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MEDICAL-SURGICAL NURSING • Capable of regeneration with limited time, survival

By: Anthony T. Villegas R.N. period.
• Kidney cells, Liver cells, Salivary cells, pancreas.
Overview of structures and functions: 3. Permanent
NERVOUS SYSTEM • Not capable of regeneration.
• The functional unit of the nervous system is the nerve cells
• Myocardial cells, Neurons, Bone cells, Osteocytes,
or neurons
Retinal Cells.
• The nervous system is composed of the ff:
Central Nervous System B. NEUROGLIA
• Brain • Support and protection of neurons.
• Spinal Cord – serves as a connecting link between the brain
& the periphery. TYPES
Peripheral Nervous System 1. Astrocytes
• Cranial Nerves –12 pairs; carry impulses to & from the brain. • maintains blood brain barrier semi-permiable.

• Spinal Nerves – 31 pairs; carry impulses to & from spinal • majority of brain tumors (90%) arises from called

cord. astrocytoma.
Autonomic Nervous System • integrity of blood brain barrier.
subdivision of the PNS that automatically controls body 2. Oligodendria
function such as breathing & heart beat. • produces myelin sheath in CNS.
Special senses of vision and hearing are also covered in this • act as insulator and facilitates rapid nerve impulse
section
transmission.
• Sympathetic nervous system – generally accelerate some 3. Microglia
body functions in response to stress. • stationary cells that carry on phagocytosis (engulfing of
• Parasympathetic nervous system – controls normal body bacteria or cellular debris, eating), pinocytosis (cell
functioning. drinking).
4. Epindymal
CELLS • secretes a glue called chemo attractants that
A. NEURONS concentrate the bacteria.
• Primary component of nervous system
• Composed of cell body (gray matter), axon, and dendrites MACROPHAGE ORGAN
Microglia Brain
• Basic cells for nerve impulse and conduction.
Monocytes Blood
Kupffers Kidney
Axon
Histiocytes Skin
• Elongated process or fiber extending from the cell body
Alveolar Macrophage Lung
• Transmits impulses (messages) away from the cell body to
dendrites or directly to the cell bodies of other neurons
Central Nervous System
• Neurons usually has only one axon
Dendrites
Composition Of Brain
• Short, blanching fibers that receives impulses and conducts
• 80% brain mass
them toward the nerve cell body.
• 10% blood
• Neurons may have many dendrites.
• 10% CSF
Synapse
Brain Mass
• Junction between neurons where an impulse is transmitted
Parts Of The Brain
Neurotransmitter
1. Cerebrum
• Chemical agent (ex. Acetylcholine, norepinephrine) involved
• largest part of the brain
in the transmission of impulse across synapse.
• outermost area (cerebral cortex) is gray matter
Myelin Sheath
• deeper area is composed of white matter
• A wrapping of myelin (whitish, fatty material) that protects
and insulates nerve fibers and enhances the speed of • function of cerebrum: integration, sensory, motor

impulse conduction. • composed of two hemisphere the Right Cerebral

o Both axons and dendrites may or may not have a Hemisphere and Left Cerebral Hemisphere enclosed in
myelin sheath (myelinated/unmyelinated) the Corpus Callosum.
o Most axons leaving the CNS are heavily myelinated • Each hemisphere divided into four lobes; many of the
by schwann cells functional areas of the cerebrum have been located in
these lobes:
Functional Classification
1. Afferent (sensory) neurons Lobes of Cerebrum
• Transmit impulses from peripheral receptors to the CNS 1. Frontal Lobe
2. Efferent (motor) neurons • controls personality, behavior
• Conduct impulses from CNS to muscle and glands • higher cortical thinking, intellectual functioning
3. Internuncial neurons (interneurons) • precentral gyrus: controls motor function
• Connecting links between afferent and efferent neurons
• Broca’s Area: specialized motor speech area - when
Properties damaged results to garbled speech.
1. Excitability – ability of neuron to be affected by changes in 2. Temporal Lobe
external environment. • hearing, taste, smell
2. Conductility – ability of neuron to transmit a wave of
• short term memory
excitetation from one cell to another.
• Wernicke’s area: sensory speech area
3. Permanent Cell – once destroyed not capable of
(understanding/formulation of language)
regeneration.
3. Pareital Lobe
• for appreciation
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY
• integrates sensory information
1. Labile
• discrimination of sensory impulses to pain, touch,
• Capable of regeneration.
pressure, heat, cold, numbness.
• Epidermal cells, GIT cells, GUT cells, cells of lungs.
2. Stable

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• Postcentral gyrus: registered general sensation (ex. • controls respiration, heart rate, swallowing, vomiting,
Touch, pressure) hiccup, vasomotor center (dilation and constriction of
4. Occipital Lobe bronchioles).
• for vision
5. Cerebellum

Insula (Island of Reil) • smallest part of the brain, lesser brain.

• visceral function activities of internal organ like gastric • coordinates muscle tone and movements and maintains
motility. position in space (equilibrium)
Limbic System (Rhinencephalon) • controls balance, equilibrium, posture and gait.

• controls smell - if damaged results to anosmia (absence

of smell). Spinal Cord

• controls libido • serves as a connecting link between the brain and

• controls long term memory periphery

Corpus Callosum • extends from foramen magnum to second lumbar

vertebra
• large fiber tract that connects the two cerebral
hemisphere • H-shaped gray matter in the center (cell bodies)

Basal Ganglia surrounded by white matter (nerve tract and fibers)

• island of gray matter within white matter of cerebrum

Gray Matter
• regulate & integrate motor activity originating in the
1. Anterior Horns
cerebral cortex
• Contains cell bodies giving rise to efferent (motor)
• part of extrapyramidal system
fibers
• area of gray matter located deep within each cerebral
2. Posterior Horns
hemisphere.
• Contains cell bodies connecting with afferent
• release dopamine (controls gross voluntary movement).
(sensory) fibers from dorsal root ganglion
3. Lateral Horns
2. Diencephalon/interbrain
• In thoracic region, contain cells giving rise to
• Connecting part of the brain, between the cerebrum &
autonomic fibers of sympathetic nervous system
the brain stem
• Contains several small structures: the thalamus &
White Matter
hypothalamus are most important
1. Ascending Tracts (sensory pathways)
Thalamus
a. Posterior Column
• acts as relay station for discrimination of sensory signals
• Carry impulses concerned with touch,
(ex. Pain, temperature, touch)
pressure, vibration, & position sense
• controls primitive emotional responses (ex. Rage, fear) b. Spinocerebellar
Hypothalamus • Carry impulses concerned with muscle
• found immediately beneath the thalamus tension & position sense to cerebellum
• plays a major role in regulation/controls of vital function:
blood pressure, thirst, appetite, sleep & wakefulness, c. Lateral Spinothalamic
temperature (thermoregulatory center) • Carry impulses resulting in pain &
• acts as controls center for pituitary gland and affects temperature sensations
both divisions of the autonomic nervous system. d. Anterior Spinothlamic
• controls some emotional responses like fear, anxiety • Carry impulses concerned with crude
and excitement. touch & pressure

• androgenic hormones promotes secondary sex 2. Descending Tracts (motor pathways)

characteristics. a. Corticospinal (pyramidal, upper motor neurons)
• early sign for males are testicular and penile • Conduct motor impulses from motor
enlargement cortex to anterior horn cells (cross in
• late sign is deepening of voice. the medulla)

• early sign for females telarch and late sign is menarch. b. Extrapyramidal
• Help to maintain muscle tone & to

3. Mesencephalon/Midbrain control body movement, especially

• acts as relay station for sight and hearing. gross automatic movements such as
walking
• size of pupil is 2 – 3 mm.

• equal size of pupil is isocoria.

Reflex Arc
• unequal size of pupil is anisocoria. • Reflex consists of an involuntary response to a stimulus
• hearing acuity is 30 – 40 dB. occurring over a neural pathway called a reflex arc.

• positive PERRLA • Not relayed to & from brain: take place at cord levels

4. Brain Stem Components

• located at lowest part of brain. a. Sensory Receptors

• contains midbrain, pons, medulla oblongata. • Receives/reacts to stimulus

• extends from the cerebral hemispheres to the foramen b. Afferent Pathways

magnum at the base of the skull. • Transmits impulses to spinal cord

• contains nuclei of the cranial nerves and the long c. Interneurons

ascending and descending tracts connecting the • Synapses with a motor neuron (anterior horn cell)
cerebrum and the spinal cord. d. Efferent Pathways
• contains vital center of respiratory, vasomotor, and • Transmits impulses from motor neuron to effector
cardiac functions. e. Effectors
• Muscle or organ that responds to stimulus
Pons
• pneumotaxic center controls the rate, rhythm and depth Supporting Structures
of respiration. 1. Skull
Medulla Oblongata • Rigid; numerous bones fused together

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• Protects & support the brain • Resulting to cholesterol and positive to ketones (CNS
2. Spinal Column depressant).
• Consists of 7 cervical, 12 thoracic, & 5 lumbar vertebrae • Resulting to acetone breath odor/fruity odor.
as well as sacrum & coccyx • And kusshmauls respiration a rapid shallow respiration.
• Supports the head & protect the spinal cord
• Which may lead to diabetic coma.
3. Meninges
4. Hepatitis
• Membranes between the skull & brain & the vertebral
• Signs of jaundice (icteric sclerae).
column & spinal cord
• Caused by bilirubin (yellow pigment)
• 3 fold membrane that covers brain and spinal cord.
5. Bilirubin
• For support and protection; for nourishment; blood
• Increase bilirubin in brain (kernicterus).
supply
• Causing irreversible brain damage.
• Area between arachnoid & pia mater is called
subarachnoid space: CSF aspiration is done
• Subdural space between the dura and arachnoid

• Layers:
Peripheral Nervous System
Dura Mater
• outermost layer, tough, leathery Spinal Nerves
Arachnoid Mater 31 pairs: carry impulses to & from spinal cord
• middle layer, weblike
Each segment of the spinal cord contains a pair of spinal
Pia Mater
nerves (one of each side of the body)
• innermost layer, delicate, clings to surface of brain
Each nerve is attached to the spinal by two roots:
4. Ventricles
1. Dorsal (posterior) roots
• Four fluid-filled cavities connecting with one
• contains afferent (sensory) nerve whose cell
another & spinal canal
body is in the dorsal roots ganglion
• Produce & circulate cerebrospinal fluid
2. Ventral (anterior) roots
5. Cerebrospinal Fluid (CSF)
• Contains efferent (motor) nerve whose nerve
• Surrounds brain & spinal cord
fibers originate in the anterior horn cell of the
• Offer protection by functioning as a shock absorber
spinal cord (lower motor neuron)
• Allows fluid shifts from the cranial cavity to the spinal
cavity Cranial Nerves
• Carries nutrient to & waste product away from nerve 12 pairs: carry impulses to & from the brain.
cells
May have sensory, motor, or mixed functions.
• Component of CSF: CHON, WBC, Glucose
6. Vascular Supply Name & Number Function
• Two internal carotid arteries anteriorly Olfactory : CN I Sensory: carries impulses for
• Two vertebral arteries leading to basilar artery sense of smell.
posteriorly Optic : CN II Sensory: carries impulses for vision.

• These arteries communicate at the base of the brain Oculomotor : CN III Motor: muscles for papillary

through the circle of willis constriction, elevation of upper eyelid;

4 out of 6 extraocular
• Anterior, middle, & posterior cerebral arteries are the
movement.
main arteries for distributing blood to each hemisphere
Trochlear : CN IV Motor: muscles for downward,
of the brain
inward, movement of the eye
• Brain stem & cerebellum are supplied by branches of
Trigeminal : CN V Mixed: impulses from face, surface
the vertebral & basilar arteries
of eyes (corneal reflex); muscle
• Venous blood drains into dural sinuses & then into
Controlling mastication.
jugular veins
Abducens : CN VI Motor: muscles for lateral deviation
7. Blood-Brain-Barrier (BBB) of eye
• Protective barrier preventing harmful agents from Facial : CN VII Mixed: impulses for taste from
entering the capillaries of the CNS; protect brain & anterior tongue; muscles for facial
spinal cord Movement.
Acoustic : CN VIII Sensory: impulses for
Substance That Can Pass Blood-Brain Barrier hearing (cochlear division) & balance (vestibular
1. Amonia Division).
• Cerebral toxin Glossopharyngeal : CN IX Mixed: impulses for

• Hepatic Encephalopathy (Liver Cirrhosis) sensation to posterior tongue & pharynx; muscle
For movement of pharynx
• Ascites
(elevation) & swallowing.
• Esophageal Varices
Vagus : CN X Mixed: impulses for sensation to
Early Signs of Hepatic Encephalopathy
lower pharynx & larynx; muscle for
• Asterexis (flapping hand tremors).
Movement of soft palate,
Late Signs of Hepatic Encephalopathy pharynx, & larynx.
• Headache Spinal Accessory : CN XI Motor: movement of
• Dizziness sternomastoid muscles & upper part of trapezius
• Confusion Muscles.

• Fetor hepaticus (amonia like breath) Hypoglossal : CN XII Motor: movement of tongue.

• decrease LOC
Autonomic Nervous System
2. Carbon Monoxide and Lead Poisoning
Part of the peripheral nervous system
• Can lead to Parkinson’s Disease.
Include those peripheral nerves (both cranial & spinal) that
• Epilepsy
regulates smooth muscles, cardiac muscles, & glands.
• Treated with calcium EDTA. Component:
3. Type 1 DM (IDDM) 1. Sympathetic Nervous System
• Causes diabetic ketoacidosis. Generally accelerates some body function in
• And increases breakdown of fats. response to stress.
• And free fatty acids 2. Parasympathetic Nervous System

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Controls normal body functioning Blood Vessel constrict smooth muscles of the skin, no effect
Abdominal blood vessels, and
Cutaneous blood vessels
Sympathetic Nervous System Parasympathetic Nervous System Dilates smooth muscles of bronchioles,
(Adrenergic) Effect (Cholinergic) Effect, Vagal, Blood vessels of the heart & skeletal muscles
Sympatholytic
- Involved in fight or aggression - Involved in flight or withdrawal
Lungs bronchodilation
response. response.
bronchoconstriction
- Release of Norepinephrine - Release of Acetylcholine.
(cathecolamines) from adrenal - Decreases all bodily activities
glands and causes except GIT.
GI Tract decrease motility
vasoconstriction.
increase motility
- Increase all bodily activity
Constrict sphincters relaxed
except GIT EFFECTS OF PNS
sphincters
- Constriction of pupils (miosis).
Possibly inhibits secretions
EFFECTS OF SNS - Increase salivation.
stimulate secretions
- Dilation of pupils (mydriasis) in - Decrease BP and Heart Rate.
Inhibits activity of gallbladder & ducts stimulate
order to be aware. - Bronchoconstriction, Decrease
activity of gallbladder & ducts
- Dry mouth (thickened saliva). RR.
Inhibits glycogenolysis in liver
- Increase BP and Heart Rate. - Diarrhea
- Bronchodilation, Increase RR - Urinary frequency.
Adrenal Gland stimulates secretion of epinephrine & no effect
- Constipation.
Norepinephrine
- Urinary Retention.
- Increase blood supply to brain,
Urinary Tract relaxes detrusor muscles
heart and skeletal muscles.
contract detrusor muscles
- SNS I. Cholinergic Agents
Contract trigone sphincter (prevent voiding)
- Mestinon, Neostignin.
relaxes trigone sphincter (allows voiding)
I. Adrenergic Agents SE:
- Give Epinephrine. - PNS effect
NEURO TRANSMITTER Decrease Increase
SE: Acethylcholine Myesthenia Gravis Bi-polar Disorder
- SNS effect Dopamine Parkinson’s Disease Schizophrenia

Contraindication:
- Contraindicated to patients
suffering from COPD
(Broncholitis, Bronchoectasis,
Emphysema, Asthma).
II. Beta-adrenergic Blocking
Agents
- Also called Beta-blockers.
Physical Examination
Comprehensive Neuro Exam
II. Anti-cholinergic Agents
Neuro Check
- To counter cholinergic agents.
1. Level of Consciousness (LOC)
- Atrophine Sulfate
a. Orientation to time, place, person
b. Speech: clear, garbled, rambling
SE:
c. Ability to follow command
- SNS effect
d. If does not respond to verbal stimuli, apply a painful

- all ending with “lol” stimulus (ex. Pressure on the nailbeds, squeeze

- Propranolol, Atenelol, trapezius muscle); note response to pain

Metoprolol. Appropriate: withdrawal, moaning

Effect of Beta-blockers Inappropriate: non-purposeful

B – broncho spasm e. Abnormal posturing (may occur spontaneously or in
E – elicits a decrease in response to stimulus)
myocardial contraction.
Decorticate Posturing: extension of leg, internal
T – treats hypertension.
rotation & abduction of arms with flexion of elbows,
A – AV conduction slows down.
wrist, & finger: (damage to corticospinal tract;
- Should be given to patients
cerebral hemisphere)
with Angina, Myocardial
Decerebrate Posturing: back arched, rigid extension
Infarction, Hypertension
of all four extremities with hyperpronation of arms &
plantar flexion of feet: (damage to upper brain stem,
ANTI- HYPERTENSIVE AGENTS
midbrain, or pons)
1. Beta-blockers – “lol”
2. Ace Inhibitors – Angiotensin
2. Glasgow Coma Scale
“pril” (Captopril, Enalapril)
Objective measurement of LOC sometimes called as the
3. Calcium Antagonist –
quick neuro check
Nifedipine (Calcibloc)
Objective evaluation of LOC, motor / verbal response
- In chronic cases of arrhythmia
A standardized system for assessing the degree of
give Lidocane, Xylocane.
neurologic impairment in critically ill client
Effectors Sympathetic (Adrenergic) Effect
Parasympathetic (Cholinergic) Effect Components
1. Eye opening
Eye dilate pupil (mydriasis) constrict 2. Verbal response
pupil (miosis) 3. Motor response

Gland of Head GCS Grading / Scoring

Lacrimal no effect 1. Conscious 15 – 14
stimulate secretions 2. Lethargy 13 – 11
Salivary scanty thick, viscous secretions 3. Stupor 10 – 8
copious thin, watery secretions 4. Coma 7
Dry mouth 5. Deep Coma 3

Heart increase rate & force of contraction 3. Pupillary Reaction & Eye Movement
decrease rate a. Observe size, shape, & equality of pupil (note size in
millimeter)
b. Reaction to light: pupillary constriction

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c. Corneal reflex: blink reflex in response to light stroking 2. Long term memory
of cornea Ask for birthday and validate on profile sheet
d. Oculocephalic reflex (doll’s eyes): present in Positive result mean retrograde amnesia and damage to
unconscious client with intact brainstem limbic system
4. Motor Function Consider educational background
a. Movement of extremities (paralysis)
b. Muscle strength Level of Orientation
5. Vital Signs: respiratory patterns (may help localize possible 1. Time: first asked
lesion) 2. Person: second asked
a. Cheyne-Stokes Respiration: regular rhythmic alternating 3. Place: third asked
between hyperventilation & apnea; may be caused by
structural cerebral dysfunction or by metabolic problems Cranial Nerves
such as diabetic coma Cranial Nerves Function
b. Central Neurogenic Hyperventilation: sustained, rapid, 1. Olfactory S
2. Optic S
regular respiration (rate of 25/min) with normal O2 level; 3. Oculomotor M
usually due to brainstem dysfunction 4. Trochlear M
(smallest)
c. Apneustic Breathing: prolonged inspiratory phase,
5. Trigeminal B (largest)
followed by a 2-to-3 sec pause; usually indicates 6. Abducens M
7. Facial B
dysfunction respiratory center in pons
8. Acoustic S
d. Cluster Breathing: cluster of irregular breathing, 9. Glossophareng B
irregularly followed by periods of apnea; usually caused eal
10. Vagus B (longest)
by a lesion in upper medulla & lower pons 11. Spinal M
e. Ataxic Breathing: breathing pattern completely irregular; Accessory
indicates damage to respiratory center of the medulla 12. Hypoglossal M

CRANIAL NERVE I: OLFACTORY

Neurologic Exam
Sensory function for smell
1. Mental status and speech (Cerebral Function)
Material Used
a. General appearance & behavior
Don’t use alcohol, ammonia, perfume because it is irritating
b. LOC
and highly diffusible.
c. Intellectual Function: memory (recent & remote),
Use coffee granules, vinegar, bar of soap, cigarette
attention span, cognitive skills
Procedure
d. Emotional status
e. Thought content Test each nostril by occluding each nostril

f. Language / speech Abnormal Findings

2. Cranial nerve assessment 1. Hyposnia: decrease sensitivity to smell

3. Cerebellar Function: posture, gait, balance, coordination 2. Dysosmia: distorted sense of smell
a. Romberg’s Test: 2 nurses, positive for ataxia 3. Anosmia: absence of smell
b. Finger to Nose Test: positive result mean dimetria Either of the 3 may indicate head injury damaging the cribriform

(inability of body to stop movement at desired point) plate of ethmoid bone where olfactory cells are located may indicate

4. Sensory Function: light touch, superficial pain, temperature, inflammatory conditions (sinusitis)

vibration & position sense

CRANIAL NERVE II: OPTIC
5. Motor Function: muscle size, tone, strength; abnormal or
Sensory function for vision or sight
involuntary movements
6. Reflexes Functions
1. Test visual acuity or central vision or distance
a. Deep tendon reflex: grade from 0 (no response); to 4
(hyperactive); 2 (normal) Use Snellen’s Chart

b. Superficial Snellen’s Alphabet chart: for literate client

c. Pathologic: babinski reflex (dorsiflexion of the great toe Snellen’s E chart: for illiterate client
with fanning of toes): indicates damage to corticospinal Snellen’s Animal chart: for pediatric client
tracts
Normal visual acuity 20/20

Numerator: is constant, it is the distance of person from

Level Of Consciouness (LOC)
the chart (6-7 m, 20 feet)
1. Conscious: awake
Denominator: changes, indicates distance by which the
2. Lethargy: lethargic (drowsy, sleepy, obtunded)
person normally can see letter in the chart.
3. Stupor
20/200 indicates blindness
Stuporous: (awakened by vigorous stimulation)
20/20 visual acuity if client is able to read letters above
Generalized body weakness
the red line.
Decrease body reflex 2. Test of visual field or peripheral vision
4. Coma a. Superiorly
Comatose b. Bitemporaly
light coma: positive to all forms of painful stimulus c. Nasally

deep coma: negative to all forms of painful stimulus d. Inferiorly

Different Painful Stimulation CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

1. Deep sternal stimulation / deep sternal pressure Controls or innervates the movement of extrinsic ocular

2. Orbital pressure muscle (EOM)

3. Pressure on great toes 6 muscles:

4. Corneal or blinking reflex Superior Rectus Superior Oblique

Conscious Client: use a wisp of cotton

Unconscious Client: place 1 drop of saline solution

Test of Memory
1. Short term memory Lateral Rectus Medial
Ask most recent activity Rectus
Positive result mean anterograde amnesia and damage
to temporal lobe

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20. TETANY – hypocalcemia (+) trousseu’s sign or carpopedal

Inferior Oblique Inferior spasm/ (+) chvostek sign (facial spasm).
Rectus 21. TETANUS – risus sardonicus
Trochlear: controls superior oblique 22. PANCREATITIS – cullen’s sign (echymosis of umbilicus) / (+)
Abducens: controls lateral rectus grey turners spots.

Oculomotor: controls the 4 remaining EOM 23. PYLORIC STENOSIS – olive like mass.
24. PDA – machine like murmur
Oculomotor 25. ADDISON’S DISEASE – bronze like skin pigmentation.
Controls the size and response of pupil 26. CUSHING’S SYNDROME – moon face appearance and buffalo
Normal pupil size is 2 – 3 mm hump.

Equal size of pupil: Isocoria 27. HYPERTHYROIDSM/GRAVES DISEASE – exopthalmus.

Unequal size of pupil: Anisocoria

Normal response: positive PERRLA DEMYELINATING DISORDERS

CRANIAL NERVE V: TRIGEMINAL Alzheimer’s disease

Largest cranial nerve Atrophy of brain tissue due to deficiency of

Consists of ophthalmic, maxillary, mandibular acetylcholine.

Sensory: controls sensation of face, mucous membrane,

S/sx
teeth, soft palate and corneal reflex
4 A’s of Alzheimer
Motor: controls the muscle of mastication or chewing
a. Amnesia – loss of memory.
Damage to CN V leads to Trigeminal Neuralgia / Tic
b. Agnosia – unable to recognized inanimate/familiar
Douloureux
objects.
Medication: Carbamezapine (Tegretol)
c. Apraxia – unable to determine purpose/ function of
objects.
CRANIAL NERVE VII: FACIAL
d. Aphasia – no speech (nodding).
Sensory: controls taste, anterior 2/3 of tongue
Pinch of sugar and cotton applicator placed on tip of tongue *Expressive aphasia
Motor: controls muscle of facial expression “motor speech center” unable to speak
Instruct client to smile, frown and if results are negative Broca’s Aphasia
there is facial paralysis or Bell’s Palsy and the primary cause *Receptive aphasia
is forcep delivery. inability to understand spoken words.
Common to Alzheimer’s
CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR
Wernike’s Aphasia
Controls balance particularly kinesthesia or position sense,
General Knowing Gnostic Area or General
refers to movement and orientation of the body in space.
Interpretative Area.

CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS

DOC
Glosopharenageal: controls taste, posterior 1/3 of tongue
Aricept (taken at bedtime)
Vagus: controls gag reflex Cognex
Uvula should be midline and if not indicative of damage to
cerebral hemisphere Management
Effects of vagal stimulation is PNS 1. Palliative & supportive
CRANIAL NERVE XI: SPINAL ACCESSORY
Innervates with sternocleidomastoid (neck) and trapezius
(shoulder) Multiple Sclerosis (MS)
Chronic intermittently progressive disorder of CNS
CRANIAL NERVE XII: HYPOGLOSSAL characterized by scattered white patches of
Controls the movement of tongue demyelination in brain and spinal cord.

Let client protrude tongue and it should be midline and if Characterized by remission and exacerbation.

unable to do indicative of damage to cerebral hemisphere S/sx are varied & multiple, reflecting the location of
and/or has short frenulum. demyelination within the CNS.
Cause unknown: maybe a slow growing virus or
Pathognomonic Signs: possibly autoimmune disorders.

1. PTB – low grade afternoon fever Incident: Affects women more than men ages 20-40
are prone & more frequent in cool or temperate
2. PNEUMONIA – rusty sputum.
climate.
3. ASTHMA – wheezing on expiration.
4. EMPHYSEMA – barrel chest.
Ig G - only antibody that pass placental circulation causing
5. KAWASAKI SYNDROME – strawberry tongue
passive immunity, short term protection
6. PERNICIOUS ANEMIA – red beefy tongue
Ig A - present in all bodily secretions (tears, saliva,
7. DOWN SYNDROME – protruding tongue
colostrums).
8. CHOLERA – rice watery stool.
Ig M - acute in inflammation.
9. MALARIA – step ladder like fever with chills.
Ig E - for allergic reaction
10. TYPHOID – rose spots in abdomen.
Ig D - for chronic inflammation.
11. DIPTHERIA – pseudo membrane.
12. MEASLES – koplick’s spots
* Give palliative or supportive care.
13. SLE – butterfly rashes.
14. LIVER CIRRHOSIS – spider like varices S/sx
15. LEPROSY – lioning face 1. Visual disturbances
16. BOLIMIA – chipmunk face. blurring of vision (primary)
17. APPENDICITIS – rebound tenderness diplopia (double vision)
18. DENGUE – petichae or positive herman’s sign. scotomas (blind spots)
19. MENINGITIS – kernig’s sign (leg pain), brudzinski sign (neck 2. Impaired sensation
pain).

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touch, pain, pressure, temperature, or position sense monitor breath sounds 1 hour after subcutaneous
paresthesia such as tingling sensation, numbness administration.

3. Mood swings or euphoria (sense of elation) 2. Urinary Incontinence

4. Impaired motor function a. Establish voiding schedule

weakness b. Anti spasmodic agent Prophantheline Bromide (Pro-

banthine) if ordered
spasticity
3. Force fluid to 3000 ml/day.
paralysis
4. Promote use of acid ash diet like cranberry juice, plums,
5. Impaired cerebral function
prunes, pineapple, vitamin C and orange: to acidify
scanning speech
urine and prevent bacterial multiplication.
ataxic gait
11. Prevent injury related to sensory problems.
nystagmus
a. Test bath water with thermometer.
dysarthria
b. Avoid heating pads, hot water bottles.
intentional tremor c. Inspect body parts frequently for injury.
6. Bladder d. Make frequent position changes.
Urinary retention or incontinence 12. Prepare client for plasma exchange if indicated: to remove
7. Constipation antibodies
8. Sexual impotence in male / decrease sexual capacity 13. Provide psychologic support to client/significant others.
a. Encourage positive attitude & assist client in setting
TRIAD SIGNS OF MS realistic goals.
b. Provide compassion in helping client adapt to changes
Ataxia in body image & self-concept.
(unsteady gait, c. Do not encourage false hope during remission.
positive romberg’s test) d. Refer to MS societies & community agencies.
14. Provide client teaching & discharge planning concerning:
a. General measures to ensure optimum health.
CHARCOTS Balance between activity & rest
TRIAD
Regular exercise such as walking, swimming,
biking in mild case.
Use energy conservation techniques
Well-balance diet
Intentional tremors
Fresh air & sunshine
Nystagmus
Avoiding fatigue, overheating or chilling, stress,

Dx infection.
b. Use of medication & side effects.
1. CSF Analysis: increase in IgG and Protein.
c. Alternative methods for sexual counseling if indicated.
2. MRI: reveals site and extent of demyelination.
3. CT Scan: increase density of white matter.
COMMON CAUSE OF UTI
4. Visual Evoked Response (VER) determine by EEG: maybe
Female
delayed
- short urethra (3-5 cm, 1-1 ½ inches)
5. Positive Lhermittes Sign: a continuous and increase - poor perineal hygiene
contraction of spinal column. - vaginal environment is moist
Nursing Management
Nursing Intervention - avoid bubble bath (can alter Ph of vagina).
1. Assess the client for specific deficit related to location of - avoid use of tissue papers
demyelination - avoid using talcum powder and perfume.
2. Promote optimum mobility Male
a. Muscles stretching & strengthening exercises - urethra (20 cm, 8 inches)
b. Walking exercises to improve gait: use wide-base gait - do not urinate after intercourse
c. Assistive devices: canes, walker, rails, wheelchair as
necessary INTRACRANIAL PRESSURE ICP
3. Administer medications as ordered
a. ACTH (adreno chorticotropic hormone), Corticosteroids Monroe Kelly Hypothesis
(prednisone) for acute exacerbations: to reduce edema
at site of demyelination to prevent paralysis. Skull is a closed container
b. Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam
(Valium) - muscle relaxants: for spacity Any alteration or increase in one of the intracranial components
c. Beta Interferons - Immunosuppresants: alter immune
response. Increase intracranial pressure
4. Encourage independence in self-care activities (normal ICP is 0 – 15 mmHg)
5. Prevent complications of immobility
6. Institute bowel program Cervical 1 – also known as atlas.
7. Maintain side rails to prevent injury related to falls. Cervical 2 – also known as axis.

8. Institute stress management techniques.

a. Deep breathing exercises Foramen Magnum

b. Yoga
9. Increase fluid intake and increase fiber to prevent Medulla Oblongata

constipation.
10. Maintain urinary elimination Brain Herniation

1. Urinary Retention
a. perform intermittent catheterization as ordered: to Increase intra cranial pressure

prevent retention. Nursing Intervention

b. Bethanecol Chloride (Urecholine) as ordered 1. alternate hot and cold compress to prevent hematoma

Nursing Management
only given subcutaneous. CSF cushions brain (shock absorber)

monitor side effects bronchospasm and wheezing. Obstruction of flow of CSF will lead to enlargement of skull
posteriorly called hydrocephalus.

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Early closure of posterior fontanels causes posterior Cyanosis

enlargement of skull in hydrocephalus. Hypercarbia may cause cerebral vasodilation
which increase ICP
DISORDERS Hypercabia
Increase Intracranial Pressure (IICP)
Increase CO2 (most powerful respiratory
Increase in intracranial bulk brought due to an increase in stimulant) retention.
any of the 3 major intracranial components: Brain Tissue,
In chronic respiratory distress syndrome
CSF, Blood.
decrease O2 stimulates respiration.
Untreated increase ICP can lead to displacement of brain b. Before and after suctioning hyperventilate the client
tissue (herniation). with resuscitator bag connected to 100% O2 & limit
Present life threatening situation because of pressure on suctioning to 10 – 15 seconds only.
vital structures in the brain stem, nerve tracts & cranial c. Assist with mechanical hyperventilation as
nerve. indicated: produces hypocarbia (decease CO2)
Increase ICP may be caused: causing cerebral constriction & decrease ICP.
head trauma/injury 2. Monitor V/S, input and output & neuro check frequently to
localized abscess detect increase in ICP
cerebral edema 3. Maintain fluid balance: fluid restriction to 1200-1500 ml/day
hemorrhage may be ordered

inflammatory condition (stroke) 4. Position the client with head of bed elevated to 30-45o angle
with neck in neutral position unless contraindicated to
hydrocephalus
improve venous drainage from brain.
tumor (rarely)
5. Prevent further increase ICP by:
a. Provide comfortable and quite environment.
S/sx
b. Avoid use of restraints.
(Early signs)
c. Maintain side rails.
1. Decrease LOC
d. Instruct client to avoid forms of valsalva maneuver like:
2. Irritability / agitation
Straining stool: administer stool softener & mild
3. Progresses from restlessness to confusion & disorientation
laxatives as ordered (Dulcolax, Duphalac)
to lethargy & coma
Excessive vomiting: administer anti-emetics as
ordered (Plasil - Phil only, Phenergan)
(Late signs)
1. Changes in Vital Signs (may be a late signs) Excessive coughing: administer anti-tussive
(dextromethorphan)
a. Systolic blood pressure increases while diastolic
Avoid stooping/bending
pressure remains the same (widening pulse
pressure) Avoid lifting heavy objects

b. Pulse rate decrease e. Avoid clustering of nursing care activity together.

c. Abnormal respiratory patterns (cheyne-stokes 6. Prevent complications of immobility.

respiration) 7. Administer medications as ordered:

d. temperature increase directly proportional to blood a. Hyperosmotic agent / Osmotic Diuretic [Mannitol
pressure. (Osmitrol)]: to reduce cerebral edema

2. Pupillary Changes Nursing Management

a. Ipsilateral (same side) dilatation of pupil with Monitor V/S especially BP: SE hypotension.
sluggish reaction to light from compression of Monitor strictly input and output every hour: (output
cranial nerve III should increase): notify physician if output is less 30
b. unilateral dilation of pupils called uncal cc/hr.
herniation Administered via side drip
c. bilateral dilation of pupils called tentorial Regulate fast drip to prevent crystal formation.
herniation b. Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral
d. Pupil eventually becomes fixed & dilated edema
3. Motor Abnormalities
drug of choice for CHF (pulmonary edema)
a. Contralateral (opposite side) hemiparesis from
loop of henle in kidneys.
compression of corticospinal tract
Nursing Management
b. abnormal posturing
Monitor V/S especially BP: SE hypotension.
c. decorticate posturing (damage to cortex and
Monitor strictly input and output every hour: (output
spinal cord).
should increase): notify physician if output is less 30
d. decerebrate posturing (damage to upper brain
cc/hr.
stem that includes pons, cerebellum and
Administered IV push or oral.
midbrain).
Given early morning
4. Headache
5. Projective Vomiting Immediate effect of 10-15 minutes.

