalia
Function:
Promote excretion of nitrogenous waste products
Maintain F&E & acid base balance

Renal Parenchyma
Cortex
Outermost layer
Site of glomeruli & proximal & distal tubules of nephron
Medulla
Middle layer
Formed by collecting tubules & ducts
Renal Sinus & Pelvis
Papillae
Projection of renal tissues located at the tip of the renal pyramids
Calices
Minor Calyx: collects urine flow from collecting ducts
Major Calyx: directs urine from renal sinus to renal pelvis
Urine flows from renal pelvis to ureters
Nephron
Functional unit of the kidney
Basic living unit
Renal Corpuscle (vascular system of nephron)
Bowmans Capsule:
Portion of the proximal tubule surrounds the glomerulus
Glomerulus:
Capillary network permeable to water, electrolytes, nutrients & waste
Impermeable to large CHON molecules
Filters blood going to kidneys
Renal Tubule

Divided into proximal convoluted tubule, descending loop of Henle,

acending loop of Henle, distal convoluted tubule & collecting ducts
Ureters
Two tubes approximately 25-35 cm long
Extend from the renal pelvis to the pelvic cavity where they enter the bladder,
convey urine from the kidney to the bladder
Passageway of urine to bladder
Ureterovesical valve: prevent backflow of urine into ureters
Bladder
Located behind the symphisis pubis
Composed of muscular elastic tissue that makes it distensible
Serve s as reservoir of urine (capable of holding 1000-1800 ml & 500 ml moderately
full)
Internal & external urethral sphincter controls the flow of urine
Urge to void stimulated by passage of urine past the internal sphincter (involuntary)
to the upper urethra
Relaxation of external sphincter (voluntary) produces emptying of the bladder
(voiding)
Urethra
Small tube that extends from the bladder to the exterior of the body
Passage of urine, seminal & vaginal fluids.
Females: located behind the symphisis pubis & anterior vagina & approximately
3-5 cm
Males: extend the entire length of the penis & approximately 20 cm
Function of kidneys
Kidneys remove nitrogenous waste & regulates F & E balance & acid base
balance
Urine is the end product
Urine formation: 25 % of total cardiac output is received by kidneys
Glomerular Filtration
Ultrafiltration of blood by the glomerulus, beginning of urine formation
Requires hydrostatic pressure & sufficient circulating volume

Pressure in bowmans capsule opposes hydrostatic pressure & filtration

If glomerular pressure insufficient to force substance out of the blood into the tubules
filtrate formation stops
Glomerular Filtration Rate (GFR)
Amount of blood filtered by the glomeruli in a given time
Normal: 125 ml / min
Filtrate formed has essentially same composition as blood plasma without the
CHON; blood cells & CHON are usually too large to pass the glomerular
membrane
Tubular Function
Tubules & collecting ducts carry out the function of reabsorption, secretion
& excretion
Reabsorption of H2O & electrolytes is controlled by anitdiuretics hormones
(ADH) released by the pituitary & aldosterone secreted by the adrenal
glands
Proximal Convoluted Tubule
Reabsorb the ff:
80% of F & E
H2O
Glucose
Amino acids
Bicarbonate
Secretes the ff:
Organic substance
Waste
Loop of Henli
Reabsorb the ff:
Na & Chloride in the ascending limb
H2O in the descending limb
Concentrate / dilutes urine
Distal Convoluted Tubule
Secretes the ff:
Potassium
Hydrogen ions
Ammonia
Reabsorb the ff:

H2O
Bicarbonate
Regulate the ff:
Ca
Phosphate concentration
Collecting Ducts
Received urine from distal convoluted tubules & reabsorb H2O (regulated by ADH)
Normal Adult: produces 1 L /day of urine
Regulation of BP
Through maintenance of volume (formation / excretion of urine)
Rennin-angiotensin system is the kidneys controlled mechanism that can contribute
to rise the BP
When the BP drops the cells of the glomerulus release rennin which then activates
angiotensin to cause vasoconstriction.

