Medical Surgical Nursing Pinoy

1 •

MEDICAL-SURGICAL NURSING By: Anthony T. Villegas R.N.

period. •

Overview of structures and functions:

3.

NERVOUS SYSTEM •

The functional unit of the nervous system is the nerve cells

•

Not capable of regeneration.

•

Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

The nervous system is composed of the ff:

Central Nervous System •

Brain

•

Spinal Cord – serves as a connecting link between the brain

B.

NEUROGLIA •

& the periphery. Peripheral Nervous System

Support and protection of neurons.

TYPES 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 astrocytoma.

cord. •

Autonomic Nervous System subdivision of the PNS that automatically controls body

•

2.

•

Oligodendria

•

produces myelin sheath in CNS.

Special senses of vision and hearing are also covered in this section

•

act as insulator and facilitates rapid nerve impulse

Sympathetic nervous system – generally accelerate some

transmission. 3.

Microglia •

bacteria or cellular debris, eating), pinocytosis (cell

functioning.

drinking). Epindymal

•

CELLS NEURONS Primary component of nervous system

•

Composed of cell body (gray matter), axon, and dendrites

•

Basic cells for nerve impulse and conduction.

Axon •

Elongated process or fiber extending from the cell body

•

Transmits impulses (messages) away from the cell body to dendrites or directly to the cell bodies of other neurons Neurons usually has only one axon

Dendrites Short, blanching fibers that receives impulses and conducts

MACROPHAGE Microglia

ORGAN Brain

Monocytes

Blood

Kupffers

Kidney

Histiocytes

Skin

Alveolar Macrophage

Lung

Central Nervous System Composition Of Brain

them toward the nerve cell body. •

Neurons may have many dendrites.

Synapse •

Junction between neurons where an impulse is transmitted

Neurotransmitter

•

Chemical agent (ex. Acetylcholine, norepinephrine) involved

•

80% brain mass

•

10% blood

•

10% CSF

Brain Mass Parts Of The Brain 1.

Cerebrum •

largest part of the brain

•

outermost area (cerebral cortex) is gray matter

•

deeper area is composed of white matter

and insulates nerve fibers and enhances the speed of

•

function of cerebrum: integration, sensory, motor

impulse conduction.

•

composed of two hemisphere the Right Cerebral

in the transmission of impulse across synapse. Myelin Sheath

•

secretes a glue called chemo attractants that concentrate the bacteria.

•

•

stationary cells that carry on phagocytosis (engulfing of

Parasympathetic nervous system – controls normal body 4.

•

integrity of blood brain barrier.

function such as breathing & heart beat.

body functions in response to stress.

A.

Kidney cells, Liver cells, Salivary cells, pancreas.

Permanent

or neurons •

Capable of regeneration with limited time, survival

A wrapping of myelin (whitish, fatty material) that protects

o 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. •

Most axons leaving the CNS are heavily myelinated by schwann cells

Each hemisphere divided into four lobes; many of the functional areas of the cerebrum have been located in these lobes:

Functional Classification 1.

Afferent (sensory) neurons •

2.

3.

Transmit impulses from peripheral receptors to the CNS

Lobes of Cerebrum 1.

Frontal Lobe

Efferent (motor) neurons

•

controls personality, behavior

•

•

higher cortical thinking, intellectual functioning

Internuncial neurons (interneurons)

•

precentral gyrus: controls motor function

•

•

Broca’s Area: specialized motor speech area - when

Conduct impulses from CNS to muscle and glands

Connecting links between afferent and efferent neurons

Properties

1. Excitability – ability of neuron to be affected by changes in

damaged results to garbled speech. 2.

external environment.

2. Conductility – ability of neuron to transmit a wave of excitetation from one cell to another.

3. Permanent Cell – once destroyed not capable of regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1.

2.

Labile •

Capable of regeneration.

•

Epidermal cells, GIT cells, GUT cells, cells of lungs.

Temporal Lobe •

hearing, taste, smell

•

short term memory

•

Wernicke’s area: sensory speech area (understanding/formulation of language)

3.

Pareital Lobe •

for appreciation

•

integrates sensory information

•

discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.

Stable

1

2 •

•

Postcentral gyrus: registered general sensation (ex.

hiccup, vasomotor center (dilation and constriction of

Touch, pressure) 4.

bronchioles).

Occipital Lobe •

for vision 5.

Cerebellum

Insula (Island of Reil)

•

smallest part of the brain, lesser brain.

•

•

coordinates muscle tone and movements and maintains

visceral function activities of internal organ like gastric

position in space (equilibrium)

motility. •

Limbic System (Rhinencephalon)

• •

controls libido

•

controls long term memory

Spinal Cord • •

•

hemisphere

•

regulate & integrate motor activity originating in the

Gray Matter 1.

cerebral cortex •

part of extrapyramidal system

•

area of gray matter located deep within each cerebral

2.

Posterior Horns

•

release dopamine (controls gross voluntary movement). 3.

Lateral Horns •

Connecting part of the brain, between the cerebrum &

In thoracic region, contain cells giving rise to autonomic fibers of sympathetic nervous system

Contains several small structures: the thalamus &

White Matter

hypothalamus are most important

1. Ascending Tracts (sensory pathways)

Thalamus

•

Contains cell bodies connecting with afferent (sensory) fibers from dorsal root ganglion

the brain stem

•

Contains cell bodies giving rise to efferent (motor) fibers

Diencephalon/interbrain •

Anterior Horns

•

hemisphere.

•

H-shaped gray matter in the center (cell bodies) surrounded by white matter (nerve tract and fibers)

Basal Ganglia island of gray matter within white matter of cerebrum

extends from foramen magnum to second lumbar vertebra

large fiber tract that connects the two cerebral

•

serves as a connecting link between the brain and periphery

Corpus Callosum

•

controls balance, equilibrium, posture and gait.

controls smell - if damaged results to anosmia (absence of smell).

2.

controls respiration, heart rate, swallowing, vomiting,

a.

Posterior Column

acts as relay station for discrimination of sensory signals

•

(ex. Pain, temperature, touch)

•

pressure, vibration, & position sense

controls primitive emotional responses (ex. Rage, fear)

b.

Spinocerebellar

Hypothalamus •

found immediately beneath the thalamus

•

plays a major role in regulation/controls of vital function:

•

c.

Lateral Spinothalamic •

temperature (thermoregulatory center) d.

Anterior Spinothlamic •

controls some emotional responses like fear, anxiety

2. Descending Tracts (motor pathways)

androgenic hormones promotes secondary sex

a. Corticospinal (pyramidal, upper motor neurons)

characteristics. •

•

early sign for males are testicular and penile

4.

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 •

3.

Carry impulses concerned with crude touch & pressure

and excitement.

•

Carry impulses resulting in pain & temperature sensations

acts as controls center for pituitary gland and affects both divisions of the autonomic nervous system.

•

Carry impulses concerned with muscle tension & position sense to cerebellum

blood pressure, thirst, appetite, sleep & wakefulness, •

Carry impulses concerned with touch,

Help to maintain muscle tone & to

Mesencephalon/Midbrain

control body movement, especially

•

acts as relay station for sight and hearing.

gross automatic movements such as

•

size of pupil is 2 – 3 mm.

•

equal size of pupil is isocoria.

•

unequal size of pupil is anisocoria.

•

hearing acuity is 30 – 40 dB.

•

positive PERRLA

walking Reflex Arc

•

Reflex consists of an involuntary response to a stimulus occurring over a neural pathway called a reflex arc.

•

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

Brain Stem

Components

•

located at lowest part of brain.

a.

•

contains midbrain, pons, medulla oblongata.

•

extends from the cerebral hemispheres to the foramen

• b.

c.

contains nuclei of the cranial nerves and the long cerebrum and the spinal cord.

•

d.

contains vital center of respiratory, vasomotor, and e.

Synapses with a motor neuron (anterior horn cell)

Efferent Pathways •

cardiac functions.

Transmits impulses to spinal cord

Interneurons

•

ascending and descending tracts connecting the

Receives/reacts to stimulus

Afferent Pathways •

magnum at the base of the skull. •

Sensory Receptors

Transmits impulses from motor neuron to effector

Effectors •

Muscle or organ that responds to stimulus

Pons •

pneumotaxic center controls the rate, rhythm and depth of respiration.

Medulla Oblongata

Supporting Structures 1.

Skull •

Rigid; numerous bones fused together

2

3 • 2.

Spinal Column • •

3.

•

Protects & support the brain

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.

Meninges •

4.

Membranes between the skull & brain & the vertebral column & spinal cord

•

3 fold membrane that covers brain and spinal cord.

•

For support and protection; for nourishment; blood

5.

supply

•

Resulting to cholesterol and positive to ketones (CNS

Area between arachnoid & pia mater is called

Hepatitis

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Signs of jaundice (icteric sclerae).

•

Caused by bilirubin (yellow pigment)

Bilirubin

•

Increase bilirubin in brain (kernicterus).

•

Causing irreversible brain damage.

subarachnoid space: CSF aspiration is done

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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 • 4.

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:

Ventricles •

1. Dorsal (posterior) roots

Four fluid-filled cavities connecting with one

•

another & spinal canal •

body is in the dorsal roots ganglion

Produce & circulate cerebrospinal fluid

2. Ventral (anterior) roots

5. Cerebrospinal Fluid (CSF) •

Surrounds brain & spinal cord

•

Offer protection by functioning as a shock absorber

•

Allows fluid shifts from the cranial cavity to the spinal cavity

•

•

6.

Contains efferent (motor) nerve whose nerve fibers originate in the anterior horn cell of the spinal cord (lower motor neuron)

Cranial Nerves

Carries nutrient to & waste product away from nerve

12 pairs: carry impulses to & from the brain.

cells

•

contains afferent (sensory) nerve whose cell

May have sensory, motor, or mixed functions.

Component of CSF: CHON, WBC, Glucose

Vascular Supply

Name & Number

•

Two internal carotid arteries anteriorly

Olfactory

•

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;

• •

of the brain Brain stem & cerebellum are supplied by branches of the vertebral & basilar arteries

•

Venous blood drains into dural sinuses & then into jugular veins

7. Blood-Brain-Barrier (BBB) •

: CN I

Sensory: carries impulses for

4 out of 6 extraocular

Anterior, middle, & posterior cerebral arteries are the main arteries for distributing blood to each hemisphere

•

Function

Protective barrier preventing harmful agents from

movement. Trochlear

: CN IV

Motor: muscles for downward,

inward, movement of the eye Trigeminal

: CN V

Mixed: impulses from face, surface

of eyes (corneal reflex); muscle Controlling mastication. Abducens

: CN VI

Motor: muscles for lateral deviation

: CN VII

Mixed: impulses for taste from

of eye Facial

entering the capillaries of the CNS; protect brain &

anterior tongue; muscles for facial

spinal cord

Movement. Acoustic

Substance That Can Pass Blood-Brain Barrier 1.

•

Cerebral toxin

•

Hepatic Encephalopathy (Liver Cirrhosis)

•

Ascites

•

Esophageal Varices

•

hearing (cochlear division) & balance (vestibular Division). Glossopharyngeal

: CN IX

Mixed: impulses for

sensation to posterior tongue & pharynx; muscle For movement of pharynx (elevation) & swallowing. Vagus

: CN X

Mixed: impulses for sensation to

lower pharynx & larynx; muscle for

Asterexis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy

3.

Sensory: impulses for

Amonia

Early Signs of Hepatic Encephalopathy

2.

: CN VIII

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Headache

•

Dizziness

•

Confusion

•

Fetor hepaticus (amonia like breath)

•

decrease LOC

Carbon Monoxide and Lead Poisoning

•

Can lead to Parkinson’s Disease.

•

Epilepsy

•

Treated with calcium EDTA.

Type 1 DM (IDDM)

Movement of soft palate, pharynx, & larynx. Spinal Accessory

: CN XI

Motor: movement of

sternomastoid muscles & upper part of trapezius Muscles. Hypoglossal

: CN XII

Motor: movement of tongue.

Autonomic Nervous System Part of the peripheral nervous system Include those peripheral nerves (both cranial & spinal) that regulates smooth muscles, cardiac muscles, & glands. Component: 1.

Sympathetic Nervous System

•

Causes diabetic ketoacidosis.

Generally

•

And increases breakdown of fats.

response to stress.

•

And free fatty acids

2.

accelerates

some

body

function

in

Parasympathetic Nervous System

3

4 Blood Vessel

Controls normal body functioning

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

- Involved in fight or aggression

Sympatholytic - Involved in flight or withdrawal

response.

response.

- Release of Norepinephrine

- Release of Acetylcholine.

(cathecolamines) from adrenal

- Decreases all bodily activities

glands and causes

except GIT.

Lungs

bronchoconstriction

GI Tract

vasoconstriction.

decrease motility increase motility

- Increase all bodily activity except GIT

bronchodilation

Constrict sphincters

EFFECTS OF PNS - Constriction of pupils (miosis).

EFFECTS OF SNS

- Increase salivation.

- Dilation of pupils (mydriasis) in

- Decrease BP and Heart Rate.

order to be aware.

- Bronchoconstriction, Decrease

- Dry mouth (thickened saliva).

RR.

- Increase BP and Heart Rate.

- Diarrhea

- Bronchodilation, Increase RR

- Urinary frequency.

relaxed

sphincters Possibly inhibits secretions stimulate secretions Inhibits activity of gallbladder & ducts stimulate activity of gallbladder & ducts Inhibits glycogenolysis in liver Adrenal Gland stimulates secretion of epinephrine &

- Constipation.

no effect

Norepinephrine

- Urinary Retention. - Increase blood supply to brain,

Urinary Tract

heart and skeletal muscles. - SNS

contract detrusor muscles

I. Cholinergic Agents

Contract trigone sphincter (prevent voiding)

- Mestinon, Neostignin. I. Adrenergic Agents

SE:

- Give Epinephrine.

- PNS effect

relaxes detrusor muscles

relaxes trigone sphincter (allows voiding) NEURO TRANSMITTER Acethylcholine Dopamine

SE: - SNS effect Contraindication:

Decrease Myesthenia Gravis Parkinson’s Disease

Increase Bi-polar Disorder Schizophrenia

Physical Examination

- Contraindicated to patients suffering from COPD

II. Anti-cholinergic Agents

(Broncholitis, Bronchoectasis,

- To counter cholinergic agents.

Emphysema, Asthma).

- Atrophine Sulfate

II. Beta-adrenergic Blocking

SE:

Agents

- SNS effect

Comprehensive Neuro Exam Neuro Check

1. Level of Consciousness (LOC) a.

Orientation to time, place, person

b. Speech: clear, garbled, rambling c.

Ability to follow command

d. If does not respond to verbal stimuli, apply a painful

- Also called Beta-blockers. - all ending with “lol”

stimulus

(ex.

Pressure

on

the

nailbeds,

- Propranolol, Atenelol,

trapezius muscle); note response to pain

Metoprolol.

Appropriate: withdrawal, moaning

Effect of Beta-blockers

Inappropriate: non-purposeful

B – broncho spasm

squeeze

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.

“pril” (Captopril, Enalapril)

Glasgow Coma Scale 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 Components

Parasympathetic (Cholinergic) Effect Eye

dilate pupil (mydriasis)

constrict

pupil (miosis)

Eye opening

2.

Verbal response

3.

