Documente Academic
Documente Profesional
Documente Cultură
Somatic NS
C- 8
T- 12
L- 5
S- 5
C- 1
ANS (or adrenergic of parasympatholitic response)
Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in –‘lol’)
- Blocks release of norepinephrine.
- Decrease body activities except GIT (diarrhea)
Ex. Propanolol, Metopanolol
SE:
B – broncho spasm (bronchoconstriction)
E – elicits a decrease in myocardial contraction
T – treats HPN
A – AV conduction slows down
Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic)
- Involved in fly or withdrawal response 1. Meiosis – constriction of pupils
- Release of acetylcholine (ACTH) 2. Increase salivation
- Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased
4. RR decrease – broncho constriction
I Cholinergic agents 5. Diarrhea – increased GI motility
ex 1. Mestinon 6. Urinary frequency
Antidote – anti cholinergic agents Atropine Sulfate – S/E – SNS 7. Acetylcholine- neurotransmitter
8. Blood vessels- vasodilated
1
S/E- of anti-hpn drugs:
1. orthostatic hpn
2. transient headache & dizziness.-Mgt. Rise slowly. Assist in ambulation.
3.) Neuroglia – attached to neurons. Supports neurons. Where brain tumors are found.
Types:
1. Astrocyte
2. Oligodendria
Astrocytoma – 90 – 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.
Astrocyte – maintains integrity of blood brain barrier (BBB).
BBB – semi permeable / selective
-Toxic substance that destroys astrocyte & destroy BBB.
Toxins that can pass in BBB:
1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide – seizure & parkinsons.
3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. 4. Ketones –DM.
OLIGODENDRIA – Produces myelin sheath – wraps around a neuron – acts as insulator facilitates rapid nerve impulse transmission.
No myelin sheath – degenerates neurons
DEMYELLENATING DSE
1.)ALZHEIMER’S DISEASE– atrophy of brain tissue due to a deficiency of acetylcholine.
S&Sx:
A – amnesia – loss of memory
A – apraxia – unable to determine function & purpose of object
A – agnosia – unable to recognize familiar object
A – aphasia –
- Expressive – brocca’s aphasia – unable to speak
- Receptive – wernickes aphasia – unable to understand spoken words
Common to Alzheimer – receptive aphasia
Drug of choice – ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.
2
Normal ICP: 0-15mmHg
Brain mass
Basal Ganglia – areas of gray matte located deep within a cerebral hemisphere
- Extra pyramidal tract
- Releases dopamine-
- Controls gross voluntary unit
MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12
INCREASED ICP – increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis
c.) Uncal herniation – unilateral dilation of pupil. (Bilateral dilation of pupil – tentorial herniation.)
d.) Possible seizure.
4
Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).
Nursing Mgt:
1.) Administer K supplements – ex Kalium Durule, K chloride
Potassium Rich food:
ABC’s of K
Vegetables Fruits
A - asparagus A – apple
B – broccoli (highest) B – banana – green
C – carrots C – cantalope/ melon
O – orange (highest) –for digitalis toxicity also.
Vit A – squash, carrots yellow vegetables & fruits, spinach, chesa
Iron – raisins,
Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretions
Don’t give grapes – may choke
S/E of Lasix:
1.) Hypokalemia
2.) Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany:
S&Sx
weakness
Paresthesia
(+) Trousseau sign – pathognomonic – or carpopedal spasm. Put bp cuff on arm=hand spasm.
(+) Chevostek’s sign
Arrhythmia
Laryngospasm
Administer – Ca gluconate – IV slowly
Nsg Mgt:
a. Monitor FBS (N=80 – 120 mg/dl)
5.) Hyperurecemia – increase serum uric acid. Tophi- urate crystals in joint.
6
Gou ty arthritis kidney stones- renal colic (pain)
Cool moist skin
Sx joint pain & swelling usually at great toe.
7
e. Photophobia
f. Changes in color perception – yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)
MAOI – antidepressant
m AR plan
n AR dil can lead to CVA or hypertensive crisis
p AR nate
3 – 4 weeks - before MAOI will take effect
Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa
Dilantin toxicity:
S/Sx:
G – gingival hyperplasia – swollen gums
i. Oral hygiene – soft toothbrush
ii. Massage gums
H – hairy tongue
A - ataxia
N – nystagmus – abnormal movement of eyeballs
A – acetaminophen/ Tylenol – non-opoid analgesic & antipyretic – febrile pts
Acetaminophen toxicity :
1. Hepato toxicity
2. Monitor liver enzymes
SGPT (ALT) – Serum Glutamic Piruvate Tyranase
SGOT- Serum Glutamic Acetate Tyranase
3. Monitor BUN (10 – 20)
Crea (.8-1)
Acetaminophen toxicity can lead to hypoglycemia
8
T – tremors, Tachycardia
I – irritability
R – restlessness
E – extreme fatigue
D – depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity – Acetylcesteine = causes outporing of secretions. Suction.
Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:
a. Nightmares
b. Extreme thirst – hyperglycemia symptoms
c. Weakness d. Diaphoresis
PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine
producing cells in substancia nigra at mid brain & basal ganglia
- Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
2. Hypoxia
3. Arteriosclerosis
4. Encephalitis
10
4. Impaired motor function:
a. Weakness
b. Spasiticity –“ tigas”
c. Paralysis –major problem
5. Impaired cerebellar function
Triad Sx of MS
I – intentional tremors
N – nystagmus – abnormal rotation of eyes Charcots triad
A – Ataxia
& Scanning speech
6. Urinary retention or incontinence
7. Constipation
8. Decrease sexual ability
Dx – MS
1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG
2. MRI – reveals site & extent of demyelination
3. Lhermitte’s response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS
- Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH – adenocorticotopic
Steroids – to reduce edema at the site of demyelination to prevent paralysis
Spinal Cord Injury
Administer drug to prevent paralysis due to edema
a. Give ACTH – steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrium)
To decrease muscle spasticity
c. Interferone – to alter immune response
d. Immunosuppresants
2. Maintain siderails
3. Assist passive ROMexercises – promote proper body alignment
4. Prevent complications of immobility
5. Encourage fluid intake & increase fiber diet – to prevent constipation
6. Provide catheterization due urinary retention
7. Give diuretics
Urinary incontinence – give Prophantheline bromide (probanthene)
MYASTHENIA GRAVIS (MG) – disturbance in transmission of impulses from nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 – 40 yo, unknown cause or idiopathic
Autoimmune – release of cholenesterase – enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness
(Ascending muscle weakness – Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
1.) Ptosis – drooping of upper lid ( initial sign)
Check Palpebral fissure – opening of upper & lower lids = to know if (+) of MG.
11
2.) Diplopia – double vision
3.) Mask like facial expression
4.) Dysphagia – risk for aspiration!
5.) Weakening of laryngeal muscles – hoarseness of voice
6.) Resp muscle weakness – lead respiratory arrest. Prepare at bedside tracheostomy set
7.) Extreme muscle weakness during activity especially in the morning.
Dx test
1. Tensilon test (Edrophonium Hcl) – temporarily strengthens muscles for 5 – 10 mins. Short term- cholinergic. PNS effect.
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent – attach to ventilator
b.) Monitor pulmonary function test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr.
5. NGT feeding
Administer meds –
a.) Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) – Long term
- Increase acetylcholine
s/e – PNS
b.) Corticosteroids – to suppress immune resp
Decadron (dexamethasone)
S&Sx
Initial :
1. Clumsiness
2. Ascending muscle weakness – lead to paralysis
3. Dysphagia
4. Decrease or diminished DTR (deep tendon reflexes)
- Paralysis
5. Alternate HPN to hypotension – lead to arrhythmia - complication
6. Autonomic changes – increase sweating, increase salivation.
12
Increase lacrimation
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)
Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl – immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding – due dysphagia
S&Sx
- Stiff neck or nuchal rigidity (initial sign)
- Headache
- Projectile vomiting – due to increase ICP
- Photophobia
- Fever chills, anorexia
- Gen body malaise
- Wt loss
- Decorticate/decerebration – abnormal posturing
- Possible seizure
13
Sx of meningeal irritation – nuchal rigidity or stiffness
Opisthotonus- rigid arching of back
Dx:
1. Lumbar puncture – lumbar/ spinal tap – use of hallow spinal needle – sub arachnoid space L3 & L4 or L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture – invasive
1. Consent / explain procedure to pt
- RN – dx procedure (lab)
- MD – operation procedure
2. Empty bladder, bowel – promote comfort
3. Arch back – to clearly visualize L3, L4
Result
1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose
b. Decrease glucose
Confirms meningitis c. increase CSF opening pressure
N 50 – 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC – reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
1. GIT irritation – take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection – alteration in normal bacterial flora
- N flora throat – streptococcus
- N flora intestine – e coli
Sx of superinfection of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapy
A – Cushing’s synd – reverse isolation - due to increased corticosteroid in body.
B – Aplastic anemia – reverse isolation - due to bone marrow depression.
C – Cancer anytype – reverse isolation – immunocompromised.
D – Post liver transplant – reverse isolation – takes steroids lifetime.
E – Prolonged use steroids – reverse isolation
F – Meningitis – strict respiratory isolation – safe after 24h of antibiotic therapy
G – Asthma – not to be isolated
Predisposing factor:
1. Thrombosis – clot (attached)
2. Embolism – dislodged clot – pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness
Femur fracture – complications: fat embolism – most feared complication w/in 24hrs
Yellow bone marrow – produces fat cells at meduallary cavity of long bone
Red bone marrow – provides WBC, platelets, RBC found at epiphisis
2.) Hemorrhage
3.) Compartment syndrome – compression of nerves/ arteries
Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery – mitral valve replacement
15
e.) Increase BP
f.) (+) Kernig’s & Brudzinski – sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria – inability to vocalize, articulate words
3. Aphasia
4. Agraphia diff writing
5. Alesia – diff reading
6. Homoninous hemianopsia – loss of half of field of vision
Left sided hemianopsia – approach Right side of pt – the unaffected side
Dx
1. CT Scan – reveals brain lesion
2. Cerebral arteriography – site & extent of mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All – graphy – invasive due to iodine dye
Post
1.) Force fluid – to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal
Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids – prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
- To prevent decubitus ulcer
- To prevent hypostatic pneumonia – after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding – if pt can’t swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia – approach on unaffected side
9. Meds
Osmotic diuretics – Mannitol
Loop diuretics – Lasix/ Furosemide
Corticosteroids – dextamethazone
Mild analgesic
Thrombolytic/ fibrolitic agents – tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants – Heparin & Coumadin” sabay”
Coumadin will take effect after 3 days
Heparin – monitor PTT partial thromboplastin time if prolonged – bleeding give Protamine SO4- antidote.
Coumadin –Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K – Aquamephyton- antidote.
Antiplatelet – PASA – aspirin paraanemo aspirin, don’t give to dengue, ulcer, and unknown headache.
Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking
2. Dietary modification
16
- Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit – physical therapy
1. Mental retardation
2. Delay in psychomotor development
CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of
consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior.
Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attack
Febrile seizure Normal if < 5 yo Epilepsy – 2nd and with history of seizure
Pathologic if > 5 yo
Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide
Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus – drug of choice: Diazepam & glucose
S & Sx
I. Generalized Seizure –
a.) Grand mal / tonic clonic seizures
With or without aura – warning symptoms of impending seizure attack- Epigastric pain- associated with
olfactory, tactile, visual, auditory sensory experience
- Epileptic cry – fall
- Loss of consciousness 3 – 5 min
- Tonic clonic contractions
- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
- Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure – (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching of mouth
- Loss of consciousness – 5 – 10 secs (quick & short)
HALLUCINATIONS
1. Auditory – schitzo – paranoid type
2. Visual – korsakoffs psychosis – chronic alcoholism
3. Tactile – addict – substance abuse
III. Status epilecticus – continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia – coma – death
Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2.
Tx:Diazepam (drug of choice), glucose
17
Dx-Convulsion- get health history!
1. CT scan – brain lesion
2. EEG electroencephalography
- Hyperactivity brain waves
Nsg Mgt
Priority – Airway & safety
1. Maintain patent a/w & promote safety
Before seizure:
1. Remove blunt/sharp objects
2. Loosen clothing
3. Avoid restraints
4. Maintain siderails
5. Turn head to side to prevent aspiration
6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at home.
7. Avoid precipitating stimulus – bright glaring lights & noises
8. Administer meds
a. Dilantin (Phenytoin) –( toxicity level – 20 )
SE Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Don’t give alcohol – lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations
2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration
- Type of seizure
- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status
epilepticus!
4. Assist in surgical procedure. Cortical resection
5. Complications: Subarachnoid hemorrhage and encephalitis
Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale – obj measurement of LOC or quick neuro check
3 components of ECS
M – motor 6
V – verbal resp 5
E – eye opening 4
15
15 – 14 – conscious
13 – 11 – lethargy
10 – 8 – stupor
7 – coma
3 – deep coma – lowest score
18
2.) Levels of orientation
3.) CN assessment
4.) Motor assessment
5.) Sensory assessment
6.) Cerebral test – Romhberg, finger to nose
7.) DTR
8.) Autonomics
Graphesthesia- can identify numbers or letters written on palm with a blunt object.
Agraphesthesia – cant identify numbers or letters written on palm with a blunt object.
CN assessment:
I– Olfactory s
II – Optic s
III – Oculomotor m
IV – Trocheal m smallest CN
V– Trigeminal b largest CN
VI – Abducens m
VII – Facial b
VIII – Acustic/auditory s
IX – Glassopharyngeal b
X– Vagus b longest CN
XI– Spinal accessory m
XII – Hypoglossal m
I. Olfactory – don’t use ammonia, alcohol, cologne irritating to mucosa – use coffee, bar soap, vinegar, cigarette tar
- Hyposmia – decrease sensitivity to smell
- Diposmia – distorted sense of smell
19
- Anosmia – absence of sense of smell
Either of 3 might indicate head injury – damage to cribriform plate of ethmoid bone where olfactory cells are located
or indicate inflammation condition – sinusitis
Common Disorders – see page 85-87 for more info on glaucoma, etc.
1. Glaucoma – Normal 12 – 21 mmHg pressure
- Increase IOP - Loss of peripheral vision – “tunnel vision”
2. Cataract – opacity of lens - Loss of central vision, “Blurring or hazy vision”
3. Retinal detachment – curtain veil – like vision & floaters
4. Macular degeneration – black spots
3 – 4 EOM
IV – sup oblique
VI – lateral rectus
Normal response – PERRLA (isocoria – equal pupil)
Anisocoria – unequal pupil
Oculomotor
1. Raising of eyelid – Ptosis
2. Controls pupil size 2 -3 cm or 1.5 – 2 mm
20
VI Facial: Sensory – controls taste – ant 2/3 of tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group – 40 yrs old
Motor- controls muscles of facial expression, smile frown, raise eyebrow
Damage – Bells palsy – facial paralysis
Cause – bells palsy pedia – R/T forcep delivery
Temporary only
Most evident clinical sign of facial symmetry: Nasolabial folds
VIII Acoustic/ vestibule cochlear (controls hearing) – controls balance (kenesthesia or position sense)
- Movement & orientation of body in space
- Organ of Corti – for hearing – true sense organ of hearing
Test 9 – 10
Pt say ah – check uvula – should be midline
Damage cerebral hemisphere is L or R
Gag reflex – place tongue depression post part of tongue
Don’t touch uvula
XI – Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)
- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia
XII – Hypoglossal – controls movement of tongue – say “ah”. Assess tongue position=midline
L or R deviation
- Push tongue against cheek
- Short frenulum lingue –
Tongue tied – “bulol”
ENDOCRINE
21
Anterior pituitary gland – adenohypophysis
Posterior pituitary gland – neurohypophysis
Posterior pituitary:
1.) Oxytocin – a.) Promotes uterine contraction preventing bleeding/ hemorrhage.
- Give after placental delivery to prevent uterine atony.
b.) Milk letdown reflex with help of prolactin.
2.) ADH – antidiuretic hormone – (vasopressin) -Prevents urination – conserve H2O
S & Sx:
1. Polyuria
2. Sx of dehydration (1st sx of dehydration in children-tachycardia)
- Excessive thirst (adult)
- Agitation
- Poor skin turgor
- Dry mucus membrane
3. Weakness & fatigue
4. Hypotension – if left untreated -
5. Hypovolemic shock
Anuria – late sign hypovolemic shock
Dx Proc:
1. Decrease urine specific gravity- concentrated urine
N= 1.015 – 1.035
2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia
Mgt:
1. Force fluid 2,000 – 3,000ml/day
2. Administer IV fluid replacement as ordered
3. Monitor VS, I&O
4. Administer meds as ordered
a.) Pitresin (vasopressin) IM
5. Prevent complications
Most feared complication – Hypovolemic shock
Predisposing factor
1. Head injury
2. Related to Bronchogenic cancer or lung caner-
Early Sign of Lung Ca - Cough –1. non productive 2. productive
3. Hyperplasia of Pit gland
Increase size of organ
22
S&Sx
1. Fluid retention
2. Increase BP – HPN
3. Edema
4. Wt gain
5. Danger of H2O intoxication –Complications: 1. cerebral edema – increase ICP – 2. seizure
Dx Proc:
1. Urine specific gravity increase – diluted urine
2. Hyponatremia – Decreased Na
Nsg Mgt:
1. Restrict fluid
2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
3. Monitorstrictly V/S, I&O, neuro check – increase ICP
4. Weigh daily
5. Assess for presence edema
6. Provide meticulous skin care
7. Prevent complications – increase ICP & seizures activity
Square face
Square jaw
PINEAL GLAND
1. Secretes Melatonin – inhibits lutenizing hormone (LH) secretion
TG hormones:
T3 T4 Thyrocalcitonin
- Triodothyronine -Tetraiodothyronine/ Tyroxine FX – antagonizes effects of parathormone
Increase metabolism brain –inc cerebration, inc v/s all v/s down, constipation
HYPOTHYROIDISM – all decreased except wt & menstruation, loss of appetite but with wt gain
menorrhagia – increase in mens
HYPERTHYROIDISM - Increase appetite – wt loss, amenorrhea
SIMPLE GOITER – enlarged thyroid gland - iodine deficiency
Predisposing factors
1. Goiter belt area - Place far from sea – no iodine. Seafood’s rich in iodine
2. Mountainous area – increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake)
Cabbage – has progoitrin – an anti thyroid agent with no iodine
Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops), all nuts.
3. Goitrogenic drugs:
Anti thyroid agents :(PTU) prephyl thiupil
Lithium carbonate, Aspirin PASA
Cobalt, Phenyl butasone
Endemic goiter – cause # 1
Sporadic goiter – caused by #2 & 3
S & Sx – enlarged TG
Mild restlessness
Mild dysphagia
Dx Proc.
1. Thyroid scan – reveals enlarged TG
2. Serum TSH – increase (confirmatory)
3. Serum T3, T4 – N or below N
Nsg Mgt:
1. Administer meds
a.) Iodine solution – Logol’s solution or saturated sol of K iodide SSKI
B. Thyroid h / Agents
1. Levothyroxine (Synthroid)
2. Liothyronine (cytomel)
3. Thyroid extract
Dx:
1. Serum T3 T4 decrease
2. Serum cholesterol increase – can lead to MI
3. RA IU – radio iodine uptake – decrease
Nsg Mgt:
1. Monitor strictly V/S. I&O – to determine presence of myxedema coma!
Myxedema Coma - Severe form of hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia
Might lead to progressive stupor & coma
Impt mgt for Myxedema coma
1. Assist mech vent – priority a/w
2. Adm thyroid hormone
3. Adm IVF replacement – force fluid
25
Mgt myxedema coma
1. Monitor VS, I&O
2. Provide dietary intake low in calories – due to wt gain
3. Skin care due to dry skin
4. Comfortable & warm environment due to cold intolerance
5. Administer IVF replacements
6. Force fluid
7. Administer meds – take AM – SE insomia. Monitor HR.
Thyroid hormones
Levothyroxine(Synthroid), Liothyronine (cytomel)
Thyroid extracts
8. Health teaching & discharge plan
a. Avoidance precipitating factors leading to myxedema coma:
1. Exposure to cold environment
2. Stress 3. Infection
4. Use of sedative, narcotics, anesthetics not allowed – CNS depressants V/S already down
Complications:
9. Hypovolemic shock, myxedema coma
10. Hormonal replacement therapy - lifetime
11. Importance of follow up care
S&Sx:
1. Increase in appetite – hyperphagia – wt loss due to increase metabolism
2. Skin is moist - perspiration
3. Heat intolerance
4. Diarrhea – increase motility
5. All VS increase = HPN, tachycardia, tachypnea, hyperthermia
6. CNS changes
8. Irritability & agitation, restlessness, tremors, insomnia, hallucinations
7. Goiter
8. Exopthalmos – pathognomonic sx
9. Amenorrhea
Dx:
1. Serum T3 & T4 - increased
2. Radio iodine uptake – increase
3. Thyroid scan – reveals enlarged TG
Nsg Mgt:
1. Monitor VS & I & O – determine presence of thyroid storm or most feared complication: Thyrotoxicosis
2. Administer meds
a. Antithyroid agents
1. Prophylthiuracil (PTU)
2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture
Most feared complication : Thrombosis – stroke CVS
Hypocalcemia Hyperphosphatemia
(Or tetany)
A. Predisposing, factors:
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to
a. Irradiation
b. Trauma
S&Sx:
1. Acute tetany
a. Tingling sensation
b. Paresthesia
c. Dysphagia
d. Laryngospasm
e. Bronchospasm
2. Chronic tetany
a. Loss of tooth enamel
b. Photophobia & cataract formation
c. GIT changes – anorexia, n/v, general body malaise
d. CNS changes – memory impairment, irritability
Dx:
1. Serum calcium – decrease (N 8.5 – 11 mg/100ml)
2. Serum phosphate increase (N 2.5 – 4.5 mg/100ml)
3. X-ray of long bone – decrease bone density
4. CT Scan – reveals degeneration of basal ganglia
Nsg Mgt:
1. Administration of meds:
a.) Acute tetany –
Ca gluconate – IV, slowly
b.) Chronic tetany
1. Oral Ca supplements
Ex. Ca gluconate
Ca carbonate
Ca lactate
Vit D (Cholecalceferol)
2. Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC MAD
Aluminum containing acids Mg containing antacids
Ex. Milk or magnesia
Aluminum OH gel Diarrhea
Ca – 99% bones
1% serum blood
Predisposing Factors:
1. Hyperplasia parathyroid gland (PTG)
2. Over compensation of PTG due to Vit D deficiency
Children – Rickets Vit D
Adults – Osteomalacia deficiency
S/Sx:
Bone fracture
1. Bone pain (especially at back), bone fracture
2. Kidney stone –
a. Renal colic
b. Cool moist skin
3. GIT changes – anorexia, n/v, ulcerations
4. CNS involvement– irritability, memory impairment
29
Dx Proc:
1. Serum Ca increase
2. Serum phosphorus decreases
3. X-ray long bones – reveals bone demineralization
Adrenal Cortex –
1. Zona fasiculata – secrets glucocorticoids. Ex. Cortisol - Controls glucose metabolism (SUGAR)
2. Zona reticularis – secrets traces of glucocorticoids & androgenic hormones
M – testosterone
F – estrogen & progesterone
Fx – promotes development of secondary sexual characteristics
3. Zona glomerulosa - secretes mineralcortisone. Ex. Aldosterone Fx: promotes Na & H2O reabsorption & excretion of
potassium (SALT)
30
Predisposing Factors:
1. Atrophy of adrenal gland
2. Fungal infections
3. Tubercular infections
S/Sx:
1. Decrease sugar – Hypoglycemia – Decreased glucocorticoids - cortisol
T – tremors, tachycardia
I - irritability
R - restlessness
E – extreme fatigue
D – diaphoresis, depression
Dx Proc:
1. FBS – decrease FBS (N 80 – 120 mg/dL)
2. Plasma cortisol – decreased
Serum Na – decreased (N 135 – 145 meg/L)
3. Serum K – increased (N 3.5 – 5.5 meg/L)
Nsg Mgt:
1. Monitor VS, I&O – to determine presence of Addisonian crisis
15. Complication of Addison’s dse : Addisonian crisis
16. Results the acute exacerbation of Addison’s dse characterized by :
Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia
17. Lead to progressive stupor & coma
2. Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone
31
2. Taper the dose (w/draw, gradually from drug) – sudden withdrawal can lead to addisonian crisis
3. Monitor S/E (Cushing’s syndrome S/Sx)
a.) HPN
b.) Hirsutism
c.) Edema
d.) Moon face & buffalo hump
e.) Increase susceptibility to infection sue to steroids- reverse isolation
32
3. Na – increase (135-145 meq/L)
4. K- decrease (3.5-5.5 meq/L)
Nsg Mgt:
1. Monitor VS, I&O
2. Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone
- promotes excretion of NA while conserving potassium
3. Restrict Na
4. Provide Dietary intake – low in CHO, low in Na & fats
High in CHON & K
5. Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc.
6. Reverse isolation
7. Skin care – due acne & striae
8. Prevent complication
- Most feared – arrhythmia & DM
(Endocrine disorder lead to MI – Hypothyroidism & DM)
9. Surgical bilateral Adrenolectomy
10. Hormonal replacement therapy – lifetime due to adrenal gland removal- no more corticosteroid!
PANCREAS – behind the stomach, mixed gland – both endocrine and exocrine gland
Acinar cells (exocrine gland) Islets of Langerhans (endocrine gland ductless)
β Cells
Secrets insulin
Fxn: hypoglycemia
Delta Cells
Secrets somatostatin
Overview only:
33
PANCREATITIS (check page 72)– acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion – self-digestion
Cause: unknown/idiopathic
18. Or alcoholism
Pathognomonic sign- (+) Cullen’s sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turner’s sign – ecchymosis of flank area
DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism
Classification:
I. Type I DM (IDDM) – “Juvenile “ onset, common in children, non-obese “brittle dse”
-Insulin dependent diabetes mellitus
Incidence rate
1.) 10% of population with DM have Type I
Predisposing Factor:
1. 90% hereditary – total destruction of pancreatic dells
2. Virus
3. Toxicity to carbon tetrachloride
4. Drugs – Steroids both cause hyperglycemia
Lasix - loop diuretics
S/Sx:
3 P’S + G
1.) Polyuria
2.) Poydipsia
3.) Polyphagia
4.) Glycosuria
5.) Weight loss
6.) Anorexia
7.) N/V
8.) Blurring of vision
9.) Increase susceptibility to infection
10.) Delayed/ poor wound healing
Mgt:
1. Insulin Therapy
Diet
Exercise
34
DKA –(+) fruity or acetone breath odor
Kassmaul’s respiration – rapid, shallow breathing
Predisposing Factor:
1. Obesity – obese people lack insulin receptors binding site
2. Hereditary
S/Sx:
1. Asymptomatic
2. 3 P’s and 1G
Tx:
1. Oral Hypoglycemic Agents (OHA)
2. Diet
3. Exercise
Complication: HONKC
H – hyper
O – osmolar
N – non
K – ketotic
C – coma
III. GESTATIONAL DM – occurs during pregnancy & terminates upon delivery of child
Predisposing Factors:
1. Unknown/ idiopathic
2. Influence of maternal hormones
S/Sx :
Same as type II –
1. Asymptomatic
2. 3 P’s & 1G
35
Liver will undergo – glucogenesis – synthesis of glucagons
& Glycogenolysis – breakdown of glucagons
& Gluconeogenesis – formation of glucose form CHO sources – CHON & fats
Hyperglycemia – pancreas will not release insulin. Glucose can’t go to cell, stays at circulation causing hyperglycemia.
increase osmotic diuresis – glycosuria
Lead to cellular starvation
Polydipsia
Atherosclerosis coma
HPN death
MI stroke
Predisposing factor:
1. Stress – between stress and infection, stress causes DKA more.
2. Hyperglycemia
3. Infection
Dx Proc:
1. FBS increase, Hct – increase (compensate due to dehydration)
N =BUN – 10 -20 mg/100ml --increased due to severe dehydration
Crea - .8 – 1 mg/100ml
Nsg Mgt:
1. Can lead to coma – assist mechanical ventilation
2. Administer .9NaCl – isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3. Monitor VS, I&O, blood sugar levels
4. Administer meds as ordered:
a.) Insulin therapy – IV push
Regular Acting Insulin – clear (2-4hrs, peak action)
b.) To counteract acidosis – Na HCO3
c.) Antibiotic to prevent infection
Insulin Therapy
A. Sources:
1. Animal source – beef/ pork-rarely used. Causes severe allergic reaction.
2. Human – has less antigenecity property
Cause less allergic reaction. Humulin
If kid is allergic to chicken – don’t give measles vaccine due it comes from chicken embryo.
3. Artificially compound
B. Types of Insulin
1. Rapid Acting Insulin - Ex. Regular acting I
2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)
3. Long acting I - Ex. Ultra lente
Types of Insulin color & consistency onset peak duration
1. Rapid clear - 2-4h -
2. Intermediate cloudy - 6-12h -
3. Long acting cloudy - 12-24h -
250 mg/dl
Adm 5 units of RA I
Peak 7-9am – monitor hypoglycemic reaction at this time- TIRED
37
b. Somogyi’s phenomenon – hypoglycemia followed by periods of hyperglycemia or rebound effect of insulin.
11. 1ml or cc of tuberculin = 100 units of insulin
- - 1 cc = 100 units
- - .5cc = 50 units
- - .1 cc = 10 units
6 units RA
Tx:
O ral
H ypoglycemic
A gents
19. Stimulates pancreas to secrete insulin
Classifications of OHA
1. First generation Sulfonylurear
a. Chlorpropamide (diabenase)
b. Tolbutamide (orinase)
c. Tolazamide (tolinase)
Nsg Mgt;
1. Monitor for PEAK action of OHA & insulin
Notify Doc
2. Monitor VS, I&O, neurocheck, blood sugar levels.
3. Administer insulin & OHA therapy as ordered.
4. Monitor signs of hyper & hypoglycemia.
Pt DM –“ hinimatay”
20. You don’t know if hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain can’t tolerate low sugar!)
Cold, clammy skin – hypo – Orange Juice or simple sugar / warm to touch – hyper – adm insulin
5. Provide nutritional intake of diabetic diet:
CHO – 50%
CHON – 30%
Fats – 20%
-Or offer alternative food products or beverage.
-Glass of orange juice.
6. Exercise – after meals when blood glucose is rising.
7. Monitor complications of DM
a. Atherosclerosis – HPN, MI, CVA
b. Microangiopathy – small blood vessels
Eyes – diabetic retinopathy , premature cataract & blindness
Kidneys – recurrent pyelonephritis & Renal Failure
(2 common causes of Renal Failure : DM & HPN)
c. Gangrene formation
d. Peripheral neuropathy
1. Diarrhea/ constipation
2. Sexual impotence
e. Shock due to cellular dehydration
8. Foot care mgt
a. Avoid waking barefooted
b. Cut toe nails straight
c. Apply lanolin lotion – prevent skin breakdown
d. Avoid wearing constrictive garments
Blood 45% formed elements – 55% plasma – fluid portion of vlood. Yellow color.
SICKLE CELL ANEMIA –sickle shaped RBC. Should be round. Impaired circulation of RBC.
-immature cells=hemolysis of RBC=decreased hgb
3 Nsg priority
1. AIRWAY (priority) – avoid deoxygenating activities
- High altitude is bad
2. Fluid deficit – promote hydration
3. Pain & comfort
40
WBC – leukocytes 5,000 – 10,000/mm3
GRANULOCYTES NON-GRANULOCYTES
1. Polymorphonuclearneutrophils 1. Monocytes (macrophage) - largest WBC
Most abundant 60-70% WBC - involved in long term phagocytes
- fx – short term phagocytosis - For chronic inflammation
For acute inflammation - Other name macrophage
3.Platelets (thrombocytes)
N- 150,000 – 450, 000/ mm3
it promotes hemostasis – prevention of blood loss by activating
clotting
- Consists of immature or baby platelets known as megakaryocytes
– target of virus – dengue
- Normal lifespan 9 – 12 days
ANEMIA
Iron deficiency Anemia – chronic normocytic, hypochromic (pale), microcytic anemia due to inadequate absorption of iron leading to
hypoxemic tissue injury.