Aldosterone
Increase BP
Increase Na &
H2O reabsorption
Hypervolemia
Color
amber
Odor
aromatic
Consistency
clear or slightly turbid
pH
4.5 8
Specific gravity 1.015 1.030
WBC/ RBC
(-)
Albumin
(-)
E coli
(-)
Mucus thread few
Amorphous urate (-)

Filtration Normal GFR/ min is 125 ml of blood

Tubular reabsorption 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption)
Tubular secretion 1 ml is excreted in urine

UTI
CYSTITIS
Inflammation of bladder due to bacterial infection

Regulation of BP:

Predisposing factors:
Microbial invasion: E. coli
High risk: women
Obstruction
Urinary retention
Increase estrogen levels
Sexual intercourse

Predisposing factor:
Ex CS hypovolemia decrease BP going to kidneys
Activation of RAAS
Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus
Angiotensin I mild vasoconstrictor
Angiotensin II vasoconstrictor

Adrenal cortex

increase CO

increase PR

S/Sx:
Pain: flank area
Urinary frequency & urgency
Burning pain upon urination
Dysuria
Hematuria
Nocturia

Fever
Chills
Anorexia
Gen body malaise

Acute / chronic inflammation of 1 or 2 renal pelvis of kidneys leading to

tubular destruction & interstitial abscess formation
Acute: infection usually ascends from lower urinary tract
Chronic: a combination of structural alteration along with infection major
cause is ureterovesical reflux with infected urine backing up into
ureters & renal pelvis
Recurrent infection will lead to renal parenchymal deterioration & Renal
Failure

Dx
Urine culture & sensitivity: (+) to E. coli
Nursing Intervention
Force fluid: 3000 ml
Warm sitz bath: to promote comfort
Monitor & assess urine for gross odor, hematuria & sediments
Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent bacterial multiplication
Administer Medication as ordered:
Systemic Antibiotics
Ampicillin
Cephalosporin
Aminoglycosides
Sulfonamides
Co-trimaxazole (Bactrim)
Gantrism (Gantanol)
Antibacterial
Nitrofurantoin (Macrodantin)
Methenamine Mandelate (Mandelamine)
Nalixidic Acid (NegGram)
Urinary Tract Anagesic
Urinary antiseptics: Mitropurantoin (Macrodantin)
Urinary analgesic: Pyridium
Provide client teachings & discharge planning
Importance of Hydration
Void after sex: to avoid stagnation
Female: avoids cleaning back & front (should be front to back)
Bubble bath, Tissue paper, Powder, perfume
Complications: Pyelonephritis
Pyelonephritis

Predisposing factor:
Microbial invasion
E. Coli
Streptococcus
Urinary retention /obstruction
Pregnancy
DM
Exposure to renal toxins
S/sx:
Acute Pyelonephritis
Severe flank pain or dull ache
Costovertibral angle pain / tenderness
Fever
Chills
N/V
Anorexia
Gen body malaise
Urinary frequency & urgency
Nocturia
Dsyuria
Hematuria
Burning sensation on urination
Chronic Pyelonephritis: client usually not aware of disease
Bladder irritability
Slight dull ache over the kidney
Chronic Fatigue

Weight loss
Polyuria
Polydypsia
HPN
Atrophy of the kidney

Presence of stone anywhere in the urinary tract

Formation of stones at urinary tract
Frequent composition of stones
Calcium
Oxalate
Uric acid

Medical Management
Urinary analgesic: Peridium
Acute
Antibiotics
Antispasmodic
Surgery: removal of any obstruction
Chronic
Antibiotics
Urinary Antiseptics
Nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
Surgery: correction of structural abnormality if possible

Predisposing factors:
Diet: increase Ca & oxalate
Increase uric acid level
Hereditary: gout or calculi
Immobility
Sedentary lifestyle
Hyperparathyroidism

Dx

S/sx

Calcium
Milk

Urine culture & sensitivity: (+) E. coli & streptococcus

Urinalysis: increase WBC, CHON & pus cells
Cystoscopic exam: urinary obstruction
Nursing Intervention
Provide CBR: acute phase
Monitor I & O
Force fluid
Acid ash diet
Administer medication as ordered
Chronic: possibility of dialysis & transplant if has renal deterioration
Complication: Renal Failure
Nephrolithiasis / Urolithiasis