Motor response

GCS Grading / Scoring

Gland of Head Lacrimal

no effect

stimulate secretions Salivary

scanty thick, viscous secretions

copious thin, watery secretions Dry mouth Heart

1.

increase rate & force of contraction decrease rate

3.

1.

Conscious

15 – 14

2.

Lethargy

13 – 11

3.

Stupor

10 – 8

4.

Coma

5.

Deep Coma

7 3

Pupillary Reaction & Eye Movement

a. Observe size, shape, & equality of pupil (note size in millimeter)

b. Reaction to light: pupillary constriction

4

5 c. Corneal reflex: blink reflex in response to light stroking

2.

Long term memory Ask for birthday and validate on profile sheet

of cornea

d. Oculocephalic reflex (doll’s eyes): present in

Positive result mean retrograde amnesia and damage to

unconscious client with intact brainstem 4.

limbic system

Motor Function

Consider educational background

a. Movement of extremities (paralysis) b.

Level of Orientation

Muscle strength

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

b. Central Neurogenic Hyperventilation: sustained, rapid, regular respiration (rate of 25/min) with normal O2 level; usually due to brainstem dysfunction

c. Apneustic Breathing: prolonged inspiratory phase, followed by a 2-to-3 sec pause; usually indicates dysfunction respiratory center in pons

d. Cluster Breathing: cluster of irregular breathing, irregularly followed by periods of apnea; usually caused by a lesion in upper medulla & lower pons

e. Ataxic Breathing: breathing pattern completely irregular; indicates damage to respiratory center of the medulla

b.

LOC

c. Intellectual Function: memory

Function S S M M

5. 6. 7. 8. 9.

Trigeminal Abducens Facial Acoustic Glossophareng

(smallest) B (largest) M B S B

eal 10. Vagus 11. Spinal

B (longest) M

Accessory 12. Hypoglossal

M

Sensory function for smell

1. Mental status and speech (Cerebral Function) General appearance & behavior

Cranial Nerves Olfactory Optic Oculomotor Trochlear

CRANIAL NERVE I: OLFACTORY

Neurologic Exam

a.

1. 2. 3. 4.

Material Used Don’t use alcohol, ammonia, perfume because it is irritating

(recent

&

and highly diffusible.

remote),

Use coffee granules, vinegar, bar of soap, cigarette

attention span, cognitive skills

2.

d.

Emotional status

e.

Thought content

f.

Language / speech

Cranial nerve assessment

3. Cerebellar Function: posture, gait, balance, coordination a. Romberg’s Test: 2 nurses, positive for ataxia

Procedure Test each nostril by occluding each nostril Abnormal Findings

1. Hyposnia: decrease sensitivity to smell 2. Dysosmia: distorted sense of smell 3. Anosmia: absence of smell

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

5. Motor Function: muscle size, tone, strength; abnormal or

CRANIAL NERVE II: OPTIC Sensory function for vision or sight

involuntary movements 6.

Reflexes

a. Deep tendon reflex: grade from 0 (no response); to 4

Functions 1.

Use Snellen’s Chart

(hyperactive); 2 (normal) b.

Test visual acuity or central vision or distance

Snellen’s Alphabet chart: for literate client

Superficial

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) 3.

person normally can see letter in the chart.

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 Decrease body reflex 4.

Coma

the red line. 2.

Test of visual field or peripheral vision 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 Ask most recent activity

Lateral Rectus

Medial

Rectus

Positive result mean anterograde amnesia and damage to temporal lobe

5

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

Inferior

Rectus Trochlear: controls superior oblique

spasm/ (+) chvostek sign (facial spasm).

21. TETANUS – risus sardonicus 22. PANCREATITIS – cullen’s sign (echymosis of umbilicus) / (+) grey turners spots.

Abducens: controls lateral rectus Oculomotor: controls the 4 remaining EOM

23. PYLORIC STENOSIS – olive like mass. 24. PDA – machine like murmur

Oculomotor Controls the size and response of pupil

25. ADDISON’S DISEASE – bronze like skin pigmentation. 26. CUSHING’S SYNDROME – moon face appearance and buffalo hump.

Normal pupil size is 2 – 3 mm Equal size of pupil: Isocoria

27. HYPERTHYROIDSM/GRAVES DISEASE – exopthalmus.

Unequal size of pupil: Anisocoria Normal response: positive PERRLA CRANIAL NERVE V: TRIGEMINAL

DEMYELINATING DISORDERS 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

refers to movement and orientation of the body in space.

Knowing

Gnostic

Area

or

General

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 characterized by scattered white patches of

CRANIAL NERVE XII: HYPOGLOSSAL 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. Incident: Affects women more than men ages 20-40

1. PTB – low grade afternoon fever

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 15. LEPROSY – lioning face

S/sx 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).

6

7

touch, pain, pressure, temperature, or position sense

monitor breath sounds 1 hour after subcutaneous

paresthesia such as tingling sensation, numbness

administration. 2.

3. Mood swings or euphoria (sense of elation) 4.

a.

Impaired motor function

banthine) if ordered

spasticity 3.

paralysis

Force fluid to 3000 ml/day.

4. Promote use of acid ash diet like cranberry juice, plums,

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 dysarthria intentional tremor 6.

Establish voiding schedule

b. Anti spasmodic agent Prophantheline Bromide (Pro-

weakness

5.

Urinary Incontinence

Bladder Urinary retention or incontinence

a.

Test bath water with thermometer.

b.

Avoid heating pads, hot water bottles.

c.

Inspect body parts frequently for injury.

d.

Make frequent position changes.

12. Prepare client for plasma exchange if indicated: to remove

7.

Constipation

8.

Sexual impotence in male / decrease sexual capacity

antibodies 13. Provide psychologic support to client/significant others. a. TRIAD SIGNS OF MS

Encourage positive attitude & assist client in setting realistic goals.

b. Ataxia

Provide compassion in helping client adapt to changes in body image & self-concept.

(unsteady gait, positive romberg’s test)

c.

Do not encourage false hope during remission.

d.

Refer to MS societies & community agencies.

14. Provide client teaching & discharge planning concerning: a.

CHARCOTS TRIAD

General measures to ensure optimum health. Balance between activity & rest Regular exercise such as walking, swimming, biking in mild case. Use energy conservation techniques Well-balance diet

Intentional tremors

Fresh air & sunshine

Nystagmus

Avoiding fatigue, overheating or chilling, stress, infection.

Dx

1. CSF Analysis: increase in IgG and Protein. 2. MRI: reveals site and extent of demyelination. 3. CT Scan: increase density of white matter. 4. Visual Evoked Response (VER) determine by EEG: maybe delayed

5. Positive Lhermittes Sign: a continuous and increase contraction of spinal column.

b.

Use of medication & side effects.

c.

Alternative methods for sexual counseling if indicated.

COMMON CAUSE OF UTI Female - short urethra (3-5 cm, 1-1 ½ inches) - poor perineal hygiene - vaginal environment is moist Nursing Management

1. 2.

Nursing Intervention

- avoid bubble bath (can alter Ph of vagina).

Assess the client for specific deficit related to location of

- avoid use of tissue papers

demyelination

- avoid using talcum powder and perfume.

Promote optimum mobility

Male

a.

- urethra (20 cm, 8 inches)

Muscles stretching & strengthening exercises

b. Walking exercises to improve gait: use wide-base gait

- do not urinate after intercourse

c. Assistive devices: canes, walker, rails, wheelchair as necessary 3.

INTRACRANIAL PRESSURE ICP

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 Any alteration or increase in one of the intracranial components

(Valium) - muscle relaxants: for spacity

c. Beta Interferons - Immunosuppresants: alter immune Increase intracranial pressure

response.

(normal ICP is 0 – 15 mmHg)

4.

Encourage independence in self-care activities

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.

9.

a.

Deep breathing exercises

b.

Yoga

Increase

fluid

intake

and

Foramen Magnum

increase

fiber

to

Medulla Oblongata

prevent

constipation. Brain Herniation

10. Maintain urinary elimination 1.

Urinary Retention a.

prevent retention. b.

Increase intra cranial pressure

perform intermittent catheterization as ordered: to Bethanecol Chloride (Urecholine) as ordered

Nursing Intervention 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.

7

8

Cyanosis

Early closure of posterior fontanels causes posterior 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.

2. Monitor V/S, input and output & neuro check frequently to

head trauma/injury

detect increase in ICP

localized abscess

3. Maintain fluid balance: fluid restriction to 1200-1500 ml/day

cerebral edema

may be ordered

hemorrhage

4. Position the client with head of bed elevated to 30-45o angle

inflammatory condition (stroke)

with neck in neutral position unless contraindicated to

hydrocephalus

improve venous drainage from brain.

tumor (rarely)

5.

S/sx (Early signs) 1.

Decrease LOC

2.

Irritability / agitation

3.

Progresses from restlessness to confusion & disorientation

Prevent further increase ICP by: a.

Provide comfortable and quite environment.

b.

Avoid use of restraints.

c.

Maintain side rails.

d.

Instruct client to avoid forms of valsalva maneuver like: Straining stool: administer stool softener & mild laxatives as ordered (Dulcolax, Duphalac)

to lethargy & coma

Excessive vomiting: administer anti-emetics as ordered (Plasil - Phil only, Phenergan)

(Late signs)

Excessive coughing: administer anti-tussive

1. Changes in Vital Signs (may be a late signs)

(dextromethorphan)

a. Systolic blood pressure increases while diastolic

Avoid stooping/bending

pressure remains the same (widening pulse

Avoid lifting heavy objects

pressure) b.

e.

Pulse rate decrease

c. Abnormal respiratory patterns (cheyne-stokes respiration) d.

6.

Prevent complications of immobility.

7.

Administer medications as ordered:

a. Hyperosmotic agent / Osmotic Diuretic [Mannitol

temperature increase directly proportional to blood

(Osmitrol)]: to reduce cerebral edema

pressure. 2.

Nursing Management

Pupillary Changes

Monitor V/S especially BP: SE hypotension.

a. Ipsilateral (same side) dilatation of pupil with 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 d. 3.

b. Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral

Pupil eventually becomes fixed & dilated

edema

Motor Abnormalities

drug of choice for CHF (pulmonary edema)

a. Contralateral (opposite side) hemiparesis from

loop of henle in kidneys.

compression of corticospinal tract b.

Nursing Management

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). 4.

Headache

5.

Projective Vomiting

Given early morning Immediate effect of 10-15 minutes. Maximum effect of 6 hours.

6. Papilledema (edema of optic disc) 7.

Avoid clustering of nursing care activity together.

c. Corticosteroids [Dexamethasone (Decadron)]: anti-

Possible seizure activity

inflammatory effect reduces cerebral edema

d. Analgesics for headache as needed:

Nursing Intervention 1.

Maintain patent airway and adequate ventilation by:

a. Prevention

of

hypoxia

(decrease

O2)

Small dose of Codein SO4 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: Restlessness Tachycardia

seizures. 8.

Assist with ICP monitoring when indicated: a.

cranial cavity by the brain, cerebral blood, & CSF

Agitation Late signs of hypoxia: Extreme restlessness Bradycardia Dyspnea

ICP monitoring records the pressure exerted within the

b.

Types of monitoring devices: Intraventricular Catheter: inserted in lateral ventricle to give direct measurement of ICP; also allows for drainage of CSF if needed.

8

9

Subarachnoid screw (bolt): inserted through the skull & dura matter into subarachnoid space. Epidural Sensor: least invasive method; placed in space between skull & dura matter for indirect measurement of ICP.

c. Monitor ICP pressure readings frequently & prevent complications: Normal ICP reading is 0-15 mmHg; a sustained increase above 15 mmHg is considered abnormal. Use strict aseptic technique when handling any part of the monitoring system. Check insertion site for signs of infection; monitor temperature. Assess system for CSF leakage, loose connections, air bubbles in he line, & occluded tubing.

9. Provide intensive nursing care for clients treated with

Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Hypokalemia - decrease potassium level - normal value is 3.4 – 5.5 meq/L Sign and Symptoms - weakness and fatigue

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 (Norcuron)]: may be administered to paralyzed the

Oral Potassium Chloride) - 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. e.

EEG monitoring as necessary

Apple

S Asparagus

f.

Provide appropriate nursing care for the client on a

Banana

Brocolli

ventilator

Cantalop

Carrots

e

Spinach

10. Observe for hyperthermia secondary to hypothalamus

Oranges

damage.

2. Hypocalcemia/Tetany - decrease calcium level - normal value is 8.5 – 11 mg/100 ml *CONGESTIVE HEART FAILURE Signs and Symptoms -

dyspnea

-

orthopnea

-

paroxysmal nocturnal dyspnea

-

productive cough

-

frothy salivation

-

cyanosis

-

rales/crackles

-

bronchial wheezing

-

pulsus alternans

-

anorexia and general body malaise

-

PMI (point of maximum impulse/apical pulse rate) is displaced laterally

-

S3 (ventricular gallop)

-

Predisposing Factors/Mitral Valve o

RHD

o

Aging

Treatment Morphine Sulfate Aminophelline Digoxin Diuretics Oxygen Gases, blood monitor RIGHT CONGESTIVE HEART FAILURE (venous congestion) Signs and Symptoms - jugular vein distention (neck) - ascites - pitting edema - weight gain - hepatosplenomegaly - jaundice - pruritus - esophageal varices - anorexia and general body malaise

Signs and Symptoms - tingling sensation - paresthesia - numbness - (+) Trousseus sign/Carpopedal spasm - (+) Chvostek’s sign Complications - arrythmia - seizures Nursing Management - Calcium Glutamate per IV slowly as ordered * Calcium Glutamate toxicity – results to seizure Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output

DECREASE

Respiratory rate Patellar relfex absent 3. Hyponatremia - decrease sodium level - normal value is 135 – 145 meq/L Signs and Symptoms - hypotension - dehydration signs (initial sign in adult is thirst, in infant tachycardia) - agitation - dry mucous membrane - poor skin turgor - weakness and fatigue Nursing Management - force fluids - administer isotonic fluid solution as ordered 4. Hyperglycemia - normal FBS is 80 – 100 mg/dl Signs and Symptoms - polyuria - polydypsia

9

10 - polyphagia

Loss of spouse

Nursing Management

Loss

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. Signs and Symptoms

1. Tremor: mainly of the upper limbs “pill rolling tremors” of extremities especially the hands; resting tremor: most

- joint pain (great toes)

common initial symptoms

- swelling Nursing Management

2.

Bradykinesia: slowness of movement

3.

Rigidity: cogwheel type

4. Stooped posture: shuffling, propulsive gait

- force fluids

5.

- administer medications as ordered

Fatigue

6. Mask like facial expression with decrease blinking of the

a. Allopurinol (Zylopril)

eyes.

- drug of choice for gout. - mechanism of action: inhibits synthesis of uric acid. b. Colchesine

7.

Difficulty rising from sitting position.

8. Quite, monotone speech 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 12. Autonomic Symptoms

* Kidney stones 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) c. Haloperidol (Haldol)

Antihypertensive _______

Anti-Histamines Drug a.

d. Phenothiazine ___________________ Antipsychotic

Diphenhydramine (benadryl) 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 causes suicide

Often employed when L-dopa loses effectiveness MAOI Inhibitor

10

11 a.