6. Papilledema (edema of optic disc) Maximum effect of 6 hours.

7. Possible seizure activity c. Corticosteroids [Dexamethasone (Decadron)]: anti-

inflammatory effect reduces cerebral edema

Nursing Intervention d. Analgesics for headache as needed:

1. Maintain patent airway and adequate ventilation by: Small dose of Codein SO4
a. Prevention of hypoxia (decrease O2) and Strong opiates may be contraindicated since they
hypercarbia (increase CO2) important: potentiate respiratory depression, alter LOC, &
Hypoxia may cause brain swelling which cause papillary changes.
increase ICP e. Anti-convulsants [Phenytoin (Dilantin)]: to prevent
Early signs of hypoxia: seizures.
Restlessness 8. Assist with ICP monitoring when indicated:
Tachycardia a. ICP monitoring records the pressure exerted within the

Agitation cranial cavity by the brain, cerebral blood, & CSF

b. Types of monitoring devices:
Late signs of hypoxia:
Extreme restlessness Intraventricular Catheter: inserted in lateral
ventricle to give direct measurement of ICP; also
Bradycardia
allows for drainage of CSF if needed.
Dyspnea

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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
Signs and Symptoms of Lasix in terms of electrolyte
of the monitoring system.
imbalances
Check insertion site for signs of infection; monitor
1. Hypokalemia
temperature.
- decrease potassium level
Assess system for CSF leakage, loose connections,
- normal value is 3.4 – 5.5 meq/L
air bubbles in he line, & occluded tubing.
Sign and Symptoms
9. Provide intensive nursing care for clients treated with - weakness and fatigue
barbiturates therapy or administration of paralyzing agents. - constipation
a. Intravenous administration of barbiturates may be - positive U wave on ECG tracing
ordered: to induce coma artificially in the client who has Nursing Management
not responded to conventional treatment. - administer potassium supplements as ordered (Kalium Durule,
b. Paralytic agents such as [vercuronium bromide Oral Potassium Chloride)
(Norcuron)]: may be administered to paralyzed the - increase intake of foods rich in potassium
client
c. Reduces metabolic demand that may protect the brain
from further injury.
d. Constant monitoring of the client’s ICP, arterial blood FRUITS VEGETABLE
gas, serum barbiturates level, & ECG is necessary. S
e. EEG monitoring as necessary Apple Asparagus

f. Provide appropriate nursing care for the client on a Banana Brocolli

ventilator Cantalop Carrots

10. Observe for hyperthermia secondary to hypothalamus e Spinach

damage. Oranges

2. Hypocalcemia/Tetany
- decrease calcium level
- normal value is 8.5 – 11 mg/100 ml
Signs and Symptoms
*CONGESTIVE HEART FAILURE
- tingling sensation
Signs and Symptoms
- paresthesia
- dyspnea
- numbness
- orthopnea
- (+) Trousseus sign/Carpopedal spasm
- paroxysmal nocturnal dyspnea
- (+) Chvostek’s sign
- productive cough
Complications
- frothy salivation
- arrythmia
- cyanosis
- seizures
- rales/crackles
Nursing Management
- bronchial wheezing
- Calcium Glutamate per IV slowly as ordered
- pulsus alternans
* Calcium Glutamate toxicity – results to seizure
- anorexia and general body malaise
- PMI (point of maximum impulse/apical pulse rate) is
Magnesium Sulfate
displaced laterally
- S3 (ventricular gallop)
Magnesium Sulfate toxicity
- Predisposing Factors/Mitral Valve
S/S
o RHD
BP
o Aging
Urine output DECREASE
Respiratory rate
Treatment
Patellar relfex absent
Morphine Sulfate
Aminophelline
3. Hyponatremia
Digoxin
- decrease sodium level
Diuretics
- normal value is 135 – 145 meq/L
Oxygen
Signs and Symptoms
Gases, blood monitor
- hypotension
- dehydration signs (initial sign in adult is thirst, in infant
RIGHT CONGESTIVE HEART FAILURE (venous congestion)
tachycardia)
Signs and Symptoms
- agitation
- jugular vein distention (neck)
- dry mucous membrane
- ascites
- poor skin turgor
- pitting edema
- weakness and fatigue
- weight gain
Nursing Management
- hepatosplenomegaly
- force fluids
- jaundice
- administer isotonic fluid solution as ordered
- pruritus
- esophageal varices
4. Hyperglycemia
- anorexia and general body malaise
- normal FBS is 80 – 100 mg/dl
Signs and Symptoms
- polyuria
- polydypsia

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- polyphagia Loss of spouse Loss

Nursing Management of Job
- monitor FBS Nursing Intervention for Suicide
direct approach towards the client
5. Hyperuricemia close surveillance is a nursing priority
- increase uric acid (purine metabolism) time to commit suicide is on weekends early morning
- foods high in uric acid (sardines, organ meats and anchovies)

S/sx
*Increase in tophi deposit leads to gouty arthritis.
1. Tremor: mainly of the upper limbs “pill rolling tremors” of
Signs and Symptoms
extremities especially the hands; resting tremor: most
- joint pain (great toes)
common initial symptoms
- swelling
2. Bradykinesia: slowness of movement
3. Rigidity: cogwheel type
Nursing Management
4. Stooped posture: shuffling, propulsive gait
- force fluids
5. Fatigue
- administer medications as ordered
6. Mask like facial expression with decrease blinking of the
a. Allopurinol (Zylopril)
eyes.
- drug of choice for gout.
7. Difficulty rising from sitting position.
- mechanism of action: inhibits synthesis of uric acid.
8. Quite, monotone speech
b. Colchesine
9. Emotional lability: state of depression
- acute gout
- mechanism of action: promotes excretion of uric acid. 10. Increase salivation: drooling type
11. Cramped, small handwriting

* Kidney stones 12. Autonomic Symptoms

Signs and Symptoms a. excessive sweating

- renal cholic b. increase lacrimation

- cool moist skin c. seborrhea

Nursing Management d. constipation

- force fluids e. decrease sexual capacity

- administer medications as ordered

a. Narcotic Analgesic Nursing Intervention

- Morphine Sulfate 1. Administer medications as ordered

- antidote: Naloxone (Narcan) toxicity leads to tremors. Anti-Parkinson Drug

b. Allopurinol (Zylopril) a. Levodopa (L-dopa) short acting

Side Effects MOA: Increase level of dopamine in the brain;
- respiratory depression (check for RR) relieves tremors; rigidity; bradykinesia
SE: GIT irritation (should be taken with meal);
Parkinson’s Disease/ Parkinsonism anorexia; N/V; postural hypotension; mental
Chronic progressive disorder of CNS characterized by changes: confusion, agitation, hallucination; cardiac
degeneration of dopamine producing cells in the substantia arrhythmias; dyskinesias.
nigra of the midbrain and basal ganglia. CI: narrow-angled glaucoma; client taking MAOI
Progressive disorder with degeneration of the nerve cell in inhibitor; reserpine; guanethidine; methyldopa;
the basal ganglia resulting in generalized decline in antipsychotic; acute psychoses
muscular function Avoid multi-vitamins preparation containing vitamin
Disorder of the extrapyramidal system B6 & food rich in vitamin B6 (Pyridoxine): reverses
Usually occurs in the older population the therapeutic effects of Levodopa
Cause Unknown: predominantly idiopathic, but sometimes Urine and stool may be darkened
disorder is postencephalitic, toxic, arteriosclerotic, Be aware of any worsening of symptoms with
traumatic, or drug induced (reserpine, methyldopa prolonged high-dose therapy: “on-off” syndrome.
(aldomet) haloperidol (haldol), phenothiazines). b. Carbidopa-levodopa (Sinemet)
Prevents breakdown of dopamine in the periphery &
Pathophysiology causes fewer side effects.
Disorder causes degeneration of dopamine producing c. Amantadine Hydrochloride (Symmetrel)
neurons in the substantia nigra in the midbrain Used in mild cases or in combination with L-dopa to
Dopamine: influences purposeful movement reduce rigidity, tremors, & bradykinesia
Depletion of dopamine results in degeneration of the basal
ganglia Anti-Cholinergic Drug
a. Benztropine Mesylate (Cogentin)
Predisposing Factors b. Procyclidine (Kemadrine)
1. Poisoning (lead and carbon monoxide) c. Trihexyphenidyl (Artane)
2. Arteriosclerosis MOA: inhinit the action of acetylcholine; used in mild
3. Hypoxia cases or in combination with L-dopa; relived tremors
4. Encephalitis & rigidity
5. Increase dosage of the following drugs: SE: dry mouth; blurred vision; constipation; urinary
a. Reserpine (Serpasil) retention; confusion; hallucination; tachycardia
b. Methyldopa (Aldomet) Antihypertensive Anti-Histamines Drug
c. Haloperidol (Haldol) _______ a. Diphenhydramine (benadryl)
d. Phenothiazine ___________________ Antipsychotic MOA: decrease tremors & anxiety
SE: Adult: drowsiness Children: CNS excitement
Side Effects Reserpine: Major depression lead to suicide (hyperactivity) because blood brain barrier is not yet
Aloneness fully developed.
b. Bromocriptine (Parlodel)
MOA: stimulate release of dopamine in the
substantia nigra
Multiple loss Often employed when L-dopa loses effectiveness
causes
suicide
MAOI Inhibitor

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a. Eldepryl (Selegilene) Signs and Symptoms

MOA: inhibit dopamine breakdown & slow - anorexia
progression of disease - nausea and vomiting
- diarrhea
Anti-Depressant Drug - dehydration causing fine tremors
a. Tricyclic - hypothyroidism
MOA: given to treat depression commonly seen in
Parkinson’s disease Nursing Management
2. Provide safe environment - force fluids

Side rails on bed - increase sodium intake to 4 – 10 g% daily

Rails & handlebars in the toilet, bathtub, & hallways 3. Aminophelline Toxicity
Signs and Symptoms
No scattered rugs
- tachycardia
Hard-back or spring-loaded chair to make getting up
- palpitations
easier
- CNS excitement (tremors, irritability, agitation and restlessness)
3. Provide measures to increase mobility
Nursing Management
Physical Therapy: active & passive ROM exercise;
- only mixed with plain NSS or 0.9 NaCl to prevent development of
stretching exercise; warm baths
crystals of precipitate.
Assistive devices
- administered sandwich method
If client “freezes” suggest thinking of something to walk
- avoid taking alcohol because it can lead to severe CNS depression
over
- avoid caffeine
4. Encourage independence in self-care activities:
4. Dilantin Toxicity
alter clothing for ease in dressing
Signs and Symptoms
use assistive device - gingival hyperplasia (swollen gums)
do not rush the client - hairy tongue
5. Improve communication abilities: - ataxia
Instruct the client to practice reading a loud - nystagmus
Listen to own voice & enunciate each syllable clearly Nursing Management
6. Refer for speech therapy when indicated. - provide oral care
7. Maintain adequate nutrition. - massage gums
Cut food into bite-size pieces 5. Acetaminophen Toxicity

Provide small frequent feeding Signs and Symptoms

- hepatotoxicity (monitor for liver enzymes)
Allow sufficient time for meals, use warming tray
- SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
8. Avoid constipation & maintain adequate bowel elimination
- SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
9. Provide significant support to client/ significant others:
- nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)
Depression is common due to changes in body image &
- hypoglycemia
self-concept
Tremors, tachycardia
10. Provide client teaching & discharge planning concerning:
Irritability
a. Nature of the disease
Restlessness
b. Use prescribed medications & side effects
Extreme fatigue
c. Importance of daily exercise as tolerated: balanced
Diaphoresis, depression
activity & rest
Antidote: Acetylceisteine (mucomyst) prepare suction apparatus as
walking
bedside.
swimming
gardening
MYASTHENIA GRAVIS (MG)
d. Activities/ methods to limit postural deformities:
neuromuscular disorder characterized by a disturbance in
Firm mattress with small pillow
the transmission of impulses from nerve to muscle cells at
Keep head & neck as erected as possible the neuromuscular junction leading to descending muscle
Use broad-based gait weakness.
Raise feet while walking Incidence rate:
e. Promotion of active participation in self-care activities.
highest between 15 & 35 years old for women, over 40
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid
for men.
Hydrazide
Affects women more than men
* Dopamine Agonist relieves tremor rigidity
Cause:
Unknown/ idiopathic
MAGIC 2’s IN DRUG MONITORING
Thought to be autoimmune disorder whereby antibodies
DRUG NORMAL RANGE TOXICITY INDICATION
destroy acetylcholine receptor sites on the postsynaptic
LEVEL
Digoxin/Lanoxin .5 – 1.5 meq/L 2 CHF membrane of the neuromuscular junction.
(increase force of Voluntary muscles are affected, especially those muscles
cardiac output) innervated by the cranial nerve.
Lithium/Lithane .6 – 1.2 meq/L 2 Bipolar
(decrease level of
Pathophysiology
Ach/NE/Serotonin)
Aminophelline 10 – 19 mg/100 ml 20 COPD Autoimmune = Release of Cholinesterase Enzymes =

(dilates bronchial tree) Cholinesterase destroy Acetylcholine (ACH) = Decrease of

Dilantin/Phenytoin 10 – 19 mg/100 ml 20 Seizures Acetylcholine (ACH)
Acetaminophen/Tylen 10 – 30 mg/100 ml 200 Osteo
Acetylcholine: activate muscle contraction
ol Arthritis
Autoimmune: it involves release of cholinesterase an
1. Digitalis Toxicity enzyme that destroys Ach
Signs and Symptoms Cholinesterase: an enzyme that destroys ACH
- nausea and vomiting
- diarrhea
S/sx
- confusion
1. Initial sign is ptosis a clinical parameter to determine ptosis
- photophobia
is palpebral fissure: cracked or cleft in the lining or
- changes in color perception (yellowish spots)
membrane of the eyelids
Antidote: Digibind
2. Diplopia
2. Lithium Toxicity
3. Dysphagia

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4. Mask like facial expression physical or emotional stress over medication with the chol
5. Hoarseness of voice, weakness of voice infection drugs (anti-cholinesterase)
6. Respiratory muscle weakness that may lead to respiratory Signs and Symptoms
arrest the client is unable to see, swallow, Signs and Symptoms
7. Extreme muscle weakness especially during exertion and speak, breathe PNS
morning; increase activity & reduced with rest. Treatment
administer cholinergic agents as ordered Treatment
Dx administer anti-cholinergic ag
1. Tensilon Test (Edrophonium Hydrochloride): IV injection of (Atrophine Sulfate)
tensilon provides temporary relief of S/sx for about 5-10
minutes and a maximum of 15 minutes. Nursing Care in Crisis:
If there is no effect there is no damage to occipital lobe a. Maintain tracheostomy set or endotracheal tube with
and midbrain and is negative for M.G. mechanical ventilation as indicated.

2. Electromyography (EMG): amplitudes of evoked potentials b. Monitor ABG & Vital Capacity

decrease rapidly. c. Administer medication as ordered:

3. Presence of anti-acetlycholine receptors antibodies in the Myasthenic Crisis: increase doses of anti-
serum. cholinesterase drug as ordered.
Medical Management Cholinergic Crisis: discontinue anti-
1. Drug Therapy cholinesterase drugs as ordered until the client
a. Anti-cholinesterase Drugs: [Ambenonium (Mytelase), recovers.
Neostigmine (Prostigmin), Pyridostigmine (Mestinon)] d. Established method of communication
MOA: block the action of cholinesterase & increase e. Provide support & reassurance.
the level of acetylcholine at the neuromuscular 6. Provide nursing care for the client with thymectomy.
junction. 7. Provide client teaching & discharge planning concerning:
SE: excessive salivation & sweating, abdominal a. Nature of the disease
cramps, N/V, diarrhea, fasciculations (muscle b. Use of prescribe medications their side effects & sign of
twitching). toxicity

b. Corticosteroids: Prednisone c. Importance of checking with physician before taking any

new medication including OTC drugs
MOA: suppress autoimmune response
d. Importance of planning activities to take advantage of
Used if other drugs are not effective
energy peaks & of scheduling frequent rest period
2. Surgery (Thymectomy)
e. Need o avoid fatigue, stress, people with upper
a. Surgical removal of thymus gland: thought to be involve
respiratory infection
in the production of acetylcholine receptor antibodies.
f. Use of eye patch for diplopia (alternate eyes)
b. May cause remission in some clients especially if
g. Need to wear medic-alert bracelet
performed early in the disease.
h. Myasthenia Gravis foundation & other community
3. Plasma Exchange (Plasmapheresis) agencies
a. Removes circulating acetylcholine receptor antibodies.
b. Use in clients who do not respond to other types of Guillain-Barre Syndrome
therapy.
a disorder of the CNS characterized by bilateral,
symmetrical, peripheral polyneuritis characterized by
Nursing Interventions
ascending muscle paralysis.
1. Administer anti-cholinesterase drugs as ordered:
Can occur at any age; affects women and men equally
a. Give medication exactly on time.
Progression of disease is highly individual; 90% of clients
b. Give with milk & crackers to decrease GI upset
stop progression in 4 weeks; recovery is usually from 3-6
c. Monitor effectiveness of drugs: assess muscle strength
months; may have residual deficits.
& vital capacity before & after medication.
Causes:
d. Avoid use of the ff drugs:
1. Unknown / idiopathic
Morphine SO4 & Strong Sedatives: respiratory
2. May be autoimmune process
depressant effects
Quinine, Curare, Procainamide, Neomycin, Predisposing Factors
Streptomycine, Kanamycine & other 1. Immunization
aminoglycosides: skeletal muscle blocking effect 2. Antecedent viral infections such as LRT infections
e. Observe for side effects
2. Promote optimal nutrition: S/sx
a. Mealtime should coincide with the peak effect of the 1. Mild Sensory Changes: in some clients severe
drugs: give medication 30 minutes before meals. misinterpretation of sensory stimuli resulting to extreme
b. Check gag reflex & swallowing ability before feeding. discomfort
c. Provide mechanical soft diet. 2. Clumsiness (initial sign)
d. If the client has difficulty in chewing & swallowing, do 3. Progressive motor weakness in more than one limb
not leave alone at mealtime; keep emergency airway & (classically is ascending & symmetrical)
suctioning equipment nearby. 4. Dysphagia: cranial nerve involvement
3. Monitor respiratory status frequently: Rate, Depth, Vital 5. Ascending muscle weakness leading to paralysis
Capacity; ability to deep breathe & cough
6. Ventilatory insufficiency if paralysis ascends to respiratory
4. Assess muscle strength frequently; plan activity to take muscles
advantage of energy peaks & provide frequent rest periods. 7. Absence or decreased deep tendon reflex
5. Observe for signs of myasthenic or cholinergic crisis. 8. Alternate hypotension to hypertension
MYASTHENIC CRISIS CHOLINERGIC CRISIS
9. Arrythmia (most feared complication)
Abrupt onset of severe, generalized Symptoms similar to myasthenic crisis &
10. Autonomic disfunction: symptoms that includes
muscle weakness with inability to in addition the side effect of anti-
a. increase salivation
swallow, speak, or maintain respirations. cholinesterase drugs (excessive
b. increase sweating
Symptoms will improve temporarily with salivation & sweating, abdominal carmp,
c. constipation
tensilon test. N/V, diarrhea, fasciculation)
Symptoms worsen with tensilon test:
Dx
keep Atropine Sulfate & emergency
1. CSF analysis: reveals increased in IgG and protein
Causes: equipment on hand.
2. EMG: slowed nerve conduction
under medication Cause:

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Medical Management
1. Mechanical Ventilation: if respiratory problems present Mode of transmission

2. Plasmapheresis: to reduce circulating antibodies 1. Airborne transmission (droplet nuclei)

3. Continuous ECG monitoring to detect alteration in heart rate 2. Via blood, CSF, lymph

& rhythm 3. By direct extension from adjacent cranial structures (nasal,

4. Propranolol: to prevent tachycardia sinuses, mastoid bone, ear, skull fracture)

5. Atropine SO4: may be given to prevent episodes of 4. By oral or nasopharyngeal route

bradycardia during endotracheal suctioning & physical

Signs and Symptoms
therapy
2. Headache, photophobia, general body malaise, irritability,

Nursing Intervention 3. Projectile vomiting: due to increase ICP

1. Maintain patent airway & adequate ventilation: 4. Fever & chills

a. Monitor rate & depth of respiration; serial vital capacity 5. Anorexia & weight loss

b. Observe for ventilatory insufficiency 6. Possible seizure activity & decrease LOC

c. Maintain mechanical ventilation as needed 7. Abnormal posturing: (decorticate and decerebrate)

d. Keep airway free of secretions & prevent pneumonia 8. Signs of Meningeal Irritation:
2. Check individual muscle groups every 2 hrs in acute phase a. Nuchal rigidity or stiff neck: initial sign
to check progression of muscle weakness b. Opisthotonos (arching of back): head & heels bent
3. Assess cranial nerve function: backward & body arched forward
a. Check gag reflex c. PS: Kernig’s sign (leg pain): contraction or pain in the
b. Swallowing ability hamstring muscles when attempting to extend the leg
c. Ability to handle secretion when the hip is flexed
d. Voice d. PS: Brudzinski sign (neck pain): flexion at the hip & knee
4. Monitor strictly the following: in response to forward flexion of the neck
a. Vital signs
b. Input and output
c. Neuro check Dx
d. ECG: due to arrhythmia 1. Lumbar Puncture:
e. Observe signs of autonomic dysfunction: acute period of Measurement & analysis of CSF shows increased
hypertension fluctuating with hypotension
pressure, elevated WBC & CHON, decrease glucose &
f. Tachycardia
culture positive for specific M.O.
g. Arrhythmias
A hollow spinal needle is inserted in the subarachnoid
5. Maintain side rails to prevent injury related to fall
space between the L3-L4 or L4-L5.
6. Prevent complications of immobility: turning the client every
2 hrs Nursing Management Before Lumbar Puncture
7. Assist in passive ROM exercise
1. Secure informed consent and explain procedure.
8. Promote comfort (especially in clients with sensory 2. Empty bladder and bowel to promote comfort.
changes): 3. Encourage to arch back to clearly visualize L3-L4.
a. Foot cradle
b. Sheepskin Nursing Management Post Lumbar Puncture
c. Guided imagery 1. Place flat on bed 12 – 24 o
d. Relaxation techniques
2. Force fluids
9. Promote optimum nutrition: 3. Check punctured site for any discoloration, drainage and
a. Check gag reflex before feeding leakage to tissues.
b. Start with pureed food 4. Assess for movement and sensation of extremities.
c. Assess need for NGT feeding: if unable to swallow; to
prevent aspiration CSF analysis reveals
10. Administer medications as ordered 1. Increase CHON and WBC
a. Corticosteroids: suppress immune response 2. Decrease glucose
b. Anti Cholinergic Agents: 3. Increase CSF opening pressure (normal pressure is 50 –
Atrophine Sulfate 100 mmHg)

c. Anti Arrythmic Agents: 4. (+) cultured microorganism (confirms meningitis)

Lidocaine (Xylocaine)
CBC reveals
Bretylium: blocks release of norepinephrine; to
1. Increase WBC
prevent increase of BP
11. Assist in plasmapheresis (filtering of blood to remove
Nursing Management
autoimmune anti-bodies)
1. Administer large doses of antibiotic IV as ordered:
12. Prevent complications:
a. Broad spectrum antibiotics (Penicillin, Tetracycline)
a. Arrythmia
b. Mild analgesics: for headaches
b. Paralysis of respiratory muscles / respiratory arrest
13. Provide psychologic support & encouragement to client /
c. Antipyretics: for fever

significant others 2. Enforced strict respiratory isolation 24 hours after initiation

14. Refer for rehabilitation to regain strength & treat any of anti biotic therapy (for some type of meningitis)

residual deficits. 3. Provide nursing care for increase ICP, seizure &
hyperthermia if they occur

INFLAMMATORY CONDITIONS OF THE BRAIN 4. Provide nursing care for delirious or unconscious client as
needed

Meningitis 5. Enforce complete bed rest

Inflammation of the meninges of the brain & spinal cord. 6. Keep room quiet & dark: if the client has headache &
Cause by bacteria, viruses, & other M.O. photophobia
7. Monitor strictly V/S, I & O & neuro check

Etiology / Most Common M.O. 8. Maintain fluid & electrolyte balance

9. Prevent complication of immobility
1. Meningococcus: most dangerous
10. Provide client teaching & discharge planning concerning:
2. Pneumococcus
a. Importance of good diet: high CHON, high calories with
3. Streptococcus: cause of adult meningitis
small frequent feedings.
4. Hemophilus Influenzae: cause of pediatric meningitis
b. Rehabilitation program for residual deficit

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mental retardation 8. Prolong use of oral contraceptives: promotes lypolysis

delayed psychomotor development (breakdown of lipids) leading to atherosclerosis that will lead
c. Prevent complications to hypertension & eventually CVA.

most feared is hydrocephalus

Pathophysiology
hearing loss/nerve deafness is second
complication 1. Interruption of cerebral blood flow for 5 min or more causes
death of neurons in affected area with irreversible loss of
consult audiologist
function.
2. Modifying Factors:
Cerebrovascular Accident (CVA) (Stroke/Brain
a. Cerebral Edema:
Attack/Apoplexy/Cerebral Thrombosis)
Develops around affected area causing further
Destruction (infarction) of brain cells caused by a reduction
impairment
in cerebral blood flow and oxygen
b. Vasospasm:
A partial or complete disruption in the brains blood supply.
Constriction of cerebral blood vessel may occur,
2 largest & most common cerebral artery affected by stroke:
causing further decrease in blood flow
a. Mid Cerebral Artery
c. Collateral Circulation:
b. Internal Cerebral Artery
May help to maintain cerebral blood flow when there
Incidence Rate:
is compromise of main blood supply
a. Affects men more than women; Men are 2-3 times high
risk; Incidence increase with age
Stages of Development
Causes:
1. Transient Ischemic Attack (TIA)
a. Thrombosis (attached) a. Initial / warning signs of impending CVA / stroke
b. Embolism (detached): most dangerous because it can b. Brief period of neurologic deficit:
go to the lungs & cause pulmonary embolism or the Visual loss / Visual disturbance
brain & cause cerebral embolism.
Hemiparesis
c. Hemorrhage
Slurred Speech / Speech disturbance
d. Compartment Syndrome: compression of nerves &
Vertigo
arteries
Aphasia

Headache: initial sign

S/sx Pulmonary Embolism
1. Sudden sharp chest pain Dizziness

2. Unexplained dyspnea Tinnitus

3. SOB Possible Increase ICP
4. Tachycardia c. May last less than 30 sec, but no more than 24 hrs with
5. Palpitations complete resolution of symptoms
6. Diaphoresis 2. Stroke in Evolution
7. Mild restlessness Progressive development of stroke symptoms over a
period of hours to days
S/sx of Cerebral Embolism 3. Complete Stroke
1. Headache Neurologic deficit remains unchanged for 2-3-days
2. disorientation period
3. Confusion
4. Decrease LOC S/sx
1. Headache
S/sx Compartment syndrome 2. Generalized Signs:
1. Fat embolism is the most feared complications w/in Vomiting
24 hrs after a femur fracture. Seizure
Yellow bone marrow are produced from the Confusion
medullary cavity of the long bones and produces Disorientation
fat cells.
Decrease LOC
If there is bone fracture there is hemorrhage and Nuchal Rigidity
there would be escape of the fat cells in the
Fever
circulation.
Hypertension
Slow Bounding Pulse
Risk Factors
Cheyne-Strokes Respiration
Disease:
1. Hypertension (+) Kernig’s & Brudzinski sign: may lead to hemorrhagic

2. Diabetes Mellitus stroke

3. Atherosclerosis / Arteriosclerosis 3. Focal Signs (related to site of infarction):

4. Myocardial Infarction Hemiplegia
5. Mitral valve replacement Homonymous hemianopsia: loss of half of visual field
6. Valvular Disease / replacement Sensory loss
7. Chronic atrial Fibrillation Aphasia
8. Post Cardiac Surgery
Dysarthia: inability to articulate words

Alexia: difficulty reading

Lifestyle:
1. Smoking Agraphia: difficulty writing

2. Sedentary lifestyle
3. Obesity (increase 20% ideal body weight) Dx

4. Hyperlipidemia more on genetics/genes that binds to 1. CT & Brain Scan: reveals brain lesions
cholesterol 2. EEG: abnormal changes
5. Type A personality 3. Cerebral Arteriography: invasive procedure due to injection
a. Deadline driven of dye (iodine based); Uses dye for visualization
b. Can do multiple tasks May show occlusion or malformation of blood vessels
c. Usually fells guilty when not doing anything Reveals the site and extent of malocclusion
6. Related to diet: increase intake of saturated fats like whole
milk Nursing Management Post Cerebral Arteriography
7. Related stress physical and emotional
Allergy Test (shellfish)

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Force fluids to release dye because it is nephro toxic b. Prevent complication (subarachnoid hemorrhage is
Check for peripheral pulse: distal (femoral) the most feared complication)

Check for hematoma formation c. Dietary modification (decrease salt, saturated fats
and caffeine)

Nursing Intervention: Acute Stage d. Importance of follow up care

1. Maintain patent airway and adequate ventilation by:

a. Assist in mechanical ventilation Nursing Intervention: Rehabiltation

b. Administer O2 inhalation 1. Hemiplegia: results from injury to cell in the cerebral motor
2. Monitor strictly V/S, I & O, neuro check & observe signs of cortex or to corticospinal tract (causes contralateral
increase ICP, shock, hyperthermia, & seizure hemiplegia since tracts crosses medulla)
3. Provide CBR as ordered a. Turn every 2 hrs (20 min only on affected side)
4. Maintain fluid & electrolyte balance & ensure adequate b. Use proper positioning & repositioning to prevent
nutrition: deformities (foot drop, external rotation of hips, flexion
a. IV therapy for the first few days of fingers, wrist drop, abduction of shoulder & arms)
b. NGT for feeding the client who is unable to swallow c. Support paralyzed arm on pillow or use sling while out of
c. Fluid restriction as ordered: to decrease cerebral edema bed to prevent subluxation of shoulders
& might also increase ICP d. Elevate extremities to prevent dependent edema
5. Maintain proper positioning & body alignment: e. Provide active & passive ROM exercises every 4 hrs
a. Elevate head 30-45 degree to decrease ICP 2. Susceptibility to hazard
b. Turn & reposition every 2 hrs (20 min only on the a. Keep side rails up at all times
affected side) b. Institute safety measures
c. Passive ROM exercise every 4 hrs: prevent contractures; c. Inspect body parts frequently for signs of injury
promote body alignment 3. Dysphagia: difficulty of swallowing
6. Promote optimum skin integrity: turn client & apply lotion a. Check for gag reflex before feeding client
every 2 hrs b. Maintain a calm, unhurried approach
7. Prevent complications of immobility by: c. Place client in upright position
a. Turn client to side d. Place food in unaffected side of the mouth
b. Provide egg crate mattresses or water bed e. Offer soft foods
c. Provide sand bag or food board. f. Give mouth care before & after meals
8. Maintain adequate elimination: 4. Homonymous Hemianopsia: loss of right or left half of each
a. Offer bed pan or urinal every 2 hrs; catheterized only if visual field
necessary a. Approach the client on unaffected side
b. Administer stool softener & suppositories as ordered: to b. Place personal belongings, food etc., on unaffected side
prevent constipation & fecal impaction c. Gradually teach the client to compensate by scanning
9. Provide quiet, restful environment (ex. Turning the head to see things on affected side)
10. Provide alternative means of communication to the client: 5. Emotional Lability: mood swings, frustrations
a. Non verbal cues a. Create a quiet, restful environment with a reduction in
b. Magic slate: not paper & pen tiring for client excessive sensory stimuli
c. If positive to hemianopsia: approach client on b. Maintain a calm, non-threatening manner
unaffected side c. Explain to family that client’s behavior is not purposeful
11. Administer medications as ordered: 6. Aphasia: most common in right hemiplegics; may be
a. Hyperosmotic agent: to decrease cerebral edema receptive / expressive

Osmotic Diuretics (Mannitol) a. Receptive Aphasia

Give simple, slow directions
Loop Diuretics Furosemide (Lasix)
Give one command at a time; gradually shift topics
Corticosteroids (Dexamethazone)
Use non-verbal techniques of communication (ex.
b. Anti-convulsants: to prevent or treat seizures
Pantomime, demonstration)
c. Thrombolytic / Fibrinolytic Agents: given to dissolve clot
b. Expressive Aphasia
(hemorrhage must be ruled out)
Listen & watch very carefully when the client
Tissue Plasminogen Activating Factor (tPA,
attempts to speak
Alteplase): SE: allergic Reaction
Anticipate client’s needs to decrease frustrations &
Streptokinase, Urokinase: SE: chest pain
feeling of helplessness
d. Anticoagulants: for stroke in evolution or embolic stroke Allow sufficient time for client to answer
(hemorrhage must be ruled out)
7. Sensory / Perceptual Deficit: more common in left
Heparin: short acting hemiplegics; characterized by impulsiveness unawareness
Check for Partial Thromboplastin Time (PTT): if of disabilities, visual neglect (neglect of affected side &
prolonged there is a risk for bleeding visual space on affected side)
Antidote: Protamine SO4 a. Assist with self-care

Warfarin (Comadin): long acting / long term therapy b. Provide safety measures
c. Initially arrange objects in environment on unaffected
Give simultaneously with Heparin cause
side
Warfarin (Coumadin) will take effect after 3 days
d. Gradually teach client to take care of the affected & turn
Check for Prothrombin Time (PT): if prolonged
frequently & look at affected side
there is a risk for bleeding
8. Apraxia: loss of ability to perform purposeful, skilled acts
Antidote: Vitamin K (Aqua Mephyton)
a. Guide client through intended movement (ex. Take
Anti Platelet: to inhibit platelet aggregation in
object such as wash cloth & guide client through
treating TIA’s
movement of washing)
PASA (Aspirin) b. Keep repeating the movement
Contraindicated for dengue, ulcer and unknown 9. Generalizations about the clients with left hemiplegia vs.
cause of headache because it may potentiate right hemiplegia & nursing care
bleeding a. Left Hemiplegia
e. Antihypertensive: if indicated for elevated BP Perceptual, sensory deficits: quick & impulsive
f. Mild Analgesics: for pain behavior
12. Provide client health teachings and discharge planning Use safety measures, verbal cues, simplicity in all
concerning area of care
a. Avoid modifiable risk factors (diet, exercise, b. Right Hemiplegia
smoking) Speech-language deficits: slow & cautious behavior

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Use pantomime & demonstration Aura is present: daydreaming like

Automatism: stereotype repetitive and non

CONVULSIVE DISORDER/CONVULSION propulsive behavior
disorder of CNS characterized by paroxysmal seizure with or Clouding of consciousness: not in contact with
without loss of consciousness abnormal motor activity
environment
alternation in sensation and perception and changes in
Mild hallucinatory sensory experience
behavior.
Seizure: first convulsive attack 3. Status Epilepticus
Epilepsy: second or series of attacks Usually refers to generalized grand mal seizure
Febrile seizure: normal in children age below 5 years Seizure is prolong (or there are repeated seizures
without regaining consciousness) & unresponsive to
Predisposing Factors treatment
1. Head injury due to birth trauma Can result in decrease in O2 supply & possible cardiac
2. Genetics arrest
3. Presence of brain tumor A continuous uninterrupted seizure activity
4. Toxicity from the ff: If left untreated can lead to hyperpyrexia and lead to
a. Lead coma and eventually death.
b. Carbon monoxide DOC: Diazepam (Valium) & Glucose
5. Nutritional and Metabolic deficiencies
6. Physical and emotional stress
C. Diagnostic Procedures
7. Sudden withdrawal to anti-convulsant drug: is predisposing 1. CT Scan – reveals brain lesions
factor for status epilepticus: DOC: Diazepam (Valium) & 2. EEG – reveals hyper activity of electrical brain waves
Glucose

D. Nursing Management
S/sx 1. Maintain patent airway and promote safety before seizure activity
Dependent on stages of development or types of seizure a. clear the site of blunt or sharp objects
1. Generalized Seizure b. loosen clothing of client
Initial onset in both hemisphere, usually involves loss of c. maintain side rails
consciousness & bilateral motor activity. d. avoid use of restrains
a. Major Motor Seizure (Grand mal Seizure): tonic-clonic e. turn clients head to side to prevent aspiration
seizure f. place mouth piece of tongue guard to prevent biting or
Signs or aura with auditory, olfactory, visual, tactile, tongue
sensory experience 2. Avoid precipitating stimulus such as bright/glaring lights and
Epileptic cry: is characterized by fall and loss of noise
consciousness for 3-5 minutes 3. Administer medications as ordered

Tonic Phase: a. Anti convulsants (Dilantin, Phenytoin)

b. Diazepam, Valium
Limbs contract or stiffens
c. Carbamazepine (Tegnetol) – trigeminal neuralgia
Pupils dilated & eye roll up to one side
d. Phenobarbital, Luminal
Glottis closes: causing noise on exhalation
4. Institute seizure and safety precaution post seizure attack
May be incontinent a. administer O2 inhalation
Occurs at same time as loss of consciousness b. provide suction apparatus
last 20-40 sec 5. Document and monitor the following
Tonic contractions: direct symmetrical extension of a. onset and duration
extremities b. types of seizures
Clonic Phase: c. duration of post ictal sleep may lead to status epilepticus

repetitive movement d. assist in surgical procedure cortical resection

increase mucus production

Overview Anatomy & Physiology of the Eye
slowly tapers

Clonic contractions: contraction of extremities

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

2. Partial or Localized Seizure Internal Structure of Eye

Begins in focal area of brain & symptoms are related to A. 3 layers of the eyeball
a dysfunction of that area 1. Outer Layer

May progress into a generalized seizure a. Sclera: tough, white connective tissue (“white of the
a. Jacksonian Seizure (focal seizure) eye”); located anteriorly & posteriorly

characterized by tingling and jerky movement of b. Cornea: transparent tissue through which light
index finger and thumb that spreads to the shoulder enters the eye; located anteriorly

and other side of the body. 2. Middle Layer

b. Psychomotor Seizure (focal motor seizure)
May follow trauma, hypoxia, drug use
Purposeful but inappropriate repetitive motor acts
a. Choroid: highly vascular layer, nourishes retina;
located posteriorly
b. Ciliary Body: anterior to choroid, secrets aqueous
humor; muscle change shape of lens

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c. Iris: pigmented membrane behind cornea, gives 4. Amblyopia: prolong squinting

color to eye; located anteriorly
Common Visual Disorder
d. Pupil: is circular opening in the middle of the iris that
Glaucoma
constrict or dilates to regulate amount of light
entering the eye Characterized by increase intraocular pressure resulting in

3. Inner Layer progressive loss of vision

a. Light-sensitive layer composed of rods & cones May cause blindness if not recognized & treated

(visual cell) Early detection is very important

Cones: specialized for fine discrimination & preventable but not curable

color vision; (daylight / colored vision) Regular eye exam including tonometry for person over age