Oxalate

Uric Acid

Cabbage
Cranberries
Nuts tea
Chocolates

Anchovies
Organ meat
Nuts
Sardines

Abdominal or flank pain

Renal colic
Cool moist skin (shock)
Burning sensation upon urination
Hematuria
Anorexia
N/V
Dx
Intravenous Pyelography (IVP): identifies site of obstruction & presence of nonradiopaque stones
KUB: reveals location, number & size of stone
Cytoscopic Exam: urinary obstruction
Stone Analysis: composition & type of stone

Urinalysis: indicates presence of bacteria, increase WBC, RBC & CHON

Medical Management
Surgery
Percutaneous Nephrostomy:
Tube is inserted through skin & underlying tissue into renal pelvis to remove
calculi
Percutaneous Nephrostolithotomy
Delivers ultrasound wave through a probe placed on the calculus
Extracorporeal Shockwave Lithotripsy:
Non-invasive
Delivers shockwaves from outside of the body to the stone causing pulverization
Pain management & diet modification
Nursing Intervention
Force fluid: 3000-4000 ml / day
Strain urine using gauze pad: to detect stones & crush all cloths
Encourage ambulation: to prevent stasis
Warm sitz bath: for comfort
Administer narcotic analgesic as ordered: Morphine SO4: to relieve pain
Application warm compress at flank area: to relieve pain
Monitor I & O
Provide modified diet depending upon the stone consistency
Calcium Stones
Limit milk & dairy products
Provide acid ash diet (cranberry or prune juice, meat, fish, eggs, poultry, grapes,
whole grains): to acidify urine
Take vitamin C
Oxalate Stone
Avoid excess intake of food / fluids high in oxalate (tea, chocolate,
rhubarb, spinach)
Maintain alkaline-ash diet (milk, vegetable, fruits except cranberry,
plums & prune): to alkalinize urine
Uric Acid Stone
Reduce food high in purine (liver, brain, kidney, venison, shellfish, meat
soup, gravies, legumes)
Maintain alkaline urine

Administer Allopurinol (Zyloprim) as ordered: to decrease uric acid production: push

fluids when giving allopurinol
Provide client teaching & discharge planning
Prevention of urinary stasis: increase fluid intake especially during hot weather &
illness
Mobility
Voiding whenever the urge is felt & at least twice during night
Adherence to prescribe diet
Complications: Renal Failure
Benign Prostatic Hypertrophy (BPH)
Mild to moderate glandular enlargement, hyperplsia & over growth of the
smooth muscles & connective tissue
As the gland enlarges it compresses the urethra: resulting to urinary retention
Enlarged prostate gland leading to
Hydroureters: dilation of urethers
Hydronephrosis: dilation of renal pelvis
Kidney stones
Renal failure
Predisposing factor:
High risk: 50 years old & above & 60-70 (3-4x at risk)
Influence of male hormone
S/sx
Urgency, frequency & hesitancy
Nocturia
Enlargement of prostate gland upon palpation by digital rectal exam
Decrease force & amount of urinary stream
Dysuria
Hematuria
Burning sensation upon urination
Terminal bubbling
Backache
Sciatica: severe pain in the lower back & down the back of thigh & leg
Dx

Digital rectal exam: enlarged prostate gland

KUB: urinary obstruction
Cystoscopic Exam: reveals enlargement of prostate gland & obstruction of urine
flow
Urinalysis: alkalinity increase
Specific Gravity: normal or elevated
BUN & Creatinine: elevated (if longstanding BPH)
Prostate-specific Antigen: elevated (normal is < 4 ng /ml)

Pre renal cause: decrease blood flow & glomerular filtrate

Ischemia & oliguria
Cardiogenic shock
Acute vasoconstriction
Septicemia
Hypovolemia
Decrease flow to kidneys
Hypotension
CHF
Hemorrhage
Dehydration