Incidence rate:
1. Common – developed country – due to high cereal intake
Third leading cause of death in the US due to accidents
2. Common – tropical countries – blood sucking parasites
3. Women – 15 – 35yo – reproductive yrs
4. Common among the poor – poor nutritional intake
THINGS TO REMEMBER:
Suicide - common in teenagers
Poisoning – common in children (aspirin)
Aspiration – common in infant
Accidents – common in adults
Choking – common in toddler
SIDS – common in infant in US
22. Common in tropical zone – Phil due blood sucks
41
Predisposing factors:
1. Chronic blood loss
a. Trauma
b. Mens
c. GIT bleeding:
i. Hematemesis-
ii. Melena – upper GIT – duodenal cancer
iii. Hematochezia – lower GIT – large intestine – fresh blood from rectum
2. Inadequate intake of food rich in iron
A. Eggs
B. Organ meats, eggs, oatmeals, dried fruits, legumes, raisins
3. Inadequate absorption of iron – due to :
a. Chronic diarrhea
b. Malabsorption syndrome –celiac disease-gluten free diet. Food for celiac pts- sardines
c. High cereal intake with low animal CHON ingestion
d. Subtotal gastrectomy- partial removal of the stomach
4. Improper cooking of food
S/Sx:
1. Usually asymptomatic
2. Weakness and Fatigue
3. Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
4. Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells
5. Atropic glossitis, dysphagia, stomatitis
6. Pica – abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior)
Dx Proc:
1. RBC
2. Hgb
3. Reticulocyte
4. Hct
5. Iron
6. Ferritin
Nsg Mgt
1. Monitor signs of bleeding of all hema test including urine & stool, GIT
2. Complete bed rest – don’t overtire pt =weakness and fatigue=activity intolerance
3. Encourage – iron rich food
23.Raisins, legumes, egg yolk
4. Instruct the pt to avoid taking tea - impairs iron absorption
5. Administer meds
a.) Oral iron preparation
Ferrous SO4
Fe gluconate
Fe Fumarate
Nsg Mgt oral iron meds:
1. Administer with meals – to lessen GIT irritation
42
2. If diluting in iron liquid prep –adm with straw
Straw
1. Lugol’s
2. Tetracycline
3. Oral iron
4. Macrodantine
If pt can’t tolerate oral iron prep – administer parenteral iron prep example:
1. Iron dextran (IV, IM)
2. Sorbitex (IM)
PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to
Hypochlorhydria – decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement.
Predisposing factor
1. Subtotal gastrectomy –partial removal stomach
2. Hereditary
3. Inflammatory dse of ileum
4. Autoimmune
5. Strict vegetable diet
STOMACH
S/Sx:
1. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
43
2.
GIT changes
a. Red – beefy tongue – PATHOGNOMONIC – mouth sores
b. Dyspepsia – indigestion
c. Wt loss
d. Jaundice
3. CNS –
Most dangerous anemia: pernicious due to neuroglogic involvement.
a. Tingling sensation
b. Paresthesia
c. (+) Romberg’s test (Ataxia)
d. Psychosis
Dx: Schilling’s test—measures reabsorption of Vit B12
Confirmatory: absence of intrinsic factor
APLASTIC ANEMIA – stem cell disorder due to bone marrow depression leading to pancytopenia – all RBC are decreased
S/Sx:
1. Anemia:
a. Weakness & fatigue
b. Headache, dizziness, dyspnea
c. cold sensitivity, pallor
d. palpitations
2. Leukopenia – increase susceptibility to infection
3. Thrombocytopenia –
a. Petecchiae
b. Oozing of blood from venipuncture site
c. ecchymoses
Dx:
1. CBC – pancytopenia
2. Bone marrow biopsy/ aspiration at post iliac crest – reveals fatty streaks in bone marrow
44
Nsg Mgt:
1. Removal of underlying cause
2. Blood transfusion as ordered
3. Complete bed rest
4. O2 inhalation
5. Reverse isolation due leukopenia
6. Monitor signs of infection
7. Avoid SQ, IM or any venipuncture site = HEPLOCK
8. Use electric razor when shaving to prevent bleeding
9. Administer meds
Immunological injury: give steroids
Immunosuppresants: Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days – 3 weeks to achieve max
therapeutic effect of drug.
BLOOD TRANSFUSION:
Objectives:
1. To replace circulating blood volume
2. To increase O2 carrying capacity of blood
3. To combat infection if there’s decrease WBC
4. To prevent bleeding if there’s platelet deficiency
Allergic Reaction:
S/Sx
1. Fever/ chills
2. Urticaria/ pruritus
3. Dyspnea
4. Laryngospasm/ bronchospasm
5. Bronchial wheezing
Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antihistamine – diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive
If (+) Hypotension – anaphylactic shock administer – epinephrine
5. Send blood unit to blood bank
6. Obtain urine & blood samples – send to lab
7. Monitor VS & IO
8. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB
Pyrogenic Reaction:
S/Sx
a.) Fever/ chills d. tachycardia
b.) Headache e. palpitations
c.) Dyspnea f. diaphoresis
Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antipyretics, antibiotics
5. Send blood unit to blood bank
6. Obtain urine & blood samples – send to lab
7. Monitor VS & IO
8. Tepid sponge bath – offer hypothermic blanket
Circulatory Overload:
Sx
a. Dyspnea
b. Orthopnea
c. Rales or crackles
d. Exertional discomfort
Nsg Mgt:
1. Stop BT
2. Notify Doc. Don’t flush due pt has circulatory overload.
3. Administer diuretics –Loop (Furosemide)
Priority cases:
Hemolytic Rxn – 1st due to hypotension – 1st priority – attend to destruction of Hgb – O2 brain damage
46
Allergic 3rd
Pyrogenic 4th
Circulatory 2nd
Hemolytic 2nd
Anaphylitic 1st priority
PLATELET DISORDERS
DIC – DISSEMINATED INTRAVASCULAR COAGULATION
24. Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a defiency of clotting factors (Prothrombin
& Fibrinogen).
Predisposing factor:
1. Rapid BT
2. Massive trauma
3. Massive burns
4. Septicemia
5. Hemolytic reaction
6. Anaphylaxis
7. Neoplasia – growth of new tissue
8. Pregnancy
S/Sx
47
1. Petechiae – widespread & systemic (lungs, lower & 4. Hemoptysis – cough blood
upper trunk) 5. Hemorrhage
2. Ecchymoses – widespread 6. Oliguria – late sx
3. Oozing of blood from venipunctured site
Dx Proc–
1. CBC – reveals decrease platelets
2. Stool for occult blood (+)
Specimen – stool
3. Opthalmoscopic exam – sub retinal hemorrhage
4. ABG analysis – metabolic acidosis
pH HCO3
R pH PCO2 respiratory alkalosis
48
Female
1. Breast cancer – 40 yrs old & up – mammography 15 – 20 mins (SBE – 7 days after mens)
2. Cervical cancer – 90% multi sexual partners
5% early pregnancy
3. Ovarian cancer
Classes of cancer
Tissue typing
1. Carcinoma – arises from surface epithelium & glandular tissues
2. Sarcoma- from connective tissue or bones
3. Multiple myeloma – from bone marrow
Pathological fracture of ribs & back pain
4. Lymphoma – from lymph glands
5. Leukemia – from blood
Warning / Danger Sx of CA
C – change in bowel /bladder habits
A – a sore that doesn’t heal
U – unusual bleeding/ Discharge
T – thickening of lump – breast or elsewhere
I – indigestion? Dysphagia
O – obvious change in wart/ mole
N – nagging cough/ hoarseness
U – unexplained anemia A - anemia
S – sudden wt loss L – loss of wt
Therapeutic Modality:
1. Chemotherapy – use various chemotherapeutic agents that kills cancer cells & kills normal rapidly producing cells – GIT,
bone marrow, and hair follicle.
Classification:
a.) Alkylating agents –
b.) Plant alkaloids – vincristine
c.) Anti metabolites – nitrogen mustard
d.) Hormones – DES
Steroids
e.) Antineoplastic antibiotics
- Diarrhea
1. Administer anti diarrheal 4 – 6h before start of chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care – offer ice chips/ popsickles
2. Inform pt – hair loss – temporary alopecia
Hair will grow back after 4 – 6 months post chemo.
-Bone marrow depression – anemia
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding
Repro organ – sterility
1. Do sperm banking before start of chemo
Renal system – increase uric acid
1. Administer allopurinol/ xyloprin (gout)
26. Inhibits uric acid
27. Acute gout – colchicines
28. Increase secretion of uric acid
Neurological changes – peristalsis – paralytic ileus
Most feared complication ff any abdominal surgery
Vincristine – plant alkaloid causes peripheral neuropathy
2. Radiation therapy – involves use of ionizing radiation that kills cancer cells & inhibit their growth & kill N rapidly producing
cells.
49
Methods of delivery
1. External radiation- involves electro magnetic waves
Ex. cobalt therapy
2. Internal radiation – injection/ implantation of radioisotopes proximal to CA site for a specific period of time.
2 types:
a.) Sealed implant – radioisotope with a container & doesn’t contaminate body fluid.
b.) Unsealed implant – radioisotope without a container & contaminates body fluid.
Ex. Phosphorus 32
Layer
1. Epicardium – outermost
2. Myocardium – inner – responsible for pumping action/ most dangerous layer - cardiogenic shock
- may lead to myocarditis, which may lead to RHD
3. Endocardium – innermost layer
Chambers
1. Upper – collecting/ receiving chamber - Atria
2. Lower – pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
Closure of AV valves – gives rise to 1st heart sound or S1 or “lub”
2. Semi lunar valve
a.) Pulmonic
b.) Aortic
Closure of semilunar valve – gives rise to 2nd heart sound or S2 or “dub”
Extra heart Sound
S3 – ventricular Gallop – CHF
S4 – atrial gallop – MI, HPN
SA node
AV
Purkenjie Fibers
Bundle of His
Complete heart block or the bundle block – insertion of pacemaker at Bundle Branch is needed
Metal – Pace Maker – change q3 – 5 yo
CAD – coronary artery dse or Ischemic Heart Dse (IHD) ==Nsg Mgt: decrease myocardial workload
Stages:
1. Atherosclerosis – Myocrdial injury
2. Angina Pectoris – Myocardial ischemia
3. MI- myocardial necrosis
ARTERIOSCLEROSIS ATHEROSCLEROSIS
- Narrowing of artery due to fat - Hardening or artery due to calcium & CHON
- lipid deposits at tunica intima. deposits at tunica media.
ATHEROSCLEROSIS
Predisposing Factor
1. Sex – male
2. Black race
3. Hyperlipidemia, increase in saturated fats
4. Smoking
5. HPN
6. DM
7. Oral contraceptive- prolonged use
8. Sedentary lifestyle
9. Obesity
10. Hypothyroidism
11. Stress
ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT
nitroglycerin, resulting fr temp myocardial ischemia.
Predisposing Factor: (same with CAD)
1. sex – male
2. black race
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10. hypothyroidism
Precipitating factors
4 E’s
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake of food – saturated fats
Nitroglycerin- act as Venodilator (if given in small doses)– dilate veins of lower ext – increase venous pooling lead to
decrease venous return.