Rods: more sensitive to light than cones, aid 40 is recommended

in peripheral vision; (night twilight vision)

Predisposing Factors
b. Optic Disk: area in retina for entrance of optic nerve,
1. Common among 40 years old and above
has no photoreceptors
2. Hereditary
3. Hypertension
B. Lens: transparent body that focuses image on retina
4. Obesity
C. Fluid of the eye
5. History of previous eye surgery, trauma, inflammation
1. Aqueous Humor: clear, watery fluid in anterior &
posterior chambers in anterior part of eye; serves as
refracting medium & provides nutrients to lens &
Types of Glaucoma:
cornea; contribute to maintenance of intraocular
1. Chronic (open-angle) Glaucoma:
pressure
Most common form
2. Vitreous Humor: clear, gelatinous material that fills
Due to obstruction of the outflow of aqueous humor, in
posterior cavity of eye; maintains transparency & form
trabecular meshwork or canal of schlemm
of eye
Visual Pathways 2. Acute (close-angle) Glaucoma:

a. Retina (rods & cones) translates light waves into neural Due to forward displacement of the iris against the

impulses that travel over the optic nerves cornea, obstructing the outflow of the aqueous humor

b. Optic nerves for each eye meet at the optic chiasm Occurs suddenly & is an emergency situation

Fibers from median halves of the retinas cross here If untreated it will result to blindness

& travel to the opposite side of the brain 3. Chronic (close-angle) Glaucoma:
Fibers from lateral halves of retinas remain similar to acute (close-angle) glaucoma, with the

uncrossed potential for an acute attack

c. Optic nerves continue from optic chiasm as optic tracts &

travels to the cerebrum (occipital lobe) where visual S/sx

impulses are perceived & interpreted 1. Chronic (open-angle) Glaucoma: symptoms develops slowly
Impaired peripheral vision (PS: tunnel vision)
Halos around light
Canal of schlemm: site of aqueous humor drainage Mild discomfort in the eye
Meibomian gland: secrets a lubricating fluid inside the eyelid
Loss of central vision if unarrested
Maculla lutea: yellow spot center of retina
2. Acute (close-angle) Glaucoma
Fovea centralis: area with highest visual acuity or acute vision
Severe eye pain
Blurred cloudy vision
2 muscles of iris:
Circular smooth muscle fiber: Constricts the pupil Halos around light

Radial smooth muscle fiber: Dilates the pupil N/V

Steamy cornea
Physiology of vision Moderate pupillary dilation
4 Physiological processes for vision to occur: 3. Chronic (close-angle) Glaucoma
1. Refraction of light rays: bending of light rays Transient blurred vision
2. Accommodation of lens Slight eye pain
3. Constriction & dilation of pupils Halos around lights
4. Convergence of eyes

Dx
Unit of measurements of refraction: diopters
1. Visual Acuity: reduced
Normal eye refraction: emmetropia
2. Tonometry: reading of 24-32 mmHg suggest glaucoma; may
Normal IOP: 12-21 mmHg
be 50 mmHg of more in acute (close-angle) glaucoma

Error of Refraction 3. Ophthalmoscopic exam: reveals narrowing of small vessels

1. Myopia: nearsightedness: Treatment: biconcave lens of optic disk, cupping of optic disk

2. Hyperopia: farsightedness: Treatment: biconvex lens 4. Perimetry: reveals defects in visual field

3. Astigmatisim: distorted vision: Treatment: cylindrical 5. Gonioscopy: examine angle of anterior chamber

4. Presbyopia: “old sight” inelasticity of lens due to aging:

Treatment: bifocal lens or double vista Medical Management
1. Chronic (open-angle) Glaucoma
Accommodation of lenses: based on thelmholtz theory of a. Drug Therapy: one or a combination of the following
accommodation Miotics eye drops (Pilocarpine): to increase outflow
Near Vision: Ciliary muscle contracts: Lens bulges of aqueous humor
Epinephrine eye drops: to decrease aqueous humor
Far Vision: ciliary muscle dilates / relaxes: lens is flat
production & increase outflow
Carbonic Anhydrase Inhibitor: Acetazolamide
Convergence of the eye: (Diamox): to decrease aqueous humor production
Error: Timolol Maleate (Timoptic): topical beta-adrenergic
1. Exotropia:1 eye normal blocker: to decrease intraocular pressure (IOP)

2. Esophoria: corrected by b. Surgery (if no improvement with drug)

corrective eye surgery
3. Strabismus: squint eye

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Filtering procedure (Trabeculectomy / Trephining): to b. Surgery performed on one eye at a time; usually in a
create artificial openings for the outflow of aqueous same day surgery unit
humor c. Local anesthesia & intravenous sedation usually used

Laser Trabeculoplasty: non-invasive procedure d. Types of cataract surgery:

performed with argon laser that can be done on an Extracapsular Extraction: lens capsule is excised &
out-client basis; procedure similar result as the lens is expressed; posterior capsule is left in
trabeculectomy place (may be used to support new artificial lens

2. Acute (close-angle) Glaucoma implant); partial removal of lens

a. Drug Therapy: before surgery Phacoemulsification: type of extracapsular

Miotics eye drops (Pilocarpine): to cause pupil to
contract & draw iris away from cornea
Osmotic Agent (Glycerin oral, Mannitol IV): to
decrease intraocular pressure (IOP)
Narcotic Analgesic: for pain
b. Surgery
Peripheral Iridectomy: portion of the iris is excised to
facilitate outflow of aqueous humor
Argon Laser Beam Surgery: non-invasive procedure
using laser produces same effect as iridectomy;
done in out-client basis
Iridectomy: usually performed on second eye later
since a large number of client have an acute acute
attack in the other eye
3. Chronic (close-angle) Glaucoma
a. Drug Therapy:
miotics (pilocarpine)
b. Surgery:
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
2. Nursing Intervention Pre-op
a. Assess vision in the unaffected eye since the affected
eye will be patched post-op
b. Provide pre-op teaching regarding measures to prevent
intraocular pressure (IOP) post-op
c. Administer medication as ordered:

bilateral peripheral iridectomy: to prevent acute Topical Mydriatics (Mydriacyl) & Cyclopegics
attacks (Cyclogyl): to dilate the pupil
Topical antibiotics: to prevent infection
Nursing Intervention Acetazolamide (Diamox) & osmotic agent (Oral
1. Administer medication as ordered Glycerin or Mannitol IV): to decrease intraocular
2. Provide quite, dark environment pressure to provide soft eyeball for surgery
3. Maintain accurate I & O with the use of osmotic agent 3. Nursing Intervention Post-op
4. Prepare client for surgery if indicated a. Reorient the client to surroundings
5. Provide post-op care b. Provide safety measures:
6. Provide client teaching & discharge planning Elevate side rails
a. Self-administration of eye drops
Provide call bells
b. Need to avoid stooping, heavy lifting or pushing,
Assist with ambulation when fully recovered from
emotional upsets, excessive fluid intake, constrictive
anesthesia
clothing around the neck
c. Prevent intraocular pressure & stress on the suture line:
c. Need to avoid the use antihistamines or
Elevate head of the bed 30-40 degree
sympathomimetic drugs (found in cold preparation) in
Have the client lie on back or unaffected side
close-angle glaucoma since they may cause mydriasis
Avoid having the client cough, sneeze, bend over, or
d. Importance of follow-up care
move head too rapidly
e. Need to wear medic-alert tag
Treat nausea with anti-emetics as ordered: to
prevent vomiting
Cataract
Decrease opacity of ocular lens Give stool softener as ordered: to prevent straining

Incidence increases with age Observe for & report signs of intraocular pressure
(IOP):

Predisposing Factor Severe eye pain

1. Aging 65 years and above Restlessness

2. May caused by changes associated with aging (“senile” Increased pulse

cataract) 4. Protect eye from injury:
3. Related to congenital a. Dressing usually removed the day after the surgery

4. May develop secondary to trauma, radiation, infection, b. Eyeglasses or eye shield used during the day

certain drugs (corticosteroids) c. Always use eye shield during the night

5. Diabetes Mellitus 5. Administer medication as ordered:

6. Prolonged exposure to UV rays a. Topical mydriatics & cycloplegic: to decrease spasm of

ciliary body & relieve pain
S/sx b. Topical antibiotics & corticosteroids
1. Loss of central vision c. Mild analgesic as needed
2. Blurring or hazy vision 6. Provide client teaching & discharge planning concerning:
3. Progressive decrease of vision a. Technique of eyedrop administration
4. Glare in bright lights b. Use of eye shield at night
5. Milky white appearance at center of pupils c. No bending, stooping, or lifting
6. Decrease perception to colors d. Report signs & symptoms of complication immediately
to physician:
Diagnostic Procedure Severe eye pain
1. Ophthalmoscopic exam: confirms presence of cataract Decrease vision
Excessive drainage
Nursing Intervention Swelling of eyelid
1. Prepare client for cataract surgery: e. Cataract glasses / contact lenses
a. Performed when client can no longer remain If a lens implant has not been performed the client
independent because of reduced vision will need glasses or contact lenses

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Temporary glasses are worn for 1-4 weeks then g. Need to report complications such as recurrence of
permanent glasses fitted detachment
Cataract glasses magnify object by 1/3 & distortion
peripheral vision Overview of Anatomy & Physiology Of Ear (Hearing)
Have the client practice manual coordination External Ear
with assistance until new spatial relationship 1. Auricle (Pinna): outer projection of ear composed of
becomes familiar cartilage & covered by skin; collects sound waves
Have client practice walking, using stairs, 2. External Auditory Canal: lined with skin; glands secretes
reaching for articles cerumen (wax), providing protection; transmits sound waves
Contact lenses cause less distortion of vision; to tympanic membrane
prescribe at one month 3. Tympanic Membrane (Eardrum): at end of external canal;
vibrates in response to sound & transmits vibrations to
Retinal Detachment middle ear
Separation of epithelial surface of retina
Detachment or the sensory retina from the pigment Middle Ear
epithelium of the retina 1. Ossicles
a. 3 small bones: malleus (Hammer) attached to
Predisposing Factors tympanic membrane, incus (anvil), stapes (stirrup)
1. Trauma b. Ossicles are set in motion by sound waves from
2. Aging process tympanic membrane
3. Severe diabetic retinopathy c. Sound waves are conducted by vibration to the
4. Post-cataract extraction footplate of the stapes in the oval widow (an opening
5. Severe myopia (near sightedness) between the middle ear & the inner ear)
2. Eustachian Tube: connects nasopharynx & middle ear;
Pathophysiology bring air into middle ear, thus equalizing pressure on both
Tear in the retina allows vitreous humor to seep behind the sides of eardrum
sensory retina & separate it from the pigment epithelium
Inner Ear
S/sx 1. Cochlea
1. Curtain veil like vision coming across field of vision Controls hearing
2. Flashes of light Contains Organ of Corti (the true organ of hearing):
3. Visual field loss the receptor end-organ for hearing
4. Floaters Transmit sound waves from the oval window &
5. Gradual decrease of central vision initiates nerve impulses carried by cranial nerve VIII
(acoustic branch) to the brain (temporal lobe of
Dx cerebrum)
1. Ophthalmoscopic exam: confirms diagnosis 2. Vestibular Apparatus
Organ of balance
Medical Management Composed of three semicircular canals & the utricle
1. Bed rest with eye patched & detached areas dependent to 3. Endolymph & Perilymph
prevent further detachment
For static equilibrium
2. Surgery: necessary to repair detachment 4. Mastoid air cells
a. Photocoagulation: light beam (argon laser) through Air filled spaces in temporal bone in skull
dilated pupil creates an inflammatory reaction &
scarring to heal the area Disorder of the Ear

b. Cryosurgery or diathermy: application of extreme cold or Otosclerosis

heat to external globe; inflammatory reaction causes Formation of new spongy bone in the labyrinth of the
scarring & healing of area ear causing fixation of the stapes in the oval window

c. Scleral buckling: shortening of sclera to force pigment This prevent transmission of auditory vibration to the
epithelium close to retina inner ear

Nursing Intervention Pre-op Predisposing Factor

1. Maintain bed rest as ordered with head of bed flat & 1. Found more often in women
detached area in a dependent position
2. Use bilateral eye patches as ordered; elevate side rails to Cause

prevent injury 1. Unknown / idiopathic

3. Identify yourself when entering the room 2. There is familial tendency

4. Orient the client frequently to time of date & surroundings; 3. Ear trauma & surgery

explain procedures
5. Provide diversional activities to provide sensory stimulation S/sx
1. Progressive hearing loss
Nursing Intervention Post-op
2. Tinnitus
1. Check orders for positioning & activity level:
a. May be on bed rest for 1-2 days
Dx
b. May need to position client so that detached area is in
dependent position 1. Audiometry: reveals conductive hearing loss
2. Administer medication as ordered: 2. Weber’s & Rinne’s Test: show bone conduction is greater
a. Topical mydriatics than air conduction
b. Analgesic as needed
3. Provide client teaching & discharge planning concerning: Medical Management
a. Techniques of eyedrop administration 1. Stapedectomy: procedure of choice
b. Use eye shield at night Removal of diseased portion of stapes &
c. No bending from waist; no heavy work or lifting for 6 replacement with prosthesis to conduct vibrations
weeks from the middle ear to inner ear
d. Restriction of reading for 3 weeks or more Usually performed under local anesthesia
e. May watch TV Used to treat otoscrlerosis
f. Need to check to physician regarding combing &
shampooing hair & shaving Nursing Intervention Pre-op

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1. Provide general pre-op nursing care, including an Atropine (decreases autonomic nervous system
explanation of post-op expectation activity)
2. Explain to the client that hearing may improve during Diazepam (Valium)
surgery & then decrease due to edema & packing
Fentanyl & Droperidol (Innovar)
2. Chronic:
Nursing Intervention Post-op
a. Drug Therapy:
1. Position the client according to the surgeon’s orders
Vasodilators (nicotinic Acid)
(possibly with operative ear uppermost to prevent
Diuretics
displacement of the graft)
2. Have the client deep breathe every 2 hours while in bed, Mild sedative or tranquilizers: Diazepam

but no coughing (Valium)

3. Elevate side rails; assist the client with ambulation & Antihistamines: Diphenhydramine (Benadryl)

move slowly: may have some vertigo Meclizine (antivert)

4. Administer medication as ordered: b. Diet:
Analgesic Low sodium diet
Antibiotics Restricted fluid intake
Anti-emetics Restrict caffeine & nicotine

Anti-motion sickness drug: Meclesine Hcl 3. Surgery:

(Bonamine) a. Surgical destruction of labyrinth causing loss of

5. Check for dressing frequently for excessive drainage or vestibular & cochlear function (if disease is
bleeding unilateral)

6. Assess facial nerve function: Ask the client to do the ff: b. Intracranial division of vestibular portion of cranial

Wrinkle forehead nerve VIII

Close eyelids c. Endolymphatic sac decompression or shunt to

equalize pressure in endolymphatic space
Puff out checks for any asymmetry
7. Question the client about the ff: report existence to
Nursing Intervention
physicians
1. Maintain bed rest in a quiet, darkened room in position
Pain
of choice; elevate side rails as needed
Headaches
2. Only move the client for essential care (bath may not be
Vertigo
essential)
Unusual sensations in the ear
3. Provide emesis basin for vomiting
8. Provide client teaching & discharge planning
4. Monitor IV Therapy; maintain accurate I&O
concerning:
5. Assist in ambulation when the attack is over
a. Warning against blowing nose or coughing; sneeze
6. Administer medication as ordered
with mouth open
7. Prepare client for surgery as indicated (pot-op care
b. Need to keep ear dry in the shower; no shampooing
includes using above measures)
until allowed
8. Provide client care & discharge planning concerning:
c. No flying for 6 mos. Especially if upper respiratory
a. Use of medication & side effects
tract infection is present
b. Low sodium diet & decrease fluid intake
d. Placement of cotton balls in auditory meatus after c. Importance of eliminating smoking
packing is removed; change twice daily

Overview of Anatomy & Physiology of Endocrine System

Meniere’s Disease
Disease of the inner ear resulting from dilatation of the
endolymphatic system & increase volume of endolymph
Characterized by recurrent & usually progressive triad of
symptoms: vertigo, tinnitus, hearing loss
Predisposing Factor
1. Incidence highest between ages 30 & 60
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

Cause
Hormones Regulation
2. Unknown / idiopathic
1. Hormones: chemical substance that acts s messenger to
3. Theories include the ff:
specific cells & organs (target organs), stimulating &
a. Allergy
inhibiting various processes
b. Toxicity
Two Major Categories
c. Localized ischemia
a. Local: hormones with specific effect in the area of
d. Hemorrhage
secretion (ex. Secretin, cholecystokinin, panceozymin
e. Viral infection
[CCK-PZ])
f. Edema
b. General: hormones transported in the blood to distant
sites where they exert their effects (ex. Cortisol)
S/sx
2. Negative Feedback Mechanisms: major means of regulating
1. Sudden attacks of vertigo lasting hours or days; attacks
hormone levels
occurs several times a year
a. Decreased concentration of a circulating hormones
2. N/V
triggers production of a stimulating hormones from
3. Tinnitus
pituitary gland; this hormones in turn stimulates its
4. Progressive hearing loss
target organ to produce hormones
5. Nystagmus
b. Increased concentration of a hormones inhibits
production of the stimulating hormone, resulting in
Dx
decreased secretion of the target organ hormone
1. Audiometry: reveals sensorineural hearing loss
3. Some hormones are controlled by changing blood levels of
2. Vestibular Test: reveals decrease function
specific substances (ex. Calcium, glucose)
4. Certain hormones (ex. Cortisol or female reproductive
Medical Management
hormones) follow rhythmic patterns of secretion
1. Acute:
5. Autonomic & CNS control (pituitary-hypothalamic axis):
hypothalamus controls release of the hormones of the

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anterior pituitary gland through releasing & inhibiting Beta Cells : Insulin : allows glucose to
factors that stimulate or inhibits hormone secretions diffuse across cell membrane;
Converts glucose to
Hormone Function glycogen
Endocrine G Hormone Functions Alpha Cells : Glucagon : increase blood
Pituitary G glucose by causing glyconeogenisis
Anterior lobe : TSH : stimulate & glycogenolysis in
thyroid G to release thyroid hormones the liver; secreted in
: ACTH : stimulate adrenal response to
cortex to produce & low blood sugar
release
adrenocoticoids Ovaries : Estrogen, Progesterone :
: FSH, LH : stimulate growth, development of secondary sex characteristics in the
maturation, & function of primary Female, maturation
& secondary sex of sex organ, sexual functioning
organ Maintenance of
: GH, Somatotropin : stimulate growth of pregnancy
body tissues & bones Testes : Testosterone : development of
: Prolactin or LTH : stimulate secondary sex characteristics in the
development of mammary gland & Male maturation of
Lactation the sex organs, sexual functioning
Posterior lobe : ADH : regulates H2O
metabolism; release during stress Pituitary Gland (Hypophysis)
Or in response to an Located in sella turcica at the base of brain
increase in plasma
“Master Gland” or master clock
osmolality
Controls all metabolic function of body
To stimulate
3 Lobes of Pituitary Gland
reabsorption of H2O &
1. Anterior Lobe PG (Adenohypophysis)
decrease urine
a. Secretes tropic hormones (hormones that stimulate
Output
target glands to produce their hormones):
: Oxytocin : stimulate uterine
adrenocorticotropic H (ACTH), thyroid-stimulating H
contractions during delivery & the
(TSH), follicle-stimulating H (FSH), luteinizing H (LH)
Release of milk in
lactation ACTH: promotes development of adrenal cortex

Intermediate lobe : MSH : affects skin LH: secretes estrogen

pigmentation FSH: secretes progesterone

b. Also secretes hormones that have direct effects on
Adrenal G tissues: somatotropic or growth H, prolactin
Adrenal Cortex : Mineralocorticoid : regulate fluid & Somatotropic / GH: promotes elongation of long
electrolyte balance; stimulate bones
(ex. Aldosterone) reabsoption Hyposecretion of GH: among children results to
of sodium, chloride, & H2O; stimulate dwarfism
potassium excretion
Hypersecretion of GH: among children results to
: Glucocorticoids : increase
gigantism
blood glucose level by increasing rate of
Hypersecretion of GH: among adults results to
(ex. Cortisol, glyconeogenesis;
acromegaly (square face)
increase CHON catabolism; increase
DOC: Ocreotide (Sandostatin)
corticosterone) mobilization of fatty
acid; promote sodium & H2O Prolactin: promotes development of mammary

retention; anti-inflammatory effect; aid body in gland; with help of oxytocin it initiates milk let

coping down reflex

with stress c. Regulated by hypothalamic releasing & inhibiting factors

: Sex Hormones : influence & by negative feedback system

development of secondary sex 2. Posterior Lobe PG (Neurohypophysis)

(androgens, estrogens characeristics Does not produce hormones
progesterones) Store & release anti-diuretic hormones (ADH) & oxytocin
Adrenal Medulla : Epinephrine, : function in acute produced by hypothalamus
stress; increase HR, BP; dilates Secretes hormones oxytocin (promotes uterine
Norepinephrine bronchioles; contractions preventing bleeding or hemorrhage)
convert glycogen to glucose when Administer oxytocin immediately after delivery to
Needed by the prevent uterine atony.
muscles for energy
Initiates milk let down reflex with help of hormone
prolactin
Thyroid G : T3, T4 : regulate metabolic
3. Intermediate Lobe PG
rate; CHO, fats, & CHON
Secretes melanocytes stimulating H (MSH)
Metabolism; aid in
MSH: for skin pigmentation
regulating physical & mental
Growth & Hyposecretion of MSH: results to albinism
development Hypersecretion of MSH: results to vitiligo
: Thyrocalcitonin : lowers 2 feared complications of albinism:
serum calcium & phosphate levels 1. Lead to blindness due to severe
photophobia
Parathyroid G : PTH : regulates serum 2. Prone to skin cancer
calcium & phosphate levels

Adrenal Glands
Pancreas (islets of Two small glands, one above each kidney; Located at
Langerhans) top of each kidney

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2 Sections of Adrenal Glands

1. Adrenal Cortex (outer portion): produces mineralocorticoids,
glucocorticoids, sex hormones Anti-diuretic Hormone: Pitressin (Vasopressin)
3 Zones/Layers Function: prevents urination thereby conserving water

Zona Fasciculata: secretes glucocortocoids (cortisol): Note: Alcohol inhibits release of ADH

controls glucose metabolism: Sugar

Zona Reticularis: secretes traces of glucocorticoids Predisposing Factor

& androgenic hormones: promotes secondary sex 1. Related to pituitary surgery

characteristics: Sex 2. Trauma

3. Inflammation
Zona Glumerulosa: secretes mineralocorticoids
4. Presence of tumor
(aldosterone): promotes sodium and water
reabsorption and excretion of potassium: Salt
S/sx
2. Adrenal Medulla (inner portion): produces epinephrine,
1. Severe polyuria with low specific gravity
norepinephrine (secretes catecholamines a power
2. Polydipsia (excessive thirst)
hormone): vasoconstrictor
3. Fatigue
2 Types of Catecholamines:
4. Muscle weakness
Epinephrine (vasoconstrictor)
5. Irritability
Norepinephrine (vasoconstrictor) 6. Weight loss
o Pheochromocytoma (adrenal medulla): Increase 7. Hypotension
secretion of norepinephrine: Leading to 8. Signs of dehydration
hypertension which is resistant to a. Adult: thirst; Children: tachycardia
pharmacological agents leading to CVA: Use b. Agitation
beta-blockers c. Poor Skin turgor
d. Dry mucous membrane
Thyroid Gland 9. Tachycardia, eventually shock if fluids is not replaced
Located in anterior portion of the neck
10. If left untreated results to hypovolemic shock (late sign
Consist of 2 lobes connected by a narrow isthmus anuria)
Produces thyroxine (T4), triiodothyronine (T3),
thyrocalcitonin Dx
3 Hormones Secreted: 1. Urine Specific Gravity (NV: 1.015 – 1.030): less than 1.004
T3: 3 molecules of iodine (more potent) 2. Serum Na: increase resulting to hypernatremia
T4: 4 molecule of iodine 3. H2O deprivation test: reveals inability to concentrate urine
T3 and T4 are metabolic hormone: increase brain
activity; promotes cerebration (thinking); increase Nursing Intervention

V/S 1. Maintain F&E balance / Force fluids 2000-3000 ml/day

a. Keep accurate I&O
Thyrocalcitonin: antagonizes the effects of
b. Weigh daily
parathormone to promote calcium reabsorption.
c. Administer IV/oral fluids as ordered to replace fluid loss
2. Monitor strictly V/S & observe for signs of dehydration &
Parathyroid Gland
hypovolemia
4 small glands located in pairs behind the thyroid gland
3. Administer hormone replacement as ordered:
Produce parathormone (PTH)
a. Vasopressin (Pitressin) & Vasopressin Tannate (Pitressin
Promotes calcium reabsorption
Tannate Oil): administered by IM injection
Warm to body temperature before giving
Pancreas
Shake tannate suspension to ensure uniform
Located behind the stomach
dispersion
Has both endocrine & exocrine function (mixed gland)
b. Lypressin (Diapid): nasal spray
Consist of Acinar Cells (exocrine gland): which secretes
4. Prevent complications: hypovolemic shock is the most
pancreatic juices: that aids in digestion
feared complication
Islets of langerhans (alpha & beta cells) involved in
5. Provide client teaching & discharge planning concerning:
endocrine function:
a. Lifelong hormone replacement: Lypressin (Diapid) as
Alpha Cell: produce glucagons: (function: needed to control polyuria & polydipsia
hyperglycemia) b. Need to wear medic-alert bracelet
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
Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH)
Hypersecretion of anti-diuretic hormone (ADH) from the PPG
even when the client has abnormal serum osmolality
Predisposing Factors
1. Head injury

Testes: located in scrotum; produces testosterone 2. Related to presence of bronchogenic cancer

Initial sign of lung cancer is non productive cough

Pineal Gland Non invasive procedure is chest x-ray

Secretes melatonin 3. Related to hyperplasia of pituitary gland (increase size of

Inhibits LH secretion organ brought about by increase of number of cells)

It controls & regulates circadian rhythm (body clock)

S/sx
1. Person with SIADH cannot excrete a dilute urine
2. Fluid retention & Na deficiency
Diabetes Incipidus (DI)
a. Hypertension
DI: dalas-ihi
b. Edema
Decrease of anti-diuretic hormone (ADH)
c. Weight gain
Hyposecretion of ADH
3. Water intoxication: may lead to cerebral edema: lead to
Hypofunction of the posterior pituitary gland (PPG) resulting increase ICP; may lead to seizure activity
in deficiency of ADH
Characterized by excessive thirst & urination Dx

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1. Urine specific gravity: is increase 2. Dysphagia

2. Serum Sodium: is decreased 3. Respiratory distress

4. Mild restlessness

Medical Management
1. Treat underlying cause if possible Dx

2. Diuretics & fluid restriction 1. Serum T4: reveals normal or below normal
2. Thyroid Scan: reveals enlarged thyroid gland.
Nursing Intervention 3. Serum Thyroid Stimulating Hormone (TSH): is increased
1. Restrict fluid: to promote fluid loss & gradual increase in (confirmatory diagnostic test)
serum Na 4. RAIU (Radio Active Iodine Uptake): normal or increased
2. Administer medications as ordered:
a. Loop diuretics (Lasix) Medical Management

b. Osmotic diuretics (Mannitol) 1. Drug Therapy:

3. Monitor strictly V/S, I&O & neuro check Hormone replacement with levothyroxine (Synthroid)
4. Weigh patient daily and assess for pitting edema (T4), dessicated thyroid, or liothyronine (Cytomel) (T3)
5. Monitor serum electrolytes & blood chemistries carefully Small dose of iodine (Lugol’s or potassium iodide
6. Provide meticulous skin care solution): for goiter resulting from iodine deficiency
7. Prevent complications 2. Avoidance of goitrogenic food or drugs in sporadic goiter
3. Surgery:
Subtotal thyroidectomy: (if goiter is large) to relieve
pressure symptoms & for cosmetic reasons

HYPOTHYROIDISM Nursing Intervention

- all are decrease except weight and menstruation 1. Administer Replacement therapy as ordered:
- memory impairment a. Lugol’s Solution / SSKI (Saturated Solution of Potassium
Signs and Symptoms Iodine)
- there is loss of appetite but there is weight gain
Color purple or violet and administered via straw to
- menorrhagia
prevent staining of teeth.
- cold intolerance
4 Medications to be taken via straw: Lugol’s, Iron,
- constipation
Tetracycline, Nitrofurantoin (DOC: for pyelonephritis)
b. Thyroid Hormones:
HYPERTHYROIDISM
Levothyroxine (Synthroid)
- all are increase except weight and menstruation
Signs and Symptoms Liothyronine (Cytomel)

- increase appetite but there is weight loss Thyroid Extracts

- amenorrhea
- exophthalmos Nursing Intervention when giving Thyroid Hormones:
1. Instruct client to take in the morning to prevent
Thyroid Disorder insomnia
2. Monitor vital signs especially heart rate because drug
Simple Goiter causes tachycardia and palpitations
Enlargement of thyroid gland due to iodine deficiency 3. Monitor side effects:

Enlargement of the thyroid gland not caused by Insomnia

inflammation of neoplasm Tachycardia and palpitations
Low level of thyroid hormones stimulate increased secretion Hypertension
of TSH by pituitary; under TSH stimulation the thyroid Heat intolerance
increases in size to compensate & produce more thyroid 2. Increase dietary intake of foods rich in iodine:
hormone Seaweeds

Seafood’s like oyster, crabs, clams and lobster but

Predisposing Factors
not shrimps because it contains lesser amount of
1. Endemic: caused by nutritional iodine deficiency, most
iodine.
common in the “goiter belt” area, areas where soil & H2O
Iodized salt: best taken raw because it is easily
are deficient in iodine; occurs most frequently during
destroyed by heat
adolescence & pregnancy
3. Assist in surgical procedure of subtotal thyroidectomy
Goiter belt area:
4. Provide client teaching & discharge planning concerning:
a. Midwest, northwest & great lakes region
Used of iodized salt in preventing & treating endemic
b. Places far from sea
goiter
c. Mountainous regions
Thyroid hormone replacement
2. Sporadic: caused by
Increase intake of goitrogenic foods (contains agent that
Hypothyroidism (Myxedema)
decrease the thyroxine production: pro-goitrin an anti-
Slowing of metabolic processes caused by hypofunction of
thyroid agent that has no iodine). Ex. cabbage, turnips,
the thyroid gland with decreased thyroid hormone secretion
radish, strawberry, carrots, sweet potato, rutabagas,
Hyposecretion of thyroid hormone
peaches, peas, spinach, broccoli, all nuts
Decrease in all V/S except wt & menses
Soil erosion washes away iodine
Adults: myxedema non pitting edema
Goitrogenic drugs:
Children: cretinism the only endocrine disorder that can lead
a. Anti-Thyroid Agent: Propylthiouracil (PTU)
to mental retardation
b. Large doses of iodine
In severe or untreated cases myxedema coma may occur:
c. Phenylbutazone
Characterized by intensification of S/sx of
d. Para-amino salicylic acid
hypothyroidism & neurologic impairment leading to
e. Lithium Carbonate
coma
f. PASA (Aspirin)
Mortality rate high; prompt recognition & treatment
g. Cobalt
essential
3. Genetic defects that prevents synthesis of thyroid hormones
Precipitating factors: failure to take prescribed
medications; infection; trauma; exposure to cold; use of
S/sx
sedatives, narcotics or anesthetics
1. Enlarged thyroid gland

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3. Provide comfortable and warm environment: due to cold

Predisposing Factors intolerance
1. Primary hypothyroidism: atrophy of the gland possibly 4. Provide a low calorie diet
caused by an autoimmune process 5. Avoid the use of sedatives; reduce the dose of any
2. Secondary hypothyroidism: caused by decreased sedatives, narcotics, or anesthetic agent by half as
stimulation from pituitary TSH ordered
3. Iatrogenic: surgical removal of the gland or over 6. Provide meticulous skin care: to prevent skin
treatment of hyperthyroidism with drugs or radioactive breakdown
iodine; disease caused by medical intervention such as 7. Increase fluid & food high in fiber: to prevent
surgery constipation; administer stool softener as ordered
4. Related to atrophy of thyroid gland due to trauma, 8. Observe for signs of myxedema coma; provide
presence of tumor, inflammation appropriate nursing care
5. Iodine deficiency a. Administer medication as ordered
6. Autoimmune (Hashimotos Disease) b. Maintain vital functions:
7. Occurs more often to women ages 30 & 60 Correct hypothermia
Maintain adequate ventilation
S/sx 9. Myxedema coma:
1. Loss of appetite: but there is wt gain A complication of hypothyroidism & an emergency
2. Anorexia case
3. Weight gain: which promotes lipolysis leading to A severe form of hypothyroidism is characterized by:
atherosclerosis and MI
Severe hypotension
4. Constipation
Bradycardia
5. Cold intolerance
Bradypnea
6. Dry scaly skin
Hypoventilation
7. Spares hair
8. Brittleness of nails Hyponatremia

9. Decrease in all V/S: except wt gain & menses Hypoglycemia

a. Hypotension Hypothermia

b. Bradycardia Leading to progressive stupor and coma

c. Bradypnea
d. Hypothermia Nursing Management for Myxedema Coma
10. Weakness and fatigue 1. Assist in mechanical ventilation
11. Slowed mental processes 2. Administer thyroid hormones as ordered
12. Dull look 3. Administer IVF replacement isotonic fluid solution as
13. Slow clumsy movement ordered / Force fluids
14. Lethargy 10. Provide client health teaching and discharge planning

15. Generalized interstitial non-pitting edema (Myxedema) concerning:

16. Hoarseness of voice a. Thyroid hormone replacement

17. Decrease libido b. Importance of regular follow-up care

18. Memory impairment c. Need in additional protection in cold weather

19. Psychosis d. Measures to prevent constipation

20. Menorrhagia e. Avoid precipitating factors leading to myxedema

coma & hypovolemic shock

Dx f. Stress & infection

1. Serum T3 and T4: is decreased g. Use of anesthetics, narcotics, and sedatives

2. Serum Cholesterol: is increased

Hyperthyroidism
3. RAIU (Radio Active Iodine Uptake): is decreased
Secretion of excessive amounts of thyroid hormone in the
Medical Management
blood causes an increase in metabolic process
1. Drug Therapy:
Increase in T3 and T4
Levothyroxine (Synthroid)
Grave’s Disease or Thyrotoxicosis
Thyroglobulin (Proloid)
Increase in all V/S except wt & menses
Dessicated thyroid

Liothyronine (Cytomel) Predisposing Factors

2. Myxedema coma is a medical emergency: 1. More often seen in women between ages 30 & 50
IV thyroid hormones 2. Autoimmune: involves release of long acting thyroid
Correction of hypothermina stimulator causing exopthalmus (protrusion of eyeballs)
Maintenance of vital function enopthalmus (late sign of dehydration among infants)

Treatment of precipitating cause 3. Excessive iodine intake

4. Related to hyperplasia (increase size of TG)
Nursing Intervention
1. Monitor strictly V/S & I&O, daily weights; observe for S/sx

edema & signs of cardiovascular complication & to 1. Increase appetite (hyperphagia): but there is weight loss
determine presence of myxedema coma 2. Heat intolerance
2. Administer thyroid hormone replacement therapy as 3. Weight loss

ordered & monitor effects: 4. Diarrhea: increase motility

a. Observe signs of thyrotoxicosis: 5. Increased in all V/S: except wt & menses
Tachycardia & palpitation a. Tachycardia

N/V b. Increase systolic BP

Diarrhea c. Palpitation
6. Warm smooth skin
Sweating
7. Fine soft hair
Tremors
8. Pliable nails
Agitation
9. CNS involvement
Dyspnea
a. Irritability & agitation
b. Increase dosage gradually, especially in clients with
b. Restlessness
cardiac complication
c. Tremors

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d. Insomnia 7. Delirium
e. Hallucinations 8. Coma
f. Sweating
g. Hyperactive movement Nursing Intervention
10. Goiter 1. Maintain patent airway & adequate ventilation;
11. PS: Exopthalmus (protrusion of eyeballs) administer O2 as ordered
12. Amenorrhea 2. Administer IV therapy as ordered
3. Administer medication as ordered:
Dx a. Anti-thyroid drugs