Nursing Intervention
Prostate message: promotes evacuation of prostatic fluid
Force fluid intake: 2000-3000 ml unless contraindicated
Provide catheterization
Administer medication as ordered:
Terazosine (Hytrin): relaxes bladder sphincter & make it easier to urinate
Finasteride (Proscar): shrink enlarge prostate gland
Surgery: Prostatectomy
Transurethral Resection of Prostate (TURP): insertion of a resectoscope into urethra
to excise prostatic tissue
Assist in cystoclysis or continuous bladder irrigation.
Nursing Intervention
Monitor symptoms of infection
Monitor symptoms gross / flank bleeding. Normal bleeding within 24h
Maintain irrigation or tube patent to flush out clots: to prevent bladder
spasm & distention

Intra-renal cause: involves renal pathology: kidney problem

Acute tubular necrosis
Endocarditis
DM
Tumors
Pyelonephritis
Malignant HPN
Acute Glomerulonephritis
Blood transfision reaction
Hypercalemia
Nephrotoxin (certain antibiotics, X-ray, dyes, pesticides, anesthesia)
Post renal cause: involves mechanical obstruction
Tumors
Stricture
Blood cloths
Urolithiasis
BPH
Anatomic malformation

Acute Renal Failure

Sudden inability of the kidney to regulate fluid & electrolyte balance & remove toxic
products from the body
Sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E
balance due to a decrease in GFR (N 125 ml/min)
Causes
Pre-renal cause: interfering with perfusion & resulting in decreased blood flow &
glomerular filtrate
Inter-renal cause: condiion that cause damage to the nephrons
Post-renal cause: mechanical obstruction anywhere from the tubules to the urethra

S/sx
Oliguric Phase: caused by reduction in glomerular filtration rate
Urine output less than 400 ml / 24 hrs; duration 1-2 weeks
S/sx
Hypernatremia

Hyperkalemia
Hyperphosphotemia
Hypermagnesemia
Hypocalcemia
Metabolic acidosis
Dx
BUN & Creatinine: elevated
Diuretic Phase: slow gradual increase in daily urine output
Diuresis may occur (output 3-5 L / day): due to partially regenerated tubules inability
to concentrate urine
Duration: 2-3 weeks
S/sx
Hyponatremia
Hypokalemia
Hypovolemia
Dx
BUN & Creatinine: elevated
Recovery or Covalescent Phase: renal function stabilized with gradual improvement
over next 3-12 mos
Nursing Intervention
Monitor / maintain F&E balance
Obtain baseline data on usual appearance & amount of clients urine
Measure I&O every hour: note excessive losses
Administer IV F&E supplements as ordered
Weight daily
Monitor lab values: assess / treat F&E & acid base imbalance as needed
Monitor alteration in fluid volume
Monitor V/S. PAP, PCWP, CVP as needed
Monitor I&O strictly
Assess every hour fro hypervolemia
Maintain ventilation
Decrease fluid intake as ordered
Administer diuretics, cardiac glycosides & hypertensive agent as
ordered
Assess every hour for hypovolemia: replace fluid as ordered

Monitor ECG
Check urine serum osmolality / osmolarity & urine specific gravity as
ordered
Promote optimal nutrition
Administer TPN as ordered
Restrict CHON intake
Prevent complication from impaired mobility
Pulmonary Embolism
Skin breakdown
Contractures
Atelectesis
Prevent infection / fever
Assess sign of infection
Use strict aseptic technique for wound & catheter care
Take temperature via rectal
Administer antipyretics as ordered & cooling blankets
Support clients / significant others: reduce level of anxiety
Provide care for client receiving dialysis
Provide client teaching & discharge planning
Adherence to prescribed dietary regime
S/sx of recurrent renal disease
Importance of planned rest period
Use of prescribe drugs only
S/sx of UTI or respiratory infection: report to MD
Chronic Renal Failure
Progressive, irreversible destruction of the kidneys that continues until nephrons are
replaced by scar tissue
Loss of renal function gradual
Irreversible loss of kidney function
Predisposing factors:
DM
HPN
Recurrent UTI/ nephritis
Urinary Tract obstruction
Exposure to renal toxins