Large doses- vasodilators
Meds:
52
A. NTG- Nsg Mgt:
1. Keep in a dry place.
2. Avoid moisture & heat, sunlight may inactivate the drug.
3. Monitor S/E:
orthostatic hypotension – dec bp
transient headache
dizziness
4. Rise slowly from sitting position
5. Assist in ambulation.
6. If giving NTG via patch:
i. avoid placing it near hairy areas-will dec drug absorption (SHAVE AREA)
ii. avoid rotating transdermal patches- will dec drug absorption
iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch
MI – MYOCARDIAL INFARCTION – heart attack – terminal stage of CVD characterized by malocclusion leading to
necrosis and scarring
Types:
A. According to Location
Most critical period upon dx of MI – 48 to 72h—most dangerous hours: first 6-8 hours (majority of arrythmias occur, PVCs)
- Majority of pt suffers from PVC premature ventricular contraction.
B. According to mortality
Killip I – 15-20% chance of mortality (75-80% survival)
Killip II – 30-35% mortality
Killip III- 45-50% mortality
Killip IV- 65-70% mortality—spiritual support is needed, pt chronically ill characterized by cardiogenic shock
Nursing Management
1. Narcotic analgesics – Morphine SO4 – to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation – low inflow (CHF-increase inflow)—2-3L/min (high inflow may lead to respiratory arrest)
3. Enforce CBR without BRP
a.) use Bedside commode
4. Avoid Valsalva maneuver (give laxatives)
5. Semi fowler
6. Provide a general liquid to soft diet that is low in saturated fats, Na, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 – 30 ml/week – wine, brandy, or whisky to induce vasodilation.
9. Assist in surgical; CABAG
Complications: 1. Pneumonia
53
2. Thrombophlebitis
3. Infarction
10. Provide pt HT
a.) Avoid modifiable risk factors (diet, lifestyle)
b.) Prevent complications:
1. Arrhythmias – PVC
2. Shock – cardiogenic shock. Late signs of cardiogenic shock in MI – oliguria
3. Thrombophlebitis - deep vein thrombosis
4. CHF – left sided
5. Dressler’s syndrome – post MI syndrome
-Resistant to medications
-Administer 150,000 – 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. ISOSURBIDE DINITRATE (Isordil)
- Antiarrythmic
1. Lydocaine blocks release of norepinephrine
2. Bretylium
- Beta-blockers – “lol”
1. PROPANOLOL (Inderal)
- ACE inhibitors - pril
1. CAPTOPRIL– (Enalapril)
- Ca – antagonist
1. NIFEDIPINE
- Thrombolytics or fibrinolytics– to dissolve clots/ thrombus
PTT PT
CHF – CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.
- Backflow
1.) Left sided heart failure:
Predisposing factors:
1.) 90% mitral valve stenosis – due RHD, aging
RHD affects mitral valve – streptococcal infection
Dx: - Aso titer – anti streptolysine O > 300 total units
Drugs given - Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging – degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis
S/Sx
Pulmonary congestion/ Edema
1. Dyspnea
2. Orthopnea (Diff of breathing- put patient on sitting pos – platypnea)—2-3 pillows or high fowlers
3. Paroxysmal nocturnal dysnea – PNO- nalulunod (DOB at night)
54
4. Productive cough with blood tinged sputum
5. Frothy saliva (from lungs)
6. Cyanosis
7. Rales/ crackles – due to fluid
8. Bronchial wheezing
9. PMI – displaced lateral – due cardiomegaly
10. Pulsus alternons – weak- pulse followed by alternating strong bounding pulse
11. Anorexia & general body malaise
12. S3 – ventricular gallop
Dx
1. CXR – cardiomegaly
2. PAP – Pulmonary Arterial Pressure
PCWP – Pulmonary CapillaryWedge Pressure
Predisposing factor
1. 90% - tricuspid stenosis
2. COPD
3. Pulmonary embolism
4. Pulmonic stenosis
5. Left sided heart failure
S/Sx
Venous congestion
- Neck or jugular vein distension
- Pitting edema
- Ascites
- Wt gain
- Hepatomegalo/ splenomegaly
- Jaundice
- Pruritus
- Esophageal varies
- Anorexia, gen body malaise
Diagnosis:
1. CXR – cardiomegaly
2. CVP – measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 – hypervolemia – give loop diuretics
Decrease CVP < 4 – hypovolemia (fluid challenge by inc IVF rate)
Flat on bed – post of pt when giving CVP
Position during CVP insertion – Trendelenburg to prevent pulmonary embolism & promote ventricular
filling.
1.) Thromboangitis obliterates/ BUERGERS DISEASE- Acute inflammatory disorder affecting small to medium sized
arteries & veins of lower extremities. Male/ feet
Predisposing factors:
- Males greater than 30yo (high risk group)
- Smokers
S/Sx
1. Intermittent claudication – leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes
Dx:
1. Oscillometry – decrease peripheral pulse volume.
2. Doppler UTZ – decrease blood flow to affected extremities.
3. Angiography – reveals site & extent of malocculsion.
5.
Nsg Mgt:
1. Encourage a slow progression of physical activity
a.) Walk 3 -4 x / day
b.) Out of bed 2 – 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM –
a.) Avoid walking barefoot
b.) Cut toe nails straight
c.) Apply lanolin lotion – prevent skin breakdown
d.) Avoid wearing constrictive garments
56
4. Avoid smoking & exposure to cold environment
5. Assist patient in surgery: BKA (Below the knee amputation)
2.)REYNAUD’S PHENOMENON – acute episodes of arterial spasm affecting digits of hands & fingers
Predisposing factors:
1. Female, 40 yrs
2. Smoking
3. Collagen dse
a.) SLE – pathognomonic sign – butterfly rash on face
Chipmunk face – bulimia nervosa
Cherry red skin – carbon monoxide poisoning
Spider angioma – liver cirrhosis
Caput medusae – leg & trunk umbilicus- Liver cirrhosis
Lion face – leprosy
Nsg Mgt:
a. Analgesics
b. Vasodilators
c. Encourage to wear gloves especially when opening a refrigerator.
d. Avoid smoking & exposure to cold environment
VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins – lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return
Predisposing factors:
a. Hereditary
b. Congenital weakness of veins
c. Thrombophlebitis
d. Heart dse
e. Pregnancy
f. Obesity
g. Prolonged immobility - Prolonged standing
S/Sx:
1. Pain especially after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs
Dx:
1. Venography
2. Trendelenberg’s test – vein distend quickly < 35 secs
Nsg Mgt:
1. Elevate legs above heart level – to promote venous return – 1 to 2 pillows
2. Measure circumference of leg muscles to determine if swollen.
3. Wear anti embolic or knee high stockings. Women – panty hose
4. Meds: Analgesics
5. Surgery: vein sweeping & ligation
Sclerotherapy – spider web varicosities
S/E thrombosis
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
- Mild restlessness
Serous membrane
Pleura
Parietal Visceral
Pleural Fluid
58
Pleural Effusion
Lungs – covered by pleural cavity, parietal lobe & visceral lobe
Alveoli – acinar cells
- site of gas exchange (O2 & CO2)-diffusion
- diffusion: Daltons law of partial pressure of gases
- basic living units
Powerful stimulating stimulant—increase CO2
COPD – decrease O2 stimulant
Ventilation – movement of air in & out of lungs
Respiration – movement of air into cells
If 1:2 – adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.
I. PNEUMONIA – inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.
Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Haemophilus pneumoniae(Bronchopneumonia) in children
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.
Predisposing factors:
1. Smoking
2. Air pollution
3. Immuno-compromised patients
a. AIDS – PLP
b. Bronchogenic CA - Non-productive to productive cough-- CXR
4. Prolonged immobility – CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue
S/Sx:
1. Productive cough – pathognomonic: greenish to rusty sputum
2. Dyspnea with prolonged respiratory grunt
3. Fever, chills, anorexia, gen body malaise
4. Wt loss
5. Pleuritic friction rub
6. Rales/ crackles
7. Cyanosis
8. Abdominal distension leading to paralytic ileus (absence of peristalsis)
Dx:
1. Sputum GSCS- gram staining & culture sensitivity - Reveals (+) culture microorganism.
2. CXR – pulmonary consolidation
3. CBC – increase WBC and inc Erythrocyte sedimentation rate
4. ABG – PO2 decrease, hypoxemia
Nsg Mgt:
1. Enforce CBR
2. Strict respiratory isolation
3. Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides – ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
4. Force fluids – 2 to 3 L/day
5. Institute pulmonary toilet-
a.) Deep breathing exercise
b.) Coughing exercise
59
c.) Chest physiotherapy – cupping
d.) Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction as necessary, O2 inhalation
8. Comfy & humid environment
9. Diet: increase CHO or calories, CHON & Vit C
10. Postural drainage - To drain secretions using gravity
PULMONARY TUBERCULOSIS (KOCH’S DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB
or tubercle bacilli or acid fast bacilli – gram (+) aerobic, motile & easily destroyed by heat or sunlight.
Predisposing factors:
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle (mycobacterium BOVIS)
5. Virulence
6. Over fatigue or stress
S/Sx:
1. Productive cough – yellowish
2. Low grade afternoon fever
3. Night sweats
4. Dyspnea
5. Anorexia, generalized body malaise, wt loss
6. Chest/ back pain
7. Hempotysis
==Airborne transmission, droplet nuclei infection
Diagnosis:
1. Skin test – Mantoux test – infection of Purified Protein Derivative PPD
DOH – 8-10 mm induration
WHO – 10-14 mm induration
Result within 48 – 72h
(+) Mantoux test – previous exposure to tubercle bacilli
Nursing Mgt:
1. CBR
2. Strict resp isolation
3. O2 inhalation
4. Semi fowler
5. Force fluid to liquefy secretions
6. Deep breathing and cough exercises
7. Nebulize & suction if necessary
8. Provide comfortable & humid environment
9. Diet – increase CHO & calories, CHON, Vit, minerals
10. Short course chemotherapy:
Intensive phase
3. PZA – Pyrazinamide – given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity
60
PZA may be replaced by ETHAMBUTOL (S/E: optic neuritis)
Standard regimen
1. Injection of streptomycin – Aminoglycosides
Ex. Kanamycin, gentamycin, neomycin
S/E:
a.) Ototoxicity – damage CN # 8 – tinnitus (ringing in the ears), dizziness, vertigo
b.) Nephrotoxicicity – monitor BUN (10-20) & Creatinine (.8-1)
HT:
a.) Avoid predisposing factors like alcoholism, crowded places
b.) Provide the dietary intake of increased CHO,calories, CHONm and Vitamin C
c.) Avoid complications:
1.) Atelectasis
2.) Miliary TB – spread of Tb to other system
b.) Strict compliance to meds (if one misses a dose, continue taking the meds)
- Religiously take meds
e) Know the importance of follow up care
HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with Histoplasma Capsulatum
transmitted from bird’s manure.