Eldepryl (Selegilene) MOA:

inhibit

Signs and Symptoms dopamine

breakdown

&

slow

- anorexia - nausea and vomiting

progression of disease

- diarrhea Anti-Depressant Drug

- dehydration causing fine tremors

a.

- hypothyroidism

Tricyclic MOA: given to treat depression commonly seen in

Nursing Management

Parkinson’s disease 2.

- force fluids

Provide safe environment 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 Hard-back or spring-loaded chair to make getting up easier 3.

stretching exercise; warm baths

Nursing Management - only mixed with plain NSS or 0.9 NaCl to prevent development of crystals of precipitate.

Assistive devices If client “freezes” suggest thinking of something to walk over

- administered sandwich method - avoid taking alcohol because it can lead to severe CNS depression - avoid caffeine

Encourage independence in self-care activities:

4. Dilantin Toxicity

alter clothing for ease in dressing

5.

- palpitations - CNS excitement (tremors, irritability, agitation and restlessness)

Provide measures to increase mobility Physical Therapy: active & passive ROM exercise;

4.

- tachycardia

Signs and Symptoms

use assistive device

- gingival hyperplasia (swollen gums)

do not rush the client

- hairy tongue

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

Allow sufficient time for meals, use warming tray

- hepatotoxicity (monitor for liver enzymes)

8.

Avoid constipation & maintain adequate bowel elimination

9.

Provide significant support to client/ significant others:

- SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)

Depression is common due to changes in body image & self-concept 10. Provide client teaching & discharge planning concerning: a.

Nature of the disease

b.

Use prescribed medications & side effects

c.

Importance of daily exercise as tolerated: balanced

- nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1) - hypoglycemia Tremors, tachycardia Irritability Restlessness Extreme fatigue Diaphoresis, depression

activity & rest

Antidote: Acetylceisteine (mucomyst) prepare suction apparatus as

walking

bedside.

swimming gardening d.

- SGPT/ALT (Serum Glutamic Pyruvate Transaminace)

MYASTHENIA GRAVIS (MG)

Activities/ methods to limit postural deformities:

neuromuscular disorder characterized by a disturbance in

Firm mattress with small pillow

e.

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:

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 DRUG Digoxin/Lanoxin

NORMAL RANGE

TOXICITY

.5 – 1.5 meq/L

LEVEL 2

Thought to be autoimmune disorder whereby antibodies

INDICATION

destroy acetylcholine receptor sites on the postsynaptic membrane of the neuromuscular junction.

CHF

(increase force of cardiac output) Lithium/Lithane

Voluntary muscles are affected, especially those muscles .6 – 1.2 meq/L

2

innervated by the cranial nerve.

Bipolar

(decrease level of Ach/NE/Serotonin) Aminophelline (dilates bronchial tree) Dilantin/Phenytoin Acetaminophen/Tylen

Pathophysiology 10 – 19 mg/100 ml

20

Autoimmune = Release of Cholinesterase Enzymes =

COPD

Cholinesterase destroy Acetylcholine (ACH) = Decrease of 10 – 19 mg/100 ml 10 – 30 mg/100 ml

ol

20 200

Seizures Osteo

Acetylcholine (ACH) Acetylcholine: activate muscle contraction

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 - confusion - photophobia

S/sx

1. Initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure: cracked or cleft in the lining or

- changes in color perception (yellowish spots) Antidote: Digibind 2. Lithium Toxicity

membrane of the eyelids 2.

Diplopia

3.

Dysphagia

11

12 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,

7. Extreme muscle weakness especially during exertion and morning; increase activity & reduced with rest.

Signs and Symptoms PNS

speak, breathe 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 Nursing Care in Crisis:

minutes and a maximum of 15 minutes.

a.

If there is no effect there is no damage to occipital lobe

Maintain tracheostomy set or endotracheal tube with mechanical ventilation as indicated.

and midbrain and is negative for M.G. b.

2. Electromyography (EMG): amplitudes of evoked potentials

Monitor ABG & Vital Capacity

c. Administer medication as ordered:

decrease rapidly.

3. Presence of anti-acetlycholine receptors antibodies in the

1.

Myasthenic Crisis: increase doses of anti-

serum.

cholinesterase drug as ordered.

Medical Management

Cholinergic Crisis: discontinue anti-

Drug Therapy

cholinesterase drugs as ordered until the client

a. Anti-cholinesterase Drugs: [Ambenonium (Mytelase),

recovers.

Neostigmine (Prostigmin), Pyridostigmine (Mestinon)] MOA: block the action of cholinesterase & increase

d.

Established method of communication

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 toxicity

twitching). c.

b. Corticosteroids: Prednisone

new medication including OTC drugs

MOA: suppress autoimmune response

d.

Used if other drugs are not effective

e.

a. Surgical removal of thymus gland: thought to be involve May cause remission in some clients especially if performed early in the disease.

3. Plasma Exchange (Plasmapheresis) Removes circulating acetylcholine receptor antibodies.

b.

Use in clients who do not respond to other types of

Use of eye patch for diplopia (alternate eyes)

g.

Need to wear medic-alert bracelet

h.

Myasthenia Gravis foundation & other community

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: a.

Give medication exactly on time.

b.

Give with milk & crackers to decrease GI upset

Can occur at any age; affects women and men equally Progression of disease is highly individual; 90% of clients stop progression in 4 weeks; recovery is usually from 3-6

c. Monitor effectiveness of drugs: assess muscle strength

months; may have residual deficits.

& vital capacity before & after medication.

Causes:

Avoid use of the ff drugs: Morphine SO4 & Strong Sedatives: respiratory depressant effects

1.

Unknown / idiopathic

2.

May be autoimmune process

Quinine, Curare, Procainamide, Neomycin,

Predisposing Factors

Streptomycine, Kanamycine & other

1.

Immunization

aminoglycosides: skeletal muscle blocking effect

2.

Antecedent viral infections such as LRT infections

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. c.

f.

agencies

a.

e.

Need o avoid fatigue, stress, people with upper respiratory infection

in the production of acetylcholine receptor antibodies.

d.

Importance of planning activities to take advantage of energy peaks & of scheduling frequent rest period

2. Surgery (Thymectomy)

b.

Importance of checking with physician before taking any

Provide mechanical soft diet.

discomfort

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 & suctioning equipment nearby.

4. Dysphagia: cranial nerve involvement

3. Monitor respiratory status frequently: Rate, Depth, Vital Capacity; ability to deep breathe & cough

4. Assess muscle strength frequently; plan activity to take advantage of energy peaks & provide frequent rest periods.

5. Observe for signs of myasthenic or cholinergic crisis. MYASTHENIC CRISIS Abrupt onset of severe, generalized

5. Ascending muscle weakness leading to paralysis 6. Ventilatory insufficiency if paralysis ascends to respiratory muscles 7.

Absence or decreased deep tendon reflex

8.

Alternate hypotension to hypertension

CHOLINERGIC CRISIS 9. Arrythmia (most feared complication) Symptoms similar to myasthenic crisis & 10. Autonomic disfunction: symptoms that includes in addition the side effect of antia. increase salivation cholinesterase drugs (excessive b. increase sweating salivation & sweating, abdominal carmp, c. constipation N/V, diarrhea, fasciculation)

muscle weakness with inability to swallow, speak, or maintain respirations. Symptoms will improve temporarily with tensilon test.

Causes: under medication

(classically is ascending & symmetrical)

Cause:

Symptoms worsen with tensilon test: Dx keep Atropine Sulfate & emergency 1. CSF analysis: reveals increased in IgG and protein equipment on hand. 2. EMG: slowed nerve conduction

12

13 Medical Management Mode of transmission

1. Mechanical Ventilation: if respiratory problems present 2. Plasmapheresis: to reduce circulating antibodies

1. Airborne transmission (droplet nuclei)

3. Continuous ECG monitoring to detect alteration in heart rate

2.

& rhythm

3. By direct extension from adjacent cranial structures (nasal, sinuses, mastoid bone, ear, skull fracture)

4. Propranolol: to prevent tachycardia 5. Atropine SO4: may be given to prevent episodes of

Via blood, CSF, lymph

4.

By oral or nasopharyngeal route

bradycardia during endotracheal suctioning & physical Signs and Symptoms

therapy 2.

1.

2. 3.

4.

Headache, photophobia, general body malaise, irritability,

Nursing Intervention

3. Projectile vomiting: due to increase ICP

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:

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

Assess cranial nerve function:

backward & body arched forward

a.

Check gag reflex

b.

Swallowing ability

hamstring muscles when attempting to extend the leg

c.

Ability to handle secretion

when the hip is flexed

d.

Voice

c. PS: Kernig’s sign (leg pain): contraction or pain in the

d. PS: Brudzinski sign (neck pain): flexion at the hip & knee

Monitor strictly the following: a.

Vital signs

b.

Input and output

c.

Neuro check

d. ECG: due to arrhythmia

in response to forward flexion of the neck

Dx

1. Lumbar Puncture:

e. Observe signs of autonomic dysfunction: acute period of

Measurement & analysis of CSF shows increased

hypertension fluctuating with hypotension

5.

f.

Tachycardia

g.

Arrhythmias

pressure, elevated WBC & CHON, decrease glucose & culture positive for specific M.O. A hollow spinal needle is inserted in the subarachnoid

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 7.

Nursing Management Before Lumbar Puncture

Assist in passive ROM exercise

8. Promote comfort (especially in clients with sensory changes): a.

Foot cradle

b.

Sheepskin

c.

Guided imagery

d.

Relaxation techniques

Check gag reflex before feeding

b.

Start with pureed food

Secure informed consent and explain procedure.

2.

Empty bladder and bowel to promote comfort.

3.

Encourage to arch back to clearly visualize L3-L4. Nursing Management Post Lumbar Puncture

1. Place flat on bed 12 – 24 o

9. Promote optimum nutrition: a.

1.

2.

Force fluids

3.

Check punctured site for any discoloration, drainage and leakage to tissues.

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 – 100 mmHg)

Atrophine Sulfate

4. (+) cultured microorganism (confirms meningitis)

c. Anti Arrythmic Agents: Lidocaine (Xylocaine)

CBC reveals

Bretylium: blocks release of norepinephrine; to

1.

prevent increase of BP

11. Assist in plasmapheresis (filtering of blood to remove autoimmune anti-bodies)

12. Prevent complications: a.

Arrythmia

b.

Paralysis of respiratory muscles / respiratory arrest

Nursing Management 1.

b. Mild analgesics: for headaches c. Antipyretics: for fever 2. Enforced strict respiratory isolation 24 hours after initiation of anti biotic therapy (for some type of meningitis)

14. Refer for rehabilitation to regain strength & treat any residual deficits.

Administer large doses of antibiotic IV as ordered:

a. Broad spectrum antibiotics (Penicillin, Tetracycline)

13. Provide psychologic support & encouragement to client / significant others

Increase WBC

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 Inflammation of the meninges of the brain & spinal cord.

5.

Enforce complete bed rest

6. Keep room quiet & dark: if the client has headache & photophobia

Cause by bacteria, viruses, & other M.O. 7.

Monitor strictly V/S, I & O & neuro check

Etiology / Most Common M.O.

8.

Maintain fluid & electrolyte balance

1. Meningococcus: most dangerous

9.

Prevent complication of immobility

2.

Pneumococcus

3. Streptococcus: cause of adult meningitis 4. Hemophilus Influenzae: cause of pediatric meningitis

10. Provide client teaching & discharge planning concerning:

a. Importance of good diet: high CHON, high calories with small frequent feedings. b.

Rehabilitation program for residual deficit

13

14

mental retardation

8. Prolong use of oral contraceptives: promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead

delayed psychomotor development c.

to hypertension & eventually CVA.

Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication

Pathophysiology

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. Cerebrovascular Accident (CVA) (Stroke/Brain

2.

Modifying Factors: a.

Attack/Apoplexy/Cerebral Thrombosis)

Cerebral Edema: Develops around affected area causing further

Destruction (infarction) of brain cells caused by a reduction

impairment

in cerebral blood flow and oxygen

b.

A partial or complete disruption in the brains blood supply.

Vasospasm: Constriction of cerebral blood vessel may occur,

2 largest & most common cerebral artery affected by stroke: a.

Mid Cerebral Artery

b.

Internal Cerebral Artery

causing further decrease in blood flow c.

Collateral Circulation: May help to maintain cerebral blood flow when there

Incidence Rate: a.

is compromise of main blood supply

Affects men more than women; Men are 2-3 times high risk; Incidence increase with age

Causes:

Stages of Development

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. c.

Hemiparesis

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

5.

Palpitations

6.

Diaphoresis

7.

Mild restlessness

c.

May last less than 30 sec, but no more than 24 hrs with complete resolution of symptoms

2.

Stroke in Evolution 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 Compartment syndrome

1. Fat embolism is the most feared complications w/in 24 hrs after a femur fracture.

S/sx 1.

Headache

2.

Generalized Signs: Vomiting Seizure

Yellow bone marrow are produced from the

Confusion

medullary cavity of the long bones and produces

Disorientation

fat cells. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. Risk Factors Disease:

Decrease LOC Nuchal Rigidity Fever Hypertension Slow Bounding Pulse Cheyne-Strokes Respiration

1.

Hypertension

(+) Kernig’s & Brudzinski sign: may lead to hemorrhagic

2.

Diabetes Mellitus

stroke

3.

Atherosclerosis / Arteriosclerosis

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 Lifestyle:

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

Dysarthia: inability to articulate words Alexia: difficulty reading Agraphia: difficulty writing

1.

Smoking

2.

Sedentary lifestyle

3.

Obesity (increase 20% ideal body weight)

4.

Hyperlipidemia more on genetics/genes that binds to

1. CT & Brain Scan: reveals brain lesions

cholesterol

2. EEG: abnormal changes

Type A personality

3. Cerebral Arteriography: invasive procedure due to injection

5.

Dx

a.

Deadline driven

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

of dye (iodine based); Uses dye for visualization

6. Related to diet: increase intake of saturated fats like whole milk 7.

Related stress physical and emotional

Nursing Management Post Cerebral Arteriography Allergy Test (shellfish)

14

15 b. Prevent complication (subarachnoid hemorrhage is

Force fluids to release dye because it is nephro toxic

the most feared complication)

Check for peripheral pulse: distal (femoral)

c. Dietary modification (decrease salt, saturated fats

Check for hematoma formation

and caffeine) d.

Nursing Intervention: Acute Stage 1.

Importance of follow up care

Maintain patent airway and adequate ventilation by: a.

Assist in mechanical ventilation

b.

Administer O2 inhalation

Nursing Intervention: Rehabiltation

1. Hemiplegia: results from injury to cell in the cerebral motor

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

2.

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 5.

d. Elevate extremities to prevent dependent edema

Maintain proper positioning & body alignment:

e.

Elevate head 30-45 degree to decrease ICP

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.

Inspect body parts frequently for signs of injury

2.

c. Passive ROM exercise every 4 hrs: prevent contractures; promote body alignment

8.

a.

Check for gag reflex before feeding client

every 2 hrs

b.

Maintain a calm, unhurried approach

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

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 necessary

b. Administer stool softener & suppositories as ordered: to prevent constipation & fecal impaction 9.

Susceptibility to hazard

3. Dysphagia: difficulty of swallowing

6. Promote optimum skin integrity: turn client & apply lotion 7.

Provide active & passive ROM exercises every 4 hrs

a.

visual field a.