Stages of CRF
Diminished Reserve Volume asymptomatic
Normal BUN & Crea, GFR < 10 30%
2. Renal Insufficiency
3. End Stage Renal disease

Fluid & Electrolytes

Hyperkalemia
Hypernatermia
Hypermagnesemia
Hyperposphatemia
Hypocalcemia
Metabolic acidosis

Integumentary
Itchiness / pruritus
Uremic frost

S/Sx:
N/V
Diarrhea / constipation
Decreased urinary output
Dyspnea
Stomatitis
Hypotension (early)
Hypertension (late)
Lethargy
Convulsion
Memory impairment
Pericardial Friction Rub
HF
Urinary System
Polyuria
Nocturia
Hematuria
Dysuria
Oliguria
CNS
Headache
Lethargy
Disorientation
Restlessness
Memory impairment
Respiratory
Kassmauls resp
Decrease cough reflex

Dx
Urinalysis: CHON, Na & WBC: elevated
Specific gravity: decrease
Platelets: decrease
Ca: decrease
Medical Management
Diet restriction
Multivitamins
Hematinics
Aluminum Hydroxide Gels
Antihypertensive
Metabolic Disturbance
Azotemia (increase BUN & Creatinine)
Hyperglycemia
Hyperinsulinemia

GIT
N/V
Stomatitis
Uremic breath
Diarrhea / constipation
Hematological
Normocytic anemia
Bleeding tendencies

Nursing Intervention
Prevent neurologic complication
Monitor for signs of uremia
Fatigue
Loss of appetite
Decreased urine output
Apathy
Confusion
Elevated BP
Edema of face & feet
Itchy skin
Restlessness
Seizures
Monitor for changes in mental functioning
Orient confused client to time, place, date & person

Institute safety measures to protect the client from falling out of bed
Monitor serum electrolytes, BUN & creatinine as ordered
Promote optimal GI function
Provide care for stomatitis
Monitor N/V & anorexia: administer antiemetics as ordered
Monitor signs of GI bleeding
Monitor & prevent alteration in F&E balance
Monitor for hyperphosphatemia: administer aluminum hydroxides gel
(amphojel, alternagel) as ordered
Paresthesias
Muscle cramps
Seizures
Abnormal reflex
Maintenance of skin integrity
Provide care for pruritus
Monitor uremic frost (urea crystallization on the skin): bathe in plain water
Monitor for bleeding complication & prevent injury to client
Monitor Hgb, Hct, platelets, RBC
Hematest all secretions
Administer hematinics as ordered
Avoid IM injections
Maintain maximal cardiovascular function
Monitor BP
Auscultate for pericardial friction rub
Perform circulation check routinely
Administer diuretics as ordered & monitor I&O
Modify digitalis dose as ordered (digitalis is excreted in kidneys)
Provide care for client receiving dialysis
Disequilibrium syndrome: from rapid removal of urea & nitrogenous waste prod
leading to:
N/V
HPN
Leg cramps
Disorientation
Paresthes
Enforce CBR
Monitor VS, I&O

Meticulous skin care. Uremic frost assist in bathing pt

4. Meds:
a.) Na HCO3 due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca Ca gluconate
5. Assist in hemodialysis
Consent/ explain procedure
Obtain baseline data & monitor VS, I&O, wt, blood exam
Strict aseptic technique
Monitor for signs of complications:
B bleeding
E embolism
D disequilibrium syndrome
S septicemia
S shock decrease in tissue perfusion
Disequilibrium syndrome from rapid removal of urea & nitrogenous waste prod leading
to:
n/v
HPN
Leg cramps
Disorientation
Paresthesia
Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to
compression of fistula.
Maintain patency of shunt by:
Palpate for thrills & auscultate for bruits if (+) patent shunt!
Bedside- bulldog clip
- If with accidental removal of fistula to prevent embolism.
- Infersole (diastole) common dialisate used
7. Complication
- Peritonitis
- Shock

8. Assist in surgery:
Renal transplantation : Complication rejection. Reverse isolation