S/Sx: Same as pneumonia & PTB – like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis
7. Fever and chills
Dx:
1. Histoplasmin skin test = (+) Histoplasma Capsulatum
2. ABG – pO2 decrease
Nsg Mgt:
1. CBR
2. Meds:
a.) Antifungal agents
Amphotericin B (Fungizone)
S/E:
a.) Nephrotoxcicity check BUN and Creatinine
b.) Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or Expectorants
3. Administer O2, force fluids
4. Encourage deep breathing and coughing exercises
5. Nebulize, suction
6. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
7. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.
CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet
mucus producing cells leading to narrowing of smaller airways.
Predisposing factors:
1. Smoking – all COPD types
2. Air pollution
S/Sx:
1. Productive cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmonary HPN – a.) Leading to peripheral edema
b.) Cor pulmonale – right ventricular hypertrophy --respiratory in origin
7. Anorexia, gen body malaise
Dx:
1. ABG
61
PO2 PCO2 Resp acidosis
2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity to allergens leading to narrowing
of smaller airways.
Predisposing factor:
1. Extrinsic Asthma – called Atopic/ allergic asthma
a.) Pollen
b.) Dust
c.) Gases
d.) Smoke/fumes
e.) Dander
f.) Lints
g.) Viral infection
Nsg Mgt:
1. CBR – all COPD
2. Meds-
a.) Bronchodilator through inhalation or metered dose inhaled / pump. Given 1st before corticosteroids to facilitate
absorption
b.) Corticosteroids – due inflammatory. Given 10 min after adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist (Acetylcysteine) – at bedside put suction machine.
e.) Antihistamine
2. Force fluids
3. Institute pulmonary toilet
4. O2 – all COPD low inflow to prevent resp distress
5. Nebulize & suction client PRN
6. Diet: increase CHO, CHON
7. Semifowler – all COPD except emphysema due late stage
8. HT
a.) Avoid predisposing factors (dust, pollen, etc), provide a comfortable environment
b.) Complications:
• Status astmaticus- give epinephrine & bronchodilators
- Emphysema
c.) Adherence to meds to prevent status asmaticus
d.) Teach the importance of follow up care
BRONCHIECTASIS – abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.
Predisposing factors:
1. Recurrent upper & lower respiratory tract infections
2. Congenital anomalies
3. Lung Tumors
4. Chest Trauma
S/Sx:
1. Productive cough
2. Dyspnea
3. Anorexia, generalized body malaise- all energy are used to increase respiration.
62
4. Cyanosis
5. Hemoptisis
Dx:
1. ABG – PO2 decrease
2. Bronchoscopy – direct visualization of bronchus using fiberscope.
3. Chest xray
Nsg Mgt: before bronchoscopy
1. Consent, explain procedure – MD/ lab explain RN
2. NPO
3. Monitor VS
Nsg Mgt after bronchoscopy
1. Feeding after return of gag reflex
2. Instruct client to avoid talking, smoking or coughing
3. Monitor signs of frank or gross bleeding
4. Monitor of laryngeal spasm
- DOB
- Prepare at bedside tracheostomy set
Diagnosis:
1. Pulmonary function test – decrease vital lung capacity
2. ABG –
a.) Panlobular / centri lobular emphysema
pCO2 increase
pO2 decrease – hypoxema resp acidosis Blue bloaters – Chronic bronchitis
b.) Panacinar/ Centriacinar
pCO2 decrease
pO2 increase – hyperaxemia resp alkalosis Pink puffers
Nursing Mgt:
1. CBR
2. Meds –
a.) Bronchodilators
b.) Corticosteroids- prone to infection
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
e.) Antipyretics PRN
--Patient is prone to develop an infection
Predisposing factors:
1. Chest trauma
2. Inflammatory lung conditions
3. Tumor
S/Sx:
1. Sudden sharp chest pain
2. unexplained Dyspnea or SOB
3. Cyanosis
4. Diminished or decreased breath sound of affected lung
5. Cool moist skin- initial sign of shock
6. Mild restlessness/ apprehension, anxiety
7. Resonance to hyperresonance
8. decreased tactile fremitus
Diagnosis:
1. ABG – pO2 decrease –
2. CXR – confirms pneumothorax/ collapse of lung
Nursing Mgt:
1. Assist in endotracheal intubation
2. Assist in thoracenthesis
3. Administer meds – Morphine SO4 – due to pain
- Anti microbial agents- due to bacteria
4. Assist in test tube thoracotomy attached to H2O sealed drainage system
Purpose of H2O sealed drainage
1. Restablish (-) pressure in the lungs- lung 6-12mm Hg
2. Promote reexpansion of the lungs
3. Drain fluid, blood and air
4. To prevent reflux of blood fluid and air
GIT
I. Upper alimentary canal - function for digestion
a. Mouth
b. Pharynx (throat)
c. Esophagus
d. Stomach- site of digestion
e. 1st half of duodenum
II. Middle Alimentary canal – Function: for absorption
- Complete absorption – large intestine
a. 2nd half of duodenum for absorption
b. Jejunum
c. Ileum
d. 1st half of ascending colon
III. Lower Alimentary Canal – Function: elimination
a. 2nd half of ascending colon for elimination
b. Transverse for complete absorption— L I
c. Descending colon
d. Sigmoid
e. Rectum
IV. Accessory Organ
a. Salivary gland
b. Verniform appendix
c. Liver
d. Pancreas – auto digestion
e. Gallbladder – storage of bile
I. Salivary Glands
1. Parotid – below & front of ear
2. Sublingual
3. Submaxillary
S/Sx:
1. Fever, chills anorexia, generalized body malaise
2. enlarged parotid gland
3. Swelling of parotid gland
4. Dysphagia
5. Earache – otalgia
Nursing Mgt:
1. CBR
2. Institute a strict respiratory isolation
3. Meds: analgesic
Antipyretic
Antibiotics – to prevent 2° complications
4. Alternate warm & cold compress at affected part (vinegar promotes cooling)
5. General liquid to soft diet
6. Complications
Women – cervicitis, vaginitis, oophoritis
Both sexes – meningitis & encephalitis/ reason why antibiotics is needed
Men – orchitis might lead to sterility if it occurs during / after puberty.
65
VERNIFORM APPENDIX – Rt iliac or Rt inguinal area
- Function – lymphatic organ – produces WBC during fetal life - ceases to function upon birth of baby
S/Sx:
1. Pathognomonic sign: (+) rebound tenderness
2. Low grade fever, anorexia, n/v
3. Diarrhea &/ or constipation
4. Pain at Rt iliac region-- MCBURNEY’S point – site of surgical incision
5. Late sign due pain – tachycardia
Diagnosis:
1. CBC – mild leukocytosis – increase WBC
2. PE – (+) rebound tenderness (flex Rt leg, palpate Rt iliac area – rebound)
3. Urinalysis—(+) acetone in urine
Complications:
Peritonitis, Septicemia
Function:
1. Produces bile
Bile – emulsifies fats—H2O and bile salts= cholesterol
Right sided pain: Cholelithiasis- easy bruising
Left sided pain: Pancreatitis
- Composed of H2O & bile salts
-Gives color to urine – urobilin
Stool color – stechobilin
2. Detoxifies drugs
3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins (needs fat for absorption)
LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Laennac Cirrhosis- loss of architectural design of the liver leading to fat necrosis and scarring
Predisposing factor:
Decrease Laennac’s cirrhosis – caused by alcoholism
1. Chronic alcoholism- major cause
2. Malnutrition – decreaseVit B, thiamin - primary cause
3. Virus –
4. Toxicity- eg. Carbon tetrachloride (CCL4)
5. Use of hepatotoxic agents
S/Sx:
Early signs:
a.) Weakness, fatigue
b.) Anorexia, n/v
c.) Stomatitis
d.) Urine – tea color
Stool – clay color
e.) Amenorrhea
f.) Decrease sexual urge
g.) Loss of pubic, axilla hair
h.) Hepatomegaly
i.) Jaundice
j.) Pruritus or urticaria
k.) Decrease bowel sounds
2. Late signs
a.) Hematological changes – all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- bleeding tendencies
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusae, Palmar errythema, loss of tortousity of the umbilicus
Hepatic coma
Diagnosis:
1. Liver enzymes- increase
SGPT (ALT)
SGOT (AST)
2. Serum cholesterol & ammonia increase
3. Indirect or conjugated bilirubin increase
4. CBC - pancytopenia
5. PTT – prolonged bleeding
6. Hepatic ultrasonogram – fat necrosis of liver globules
Nursing Mgt
1. CBR
67
2. Restrict Na!
3. Monitor VS, I&O
4. Weigh pt daily & assess pitting edema
5. Measure abdominal girth daily – notify MD
6. Meticulous skin care
7. Diet – increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
8. Complications of liver cirrhosis:
a.) Ascites – fluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics – 10 – 15 min effect
2. Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted
Bilirubin
Kernicterus/ hyperbilirubinia
Pancreas – mixed gland (exocrine & endocrine gland); found behind the stomach
PANCREATITIS – acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto
digestion (self-digestion).
Bleeding of pancreas - Cullen’s sign on umbilical area
Predisposing factors:
1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs – Thiazide diuretics,aspirin, pills, Pentamidine HCL (Pentam) for clients with AIDS,
7. Diet – increase saturated fats
S/Sx:
1. Severe Lt epigastric pain – radiates from back &flank area (left upper quadrant)
- Aggravated by eating, accompanied by DOB
2. N/V
3. Tachycardia
4. Palpitation due to pain
5. Dyspepsia /indigestion
6. Decrease bowel sounds
7. (+) Cullen’s sign - ecchymosis of umbilicus hemorrhage
8. (+) Grey Turner’s spots – ecchymosis of flank area
9. Hypocalcemia
Diagnosis:
1. Serum amylase & lipase – increase
2. Urine lipase – increase
3. Serum Ca – decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine Hcl (Demerol)
Don’t give Morphine SO4 –will cause spasm of sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- Ex. Papavarine Hcl
Prophantheline Bromide (Profanthene)
68
c.) Vasodilator – NTG
d.) Antacid – Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation
f.) Ca – gluconate
Diagnosis:
1. Oral cholecystogram (or gallbladder series)- confirms presence of gall stones
2. Increased indirect bilirubin
3. Increased alkaline phosphatase
4. increased serum and amylase
Nursing Mgt:
1. Meds – a.) Narcotic analgesic - Meperdipine Hcl – Demerol
b.) Anti cholinergic/Anti-spasmodic - Atropine SO4
c.) Anti emetic
Phenergan – Phenothiazide with anti emetic properties
d) Broad spectrum antibiotics
2. Diet – increase CHO, moderate CHON, decrease fats
3. Meticulous skin care
4. Surgery: Cholecystectomy
Nursing Mgt post cholecystectomy
-Maintain patency of T-tube intact & prevent infection
PEPTIC ULCER DISEASE – (PUD) – excoriation / erosion of submucosa & mucosal lining due to:
a.) Hypercecretion of acid – pepsin
b.) Decrease resistance to mucosal barrier
Incidence Rate:
1. Men – 40 – 55 yrs old
2. Aggressive persons/ type A personality
3. Hereditary
4. Emotional Stress
Predisposing factors:
1. Hereditary
2. Emotional
3. Smoking – vasoconstriction – GIT ischemia
4. Alcoholism – stimulates release of histamine = Parietal cell release Hcl acid = ulceration
5. Caffeine – tea, soda, chocolate
6. Irregular diet
7. Rapid eating
8. Ulcerogenic drugs – NSAIDS, aspirin, steroids, indomethacin, ibuprofen
Indomethacin - S/E corneal cloudiness. Needs annual eye check up.