Approach the client on unaffected side

b.

Place personal belongings, food etc., on unaffected side

c. Gradually teach the client to compensate by scanning

Provide quiet, restful environment

(ex. Turning the head to see things on affected side)

10. Provide alternative means of communication to the client: a.

Non verbal cues

5. Emotional Lability: mood swings, frustrations a.

b. Magic slate: not paper & pen tiring for client

Create a quiet, restful environment with a reduction in excessive sensory stimuli

c. If positive to hemianopsia: approach client on unaffected side

b.

Maintain a calm, non-threatening manner

c.

Explain to family that client’s behavior is not purposeful

6. Aphasia: most common in right hemiplegics; may be

11. Administer medications as ordered:

a. Hyperosmotic agent: to decrease cerebral edema

receptive / expressive a.

Osmotic Diuretics (Mannitol)

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 c. Thrombolytic / Fibrinolytic Agents: given to dissolve clot (hemorrhage must be ruled out)

Pantomime, demonstration) b.

Expressive Aphasia 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 (hemorrhage must be ruled out)

Allow sufficient time for client to answer

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

b.

Provide safety measures

c.

Initially arrange objects in environment on unaffected

Warfarin (Comadin): long acting / long term therapy Give simultaneously with Heparin cause Warfarin (Coumadin) will take effect after 3 days Check for Prothrombin Time (PT): if prolonged there is a risk for bleeding

side d.

Gradually teach client to take care of the affected & turn frequently & look at affected side

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.

Contraindicated for dengue, ulcer and unknown

Keep repeating the movement

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.

behavior

Mild Analgesics: for pain

12. Provide client health teachings and discharge planning

Use safety measures, verbal cues, simplicity in all

concerning

a. Avoid

area of care modifiable

smoking)

risk

factors

(diet,

exercise,

b.

Right Hemiplegia Speech-language deficits: slow & cautious behavior

15

16

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

7. Sudden withdrawal to anti-convulsant drug: is predisposing factor for status epilepticus: DOC: Diazepam (Valium) &

C. Diagnostic Procedures 1. CT Scan – reveals brain lesions 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 1.

a. clear the site of blunt or sharp objects

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 a. Anti convulsants (Dilantin, Phenytoin)

Tonic Phase:

b. Diazepam, Valium

Limbs contract or stiffens

c. Carbamazepine (Tegnetol) – trigeminal neuralgia

Pupils dilated & eye roll up to one side Glottis closes: causing noise on exhalation

d. Phenobarbital, Luminal 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 d. assist in surgical procedure cortical resection

repetitive movement increase mucus production slowly tapers Clonic contractions: contraction of extremities Postictal sleep: unresponsive sleep

Overview Anatomy & Physiology of the Eye External Structure of Eye

a. Eyelids (Palpebrae) & Eyelashes: protect the eye from

Seizure ends with postictal period of confusion, drowsiness

b. Absence Seizure (Petit mal Seizure):

foreign particles

b. Conjunctiva: Palpebral Conjunctiva: pink; lines inner surface of

Usually non-organic brain damage present

eyelids

Must be differentiated from daydreaming

Bulbar Conjunctiva: white with small blood vessels,

Sudden onset with twitching & rolling of eyes that last 20-40 sec

covers anterior sclera

c. Lacrimal Apparatus (lacrimal gland & its ducts & passage):

Common among pediatric clients characterized by:

produces tears to lubricate the eye & moisten the cornea;

Blank stare

tears drain into the nasolacrimal duct, which empties into

Decrease blinking of eyes

nasal cavity

Twitching of mouth

d. The movement of the eye is controlled by 6 extraocular muscles (EOM)

Loss of consciousness (5 – 10 seconds) 2.

Partial or Localized Seizure Begins in focal area of brain & symptoms are related to a dysfunction of that area

Internal Structure of Eye A.

3 layers of the eyeball 1.

a. Sclera: tough, white connective tissue (“white of the

May progress into a generalized seizure

eye”); located anteriorly & posteriorly

a. Jacksonian Seizure (focal seizure)

b. Cornea: transparent tissue through which light

characterized by tingling and jerky movement of

enters the eye; located anteriorly

index finger and thumb that spreads to the shoulder and other side of the body.

b. Psychomotor Seizure (focal motor seizure) May follow trauma, hypoxia, drug use Purposeful but inappropriate repetitive motor acts

Outer Layer

2.

Middle Layer

a. Choroid: highly vascular layer, nourishes retina; located posteriorly

b. Ciliary Body: anterior to choroid, secrets aqueous humor; muscle change shape of lens

16

17 c. Iris: pigmented membrane behind cornea, gives

4. Amblyopia: prolong squinting

color to eye; located anteriorly

d. Pupil: is circular opening in the middle of the iris that constrict or dilates to regulate amount of light

Common Visual Disorder Glaucoma Characterized by increase intraocular pressure resulting in

entering the eye 3.

Inner Layer

progressive loss of vision

a. Light-sensitive layer composed of rods & cones

May cause blindness if not recognized & treated Early detection is very important

(visual cell) 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, has no photoreceptors

B. Lens: transparent body that focuses image on retina C. Fluid of the eye

1. Aqueous Humor: clear, watery fluid in anterior &

1.

Common among 40 years old and above

2.

Hereditary

3.

Hypertension

4.

Obesity

5.

History of previous eye surgery, trauma, inflammation

posterior chambers in anterior part of eye; serves as refracting medium & provides nutrients to lens & cornea; contribute to maintenance of intraocular pressure

Types of Glaucoma:

1. Chronic (open-angle) Glaucoma: 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

2. Acute (close-angle) Glaucoma:

Visual Pathways

Due to forward displacement of the iris against the

a. Retina (rods & cones) translates light waves into neural b.

impulses that travel over the optic nerves

cornea, obstructing the outflow of the aqueous humor

Optic nerves for each eye meet at the optic chiasm

Occurs suddenly & is an emergency situation If untreated it will result to blindness

Fibers from median halves of the retinas cross here & 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

1. Chronic (open-angle) Glaucoma: symptoms develops slowly

impulses are perceived & interpreted

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 Maculla lutea: yellow spot center of retina Fovea centralis: area with highest visual acuity or acute vision

Loss of central vision if unarrested

2. Acute (close-angle) Glaucoma 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 Normal eye refraction: emmetropia

1. Visual Acuity: reduced 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

3. Ophthalmoscopic exam: reveals narrowing of small vessels

Error of Refraction

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: Medical Management

Treatment: bifocal lens or double vista

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

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

Epinephrine eye drops: to decrease aqueous humor 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

17

18 b.

Filtering procedure (Trabeculectomy / Trephining): to

same day surgery unit

create artificial openings for the outflow of aqueous 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 implant); partial removal of lens

2. Acute (close-angle) Glaucoma

Phacoemulsification: type of extracapsular

a. Drug Therapy: before surgery

extraction; a hollow needle capable of ultrasonic

Miotics eye drops (Pilocarpine): to cause pupil to

vibration is inserted into lens, vibrations emulsify

contract & draw iris away from cornea

the lens, which is aspirated

Osmotic Agent (Glycerin oral, Mannitol IV): to

Intracapsular Extraction: lens is totally removed

decrease intraocular pressure (IOP)

within its capsules, may be delivered from eye by

Narcotic Analgesic: for pain b.

cryoextraction (lens is frozen with metal probe &

Surgery

removed); total removal of lens & surrounding

Peripheral Iridectomy: portion of the iris is excised to

capsules

facilitate outflow of aqueous humor

e. Peripheral Iridectomy: may be performed at the time of

Argon Laser Beam Surgery: non-invasive procedure

surgery; small hole cut in iris to prevent development of

using laser produces same effect as iridectomy;

secondary glaucoma

done in out-client basis

f.

Iridectomy: usually performed on second eye later since a large number of client have an acute acute

Intraocular Lens Implant: often performed at the time of surgery

2.

attack in the other eye

Nursing Intervention Pre-op a.

3. Chronic (close-angle) Glaucoma

Assess vision in the unaffected eye since the affected eye will be patched post-op

a. Drug Therapy:

b. Provide pre-op teaching regarding measures to prevent intraocular pressure (IOP) post-op

miotics (pilocarpine) b.

Surgery performed on one eye at a time; usually in a

c.

Surgery:

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

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 a.

3.

Nursing Intervention Post-op

Elevate side rails

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.

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 d.

Importance of follow-up care

e.

Need to wear medic-alert tag

Prevent intraocular pressure & stress on the suture line:

Avoid having the client cough, sneeze, bend over, or move head too rapidly 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):

1.

Predisposing Factor

Severe eye pain

Aging 65 years and above

Restlessness Increased pulse

2. May caused by changes associated with aging (“senile” cataract) 3.

4.

Related to congenital

4. May develop secondary to trauma, radiation, infection, certain drugs (corticosteroids) 5.

Diabetes Mellitus

6.

Prolonged exposure to UV rays

5.

Protect eye from injury: a.

Dressing usually removed the day after the surgery

b.

Eyeglasses or eye shield used during the day

c.

Always use eye shield during the night

Administer medication as ordered:

a. Topical mydriatics & cycloplegic: to decrease spasm of ciliary body & relieve pain

S/sx

b.

Topical antibiotics & corticosteroids

1.

Loss of central vision

c.

Mild analgesic as needed

2.

Blurring or hazy vision

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

6.

Provide client teaching & discharge planning concerning:

to physician: Severe eye pain

Diagnostic Procedure

1. Ophthalmoscopic exam: confirms presence of cataract

Decrease vision Excessive drainage

Nursing Intervention 1.

Prepare client for cataract surgery: a.

Swelling of eyelid e.

Cataract glasses / contact lenses

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

18

19 g. Need to report complications such as recurrence of

Temporary glasses are worn for 1-4 weeks then permanent glasses fitted

detachment

Cataract glasses magnify object by 1/3 & distortion peripheral vision Have the client practice manual coordination with assistance until new spatial relationship

Overview of Anatomy & Physiology Of Ear (Hearing) External Ear

1. Auricle (Pinna): outer projection of ear composed of cartilage & covered by skin; collects sound waves

becomes familiar Have client practice walking, using stairs,

2. External Auditory Canal: lined with skin; glands secretes cerumen (wax), providing protection; transmits sound waves

reaching for articles

to tympanic membrane

Contact lenses cause less distortion of vision; 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 epithelium of the retina

Middle Ear 1.

Ossicles

a. 3 small bones: malleus (Hammer) attached to tympanic membrane, incus (anvil), stapes (stirrup)

Predisposing Factors 1.

Trauma

2.

Aging process

3.

Severe diabetic retinopathy

4.

Post-cataract extraction

b.

Ossicles are set in motion by sound waves from tympanic membrane

c. Sound waves are conducted by vibration to the 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 1.

S/sx

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

1. Bed rest with eye patched & detached areas dependent to

Composed of three semicircular canals & the utricle 3.

Endolymph & Perilymph

prevent further detachment

2. Surgery: necessary to repair detachment a. Photocoagulation: light beam (argon laser) through

For static equilibrium 4.

Mastoid air cells Air filled spaces in temporal bone in skull

dilated pupil creates an inflammatory reaction & scarring to heal the area

b. Cryosurgery or diathermy: application of extreme cold or

Disorder of the Ear 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 This prevent transmission of auditory vibration to the

c. Scleral buckling: shortening of sclera to force pigment

inner ear

epithelium close to retina

Predisposing Factor

Nursing Intervention Pre-op 1.

Maintain bed rest as ordered with head of bed flat &

1.

Found more often in women

detached area in a dependent position Cause

2. Use bilateral eye patches as ordered; elevate side rails to 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 S/sx

5. Provide diversional activities to provide sensory stimulation Nursing Intervention Post-op 1.

Check orders for positioning & activity level: a.

May be on bed rest for 1-2 days

b.

May need to position client so that detached area is in dependent position

2.

3.

Administer medication as ordered: a.

Topical mydriatics

b.

Analgesic as needed

Provide client teaching & discharge planning concerning:

1.

Progressive hearing loss

2.

Tinnitus Dx

1. Audiometry: reveals conductive hearing loss 2. Weber’s & Rinne’s Test: show bone conduction is greater than air conduction Medical Management

1. Stapedectomy: procedure of choice

a.

Techniques of eyedrop administration

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

19

20 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 Nursing Intervention Post-op

Fentanyl & Droperidol (Innovar) 2.

Chronic:

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)

Mild sedative or tranquilizers: Diazepam

2. Have the client deep breathe every 2 hours while in bed,

(Valium)

but no coughing

Antihistamines: Diphenhydramine (Benadryl)

3. Elevate side rails; assist the client with ambulation & move slowly: may have some vertigo

Meclizine (antivert)

4. Administer medication as ordered:

b.

Analgesic

Low sodium diet

Antibiotics

Restricted fluid intake

Anti-emetics

Restrict caffeine & nicotine

Anti-motion sickness drug: Meclesine Hcl

3.

Surgery:

a. Surgical destruction of labyrinth causing loss of

(Bonamine) 5.

Check for dressing frequently for excessive drainage or

vestibular & cochlear function (if disease is

bleeding

unilateral) b.

6. Assess facial nerve function: Ask the client to do the ff:

c. Endolymphatic sac decompression or shunt to

Close eyelids

equalize pressure in endolymphatic space

Puff out checks for any asymmetry

7. Question the client about the ff: report existence to physicians Pain Headaches Vertigo Unusual sensations in the ear Provide client teaching & discharge planning concerning:

a. Warning against blowing nose or coughing; sneeze with mouth open

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

c. No flying for 6 mos. Especially if upper respiratory

Intracranial division of vestibular portion of cranial nerve VIII

Wrinkle forehead

8.

Diet:

Nursing Intervention 1.

Maintain bed rest in a quiet, darkened room in position of choice; elevate side rails as needed

2. Only move the client for essential care (bath may not be essential)

3. Provide emesis basin for vomiting 4.

Monitor IV Therapy; maintain accurate I&O

5.

Assist in ambulation when the attack is over

6.

Administer medication as ordered

7. Prepare client for surgery as indicated (pot-op care includes using above measures)

8. Provide client care & discharge planning concerning:

tract infection is present

d. Placement of cotton balls in auditory meatus after

a.

Use of medication & side effects

b.

Low sodium diet & decrease fluid intake

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

Endocrine System Is composed of an interrelated complex of glands (Pituitary

Characterized by recurrent & usually progressive triad of

G, Adrenal G, Thyroid G, Parathyroid G, Islets of langerhans

symptoms: vertigo, tinnitus, hearing loss

of the pancreas, Ovaries & Testes) that secretes a variety of hormones directly into the bloodstream.

Predisposing Factor 1.

Incidence highest between ages 30 & 60 Cause

2.

Unknown / idiopathic

3.

Theories include the ff: a.

Allergy

b.

Toxicity

c.

Localized ischemia

d.

Hemorrhage

e.

Viral infection

f.

Edema

S/sx 1.

Sudden attacks of vertigo lasting hours or days; attacks occurs several times a year

2.

N/V

3.

Tinnitus

4.

Progressive hearing loss

5.