1. Serum T3 and T4: is increased b. Corticosteroids

2. RAIU (Radio Active Iodine Uptake): is increased c. Sedatives

d. Cardiac Drugs
3. Thyroid Scan: reveals an enlarged thyroid gland

Thyroidectomy
Medical Management
Partial or total removal of thyroid gland
1. Drug Therap:
Indication:
a. Anti-thyroid drugs: Propylthiouracil (PTU) &
methimazole (Tapazole): blocke synthesis of thyroid Subtotal Thyroidectomy: hyperthyroidism
hormone; toxic effect include agranulocytosis Total Thyroidectomy: thyroid cancer
b. Adrenergic Blocking Agent: Propranolol (Inderal):
used to decrease sympathetic activity & alleviate Nursing Intervention Pre-op
symptoms such as tachycardia 1. Ensure that the client is adequately prepared for surgery
2. Radioactive Iodine Therapy a. Cardiac status is normal
a. Radioactive isotope of iodine (ex. 131I): given to b. Weight & nutritional status is normal
destroy the thyroid gland, thereby decreasing 2. Administer anti-thyroid drugs as ordered: to suppressed
production of thyroid hormone the production of thyroid hormone & to prevent thyroid
b. Used in middle-aged or older clients who are storm
resistant to, or develop toxicity from drug therapy 3. Administer iodine preparation Lugol’s Solution (SSKI) or
c. Hypothyroidism is a potential complication Potassium Iodide Solution: to decrease vascularity of the
3. Surgery: Thyroidectomy performed in younger client for thyroid gland & to prevent hemorrhage.
whom drug therapy has not been effective
Nursing Intervention Post-Op
Nursing Intervention 1. Monitor V/S & I&O
1. Monitor strictly V/s & I&O, daily weight 2. Check dressing for signs of hemorrhage: check for
2. Administer anti-thyroid medications as ordered: wetness behind the neck
a. Propylthiouracil (PTU) 3. Place client in semi-fowlers position & support head with

b. Methimazole (Tapazole) pillow

3. Provide for period of uninterrupted rest: 4. Observe for respiratory distress secondary to
a. Assign a private room away from excessive activity hemorrhage, edema of glottis, laryngeal nerve damage,

b. Administer medication to promote sleep as ordered or tetany: keep tracheostomy set, O2 & suction nearby

4. Provide comfortable and cold environment 5. Assess for signs of tetany: due to hypocalcemia: due to
5. Minimized stress in the environment secondary accidental removal of parathyroid glands:
6. Encourage quiet, relaxing diversional activities keep Calcium Gluconate available:

7. Provide dietary intake that is high in CHO, CHON, Watch out for accidental removal of parathyroid
calories, vitamin & minerals with supplemental feeding which may lead to hypocalcemia (tetany)
between meals & at bedtime; omit stimulant Classic S/sx of Tetany
8. Observe for & prevent complication Positive trousseu’s sign
a. Exophthalmos: protects eyes with dark glasses & Positive chvostek sign
artificial tears as ordered Observe for arrhythmia, seizure: give Calcium
b. Thyroid Storm Gluconate IV slowly as ordered
9. Provide meticulous skin care 6. Ecourage clients voice to rest:
10. Maintain side rails a. Some hoarseness is common
11. Provide bilateral eye patch to prevent drying of the eyes b. Check every 30-60 min for extreme hoarseness or
12. Assist in surgical procedures subtotal Thyroidectomy: any accompanying respiratory distress
13. Provide client teaching & discharge planning 7. Observe for signs of thyroid storm / thyrotoxicosis: due
concerning: to release of excessive amount of thyroid hormone
a. Need to recognized & report S/sx of agranulocytosis during surgery
(fever, sore throat, skin rash): if taking anti-thyroid
drugs Agitation
b. S/sx of hyperthyroidism & hypothyroidism

Thyroid Storm
Uncontrolled & potentially life-threatening hyperthyroidism
caused by sudden & excessive release of thyroid hormone
TRIAD SIGNS
into the bloodstream

Precipitating Factors Hyperthermia

1. Stress Tachycardia
2. Infection Administer medications as ordered:
3. unprepared thyroid surgery Anti Pyretics
Beta-blockers
S/sx
Monitor strictly vital signs, input and output and
1. Apprehension
neuro check.
2. Restlessness
Maintain side rails
3. Extremely high temp (up to 106 F / 40.7 C)
Offer TSB
4. Tahchycardia
8. Administer IV fluids as ordered: until the client is
5. HF
tolerating fluids by mouth
6. Respiratory Distress
9. Administer analgesics as ordered: for incisional pain

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10. Relieve discomfort from sore throat:

a. Cool mist humidifier to thin secretions Nursing Management
b. Administer analgesic throat lozenges before meals 1. Administer medications as ordered such as:
prn as ordered a. Acute Tetany: Calcium Gluconate slow IV drip as
11. Encourage coughing & deep breathing every hour ordered
12. Assist the client with ambulation: instruct the client to b. Chronic Tetany:
place the hands behind the neck: to decrease stress on
Oral calcium preparation: Calcium Gluconate,
suture line if added support is necessary
Calcium Lactate, Calcium Carbonate (Os-Cal)
13. Hormonal replacement therapy for lifetime
Large dose of vitamin D (Calciferol): to help
14. Watch out for accidental laryngeal damage which may
absorption of calcium
lead to hoarseness of voice: encourage client to
talk/speak immediately after operation and notify
CHOLECALCIFEROL ARE DERIVED FROM
physician
15. Provide client teaching& discharge planning concerning:
Drug Diet (Calcidiol)
a. S/sx of hyperthyroidism & hypothyroidism Sunlight (Calcitriol)
b. Self administration of thyroid hormone: if total
thyroidectomy is performed
Phosphate Binder: Aluminum Hydroxide Gel
c. Application of lubricant to the incision once suture is
(Amphogel) or aluminum carbonate gel, basic
removed
(basaljel): to decrease phosphate levels
d. Perform ROM neck exercise 3-4 times a day
e. Importance of follow up care with periodic serum
ANTACID
calcium level

A.A.C
MAD

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

Predisposing Factors
1. May be hereditary Aluminum

2. Idiopathic Hydroxide

3. Caused by accidental damage to or removal of Gel

parathyroid gland during thyroidectomy surgery

Side Effect: Constipation
4. Atrophy of parathyroid gland due to: inflammation,
Side Effect: Diarrhea
tumor, trauma
2. Institute seizure & safety precaution
3. Provide quite environment free from excessive stimuli
S/sx
4. Avoid precipitating stimulus such as glaring lights and
1. Acute hypocalcemia (tetany)
noise
a. Paresthesia: tingling sensation of finger & around lip
5. Monitor signs of hoarseness or stridor; check for signs
b. Muscle spasm
for Chvostek’s & Trousseau’s sign
c. laryngospasm/broncospasm
6. Keep emergency equipment (tracheostomy set,
d. Dysphagia
injectable Calcium Gluconate) at bedside: for presence
e. Seizure: feared complications
of laryngospasm
f. Cardiac arrhythmia: feared complications
7. For tetany or generalized muscle cramp: may use
g. Numbness
rebreathing bag or paper bag to produce mild
h. Positive trousseu’s sign: carpopedal spasm respiratory acidosis: to promote increase ionized Ca
i. Positive chvostek sign levels
2. Chronic hypocalcemia (tetany) 8. Monitor serum calcium & phosphate level
a. Fatigue 9. Provide high-calcium & low-phosphorus diet
b. Weakness 10. Provide client teaching & discharge planning
c. Muscle cramps concerning:
d. Personality changes a. Medication regimen: oral calcium preparation & vit
e. Irritability D to be taken with meal to increase absorption
f. Memory impairment b. Need to recognized & report S/sx of
g. Agitation hypo/hypercalcemia
h. Dry scaly skin c. Importance of follow-up care with periodic serum
i. Hair loss calcium level
j. Loss of tooth enamel d. Prevent complications
k. Tremors e. Hormonal replacement therapy for lifetime
l. Cardiac arrhythmias
m. Cataract formation Hyperparathyroidism
n. Photophobia Increase secretion of PTH that results in an altered state of
o. Anorexia calcium, phosphate & bone metabolism
p. N/V Decrease parathormone

Hypercalcemia: bone demineralization leading to bone

Diagnostic Procedures
fracture (calcium is stored 99% in bone and 1% blood)
1. Serum Calcium level: decreased (normal value: 8.5 – 11
Kidney stones
mg/100 ml)
2. Serum Phosphate level: increased (normal value: 2.5 –
Predisposing Factors
4.5 mg/100 ml)
1. Most commonly affects women between ages 35 & 65
3. Skeletal X-ray of long bones: reveals a increased in bone
2. Primary Hyperparathyroidism: caused by tumor &
density
hyperplasia of parathyroid gland
4. CT Scan: reveals degeneration of basal ganglia

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3. Secondary Hyperparathyroidism: cause by 4. Hyponatremia: hypotension, signs of dehydration,

compensatory over secretion of PTH in response to weight loss, weak pulse
hypocalcemia from: 5. Decrease tolerance to stress
a. Children: Ricketts 6. Hyperkalemia: agitation, diarrhea, arrhythmia
b. Adults: Osteomalacia 7. Decrease libido
c. Chronic renal disease 8. Loss of pubic and axillary hair
d. Malabsorption syndrome 9. Bronze like skin pigmentation

S/sx Dx
1. Bone pain (especially at back); Bone demineralization; 1. FBS: is decreased (normal value: 80 – 100 mg/dl)
Pathologic fracture 2. Plasma Cortisol: is decreased
2. Kidney stones; Renal colic; Polyuria; Polydipsia; Cool 3. Serum Sodium: is decrease (normal value: 135 – 145
moist skin meq/L)
3. Anorexia; N/V; Gastric Ulcer; Constipation 4. Serum Potassium: is increased (normal value: 3.5 – 4.5
4. Muscle weakness; Fatigue meq/L)
5. Irritability / Agitation; Personality changes; Depression;
Memory impairment Nursing Intervention
6. Cardiac arrhythmias; HPN
1. Administer hormone replacement therapy as ordered:
a. Glucocorticoids: stimulate diurnal rhythm of cortisol
Dx
release, give 2/3 of dose in early morning & 1/3 of
1. Serum Calcium: is increased
dose in afternoon
2. Serum Phosphate: is decreased
Corticosteroids: Dexamethasone (Decadrone)
3. Skeletal X-ray of long bones: reveals bone
Hydrocortisone: Cortisone (Prednisone)
demineralization
b. Mineralocorticoids:

Nursing Intervention Fludrocortisone Acetate (Florinef)

1. Administer IV infusions of normal saline solution & give

diuretics as ordered: Nursing Management when giving steroids

2. Monitor I&O & observe fluid overload & electrolytes 1. Instruct client to take 2/3 dose in the morning and

imbalance 1/3 dose in the afternoon to mimic the normal

3. Assist client with self care: Provide careful handling, diurnal rhythm

Moving, Ambulation: to prevent pathologic fracture 2. Taper dose (withdraw gradually from drug)

4. Monitor V/S: report irregularities 3. Monitor side effects:

5. Force fluids 2000-3000 L/day: to prevent kidney stones Hypertension

Edema
6. Provide acid-ash juices (ex. Cranberry, orange juice): to
acidify urine & prevent bacterial growth Hirsutism

7. Strain urine: using gauze pad: for stone analysis Increase susceptibility to infection

8. Provide low-calcium & high-phosphorus diet Moon face appearance

9. Provide warm sitz bath: for comfort 2. Monitor V/S

3. Decrease stress in the environment
10. Administer medications as ordered: Morphine Sulfate
4. Prevent exposure to infection
(Demerol)
11. Maintain side rails 5. Provide rest period: prevent fatigue

12. Assist in surgical procedure: Parathyroidectomy 6. Weight daily

13. Provide client teaching & discharge planning 7. Provide small frequent feeding of diet: decrease in K,
increase cal, CHO, CHON, Na: to prevent hypoglycemia,
concerning:
& hyponatremia & provide proper nutrition
a. Need to engage in progressive ambulatory activities
b. Increase fluid intake 8. Monitor I&O: to determine presence of addisonian crisis
(complication of addison’s disease)
c. Use of calcium preparation & importance of high-
9. Provide meticulous skin care
calcium diet following a parathyroidectomy
10. Provide client teaching & discharge planning
d. Prevent complications: renal failure
concerning:
e. Hormonal replacement therapy for lifetime
a. Disease process: signs of adrenal insufficiency
f. Importance of follow up care
b. Use of prescribe medication for lifelong replacement
Addison’s Disease therapy: never omit medication

Primary adrenocortical insufficiency; hypofunction of the c. Need to avoid stress, trauma & infection: notify the
adrenal cortex causes decrease secretion of the physician if these occurs as medication dosage may

mineralcorticoids, glucocorticoids, & sex hormones need to be adjusted

d. Stress management technique
Hyposecretion of adrenocortical hormone leading to:
e. Diet modification
Metabolic disturbance: Sugar
f. Use of salt tablet (if prescribe) or ingestion of salty
Fluid and electrolyte imbalance: Na, H2O, K
foods (potato chips): if experiencing increase
Deficiency of neuromascular function: Salt, Sex sweating
g. Importance of alternating regular exercise with rest
Predisposing Factors periods
1. Relatively rare disease caused by: h. Avoidance of strenuous exercise especially in hot
Idiopathic atrophy of the adrenal cortex: due to an weather
autoimmune process i. Avoid precipitating factor: leading to addisonian
Destruction of the gland secondary to TB or fungal crisis: stress, infection, sudden withdrawal to
infections steroids
j. Prevent complications: addisonian crisis,
S/sx hypovolemic shock
1. Fatigue, Muscle weakness k. Importance of follow up care
2. Anorexia, N/V, abdominal pain, weight loss
3. History of hypoglycemic reaction / Hypoglycemia:
tremors, tachycardia, irritability, restlessness, extreme
fatigue, diaphoresis, depression
Addisonian Crisis

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Severe exacerbation of addison’s diseasecaused by acute 4. Force fluids

adrenal insufficiency 5. If crisis precipitate by infection: administer
antibiotics as ordered
Predisposing Factors 6. Maintain strict bed rest & eliminate all forms of
1. Strenuous activity stressful stimuli
2. Stress 7. Monitor V/S, I&O & daily weight
3. Trauma 8. Protect client from infection
4. Infection 9. Provide client teaching & discharge planning
5. Failure to take prescribe medicine concerning: same as addison’s disease
6. Iatrogenic: Cushing Syndrome
Surgery of pituitary gland or adrenal gland Condition resulting from excessive secretion of
Rapid withdrawal of exogenous steroids in a corticosteroids, particularly glucocorticoid cortisol
client on long-term steroid therapy Hypersecretion of adrenocortical hormones

S/sx Predisposing Factors

1. Generalized muscle weakness 1. Primary Cushing’s Syndrome: caused by adrenocortical
2. Severe hypotension tumors or hyperplasia
3. Hypovolemic shock: vascular collapse 2. Secondary Cushing’s Syndrome (also called Cushing’s
4. Hyponatremia: leading to progressive stupor and disease): caused by functioning pituitary or nonpituitary
coma neoplasm secreting ACTH, causing increase secretion of
glucocorticoids
Nursing Intervention 3. Iatrogenic: cause by prolonged use of corticosteroids
1. Assist in mechanical ventilation 4. Related to hyperplasia of adrenal gland
2. Administer IV fluids (5% dextrose in saline, plasma) 5. Increase susceptibility to infections
as ordered: to treat vascular collapse
3. Administer IV glucocorticoids: Hydrocortisone (Solu- S/sx
Cortef) & vasopressors as ordered
1. Muscle weakness 14. Signs of masculinization in women: menstrual
2. Fatigue dysfunction, decrease libido
3. Obese trunk with thin arms & legs 15. Osteoporosis
4. Muscle wasting 16. Decrease resistance to infection
5. Irritability 17. Hypertension
6. Depression 18. Edema
7. Frequent mood swings 19. Hypernatremia
8. Moon face 20. Weight gain
9. Buffalo hump 21. Hypokalemia
10. Pendulous abdomen 22. Constipation
11. Purple striae on trunk 23. U wave upon ECG (T wave hyperkalemia)
12. Acne 24. Hirsutis
13. Thin skin 25. Easy bruising
c. Need to avoid stress & infection
Dx d. Change in medication regimen (alternate day
1. FBS: is increased therapy or reduce dosage): if caused of condition is
2. Plasma Cortisol: is increased prolonged corticosteroid therapy

3. Serum Sodium: is increased e. Prevent complications (DM)

4. Serum Potassium: is decreased f. Hormonal replacement for lifetime: lifetime due to
adrenal gland removal: no more corticosteroid!

Nursing Intervention g. Importance of follow up care

1. Maintain muscle tone

a. Provide ROM exercise Diabetes Mellitus (DM)

b. Assist in ambulation Represent a heterogenous group of chronic disorders

2. Prevent accidents fall & provide adequate rest characterized by hyperglycemia
3. Protect client from exposure to infection Hyperglycemia: due to total or partial insulin deficiency or
4. Maintain skin integrity insensitivity of the cells to insulin
a. Provide meticulous skin care Characterized by disorder in the metabolism of CHO, fats,
b. Prevent tearing of the skin: use paper tape if CHON, as well as changes in the structure & function of
necessary blood vessels
5. Minimize stress in the environment Metabolic disorder characterized by non utilization of
6. Monitor V/S: observe for hypertension & edema carbohydrates, protein and fat metabolism
7. Monitor I&O & daily weight: assess for pitting edema:
Measure abdominal girth: notify physician Pathophysiology
8. Provide diet low in Calorie & Na & high in CHON, K, Ca, Lack of insulin causes hyperglycemia (insulin is necessary for the
Vitamin D transport of glucose across the cell membrane) = Hyperglycemia

9. Monitor urine: for glucose & acetone; administer insulin leads to osmitic diuresis as large amounts of glucose pass through

as ordered the kidney result polyuria & glycosuria = Diuresis leads to cellular

10. Provide psychological support & acceptance dehydration & F & E depletion causing polydipsia (excessive thirst)

11. Prepare client for hypophysectomy or radiation: if = Polyphagia (hunger & increase appetite) result from cellular
starvation = The body turns to fat & CHON for energy but in the
condition is caused by a pituitary tumor
absence of glucose in the cell fat cannot be completely metabolized
12. Prepare client for Adrenalectomy: if condition is caused
& ketones (intermediate products of fat metabolism) are produced =
by an adrenal tumor or hyperplasia
This leads to ketonemia, ketonuria (contributes to osmotic diuresis)
13. Restrict sodium intake
& metabolic acidosis (ketones are acid bodies) = Ketone sacts as
14. Administer medications as ordered: Spironolactone
CNS depressants & can cause coma = Excess loss of F & E leads to
(Aldactone): potassium sparring diuretics
hypovolemia, hypotension, renal failure & decease blood flow to the
15. Provide client teaching & discharge planning
brain resulting in coma & death unless treated.
concerning:
a. Diet modification
MAIN FOODSTUFF ANABOLISM CATABOLISM
b. Importance of adequate rest

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1. CHO Glucose Glycogen

2. CHON Amino Acids Nitrogen Cholesterol
3. Fats Fatty Acids Free Fatty Acids
Ketones
: cholesterol
Atherosclerosis Diabetic
: ketones
Keto Acidosis

Hypertension
HYPERGLYCEMIA Acetone Breath
Kussmaul’s Respiration
Increase osmotic diuresis odor
MI CVA
Glycosuria
Polyuria
Death
Diabetic Coma
Cellular starvation: weight loss Cellular
dehydration

Stimulates the appetite / satiety center Classification Of DM

Stimulates the thirst center 1. Type I Insulin-dependent Diabetes Mellitus (IDDM)
(Hypothalamus) Secondary to destruction of beta cells in the islets of
(Hypothalamus) langerhans in the pancreas resulting in little of no insulin
production
Polyphagia Non-obese adults
Polydypsia Requires insulin injection
* liver has glycogen that undergo glycogenesis/glycogenolysis Juvenile onset type (Brittle disease)

GLUCONEOGENESIS
Incidence Rate
Formation of glucose from non-CHO sources
1. 10% general population has Type I DM

Increase protein formation

Predisposing Factors
1. Autoimmune response
Negative Nitrogen balance
2. Genetics / Hereditary (total destruction of pancreatic
cells)
Tissue wasting (Cachexia)
3. Related to viruses
4. Drugs: diuretics (Lasix), Steroids, oral contraceptives
INCREASE FAT CATABOLISM
5. Related to carbon tetrachloride toxicity

Free fatty acids

S/sx
1. Polyuria 7. Anorexia
2. Polydipsia 8. N/V
3. Polyphagia 9. Blurring of vision
4. Glucosuria 10. Increase susceptibility to infection
5. Weight loss 11. Delayed / poor wound healing
6. Fatigue
d. Insulin Pumps: externally worn device that closely
Dx mimic normal pancreatic functioning
1. FBS: 5. Exercise: helpful adjunct to therapy as exercise
a. A level of 140 mg/dl of greater on at two occasions decrease the body’s need for insulin
confirms DM
b. May be normal in Type II DM Characteristics of Insulin Preparation
2. Postprandial Blood Sugar: elevated Drug Synonym Appearance Onset Peak
3. Oral Glucose Tolerance Test (most sensitve test): Duration Compatible Mixed
elevated Rapid Acting
4. Glycosolated Hemoglobin (hemoglobin A1c): elevated Insulin Injection Regular Ins Clear ½-1 2-4 6-8
All insulin prep

Medical Management
1. Insulin therapy except lente
2. Exercise
3. Diet: Insulin, Zinc Semilente Ins Cloudy ½-1 4-6 12-
a. Consistency is imperative to avoid hypoglycemia 16 Lente prep
b. High-fiber, low-fat diet also recommended suspension,
4. Drug therapy: prompt
a. Insulin:
Short Acting: used in treating ketoacidosis; Intermediate Acting

during surgery, infection, trauma; management Isophane Ins NPH Ins Cloudy 1-1 ½ 8-12 18-

of poorly controlled diabetes; to supplement 24 Regular Ins

long-acting insulins injection

injection
Intermediate: used for maintenance therapy

Long Acting: used for maintenance therapy in

Insulin Zinc Lente Ins Cloudy 1-1 ½ 8-12 18-
clients who experience hyperglycemia during
24 Regular Ins &
the night with intermediate-acting insulin
Suspension
b. Insulin preparation can consist of mixture of pure
semilente prep
pork, pure beef, or human insulin. Human insulin is
the purest insulin & has the lowest antigenic effect
Long Acting
c. Human Insulin: is recommended for all newly
Insulin Zinc Ultralente Ins Cloudy 4-8 16-20 30-
diagnosed Type I & Type II DM who need short-term
36 Regular Ins &
insulin therapy; the pregnant client & diabetic client
suspension,
with insulin allergy or severe insulin resistance
semilente prep
extended

29
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Complication absorption of glucose &

1. Diabetic Ketoacidosis (DKA)
improves insulin sensitivity

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

May result to partial deficiency of insulin production &/or Oral Alpha-glucosidose Inhibitor

an insensitivity of the cells to insulin Acarbose (Precose) Unknown 1 Unknown

:Delay glucose absorption
Obese adult over 40 years old
Maturity onset type
& digestion of CHO,

Incidence Rate
lowering blood sugar
1. 90% of general population has Type II DM
Miglitol (Glyset) 2-3
Troglitazone (Rezulin) Rapid 2-3 Unknown
Predisposing Factors
:Reduce plasma glucose &
1. Genetics
2. Obesity: because obese persons lack insulin receptor
insulin
binding sites

:Potetiates action of insulin

S/sx
1. Usually asymptomatic
in skeletal muscle &
2. Polyuria
3. Polydypsia
decrease glucose
4. Polyphagia
5. Glycosuria
production in liver
6. Weight gain / Obesity
7. Fatigue
Complications
8. Blurred Vision
1. Hyper Osmolar Non-Ketotic Coma (HONKC)
9. Increase susceptibility to infection
10. Delayed / poor wound healing
Nursing Intervention
1. Administer insulin or oral hypoglycemic agent as
Dx
ordered: monitor hypoglycemia especially during period
5. FBS:
of drug peak action
c. A level of 140 mg/dl of greater on at two occasions
2. Provide special diet as ordered:
confirms DM
a. Ensure that the client is eating all meals
d. May be normal in Type II DM
b. If all food is not ingested: provide appropriate
6. Postprandial Blood Sugar: elevated
substitute according to the exchange list or give
7. Oral Glucose Tolerance Test (most sensitve test):
measured amount of orange juice to substitute for
elevated
leftover food; provide snack later in the day
8. Glycosolated Hemoglobin (hemoglobin A1c): elevated
3. Monitor urine sugar & acetone (freshly voided
specimen)
Medical Management
4. Perform finger sticks to monitor blood glucose level as
1. Ideally manage by diet & exercise
ordered (more accurate than urine test)
2. Oral Hypoglycemic agents or occasionally insulin: if diet
5. Observe signs of hypo/hyperglycemia
& exercise are not effective in controlling hyperglycemia
6. Provide meticulous skin care & prevent injury
3. Insulin is needed in acute stress: ex. Surgery, infection
7. Maintain I&O; weight daily
4. Diet: CHO 50%, CHON 30% & Fats 20%
8. Provide emotional support: assist client in adapting
a. Weight loss is important since it decreases insulin
change in lifestyle & body image
resistance
9. Observe for chronic complications & plan of care
b. High-fiber, low-fat diet also recommended
accordingly:
5. Drug therapy:
a. Atherosclerosis: leads to CAD, MI, CVA & Peripheral
a. Occasional use of insulin
Vascular Disease
b. Oral hypoglycemic agent:
b. Microangiopathy: most commonly affects eyes &
Used by client who are not controlled by diet &
kidneys
exercise
c. Kidney Disease
Increase the ability of islet cells of the pancreas
Recurrent Pyelonephritis
to secret insulin; may have some effect on cell
Diabetic Nephropathy
receptors to decrease resistance to insulin
d. Ocular Disorder
6. Exercise: helpful adjunct to therapy as exercise
Premature Cataracts
decrease the body’s need for insulin
Diabetic Retinopathy
e. Peripheral Neuropathy
Oral Hypoglycemic Agent
Affects PNS & ANS
Drug Onset Peak Duration
Cause diarrhea, constipation, neurogenic
Comments
bladder, impotence, decrease sweating
Oral Sulfonylureas
10. Provide client teaching & discharge planning
Acetohexamide (Dymelor) 1 4-6 12-
concerning:
24
a. Disease process
Chlorpropamide (Diabinase) 1 4-6 40-60
b. Diet
Glyburide (Micronase, Diabeta) 15 min- 1 hr 2-8 10-24
Client should be able to plan a meal using

Oral Biguanides exchange lists before discharge

Metformin (Glucophage) 2-2.5 10- Emphasize importance of regularity of meals;

16 :Decrease glucose never skip meals
c. Insulin
production in liver How to draw up into syringe
Use insulin at room temp
:Decrease intestinal Gently roll the vial between palms
Draw up insulin using sterile technique

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If mixing insulin, draw up clear insulin, Notify physician

before cloudy insulin Monitor urine or blood glucose level & urine
Injection technique ketones frequently
Systematically rotate the site: to prevent If N/V occurs: sip on clear liquid with simple
lipodystrophy: (hypertrophy or atrophy of sugar
tissue) h. Foot care
Insert needle at a 45 (skinny clients) or 90 Wash foot with mild soap & water & pat dry
(fat or obese clients) degree angle Apply lanolin lotion to feet: to prevent drying &
depending on amount of adipose tissue cracking
May store current vial of insulin at room Cut toenail straight across
temperature; refrigerate extra supplies Avoid constrictive garments such as garters
Somogyi’s phenomenon: hypoglycemia followed Wear clean, absorbent socks (cotton or wool)
by periods of hyperglycemia or rebound effect of
Purchase properly fitting shoes & break new
insulin.
shoes in gradually
Provide many opportunities for return
Never go barefoot
demonstration
Inspect foot daily & notify physician: if cut,
d. Oral hypoglycemic agent
blister, or break in skin occurs
Stress importance of taking the drug regularly
i. Exercise
Avoid alcohol intake while on medication: it can
Undertake regular exercise; avoid sporadic,
lead to severe hypoglycemia reaction
vigorous exercise
Instruct the client to take it with meals: to Food intake may need to be increased before
lessen GIT irritation & prevent hypoglycemia exercising
e. Urine testing (not very accurate reflection of blood Exercise is best performed after meals when the
glucose level) blood sugar is rising
May be satisfactory for Type II diabetics since
they are more stable j. Complication
Use clinitest, tes-tape, diastix, for glucose Learn to recognized S/sx of hypo/hyperglycemia:
testing for hypoglycemia (cold and clammy skin), for
Perform test before meals & at bedtime hyperglycemia (dry and warm skin): administer
Use freshly voided specimen simple sugars
Be consistent in brand of urine test used Eat candy or drink orange juice with sugar
Report results in percentage added for insulin reaction (hypoglycemia)
Report result to physician if results are greater Monitor signs of DKA & HONKC
that 1%, especially if experiencing symptoms of k. Need to wear a Medic-Alert bracelet
hyperglycemia
Urine testing for ketones should be done by Diabetic Ketoacidosis (DKA)
Type I diabetic clients when there is persistent Acute complication of DM characterized by hyperglycemia &
glycosuria, increase blood glucose level or if the accumulation of ketones in the body: cause metabolic
client is not feeling well (acetest, ketostix) acidosis
f. Blood glucose monitoring Acute complication of Type I DM: due to severe
Use for Type I diabetic client: since it gives exact hyperglycemia leading to severe CNS depression
blood glucose level & also detects hypoglycemia Occurs in insulin-dependent diabetic clients
Instruct client in finger stick technique: use of Onset slow: maybe hours to days
monitor device (if used), & recording &
utilization of test results Predisposing Factors
g. General care 1. Undiagnosed DM
Perform good oral hygiene & have regular dental 2. Neglect to treatment
exam 3. Infection
Have regular eye exam 4. cardiovascular disorder
Care for “sick days” (ex. Cold or flu) 5. Hyperglycemia

Do not omit insulin or oral hypoglycemic 6. Physical & Emotional Stress: number one precipitating
agent: since infection causes increase blood factor

sugar
S/sx
1. Polyuria 10. Dry mucous membrane; soft eyeballs
2. Polydipsia 11. Blurring of vision
3. Polyphagia 12. PS: Acetone breath odor
4. Glucosuria 13. PS: Kussmaul’s Respiration (rapid shallow breathing) or
5. Weight loss tachypnea
6. Anorexia 14. Alteration in LOC
7. N/V 15. Hypotension
8. Abdominal pain 16. Tachycardia
9. Skin warm, dry & flushed 17. CNS depression leading to coma
8. ABG: metabolic acidosis with compensatory respiratory
Dx alkalosis
1. FBS: is increased
2. Serum glucose & ketones level: elevated Nursing Intervention

3. BUN (normal value: 10 – 20): elevated: due to 1. Maintain patent airway

dehydration 2. Assist in mechanical ventilation

4. Creatinine (normal value: .8 – 1): elevated: due to 3. Maintain F&E balance:

dehydration a. Administer IV therapy as ordered:
5. Hct (normal value: female 36 – 42, male 42 – 48): Normal saline (0.9% NaCl), followed by
elevated: due to dehydration hypotonic solutions (.45% NaCl) sodium
6. Serum Na: decrease chloride: to counteract dehydration & shock

7. Serum K: maybe normal or elevated at first When blood sugar drops to 250 mg/dl: may add
5% dextrose to IV

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Potassium will be added: when the urine output

is adequate
b. Observe for F&E imbalance, especially fluid
overload, hyperkalemia & hypokalemia
4. Administer insulin as ordered: regular acting
insulin/rapid acting insulin
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)

a. Regular insulin IV (drip or push) & / or Hyperosmolar: increase osmolarity (severe dehydration)
subcutaneously (SC) Non-ketotic: absence of lypolysis (no ketones)
b. If given IV drip: give small amount of albumin since
insulin adheres to IV tubing Predisposing Factors
c. Monitor blood glucose level frequently 1. Undiagnosed diabetes
5. Administer medications as ordered: 2. Infection or other stress
a. Sodium Bicarbonate: to counteract acidosis 3. Certain medications (ex. dilantin, thiazide, diuretics)

b. Antibiotics: to prevent infection 4. Dialysis

6. Check urine output every hour 5. Hyperalimentation

7. Monitor V/S, I&O & blood sugar levels 6. Major burns

8. Assist client with self-care 7. Pancreatic disease

9. Provide care for unconscious client if in a coma

10. Discuss with client the reasons ketosis developed & S/sx

provide additional diabetic teaching if indicated

1. Polyuria 10. Dry mucous membrane; soft eyeballs
2. Polydipsia 11. Blurring of vision
3. Polyphagia 12. Hypotension
4. Glucosuria 13. Tachycardia
5. Weight loss 14. Headache and dizziness
6. Anorexia 15. Restlessness
7. N/V 16. Seizure activity
8. Abdominal pain 17. Alteration / Decrease LOC: diabetic coma
9. Skin warm, dry & flushed
The hematologic system also plays an important role in
Dx hormone transport, the inflammatory & immune responses,
1. Blood glucose level: extremely elevated temperature regulation, F&E balance & acid-base balance.
2. BUN: elevated: due to dehydration
3. Creatinine: elevted: due to dehydration
HEMATOLOGICAL SYSTEM
4. Hct: elevated: due to dehydration
5. Urine: (+) for glucose
I. Blood II. Blood Vessels
III. Blood Forming Organs
Nursing Intervention
1. Maintain patent airway 1. Arteries 1.
Liver
2. Assist in mechanical ventilation 55% Plasma 45% Formed 2. Veins 2.
3. Maintain F&E balance: Thymus
(Fluid) cellular elements 3. Capillaries 3.
a. Administer IV therapy as ordered: Spleen
4.
Normal saline (0.9% NaCl), followed by Lymphoid Organ
hypotonic solutions (.45% NaCl) sodium Serum Plasma CHON 5.
Lymph Nodes
chloride: to counteract dehydration & shock (formed in liver) 6.
When blood sugar drops to 250 mg/dl: may add Bone Marrow
1. Albumin
5% dextrose to IV 2. Globulins
3. Prothrombin and Fibrinogen
Potassium will be added: when the urine output
is adequate
b. Observe for F&E imbalance, especially fluid Bone Marrow
overload, hyperkalemia & hypokalemia Contained inside all bones, occupies interior of spongy
4. Administer insulin as ordered: bones & center of long bones; collectively one of the largest
a. Regular insulin IV (drip or push) & / or organs in the body (4-5% of total body weight)
subcutaneously (SC) Primary function is Hematopoiesis: the formation of blood
b. If given IV drip: give small amount of albumin since cells
insulin adheres to IV tubing All blood cells start as stem cells in the bone marrow; these
c. Monitor blood glucose level frequently mature into different, specific types of cells, collectively
5. Administer medications as ordered: referred to as Formed Elements of Blood or Blood
a. Antibiotics: to prevent infection Components:
6. Check urine output every hour 1. Erythrocytes
7. Monitor V/S, I&O & blood sugar levels 2. Leukocytes
8. Assist client with self-care 3. Thrombocytes
9. Provide care for unconscious client if in a coma Two kinds of Bone Marrow:
10. Discuss with client the reasons ketosis developed & 1. Red Marrow
provide additional diabetic teaching if indicated 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
Overview of Anatomy & Physiology of Hematologic System 2. Yellow Marrow
Red marrow that has changed to fats; found in long
The structure of the hematological of hematopoietic system bone; does not contribute to hematopoiesis
includes the blood, blood vessels, & blood forming organs
(bone marrow, spleen, liver, lymph nodes, & thymus gland). Blood
The major function of blood: is to carry necessary materials Composed of plasma (55%) & cellular components (45%)
(O2, nutrients) to cells & remove CO2 & metabolic waste Hematocrit
products. 1. Reflects portion of blood composed of red blood cells