NSAID and steroids= gastropathy
According to location
1. Stress ulcer
2. Gastric ulcer
3. Duodenal ulcer – most common
Hypovolemia
GIT schemia
Ulcerations
Hyperacidity
Ulcerations
Treatment: Vagotomy- done to prevent hemorrhage and shock prior to surgery on the stomach
70
- gaseous & burning - cramping & burning pain
- not usually relieved by food & - usually relieved by food & antacid
antacid - 12 MN – 3am pain
HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion
VOMITING common Not common
HEMORRHAGE hematemesis Melena
WT Wt loss Wt gain
COMPLICATIONS a. stomach cancer a. perforation
b. hemorrhage
HIGH RISK 60 years old and above 20 years old and above
90-95% are cases ofduodenal ulcers- less bicarbonate ions, decrease so increase incidence
Diagnosis:
1. Endoscopic exam
2. Stool from occult blood (+)
3. Gastric analysis – Gastric Ulcer: normal gastric acid secretion
Duodenal: increased gastric acid secretion
4. GI series – confirms presence of ulceration
Nursing Mgt:
1. Diet – bland, non irritating, non spicy
2. Avoid caffeine & milk/ milk products
AAC
Aluminum containing antacids Magnesium containing antacids
Ex. aluminum hydroxide gel ex. milk of magnesia
(Amphogel) S/E diarrhea
S/E constipation
Nursing Mgt:
1. Administer antacid & H2 receptor antagonist (Cimetidine) – 1hr apart
-Cemetidine decrease antacid absorption & vise versa
c.) Cytoprotective agents
Ex
1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
2. Misoprostol (Cytotec) –SE: menstrual spotting
d.) Sedatives/ Tranquilizers - Valium, lithium
e.)Anticholinergics / Antispasmodic
1. Atropine SO4
2. Prophantheline Bromide (Profanthene)
(Pt has history of hpn crisis with peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na.
Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.
Nursing Mgt:
1. Monitor NGT output or drainage immediately post op- bright red
a.) Immediately post op should be bright red
b.) Within 36- 48h – output is yellow green
c.) After 48h – output is dark red due to HCl acid
2. Administer meds:
a.) Analgesic
b.) Antibiotic
c.) Antiemetics
3. Maintain patent IV line
4. VS, I&O & bowel sounds
5. Complications:
a.) Hemorrhage – hypovolemic shock
Late signs – anuria
71
b.) Peritonitis
c.) Paralytic ileus – most feared
d.) Hypokalemia
e.) Thromobphlebitis
f.) Pernicious anemia
g.) Septicemia
7.)Dumping syndrome – common complication – rapid gastric emptying of hypertonic food solutions – CHYME leading to
hypovolemia.
Sx of Dumping syndrome:
1. Dizziness
2. Diaphoresis
3. Diarrhea
4. Palpitations
Nursing mgt:
1. Avoid fluids in chilled solutions, sweets (fluids must be taken after meals)
2. Small frequent feedings-6 equally divided feedings
3. Diet – decrease CHO, moderate fats & CHON
4. Flat on bed 15 -30 minutes after q feeding
DIVERTICULITIS/DIVERTICULOSIS
1. Diverticulum- an outpouching of the intestinal mucosa particularly the sigmoid colon
2. Diverticulosis- multiple diverticulum
3. Diverticulitis- inflammation of diverticula
A. Predisposing Factors
1. High Risk Groups- men (40-45yo)
2. Congenital weakness of muscle fibers of the intestine.
3. low roughage and fiber in the diet
S/S:
1. Intermittent lower left abdominal quadrant pain, particularly in the rectosigmoid area
2. tenderness
3. alternating bouts of constipation or diarrhea with blood or mucous
Dx:
1. Barium enema—reveals inflammatory process
2. CBC reveals: decreased hematocrit and hemoglobin
Nsg Mgt:
1. Administer meds as ordered:
a. antibiotics
b. bulk laxatives
c. stool softeners
d. anti spasmodic agents
2. Instruct clients to take foods high in fiber if there is diverticulosis
3. Monitor for signs of infection
Feared complications: Peritonitis
4. Assists in surgical procedure
Resection of the diseased bowel and creation of a colostomy
BURNS – direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority – infection (all kinds of burns)
Head burn-priority- a/w
2nd priority for 1st & 2nd ° - pain
2nd priority for 3rd ° - F&E
Stages:
1. Emergent phase – Removal of pt from cause of burn. Determine source or loc or burn
2. Shock phase – 48 - 72°. Characterized by shifting of fluids from intravascular to interstitial space
=Hypovolemia
S/Sx:
- BP decrease
- Urine output
- HR increase
- Hct increase
- Serum Na decrease
- Serum K increase
- Met acidosis
3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
4. Recovery/ convalescent phase – complete diuresis. Wound healing starts immediately after tissue injury.
Class:
I. Partial Burn
1. 1st degree – superficial burns
72
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure with no fluid filled vesicles
2. 2nd degree – deep burns
- Affects epidermis & dermis
- Cause –chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
1. Third & 4th degrees burn
- Affects all layers of skin, muscles, bones
- Cause – electrical
- Less painful
- Dry, thick, leathery wound surface – known as ESCHAR – devitalized or necrotic tissue.
Assessment findings
Rule of nines
Head & neck = 9%
Ant chest = 18%
Post chest = 18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum= 1%
Total 100%
Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth – Claustridium tetany
Tetany
Tetanolysin tetanospasmin
Function of kidneys:
1. Urine formation
73
2. Regulation of BP
Urine formation – 25% of total CO (Cardiac Output) is received by kidneys (3,000-6,000 ml.)
125ml/ min filtered by the glomerulus > Glomerular filtration rate
1. Filtration
2. Tubular Reabsorption—124ml of ultra filtered are reabsorbed in the blood
3. Tubular Secretion- 1 ml is excreted in the urine
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
Causes of CRF:
1. HPN
2. DM
Regulation of BP:
Predisposing factor:
Ex CS – hypovolemia – decrease BP going to kidneys
Activation of RAAS
Angiotensin II vasoconstrictor
Aldosterone
Increase BP
Increase Na &
H2O reabsorption
Hypervolemia
Color – amber
Odor – aromatic
Consistency – clear or slightly turbid
pH – 4.5 – 8
Specific gravity – 1.015 – 1.030
WBC/ RBC – (-)
Albumin – (-)
E coli – (-)
Mucus thread – few
Amorphous urate (-)
Urethra – extends to external surface of body. Passage of urine, seminal & vaginal fluids.
- Women 3 – 5 cm or 1 to 1 ½ “
- Male – 20cm or 8”
UTI
CYSTITIS – inflammation of bladder
Predisposing factors:
1. Microbial invasion – E. coli
2. High risk – women
3. Obstruction
4. Urinary retention
5. Increase estrogen levels
6. Sexual intercourse
S/Sx:
1. Pain – flank area
2. Urinary frequency & urgency
3. Burning upon urination
4. Dysuria & hematuria
74
5. Fever, chills, anorexia, gen body malaise
6. Nocturia
Diagnosis: Urine culture & sensitivity - 80% of the cases are (+) to E. coli
Nursing Mgt:
1. Force fluid – 2000 ml= to prevent bacterial multiplication
2. Warm sitz bath – to promote comfort
3. Monitor & assess for gross hematuria
4. Monitor and assess urine for color, odor, and bleeding N pH: 4.8
5. Acid ash diet – cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
6. Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides – cotrimoxazole (Bactrim)
- Gantrism (ganthanol)
Aminoglycosides: Gentamycin
Urinary antiseptics – Nitrofurantoin (Macrodantin)
Urinary analgesic- Pyridum
6. Ht
a.) Importance of Hydration
b.) Void after sex (male and female)
c.) Female – avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications:
Pyelonephritis
PYELONEPHRITIS – acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, interstitial abscess
formation.
- Lead to Renal Failure
Predisposing factor:
1. Microbial invasion (Bacterial)
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins or nephrotoxic agents
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary frequency, urgency
d.) Nocturia, dysuria, hematuria
e.) Burning upon urination
Chronic Pyelonephritis
a.) Fatigue, wt loss, weakness
b.) Polyuria, polydypsia
c.) HPN
Diagnosis:
1. Urine culture & sensitivity – (+) E. coli & streptococcus
2. Urinalysis
(+) WBC, (+)RBC, (+) Pus cells
3. Cystoscopic exam – urinary obstruction
Nursing Mgt:
1. Provide CBR – especially during acute phase
2. Force fluid
3. Acid ash diet
4. Provide a warm sitz bath for comfort
5. Meds:
a.) Urinary antiseptic – nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
b.) Urinary analgesic – Pyridium
2. Complication- Renal Failure
75
milk cabbage anchovies
cranberries organ meat
nuts tea nuts
chocolates sardines
Predisposing factors:
1. Diet – increase Ca & oxalate
2. Hereditary – gout
3. Obesity
4. Sedentary lifestyle
5. Hyperparathyroidism
S/Sx:
1. Renal colic
2. Cool moist skin (shock)
3. Burning upon urination
4. Hematuria
5. Anorexia, n/v
Diagnosis:
1. IVP – intravenous pyelography. Reveals location of stone
2. KUB – reveals location of stone
3. Cytoscopic exam- urinary obstruction
4. Stone analysis – composition & type of stone
5. Urinalysis – increase EBC, increase CHON
Nursing Mgt:
1.Force fluid
2.Strain urine using gauze pad
3.Warm sitz bath – for comfort
4.Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent IV line
d.) Diet – if + Ca stones – acid ash diet
If + oxalate stone – alkaline ash diet - (Ex milk/ milk products)
If + uric acid stones – decrease organ meat / anchovies sardines
6. Surgery
a.) Nephectomy – removal of affected kidney
Litholapoxy – removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones
b.) Extracorporeal shock wave lithotripsy
- Non - invasive
- Dissolve stones by shock wave
7. Complications: Renal Failure
Predisposing factor:
1. High risk – 50 years old & above
60 – 70 – (3 to 4 x at risk)
Prostate cancer: 40 years old & above
2. Influence of male hormone
S/Sx:
1.Decrease force of and amount of urinary stream
2.Dysuria
3.Hematuria
4.Burning upon urination
5.Terminal dribbling—early sign of BPH
6.Backache
7.Sciatica
8. Hesitancy
Diagnosis:
1. Digital rectal exam – enlarged prostate gland
2. KUB – urinary obstruction
3. Cystoscopic exam – obstruction
4. Urinalysis – increase WBC, CHON, RBC
Nursing Mgt:
1. Prostatic message – promotes evacuation of prostatic fluid
2. Limit fluid intake
3. Provide catheterization
4. Provide a warm sitz bath for comfort
5. Meds:
76
a. Terazozine (hytrin) - Relaxes bladder sphincter, relaxes the smooth muscle of urinary sphincter
S/E: HA, hypotension
b. Fenasteride (Proscar) - Atrophy of Prostate Gland (given after meals)
S/E: N&V, Anorexia
5. Surgery: Prostatectomy – TURP- Transurethral resection of Prostate- No incision
Without incision: for debilitated clients
-Assist in cystoclysis or continuous bladder irrigation.