Nystagmus Dx

1. Audiometry: reveals sensorineural hearing loss 2. Vestibular Test: reveals decrease function Medical Management 1.

Acute:

Its major function, together with the nervous system: is to regulate body function Hormones Regulation

1. Hormones: chemical substance that acts s messenger to specific cells & organs (target organs), stimulating & inhibiting various processes Two Major Categories

a. Local: hormones with specific effect in the area of secretion (ex. Secretin, cholecystokinin, panceozymin [CCK-PZ])

b. General: hormones transported in the blood to distant sites where they exert their effects (ex. Cortisol)

2. Negative Feedback Mechanisms: major means of regulating hormone levels a.

Decreased concentration of a circulating hormones triggers production of a stimulating hormones from pituitary gland; this hormones in turn stimulates its target organ to produce hormones

b.

Increased concentration of a hormones inhibits production of the stimulating hormone, resulting in decreased secretion of the target organ hormone

3. Some hormones are controlled by changing blood levels of specific substances (ex. Calcium, glucose)

4. Certain hormones (ex. Cortisol or female reproductive hormones) follow rhythmic patterns of secretion

5. Autonomic & CNS control (pituitary-hypothalamic axis): hypothalamus controls release of the hormones of the

20

21 anterior pituitary gland through releasing & inhibiting

Beta Cells

factors that stimulate or inhibits hormone secretions

diffuse across cell membrane;

: Insulin

: allows glucose to Converts glucose to

Hormone Function Endocrine G

glycogen Hormone

Functions

Alpha Cells

Pituitary G

: Glucagon

: increase blood

glucose by causing glyconeogenisis

Anterior lobe

: TSH

: stimulate

& glycogenolysis in

thyroid G to release thyroid hormones : ACTH

the liver; secreted in : stimulate adrenal

response to

cortex to produce &

low blood sugar

release : FSH, LH

adrenocoticoids

Ovaries

: stimulate growth,

development of secondary sex characteristics in the

: Estrogen, Progesterone

maturation, & function of primary

:

Female, & secondary sex

maturation

of sex organ, sexual functioning

organ

Maintenance of : GH, Somatotropin

: stimulate growth of

body tissues & bones

pregnancy Testes

: Prolactin or LTH

: stimulate

: Testosterone

development of mammary gland &

: ADH

development

of

Male maturation of Lactation

Posterior lobe

:

secondary sex characteristics in the the sex organs, sexual functioning

: 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 : Oxytocin

target glands to produce their hormones):

: stimulate uterine

adrenocorticotropic H (ACTH), thyroid-stimulating H

contractions during delivery & the

(TSH), follicle-stimulating H (FSH), luteinizing H (LH)

Release of milk in

ACTH: promotes development of adrenal cortex

lactation Intermediate lobe

: MSH

LH: secretes estrogen

: affects skin

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 : Glucocorticoids

Hypersecretion of GH: among children results to

: increase

gigantism

blood glucose level by increasing rate of (ex. Cortisol,

Hypersecretion of GH: among adults results to

glyconeogenesis;

acromegaly (square face)

increase CHON catabolism; increase corticosterone)

DOC: Ocreotide (Sandostatin)

mobilization of fatty

Prolactin: promotes development of mammary

acid; promote sodium & H2O

gland; with help of oxytocin it initiates milk let

retention; anti-inflammatory effect; aid body in

down reflex

coping c.

with stress : Sex Hormones

& by negative feedback system

: influence

2. Posterior Lobe PG (Neurohypophysis)

development of secondary sex

Adrenal Medulla

(androgens, estrogens characeristics

Does not produce hormones

progesterones)

Store & release anti-diuretic hormones (ADH) & oxytocin

: 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 Thyroid G

Regulated by hypothalamic releasing & inhibiting factors

Initiates milk let down reflex with help of hormone : T3, T4

: regulate metabolic

rate; CHO, fats, & CHON Metabolism;

aid

in

prolactin 3.

Intermediate Lobe PG Secretes melanocytes stimulating H (MSH) 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

21

22 2 Sections of Adrenal Glands

1. Adrenal Cortex (outer portion): produces mineralocorticoids, glucocorticoids, sex hormones 3 Zones/Layers

Anti-diuretic Hormone: Pitressin (Vasopressin) Function: prevents urination thereby conserving water Note: Alcohol inhibits release of ADH

Zona Fasciculata: secretes glucocortocoids (cortisol): controls glucose metabolism: Sugar

Predisposing Factor

Zona Reticularis: secretes traces of glucocorticoids & androgenic hormones: promotes secondary sex

1.

Related to pituitary surgery

characteristics: Sex

2.

Trauma

3.

Inflammation

4.

Presence of tumor

Zona Glumerulosa: secretes mineralocorticoids (aldosterone): promotes sodium and water reabsorption and excretion of potassium: Salt

2. Adrenal Medulla (inner portion): produces epinephrine, norepinephrine (secretes catecholamines a power hormone): vasoconstrictor 2 Types of Catecholamines: Epinephrine (vasoconstrictor) Norepinephrine (vasoconstrictor)

o

S/sx 1.

Severe polyuria with low specific gravity

2. Polydipsia (excessive thirst) 3.

Fatigue

4.

Muscle weakness

5.

Irritability

6.

Weight loss

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 3 Hormones Secreted:

Dx

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 Nursing Intervention

activity; promotes cerebration (thinking); increase V/S

1.

Thyrocalcitonin: antagonizes the effects of parathormone to promote calcium reabsorption. Parathyroid Gland 4 small glands located in pairs behind the thyroid gland Produce parathormone (PTH)

2.

Maintain F&E balance / Force fluids 2000-3000 ml/day a.

Keep accurate I&O

b.

Weigh daily

c.

Administer IV/oral fluids as ordered to replace fluid loss

Monitor strictly V/S & observe for signs of dehydration & hypovolemia

3. Administer hormone replacement as ordered: 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) Consist of Acinar Cells (exocrine gland): which secretes pancreatic juices: that aids in digestion Islets of langerhans (alpha & beta cells) involved in

b. Lypressin (Diapid): nasal spray 4. Prevent complications: hypovolemic shock is the most feared complication 5.

endocrine function:

Provide client teaching & discharge planning concerning:

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:

Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH)

antagonizes the effects of growth hormones)

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

Gonads Predisposing Factors

Ovaries: located in pelvic cavity; produce estrogen & progesterone

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 Non invasive procedure is chest x-ray

Pineal Gland 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)

Diabetes Incipidus (DI) DI: dalas-ihi Decrease of anti-diuretic hormone (ADH) Hyposecretion of ADH Hypofunction of the posterior pituitary gland (PPG) resulting

S/sx 1.

Person with SIADH cannot excrete a dilute urine

2.

Fluid retention & Na deficiency a.

Hypertension

b.

Edema

c.

Weight gain

3. Water intoxication: may lead to cerebral edema: lead to increase ICP; may lead to seizure activity

in deficiency of ADH Characterized by excessive thirst & urination

Dx

22

23 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

2.

Diuretics & fluid restriction

Dx

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 serum Na

(confirmatory diagnostic test)

4. RAIU (Radio Active Iodine Uptake): normal or increased

2. Administer medications as ordered: a. Loop diuretics (Lasix) b. Osmotic diuretics (Mannitol)

Medical Management 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 - all are decrease except weight and menstruation

Nursing Intervention 1.

- memory impairment

Administer Replacement therapy as ordered:

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.

HYPERTHYROIDISM

Thyroid Hormones: Levothyroxine (Synthroid)

- all are increase except weight and menstruation Signs and Symptoms

Liothyronine (Cytomel)

- increase appetite but there is weight loss

Thyroid Extracts

- amenorrhea Nursing Intervention when giving Thyroid Hormones:

- exophthalmos

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 3.

Enlargement of thyroid gland due to iodine deficiency 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 adolescence & pregnancy Goiter belt area: a.

Midwest, northwest & great lakes region

b.

Places far from sea

c.

Mountainous regions

2. Sporadic: caused by Increase intake of goitrogenic foods (contains agent that decrease the thyroxine production: pro-goitrin an antithyroid agent that has no iodine). Ex. cabbage, turnips, radish, strawberry, carrots, sweet potato, rutabagas, peaches, peas, spinach, broccoli, all nuts Soil erosion washes away iodine Goitrogenic drugs:

a. Anti-Thyroid Agent: Propylthiouracil (PTU)

3.

Monitor side effects:

b.

Large doses of iodine

c.

Phenylbutazone

d.

Para-amino salicylic acid

e.

Lithium Carbonate

f.

PASA (Aspirin)

g.

Cobalt

Genetic defects that prevents synthesis of thyroid hormones

destroyed by heat 3.

Assist in surgical procedure of subtotal thyroidectomy

4.

Provide client teaching & discharge planning concerning: Used of iodized salt in preventing & treating endemic goiter Thyroid hormone replacement

Hypothyroidism (Myxedema) Slowing of metabolic processes caused by hypofunction of the thyroid gland with decreased thyroid hormone secretion Hyposecretion of thyroid hormone Decrease in all V/S except wt & menses Adults: myxedema non pitting edema Children: cretinism the only endocrine disorder that can lead to mental retardation In severe or untreated cases myxedema coma may occur: Characterized by intensification of S/sx of hypothyroidism & neurologic impairment leading to coma Mortality rate high; prompt recognition & treatment essential Precipitating factors: failure to take prescribed

S/sx 1.

Enlarged thyroid gland

medications; infection; trauma; exposure to cold; use of sedatives, narcotics or anesthetics

23

24 3. Provide comfortable and warm environment: due to cold Predisposing Factors

1. Primary hypothyroidism: atrophy of the gland possibly caused by an autoimmune process

intolerance 4.

Provide a low calorie diet

5.

Avoid the use of sedatives; reduce the dose of any sedatives, narcotics, or anesthetic agent by half as

2. Secondary hypothyroidism: caused by decreased

ordered

stimulation from pituitary TSH

3. Iatrogenic: surgical removal of the gland or over

6.

breakdown

treatment of hyperthyroidism with drugs or radioactive 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, 5.

8. Observe for signs of myxedema coma; provide

presence of tumor, inflammation

appropriate nursing care

Iodine deficiency

a.

6. Autoimmune (Hashimotos Disease) 7.

Provide meticulous skin care: to prevent skin

Administer medication as ordered

b. Maintain vital functions:

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.

case

Anorexia

3. Weight gain: which promotes lipolysis leading to

A severe form of hypothyroidism is characterized by:

atherosclerosis and MI 4.

Constipation

5.

Cold intolerance

6.

Dry scaly skin

7.

Spares hair

8.

Brittleness of nails

Severe hypotension Bradycardia Bradypnea Hypoventilation Hyponatremia Hypoglycemia

9. Decrease in all V/S: except wt gain & menses 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 ordered / Force fluids

13. Slow clumsy movement 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

1. Serum T3 and T4: is decreased 2. Serum Cholesterol: is increased 3. RAIU (Radio Active Iodine Uptake): is decreased Medical Management

1. Drug Therapy: Levothyroxine (Synthroid) Thyroglobulin (Proloid)

f.

Stress & infection

g.

Use of anesthetics, narcotics, and sedatives

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

Dessicated thyroid Liothyronine (Cytomel) 2.

Myxedema coma is a medical emergency: IV thyroid hormones

Predisposing Factors 1.

More often seen in women between ages 30 & 50

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 S/sx

1. Monitor strictly V/S & I&O, daily weights; observe for edema & signs of cardiovascular complication & to

1. Increase appetite (hyperphagia): but there is weight loss

determine presence of myxedema coma

2.

Heat intolerance

3.

Weight loss

2. Administer thyroid hormone replacement therapy as 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

Sweating Tremors Agitation Dyspnea b.

Increase dosage gradually, especially in clients with cardiac complication

6.

Warm smooth skin

7.

Fine soft hair

8.

Pliable nails

9.

CNS involvement a.

Irritability & agitation

b.

Restlessness

c.

Tremors

24

25 d.

Insomnia

7.

Delirium

e.

Hallucinations

8.

Coma

f.

Sweating

g.

Hyperactive movement

10. Goiter

Nursing Intervention 1.

administer O2 as ordered

11. PS: Exopthalmus (protrusion of eyeballs) 12. Amenorrhea

Maintain patent airway & adequate ventilation;

2.

Administer IV therapy as ordered

3.

Administer medication as ordered: 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

Dx

3. Thyroid Scan: reveals an enlarged thyroid gland Medical Management 1.

Drug Therap:

a. Anti-thyroid drugs: Propylthiouracil (PTU) &

Thyroidectomy Partial or total removal of thyroid gland Indication:

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 symptoms such as tachycardia 2.

Nursing Intervention Pre-op 1.

Ensure that the client is adequately prepared for surgery

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.

the production of thyroid hormone & to prevent thyroid

production of thyroid hormone b. c.

storm

Used in middle-aged or older clients who are resistant to, or develop toxicity from drug therapy

Administer anti-thyroid drugs as ordered: to suppressed

3.

Administer iodine preparation Lugol’s Solution (SSKI) or Potassium Iodide Solution: to decrease vascularity of the

Hypothyroidism is a potential complication

thyroid gland & to prevent hemorrhage.

3. Surgery: Thyroidectomy performed in younger client for whom drug therapy has not been effective

Nursing Intervention Post-Op Nursing Intervention 1.

Monitor strictly V/s & I&O, daily weight

2.

Administer anti-thyroid medications as ordered:

a. Propylthiouracil (PTU)

1.

2. Check dressing for signs of hemorrhage: check for wetness behind the neck 3.

Provide for period of uninterrupted rest:

Place client in semi-fowlers position & support head with pillow

b. Methimazole (Tapazole) 3.

Monitor V/S & I&O

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

5. Assess for signs of tetany: due to hypocalcemia: due to

4.

Provide comfortable and cold environment

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,

8.

calories, vitamin & minerals with supplemental feeding

which may lead to hypocalcemia (tetany)

between meals & at bedtime; omit stimulant

Classic S/sx of Tetany

Observe for & prevent complication

Positive trousseu’s sign

a. Exophthalmos: protects eyes with dark glasses &

Positive chvostek sign

b. 9.

Watch out for accidental removal of parathyroid

artificial tears as ordered

Observe for arrhythmia, seizure: give Calcium

Thyroid Storm

Gluconate IV slowly as ordered

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: 13. Provide client teaching & discharge planning

any accompanying respiratory distress

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 b.

Agitation

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 1.

Stress

2.

Infection

3.

unprepared thyroid surgery

Hyperthermia Tachycardia Administer medications as ordered: Anti Pyretics Beta-blockers

S/sx 1.

Apprehension

2.

Restlessness

3. Extremely high temp (up to 106 F / 40.7 C) 4.

Tahchycardia

5.

HF

6.

Respiratory Distress

Monitor strictly vital signs, input and output and neuro check. Maintain side rails Offer TSB

8. Administer IV fluids as ordered: until the client is tolerating fluids by mouth

9. Administer analgesics as ordered: for incisional pain

25

26 10. Relieve discomfort from sore throat: a.

Cool mist humidifier to thin secretions

b.

Administer analgesic throat lozenges before meals

Nursing Management

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: a.

S/sx of hyperthyroidism & hypothyroidism

b.

Self administration of thyroid hormone: if total

Drug

Diet (Calcidiol) Sunlight (Calcitriol)

thyroidectomy is performed c.

Phosphate Binder: Aluminum Hydroxide Gel

Application of lubricant to the incision once suture is

(Amphogel) or aluminum carbonate gel, basic

removed d.

Perform ROM neck exercise 3-4 times a day

e.