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2. Centrifugation of blood results in separation into top g. Hemoglobin: normal value female 12 – 14 gms% male
layer of plasma, middle layer of leukocytes & platelets, 14 – 16 gms%
& bottom layer of erythrocytes h. Hematocrit red cell percentage in wholeblood (normal
3. Majority of formed elements is erythrocytes; volume of value: female 36 – 42% male 42 – 48%)
leukocytes & platelets is negligible i. Substances needed for maturation of RBC:
Distribution a. Folic acid
1. 1300 ml in pulmonary circulation b. Iron
a. 400 ml arterial c. Vitamin c
b. 60 ml capillary d. Vitamin b12 (Cyanocobalamin)
c. 840 ml venous e. Vitamin b6 (Pyridoxine)
2. 3000 ml in systemic circulation f. Intrinsic factor
a. 550 ml arterial
b. 300 ml capillary
2. Leukocytes (WBC)
c. 2150 ml venous
a. Normal value: 5000 – 10000/mm3
b. Granulocytes and mononuclear cells: involved in the
Plasma
protection from bacteria and other foreign substances
Liquid part of the blood; yellow in color because of pigments
c. Granulocytes:
Consists of serum (liquid portion of plasma) & fibrinogen
• Polymorphonuclear Neutrophils
Contains plasma CHON such as albumin, serum, globulins,
- 60 – 70% of WBC
fibrinogen, prothrombin, plasminogen
- Involved in short term phagocytosis for acute
1. Albumin
inflammation
Largest & numerous plasma CHON
- Mature neutrophils: polymorphonuclear
Involved in regulation of intravascular plasma
leukocytes
volume
- Immature neutrophils: band cells (bacterial
Maintains osmotic pressure: preventing edema
infection usually produces increased numbers of
2. Serum Globulins band cells)
a. Alpha: role in transport steroids, lipids, bilirubin & • Polymorphonuclear Basophils
hormones
- For parasite infections
b. Beta: role in transport of iron & copper - Responsible for the release of chemical
c. Gamma: role in immune response, function of mediation for inflammation
antibodies - Involved in prevention of clotting in
3. Fibrinogens, Prothrombin, Plasminogens: clotting factors microcirculation and allergic reactions
to prevent bleeding • Polymorphonuclear Eosinophils
- Involved in phagocytosis and allergic reaction
Cellular Components or Formed Elements
• Eosinophils & Basophils: are reservoirs of histamine,
1. Erythrocytes (RBC) serotonin & heparin
a. Normal value: 4 – 6 million/mm3 d. Non Granulocytes
b. No nucleus, Biconcave shape discs, Chiefly sac of • Mononuclear cells: large nucleated cells
hemoglobin
a. Monocytes:
c. Call membrane is highly diffusible to O2 & CO2
Involved in long-term phagocytosis for
d. Responsible for O2 transport via hemoglobin (Hgb)
chronic inflammation
Two portion: iron carried on heme portion; second
Play a role in immune response
portion is CHON
Macrophage in blood
Normal blood contains 12-18 g Hgb/100 ml blood;
Largest WBC
higher (14-18 g) in men than in women (12-14 g)
Produced by bone marrow: give rise to
e. Production
histiocytes (kupffer cells of liver),
Start in bone marrow as stem cells, release as
macrophages & other components of
reticulocytes (immature cells), mature into
reticuloendothelial system
erythrocytes
b. Lymphocytes: immune cells; produce
Erythropoietin stimulates differentiation; produced
substances against foreign cells; produced
by kidneys & stimulated by hypoxia
primarily in lymph tissue (B cells) & thymus (T
Iron, vitamin B12, folic acid, pyridoxine vitamin B6,
cells)
& other factors required for erythropoiesis
Lymphocytes
f. Hemolysis (Destruction)
Normal life span of RBC is 80 – 120 days and is
B-cell T-cell Natural killer cell
killed in red pulp of spleen - bone marrow - thymus - anti-viral
and anti-tumor property
Immature RBCs destroyed in either bone marrow or
for immunity
other reticuloendothelial organs (blood, connective
tissue, spleen, liver, lungs and lymph nodes)
Mature cells remove chiefly by liver and spleen
HIV
Bilirubin (yellow pigment): by product of Hgb (red c. Thrombocytes (Platelets)
pigment) released when RBCs destroyed, excreted
• Normal value: 150,000 – 450,000/mm3
in bile
• Normal life span of platelet is 9 – 12 days
Biliverdin (green pigment)
• Fragments of megakaryocytes formed in
Hemosiderin (golden brown pigment)
bone marrow
Iron: feed from Hgb during bilirubin formation; • Production regulated by thrombopoietin
transported to bone marrow via transferring and and
• Essential factors in coagulation via
reclaimed for new Hgb production
adhesion, aggregation & plug formation
Premature destruction: may be caused by RBC
• Release substances involved in coagulation
membrane abnormalities, Hgb abnormalities,
• Promotes hemostasis (prevention of blood
extrinsic physical factors (such as the enzyme
loss)
defects found in G6PD)
• Consist of immature or baby platelets or
Normal age RBCs may be destroyed by gross
megakaryocytes which is the target of
damage as in trauma or extravascular hemolysis (in
dengue virus
spleen, liver, bone marrow)

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Signs of Platelet Dysfunction

1. Petechiae reaction
2. Echhymosis _____________________________________________________________________
3. Oozing of blood from venipunctured site __________________
Pyrogenic Recipient Leukocytes Within 15-90
Blood Groups Fever, chills, Stop transfusion.
Erythrocytes carry antigens, which determine the different possesses agglutination min after
blood group flushing, Treat temp.
Blood-typing system are based on the many possible antibodies bacterial initiation of
antigens, but the most important are the antigens of the palpitation, Transfuse with
ABO & Rh blood groups because they are most likely to be directed against organism transfusion
involved in transfusion reactions tachycardia, leukocytes-poor
WBC; bacterial
1. ABO Typing occasional blood of washed
a. Antigens of systems are labeled A & B contamination;
b. Absence of both antigens results in type O blood lumbar pain RBC.
c. Presence of both antigen is type AB Multitransfused
d. Presence of either type A or B results in type A & type B, Administer
respectively client;
e. Type O: universal donor antibiotics prn

f. Antibodies are automatically formed against ABO multiparous

antigens not on persons own RBC client

2. Rh Typing _____________________________________________________________________

a. Identifies presence or absence of Rh antigens (Rh + or __________________

Rh -) Circulatory Too rapid Fluid volume During & after

b. Anti-Rh antibodies not automatically formed in Rh (-) Dyspnea, Slow infusion rate
Overload infusion in overload
persons, but if Rh (+) blood is given, antibody formation
transfusion increase BP, Used packed cells
starts & second exposure to Rh antigen will trigger a
Susceptible
transfusion reaction
tachycardia, instead of whole
c. Important for Rh (-) woman carrying Rh (+) baby; 1st
Client
pregnancy not affected, but subsequent pregnancy with
orthopnea, blood.
an Rh (+) baby, mother’s antibodies attack baby’s RBC

cyanosis, anxiety Monitor CVP

Complication of Blood Transfusion
t
Type Causes Mechanism Occurrence S/sx
hro
Intervention
ug
ha
Hemolytic ABO Antibodies in Acute:
Headache, Stop transfusion.
Incompatibility; recipient plasma first 5 min separate line.

lumbar or continue saline IV _____________________________________________________________________

Rh react w/ antigen after __________________

completion sternal pain, send blood unit & Air Embolism Blood given Bolus of air Anytime

Incompatibility; in donor cells. of transfusion Dyspnea, Clamp tubing.

diarrhea, fever, client blood under air blocks pulmonary

Use of dextrose Agglutinated cell increase pulse, Turn client on

chills, flushing, sample to lab. pressure artery outflow

solutions; block capillary Delayed: wheezing, chest left side

heat along vein, Watch for following severe

Wide temp blood flow to days to 2 pain, decrease BP,

restlessness, hemoglobinuria. blood loss

fluctuation organs. weeks after apprehension

anemia, jaundice, Treat or prevent _____________________________________________________________________

Hemolysis (Hgb __________________Thrombo- Used of large Platelets

dyspnea, signs shock, DIC, & When large Abnormal Assess for signs

into plasma & of cytopenia amount of deteriorate amount of blood

shock, renal renal shutdown bleeding of bleeding.

urine) banked blood rapidly in stored given over

shutdown, DIC 24 hr Initiate bleeding

blood
precautions.

Complication of Blood Transfusion Use fresh blood.

Type Causes Mechanism Occurrence S/sx _____________________________________________________________________

Intervention __________________
Citrate Large amount Citrate binds After large

Allergic Transfer of an Immune Within 30 min Neuromascular Monitor/treat

Uticaria, larygeal Stop transfusion. Intoxication of citrated blood ionic calcium amount of

antigen & sensitivity to start of irritability hypocalcemia.

edema, wheezing Administer in client with banked blood

antibody from foreign serum transfusion Bleeding due to Avoid large

dyspnea, antihistamine & decrease liver

donor to CHON decrease calcium amounts of

bronchospasm, or epinephrine. function

recipient; citrated blood.

headache, Treat
Allergic donor Monitor liver fxn
anaphylaxis life-threatening

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_____________________________________________________________________ Liver also involved in synthesis of clotting factors, synthesis

__________________ of antithrombins.
Hyperkalemia Potassium level Release of In client with
Nausea, colic, Administer blood Blood Tranfusion
increase in potassium into renal Purpose
diarrhea, muscle less than 5-7 1. RBC: Improve O2 transport
stored blood plasma with insufficiency 2. Whole Blood, Plasma, Albumin: volume expansion
spasm, ECG days old in client
3. Fresh Frozen Plasma, Albumin, Plasma Protein Fraction:
red cell lysis
provision of proteins
changes (tall with impaired
4. Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole
Blood: provision of coagulation factors
peaked T-waves, potassium
5. Platelet Concentration, Fresh Whole Blood: provision of
platelets
short Q-T excretion
s
Blood & Blood Products
egments)
1. Whole Blood: provides all components
a. Large volume can cause difficulty: 12-24 hr for Hgb
Blood Coagulation
& Hct to rise
Conversion of fluid blood into a solid clot to reduce blood
b. Complications: volume overload, transmission of
loss when blood vessels are ruptured
hepatitis or AIDS, transfusion reacion, infusion of
excess potassium & sodium, infusion of
System that Initiating Clotting
anticoagulant (citrate) used to keep stored blood
1. Intrinsic System: initiated by contact activation following
from clotting, calcium binding & depletion (citrate)
endothelial injury (“intrinsic” to vessel itself)
in massive transfusion therapy
a. Factor XII: initiate as contact made between damaged
2. Red Blood Cell (RBC)
vessel & plasma CHON
a. Provide twice amount of Hgb as an equivalent
b. Factors VIII, IX & XI activated
amount of whole blood
2. Extrinsic System:
b. Indicate in cases of blood loss, pre-op & post-op
a. Initiated by tissue thromboplastins released from injured
client & those with incipient congestive failure
vessels (“extrinsic” to vessel)
c. Complication: transfusion reaction (less common
b. Factor VII activated
than with whole blood: due to removal of plasma
protein)
Common Pathways: activated by either intrinsic or extrinsic
3. Fresh Frozen Plasma
pathways
a. Contains all coagulation factors including V & VIII
1. Platelet factor 3 (PF3) & calcium react with factor X & V
b. Can be stored frozen for 12 months; takes 20
2. Prothrombin converted to thrombin via thromboplastin
minutes to thaw
3. Thrombin acts on fibrinogens, forming soluble fibrin
c. Hang immediately upon arrival to unit (loses its
4. Soluble fibrin polymerized by factor XIII to produce a stable,
coagulation factor rapidly)
insoluble fibrin clot
4. Platelets
a. Will raise recipient’s platelet count by 10,000/mm3
Clot Resolution: takes place via fibrinolytic system by plasmin &
b. Pooled from 4-8 units of whole blood
proteolytic enzymes; clots dissolves as tissue repairs.
c. Single-donor platelet transfusion may be necessary
for clients who have developed antibodies;
compatibilities testing may be necessary
Spleen
5. Factor VIII Fractions (Cryoprecipitate): contains factor
Largest Lymphatic Organ: functions as blood filtration
VIII, fibrinogens & XIII
system & reservoir
6. Granulocytes
Vascular bean shape; lies beneath the diaphragm, behind &
a. Do not increase WBC: increase marginal pool (at
to the left of the stomach; composed of fibrous tissue
tissue level) rather than circulating pool
capsule surrounding a network of fiber
b. Premedication with steroids, antihistamine &
Contains two types of pulp:
acetaminophen
a. Red Pulp: located between the fibrous strands,
c. Respiratory distress with shortness of breath,
composed of RBC, WBC & macrophages
cyanosis & chest pain may occur; requires cessation
b. White Pulp: scattered throughout the red pulp, produces
of transfusion & immediate attention
lymphocytes & sequesters lymphocytes, macrophages,
d. Shaking chills or rigors common, require brief
& antigens
cessation of therapy, administration of meperdine IV
1%-2% of red cell mass or 200 ml blood/minute stored in the until rigors are diminished & resumption of
spleen; blood comes via splenic artery to the pulp for transfusion when symptoms relieved
cleansing, then passes into splenic venules that are lined
7. Volume Expander: albumin; percentage concentration
with phagocytic cells & finally to the splenic vein to the liver.
varies (50-100 ml/unit); hyperosmolar solution should
Important hematopoietic site in fetus; postnatally not be used in dehydrated clients
procedures lymphocytes & monocytes
Important in phagocytosis; removes misshapen Goals / Objectives
erythrocytes, unwanted parts of erythrocytes 1. Replace circulating blood volume
Also involved in antibody production by plasma cells & iron 2. Increase the O2 carrying capacity of blood
metabolism (iron released from Hgb portion of destroyed 3. Prevent infection: if there is a decrease in WBC
erythrocytes returned to bone marrow)
4. Prevent bleeding: if there is platelet deficiency
In the adult functions of the spleen can be taken over by the
reticuloendothelial system.
Principles of blood transfusion
1. Proper refrigeration
Liver
a. Expiration of packed RBC is 3-6 days
Involved in bile production (via erythrocyte destruction & b. Expiration of platelet is 3-5 days
bilirubin production) & erythropoeisis (during fetal life & 2. Proper typing and cross matching
when bone marrow production is insufficient).
a. Type O: universal donor
Kupffer cells of liver have reticuloendothelial function as
b. Type AB: universal recipient
histiocytes; phagocytic activity & iron storage.
c. 85% of population is RH positive
3. Aseptically assemble all materials needed for BT

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a. Filter set
b. Gauge 18-19 needle S/sx Pyrogenic reactions
c. Isotonic solution (0.9 NaCl / plain NSS): to prevent 1. Fever and chills
hemolysis 2. Headache
4. Instruct another RN to re check the following 3. Tachycardia
a. Client name 4. Palpitations
b. Blood typing & cross matching 5. Diaphoresis
c. Expiration date 6. Dyspnea
d. Serial number
5. Check the blood unit for bubbles cloudiness, sediments Nursing Management
and darkness in color because it indicates bacterial 1. Stop BT
contamination 2. Notify physician
a. Never warm blood: it may destroy vital factors in 3. Flush with plain NSS

blood. 4. Administer medications as ordered

b. Warming is only done: during emergency situation & a. Antipyretic

if you have the warming device b. Antibiotic

c. Emergency rapid BT is given after 30 minutes & let 5. Send the blood unit to blood bank for re examination

natural room temperature warm the blood. 6. Obtain urine & blood sample & send to laboratory for re-

6. BT should be completed less than 4 hours because examination

7. Monitor vital signs & I&O
blood that is exposed at room temperature more than 2
8. Render TSB
hours: causes blood deterioration that can lead to
bacterial contamination
7. Avoid mixing or administering drugs at BT line: to
S/sx of Circulatory reaction
prevent hemolysis
1. Orthopnea
8. Regulate BT 10-15 gtts/min or KVO rate or equivalent to
2. Dyspnea
100 cc/hr: to prevent circulatory overload
3. Rales / Crackles upon auscultation
9. Monitor strictly vital signs before, during & after BT
4. Exertional discomfort
especially every 15 minutes for first hour because
majority of transfusion reaction occurs during this period
Nursing Management
a. Hemolytic reaction
1. Stop BT
b. Allergic reaction
2. Notify physician
c. Pyrogenic reaction
3. Administer medications as ordered
d. Circulatory overload
a. Loop diuretic (Lasix)
e. Air embolism
f. Thrombocytopenia
Nursing Care
g. Cytrate intoxication
1. Assess client for history of previous blood transfusions &
h. Hyperkalemia (caused by expired blood)
any adverse reaction
2. Ensure that the adult client has an 18-19 gauge IV
S/sx of Hemolytic reaction
catheter in place
1. Headache and dizziness
3. Use 0.9% sodium chloride
2. Dyspnea
4. At least two nurse should verify the ABO group, RH type,
3. Diarrhea / Constipation
client & blood numbers & expiration date
4. Hypotension
5. Take baseline V/S before initiating transfusion
5. Flushed skin
6. Lumbasternal / Flank pain
6. Start transfusion slowly (2 ml/min)
7. Stay with the client during the first 15 min of the
7. Urine is color red / portwine urine
transfusion & take V/S frequently
8. Maintain the prescribed transfusion rate:
Nursing Management
1. Stop BT
a. Whole Blood: approximately 3-4 hr

2. Notify physician b. RBC: approximately 2-4 hr

3. Flush with plain NSS c. Fresh Frozen Plasma: as quickly as possible
4. Administer isotonic fluid solution: to prevent shock and d. Platelet: as quickly as possible
acute tubular necrosis e. Cryoprecipitate: rapid infusion
5. Send the blood unit to blood bank for re-examination f. Granulocytes: usually over 2 hr
6. Obtain urine & blood sample & send to laboratory for re- g. Volume Expander: volume-dependent rate
examination
9. Monitor for adverse reaction
7. Monitor vital signs & I&O
10. Document the following:
a. Blood component unit number (apply sticker if
S/sx of Allergic reaction
available)
1. Fever
b. Date of infusion starts & end
2. Dyspnea
c. Type of component & amount transfused
3. Broncial wheezing
d. Client reaction & vital signs
4. Skin rashes
e. Signature of transfusionist
5. Urticaria
6. Laryngospasm & Broncospasm
HIV
- 6 months – 5 years incubation period
Nursing Management
- 6 months window period
1. Stop BT
- western blot opportunistic
2. Notify physician
- ELISA
3. Flush with plain NSS
- drug of choice AZT (Zidon Retrovir)
4. Administer medications as ordered
a. Anti Histamine (Benadryl): if positive to
2 Common fungal opportunistic infection in AIDS
hypotension, anaphylactic shock: treat with
1. Kaposis Sarcoma
Epinephrine
2. Pneumocystic Carini Pneumonia
5. Send the blood unit to blood bank for re examination
6. Obtain urine & blood sample & send to laboratory for re-
Blood Disorder
examination
7. Monitor vital signs and intake and output
Iron Deficiency Anemia (Anemias)

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A chronic microcytic anemia resulting from inadequate 5. Instruct the client to avoid taking tea and coffee:
absorption of iron leading to hypoxemic tissue injury because it contains tannates which impairs iron
Chronic microcytic, hypochromic anemia caused by either absorption
inadequate absorption or excessive loss of iron 6. Administer iron preparation as ordered:

Acute or chronic bleeding principal cause in adults (chiefly a. Oral Iron Preparations: route of choice

from trauma, dysfunctional uterine bleeding & GI bleeding) Ferrous Sulfate

May also be caused by inadequate intake of iron-rich foods Ferrous Fumarate

or by inadequate absorption of iron Ferrous Gluconate
In iron-deficiency states, iron stores are depleted first,
followed by a reduction in Hgb formation Nursing Management when taking oral iron
preparations
Incidence Rate Instruct client to take with meals: to lessen GIT
1. Common among developed countries & tropical zones irritation
(blood-sucking parasites) Dilute in liquid preparations well & administer
2. Common among women 15 & 45 years old & children using a straw: to prevent staining of teeth
affected more frequently, as are the poor When possible administer with orange juice as
3. Related to poor nutrition vitamin C (ascorbic acid): to enhance iron
absorption
Predisposing Factors Warn clients that iron preparations will change
1. Chronic blood loss due to: stool color & consistency (dark & tarry) & may
a. Trauma cause constipation
b. Heavy menstruation Antacid ingestion will decrease oral iron
c. Related to GIT bleeding resulting to hematemasis effectiveness
and melena (sign for upper GIT bleeding)
d. Fresh blood per rectum is called hematochezia b. Parenteral: used in clients intolerant to oral
2. Inadequate intake or absorption of iron due to: preparations, who are noncompliant with therapy or
a. Chronic diarrhea who have continuing blood losses
b. Related to malabsorption syndrome
c. High cereal intake with low animal CHON digestion Nursing Management when giving parenteral
d. Partial or complete gastrectomy iron preparation
e. Pica Use one needle to withdraw & another to
3. Related to improper cooking of foods administer iron preparation as tissue staining &
irritation are a problem
S/sx Use Z-track injection technique: to prevent
1. Usually asymptomatic (mild cases) leakage into tissue
2. Weakness & fatigue (initial signs) Do not massage injection site but encourage
3. Headache & dizziness ambulation as this will enhance absorption;
4. Pallor & cold sensitivity advice against vigourous exercise & constricting
5. Dyspnea garments
6. Palpitations Observe for local signs of complication:
7. Brittleness of hair & nails, spoon shape nails Pain at the injection site
(koilonychias) Development of sterile abscesses
8. Atrophic Glossitis (inflammation of tongue) Lymphadenitis
a. Stomatitis PLUMBER Fever & chills
VINSON’S SYNDROME Headache
b. Dysphagia
Urticaria
9. PICA: abnormal appetite or craving for non edible foods
Pruritus
Hypotension
Dx
Skin rashes
1. RBC: small (microcytic) & pale (hypochromic)
Anaphylactic shock
2. RBC: is decreased
3. Hgb: decreased
Medications administered via straw
4. Hct: moderately decreased Lugol’s Solution
5. Serum iron: decreased Iron
6. Reticulocyte count: is decreased Tetracycline
7. Serum ferritin: is decreased Nitrofurantoin (Macrodentin)
8. Hemosiderin: absent from bone marrow 7. Administer with Vitamin C or orange juice for absorption
8. Monitor & inform client of side effects
Nursing Intervention a. Anorexia
1. Monitor for s/sx of bleeding through hematest of all b. N/V
elimination including urine, stool & gastrict content c. Abdominal pain
2. Enforce CBR / Provide adequate rest: plan activities so d. Diarrhea / constipation
as not to over tire the client e. Melena
3. Provide thorough explanation of all diagnostic exam 9. If client can’t tolerate / no compliance administer
used to determine sources of possible bleeding: help parenteral iron preparation
allay anxiety & ensure cooperation a. Iron Dextran (IM, IV)
4. Instruct client to take foods rich in iron b. Sorbitex (IM)
a. Organ meat 10. Provide dietary teaching regarding food high in iron
b. Egg yolk 11. Encourage ingestion of roughage & increase fluid intake:
c. Raisin to prevent constipation if oral iron preparation are being
d. Sweet potatoes taken
e. Dried fruits
f. Legumes Pernicious Anemia
g. Nuts
Chronic progressive, macrocytic anemia caused by a
deficiency of intrinsic factor; the result is abnormally large

37
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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
a. Measures absorption of radioactive vitamin B12
bothe before & after parenteral administration of
intrinsic factor
b. Definitive test for pernicious anemia
c. Used to detect lack of intrinsic factor
d. Fasting client is given radioactive vitamin B12 by
mouth & non-radioactive vitamin B12 IM to permit

Lack of intrinsic factor is caused by gastric mucosal atrophy some excretion of radioactive vitamin B12 in the

(possibly due to heredity, prolonged iron deficiency, or an urine if it os absorbed

autoimmune disorder); can also results in clients who have e. 24-48 hour urine collection is obtained: client is

had a total gastrctomy if vitamin B12 is not administer encourage to drink fluids
f. If indicated, second stage schilling test performed 1
Pathophysiology week after first stage. Fasting client is given
1. Intrinsic factor is necessary for the absorbtion of vitamin radioactive vitamin B12 combined with human
B12 into small intestines intrinsic factor & test is repeated
2. B12 deficiency diminished DNA synthesis, which results 7. Gastric Analysis: decrease free hydrochloric acid
in defective maturation of cell (particularly rapidly 8. Large number of reticulocytes in the blood following
dividing cells such as blood cells & GI tract cells) parenteral vitamin B12 administration
3. B12 deficiency can alter structure & function of
peripheral nerves, spinal cord, & the brain Medical Management
1. Drug Therapy:
STOMACH
a. Vitamin B12 injection: monthly maintenance
Pareital cells/Argentaffin or Oxyntic cells
b. Iron preparation: (if Hgb level inadequate to meet
increase numbers of erythrocytes)
Produces intrinsic factors
c. Folic Acid
Secretes hydrochloric acid
Controversial
Reverses anemia & GI symptoms but may
Promotes reabsorption of Vit B12
intensify neurologic symptoms
Aids in digestion
May be safe if given in small amounts in
addition to vitamin B12
Promotes maturation of RBC
2. Transfusion Therapy
Nursing Intervention
Predisposing Factors
1. Enforce CBR: necessary if anemia is severe
1. Usually occurs in men & women over age of 50 with an
increase in blue-eyed person of Scandinavian decent 2. Adminster Vitamin B12 injections at monthly intervals for
2. Subtotal gastrectomy lifetime as ordered

3. Hereditary factors Never given orally because there is possibility of

4. Inflammatory disorders of the ileum developing tolerance

5. Autoimmune Site of injection for Vitamin B12 is dorsogluteal and

6. Strictly vegetarian diet ventrogluteal
S/sx No side effects
1. Anemia 3. Provide a dietary intake that is high in CHON, vitamin c
2. Weakness & fatigue and iron (fish, meat, milk / milk product & eggs)
3. Headache and dizziness 4. Avoid highly seasoned, coursed, or very hot foods: if
4. Pallor & cold sensitivity client has mouth sore
5. Dyspnea & palpitations: as part of compensation 5. Provide safety when ambulating (especially when
6. GIT S/sx: carrying hot item)
a. Mouth sore 6. Instruct client to avoid irritating mouth washes instead
b. PS: Red beefy tongue use soft bristled toothbrush
c. Indigestion / dyspepsia 7. Avoid heat application to prevent burns
d. Weight loss 8. Provide client teaching & discharge planning
e. Constipation / diarrhea concerning:
f. Jaundice a. Dietery instruction
7. CNS S/sx: b. Importance of lifelong vitamin B12 therapy
a. Tingling sensation c. Rehabilitation & physical therapy for neurologic
b. Numbness deficit, as well as instruction regarding safety
c. Paresthesias of hands & feet
d. Paralysis Aplastic Anemia
e. Depression Stem cell disorder leading to bone marrow depression
f. Psychosis leading to pancytopenia
g. Positive to Romberg’s test: damage to cerebellum Pancytopenia or depression of granulocytes, platelets &
resulting to ataxia erythrocytes production: due to fatty replacement of the
bone marrow
Dx Bone marrow destruction may be idiopathic or secondary
1. Erythrocytes count: decrease
2. Blood Smear: oval, macrocytic erythrocytes with a PANCYTOPENIA
proportionate amount of Hgb
3. Bilirubin (indirect): elevated unconjugated fraction Decrease RBC Decrease WBC
Decrease Platelet
4. Serum LDH: elevated (anemia) (leukopenia)
5. Bone Marrow: (thrombocytopenia)
a. Increased megaloblasts (abnormal erythrocytes)
b. Few normoblasts or maturing erythrocytes Predisposing Factors
c. Defective leukocytes maturation 1. Chemicals (Benzene and its derivatives)
6. Positive Schilling’s Test: reveals inadequate / decrease 2. Related to radiation / exposure to x-ray
absorption of Vitamin B12 3. Immunologic injury
4. Drugs:

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a. Broad Spectrum Antibiotics: Chloramphenicol b. Identification of offending agent & importance of

(Sulfonamides) avoiding it (if possible) in future
b. Cytotoxic agent / Chemotherapeutic Agents:
Methotrexate (Alkylating Agent) Disseminated Intravascular Coagulation (DIC)

Vincristine (Plant Alkaloid) Diffuse fibrin deposition within arterioles & capillaries with

Nitrogen Mustard (Antimetabolite) widespread coagulation all over the body & subsequent

Phenylbutazones (NSAIDS) depletion of clotting factors

Acute hemorrhagic syndrome characterized by wide spread

S/sx bleeding and thrombosis due to a deficiency of prothrombin

1. Anemia and fibrinogen

a. Weakness & fatigue Hemorrhage from kidneys, brain, adrenals, heart & other

b. Headache & dizziness organs

c. Pallor & cold sensitivity May be linked with entry of thromboplasic substance into
d. Dyspnea & palpitations the blood
2. Leukopenia Mortality rate is high usually because underlying disease
a. Increase susceptibility to infection cannot be corrected
3. Thrombocytopenia
a. Petechiae (multiple petechiae is called purpura)
b. Ecchymosis Pathophysiology

c. Oozing of blood from venipunctured sites 1. Underlying disease (ex. toxemia of pregnancy, cancer)
Dx cause release of thromboplastic substance that promote

1. CBC: reveals pancytopenia the deposition of fibrin throughout the microcirculation

2. Normocytic anemia, granulocytopenia, 2. Microthrombi form in many organs, causing

thrombocytopenia microinfarcts & tissue necrosis

3. Bone marrow biopsy: aspiration (site is the posterior iliac 3. RBC are trapped in fibrin strands & are hemolysed

crest): marrow is fatty & contain very few developing 4. Platelets, prothrombin & other clotting factors are

cells; reveals fat necrosis in bone marrow destroyed, leading to bleeding

5. Excessive clotting activates the fibrinolytic system,

Medical Management which inhibits platelet function, causing futher bleeding.

1. Blood transfusion: key to therapy until client’s own

Predisposing Factors
marrow begins to produce blood cells
1. Related to rapid blood transfusion
2. Aggressive treatment of infection
2. Massive burns
3. Bone marrow transplantation
3. Massive trauma
4. Drug Therapy:
4. Anaphylaxis
a. Corticosteroids & / or androgens: to stimulate bone
5. Septecemia
marrow function & to increase capillary resistance
6. Neoplasia (new growth of tissue)
(effective in children but usually not in adults)
7. Pregnancy
b. Estrogen & / or progesterone: to prevent
amenorrhea in female clients
S/sx
5. Identification & withdrawal of offending agent or drug
1. Petechiae & Ecchymosis on the skin, mucous
membrane, heart, eyes, lungs & other organs
Nursing Intervention
(widespread and systemic)
1. Removal of underlying cause
2. Prolonged bleeding from breaks in the skin: oozing of
2. Administer Blood Transfusion as ordered
blood from punctured sites
3. Administer O2 inhalation
3. Severe & uncontrollable hemorrhage during childbirth or
4. Enforce CBR
surgical procedure
5. Institute reverse isolation
4. Hemoptysis
6. Provide nursing care for client with bone marrow
5. Oliguria & acute renal failure (late sign)
transplant
6. Convulsion, coma, death
7. Administer medications as ordered:
a. Corticosteroids: caused by immunologic injury
Dx
b. Immunosuppressants: Anti Lymphocyte Globulin
1. PT: prolonged
Given via central venous catheter 2. PTT: usually prolonged
Given 6 days to 3 weeks to achieve maximum 3. Thrombin Time: usually prolonged
therapeutic effect of drug 4. Fibrinogen level: usually depressed
8. Monitor for signs of infection & provide care to minimize
5. Fibrin splits products: elevated
risk:
6. Protamine Sulfate Test: strongly positive
a. Monitor neuropenic precautions
7. Factor assay (II, V, VII): depressed
b. Encourage high CHON, vitamin diet: to help reduce
8. CBC: reveals decreased platelets
incidence of infection
9. Stool occult blood: positive
c. Provide mouth care before & after meals
d. Fever 10. ABG analysis: reveals metabolic acidosis
e. Cough 11. Opthamoscopic exam: reveals sub retinal hemorrhages
9. Monitor signs of bleeding & provide measures to
minimize risk: Medical Management

a. Use soft toothbrush when brushing teeth & electric 1. Identification & control the underlying disease is key

razor when shaving: prevent bleeding 2. Blood Tranfusions: include whole blood, packed RBC,
b. Avoid IM, subcutaneous, venipunctured sites: platelets, plasma, cryoprecipitites & volume expanders

Instead provide heparin lock 3. Heparin administration

c. Hematest urine & stool a. Somewhat controversial

d. Observe for oozing from gums, petechiae or b. Inhibits thrombin thus preventing further clot

ecchymoses formation, allowing coagulation factors to

10. Provide client teaching & discharge planning accumulate

concerning:
a. Self-care regimen Nursing Intervention
1. Monitor blood loss & attemp to quantify

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2. Monitor for signs of additional bleeding or thrombus • 2 chambers, function as receiving chambers, lies above the
formation ventricles
3. Monitor all hema test / laboratory data including stool • Upper Chamber (connecting or receiving)
and GIT
• Right Atrium: receives systemic venous blood through
4. Prevent further injury
the superior vena cava, inferior vena cava & coronary
a. Avoid IM injection
sinus
b. Apply pressure to bleeding site
• Left Atrium: receives oxygenated blood returning to the
c. Turn & position the client frequently & gently
heart from the lungs trough the pulmonary veins
d. Provide frequent nontraumatic mouth care (ex. soft
Ventricles
toothbrush or gauze sponge)
• 2 thick-walled chambers; major responsibility for forcing
5. Administer isotonic fluid solution as ordered: to prevent
blood out of the heart; lie below the atria
shock
6. Administer oxygen inhalation
• Lower Chamber (contracting or pumping)

7. Force fluids • Right Ventricle: contracts & propels deoxygenated blood

8. Administer medications as ordered: into pulmonary circulation via the aorta during
a. Vitamin K ventricular systole; Right atrium has decreased pressure
b. Pitressin / Vasopresin: to conserve fluids which is 60 – 80 mmHg
c. Heparin / Comadin is ineffective • Left Ventricle: propels blood into the systemic circulation
9. Provide heparin lock via aortaduring ventricular systole; Left ventricle has
10. Institute NGT decompression by performing gastric increased pressure which is 120 – 180 mmHg in order to
lavage: by using ice or cold saline solution of 500-1000 propel blood to the systemic circulation
ml
11. Monitor NGT output Valves
12. Prevent complication • To promote unidimensional flow or prevent backflow
a. Hypovolemic shock: Anuria (late sign of Atrioventricular Valve
hypovolemic shock) • Guards opening between
13. Provide emotional support to client & significant other • Mitral Valve: located between the left atrium & left
14. Teach client the importance of avoiding aspirin or ventricle; contains 2 leaflets attached to the chordae
aspirin-containing compounds tandinae
• Tricuspid Valve: located between the right atrium & right
ventricle; contains 3 leaflets attached to the chordae
Overview of the Structure & Functions of the Heart
tandinae

• Cardiovascular system consists of the heart, arteries, veins

Functions
& capillaries. The major function are circulation of blood,
• Permit unidirectional flow of blood from specific atrium to
delivery of O2 & other nutrients to the tissues of the body &
specific ventricle during ventricular diastole
removal of CO2 & other cellular products metabolism
• Prevent reflux flow during ventricular systole
Heart
• Valve leaflets open during ventricular diastole; Closure of AV
• Muscular pumping organ that propel blood into the arerial
valves give rise to first heart sound (S1 “lub”)
system & receive blood from the venous system of the body.
Semi-lunar Valve
• Located on the left mediastinum
• Pulmonary Valve
• Resemble like a close fist
• Located between the left ventricle & pulmonary artery
• Weighs approximately 300 – 400 grams
• Aortic Valve
• Covered by a serous membrane called the pericardium
• Located between left ventricle & aorta

Heart Wall / Layers of the Heart Function

Pericardium • Pemit unidirectional flow of the blood from specific ventricle

• Composed of fibrous (outermost layer) & serous pericardium to arterial vessel during ventricular diastole

(parietal & visceral); a sac that function to protect the heart • Prevent reflux blood flow during ventricular diastole

from friction • Valve open when ventricle contract & close during

• In between is the pericardial fluid which is 10 – 20 cc: ventricular diastole; Closure of SV valve produces second

Prevent pericardial friction rub heart sound (S2 “dub”)

• 2 layers of pericardium
Extra Heart Sounds
• Parietal: outer layer
• S3: ventricular gallop usually seen in Left Congestive Heart
• Visceral: inner layer
Failure
Epicardium
• S4: atrial gallop usually seen in Myocardial Infarction and
• Covers surface of the heart, becomes continuous with
Hypertension
visceral layer of serous pericardium
• Outer layer
Coronary Circulation
Myocardium
Coronary Arteries
• Middle muscular layer
• Branch off at the base of the aorta & supply blood to the
• Myocarditis can lead to cardiogenic shock and rheumatic myocardium & the conduction system
heart disease • Arises from base of the aorta
Endocardium
• Types of Coronary Arteries
• Thin, inner membrabous layer lining the chamber of the
• Right Main Coronary Artery
heart
• Left Main Coronary Artery
• Inner layer
Coronary Veins
Papillary Muscle
• Return blood from the myocardium back to the right atrium
• Arise from the endocardial & myocardial surface of the
via the coronary sinus
ventricles & attach to the chordae tendinae
Chordae Tendinae
Conduction System
• Attach to the tricuspid & mitral valves & prevent eversion
Sinoatrial Node (SA node or Keith Flack Node)
during systole
• Located at the junction of superior vena cava and right
atrium
Chambers of the Heart
• Acts as primary pacemaker of the heart
Atria

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• 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
• 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

• Right Bundle Branch: divided into anterior lateral & arteries; most contains valves that prevent retrograde blood

posterior; transmits impulses down the right side of the flow; they carry deoxygenated blood back to the heart.

interventricular myocardium When the skeletal surrounding veins contract, the veins are
compressed, promoting movement of blood back to the
• Left Bundle Branch: divided into anterior & posterior
heart.
• Anterior Portion: transmits impulses to the anterior
endocardial surface of the left ventricle
• Posterior Portion: transmits impulse over the Cardiac Disorders
posterior & inferior endocardial surface of the left Coronary Arterial Disease / Ischemic Heart Disease
ventricle

Stages of Development of Coronary Artery Disease

Purkinje Fibers
1. Myocardial Injury: Atherosclerosis
• Transmit impulses to the ventricle & provide for
2. Myocardial Ischemia: Angina Pectoris
depolarization after ventricular contraction
3. Myocardial Necrosis: Myocardial Infarction
• Located at the walls of the ventricles for ventricular
contraction
ATHEROSCLEROSIS
ATHEROSCLEROSIS ARTERIOSCLEROSIS
• Narrowing of artery • Hardening of artery
• Lipid or fat deposits • Calcium and protein
• Tunica intima deposits
SA NODE
• Tunica media
AV NODE
Predisposing Factors
1. Sex: male
BUNDLE OF HIS 2. Race: black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle

PURKINJE FIBERS 7. Diabetes Mellitus

8. Hypothyroidism
Electrical activity of heart can be visualize by attaching electrodes 9. Diet: increased saturated fats
to the skin & recording activity by ECG 10. Type A personality
Electrocadiography (ECG) Tracing
• P wave (atrail depolarization) contraction S/sx
• QRS wave (ventricular depolarization) 1. Chest pain
2. Dyspnea
• T wave (ventricular repolarization)
3. Tachycardia
• Insert pacemaker if there is complete heart block
4. Palpitations
• Most common pacemaker is the metal pacemaker and lasts
5. Diaphoresis
up to 2 – 5 years