Complication:
1. Hemorrhage
2. Urinary obstruction
3. Penile dysfunction
Nursing mgt:
c. Monitor signs and symptoms of infection
d. Monitor symptoms gross/ frank bleeding. Normal bleeding within 24h.
3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention
ACUTE RENAL FAILURE – sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E balance
due to a decrease in GFR. (N 125 ml/min)
Predisposing factors:
Pre renal cause- decrease blood flow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension decrease flow to kidneys
4. CHF
5. Hemorrhage
6. Dehydration (chronic diarrhea)
Intra-renal cause – involves renal pathology= kidney problem
1. Acute tubular necrosis 3. HPN
2. Pyelonephritis 4. Acute Glumerulonephritis
Stages of CRF
1. Diminished Reserve Volume – asymptomatic
Normal BUN & Crea, GFR < 10 – 30%
2. Renal Insufficiency
3. End Stage Renal disease
S/Sx:
1.) Urinary System 2.) Metabolic disturbances
a.) polyuria a.) azotemia (increase BUN & Crea)
77
b.) nocturia b.) hyperglycemia
c.) hematuria c.) hyperinulinemia
d.) Dysuria
e.) oliguria
3.) CNS 4.) GIT
a.) headache a.) n/v
b.) lethargy b.) stomatitis
c.) disorientation c.) uremic breath
d.) restlessness d.) diarrhea/ constipation
e.) memory impairment
5.) Respiratory 6.) hematological
a.) Kassmaul’s resp a.) Normocytic anemia
b.) decrease cough bleeding tendencies
reflex
7.) Fluid & Electrolytes 8.) Integumentary
a.) hyperkalemia a.) itchiness/ pruritus
b.) hypernatermia b.) uremic frost
c.) hypermagnesemia 9.) Cardiovascular changes
d.) hyperposphatemia a. HPN
e.) hypocalcemia b. CHF
f.) met acidosis c. Pericarditis
Nursing Mgt:
1. Enforce CBR, reverse isolation
2. Monitor strictly VS, I&O, neurocheck, monitor for signs of hypocalcemia
3. Meticulous skin care. Uremic frost – assist in bathing pt
4. Meds:
a.) Na HCO3 – due Hyperkalemia
b.) Kayexelate enema
c.) Anti HPN – Hydralazine (Apresoline)
d.) Vit & minerals (Multivitamins)
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca – Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
2.) Weigh patient
3.) Obtain baseline data & monitor VS before and during q30mins, I&O, wt, blood exam
4.) Encourage patient to void
5.) Strict aseptic technique
6.) Monitor for signs of complications:
B – bleeding (due to heparin)
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:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) Paresthesia
2. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
3. Maintain patency of shunt by:
i. Palpate for thrills & auscultate for bruits if (+) patent shunt!
ii. Bedside- bulldog clip
- If with accidental removal of fistula to prevent embolism.
- Infersole (diastole) – common dialisate used
7. Complication
- Peritonitis (most feared)
- Shock
Inflow time: 10-20mins
Indwelling time: 30-45 mins
8. Assist in surgery:
Renal transplantation : Complication – rejection (feared complication). Reverse isolation
Rejection time in Acute—6mos to 1 year
Rejection time in Chronic—5-10 years
EYES
External parts
1. Orbital cavity – made up of connective tissue protects eye form trauma.
2. EOM – extrinsic ocular muscles – involuntary muscles of eye needed for gazing movement.
3. Eyelashes/ eyebrows – esthetic purposes
4. Eyelids – palpebral fissure – opening upper & lower lid. Protects eye from direct sunlight
Meibomean gland – secrets a lubricating fluid inside eyelid
b.) Stye/ sty or Hordeolum- inflamed Meibomean gland
78
5. Conjunctiva
6. Lacrimal apparatus – tears
Process of grieving
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
2. Intrinsic coat
I. sclerotic coat – outer most
a.) Sclera – white. Occupies ¾ post of eye. Refracts light rays
b.) Canal of schlera – site of aqueous humor drainage
c.) Cornea – transparent structure of eye
No auto receptors
Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays – bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes
ERROR of refraction
1. Myopia – near sightedness – Treatment: biconcave lens
2. Hyperopia/ or farsightedness – Treatment: biconvex lens
3. Astigmatisim – distorted vision – Treatment: cylindrical
4. Prebyopia – “old slight” – inelasticity of lens due to aging – Treatment: bifocal lens or double vista
Accommodation of lenses – based on thelmholtz theory of accommodation
Type:
1. Chronic – (open angle G.) – most common type
Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema
2. Acute (close angle G.) – Most dangerous type
Forward displacement of iris to cornea leading to blindness.
3. Chronic (closed – angle) - Precipitated by acute attack
S/Sx:
1. Loss of peripheral vision – tunnel vision
2. Halos around lights
3. Headache
4. n/v
5. Steamy cornea
6. Eye discomfort
7. If untreated – gradual loss of central vision – blindness
Diagnosis:
1. Tonometry – increase IOP >12- 21 mmHg
2. Perimetry – decrease peripheral vision
3. Gonioscopy – abstruction in anterior chamber
Nursing mgt:
1. Enforce CBR
2. Maintain siderails
3. Administer meds
a.) Miotics – lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)
b.) Epinephrine eye drops – decrease secretion of aqueous humor
c.) Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
2. Surgery:
Invasive:
a.) Trabeculectomy – eyetrephining – removal of trabelar meshwork of canal or schlera to drain aqueous humor
b.) Peripheral Iridectomy – portion of iris is excised to drain aqueous humor
Non-invasive:
Trabeculoctomy (eye laser surgery)
S/Sx:
1. Loss of central vision - “Hazy or blurring of vision”
2. Painless
3. Milky white appearance at center of pupil
4. Decrease perception of colors
80
4. Surgery
E – extra
C - capsular
C – cataract partial removal of lens
L - lens
E – extraction
I - intra
C - capsular
C – cataract total removal of lens & surrounding capsules
L - lens
E – extraction
Nursing Mgt:
S/Sx:
1. “Curtain –veil” like vision
2. Flashes of lights
3. Floaters
4. Gradual decrease in central vision
5. Headache
EAR –
1. Hearing
2. Balance (Kinesthesia or position sense)
Parts:
1. Outer-
a.) Pinna/ auricle – protects ear from direct trauma
b.) Ext. auditory meatus – has ceruminous gland. Cerumen
c.) Tympanic membrane – transmits sound waves to middle ear
1. Hammer -malleus
2. Anvil -Incus for bone conduction disorder conductive hearing loss
3. Stirrups -stapes
81
b. Eustachian tube - Opens to allow equalization of pressure on both ears
- Yawn, chew, and swallow
Children – straight, wide, short
c.) Otitis media
Adult – long, narrow & slanted
c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth – for balance, vestibule
Surgery
Stapedectomy – removal of stapes, spongy bone & implantation of graft/ ear prosthesis
Predisposing factor:
1. Familiar tendency
2. Ear trauma & surgery
S/Sx:
1. Tinnitus
2. Conductive hearing loss
Diagnosis:
1. Audiometry – various sound stimulates (+) conductive hearing loss
2. Weber’s test – Normal AC> BC
result BC > AC
Stapedectomy
Nursing Mgt post op
1. Position pt unaffected side
2. DBE
No coughing & blowing of nose
- Night lead to removal of graft
3. Meds:
a.) Analgesic
b.) Antiemetic
c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)
4. Assess – motor function – facial nerve - (Smile, frown, raise eyebrow)
5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap
82
Ear trauma & infection
S/Sx:
1. TRIAD symptoms of Meniere’s disease
a.) Tinnitus
b.) Vertigo
c.) Sensory neural hearing loss
2. Nystagmus
3. n/v
4. Mild apprehension, anxiety
5. Tachycardia
6. Palpitations
7. Diaphoresis
Diagnosis:
1. Audiometry – (+) sensory hearing loss
Nursing mgt:
1. Comfy & darkened environment
2. Siderails
3. Emetic basin
4. Meds:
a.) Diuretics –to remove endolymph
b.) Vasodilator
c.) Antihistamine
d.) Antiemetic
e.) Antimotion sickness agent
f.) Sedatives/ tranquilizers
5. Restrict Na
6. Limit fluid intake
7. Avoid smoking
8. Surgery – endolymphatic sac decompression- Shunt
IV NOTES
Clindamycin, KCl===NOT for IV push—it may cause arrhythmia
Chloramphenicol===NOT for IM
Procaine, Penicillin, Benzatine, Pen G, Vancomycin HCl, Acyclovir (Zovirax) ===NOT for IV
Dopamine
Dobutamine
Not to be diluted in LR
Penicillin G
Ampicillin
Cephalosporin
NaHCO3
Pathognomonic sign:
Pernicious Anemia- red beefy tongue
Carbon monoxide poisoning- cherry red face
Addison’s Disease- bronze pigmentation of skin
Cushing’s syndrome- buffalo hump
Bulimia Nervosa- chipmunk face
Liver Cirrhosis- spider angioma & Caput medusae
Leprosy- lion face
SLE- butterfly rash on face
Emphysema- barrel chest
Parkinson’s – pill rolling tremors
Myasthenia Gravis- ptosis & Descending paralysis
83
GBS- Ascending paralysis- clumsiness
Meningitis- nuchal rigidity. Kernig’s & Brudzinskis sign
Hypoparathyroidism- Trousseau sign & Chvosteck sign
Pancreatitis- Cullen’s sign & Grey Turner’s sign
DKA- Acetone breath odor & Kussmaul’s respiration
Angina Pectoris- Levine’s sign
Pneumonia- rusty sputum
Chronic bronchitis- Blue bloaters
Asthma- Pink puffers
Appendicitis- rebound tenderness
Glaucoma-loss of peripheral vision- Tunnel vision
Cataract- Loss of central vision
Retinal detachment-Curtain-veil like vision
Autoimmune diseases
Multiple Sclerosis Hypothyroidism Acute Glomerulonephritis
Myasthenia Gravis Hyperthyroidism
GBS Pernicious Anemia
Isolation precautions:
Cushing’s synd – reverse isolation - due to increased corticosteroid in body.
Aplastic anemia – reverse isolation - due to bone marrow depression.
Cancer any type – reverse isolation – immunocompromised.
Post liver transplant – reverse isolation – takes steroids lifetime.
Prolonged use steroids – reverse isolation
Meningitis – strict respiratory isolation – safe after 24h of antibiotic therapy
TB- strict respiratory isolation
84