Importance of follow up care with periodic serum

(basaljel): to decrease phosphate levels 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

4. Atrophy of parathyroid gland due to: inflammation, tumor, trauma S/sx

1. Acute hypocalcemia (tetany) a. Paresthesia: tingling sensation of finger & around lip b.

Muscle spasm

c.

laryngospasm/broncospasm

d.

Dysphagia

Side Effect: Constipation Side Effect: Diarrhea 2.

Institute seizure & safety precaution

3.

Provide quite environment free from excessive stimuli

4.

Avoid precipitating stimulus such as glaring lights and noise

5.

for Chvostek’s & Trousseau’s sign

6. Keep emergency equipment (tracheostomy set, injectable Calcium Gluconate) at bedside: for presence

e. Seizure: feared complications f.

Cardiac arrhythmia: feared complications

g.

Numbness

of laryngospasm

7. For tetany or generalized muscle cramp: may use rebreathing bag or paper bag to produce mild

h. Positive trousseu’s sign: carpopedal spasm i.

respiratory acidosis: to promote increase ionized Ca

Positive chvostek sign

2. Chronic hypocalcemia (tetany)

Monitor signs of hoarseness or stridor; check for signs

levels 8.

Monitor serum calcium & phosphate level Provide high-calcium & low-phosphorus diet

a.

Fatigue

9.

b.

Weakness

10. Provide client teaching & discharge planning

c.

Muscle cramps

concerning:

d.

Personality changes

a.

e.

Irritability

f.

Memory impairment

g.

Agitation

h.

Dry scaly skin

i.

Hair loss

j.

Loss of tooth enamel

d.

Prevent complications

k.

Tremors

e.

Hormonal replacement therapy for lifetime

l.

Cardiac arrhythmias

m. Cataract formation

Medication regimen: oral calcium preparation & vit D to be taken with meal to increase absorption

b.

Need to recognized & report S/sx of hypo/hypercalcemia

c.

Importance of follow-up care with periodic serum calcium level

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

Diagnostic Procedures

1. Serum Calcium level: decreased (normal value: 8.5 – 11 mg/100 ml)

Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood) Kidney stones

2. Serum Phosphate level: increased (normal value: 2.5 – 4.5 mg/100 ml)

3. Skeletal X-ray of long bones: reveals a increased in bone density

4. CT Scan: reveals degeneration of basal ganglia

Predisposing Factors 1.

Most commonly affects women between ages 35 & 65

2. Primary Hyperparathyroidism: caused by tumor & hyperplasia of parathyroid gland

26

27 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 Dx

S/sx 1. 2.

Bone pain (especially at back); Bone demineralization;

1. FBS: is decreased (normal value: 80 – 100 mg/dl)

Pathologic fracture

2. Plasma Cortisol: is decreased

Kidney stones; Renal colic; Polyuria; Polydipsia; Cool

3. Serum Sodium: is decrease (normal value: 135 – 145

moist skin 3.

Anorexia; N/V; Gastric Ulcer; Constipation

4.

Muscle weakness; Fatigue

5.

Irritability / Agitation; Personality changes; Depression;

meq/L)

4. Serum Potassium: is increased (normal value: 3.5 – 4.5 meq/L)

Memory impairment 6.

Cardiac arrhythmias; HPN

Nursing Intervention

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: Fludrocortisone Acetate (Florinef)

Nursing Intervention 1.

Administer IV infusions of normal saline solution & give Nursing Management when giving steroids

diuretics as ordered: 2.

1.

Monitor I&O & observe fluid overload & electrolytes

Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal

imbalance

diurnal rhythm

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

2. Taper dose (withdraw gradually from drug)

Moving, Ambulation: to prevent pathologic fracture

3.

4. Monitor V/S: report irregularities

Monitor side effects:

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

Hypertension

6. Provide acid-ash juices (ex. Cranberry, orange juice): to

Edema Hirsutism

acidify urine & prevent bacterial growth

7. Strain urine: using gauze pad: for stone analysis

Increase susceptibility to infection

8.

Moon face appearance

Provide low-calcium & high-phosphorus diet

9. Provide warm sitz bath: for comfort

2.

Monitor V/S

10. Administer medications as ordered: Morphine Sulfate

3.

Decrease stress in the environment

4.

Prevent exposure to infection

(Demerol) 11. Maintain side rails

5. Provide rest period: prevent fatigue

12. Assist in surgical procedure: Parathyroidectomy

6.

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: a.

Need to engage in progressive ambulatory activities

b.

Increase fluid intake

& hyponatremia & provide proper nutrition

8. Monitor I&O: to determine presence of addisonian crisis (complication of addison’s disease)

c. Use of calcium preparation & importance of highcalcium diet following a parathyroidectomy

d. Prevent complications: renal failure e.

Hormonal replacement therapy for lifetime

f.

Importance of follow up care

Weight daily

9.

Provide meticulous skin care

10. Provide

client

teaching

&

discharge

planning

concerning:

a. Disease process: signs of adrenal insufficiency b. Use of prescribe medication for lifelong replacement therapy: never omit medication

Addison’s Disease 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

Hyposecretion of adrenocortical hormone leading to: Metabolic disturbance: Sugar Fluid and electrolyte imbalance: Na, H2O, K

d.

Stress management technique

e.

Diet modification

f.

Use of salt tablet (if prescribe) or ingestion of salty foods (potato chips): if experiencing increase

Deficiency of neuromascular function: Salt, Sex

sweating g.

Predisposing Factors

1. Relatively rare disease caused by:

periods h.

Avoidance of strenuous exercise especially in hot weather

Idiopathic atrophy of the adrenal cortex: due to an autoimmune process

Importance of alternating regular exercise with rest

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.

hypovolemic shock

S/sx 1.

Fatigue, Muscle weakness

2.

Anorexia, N/V, abdominal pain, weight loss

Prevent complications: addisonian crisis,

k.

Importance of follow up care

3. History of hypoglycemic reaction / Hypoglycemia: tremors, tachycardia, irritability, restlessness, extreme fatigue, diaphoresis, depression Addisonian Crisis

27

28

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

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

6. Iatrogenic:

stressful stimuli

concerning: same as addison’s disease 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 1.

Generalized muscle weakness

2.

Severe hypotension

3. Hypovolemic shock: vascular collapse

Predisposing Factors

1. Primary Cushing’s Syndrome: caused by adrenocortical tumors or hyperplasia

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 1.

Assist in mechanical ventilation

2. Administer IV fluids (5% dextrose in saline, plasma)

3. Iatrogenic: cause by prolonged use of corticosteroids 4.

Related to hyperplasia of adrenal gland

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

2.

Fatigue

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

14. Signs of masculinization in women: menstrual dysfunction, decrease libido

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.

Dx

Need to avoid stress & infection

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 1.

g.

Importance of follow up care

Maintain muscle tone a.

Provide ROM exercise

b.

Assist in ambulation

Diabetes Mellitus (DM) 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.

Characterized by disorder in the metabolism of CHO, fats,

Provide meticulous skin care

b. Prevent tearing of the skin: use paper tape if necessary 5.

Minimize stress in the environment

6. Monitor V/S: observe for hypertension & edema

CHON, as well as changes in the structure & function of blood vessels Metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism

7. Monitor I&O & daily weight: assess for pitting edema: Measure abdominal girth: notify physician 8.

Pathophysiology

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 as ordered

leads to osmitic diuresis as large amounts of glucose pass through 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

condition is caused by a pituitary tumor

12. Prepare client for Adrenalectomy: if condition is caused by an adrenal tumor or hyperplasia 13. Restrict sodium intake

14. Administer medications as ordered: Spironolactone (Aldactone): potassium sparring diuretics 15. Provide client teaching & discharge planning concerning: a.

Diet modification

b.

Importance of adequate rest

starvation = The body turns to fat & CHON for energy but in the absence of glucose in the cell fat cannot be completely metabolized & ketones (intermediate products of fat metabolism) are produced = This leads to ketonemia, ketonuria (contributes to osmotic diuresis) & metabolic acidosis (ketones are acid bodies) = Ketone sacts as CNS depressants & can cause coma = Excess loss of F & E leads to hypovolemia, hypotension, renal failure & decease blood flow to the brain resulting in coma & death unless treated. MAIN FOODSTUFF

ANABOLISM

CATABOLISM

28

29 1. CHO

Glucose

Glycogen

2. CHON

Amino Acids

Nitrogen

3. Fats

Fatty Acids

Free Fatty Acids

Cholesterol Ketones

: cholesterol Atherosclerosis

: ketones

Diabetic

Keto Acidosis Hypertension Acetone

HYPERGLYCEMIA

Breath

Kussmaul’s Respiration

Increase osmotic diuresis

odor MI

CVA

Glycosuria Polyuria

Death

Cellular starvation: weight loss dehydration

Diabetic Coma

Cellular

Classification Of DM

Stimulates the appetite / satiety center

1. Type I Insulin-dependent Diabetes Mellitus (IDDM)

Stimulates the thirst center (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.

Negative Nitrogen balance

Autoimmune response

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 1.

mimic normal pancreatic functioning

FBS: a.

5. Exercise: helpful adjunct to therapy as exercise

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

2. Postprandial Blood Sugar: elevated

Characteristics of Insulin Preparation Drug

3. Oral Glucose Tolerance Test (most sensitve test): elevated

4. Glycosolated Hemoglobin (hemoglobin A1c): elevated

Synonym Duration

Appearance

Onset

Peak

Compatible Mixed

Rapid Acting Insulin Injection Regular Ins

Clear

½-1

2-4

6-8

Cloudy

½-1

4-6

12-

Cloudy

1-1 ½

8-12

18-

Cloudy

1-1 ½

8-12

18-

Cloudy

4-8

16-20

30-

All insulin prep Medical Management except lente

1.

Insulin therapy

2.

Exercise

3.

Diet:

Insulin, Zinc

Semilente Ins

a.

Consistency is imperative to avoid hypoglycemia

16

Lente prep

b.

High-fiber, low-fat diet also recommended

suspension,

4.

Drug therapy: a.

prompt

Insulin: Short Acting: used in treating ketoacidosis;

Intermediate Acting

during surgery, infection, trauma; management

Isophane Ins

NPH Ins

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 clients who experience hyperglycemia during the night with intermediate-acting insulin

b. Insulin preparation can consist of mixture of pure

Insulin Zinc

Lente Ins

24

Regular Ins &

Suspension semilente prep

pork, pure beef, or human insulin. Human insulin is the purest insulin & has the lowest antigenic effect

c. Human Insulin: is recommended for all newly diagnosed Type I & Type II DM who need short-term insulin therapy; the pregnant client & diabetic client with insulin allergy or severe insulin resistance

Long Acting Insulin Zinc

Ultralente Ins

36

Regular Ins &

suspension, semilente prep extended

29

30

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)

Maturity onset type

lowering blood sugar

90% of general population has Type II DM

Miglitol (Glyset)

2. Obesity: because obese persons lack insulin receptor binding sites

1.

Usually asymptomatic

2.

Polyuria

3.

Polydypsia

4.

Polyphagia

5.

Glycosuria

6.

Weight gain / Obesity

7.

Fatigue

8.

Blurred Vision

9.

Increase susceptibility to infection

in skeletal muscle & decrease glucose production in liver Complications

1. Hyper Osmolar Non-Ketotic Coma (HONKC) Nursing Intervention

1. Administer insulin or oral hypoglycemic agent as

Dx

ordered: monitor hypoglycemia especially during period

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

of drug peak action

2. Provide special diet as ordered: a.

May be normal in Type II DM

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

8. Glycosolated Hemoglobin (hemoglobin A1c): elevated

& exercise are not effective in controlling hyperglycemia Insulin is needed in acute stress: ex. Surgery, infection

4. Diet: CHO 50%, CHON 30% & Fats 20% Weight loss is important since it decreases insulin resistance

ordered (more accurate than urine test) 5.

Observe signs of hypo/hyperglycemia

6.

Provide meticulous skin care & prevent injury

7.

Maintain I&O; weight daily

8. Provide emotional support: assist client in adapting change in lifestyle & body image 9.

High-fiber, low-fat diet also recommended

Observe for chronic complications & plan of care accordingly:

Drug therapy: a.

3. Monitor urine sugar & acetone (freshly voided 4. Perform finger sticks to monitor blood glucose level as

Ideally manage by diet & exercise

2. Oral Hypoglycemic agents or occasionally insulin: if diet

5.

leftover food; provide snack later in the day specimen)

Medical Management

b.

a. Atherosclerosis: leads to CAD, MI, CVA & Peripheral

Occasional use of insulin

Vascular Disease

b. Oral hypoglycemic agent: Used by client who are not controlled by diet & exercise

b. Microangiopathy: most commonly affects eyes & kidneys c.

Increase the ability of islet cells of the pancreas receptors to decrease resistance to insulin

Diabetic Nephropathy d.

6. Exercise: helpful adjunct to therapy as exercise

Diabetic Retinopathy e.

Oral Hypoglycemic Agent Peak

Ocular Disorder Premature Cataracts

decrease the body’s need for insulin

Onset

Kidney Disease Recurrent Pyelonephritis

to secret insulin; may have some effect on cell

Drug

Ensure that the client is eating all meals

b. If all food is not ingested: provide appropriate

6. Postprandial Blood Sugar: elevated

a.

Unknown

insulin

10. Delayed / poor wound healing

3.

2-3

:Potetiates action of insulin

S/sx

1.

Rapid

:Reduce plasma glucose &

Genetics

d.

2-3

Troglitazone (Rezulin)

Predisposing Factors

c.

Unknown

& digestion of CHO,

Incidence Rate

1.

1

:Delay glucose absorption

Obese adult over 40 years old

1.

Unknown

Peripheral Neuropathy Affects PNS & ANS

Duration

Cause diarrhea, constipation, neurogenic

Comments

bladder, impotence, decrease sweating

Oral Sulfonylureas Acetohexamide (Dymelor)

1

4-6

12-

10. Provide client teaching & discharge planning concerning:

24 Chlorpropamide (Diabinase)

1

Glyburide (Micronase, Diabeta) 15 min- 1 hr

4-6

40-60

2-8

10-24

a.

Disease process

b.

Diet Client should be able to plan a meal using exchange lists before discharge

Oral Biguanides Metformin (Glucophage) 16

2-2.5

Emphasize importance of regularity of meals;

10-

never skip meals

:Decrease glucose c. production in liver

Insulin 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

30

31

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 d.

Inspect foot daily & notify physician: if cut,

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

f.

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

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 g.

General care

Predisposing Factors 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 factor

agent: since infection causes increase blood 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

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

tachypnea

8. ABG: metabolic acidosis with compensatory respiratory Dx

alkalosis

1. FBS: is increased Nursing Intervention

2. Serum glucose & ketones level: elevated 3. BUN (normal value: 10 – 20): elevated: due to dehydration

4. Creatinine (normal value: .8 – 1): elevated: due to dehydration

5. Hct (normal value: female 36 – 42, male 42 – 48): elevated: due to dehydration

1.

Maintain patent airway

2.

Assist in mechanical ventilation

3. Maintain F&E balance: a. Administer IV therapy as ordered: Normal saline (0.9% NaCl), followed by 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

31

32

Potassium will be added: when the urine output is adequate b.

Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC)

Observe for F&E imbalance, especially fluid

Characterized by hyperglycemia & a hyperosmolar state

overload, hyperkalemia & hypokalemia

without ketosis Occurs in non-insulin-dependent diabetic or non-diabetic

4. Administer insulin as ordered: regular acting insulin/rapid acting insulin

persons (typically elderly clients)

a. Regular insulin IV (drip or push) & / or

Hyperosmolar: increase osmolarity (severe dehydration) Non-ketotic: absence of lypolysis (no ketones)

subcutaneously (SC)

b. If given IV drip: give small amount of albumin since Predisposing Factors

insulin adheres to IV tubing 1.

Undiagnosed diabetes

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

c. 5.

Monitor blood glucose level frequently

S/sx

10. Discuss with client the reasons ketosis developed & 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 III. Blood Forming Organs

Nursing Intervention 1.

Maintain patent airway

2.

Assist in mechanical ventilation

3. Maintain F&E balance: a. Administer IV therapy as ordered: Normal saline (0.9% NaCl), followed by hypotonic solutions (.45% NaCl) sodium chloride: to counteract dehydration & shock When blood sugar drops to 250 mg/dl: may add

Liver 55% Plasma Thymus (Fluid) Spleen

II. Blood Vessels

45% Formed cellular elements

1. Arteries

1.

2. Veins

2.

3. Capillaries

3. 4.

Lymphoid Organ Serum Lymph Nodes

Plasma CHON

5.

(formed in liver)

6.

Bone Marrow 1. Albumin 2. Globulins 3. Prothrombin and Fibrinogen

5% dextrose to IV 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 organs in the body (4-5% of total body weight)

a. Regular insulin IV (drip or push) & / or subcutaneously (SC)

Primary function is Hematopoiesis: the formation of blood cells

b. If given IV drip: give small amount of albumin since c. 5.

insulin adheres to IV tubing

All blood cells start as stem cells in the bone marrow; these

Monitor blood glucose level frequently

mature into different, specific types of cells, collectively

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.

provide additional diabetic teaching if indicated

Red Marrow Carries out hematopoiesis; production site of erythroid, myeloid, & thrombocytic component of blood; one source of lymphocytes & macrophages Found in the ribs, vertebral column, other flat bones

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

32

33 2.

g. Hemoglobin: normal value female 12 – 14 gms% male

Centrifugation of blood results in separation into top layer of plasma, middle layer of leukocytes & platelets,

14 – 16 gms%

& bottom layer of erythrocytes 3.

h. Hematocrit red cell percentage in wholeblood (normal

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 a.

550 ml arterial

b.

300 ml capillary

c.

2150 ml venous

f.

Intrinsic factor

2. Leukocytes (WBC) 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

•

Contains plasma CHON such as albumin, serum, globulins, fibrinogen, prothrombin, plasminogen 1.

Albumin

-

60 – 70% of WBC

-

Involved in short term phagocytosis for acute inflammation

Largest & numerous plasma CHON

-

Involved in regulation of intravascular plasma

-

Maintains osmotic pressure: preventing edema

•

b. Beta: role in transport of iron & copper

Immature

-

For parasite infections

-

Responsible

-

3. Fibrinogens, Prothrombin, Plasminogens: clotting factors

cells

(bacterial

for

the

release

of

chemical

Involved

in

prevention

of

clotting

in

microcirculation and allergic reactions

to prevent bleeding

•

Polymorphonuclear Eosinophils -

Cellular Components or Formed Elements

•

1. Erythrocytes (RBC)

Involved in phagocytosis and allergic reaction

Eosinophils & Basophils: are reservoirs of histamine, serotonin & heparin

Normal value: 4 – 6 million/mm3

d.

b. No nucleus, Biconcave shape discs, Chiefly sac of

Non Granulocytes

•

hemoglobin

Mononuclear cells: large nucleated cells a.

Call membrane is highly diffusible to O2 & CO2

Monocytes: 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

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,

f.

band

mediation for inflammation

antibodies

& other factors required for erythropoiesis

neutrophils:

Polymorphonuclear Basophils

c. Gamma: role in immune response, function of

e.

polymorphonuclear

band cells)

hormones

c.

neutrophils:

infection usually produces increased numbers of

Serum Globulins

a. Alpha: role in transport steroids, lipids, bilirubin &

a.

Mature leukocytes

volume

2.

Polymorphonuclear Neutrophils

cells) Lymphocytes

Hemolysis (Destruction) Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen Immature RBCs destroyed in either bone marrow or other reticuloendothelial organs (blood, connective

B-cell T-cell - bone marrow - thymus and anti-tumor property for immunity

Natural killer cell anti-viral

tissue, spleen, liver, lungs and lymph nodes) Mature cells remove chiefly by liver and spleen Bilirubin (yellow pigment): by product of Hgb (red pigment) released when RBCs destroyed, excreted in bile Biliverdin (green pigment) Hemosiderin (golden brown pigment) Iron: feed from Hgb during bilirubin formation; transported to bone marrow via transferring and and reclaimed for new Hgb production Premature destruction: may be caused by RBC membrane abnormalities, Hgb abnormalities, extrinsic physical factors (such as the enzyme defects found in G6PD) Normal age RBCs may be destroyed by gross damage as in trauma or extravascular hemolysis (in spleen, liver, bone marrow)

HIV

c. Thrombocytes (Platelets) •

Normal value: 150,000 – 450,000/mm3

•

Normal life span of platelet is 9 – 12 days

•

Fragments of megakaryocytes formed in bone marrow

•

Production regulated by thrombopoietin

•

Essential factors in coagulation via adhesion, aggregation & plug formation

•

Release substances involved in coagulation

•

Promotes hemostasis (prevention of blood loss)

•

Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus

33

34 Signs of Platelet Dysfunction 1.

Petechiae

2.

Echhymosis

_____________________________________________________________________

3.

Oozing of blood from venipunctured site

__________________

reaction

Pyrogenic Blood Groups

Recipient

Fever, chills,

Erythrocytes carry antigens, which determine the different

flushing, palpitation,

antigens, but the most important are the antigens of the

agglutination bacterial

tachycardia,

involved in transfusion reactions

after

initiation

of

Transfuse with

directed against

ABO & Rh blood groups because they are most likely to be

min

Treat temp.

antibodies

Blood-typing system are based on the many possible

Within 15-90

Stop transfusion.

possesses

blood group

Leukocytes

organism

transfusion

leukocytes-poor

WBC; bacterial 1.

2.

occasional

ABO Typing

blood of washed

contamination;

a.

Antigens of systems are labeled A & B

b.

Absence of both antigens results in type O blood

c.

Presence of both antigen is type AB

Multitransfused

d.

Presence of either type A or B results in type A & type B,

Administer

respectively

client;

lumbar pain

RBC.

e. Type O: universal donor

antibiotics prn

f.

Antibodies are automatically formed against ABO

multiparous

antigens not on persons own RBC

client

Rh Typing

_____________________________________________________________________

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

__________________ Circulatory

Rh -)

Dyspnea,

b. Anti-Rh antibodies not automatically formed in Rh (-) persons, but if Rh (+) blood is given, antibody formation

Overload transfusion

starts & second exposure to Rh antigen will trigger a

tachycardia,

c. Important for Rh (-) woman carrying Rh (+) baby; 1st

During & after

Slow infusion rate infusion in

overload

increase BP,

Used packed cells

instead of whole

Client

pregnancy not affected, but subsequent pregnancy with

orthopnea,

an Rh (+) baby, mother’s antibodies attack baby’s RBC

blood.

cyanosis, anxiety

Complication of Blood Transfusion Causes

Fluid volume

Susceptible

transfusion reaction

Type

Too rapid

Mechanism

Occurrence

Monitor CVP t

S/sx hro

Intervention

ug Hemolytic

ABO

Headache,

Antibodies in Stop transfusion.

Incompatibility; recipient plasma lumbar or

continue saline IV

Rh

react w/ antigen

completion

ha

Acute:

sternal pain,

_____________________________________________________________________ __________________

after

Air Embolism

send blood unit &

Incompatibility; in donor cells.

separate line.

first 5 min

Dyspnea,

of transfusion

diarrhea, fever,

client blood

Use of dextrose

Agglutinated cell

pressure wheezing, chest

blood flow to

restlessness,

hemoglobinuria.

fluctuation

organs.

anemia, jaundice,

shock, renal

left side

blood loss apprehension

weeks after

_____________________________________________________________________

Treat or prevent

__________________ThromboWhen large

shock, DIC, & into plasma &

artery outflow

pain, decrease BP,

days to 2

Hemolysis (Hgb dyspnea, signs

blocks pulmonary

following severe

Watch for

Wide temp

Anytime

increase pulse, Turn client on

block capillary Delayed:

heat along vein,

Bolus of air

Clamp tubing.

under air

chills, flushing, sample to lab. solutions;

Blood given

of

cytopenia

Abnormal

amount of

bleeding

renal shutdown 24 hr

shutdown, DIC

Platelets

Assess for signs

deteriorate

amount

of

blood

of bleeding.

banked blood

urine)

Used of large

rapidly in stored

given

over

Initiate bleeding blood precautions. Use fresh blood.

Complication of Blood Transfusion Type

Causes

Mechanism

Occurrence

S/sx

_____________________________________________________________________ __________________

Intervention

Citrate Allergic

Transfer of an Uticaria, larygeal antigen & edema, wheezing

Immune

Stop transfusion. sensitivity to

dyspnea,

antihistamine &

donor to

CHON

bronchospasm, or epinephrine. recipient;

Citrate binds

Neuromascular Monitor/treat Intoxication

of citrated blood

irritability

ionic calcium

amount of

hypocalcemia.

in client with transfusion

After large

Bleeding due to

banked

blood

Avoid large

decrease liver decrease calcium

amounts of

function citrated blood.

Treat

Allergic donor anaphylaxis

start of

Administer

antibody from foreign serum

headache,

Within 30 min

Large amount

Monitor liver fxn

life-threatening

34

35 _____________________________________________________________________

Liver also involved in synthesis of clotting factors, synthesis

__________________

of antithrombins.

Hyperkalemia

Potassium level Release of

Nausea, colic,

Administer blood

increase in diarrhea, muscle stored blood spasm, ECG

In client with Blood Tranfusion

potassium into renal

Purpose

less than 5-7 plasma with

1. RBC: Improve O2 transport insufficiency

2. Whole Blood, Plasma, Albumin: volume expansion

days old in client

3. Fresh Frozen Plasma, Albumin, Plasma Protein Fraction:

red cell lysis changes (tall

peaked T-waves, short Q-T

provision of proteins

with impaired

4. Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole Blood: provision of coagulation factors

potassium

5. Platelet Concentration, Fresh Whole Blood: provision of platelets

excretion s egments)

Blood & Blood Products

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)

a. Factor XII: initiate as contact made between damaged vessel & plasma CHON b. 2.

in massive transfusion therapy

2. Red Blood Cell (RBC) a.

Factors VIII, IX & XI activated

amount of whole blood

Extrinsic System:

b.

a. Initiated by tissue thromboplastins released from injured

c. Complication: transfusion reaction (less common

Factor VII activated

Common Pathways: activated by either intrinsic or extrinsic pathways

than with whole blood: due to removal of plasma protein) 3.

1. Platelet factor 3 (PF3) & calcium react with factor X & V 2.

Prothrombin converted to thrombin via thromboplastin

3.

Thrombin acts on fibrinogens, forming soluble fibrin

4.

Soluble fibrin polymerized by factor XIII to produce a stable, insoluble fibrin clot

Indicate in cases of blood loss, pre-op & post-op client & those with incipient congestive failure

vessels (“extrinsic” to vessel) b.

Provide twice amount of Hgb as an equivalent

Fresh Frozen Plasma a.

Contains all coagulation factors including V & VIII

b.

Can be stored frozen for 12 months; takes 20 minutes to thaw

c. Hang immediately upon arrival to unit (loses its coagulation factor rapidly) 4.

Platelets

a. Will raise recipient’s platelet count by 10,000/mm3

Clot Resolution: takes place via fibrinolytic system by plasmin & proteolytic enzymes; clots dissolves as tissue repairs.

b.

Pooled from 4-8 units of whole blood

c.

Single-donor platelet transfusion may be necessary for clients who have developed antibodies; compatibilities testing may be necessary

Spleen Largest Lymphatic Organ: functions as blood filtration system & reservoir Vascular bean shape; lies beneath the diaphragm, behind &

5. Factor VIII Fractions (Cryoprecipitate): contains factor VIII, fibrinogens & XIII 6.

Granulocytes

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.

Contains two types of pulp:

Premedication with steroids, antihistamine & acetaminophen

a. Red Pulp: located between the fibrous strands,

c.

composed of RBC, WBC & macrophages

Respiratory distress with shortness of breath, 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.

& antigens

Shaking chills or rigors common, require brief 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.

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)

Replace circulating blood volume

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.

Liver Involved in bile production (via erythrocyte destruction & bilirubin production) & erythropoeisis (during fetal life &

2.

Proper refrigeration a.

Expiration of packed RBC is 3-6 days

b.

Expiration of platelet is 3-5 days

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. 3.

85% of population is RH positive

Aseptically assemble all materials needed for BT

35

36 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

2.

Headache

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

hemolysis 4.

5.

Nursing Management

Check the blood unit for bubbles cloudiness, sediments 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

4.

Administer medications as ordered

blood.

b. Warming is only done: during emergency situation & if you have the warming device c.

a.

Antipyretic

b.

Antibiotic

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 reexamination

6. BT should be completed less than 4 hours because blood that is exposed at room temperature more than 2 hours: causes blood deterioration that can lead to

7.

Monitor vital signs & I&O

8.

Render TSB

bacterial contamination

7. Avoid mixing or administering drugs at BT line: to

S/sx of Circulatory reaction

prevent hemolysis

8. Regulate BT 10-15 gtts/min or KVO rate or equivalent to 100 cc/hr: to prevent circulatory overload 9.

Monitor strictly vital signs before, during & after BT especially every 15 minutes for first hour because

1.

Orthopnea

2.

Dyspnea

3.

Rales / Crackles upon auscultation

4.

Exertional discomfort

majority of transfusion reaction occurs during this period a.

Hemolytic reaction

b.

Allergic reaction

c.

Pyrogenic reaction

d.

Circulatory overload

e.

Air embolism

f.

Thrombocytopenia

g.

Cytrate intoxication

Nursing Management

2.

Dyspnea

3.

Diarrhea / Constipation

4.

Hypotension

5.

Flushed skin

6.

Lumbasternal / Flank pain

2.

Notify physician

3.

Administer medications as ordered

Nursing Care 1.

Assess client for history of previous blood transfusions & any adverse reaction

2.

S/sx of Hemolytic reaction Headache and dizziness

Stop BT

a. Loop diuretic (Lasix)

h. Hyperkalemia (caused by expired blood)

1.

1.

Ensure that the adult client has an 18-19 gauge IV catheter in place

3.

Use 0.9% sodium chloride

4. At least two nurse should verify the ABO group, RH type, client & blood numbers & expiration date 5.

Take baseline V/S before initiating transfusion

6. Start transfusion slowly (2 ml/min) 7.

7. Urine is color red / portwine urine

Stay with the client during the first 15 min of the transfusion & take V/S frequently

8.

Nursing Management

Maintain the prescribed transfusion rate:

a. Whole Blood: approximately 3-4 hr

1.

Stop BT

2.

Notify physician

b. RBC: approximately 2-4 hr

3.