Treatment
Abnormal ECG Tracing
P - Percutaneous
• Positive U wave: Hypokalemia T - Transluminal
• Peak T wave: Hyperkalemia C - Coronary

• ST segment depression: Angina Pectoris A – Angioplasty

• ST segment elevation: Myocardial Infarction

C - Coronary
• T wave inversion: Myocardial Infarction A - Arterial
• Widening of QRS complexes: Arrythmia B - Bypass
A - And
Vascular System G - Graft
• Major function of the blood vessels isto supply the tissue S - Surgery

with blood, remove wastes, & carry unoxygenated blood

back to the heart
Objectives

Types of Blood Vessels 1. Revascularize myocardium

Arteries 2. To prevent angina

• Elastic-walled vessels that can stretch during systole & 3. Increase survival rate

recoil during diastole; they carry blood away from the heart 4. Done to single occluded vessels

& distribute oxygenated blood throughout the body 5. If there is 2 or more occluded blood vessels CABG is done

Arterioles
3 Complications of CABG

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1. Pneumonia: encourage to perform deep breathing, coughing a. Nitroglycerine (NTG): when given in small doses will act
exercise and use of incentive spirometer as venodilator, but in large doses will act as vasodilator
2. Shock • Give 1st dose of NTG: sublingual 3-5 minutes
3. Thrombophlebitis
• Give 2nd dose of NTG: if pain persist after giving 1st
dose with interval of 3-5 minutes
Angina Pectoris
• Give 3rd & last dose of NTG: if pain still persist at 3-5
• Transient paroxysmal chest pain produced by insufficient
minutes interval
blood flow to the myocardium resulting to myocardial
ischemia
Nursing Management when giving NTG
• Clinical syndrome characterized by paroxysmal chest pain
1. NTG Tablets (sublingual)
that is usually relieved by rest or nitroglycerine due to
• Keep the drug in a dry place, avoid moisture and
temporary myocardial ischemia
exposure to sunlight as it may inactivate the drug

Predisposing Factors
• Relax for 15 minutes after taking a tablet: to prevent

1. Sex: male dizziness

2. Race: black • Monitor side effects:

3. Smoking • Orthostatic hypotension
4. Obesity • Transient headache & dizziness: frequent side
5. Hyperlipidemia effect
6. Sedentary lifestyle
• Instruct the client to rise slowly from sitting position
7. Diabetes Mellitus
• Assist or supervise in ambulation
8. Hypertension
2. NTG Nitrol or Transdermal patch
9. CAD: Atherosclerosis
• Avoid placing near hairy areas as it may decrease
10. Thromboangiitis Obliterans
drug absorption
11. Severe Anemia
• Avoid rotating transdermal patches as it may
12. Aortic Insufficiency: heart valve that fails to open & close
decrease drug absorption
efficiently
• Avoid placing near microwave ovens or during
13. Hypothyroidism
defibrillation as it may lead to burns (most
14. Diet: increased saturated fats
important thing to remember)
15. Type A personality
b. Beta-blockers
• Propanolol: side effects PNS
Precipitating Factors
4 E’s of Angina Pectoris • Not given to COPD cases: it causes bronchospasm

1. Excessive physical exertion: heavy exercises, sexual activity c. ACE Inhibitors

2. Exposure to cold environment: vasoconstriction • Enalapril

3. Extreme emotional response: fear, anxiety, excitement, d. Calcium Antagonist

strong emotions • Nefedipine

4. Excessive intake of foods or heavy meal 4. Administer oxygen inhalation

5. Place client on semi-to high fowlers position

S/sx 6. Monitor strictly V/S, I&O, status of cardiopulmonary fuction

1. Levine’s Sign: initial sign that shows the hand clutching the & ECG tracing

chest 7. Provide decrease saturated fats sodium and caffeine

8. Provide client health teachings and discharge planning
2. Chest pain: characterized by sharp stabbing pain located at
sub sterna usually radiates from neck, back, arms, shoulder Avoidance of 4 E’s

and jaw muscles usually relieved by rest or taking Prevent complication (myocardial infarction)
nitroglycerine (NTG) Instruct client to take medication before indulging into
3. Dyspnea physical exertion to achieve the maximum therapeutic
4. Tachycardia effect of drug
5. Palpitations Reduce stress & anxiety: relaxation techniques & guided
6. Diaphoresis imagery
Avoid overexertion & smoking
Avoid extremes of temperature
Dx
Dress warmly in cold weather
1. History taking and physical exam
Participate in regular exercise program
2. ECG: may reveals ST segment depression & T wave
Space exercise periods & allow for rest periods
inversion during chest pain
The importance of follow up care
3. Stress test / treadmill test: reveal abnormal ECG during
9. Instruct the client to notify the physician immediately if pain
exercise
occurs & persists despite rest & medication administration
4. Increase serum lipid levels
5. Serum cholesterol & uric acid is increased
Myocardial Infarction
• Death of myocardial cells from inadequate oxygenation,
Medical Management
often caused by sudden complete blockage of a coronary
1. Drug Therapy: if cholesterol is elevated
artery
• Nitrates: Nitroglycerine (NTG)
• Characterized by localized formation of necrosis (tissue
• Beta-adrenergic blocking agent: Propanolol
destruction) with subsequent healing by scar formation &
• Calcium-blocking agent: nefedipine fibrosis

• Ace Inhibitor: Enapril • Heart attack

2. Modification of diet & other risk factors • Terminal stage of coronary artery disease characterized by

3. Surgery: Coronary artery bypass surgery malocclusion, necrosis & scarring.

4. Percutaneuos Transluminal Coronary Angioplasty (PTCA)

Types

Nursing Intervention 1. Transmural Myocardial Infarction: most dangerous type

1. Enforce complete bed rest characterized by occlusion of both right and left coronary

2. Give prompt pain relievers with nitrates or narcotic artery

analgesic as ordered 2. Subendocardial Myocardial Infarction: characterized by

3. Administer medications as ordered: occlusion of either right or left coronary artery

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2. Administer oxygen low flow 2-3 L / min: to prevent

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
respiratory arrest or dyspnea & prevent arrhythmias
3. Enforce CBR in semi-fowlers position without bathroom
privileges (use bedside commode): to decrease cardiac
workload
4. Instruct client to avoid forms of valsalva maneuver
5. Place client on semi fowlers position
6. Monitor strictly V/S, I&O, ECG tracing & hemodynamic

2. Race: black procedures

3. Smoking 7. Perform complete lung / cardiovascular assessment

4. Obesity 8. Monitor urinary output & report output of less than 30 ml /

5. CAD: Atherosclerotic hr: indicates decrease cardiac output

6. Thrombus Formation 9. Provide a full liquid diet with gradual increase to soft diet:
7. Genetic Predisposition low in saturated fats, Na & caffeine

8. Hyperlipidemia 10. Maintain quiet environment

9. Sedentary lifestyle 11. Administer stool softeners as ordered: to facilitate bowel

10. Diabetes Mellitus evacuation & prevent straining
11. Hypothyroidism 12. Relieve anxiety associated with coronary care unit (CCU)
12. Diet: increased saturated fats environment

13. Type A personality 13. Administer medication as ordered:

a. Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate,
S/sx Isodil (ISD): sublingual
1. Chest pain b. Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium
• Excruciating visceral, viselike pain with sudden onset • Side Effects: confusion and dizziness
located at substernal & rarely in precordial c. Beta-blockers: Propanolol (Inderal)
• Usually radiates from neck, back, shoulder, arms, jaw & d. ACE Inhibitors: Captopril (Enalapril)
abdominal muscles (abdominal ischemia): severe
e. Calcium Antagonist: Nefedipine
crushing
f. Thrombolytics / Fibrinolytic Agents: Streptokinase,
• Not usually relieved by rest or by nitroglycerine
Urokinase, Tissue Plasminogen Activating Factor (TIPAF)
2. N/V
• Side Effects: allergic reaction, urticaria, pruritus
3. Dyspnea
• Nursing Intervention: Monitor for bleeding time
4. Increase in blood pressure & pulse, with gradual drop in
blood pressure (initial sign) g. Anti Coagulant

5. Hyperthermia: elevated temp • Heparin

6. Skin: cool, clammy, ashen • Antidote: Protamine Sulfate

7. Mild restlessness & apprehension • Nursing Intervention: Check for Partial Thrombin
8. Occasional findings: Time (PTT)
• Pericardial friction rub • Caumadin (Warfarin)
• Split S1 & S2 • Antidote: Vitamin K
• Rales or Crackles upon auscultation
• Nursing Intervention: Check for Prothrombin
• S4 or atrial gallop Time (PT)
h. Anti Platelet: PASA (Aspirin): Anti thrombotic effect
Dx
• Side Effects: Tinnitus, Heartburn, Indigestion /
1. Cardiac Enzymes
Dyspepsia
• CPK-MB: elevated
• Contraindication: Dengue, Peptic Ulcer Disease,
• Creatinine phosphokinase (CPK): elevated Unknown cause of headache
• Heart only, 12 – 24 hours 14. Provide client health teaching & discharge planning
• Lactic acid dehydrogenase (LDH): is increased concerning:
a. Effects of MI healing process & treatment regimen
• Serum glutamic pyruvate transaminase (SGPT): is
b. Medication regimen including time name purpose,
increased
schedule, dosage, side effects
• Serum glutamic oxal-acetic transaminase (SGOT): is
c. Dietary restrictions: low Na, low cholesterol, avoidance
increased
of caffeine
2. Troponin Test: is increased
d. Encourage client to take 20 – 30 cc/week of wine, whisky
3. ECG tracing reveals
and brandy: to induce vasodilation
• ST segment elevation
e. Avoidance of modifiable risk factors
• T wave inversion
f. Prevent Complication
• Widening of QRS complexes: indicates that there is • Arrhythmia: caused by premature ventricular
arrhythmia in MI contraction
4. Serum Cholesterol & uric acid: are both increased • Cardiogenic shock: late sign is oliguria
5. CBC: increased WBC
• Left Congestive Heart Failure

• Thrombophlebitis: homan’s sign

Nursing Intervention
• Stroke / CVA
• Goal: Decrease myocardial oxygen demand
• Dressler’s Syndrome (Post MI Syndrome): client is
resistant to pharmacological agents: administer
1. Decrease myocardial workload (rest heart)
150,000-450,000 units of streptokinase as ordered
• Establish a patent IV line
g. Importance of participation in a progressive activity
• Administer narcotic analgesic as ordered: Morphine
program
Sulfate IV: provide pain relief (given IV because after an
h. Resumption of ADL particularly sexual intercourse: is 4-6
infarction there is poor peripheral perfusion & because
weeks post cardiac rehab, post CABG & instruct to:
serum enzyme would be affected by IM injection as
• Make sex as an appetizer rather than dessert
ordered)
• Instruct client to assume a non weight bearing
• Side Effects: Respiratory Depression
position
• Antidote: Naloxone (Narcan) • Client can resume sexual intercourse: if can climb or
• Side Effects of Naloxone Toxicity: is tremors use the staircase

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i. Need to report the ff s/sx: • Weakened right ventricle is unable to pump blood into he
• Increased persistent chest pain pulmonary system: systemic venous congestion occurs as
• Dyspnea pressure builds up
• Weakness
• Fatigue Predisposing Factors
1. Right ventricular infarction
• Persistent palpitation
2. Atherosclerotic heart disease
• Light headedness
3. Tricuspid valve stenosis
j. Enrollment of client in a cardiac rehabilitation program
4. Pulmonary embolism
k. Strict compliance to mediation & importance of follow
5. Related to COPD
up care
6. Pulmonic valve stenosis
7. Left sided heart failure
Congestive Heart Failure
• Inability of the heart to pump an adequate supply of blood
S/sx
to meet the metabolic needs of the body
1. Anorexia
• Inability of the heart to pump blood towards systemic
2. Nausea
circulation
3. Weight gain
4. Neck / jugular vein distension
Types of Heart Failure
5. Pitting edema
1. Left Sided Heart Failure
6. Bounding pulse
2. Right Sided Heart Failure
7. Hepatomegaly / Slenomegaly
3. High-Output Failure
8. Cool extremities
9. Ascites
Left Sided Heart Failure
10. Jaundice
• Left ventricular damage causes blood to back up through 11. Pruritus
the left atrium & into the pulmonary veins: Increased 12. Esophageal varices
pressure causes transudation into interstitial tissues of the Dx
lungs which result pulmonary congestion. 1. Chest X-ray (CXR): reveals cardiomegaly
2. Central Venous Pressure (CVP): measure fluid status:
Predisposing Factors
elevated
1. 90% is mitral valve stenosis due to RHD: inflammation of
• Measure pressure in right atrium: 4-10 cm of water
mitral valve due to invasion of Group A beta-hemolytic
• If CVP is less than 4 cm of water: Hypovolemic shock:
streptococcus
increase IV flow rate
2. Myocardial Infarction
3. Ischemic heart disease • If CVP is more than 10 cm of water: Hypervolemic shock:

4. Hypertension Administer loop diuretics as ordered

5. Aortic valve stenosis • Nursing Intervention:

• When reading CVP patient should be flat on bed
S/sx • Upon insertion place client in trendelendberg
1. Dyspnea position: to promote ventricular filling and prevent
2. Paroxysmal nocturnal dyspnea (PND): client is awakened at pulmonary embolism
night due to difficulty of breathing 3. Echocardiography: reveals increased size of cardiac
3. Orthopnea: use 2-3 pillows when sleeping or place in high chambers (cardiomyopathy)
fowlers 4. Liver enzymes: SGPT & SGOT: is increased
4. Tiredness
5. ABG: decreased pO2
5. Muscle Weakness
6. Productive cough with blood tinged sputum
Medical Management
7. Tachycardia
1. Determination & elimination / control of underlying cause
8. Frothy salivation
2. Drug therapy: digitalis preparations, diuretics, vasodilators
9. Cyanosis
3. Sodium-restricted diet: to decrease fluid retention
10. Pallor
4. If medical therapies unsuccessful: mechanical assist devices
11. Rales / Crackles
(intra-aortic balloon pump), cardiac transplantation, or
12. Bronchial wheezing
mechanical heart may be employed
13. Pulsus Alternans: weak pulse followed by strong bounding
5. Treatment for Left Sided Heart Failure Only:
pulse
14. PMI is displaced laterally: due to cardiomegaly M – Morphine SO4

15. Possible S3: ventricular gallop A – Aminophylline

D – Digitalis
Dx D – Diuretics
1. Chest X-ray (CXR): reveals cardiomegaly O – O2
2. Pulmonary Arterial Pressure (PAP): measures pressure in
G – Gases
right ventricle or cardiac status: increased
3. Pulmonary Capillary Wedge Pressure (PCWP): measures end Nursing Intervention
systolic and dyastolic pressure: increased
Goal: Increase cardiac contractility thereby increasing cardiac
4. Central Venous Pressure (CVP): indicates fluid or hydration output of 3-6 L / min
status
• Increase CVP: decreased flow rate of IV 1. Monitor respiratory status & provide adequate ventilation
• Decrease CVP: increased flow rate of IV (when HF progress to pulmonary edema)

5. Swan-Ganz catheterization: cardiac catheterization a. Administer O2 therapy: high inflow 3-4 L / min delivered

6. Echocardiography: shows increased sized of cardiac via nasal cannula

chamber (cardiomyopathy): dependent on extent of heart b. Maintain client in semi or high fowlers position:
failure maximize oxygenation by promoting lung expansion

7. ABG: reveals PO2 is decreased (hypoxemia), PCO2 is c. Monitor ABG

increased (respiratory acidosis) d. Assess for breath sounds: noting any changes
2. Provide physical & emotional rest

Right Sided Heart Failure a. Constantly assess level of anxiety

b. Maintain bed rest with limited activity

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c. Maintain quiet & relaxed environment S/sx

d. Organized nursing care around rest periods 1. Intermittent claudication: leg pain upon walking
3. Increase cardiac output 2. Cold sensitivity & changes in skin color 1st white (pallor)
a. Administer digitalis as ordered & monitor effects changing to blue (cyanosis) then red (rubor)
• Cardiac glycosides: Digoxin (Lanoxin) 3. Decreased or absent peripheral pulses (posterior tibial &
• Action: Increase force of cardiac contraction dorsalis pedis)
4. Trophic changes
• Contraindication: If heart rate is decreased do not
5. Ulceration & Gangrene formation (advanced)
give
b. Monitor ECG & hemodynamic monitoring
Dx
c. Administer vasodilators as ordered
1. Oscillometry: may reveal decrease in peripheral pulse
• Vasodilators: Nitroglycerine (NTG)
volume
d. Monitor V/S
2. Doppler (UTZ): reveals decrease blood flow to the affected
4. Reduce / eliminate edema
extremity
a. Administer diuretics as ordered
3. Angiography: reveals location & extent of obstructive
• Loop Diuretics: Lasix (Furosemide)
process
b. Daily weight
c. Maintain accurate I&O
Medical Management
d. Assess for peripheral edema
1. Drug Therapy
e. Measure abdominal girth daily
a. Vasodilators: to improve arterial circulation
f. Monitor electrolyte levels
(effectiveness ?)
g. Monitor CVP & Swan-Ganz reading
• Papaverine
h. Provide Na restricted diet as ordered
i. Provide meticulous skin care • Isoxsuprine HCL (Vasodilan)

5. If acute pulmonary edema occurs: For Left Sided Heart • Nylidrin HCL (Arlidin)
Failure only • Nicotinyl Alcohol (Roniacol)
a. Administer Narcotic Analgesic as ordered
• Cyclandelate (Cyclospasmol)
• Narcotic analgesic: Morphine SO4
• Tolazoline HCL (Priscoline)
• Action: to allay anxiety & reduce preload & afterload
b. Analgesic: to relieve ischemic pain
b. Administer Bronchodilator as ordered
c. Anti-coagulant: to prevent thrombus formation
• Bronchodilators: Aminophylline IV
2. Surgery
• Action: relieve bronchospasm, increase urinary a. Bypass Grafting
output & increase cardiac output b. Endarterectomy
c. Administer Anti-arrythmic as ordered c. Balloon Catheter Dilation
• Anti-arrythmic: Lidocaine (Xylocane) d. Lumbar Sympathectomy: to increase blood flow
6. Assist in bloodless phlebotomy: rotating tourniquet, rotated e. Amputation: may be necessary
clockwise every 15 minutes: to promote decrease venous
return or reducing preload Nursing Intervention
7. Provide client teaching & discharge planning concerning: 1. Encourage a slow progressive physical activity

a. Need to monitor self daily for S/sx of Heart Failure (pedal • Walking at least 2 times / day
edema, weight gain, of 1-2 kg in a 2 day period, • Out of bed at least 3-4 times / day
dyspnea, loss of appetite, cough) 2. Administer medications as ordered
b. Medication regimen including name, purpose, dosage, • Analgesics
frequency & side effects (digitalis, diuretics) • Vasodilators
c. Prescribe diet plan (low Na, cholesterol, caffeine: small • Anti-coagulants
frequent meals) 3. Foot care management:
d. Need to avoid fatigue & plan for rest periods
• Need to avoid trauma to the affected extreminty
e. Prevent complications
4. Importance of stop smoking
• Arrythmia
5. Need to maintain warmth especially in cold weather
• Shock 6. Prepare client for surgery: below knee amputation (BKA)
• Right ventricular hypertrophy 7. Importance of follow-up care
• MI
• Thrombophlebitis Raynaud’s Phenomenon
f. Importance of follow-up care Intermittent episodes of arterial spasm most frequently
involving the fingers or digits of the hands
Peripheral Vascular Disorder
Predisposing Factors
Arterial Ulcer 1. High risk group: female between the teenage years & age
1. Thromboangiitis Obliterans (Buerger’s Disease) 40 years old & above
2. Raynaud’s Phenomenon 2. Smoking
3. Collagen diseases
Venous Ulcer a. Systemic Lupus Erythematosus (SLE): butterfly rash
1. Varicose Veins b. Rheumatoid Arthritis
2. Thrombophlebitis (deep vein thrombosis) 4. Direct hand trauma
a. Piano playing
Thromboangiitis Obliterans (Buerger’s Disease) b. Excessive typing
• Acute inflammatory disorder affecting the small / medium c. Operating chainsaw

sized arteries & veins of the lower extremities

• Occurs as focal, obstructive, process; result in occlusion of a S/sx

vessel with a subsequent development of collateral 1. Coldness

circulation 2. Numbness
3. Tingling in one or more digits

Predisposing Factors 4. Pain: usually precipitated by exposure to cold, Emotional

1. High risk groups - men 25-40 years old upset & Tobacco use

2. High incident among smokers 5. Intermittent color changes: pallor (white), cyanosis (blue),
rubor (red)

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6. Small ulceration & gangrene a tips of digits (advance) • Assess for increase of bleeding particularly in groin
area
Dx 7. Provide client teaching & discharge planning
1. Doppler UTZ: decrease blood flow to the affected extremity
2. Angiography: reveals site & extent of malocclusion
Thrombophlebitis (Deep vein thrombosis)

Medical Management • Inflammation of the vessel wall with formation of clot

1. Administer medications as ordered (thrombus), may affect superficial or deep veins
a. Catecholamine-depliting antihypertinsive drugs: • Inflammation of the veins with thrombus formation
• Reserpine • Most frequent veins affected are the saphenous, femoral &
• Guanethidine Monosulfate (Ismelin) popliteal
b. Vasodilators • Can result in damage to the surrounding tissue, ischemia &
Nursing Intervention necrosis
1. Importance of stop smoking
2. Need to maintain warmth especially in cold weather Predisposing Factors
3. Need to wear gloves when handling cold object / opening a 1. Obesity
freezer or refrigerator door 2. Smoking
3. Related to pregnancy
4. Severe anemia
5. Prolong use of oral contraceptives: promotes lipolysis
Varicose Veins 6. Prolonged immobility
• Dilated veins that occurs most often in the lower extremities 7. Trauma
& trunk. As the vessel dilates the valves become stretched 8. Dehydration
& incompetent with result venous pooling / edema 9. Sepsis
• Abnormal dilation of veins of lower extremities and trunks 10. Congestive heart failure

due to incompetent valve resulting to increased venous 11. Myocardial infarction

pooling resulting to venous stasis causing decrease venous 12. Post-op complication: surgery
return 13. Venous cannulation: insertion of various cardiac catheter
14. Increase in saturated fats in the diet.
Predisposing Factors
1. Hereditary S/sx
2. Congenital weakness of the veins 1. Pain in the affected extremity
3. Thrombophlebitis 2. Superficial vein: Tenderness, redness induration along
4. Cardiac disorder course of the vein
5. Pregnancy 3. Deep vein:
6. Obesity • Swelling
7. Prolonged standing or sitting • Venous distention of limb
• Tenderness over involved vein
S/sx
• Positive homan’s sign: pain at the calf or leg muscle
1. Pain after prolonged standing: relieved by elevation
upon dorsi flexion of the foot
2. Swollen dilated tortuous skin veins
• Cyanosis
3. Warm to touch
4. Heaviness in legs
Dx

Dx
1. Venography (Phlebography): increased uptake of radioactive
material
1. Venography
2. Trendelenburg Test: veins distends quickly in less than 35 2. Doppler ultrasonography: impairment of blood flow ahead of
thrombus
seconds
3. Doppler Ultrasound: decreased or no blood flow heard after 3. Venous pressure measurement: high in affected limb until
collateral circulation is developed
calf or thigh compression

Medical Management
Medical Management
1. Anti-coagulant therapy
1. Vein Ligation: involves ligating the saphenous vein where it
a. Heparin
joins the femoral vein & stripping the saphenous vein
system fro groin to ankles • Action: block conversion of prothrombin to thrombin

2. Sclerotherapy: can recur & only done in spider web & reduces formation or extension of thrombus

varicosities & danger of thrombosis (2-3 years for embolism) • Side effects:

• Spontaneous bleeding
Nursing Intervention • Injection site reaction
1. Elevate legs above heart level: to promote increased venous • Ecchymoses
return by placing 2-3 pillows under the legs
• Tissue irritation & sloughing
2. Measure the circumference of ankle & calf muscle daily: to
• Reversible transient alopecia
determine if swollen
• Cyanosis
3. Apply anti-embolic / knee-length stockings
• Pan in the arms or legs
4. Provide adequate rest
5. Administer medications as ordered • Thrombocytopenia

a. Analgesics: for pain b. Warfarin (Coumadin)

6. Prepare client for vein ligation if necessary • Action: block prothrombin synthesis by interfering

a. Provide routine pre-op care: usually OPD with vit. K synthesis

b. In addition to routine post-op care: • Side effects:

• Keep affected extremity elevated above the level of • GI:

the heart: to prevent edema • Anorexia

• Apply elastic bandage & stockings which should be • N/V
removed every 8 hours for short periods & reapplied • Diarrhea
• Assist out of bed within 24 hours ensuring the • Stomatitis
elastic stockings is applied
• Hypersensitivity:

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• Dermatitis • Swim several times weekly

• Urticaria • Gradually increased walking distance
• Pruritus g. Importance of weight reduction: if obese
• Fever h. Monitor for signs of complications

• Other: a. Pulmonary Embolism

• Sudden sharp chest pain
• Transient hair loss
• Unexplained dyspnea
• Burning sensation of feet
• Tachycardia
• Bleeding complication
• Palpitations
2. Surgery
a. Vein ligation & stripping • Diaphoresis

b. Venous thrombectomy: removal of cloth in the • Restlessness

iliofemoral region
c. Plication of the inferior vena cava: insertion of an Overview of Anatomy & Physiology of the Respiratory System

umbrella-like prosthesis into the lumen of the vena

cava: to filter incoming cloth Upper Respiratory System
Structure of the respiratory system, primarily an air
Nursing Intervention conduction system, include the nose, pharynx & larynx. Air

1. Elevate legs above heart level: to promote increase venous is filtered warmed & humidified in the upper airway before

return & decreased edema passing to lower airway.

2. Apply warm moist pack: to reduce lymphatic congestion

Nose
3. Administer anti-coagulant as ordered:
a. Heparin 1. External nose is a frame work of bone & cartilage , internally
divided into two passages or nares (nasal cavity) by the
• Monitor PTT: dosage should be adjusted to keep PTT
septum: air enters the system through the nares
between 1.5-2.5 times normal control level
2. The septum is covered with mucous membrane, where the
• Use infusion pump to administer heparin
olfactory receptors are located. Turbinates, located
• Ensure proper injection technique
internally, assist in warming & moistening the air
• Use 26 or 27 gauge syringe with ½-5/8 inch
3. The major function of the nose are warming, moistening &
needle, inject into fatty layer of abdomen above
filtering air.
iliac crest
4. Consist of anastomosis of capillaries known as Keissel Rach
• Avoid injecting within 2 inches of umbilicus
Plexus: the site of nose bleeding
• Insert needle at 45-90o to skin

• Do not withdraw plunger to assess blood return Pharynx

• Apply gentle pressure after removal of needle: 1. A muscular passageway commonly called the throat
avoid massage 2. Air passes through the nose to the pharynx

• Assess for increased bleeding tendencies 3. Serves as a muscular passageway for both food and air

(hematuria, hematemesis, bleeding gums,

petechiae of soft palate, conjunctiva retina, Composed of three section

ecchymoses, epistaxis, bloody spumtum, melena) & 1. Nasopharynx: located above the soft palate of the mouth,
instruct the client to observe for & report these contains the adenoids & opening to the eustachian tubes

• Have antidote (Protamine Sulfate) available 2. Oropharynx: located directly behind the mouth & tongue,
contains the palatine tonsils; air & food enter the body
• Instruct the client to avoid aspirin, antihistamines 7
through oropharynx
cough preparations containing glyceryl guaiacolate
3. Laryngopharynx: extends from the epiglotitis to the sixth
& obtain MD permission before using other OTC
cervical level
drugs
b. Warfarin (Coumadin)
Larynx
• Assess PT daily: dosage should be adjusted to
1. Sometimes called “voice Box” connects upper & lower
maintain PT at 1.5-2.5 times normal control level;
airways
INR of 2
2. Framework is formed by the hyoid bone, epiglotitis &
• Obtain careful medication history (there are many
thyroid, cricoid & arytenoids cartilages
drug-drug interaction) 3. Larynx opens to allow respiration & closes to prevent
• Advise client to withhold dose & notify MD aspiration when food passes through the pharynx
immediately if bleeding occur 4. Vocal cords of larynx permit speech & are involved in the
• Have antidote (Vitamin K) available cough reflex

• Alert client to factors that may affect the 5. For phonation (voice production)
anticoagulant response (high-fat diet or sudden Glottis
increased in vit. K-rich food) 1. Opening of larynx

• Instruct the client to wear medic-alert bracelet 2. Opens to allow passage of air

4. Assess V/S every 4 hours 3. Closes to allow passage of food going to the esophagus

5. Monitor chest pain or shortness of breath: possible 4. The initial sign of complete airway obstruction is the
inability to cough
pulmonary embolism
6. Measure thigh, calves, ankles & instep every morning
Lower Respiratory System
7. Provide client teaching & discharge planning
a. Need to avoid standing, sitting for long period, Consist of trachea, bronchi & branches, & the lungs &

constrictive clothing, crossing legs at the knee, smoking, associated structures

oral contraceptives For gas exchange

b. Importance of adequate hydration: to prevent

hypercoagubility Trachea

c. Use elastic stockings when ambulatory AKA “Windpipe”

d. Importance of planned rest periods with elevation of the Air move from the pharynx to larynx to trachea (length 11-
feet 13 cm, diameter 1.5-2.5 cm in adult)
e. Drug regimen Extend from the larynx to the second costal cartilage, where
f. Plan for exercise / activity it bifurcates & is supported by 16-20 C-shaped cartilage
• Begin with dorsiflexion of the feet while sitting or rings
lying down

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The area where the trachea divides into two branches is Form the last part of the airway
called the carina Functionally the same as the alveolar ducts they are
Consist of cartilaginous rings surrounded by alveoli & are responsible for the 65% of the
Serves as passageway of air going to the lungs alveolar gas exchange

Site of tracheostomy Type II Cells of Alveoli

Secretes surfactant

Bronchi Decrease surface tension

Right main bronchus Prevent collapse of alveoli

Larger & straighter than the left Composed of lecithin and spingomyelin

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
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
Lungs Inflammation of the alveolar spaces of the lungs, resulting in
Right lung (consist of 3 lobes, 10 segments) consolidation of lung tissue as the alveoli fill with exudates

Left lung (consist of 2 lobes, 8 segments) Inflammation of the lung parenchyma leading to pulmonary

Main organ of respiration, lie within the thoracic cavity on consolidation as the alveoli is filled with exudates

either side of the heart

Etiologic Agents
Broad area of lungs resting on diaphragm is called the base
& the narrow superior portion called the apex
1. Streptococcus Pneumonae: causing pneumococal
pneumonia

Pleura 2. Hemophylus Influenzae: causing broncho pneumonia

Serous membranes covering the lungs, continuous with the 3. Diplococcus Pneumoniae

parietal pleura that lines the chest wall 4. Klebsella Pneumoniae

5. Escherichia Pneumoniae

Parietal Pleura 6. Pseudomonas

Lines the chest walls & secretes small amounts of

High Risk Groups
lubricating fluid into the intrapleural space (space between
1. Children below 5 years old
the parietal pleura & visceral pleura) this fluid holds the
2. Elderly
lungs & chest wall together as a single unit while allowing
them to move separately
Predisposing Factors
1. Smoking
Chest Wall
2. Air pollution
Includes the ribs cage, intercostal muscles & diaphragm
3. Immuno compromised
Chest is a C shaped & supported by 12 pairs of ribs & costal
4. Related to prolonged immobility (CVA clients): causing
cartilages, the ribs have several attached muscles
hypostatic pneumonia
Contraction of the external intercostal muscles raises
5. Aspiration of food: causing aspiration pneumonia
the ribs cage during inspiration & helps increase the size
of the thoracic cavity
S/sx
The internal intercoastal muscles tends to pull ribs down
1. Productive cough with greenish to rusty sputum
& in & play a role in forced expiration
2. Rapid shallow respiration with expiratory grunt
3. Nasal flaring
Diaphragm
4. Intercostal rib retraction
A major muscle of ventilation (the exchange of air between
5. Use of accessory muscles of respiration
the atmosphere & the alveoli).
6. Dullness to flatness upon auscultation
7. Possible pleural friction rub
Alveoli
8. High-pitched bronchial breath sound
Are functional cellular unit of the lungs; about half arise
9. Rales / crackles (early) progressing to coarse (later)
directly from alveolar ducts & are responsible for about 35%
10. Fever
of alveolar gas exchange
11. Chills
Produces surfactants
12. Anorexia
Site of gas exchange (CO2 and O2) 13. General body malaise
Diffusion (Dalton’s law of partial pressure of gases) 14. Weight loss
15. Bronchial wheezing
Surfactant 16. Cyanosis

A phospholipids substance found in the fluid lining the 17. Chest pain

alveolar epithelium 18. Abdominal distention leading to paralytic ileus (absence of

Reduces surface tension & increase stability of the alveoli & peristalsis)

prevents their collapse

Dx

Alveolar Ducts 1. Sputum Gram Staining & Culture Sensitivity: positive to

Arises from the respiratory bronchioles & lead to the alveoli cultured microorganisms
2. Chest x-ray: reveals pulmonary consolidation over affected
Alveolar Sac area

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3. ABG analysis: reveals decrease PO2 Chills

4. CBC: reveals increase WBC, erythrocyte sedimentation rate Increased pain
is increased Difficulty in breathing
Weight loss
Nursing Intervention Persistent fatigue
1. Facilitate adequate ventilation f. Avoid smoking
Administer O2 as needed & assess its effectiveness: low g. Prevent complications
inflow Atelectasis
Place client semi fowlers position Meningitis
Turn & reposition frequently client who are immobilized h. Importance of follow up care
Administer analgesic as ordered: DOC: codeine: to
relieve pain associated with breathing Histoplasmosis
Auscultate breath sound every 2-4 hour Systemic fungal disease caused by inhalation of dust
Monitor ABG contaminated by histoplasma capsulatum which is
2. Facilitate removal of secretions transmitted to bird manure
General hydration Acute fungal infection caused by inhalation of contaminated

Deep breathing & coughing exercise: tends to promote dust or particles with histoplasma capsulatum derived from

expectoration birds manure

Tracheobronchial suctioning as needed

S/sx
Administer Mucolytic or Expectorant as ordered
1. Similar to PTB or Pneumonia
Aerosol treatment via nebulizer
2. Productive cough
Humidification of inhaled air
3. Fever, chills, anorexia, general body malaise
Chest physiotherapy (Postural Drainage): tends to
4. Chest and joint pains
promote expectoration
5. Dyspnea
3. Observe color characteristics of sputum & report any 6. Cyanosis
changes: encourage client to perform good oral hygiene 7. Hemoptysis
after expectoration 8. Sometimes asymptomatic
4. Provide adequate rest & relief control of pain
Enforce CBR with limited activity Dx
Limit visits & minimized conversation 1. Chest X-ray: often appears similar to PTB
Plan for uninterrupted rest periods 2. Histoplasmin Skin Test: positive
Maintain pleasant & restful environment 3. ABG analysis: PO2 decrease
5. Administer antibiotic as ordered: monitor effects & possible
toxicity Medical Management
Broad Spectrum Antibiotic 1. Anti-fungal Agent: Amphotericin B (Fungizone)
Penicillin
Very toxic: toxicity includes anorexia, chills, fever,
Tetracycline headaches & renal failure
Microlides (Zethromax) Acetaminophen, Benadryl & Steroids is given with
Azethromycin: Side Effect: Ototoxicity Amphotericin B: to prevent reaction
6. Prevent transmission: respiratory isolation client with
staphylococcal pneumonia Nursing Intervention
7. Control fever & chills: 1. Monitor respiratory status

Monitor temperature A 2. Enforce CBR

Administer antipyretic as ordered 3. Administer oxygen inhalation

4. Administer medications as ordered
Increased fluid intake
a. Antifungal: Amphotericin B (Fungizone)
Provide frequent clothing & linen changing
Observe severe side effects:
8. Assist in postural drainage: uses gravity & various position
to stimulate the movement of secretions Fever: acetaminophen given prophylactically

Anaphylactic reaction: Benadryl & Steroids given

Nursing Management for Postural Drainage prophylactically
a. Best done before meals or 2-3 hours: to prevent gastro Abnormal renal function with hypokalemia &
esophageal reflux azotemia: Nephrotoxicity, check for BUN and
b. Monitor vital signs Creatinine, Hypokalemia
c. Encourage client deep breathing exercises 5. Force fluids to liquefy secretions
d. Administer bronchodilators 20-30 minutes before 6. Nebulize & suction as needed
procedure 7. Prevent complications: bronchiectasis
e. Stop if client cannot tolerate procedure 8. Prevent the spread of infection by spraying of breeding
f. Provide oral care after procedure places
g. Contraindicated with
Unstable V/S Chronic Obstructive Pulmonary Disease (COPD)
Hemoptysis

Clients with increase intra ocular pressure (Normal Chronic Bronchitis

IOP 12 – 21 mmHg) Excessive production of mucus in the bronchi with

Increase ICP accompanying persistent cough

9. Provide increase CHO, calories, CHON & vitamin C Characteristic include hypertrophy / hyperplasia of the
10. Provide client teaching & discharge planning mucus secreting gland in the bronchi, decreased ciliary
a. Medication regimen / antibiotic therapy activity, chronic inflammation & narrowing of the airway
b. Need for adequate rest, limited activity, good nutrition, Inflammation of bronchus resulting to hypertrophy or
with adequate fluid intake & good ventilation hyperplasia of goblet mucous producing cells leading to
c. Need to continue deep breathing & coughing exercise narrowing of smaller airways
for at least 6-8 weeks after discharge AKA “Blue Bloaters”
d. Availability of vaccines
e. Need to report S/sx of respiratory infection Predisposing Factors
Persistent or recurrent fever 1. Smoking
Changes in characteristics color of sputum 2. Air pollution

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c. Mucomysts (acetylceisteine): at bed side put suction

S/sx machine
1. Productive copious cough (consistent to all COPD) d. Mucolytics / expectorants
2. Dyspnea on exertion e. Anti histamine
3. Use of accessory muscle of respiration 2. Physical Therapy
4. Scattered rales / rhonchi 3. Hyposensitization
5. Feeling of gastric fullness 4. Execise
6. Slight Cyanosis Nursing Intervention
7. Distended neck veins 1. Enforce CBR
8. Ankle edema 2. O2 inhalation: low flow 2-3 L/min: to prevent respiratory
9. Prolonged expiratory grunt distress
10. Anorexia and generalized body malaise 3. Administer medications as ordered
11. Pulmonary hypertension 4. Force fluids 2-3 L/day
a. Leading to peripheral edema 5. Semi fowlers position: to promote lung expansion
b. Cor Pulmonale (right ventricular hypertrophy) 6. Nebulize & suction when needed
7. Provide client health teachings and discharge planning
Dx concerning
1. ABG analysis: reveals PO2 decrease (hypoxemia): causing a. Avoidance of precipitating factor
cyanosis, PCO2 increase b. Prevent complications
Emphysema
Bronchial Asthma Status Asthmaticus: severe attack of asthma which
Immunologic / allergic reaction results in histamine release cause poor controlled asthma
which produces three mainairway response: Edema of DOC: Epinephrine
mucus membrane, Spasm of the smooth muscle of bronchi Steroids
& bronchioles, Accumulation of tenacious secretions Bronchodilators
Reversible inflammatory lung condition due to c. Regular adherence to medications: to prevent
hypersensitivity to allergens leading to narrowing of smaller development of status asthmaticus
airways d. Importance of follow up care

Predisposing Factors (Depending on Types) Bronchiectasis

1. Extrinsic Asthma (Atopic / Allergic) Permanent abnormal dilation of the bronchi with destruction
Causes of muscular & elastic structure of the bronchial wall
Pollen Abnormal permanent dilation of bronchus leading to
Dust destruction of muscular and elastic tissues of alveoli
Fumes
Smoke Predisposing Factors
Gases 1. Caused by bacterial infection

Danders 2. Recurrent lower respiratory tract infections

Furs 3. Chest trauma

Lints
4. Congenital defects (altered bronchial structure)
5. Related to presence of tumor (lung tumor)

2. Intrinsic Asthma (Non atopic / Non allergic) 6. Thick tenacious secretion

Causes
Sx
Hereditary
1. Productive cough with mucopurulent sputum
Drugs (aspirin, penicillin, beta blocker)
2. Dyspnea in exertion
Foods (seafoods, eggs, milk, chocolates, chicken)
3. Cyanosis
Food additives (nitrates) 4. Anorexia & generalized body malaise
Sudden change in temperature, air pressure and 5. Hemoptysis (only COPD with sign)
humidity 6. Wheezing
Physical and emotional stress 7. Weight loss

3. Mixed Type: 90 – 95% Dx

1. CBC: elevation in WBC
S/sx 2. ABG: PO2 decrease
1. Cough that is non productive 3. Bronchoscopy: reveals sources & sites of secretion: direct
2. Dyspnea visualization of bronchus using fiberscope
3. Wheezing on expiration
4. Cyanosis Nursing Management before Bronchoscopy
5. Mild Stress or apprehension 1. Secure inform consent and explain procedure to client
6. Tachycardia, palpitations 2. Maintain NPO 6-8 hours prior to procedure
7. Diaphoresis 3. Monitor vital signs & breath sound

Dx Post Bronchoscopy
1. Pulmonary Function Test Incentive spirometer: reveals 1. Feeding initiated upon return of gag reflex
decrease vital lung capacity 2. Avoid talking, coughing and smoking, may cause irritation
2. ABG analysis: PO2 decrease 3. Monitor for signs of gross
3. Before ABG test for positive Allens Test, apply direct 4. Monitor for signs of laryngeal spasm: prepare tracheostomy
pressure to ulnar & radial artery to determine presence of set
collateral circulation

Medical Management
Medical Management
1. Surgery
1. Drug Therapy
Pneumonectomy: 1 lung is removed & position on
a. Bronchodilators: given via inhalation or metered dose
affected side
inhaler or MDI for 5 minutes
Segmental Wedge Lobectomy: promote re-expansion of
b. Steroids: decrease inflammation: given 10 min after
lungs
bronchodilator
Unaffected lobectomy: facilitate drainage

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4. Facilitate removal of secretions:

Emphysema a. Force fluids at least 3 L/day
Enlargement & destruction of the alveolar, bronchial & b. Provide chest physiotherapy, coughing & deep breathing
bronchiolar tissue with resultant loss of recoil, air tapping, c. Nebulize & suction when needed
thoracic overdistension, sputum accumulation & loss of d. Provide oral hygiene after expectoration of sputum
diaphragmatic muscle tone 5. Improve ventilation
These changes cause a state of CO2 retention, hypoxia & a. Position client to semi or high fowlers
respiratory acidosis b. Instruct the client diaphragmatic muscles to breathe
Irreversible terminal stage of COPD characterized by c. Encourage productive cough after all treatment (splint
Inelasticity of alveoli abdomen to help produce more expulsive cough)

Air trapping d. Employ pursed-lip breathing techniques (prolonged slow

Maldistribution of gases relaxed expiration against pursed lips)
e. Institute pulmonary toilet
Overdistention of thoracic cavity (barrel chest)
6. Institute PEEP (positive end expiratory pressure) in
mechanical ventilation promotes maximum alveolar lung
Predisposing Factors
expansion
1. Smoking
7. Provide comfortable & humid environment
2. Inhaled irritants: air pollution
8. Provide high carbohydrates, protein, calories, vitamins and
3. Allergy or allergic factor
minerals
4. High risk: elderly
9. Provide client teachings and discharge planning concerning
5. Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to
a. Prevention of recurrent infection
release elastase for recoil of alveoli
Avoid crowds & individual with known infection
Adhere to high CHON, CHO & increased vit C diet
S/sx
1. Productive cough Received immunization for influenza & pneumonia

2. Sputum production Report changes in characteristic & color of sputum

3. Anorexia & generalized body malaise immediately

4. Weight loss Report of worsening of symptoms (increased

5. Flaring of nostrils (alai nares) tightness of chest, fatigue, increased dyspnea)

6. Use of accessory muscles b. Control of environment

7. Dyspnea at rest Use home humidifier at 30-50%

8. Increased rate & depth of breathing Wear scarf over nose & mouth in cold weather: to
9. Decrease respiratory excursion prevent bronchospasm
10. Resonance to hyper resonance Avoid smoking & contact with environmental smoke
11. Decrease or diminished breath sounds with prolong Avoid abrupt change in temperature
expiration c. Avoidance of inhaled irritants
12. Decrease tactile fremitus Stay indoor: if pollution level is high
13. Prolong expiratory grunt Use air conditioner with efficiency particulate air
14. Rales or rhonchi filter: to remove particles from air
15. Bronchial wheezing d. Increase activity tolerance
16. Barrel chest Start with mild exercise: such as walking & gradual
17. Purse lip breathing: to eliminates excess CO2 (compensatory increase in amount & duration
mechanism) Used breathing techniques: (pursed lip,
diaphragmatic) during activities / exercise: to control
Dx breathing
1. Pulmonary Function Test: reveals decrease vital lung Have O2 available as needed to assist with activities
capacity
Plan activities that require low amount of energy
2. ABG analysis: reveals
Plan rest period before & after activities
Panlobular/centrilobular e. Prevent complications
Decrease PO2 (hypoxemia leading to chronic Atelectasis
bronchitis, “Blue Bloaters”) Cor Pulmonale: R ventricular hypertrophy
Decrease ph
CO2 narcosis: may lead to coma
Increase PCO2
Pneumothorax: air in the pleural space
Respiratory acidosis f. Strict compliance to medication
Panacinar/centriacinar g. Importance of follow up care
Increase PO2 (hyperaxemia, “Pink Puffers”)
Decrease PCO2 Oncology Nursing
Increase ph Pathophysiology & Etiology of Cancer
Respiratory alkalosis Evolution of Cancer Cells
• All cells constantly change through growth, degeneration,
Nursing Intervention repair, & adaptation. Normal cells must divide & multiply to
1. Enforce CBR meet the needs of the organism as a whole, & this cycle of
2. Administer oxygen inhalation via low inflow cell growth & destruction is an integral part of life
3. Administer medications as ordered processes. The activities of the normal cell in the human
a. Bronchodilators: used to treat bronchospam body are all coordinated to meet the needs of the organism
Aminophylline as a whole, but when the regulatory control mechanisms of

Isoproterenol (Isuprel) normal fail, & growth continues in excess of the body needs,

Terbutalin (Brethine) neoplasia results.

Metaproterenol (Alupent) • The term neoplasia refers to both benign & malignant
growths, but malignant cells behave very differently from
Theophylline
normal cells & have special features characteristics of the
Isoetharine (Bronkosol)
cancer process.
b. Corticosteroids:
• Since the growth control mechanism of normal cells is
Prednisone
c. Anti-microbial / Antibiotics: to treat bacterial infection not entirely understood, it is not clear what allows the

Tetracycline uncontrolled growth, therefore no definitive cure has

Ampicilline been found.

d. Mucolytics / expectorants

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Characteristics of Malignant Cells • Probably normal (slight changes)

• Cancer cells are mutated stem cells that have undergone
• Doubtful (more severe changes)
structural changes so that they are unable to perform the
• Probably cancer or precancerous
normal functions of specialized tissues.
• Definitely cancer
• They may function is a disorderly way to crease normal
Client Factors
function completely, only functioning for their own survival
1. Seven warning signs of cancer
& growth.
2. BSE – breast self – examination
• The most undifferentiated cells are also called anaplastic.
3. Importance of retal exam for those over age 40
4. Hazards of smoking
Rate of Growth
5. Oral self – examination as well as annual exam of mouth
• Cancer cells have uncontrolled growth or cell division
& teeth
• Rate at which a tumor grows involves both increased cell
6. Hazards of excess sun exposure
division & increased survival time of cells.
7. Importance of pap smear
• Malignant cells do not form orderly layers, but pile on top of
8. P.E. with lab work – up: every 3 years ages 20-40; yearly
each other to eventually form tumors. for age 40 & over
9. TSE – testicular self – examination
Pre-disposing Factors
• Testicular Cancer
• G – Genetics
i. Most common cancer in men between
• Some cancers shows familial pattern
the age of 15 & 34
• Maybe caused by inherited genetics defects • Warning signs that men should look for:
• I – Immunologic i. Painless swelling
• Failure of the immune system to respond & eradicate ii. Feeling of heaviness
cancer cells iii. Hard lump (size of a pea)
• Immunosuppressed individuals are more susceptible to iv. Sudden collection fluid in the scrotum
cancer v. Dull ache in the lower abdomen or in the
• V – Viral groin
o Viruses have been shown to be the cause of certain vi. Pain in the testicle or in the scrotum

tumors in animals vii. Enlargement or tenderness of the

o Viruses ( HTLV-I, Epstein Barr Virus, Human breasts

Papilloma Virus) linked to human tumors

7 Warning Signs of Cancer
o Oncovirus (RNA – Type Viruses) thought to be culprit
C: change in bowel or bladder habits
• E – Environmental
A: a sore that doesn’t heal
o Majority (over 80%) of human cancer related to
U: unusual bleeding or discharge
environmental carcinogens
T: thickening of lump in breast or elsewhere
o Types:
I: indigestion or dysphagia
Physical
O: obvious change in wart or mole
• Radiation: X – ray, radium, nuclear
N: nagging cough or hoarseness
explosion & waste, UV
• Trauma or chronic irritation
Treatment of Cancer
Chemical Therapeutic Modality
• Nitrates, & food additives, polycyclic
hydrocarbons, dyes, alkylating Chemotherapy
agents
• Drugs: arsenicals, stilbestol, • Ability of the drug to kill cancer cells; normal cells may also
urethane be damaged, producing side effects.
• Cigarette smoke • Different drug act on tumor cell in different stages of the cell
• hormones growth cycle.
Classification of Cancer
Tissue Typing: Types of Chemotherapeutic Drugs

• Carcinoma – arises from surface, glandular, or parenchymal

epithelium 1. Antimetabolites
1. Squamous Cell Carcinoma – surface epithelium o Foster cancer cell death by interfering with cellular

2. Adenocarcinoma – glandular or parenchymal tissue metabolic process.

2. Alkylating Agent
• Sarcoma – arises from connective tissue
o act with DNA to hinder cell growth & division.
• Leukemia – from blood
3. Plant Alkaloids
• Lymphoma – from lymph glands o obtained from periwinkle plant.
• Multiple Myeloma – from bone marrow o makes the host’s body a less favorable environment

Stages of Tumor Growth for the growth of cancer cells.

A. Staging System: 4. Antitumor Antibiotics

• TNM System: uses letters & numbers to designate the o affect RNA to make environment less favorable for

extent of tumors cancer growth.

o T– stands for primary growth; 1-4 with increasing 5. Steroids & Sex Hormones
o alter the endocrine environment to make it less
size; T1S indicates carcinoma in situ
o N – stands for lymph nodes involvement: 0-4 conducive to growth of cancer cells.

indicates progressively advancing nodal disease

Major Side Effects & Nursing Intervention
o M – stands for metastasis; 0 indicates no distant
metastases, 1 indicates presence of metastases
A. GI System
• Stages 0 – IV: all cancers divided into five stages
incorporating size, nodal involvement & spread
• Nausea & Vomiting
o Administer antiemetics routinely q 4-6 hrs as well as
B. Cytologic Diagnosis of Cancer
prophylactically before chemotherapy is initiated.
1. Involves in the study of shed cells (ex. Pap smear)
o Withhold food/fluid 4-6 hrs before chemotherapy
2. Classified by degree of cellular abnormality
o Provide bland food in small amounts after treatment
• Normal

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• Diarrhea
o Administer antidiarrheals.
o Maintain good perineal care.
o Give clear liquids as tolerated.
o Monitor K, Na, Cl levels.
• Stomatitis (mouth sore)
o Provide & teach the client good oral hygiene,
including avoidance of commercial mouthwashes.
o Rinse with viscous lidocaine before meals to provide
analgesic effect.
o Perform a cleansing rinse with plain H2O or dilute a
H2O soluble lubricant such as hydrogen peroxide
after meal.
o Apply H2O lubricant such as K-Y jelly to lubricate
cracked lips.
o Advice client to suck on Popsicles or ice chips to
provide moisture.
B. Hematologic System
• Thrombocytopenia
o Avoid bumping or bruising the skin.
o Protect client from physical injury.
o Avoid aspirin or aspirin products.
o Avoid giving IM injections.
o Monitor blood counts carefully.
o Assess for signs of increase bleeding tendencies
(epistaxis, petechiae, ecchymoses)
• Leukopenia
o Use careful handwashing technique.
o Maintain reverse isolation if WBC count drops below
1000/mm
o Assess for signs of respiratory infection
o Avoid crowds/persons with known infection
• Anemia
o Provide adequate rest period
o Monitor hemoglobin & hematocrit
o Protect client from injury
o Administer O2 if needed
C. Integumentary System
• Alopecia
o Explain that hair loss is not permanent
o Offer support & encouragement
o Scalp tourniquets or scalp hypothermia via ice pack
may be ordered to minimize hair loss with some
agent
o Advice client to obtain wig before initiating
treatment
D. Renal System
• Encourage fluid & frequent voiding to prevent accumulation
of metabolites in bladder; R: may cause direct damage to
kidney by excretion of metabolites.
• Increased excretion of uric acid may damage kidney
• Administer allopurinol (Zyloprim) as ordered; R: to prevent
uric acid formation; encourage fluids when administering
allopurinol
E. Reproductive System
• Damage may occur to both men & women resulting
infertility &/or mutagenic damage to chromosomes
• Banking sperm often recommended for men before
chemotherapy
• Clients & partners advised to use reliable methods of
contraception during chemotherapy
F. Neurologic System
53
• Plant alkaloids (vincristine) cause neurologic damage with
repeated doses
• Peripheral neuropathies, hearing loss, loss of deep tendon
reflex, & paralytic ileus may occur.
Radiation Therapy
• Uses ionizing radiation to kill or limit the growth of cancer
cells, maybe internal or external.
• It not only injured cell membrane but destroy & alter DNA so
that the cell cannot reproduce.
• Effects cannot be limited to cancer cells only; all exposed
cells including normal cells will be injured causing side
effects.
• Localized effects are related to the area of the body being
treated; generalized effects maybe related to cellular
breakdown products.
Types of Energy Emitted
• Alpha – particles cannot passed through skin, rarely used.
• Beta – particle cannot passed through skin, more
penetrating than alpha, generally emitted from radioactive
isotopes, used for internal source.
• Gamma – penetrate more deeper areas of the body, most
common form of external radiotherapy (ex. Electromagnetic
or X-ray)
Methods of Delivery
• External Radiation Therapy – beams high energy rays
directly to the affected area. Ex. Cobalt therapy
• Internal Radiation Therapy – radioactive material is injected
or implanted in the client’s body for designated period of
time.
o Sealed Implants – a radioisotope enclosed in a
container so it does not circulate in the body;
client’s body fluids should not be contaminated.
o Unsealed source – a radioisotope that is not encased
in a container & does circulate in the body &
contaminate body fluids.
Factors Controlling Exposure
• Half-life – time required for half of radioactive atoms to
decay.
1. Each radioisotope has different half-life.
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.
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• Monitor electrolytes particularly Na, K, Cl 1. Synarthroses: immovable joints

D. Anemia, Leukopenia, Thrombocytopenia 2. Amphiarthroses: partially movable joints
• Isolate from those with known infection. 3. Diarthroses (synovial): freely movable joints
• Provide frequent rest period. • Have a joint cavity (synovial cavity) between the
• Encourage high CHON diet. articulating bone surfaces
• Avoid injury. • Articular cartilage covers the ends of the bones
• Assess for bleeding. • A fibrous capsule encloses the joint
• Monitor CBC, WBC, & platelets. • Capsule is lined with synovial membrane that secretes
synovial fluid to lubricate the joint and reduce friction.
Burns Muscles

• direct tissue injury caused by thermal, electric, chemical & • Functions of Muscles

smoke inhaled (TECS) • Provide shape to the body

Type: • Protect the bones
1. Thermal • Maintain posture
2. Smoke Inhalation
• Cause movement of body parts by contraction
3. Chemical
• Types of Muscles
4. Electrical
• Cardiac: involuntary; found only in heart

Classification • Smooth: involuntary; found in walls of hollow structures

• Partial Thickness (e.g. intestines)

1. Superficial partial thickness (1st degree) • Striated (skeletal): voluntary

Depth: epidermis only

Causes: sunburn, splashes of hot liquid 1. Characteristics of skeletal muscles

Sensation: painful • Muscles are attached to the skeleton at the point of

origin and to bones at the point of insertion.
Characteristics: erythema, blanching on
pressure, no vesicles • Have properties of contraction and extension, as

2. Deep Partial Thickness (2nd degree) well as elasticity, to permit isotonic (shortening and
thickening of the muscle) and isometric (increased
Depth: epidermis & dermis
muscle tension) movement.
Causes: flash, scalding, or flame burn
• Contraction is innervated by nerve stimulation.
Sensation: very painful
Characteristics: fluid filled vesicles; red,
Cartilage
shinny, wet after vesicles ruptures
• A form of connective tissue
• Full Thickness (3rd & 4th degree)
• Major functions are to cushion bony prominences and offer
1. Depth: all skin layers & nerve endings; may involve
protection where resiliency is required
muscles, tendons & bones
2. Causes: flames, chemicals, scalding, electric current
Tendons and Ligaments
3. Sensation: little or no pain
• Composed of dense, fibrous connective tissue
4. Characteristics: wound is dry, white, leathery, or
• Functions
hard
1. Ligaments attach bone to bone

Overview Of Anatomy & Physiology Of Musculoskeletal System 2. Tendons attach muscle to bone

• Consist of bones, muscles, joints, cartilages, tendons,

Rheumatoid Arthritis (RA)
ligaments, bursae
• Chronic systemic disease characterized by inflammatory
• To provide a structural framework for the body
changes in joints and related structures.
• To provide a means for movement
• Joint distribution is symmetric (bilateral): most commonly
affects smaller peripheral joints of hands & also commonly
Bones
involves wrists, elbows, shoulders, knees, hips, ankles and
• Function of Bones
jaw.
• Provide support to skeletal framework
• If unarrested, affected joints progress through four stages of
• Assist in movement by acting as levers for muscles
deterioration: synovitis, pannus formation, fibrous ankylosis,
• Protect vital organ & soft tissue
and bony ankylosis.
• Manufacture RBC in the red bone marrow Cause
(hematopoiesis) 1. Cause unknown or idiopathic
• Provide site for storage of calcium & phosphorus 2. Maybe an autoimmune process
1. Types of Bones 3. Genetic factors
• Long Bones 4. Play a role in society (work)
• Central shaft (diaphysis) made of compact bone &
two end (epiphyses) composed of cancellous bones Predisposing factors
(ex. Femur & humerus) 1. Occurs in women more often than men (3:1) between the
• Short Bones ages 35-45.

• Cancellous bones covered by thin layer of compact 2. Fatigue

bone (ex. Carpals & tarsals) 3. Cold

• Flat Bones 4. Emotional stress

5. Infection
• Two layers of compact bone separated by a layer of
cancellous bone (ex. Skull & ribs)
S/sx
• Irregular Bones
1. Fatigue
• Sizes and shapes vary (ex. Vertebrae & mandible) 2. Anorexia & body malaise
3. Weight loss
Joints 4. Slight elevation in temperature
• Articulation of bones occurs at joints 5. Joints are painful: warm, swollen, limited in motion, stiff in
• Movable joints provide stabilization and permit a variety of morning & after a period of inactivity & may show crippling
movements deformity in long-standing disease.
6. Muscle weakness secondary to inactivity
Classification 7. History of remissions and exacerbations

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8. Some clients have additional extra-articular manifestations: b. Maintain proper body alignment.
subcutaneous nodules; eye, vascular, lung, or cardiac c. Have client lie prone for ½ hour twice a day.
problems. d. Avoid pillows under knees.
e. Keep joints mainly in extension, not flexion.
Dx f. Prevent complications of immobility.
1. X-rays: shows various stages of joint disease 6. Provide heat treatments: warm bath, shower or whirlpool;
2. CBC: anemia is common warm, moist compresses; paraffin dips as ordered.

3. ESR: elevated a. May be more effective in chronic pain.

b. Reduce stiffness, pain & muscle spasm.
4. Rheumatoid factor positive
7. Provide cold treatments as ordered: most effective during
5. ANA: may be positive
acute episodes.
6. C-reactive protein: elevated
8. Provide psychologic support and encourage client to express
feelings.
Medical Management
9. Assists clients in setting realistic goals; focus on client
1. Drug therapy
strengths.
a. Aspirin: mainstay of treatment: has both analgesic and
10. Provide client teaching & discharge planning & concerning.
anti-inflammatory effect.
a. Use of prescribed medications & side effects
b. Nonsteroidal anti-inflammatory drugs (NSAIDs): relieve
b. Self-help devices to assist in ADL and to increase
pain and inflammation by inhibiting the synthesis of
independence
prostaglandins.
c. Importance of maintaining a balance between activity &
• Ibuprofen (Motrin)
rest
• Indomethacin (Indocin) d. Energy conservation methods
• Fenoprofen (Nalfon) e. Performance of ROM, isometric & prescribed exercises
f. Maintenance of well-balanced diet
• Mefenamic acid (Ponstel)
g. Application of resting splints as ordered
• Phenylbutazone (Butazolidin)
h. Avoidance of undue physical or emotional stress
• Piroxicam (Feldene) i. Importance of follow-up care
• Naproxen (Naprosyn)
Osteoarthritis
• Sulindac (Clinoril)
Chronic non-systemic disorder of joints characterized by
c. Gold compounds (Chrysotherapy)
degeneration of articular cartilage
• Injectable form: given IM once a week; take 3-6
Weight-bearing joints (spine, knees and hips) & terminal
months to become effective
interphalangeal joints of fingers most commonly affected
• Sodium thiomalate (Myochrysine)

• Aurothioglucose (Solganal) Incident Rate

• SI: monitor blood studies & urinalysis 1. Women & men affected equally

frequently 2. Incidence increases with age

• Proteinuria
Predisposing Factors
• Mouth ulcers
1. Most important factor in development is aging (wear & tear
• Skin rash
on joints)
• Aplastic anemia.
2. Obesity
• Oral form: smaller doses are effective; take 3-6
3. Joint trauma
months to become effective
• Auranofin (Ridaura) S/sx
• SI: blood & urine studies should be 1. Pain: (aggravated by use & relieved by rest) & stiffness of
monitored. joints
• Diarrhea 2. Heberden’s nodes: bony overgrowths at terminal
d. Corticosteroids interphalangeal joints

• Intra-articular injections: temporarily suppress 3. Decreased ROM with possible crepitation (grating sound
inflammation in specific joints. when moving joints)

• Systemic administration: used only when client does

Dx
not respond to less potent anti-inflammatory drugs.
1. X-rays: show joint deformity as disease progresses
e. Methotrexate: given to suppress immune response
2. ESR: may be slightly elevated when disease is inflammatory
• Cytoxan

• SI: bone marrow suppression.

Nursing Interventions
2. Physical therapy: to minimize joint deformities.
1. Assess joints for pain & ROM.
3. Surgery: to remove severely damaged joints (e.g. total hip 2. Relieve strain & prevent further trauma to joints.
replacement; knee replacement). a. Encourage rest periods throughout day.
b. Use cane or walker when indicated.
Nursing Interventions c. Ensure proper posture & body mechanics.
1. Assess joints for pain, swelling, tenderness & limitation of d. Promote weight reduction: if obese
motion.
e. Avoid excessive weight-bearing activities & continuous
2. Promote maintenance of joint mobility and muscle strength.
standing.
a. Perform ROM exercises several times a day: use of heat
3. Maintain joint mobility and muscle strength.
prior to exercise may decrease discomfort; stop exercise
a. Provide ROM & isometric exercises.
at the point of pain.
b. Ensure proper body alignment.
b. Use isometric or other exercise to strengthen muscles.
c. Change client’s position frequently.
3. Change position frequently: alternate sitting, standing & 4. Promote comfort / relief of pain.
lying. a. Administer medications as ordered:
4. Promote comfort & relief / control of pain. Aspirin & NSAID: most commonly used
a. Ensure balance between activity & rest.
Corticosteroids (Intra-articular injections): to relieve
b. Provide 1-2 scheduled rest periods throughout day.
pain & improve mobility.
c. Rest & support inflamed joints: if splints used: remove 1- b. Apply heat or ice as ordered (e.g. warm baths,
2 times/day for gentle ROM exercises.
compresses, hot packs): to reduce pain.
5. Ensure bed rest if ordered for acute exacerbations.
5. Prepare client for joint replacement surgery if necessary.
a. Provide firm mattress.

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6. Provide client teaching and discharge planning concerning 1. Occurs most frequently in young women
a. Used of prescribed medications and side effects
b. Importance of rest periods Predisposing Factors
c. Measures to relieve strain on joints 1. Cause unknown
d. ROM and isometric exercises 2. Immune
e. Maintenance of a well-balanced diet 3. Genetic & viral factors have all been suggested
f. Use of heat/ice as ordered.
Pathophysiology
1. A defect in body’s immunologic mechanisms produces
Gout autoantibodies in the serum directed against components of
A disorder of purine metabolism; causes high levels of uric the client’s own cell nuclei.
acid in the blood & the precipitation of urate crystals in the 2. Affects cells throughout the body resulting in involvement of
joints many organs, including joints, skin, kidney, CNS &
Inflammation of the joints caused by deposition of urate cardiopulmonary system.
crystals in articular tissue
S/sx
Incident Rate 1. Fatigue
1. Occurs most often in males 2. Fever
2. Familial tendency 3. Anorexia
4. Weight loss
S/sx 5. Malaise
1. Joint pain 6. History of remissions & exacerbations
2. Redness 7. Joint pain
3. Heat 8. Morning stiffness
4. Swelling 9. Skin lesions

5. Joints of foot (especially great toe) & ankle most commonly Erythematous rash on face, neck or extremities may
affected (acute gouty arthritis stage) occur
6. Headache Butterfly rash over bridge of nose & cheeks
7. Malaise Photosensitivity with rash in areas exposed to sun
8. Anorexia 10. Oral or nasopharyngeal ulcerations
9. Tachycardia 11. Alopecia
10. Fever 12. Renal system involvement
11. Tophi in outer ear, hands & feet (chronic tophaceous stage) Proteinuria
Hematuria
Dx Renal failure
1. CBC: uric acid elevated 13. CNS involvement
Peripheral neuritis
Medical Management Seizures
1. Drug therapy
Organic brain syndrome
a. Acute attack:
Psychosis
Colchicine IV or PO: discontinue if diarrhea occurs
14. Cardiopulmonary system involvement
NSAID: Indomethacin (Indocin)
Pericarditis
Naproxen (Naprosyn)
Pleurisy
Phenylbutazone (Butazolidin) 15. Increase susceptibility to infection
b. Prevention of attacks
Uricosuric agents: increase renal excretion of uric Dx
acid 1. ESR: elevated
Probenecid (Benemid)
2. CBC: RBC anemia, WBC & platelet counts decreased
Sulfinpyrazone (Anturanel)
3. Anti-nuclear antibody test (ANA): positive
Allopurinal (Zyloprim): inhibits uric acid formation
4. Lupus Erythematosus (LE prep): positive
2. Low-purine diet may be recommended
5. Anti-DNA: positive
3. Joint rest & protection
6. Chronic false-positive test for syphilis
4. Heat or cold therapy

Medical Management
Nursing Interventions
1. Drug therapy
1. Assess joints for pain, motion & appearance.
a. Aspirin & NSAID: to relieve mild symptoms such as fever
2. Provide bed rest & joint immobilization as ordered.
& arthritis
3. Administer anti-gout medications as ordered.
b. Corticosteroids: to suppress the inflammatory response
4. Administer analgesics as ordered: for pain
in acute exacerbations or severe disease
5. Increased fluid intake to 2000-3000 ml/day: to prevent
c. Immunosuppressive agents: to suppress the immune
formation of renal calculi.
response when client unresponsive to more
6. Apply local heat or cold as ordered: to reduce pain
conservative therapy
7. Apply bed cradle: to keep pressure of sheets off joints.
Azathioprine (Imuran)
8. Provide client teaching and discharge planning concerning
Cyclophosphamide (Cytoxan)
a. Medications & their side effects
2. Plasma exchange: to provide temporary reduction in amount
b. Modifications for low-purine diet: avoidance of shellfish,
of circulating antibodies.
liver, kidney, brains, sweetbreads, sardines, anchovies
c. Limitation of alcohol use 3. Supportive therapy: as organ systems become involved.

d. Increased in fluid intake

e. Weight reduction if necessary Nursing Interventions

f. Importance of regular exercise 1. Assess symptoms to determine systems involved.

2. Monitor vital signs, I&O, daily weights.

Systemic Lupus Erythematosus (SLE) 3. Administer medications as ordered.

Chronic connective tissue disease involving multiple organ 4. Institute seizure precautions & safety measures: with CNS
systems involvement.
5. Provide psychologic support to client / significant others.

Incident Rate 6. Provide client teaching & discharge planning concerning

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a. Disease process & relationship to symptoms • Salivary gland: located in the mouth produce secretion
b. Medication regimen & side effects. containing pyalin for starch digestion & mucus for
c. Importance of adequate rest. lubrication
d. Use of daily heat & exercises as prescribed: for arthritis. • Pharynx: aids in swallowing & functions in ingestion by
e. Need to avoid physical or emotional stress providing a route for food to pass from the mouth to the
f. Maintenance of a well-balanced diet esophagus
g. Need to avoid direct exposure to sunlight: wear hat &
other protective clothing Esophagus
h. Need to avoid exposure to persons with infections • Muscular tube that receives foods from the pharynx &
i. Importance of regular medical follow-up propels it into the stomach by peristalsis
j. Availability of community agencies

Stomach
• Located on the left side of the abdominal cavity occupying
Osteomyelitis
the hypochondriac, epigastric & umbilical regions
Infection of the bone and surrounding soft tissues, most • Stores & mixes food with gastric juices & mucus producing
commonly caused by S. aureus. chemical & mechanical changes in the bolus of food
Infection may reach bone through open wound (compound • The secretion of digestive juice is stimulated by
fracture or surgery), through the bloodstream, or by direct
smelling, tasting & chewing food which is known as
extension from infected adjacent structures.
cephalic phase of digestion
Infections can be acute or chronic; both cause bone • The gastric phase is stimulated by the presence of food
destruction.
in the stomach & regulated by neural stimulation via
PNS & hormonal stimulation through secretion of gastrin
S/sx
by the gastric mucosa
1. Malaise
• After processing in the stomach the food bolus called
2. Fever
chyme is released into the small intestine through the
3. Pain & tenderness of bone
duodenum
4. Redness & swelling over bone
• Two sphincters control the rate of food passage
5. Difficulty with weight-bearing
6. Drainage from wound site may be present.
• Cardiac Sphincter: located at the opening between the
esophagus & stomach

Dx • Pyloric Sphincter: located between the stomach &

1. CBC: WBC elevated duodenum

2. Blood cultures: may be positive • Three anatomic division

3. ESR: may be elevated • Fundus

Nursing Interventions
1. Administer analgesics & antibiotics as ordered.
2. Use sterile techniques during dressing changes.
3. Maintain proper body alignment & change position
frequently: to prevent deformities.
4. Provide immobilization of affected part as ordered.
5. Provide psychologic support & diversional activities
(depression may result from prolonged hospitalization)
6. Prepare client for surgery if indicated.
Incision & drainage: of bone abscess
Sequestrectomy: removal of dead, infected bone &
cartilage
Bone grafting: after repeated infections
Leg amputation
7. Provide client teaching and discharge planning concerning
Use of prescribed oral antibiotic therapy & side effects
Importance of recognizing & reporting signs &
complications (deformity, fracture) or recurrence
FRACTURES
A. General information
1.
B. Medical management
C. Assessment findings
D. Nursing interventions
Overview of Anatomy & Physiology Gastro Intestinal Track System
• The primary function of GIT are the movement of food,
digestion, absorption, elimination & provision of a
continuous supply of the nutrients electrolytes & H2O.
• Body
• Antrum
• Gastric Secretions:
• Pepsinogen: secreted by the chief cells located in the
fundus aid in CHON digestion
• Hydrocholoric Acid: secreted by parietal cells, function in
CHON digestion & released in response to gastrin
• Intrinsic Factor: secreted by parietal cell, promotes
absorption of Vit B12
• Mucoid Secretion: coat stomach wall & prevent auto
digestion
1st half of duodenum
Middle Alimentary canal: Function for absorption; Complete
absorption: large intestine
Small Intestines
• Composed of the duodenum, jejunum & ileum
• Extends from the pylorus to the ileocecal valve which
regulates flow into the large intestines to prevent reflux to
the into the small intestine
• Major function: digestion & absorption of the end product of
digestion
• Structural Features:
• Villi (functional unit of the small intestines): finger like
projections located in the mucous membrane;
containing goblet cells that secrets mucus & absorptive
cells that absorb digested food stuff
• Crypts of Lieberkuhn: produce secretions containing
digestive enzymes
• Brunner’s Gland: found in the submucosaof the

Upper alimentary canal: function for digestion duodenum, secretes mucus

Mouth
• Consist of lips & oral cavity 2nd half of duodenum
Jejunum
• Provides entrance & initial processing for nutrients &
Ileum
sensory data such as taste, texture & temperature
1st half of ascending colon
• Oral Cavity: contains the teeth used for mastication &
the tongue which assists in deglutition & the taste
Lower Alimentary Canal: Function: elimination
sensation & mastication
Large Intestine
• Divided into four parts:

• Cecum (with appendix)

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• Colon (ascending, transverse, descending, sigmoid) • Trypsinogen & Chymotrypsin: for protein digestion

• Rectum • Amylase: breakdown starch to disacchardes

• 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
• 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

• Bacteria in the large intestine: aid in the synthesis of • Food then passes into the esophagus where it is

vitamin K & some of the vitamin B groups propelled into the stomach

• Feces (solid waste): leave the body via rectum & anus • In the stomach food is processed by gastric secretions
into a substance called chyme
• Anus: contains internal sphincter (under involuntary
• In the small intestines CHO are hydrolyzed to
control) & external sphincter (voluntary control)
monosaccharides, fats to glycerol & fatty acid & CHON
• Fecal matter: usually 75% water & 25% solid wastes
to amino acid to complete the digestive process
(roughage, dead bacteria, fats, CHON, inorganic matter)
• When chymes enters the duodenum, mucus is
a. 2nd half of ascending colon
secreted to neutralized hydrocholoric acid, in
b. Transverse
response to release secretin, pancreas releases
c. Descending colon
bicarbonate to neutralized acid chyme
d. Sigmoid
e. Rectum • Cholecystokinin & Pancreozymin (CCKPZ)

• Are produced by the duodenal mucosa

Accessory Organ • Stimulate contraction of the gallbladder along
Liver with relaxation of the sphincter of oddi (to allow
• Largest internal organ: located in the right hypochondriac & bile flow from common bile duct into the
epigastric regions of the abdomen duodenum) & stimulate release of the

• Liver Loobules: functional unit of the liver composed of pancreatic enzymes

hepatic cells Salivary Glands

1. Parotid – below & front of ear
• Hepatic Sinusoids (capillaries): are lined with kupffer cells
2. Sublingual
which carry out the process of phagocytosis
3. Submaxillary
• Portal circulation brings blood to the liver from the stomach,
spleen, pancreas & intestines
- Produces saliva – for mechanical digestion
• Function:
- 1200 -1500 ml/day - saliva produced
• Metabolism of fats, CHO & CHON: oxidizes these
nutrient for energy & produces compounds that can be
Disorder of the GIT
stored
Peptic Ulcer Disease (PUD)
• Production of bile
Gastric Ulcer
• Conjugation & excretion (in the form of glycogen, fatty • Ulceration of the mucosal lining of the stomach
acids, minerals, fat-soluble & water-soluble vitamins) of • Most commonly found in the antrum
bilirubin
• Excoriation / erosion of submucosa & mucosal lining due to:
• Storage of vitamins A, D, B12 & iron
• Hypersecretion of acid: pepsin
• Synthesis of coagulation factors
• Decrease resistance to mucosal barrier
• Detoxification of many drugs & conjugation of sex
• Caused by bacterial infection: Helicobacter Pylori
hormones

Salivary gland Doudenal Ulcer

Verniform appendix • Most commonly found in the first 2 cm of the duodenum

Liver • Characterized by gastric hyperacidity & a significant rate of

Pancreas: auto digestion gastric emptying
Gallbladder: storage of bile
Predisposing factor
Biliary System • Smoking: vasoconstriction: effect GIT ischemia
• Consist of the gallbladder & associated ductal system (bile • Alcohol Abuse: stimulates release of histamine: Parietal cell
ducts) release Hcl acid = Ulceration
• Gallbladder: lies under the surface of the liver • Emotional Stress
• Function: to concentrate & store bile • Drugs:

• Ductal System: provides a route for bile to reach the • Salicylates (Aspirin)
intestines • Steroids
• Bile: is formed in the liver & excreted into hepatic duct • Butazolidin

• Hepatic Duct: joins with the cystic duct (which drains

the gallbladder) to form the common bile duct S/sx

• If the sphincter of oddi is relaxed: bile enters the duodenum, Gastric Ulcer
Duodenal Ulcer
if contracted: bile is stored in gallbladder
Site Antrum or lesser Duodenal bulb
curvature
Pancreas
• Pain • 30 min-1 hr • 2-3 hrs after
• Positioned transversely in the upper abdominal cavity
after eating eating
• Consist of head, body & tail along with a pancreatic duct
• Left • Mid
which extends along the gland & enters the duodenum via
epigastrium epigastrium
the common bile duct
• Gaseous & • Cramping &
• Has both exocrine & endocrine function
burning burning
• Function in GI system: is exocrine • Not usually • Usually
• Exocrine cells in the pancreas secretes: relieved by relieved by

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food & food & • Removal of ½ of • Removal of ½ -3/4 of

antacid antacid stomach & stomach & duodenal bulb
• 12 MN – anastomoses of gastric & anastomostoses of
3am pain stump to the gastric stump to jejunum.
• Hypersecreti • Normal • Increased duodenum.
on gastric acid gastric acid
secretion secretion Nursing Intervention Post op
• Vomiting • Common • Not common 1. Monitor NGT output
• Hemorrhage • Hematemeis • Melena
• Weight • Weight loss • Weight gain • Immediately post op should be bright red
• Complication • Stomach • Perforation • Within 36-42 hrs: output is yellow green
s cause
• After 42 hrs: output is dark red
• Hemorrhage
2. Administer medication
• High Risk • 60 years old • 20 years old
Dx • Analgesic

• Hgb & Hct: decrease (if anemic) • Antibiotic

• Endoscopy: reveals ulceration & differentiate ulceration from • Antiemetics

gastric cancer 3. Maintain patent IV line

• Gastric Analysis: normal gastric acidity 4. Monitor V/S, I&O & bowel sounds
5. Complications:
• Upper GI series: presence of ulcer confirm
• Hemorrhage: Hypovolemic shock: Late signs: anuria

• Peritonitis
Medical Management
1. Supportive: • Paralytic ileus: most feared

• Rest • Hypokalemia
• Bland diet • Thromobphlebitis
• Stress management • Pernicious anemia
2. Drug Therapy:
• Antacids: neutralizes gastric acid Nursing Intervention
1. Administer medication as ordered
• Aluminum hydroxide: binds phosphate in the GIT &
2. Diet: bland, non irritating, non spicy
neutralized gastric acid & inactivates pepsin
3. Avoid caffeine & milk / milk products: Increase gastric acid
• Magnesium & aluminum salt: neutralized gastric
secretion
acid & inactivate pepsin if pH is raised to >=4
4. Provide client teaching & discharge planning
a. Medical Regimen
Aluminum containing Antacids Magnesium
• Take medication at prescribe time
containing Antacids
Ex. Aluminum OH gel (Amphojel) Ex. Milk of Magnesia • Have antacid available at all times

SE: Constipation SE: Diarrhea • Recognized situation that would increase the need
for antacids
• Avoid ulcerogenic drugs: salicylates, steroids

• Know proper dosage, action & SE

Maalox b. Proper Diet
SE: fever
• Bland diet consist of six meals / day
• Eat slowly
• Histamines (H2) receptor antagonist: inhibits gastric
• Avoid acid producing substance: caffeine, alcohol,
acid secretion of parietal cells
highly seasoned food
• Ranitidine (Zantac): has some antibacterial action
• Avoid stressfull situation at mealtime
against H. pylori
• Plan rest period after meal
• Cimetidine (Tagamet)
• Avoid late bedtime snacks
• Famotidine (Pepcid)
c. Avoidance of stress-producing situation & development
• Anticholinergic: of stress production methods
• Atropine SO4: inhibit the action of acetylcholine at • Relaxation techniques
post ganglionic site (secretory glands) results • Exercise
decreases GI secretions • Biofeedback
• Propantheline: inhibit muscarinic action of
acetylcholine resulting decrease GI secretions Dumping syndrome
• Proton Pump Inhibitor: inhibit gastric acid secretion • Abrupt emptying of stomach content into the intestine
regardless of acetylcholine or histamine release • Rapid gastric emptying of hypertonic food solutions
• Omeprazole (Prilosec): diminished the accumulation • Common complication of gastric surgery
of acid in the gastric lumen & healing of duodenal • Appears 15-20 min after meal & last for 20-60 min
ulcer
• Associated with hyperosmolar CHYME in the jejunum which
• Pepsin Inhibitor: reacts with acid to form a paste that draws fluid by osmosis from the extracellular fluid into the
binds to ulcerated tissue to prevent further destruction bowel. Decreased plasma volume & distension of the bowel
by digestive enzyme pepsin stimulates increased intestinal motility
• Sucralfate (Carafate): provides a paste like subs that
coats mucosal lining of stomach S/sx
• Metronidazole & Amoxacillin: for ulcer caused by 1. Weakness
Helicobacter Pylori 2. Faintness
3. Surgery: 3. Feeling of fullness

• Gastric Resection 4. Dizziness

5. Diaphoresis
• Anastomosis: joining of 2 or more hollow organ
6. Diarrhea
• Subtotal Gastrectomy: Partial removal of stomach
7. Palpitations
• Before surgery for BI or BII

• Do Vagotomy (severing or cutting of vagus Nursing Intervention

nerve) & Pyloroplasty (drainage) first 1. Avoid fluids in chilled solutions
2. Small frequent feeding: six equally divided feedings
Billroth I (Gastroduodenostomy) Billroth II (Gastrojejunostomy)

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3. Diet: decrease CHO, moderate fats & CHON • Bleeding of Pancreas: Cullen’s sign at umbilicus
4. Flat on bed 15-30 min after q feeding
Predisposing factors:
Disorders of the Gallbladder 1. Chronic alcoholism
Cholecystitis / Cholelithiasis 2. Hepatobilary disease
• Cholecystitis: 3. Trauma
• Acute or chronic inflammation of the gallbladder 4. Viral infection

• Most commonly associated with gallstones 5. Penetrating duodenal ulcer

• Inflammation occurs within the walls of the gallbladder 6. Abscesses

7. Obesity
& creates thickening accompanied by edema
8. Hyperlipidemia
• Consequently there is impaired circulation, ischemia &
9. Hyperparathyroidism
eventually necrosis
10. Drugs: Thiazide, steroids, diuretics, oral contraceptives
• Cholelithiasis:
• Formation of gallstones & cholesterol stones
S/Sx:
• Inflammation of gallbladder with gallstone formation.
1. Severe left upper epigastric pain radiates from back & flank
area: aggravated by eating with DOB
Predisposing Factor:
2. N/V
1. High risk: women 40 years old
3. Tachycardia
2. Post menopausal women: undergoing estrogen therapy
4. Palpitation: due to pain
3. Obesity
5. Dyspepsia: indigestion
4. Sedentary lifestyle
6. Decrease bowel sounds
5. Hyperlipidemia
7. (+) Cullen’s sign: ecchymosis of umbilicus
6. Neoplasm
Hemorrhage
8. (+) Grey Turner’s spots: ecchymosis of flank area
S/sx:
1. Severe Right abdominal pain (after eating fatty food): 9. Hypocalcemia
Occurring especially at night
2. Intolerance of fatty food Dx
3. Anorexia
1. Serum amylase & lipase: increase
4. N/V
2. Urinary amylase: increase
5. Jaundice
3. Blood Sugar: increase
6. Pruritus
4. Lipids Level: increase
7. Easy bruising
8. Tea colored urine 5. Serum Ca: decrease
9. Steatorrhea 6. CT Scan: shows enlargement of the pancreas

Dx Medical Management

1. Direct Bilirubin Transaminase: increase 1. Drug Therapy

2. Alkaline Phosphatase: increase • Narcotic Analgesic: for pain

3. WBC: increase • Meperidine Hcl (Demerol)

4. Amylase: increase • Don’t give Morphine SO4: will cause spasm of
5. Lipase: increase Sphincter of Oddi
6. Oral cholecystogram (or gallbladder series): confirms • Smooth muscle relaxant: to relieve pain
presence of stones • Papaverine Hcl
Medical Management
• Anticholinergic: to decrease pancreatic stimulation
1. Supportive Treatment: NPO with NGT & IV fluids
• Atrophine SO4
2. Diet modification with administration of fat soluble vitamins
• Propantheline Bromide (Profanthene)
3. Drug Therapy
• Narcotic analgesic: DOC: Meperdipine Hcl (Demerol): for • Antacids: to decrease pancreatic stimulation

pain • Maalox

• (Morpine SO4: is contraindicated because it causes • H2 Antagonist: to decrease pancreatic stimulation

spasm of the Sphincter of Oddi) • Ranitidin (Zantac)
• Antocholinergic: (Atrophine SO4): for pain
• Vasodilators: to decrease pancreatic stimulation
• (Anticholinergic: relax smooth muscles & open bile
• Nitroglycerine (NTG)
ducts)
• Ca Gluconate: to decrease pancreatic stimulation
• Antiemetics: Phenothiazide (Phenergan): with anti
2. Diet Modification
emetic properties
3. NPO (usually)
4. Surgery: Cholecystectomy / Choledochostomy
4. Peritoneal Lavage
5. Dialysis
Nursing Intervention
1. Administer pain medication as ordered & monitor effects
Nursing Intervention
2. Administer IV fluids as ordered
1. Administer medication as ordered
3. Diet: increase CHO, moderate CHON, decrease fats
2. Withhold food & fluid & eliminate odor: to decrease
4. Meticulous skin care: to relieved priritus
pancreatic stimulation / aggravates pain

Disorders of the Pancreas

3. Assist in Total Parenteral Nutrition (TPN) or

Pancreatitis hyperalimentation

• An inflammatory process with varying degrees of pancreatic • Complication of TPN

edema, fat necrosis or hemorrhage • Infection

• Proteolytic & lipolytic pancreatic enzymes are activated in • Embolism

the pancreas rather than in the duodenum resulting in • Hyperglycemia

tissue damage & auto digestion of pancreas 4. Institute non-pharmacological measures: to decrease pain
• Acute or chronic inflammation of pancreas leading to • Assist client to comfortable position: Knee chest or fetal
pancreatic edema, hemorrhage & necrosis due to auto like position
digestion

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• Teach relaxation techniques & provide quiet, restful

environment Liver Cirrhosis
5. Provide client teaching & discharge planning Chronic progressive disease characterized by inflammation,
• Dietary regimen when oral intake permitted fibrosis & degeneration of the liver parenchymal cell

• 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
Destroyed liver cell are replaced by scar tissue, resulting in
architectural changes & malfunction of the liver
Lost of architectural design of liver leading to fat necrosis &
scarring
Types
Laennec’s Cirrhosis:
Associated with alcohol abuse & malnutrition
Characterized by an accumulation of fat in the liver cell

• Persistent weight loss progressing to widespread scar formation

Postnecrotic Cirrhosis
• Severe epigastric or back pain
Result in severe inflammation with massive necrosis as a
• Frothy foul smelling bowel movement
complication of viral hepatitis
• Irritability, confusion, persistent elevation of
Cardiac Cirrhosis
temperature (2 day)
Occurs as a consequence of right sided heart failure
Manifested by hepatomegaly with some fibrosis
Apendicitis
Biliary Cirrhosis
• Inflammation of the appendix that prevents mucus from
Associated with biliary obstruction usually in the common bile
passing into the cecum duct
• Inflammation of verniform appendix Results in chronic impairment of bile excretion
• If untreated: ischemia, gangrene, rupture & peritonitis
• May cause by mechanical obstruction (fecalith, intestinal S/sx
parasites) or anatomic defect Fatigue
• May be related to decrease fiber in the diet Anorexia
N/V

Predisposing factor: Dyspepsia: Indigestion

1. Microbial infection Weight loss

2. Feacalith: undigested food particles like tomato seeds, Flatulence

guava seeds etc. Change (Irregular) bowel habit

3. Intestinal obstruction Ascites

Peripheral edema

S/Sx: Hepatomegaly: pain located in the right upper quadrant

1. Pathognomonic sign: (+) rebound tenderness Atrophy of the liver

2. Low grade fever Fetor hepaticus: fruity, musty odor of chronic liver

3. N/V disease

4. Decrease bowel sound Aterixis: flapping of hands & tremores

5. Diffuse pain at lower Right iliac region Hard nodular liver upon palpation
Increased abdominal girth
6. Late sign: tachycardia: due to pain
Changes in moods
Alertness & mental ability
Dx
Sensory deficits
1. CBC: mild leukocytosis: increase WBC
Gynecomastia
2. PE: (+) rebound tenderness (flex Right leg, palpate Right
Decrease of pubic & axilla hair in males
iliac area: rebound)
Amenorrhea in female
3. Urinalysis: elevated acetone in urine
Jaundice
Pruritus or urticaria
Medical Management
Easy bruising
• Surgery: Appendectomy 24-45 hrs Spider angiomas on nose, cheeks, upper thorax &
shoulder
Nursing Intervention Palmar erythema
1. Administer antibiotics / antipyretic as ordered Muscle atrophy
2. Routinary pre-op nursing measures:
• Skin prep Dx
• NPO Liver enzymes: increase

• Avoid enema, cathartics: lead to rupture of appendix SGPT (ALT)

SGOT (AST)
3. Don’t give analgesic: will mask pain
LDH Alkaline Phosphate
• Presence of pain means appendix has not ruptured
Serum cholesterol & ammonia: increase
4. Avoid heat application: will rupture appendix
Indirect bilirubin: increase
5. Monitor VS, I&O bowel sound CBC: pancytopenia
PT: prolonged
Nursing Intervention post op Hepatic Ultrasonogram: fat necrosis of liver lobules
1. If (+) Pendrose drain (rubber drain inserted at surgical
wound for drainage of blood, pus etc): indicates rupture of Nursing Intervention
appendix CBR with bathroom privileges
2. Position the client semi-fowlers or side lying on right: to Encourage gradual, progressive, increasing activity with
facilitate drainage planned rest period
3. Administer Meds: Institute measure to relieve pruritus
• Analgesic: due post op pain Do not use soap & detergent

• Antibiotics: for infection Bathe with tepid water followed by application of emollient
lotion
• Antipyretics: for fever (PRN)
Provide cool, light, non-constrictive clothing
4. Monitor VS, I&O, bowel sound
Keep nail short: to avoid skin excoriation from scratching
5. Maintain patent IV line
Apply cool, moist compresses to pruritic area
6. Complications: Peritonitis, Septicemia
Monitor VS, I & O

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Prevent Infection Formed by collecting tubules & ducts

Prevent skin breakdown: by turning & skin care
Provide reverse isolation for client with severe leukopenia:
handwashing technique
Monitor WBC
Diet:
Small frequent meals
Restrict Na!
High calorie, low to moderate CHON, high CHO, low fats with
supplemental Vit A, B-complex, C, D, K & folic acid
Monitor / prevent bleeding
Measure abdominal girth daily: notify MD
With pt daily & assess pitting edema
Administer diuretics as ordered
Provide client teaching & discharge planning
Avoidance of hepatotoxicity drug: sedative, opiates or OTC
drugs detoxified by liver
How to assess weight gain & increase abdominal girth
Avoid person with upper respiratory infection
Reporting signs of reccuring illness (liver tenderness, increase
jaundice, increase fatigue, anorexia)
Avoid all alcohol
Avoid straining stool vigorous blowing of nose & coughing: to
decrease incidence of bleeding
Complications:
Ascites: accumolation of free fluid in abdominal cavity
Nursing Intervention
Meds: Loop diuretics: 10-15 min effect
Assist in abdominal paracentesis: aspiration of fluid
Void before paracentesis: to prevent accidental puncture of
bladder as trochar is inserted
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.
Renal Sinus & Pelvis
Papillae
Projection of renal tissues located at the tip of the renal
pyramids
Calices
Minor Calyx: collects urine flow from collecting ducts
Major Calyx: directs urine from renal sinus to renal pelvis
Urine flows from renal pelvis to ureters
Nephron
Functional unit of the kidney
Basic living unit
Renal Corpuscle (vascular system of nephron)
Bowman’s Capsule:
Portion of the proximal tubule surrounds the glomerulus
Glomerulus:
Capillary network permeable to water, electrolytes,
nutrients & waste
Impermeable to large CHON molecules
Filters blood going to kidneys
Renal Tubule
Divided into proximal convoluted tubule, descending
loop of Henle, acending loop of Henle, distal
convoluted tubule & collecting ducts
Ureters
Two tubes approximately 25-35 cm long
Extend from the renal pelvis to the pelvic cavity where they
enter the bladder, convey urine from the kidney to the
bladder
Passageway of urine to bladder
Ureterovesical valve: prevent backflow of urine into ureters
Bladder
Located behind the symphisis pubis
Composed of muscular elastic tissue that makes it distensible
Serve s as reservoir of urine (capable of holding 1000-1800 ml &
500 ml moderately full)
Internal & external urethral sphincter controls the flow of urine
Urge to void stimulated by passage of urine past the internal
sphincter (involuntary) to the upper urethra
Relaxation of external sphincter (voluntary) produces emptying
of the bladder (voiding)

Hepatic encephalopathy Urethra

Small tube that extends from the bladder to the exterior of
Nursing Intervention the body
Assist in mechanical ventilation: due coma Passage of urine, seminal & vaginal fluids.
Monitor VS, neuro check Females: located behind the symphisis pubis & anterior
Siderails: due restless vagina & approximately 3-5 cm
Administer meds Males: extend the entire length of the penis & approximately
Laxatives: to excrete ammonia 20 cm

Overview of Anatomy & Physiology Of GUT System Function of kidneys

Kidneys remove nitrogenous waste & regulates F & E
GUT: Genito-urinary tract balance & acid base balance
GUT includes the kidneys, ureters, urinary bladder, urethra & the Urine is the end product
male & female genitalia
Function: Urine formation: 25 % of total cardiac output is received by kidneys
Promote excretion of nitrogenous waste products Glomerular Filtration
Maintain F&E & acid base balance Ultrafiltration of blood by the glomerulus, beginning of urine
formation
Kidneys Requires hydrostatic pressure & sufficient circulating volume
Two of bean shaped organ that lie in the retroperitonial Pressure in bowman’s capsule opposes hydrostatic pressure &
space on either side of the vertebral column filtration
Retroperitonially (back of peritoneum) on either side of If glomerular pressure insufficient to force substance out of the
vertebral column blood into the tubules filtrate formation stops
Adrenal gland is on top of each kidneys Glomerular Filtration Rate (GFR)
Encased in Bowmans’s capsule Amount of blood filtered by the glomeruli in a given time
Normal: 125 ml / min
Renal Parenchyma Filtrate formed has essentially same composition as blood
Cortex plasma without the CHON; blood cells & CHON are
Outermost layer usually too large to pass the glomerular membrane
Site of glomeruli & proximal & distal tubules of nephron
Medulla Tubular Function
Middle layer

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Tubules & collecting ducts carry out the function of Odor – aromatic
reabsorption, secretion & excretion Consistency – clear or slightly turbid
Reabsorption of H2O & electrolytes is controlled by pH – 4.5 – 8
anitdiuretics hormones (ADH) released by the Specific gravity – 1.015 – 1.030
pituitary & aldosterone secreted by the adrenal WBC/ RBC – (-)
glands Albumin – (-)
Proximal Convoluted Tubule E coli – (-)
Reabsorb the ff: Mucus thread – few
80% of F & E Amorphous urate (-)
H2O
Glucose
Amino acids UTI
Bicarbonate CYSTITIS
Secretes the ff: Inflammation of bladder due to bacterial infection
Organic substance
Waste Predisposing factors:
Loop of Henli Microbial invasion: E. coli
Reabsorb the ff: High risk: women
Na & Chloride in the ascending limb Obstruction
H2O in the descending limb Urinary retention
Concentrate / dilutes urine Increase estrogen levels
Distal Convoluted Tubule Sexual intercourse
Secretes the ff:
Potassium S/Sx:
Hydrogen ions Pain: flank area
Ammonia Urinary frequency & urgency
Reabsorb the ff: Burning pain upon urination
H2O Dysuria
Bicarbonate Hematuria
Regulate the ff: Nocturia
Ca Fever
Phosphate concentration Chills
Collecting Ducts Anorexia
Received urine from distal convoluted tubules & reabsorb H2O Gen body malaise
(regulated by ADH)
Dx
Normal Adult: produces 1 L /day of urine Urine culture & sensitivity: (+) to E. coli

Regulation of BP Nursing Intervention

Through maintenance of volume (formation / excretion of urine) Force fluid: 3000 ml
Rennin-angiotensin system is the kidneys controlled mechanism Warm sitz bath: to promote comfort
that can contribute to rise the BP Monitor & assess urine for gross odor, hematuria & sediments
When the BP drops the cells of the glomerulus release rennin Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent
which then activates angiotensin to cause vasoconstriction. bacterial multiplication
Administer Medication as ordered:
Systemic Antibiotics
Filtration – Normal GFR/ min is 125 ml of blood Ampicillin
Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes Cephalosporin
is for reabsorption) Aminoglycosides
Tubular secretion – 1 ml is excreted in urine Sulfonamides
Co-trimaxazole (Bactrim)
Regulation of BP: Gantrism (Gantanol)
Antibacterial
Predisposing factor: Nitrofurantoin (Macrodantin)
Ex CS – hypovolemia – decrease BP going to kidneys Methenamine Mandelate (Mandelamine)
Activation of RAAS Nalixidic Acid (NegGram)
Urinary Tract Anagesic
Release of Renin (hydrolytic enzyme) at Urinary antiseptics: Mitropurantoin (Macrodantin)
juxtaglomerular apparatus Urinary analgesic: Pyridium
Provide client teachings & discharge planning
Angiotensin I mild vasoconstrictor Importance of Hydration
Void after sex: to avoid stagnation
Angiotensin II vasoconstrictor Female: avoids cleaning back & front (should be front to
back)
Bubble bath, Tissue paper, Powder, perfume
Adrenal cortex increase CO increase PR Complications: Pyelonephritis

Aldosterone Pyelonephritis
Increase BP Acute / chronic inflammation of 1 or 2 renal pelvis of
Increase Na & kidneys leading to tubular destruction & interstitial
H2O reabsorption abscess formation
Acute: infection usually ascends from lower urinary tract
Hypervolemia 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
Color – amber

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Predisposing factor: Chocolates Sardines

Microbial invasion
E. Coli Predisposing factors:
Streptococcus Diet: increase Ca & oxalate
Urinary retention /obstruction Increase uric acid level
Pregnancy Hereditary: gout or calculi
DM Immobility
Exposure to renal toxins Sedentary lifestyle
Hyperparathyroidism
S/sx:
Acute Pyelonephritis S/sx
Severe flank pain or dull ache Abdominal or flank pain
Costovertibral angle pain / tenderness Renal colic
Fever Cool moist skin (shock)
Chills Burning sensation upon urination
N/V Hematuria
Anorexia Anorexia
Gen body malaise N/V
Urinary frequency & urgency
Nocturia Dx
Dsyuria Intravenous Pyelography (IVP): identifies site of obstruction &
Hematuria presence of non-radiopaque stones
Burning sensation on urination KUB: reveals location, number & size of stone
Cytoscopic Exam: urinary obstruction
Chronic Pyelonephritis: client usually not aware of Stone Analysis: composition & type of stone
disease Urinalysis: indicates presence of bacteria, increase WBC, RBC &
Bladder irritability CHON
Slight dull ache over the kidney
Chronic Fatigue Medical Management
Weight loss Surgery
Polyuria Percutaneous Nephrostomy:
Polydypsia Tube is inserted through skin & underlying tissue into renal
HPN pelvis to remove calculi
Atrophy of the kidney Percutaneous Nephrostolithotomy
Delivers ultrasound wave through a probe placed on the
Medical Management calculus
Urinary analgesic: Peridium Extracorporeal Shockwave Lithotripsy:
Acute Non-invasive
Antibiotics Delivers shockwaves from outside of the body to the stone causing
Antispasmodic pulverization
Surgery: removal of any obstruction Pain management & diet modification
Chronic
Antibiotics Nursing Intervention
Urinary Antiseptics Force fluid: 3000-4000 ml / day
Nitrofurantoin (macrodantin) Strain urine using gauze pad: to detect stones & crush all cloths
SE: peripheral neuropathy Encourage ambulation: to prevent stasis
GI irritation Warm sitz bath: for comfort
Hemolytic anemia Administer narcotic analgesic as ordered: Morphine SO4: to
Staining of teeth relieve pain
Surgery: correction of structural abnormality if possible Application warm compress at flank area: to relieve pain
Monitor I & O
Dx Provide modified diet depending upon the stone consistency
Urine culture & sensitivity: (+) E. coli & streptococcus Calcium Stones
Urinalysis: increase WBC, CHON & pus cells Limit milk & dairy products
Cystoscopic exam: urinary obstruction Provide acid ash diet (cranberry or prune juice, meat, fish,
eggs, poultry, grapes, whole grains): to acidify urine
Nursing Intervention Take vitamin C
Provide CBR: acute phase Oxalate Stone
Monitor I & O Avoid excess intake of food / fluids high in oxalate
Force fluid (tea, chocolate, rhubarb, spinach)
Acid ash diet Maintain alkaline-ash diet (milk, vegetable, fruits
Administer medication as ordered except cranberry, plums & prune): to alkalinize
Chronic: possibility of dialysis & transplant if has renal urine
deterioration Uric Acid Stone
Complication: Renal Failure Reduce food high in purine (liver, brain, kidney, venison,
shellfish, meat soup, gravies, legumes)
Nephrolithiasis / Urolithiasis Maintain alkaline urine
Presence of stone anywhere in the urinary tract Administer Allopurinol (Zyloprim) as ordered: to decrease uric
Formation of stones at urinary tract acid production: push fluids when giving allopurinol
Frequent composition of stones Provide client teaching & discharge planning
Calcium Prevention of urinary stasis: increase fluid intake especially
Oxalate during hot weather & illness
Uric acid Mobility
Voiding whenever the urge is felt & at least twice during night
Calcium Oxalate Uric Acid Adherence to prescribe diet
Complications: Renal Failure
Milk Cabbage Anchovies
Cranberries Organ meat Benign Prostatic Hypertrophy (BPH)
Nuts tea Nuts

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Mild to moderate glandular enlargement, hyperplsia & over Hypovolemia Decrease

growth of the smooth muscles & connective tissue flow to kidneys
As the gland enlarges it compresses the urethra: resulting to Hypotension
urinary retention CHF
Enlarged prostate gland leading to Hemorrhage
Hydroureters: dilation of urethers Dehydration
Hydronephrosis: dilation of renal pelvis
Kidney stones Intra-renal cause: involves renal pathology: kidney problem
Renal failure Acute tubular necrosis
Endocarditis
Predisposing factor: DM
High risk: 50 years old & above & 60-70 (3-4x at risk) Tumors
Influence of male hormone Pyelonephritis
Malignant HPN
S/sx Acute Glomerulonephritis
Urgency, frequency & hesitancy Blood transfision reaction
Nocturia Hypercalemia
Enlargement of prostate gland upon palpation by digital Nephrotoxin (certain antibiotics, X-ray, dyes, pesticides,
rectal exam anesthesia)
Decrease force & amount of urinary stream
Dysuria Post renal cause: involves mechanical obstruction
Hematuria Tumors
Burning sensation upon urination Stricture
Terminal bubbling Blood cloths
Backache Urolithiasis
Sciatica: severe pain in the lower back & down the back BPH
of thigh & leg Anatomic malformation

Dx S/sx
Digital rectal exam: enlarged prostate gland Oliguric Phase: caused by reduction in glomerular filtration rate
KUB: urinary obstruction Urine output less than 400 ml / 24 hrs; duration 1-2 weeks
Cystoscopic Exam: reveals enlargement of prostate gland & S/sx
obstruction of urine flow Hypernatremia
Urinalysis: alkalinity increase Hyperkalemia
Specific Gravity: normal or elevated Hyperphosphotemia
BUN & Creatinine: elevated (if longstanding BPH) Hypermagnesemia
Prostate-specific Antigen: elevated (normal is < 4 ng /ml) Hypocalcemia
Metabolic acidosis
Nursing Intervention Dx
Prostate message: promotes evacuation of prostatic BUN & Creatinine: elevated
fluid Diuretic Phase: slow gradual increase in daily urine output
Force fluid intake: 2000-3000 ml unless contraindicated Diuresis may occur (output 3-5 L / day): due to partially
Provide catheterization regenerated tubules inability to concentrate urine
Administer medication as ordered: Duration: 2-3 weeks
Terazosine (Hytrin): relaxes bladder sphincter & make it S/sx
easier to urinate Hyponatremia
Finasteride (Proscar): shrink enlarge prostate gland Hypokalemia
Surgery: Prostatectomy Hypovolemia
Transurethral Resection of Prostate (TURP): insertion of a Dx
resectoscope into urethra to excise prostatic tissue BUN & Creatinine: elevated
Assist in cystoclysis or continuous bladder irrigation. Recovery or Covalescent Phase: renal function stabilized with
Nursing Intervention gradual improvement over next 3-12 mos
Monitor symptoms of infection
Monitor symptoms gross / flank bleeding. Normal Nursing Intervention
bleeding within 24h Monitor / maintain F&E balance
Maintain irrigation or tube patent to flush out clots: to Obtain baseline data on usual appearance & amount of
prevent bladder spasm & distention client’s urine
Measure I&O every hour: note excessive losses
Administer IV F&E supplements as ordered
Weight daily
Acute Renal Failure Monitor lab values: assess / treat F&E & acid base
Sudden inability of the kidney to regulate fluid & electrolyte imbalance as needed
balance & remove toxic products from the body Monitor alteration in fluid volume
Sudden immobility of kidneys to excrete nitrogenous waste Monitor V/S. PAP, PCWP, CVP as needed
products & maintain F&E balance due to a decrease in GFR Monitor I&O strictly
(N 125 ml/min) Assess every hour fro hypervolemia
Maintain ventilation
Causes Decrease fluid intake as ordered
Pre-renal cause: interfering with perfusion & resulting in Administer diuretics, cardiac glycosides &
decreased blood flow & glomerular filtrate hypertensive agent as ordered
Inter-renal cause: condiion that cause damage to the nephrons Assess every hour for hypovolemia: replace fluid as
Post-renal cause: mechanical obstruction anywhere from the ordered
tubules to the urethra Monitor ECG
Check urine serum osmolality / osmolarity & urine
Pre renal cause: decrease blood flow & glomerular filtrate specific gravity as ordered
Ischemia & oliguria Promote optimal nutrition
Cardiogenic shock Administer TPN as ordered
Acute vasoconstriction Restrict CHON intake
Septicemia Prevent complication from impaired mobility

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Pulmonary Embolism
Skin breakdown Dx
Contractures Urinalysis: CHON, Na & WBC: elevated
Atelectesis Specific gravity: decrease
Prevent infection / fever Platelets: decrease
Assess sign of infection Ca: decrease
Use strict aseptic technique for wound & catheter care
Take temperature via rectal Medical Management
Administer antipyretics as ordered & cooling blankets Diet restriction
Support clients / significant others: reduce level of anxiety Multivitamins
Provide care for client receiving dialysis Hematinics
Provide client teaching & discharge planning Aluminum Hydroxide Gels
Adherence to prescribed dietary regime Antihypertensive
S/sx of recurrent renal disease
Importance of planned rest period Nursing Intervention
Use of prescribe drugs only Prevent neurologic complication
S/sx of UTI or respiratory infection: report to MD Monitor for signs of uremia
Fatigue
Chronic Renal Failure Loss of appetite
Progressive, irreversible destruction of the kidneys that Decreased urine output
continues until nephrons are replaced by scar tissue Apathy
Loss of renal function gradual Confusion
Irreversible loss of kidney function Elevated BP
Edema of face & feet
Predisposing factors: Itchy skin
DM Restlessness
HPN Seizures
Recurrent UTI/ nephritis Monitor for changes in mental functioning
Urinary Tract obstruction Orient confused client to time, place, date & person
Exposure to renal toxins Institute safety measures to protect the client from
falling out of bed
Stages of CRF Monitor serum electrolytes, BUN & creatinine as ordered
Diminished Reserve Volume – asymptomatic Promote optimal GI function
Normal BUN & Crea, GFR < 10 – 30% Provide care for stomatitis
2. Renal Insufficiency Monitor N/V & anorexia: administer antiemetics as
3. End Stage Renal disease ordered
Monitor signs of GI bleeding
Monitor & prevent alteration in F&E balance
S/Sx: Monitor for hyperphosphatemia: administer aluminum
N/V hydroxides gel (amphojel, alternagel) as ordered
Diarrhea / constipation Paresthesias
Decreased urinary output Muscle cramps
Dyspnea Seizures
Stomatitis Abnormal reflex
Hypotension (early) Maintenance of skin integrity
Hypertension (late) Provide care for pruritus
Lethargy Monitor uremic frost (urea crystallization on the skin): bathe
Convulsion in plain water
Memory impairment Monitor for bleeding complication & prevent injury to client
Pericardial Friction Rub Monitor Hgb, Hct, platelets, RBC
HF Hematest all secretions
Administer hematinics as ordered
Avoid IM injections
Urinary System Metabolic Disturbance Maintain maximal cardiovascular function
Polyuria Azotemia (increase BUN Monitor BP
Nocturia & Creatinine) Auscultate for pericardial friction rub
Hematuria Hyperglycemia Perform circulation check routinely
Dysuria Hyperinsulinemia Administer diuretics as ordered & monitor I&O
Oliguria Modify digitalis dose as ordered (digitalis is excreted in
CNS GIT kidneys)
Headache N/V Provide care for client receiving dialysis
Lethargy Stomatitis Disequilibrium syndrome: from rapid removal of urea &
Disorientation Uremic breath nitrogenous waste prod leading to:
Restlessness Diarrhea / N/V
Memory impairment constipation HPN
Respiratory Hematological
Leg cramps
Kassmaul’s resp Normocytic anemia
Disorientation
Decrease cough Bleeding tendencies
Paresthes
reflex
Fluid & Electrolytes Integumentary Enforce CBR
Hyperkalemia Itchiness / Monitor VS, I&O
Hypernatermia pruritus Meticulous skin care. Uremic frost – assist in bathing
Hypermagnese Uremic frost pt
mia 4. Meds:
Hyperposphate a.) Na HCO3 – due Hyperkalemia
mia b.) Kagexelate enema
Hypocalcemia c.) Anti HPN – hydralazine
Metabolic d.) Vit & minerals
acidosis e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation

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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

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