Flush with plain NSS

c. Fresh Frozen Plasma: as quickly as possible d. Platelet: as quickly as possible

4. Administer isotonic fluid solution: to prevent shock and acute tubular necrosis

e. Cryoprecipitate: rapid infusion

5.

Send the blood unit to blood bank for re-examination

f.

6.

Obtain urine & blood sample & send to laboratory for re-

g. Volume Expander: volume-dependent rate

examination 7.

9.

Monitor vital signs & I&O

Fever

2.

Dyspnea

3.

Broncial wheezing

4.

Skin rashes

5.

Urticaria

6.

Laryngospasm & Broncospasm Nursing Management

1.

Stop BT

2.

Notify physician

3.

Flush with plain NSS

4.

Administer medications as ordered

a. Anti Histamine (Benadryl): if positive to hypotension, anaphylactic shock: treat with Epinephrine 5.

Send the blood unit to blood bank for re examination

6.

Obtain urine & blood sample & send to laboratory for re-

Monitor for adverse reaction

10. Document the following:

a. Blood component unit number (apply sticker if

S/sx of Allergic reaction 1.

Granulocytes: usually over 2 hr

available) b.

Date of infusion starts & end

c.

Type of component & amount transfused

d.

Client reaction & vital signs

e.

Signature of transfusionist

HIV - 6 months – 5 years incubation period - 6 months window period - western blot opportunistic - ELISA - drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1. Kaposis Sarcoma 2. Pneumocystic Carini Pneumonia Blood Disorder

examination 7.

Monitor vital signs and intake and output

Iron Deficiency Anemia (Anemias)

36

37

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 6.

inadequate absorption or excessive loss of iron

Administer iron preparation as ordered: a.

Acute or chronic bleeding principal cause in adults (chiefly

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, Nursing Management when taking oral iron

followed by a reduction in Hgb formation

preparations Incidence Rate

Instruct client to take with meals: to lessen GIT

1. Common among developed countries & tropical zones 2. 3.

irritation

(blood-sucking parasites)

Dilute in liquid preparations well & administer

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

Related to poor nutrition

vitamin C (ascorbic acid): to enhance iron absorption

1.

Predisposing Factors

Warn clients that iron preparations will change

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 2.

3.

b. Parenteral: used in clients intolerant to oral

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

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) a. Stomatitis

Lymphadenitis PLUMBER

Fever & chills

VINSON’S SYNDROME b.

Headache

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

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

e.

Melena

1.

as not to over tire the client

3. Provide thorough explanation of all diagnostic exam

4.

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)

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

g.

Nuts

Pernicious Anemia Chronic progressive, macrocytic anemia caused by a deficiency of intrinsic factor; the result is abnormally large

37

38 a. Measures absorption of radioactive vitamin B12

erythrocytes & hypochlorhydria (a deficiency of hydrochloric acid in gastric secretion)

bothe before & after parenteral administration of

Chronic anemia characterized by a deficiency of intrinsic

intrinsic factor

factor leading to hypochlorhydria (decrease hydrochloric

b.

Definitive test for pernicious anemia

acid secretion)

c.

Used to detect lack of intrinsic factor

Characterized by neurologic & GI symptoms; death usually

d. Fasting client is given radioactive vitamin B12 by

resuls if untreated

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 e.

autoimmune disorder); can also results in clients who have

24-48 hour urine collection is obtained: client is encourage to drink fluids

had a total gastrctomy if vitamin B12 is not administer

f. Pathophysiology

If indicated, second stage schilling test performed 1 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

2. B12 deficiency diminished DNA synthesis, which results in defective maturation of cell (particularly rapidly

intrinsic factor & test is repeated

7. Gastric Analysis: decrease free hydrochloric acid 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 STOMACH

Medical Management 1.

Drug Therapy:

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.

Secretes hydrochloric acid

Folic Acid Controversial Reverses anemia & GI symptoms but may

Promotes reabsorption of Vit B12

intensify neurologic symptoms

Aids in digestion Promotes maturation of RBC Predisposing Factors 1.

Usually occurs in men & women over age of 50 with an increase in blue-eyed person of Scandinavian decent

May be safe if given in small amounts in addition to vitamin B12 2.

Transfusion Therapy Nursing Intervention

1. Enforce CBR: necessary if anemia is severe 2. Adminster Vitamin B12 injections at monthly intervals for lifetime as ordered

2.

Subtotal gastrectomy

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

2.

Weakness & fatigue

3.

Headache and dizziness

4.

Pallor & cold sensitivity

5. Dyspnea & palpitations: as part of compensation 6.

3. Provide a dietary intake that is high in CHON, vitamin c and iron (fish, meat, milk / milk product & eggs)

4. Avoid highly seasoned, coursed, or very hot foods: if client has mouth sore

5. Provide safety when ambulating (especially when

GIT S/sx: a.

Mouth sore

carrying hot item) 6.

b. PS: Red beefy tongue

Instruct client to avoid irritating mouth washes instead 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

b. Importance of lifelong vitamin B12 therapy

7. CNS S/sx:

c.

Rehabilitation & physical therapy for neurologic

a.

Tingling sensation

b.

Numbness

c.

Paresthesias of hands & feet

d.

Paralysis

e.

Depression

Stem cell disorder leading to bone marrow depression

f.

Psychosis

leading to pancytopenia

g. Positive to Romberg’s test: damage to cerebellum resulting to ataxia

deficit, as well as instruction regarding safety Aplastic Anemia

Pancytopenia or depression of granulocytes, platelets & erythrocytes production: due to fatty replacement of the bone marrow

Dx

Bone marrow destruction may be idiopathic or secondary

1. Erythrocytes count: decrease PANCYTOPENIA

2. Blood Smear: oval, macrocytic erythrocytes with a proportionate amount of Hgb

3. Bilirubin (indirect): elevated unconjugated fraction 4. Serum LDH: elevated 5.

Decrease RBC Decrease Platelet (anemia)

Bone Marrow:

Decrease WBC (leukopenia)

(thrombocytopenia)

a. Increased megaloblasts (abnormal erythrocytes) b.

Few normoblasts or maturing erythrocytes

c.

Defective leukocytes maturation

6. Positive Schilling’s Test: reveals inadequate / decrease absorption of Vitamin B12

Predisposing Factors

1. Chemicals (Benzene and its derivatives) 2.

Related to radiation / exposure to x-ray

3.

Immunologic injury

4.

Drugs:

38

39 a. Broad Spectrum Antibiotics: Chloramphenicol

b. Identification of offending agent & importance of

(Sulfonamides) b.

avoiding it (if possible) in future

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

1.

2. 3.

S/sx

bleeding and thrombosis due to a deficiency of prothrombin

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

Leukopenia

Mortality rate is high usually because underlying disease

a.

cannot be corrected

Increase susceptibility to infection

Thrombocytopenia

a. Petechiae (multiple petechiae is called purpura) Pathophysiology

b.

Ecchymosis

c.

Oozing of blood from venipunctured sites

1. Underlying disease (ex. toxemia of pregnancy, cancer) cause release of thromboplastic substance that promote

Dx

the deposition of fibrin throughout the microcirculation

1. CBC: reveals pancytopenia 2.

Normocytic anemia, granulocytopenia,

2.

Microthrombi form in many organs, causing microinfarcts & tissue necrosis

thrombocytopenia

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 destroyed, leading to bleeding

cells; reveals fat necrosis in bone marrow 5.

which inhibits platelet function, causing futher bleeding.

Medical Management

1. Blood transfusion: key to therapy until client’s own marrow begins to produce blood cells 2.

Aggressive treatment of infection

3.

Bone marrow transplantation

4.

Drug Therapy:

a. Corticosteroids & / or androgens: to stimulate bone marrow function & to increase capillary resistance (effective in children but usually not in adults)

b. Estrogen & / or progesterone: to prevent

Predisposing Factors 1.

Related to rapid blood transfusion

2.

Massive burns

3.

Massive trauma

4.

Anaphylaxis

5.

Septecemia

6. Neoplasia (new growth of tissue) 7.

amenorrhea in female clients 5.

Identification & withdrawal of offending agent or drug

Removal of underlying cause

2.

Administer Blood Transfusion as ordered

3. Administer O2 inhalation 4.

Enforce CBR

5.

Institute reverse isolation

6.

Provide nursing care for client with bone marrow transplant

7.

Administer medications as ordered:

1. Petechiae & Ecchymosis on the skin, mucous membrane, heart, eyes, lungs & other organs (widespread and systemic) 2.

Given via central venous catheter Given 6 days to 3 weeks to achieve maximum therapeutic effect of drug 8.

Monitor for signs of infection & provide care to minimize risk: a.

Monitor neuropenic precautions

b. Encourage high CHON, vitamin diet: to help reduce incidence of infection

9.

Prolonged bleeding from breaks in the skin: oozing of blood from punctured sites

3.

Severe & uncontrollable hemorrhage during childbirth or surgical procedure

4.

Hemoptysis

5. Oliguria & acute renal failure (late sign) 6.

a. Corticosteroids: caused by immunologic injury b. Immunosuppressants: Anti Lymphocyte Globulin

Pregnancy S/sx

Nursing Intervention 1.

Excessive clotting activates the fibrinolytic system,

Convulsion, coma, death Dx

1. PT: prolonged 2. PTT: usually prolonged 3. Thrombin Time: usually prolonged 4. Fibrinogen level: usually depressed 5. Fibrin splits products: elevated 6. Protamine Sulfate Test: strongly positive 7. Factor assay (II, V, VII): depressed 8. CBC: reveals decreased platelets 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

Monitor signs of bleeding & provide measures to Medical Management

minimize risk:

a. Use soft toothbrush when brushing teeth & electric razor when shaving: prevent bleeding

1.

2. Blood Tranfusions: include whole blood, packed RBC, platelets, plasma, cryoprecipitites & volume expanders

b. Avoid IM, subcutaneous, venipunctured sites: Instead provide heparin lock

Identification & control the underlying disease is key

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 formation, allowing coagulation factors to

ecchymoses

accumulate

10. Provide client teaching & discharge planning concerning: a.

Nursing Intervention

Self-care regimen 1.

Monitor blood loss & attemp to quantify

39

40 2.

Monitor for signs of additional bleeding or thrombus

•

formation 3.

Monitor all hema test / laboratory data including stool

ventricles

•

and GIT 4.

Avoid IM injection

b.

Apply pressure to bleeding site

c.

Turn & position the client frequently & gently

d. Provide frequent nontraumatic mouth care (ex. soft toothbrush or gauze sponge)

5. Administer isotonic fluid solution as ordered: to prevent shock

Upper Chamber (connecting or receiving)

•

Prevent further injury a.

2 chambers, function as receiving chambers, lies above the

Right Atrium: receives systemic venous blood through the superior vena cava, inferior vena cava & coronary sinus

•

Left Atrium: receives oxygenated blood returning to the heart from the lungs trough the pulmonary veins

Ventricles •

2 thick-walled chambers; major responsibility for forcing blood out of the heart; lie below the atria

•

Lower Chamber (contracting or pumping)

6.

Administer oxygen inhalation

7.

Force fluids

8.

Administer medications as ordered:

into pulmonary circulation via the aorta during

a.

ventricular systole; Right atrium has decreased pressure

•

Vitamin K

which is 60 – 80 mmHg

b. Pitressin / Vasopresin: to conserve fluids c. 9.

Right Ventricle: contracts & propels deoxygenated blood

•

Heparin / Comadin is ineffective

Provide heparin lock

Left Ventricle: propels blood into the systemic circulation via aortaduring ventricular systole; Left ventricle has

10. Institute NGT decompression by performing gastric

increased pressure which is 120 – 180 mmHg in order to propel blood to the systemic circulation

lavage: by using ice or cold saline solution of 500-1000 ml 11. Monitor NGT output 12. Prevent complication

a. Hypovolemic shock: Anuria (late sign of hypovolemic shock)

Valves •

To promote unidimensional flow or prevent backflow

Atrioventricular Valve •

13. Provide emotional support to client & significant other

Guards opening between

•

14. Teach client the importance of avoiding aspirin or

ventricle; contains 2 leaflets attached to the chordae

aspirin-containing compounds

tandinae

•

Cardiovascular system consists of the heart, arteries, veins & capillaries. The major function are circulation of blood, delivery of O2 & other nutrients to the tissues of the body & removal of CO2 & other cellular products metabolism

Heart •

Muscular pumping organ that propel blood into the arerial system & receive blood from the venous system of the body.

•

Located on the left mediastinum

•

Resemble like a close fist

•

Weighs approximately 300 – 400 grams

•

Covered by a serous membrane called the pericardium

tandinae Functions •

Permit unidirectional flow of blood from specific atrium to specific ventricle during ventricular diastole

•

Prevent reflux flow during ventricular systole

•

Valve leaflets open during ventricular diastole; Closure of AV valves give rise to first heart sound (S1 “lub”)

Semi-lunar Valve

•

Pulmonary Valve •

•

•

• •

(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

•

Parietal: outer layer

•

Visceral: inner layer

Covers surface of the heart, becomes continuous with

Extra Heart Sounds

•

Outer layer

Myocardium •

Middle muscular layer

•

Myocarditis can lead to cardiogenic shock and rheumatic heart disease

Endocardium •

•

Coronary Circulation Coronary Arteries •

Papillary Muscle •

Arise from the endocardial & myocardial surface of the

•

Arises from base of the aorta

•

Types of Coronary Arteries

•

Attach to the tricuspid & mitral valves & prevent eversion during systole

Chambers of the Heart Atria

•

Right Main Coronary Artery

•

Left Main Coronary Artery

Coronary Veins •

Return blood from the myocardium back to the right atrium via the coronary sinus

ventricles & attach to the chordae tendinae Chordae Tendinae

Branch off at the base of the aorta & supply blood to the myocardium & the conduction system

Thin, inner membrabous layer lining the chamber of the Inner layer

S4: atrial gallop usually seen in Myocardial Infarction and Hypertension

heart •

S3: ventricular gallop usually seen in Left Congestive Heart Failure

visceral layer of serous pericardium •

Pemit unidirectional flow of the blood from specific ventricle to arterial vessel during ventricular diastole

Composed of fibrous (outermost layer) & serous pericardium

Epicardium •

Located between left ventricle & aorta

Function •

Pericardium

Located between the left ventricle & pulmonary artery

Aortic Valve •

Heart Wall / Layers of the Heart

Tricuspid Valve: located between the right atrium & right ventricle; contains 3 leaflets attached to the chordae

Overview of the Structure & Functions of the Heart •

Mitral Valve: located between the left atrium & left

Conduction System Sinoatrial Node (SA node or Keith Flack Node) •

Located at the junction of superior vena cava and right atrium

•

Acts as primary pacemaker of the heart

40

41 • •

Initiates the cardiac impulse which spreads across the atria

•

Small arteries that distribute blood to the capillaries &

& into AV node

function in controlling systemic vascular resistance &

Initiates electrical impulse of 60-100 bpm

therefore arterial pressure Capilliaries

Atrioventricular Node (AV node or Tawara Node)

•

The following exchanges occurs in the capilliaries

•

Located at the inter atrial septum

•

O2 & CO2

•

Delays the impulse from the atria while the ventricles fill

•

Solutes between the blood & tissue

•

Delay of electrical impulse for about .08 milliseconds to

•

Fluid volume transfer between the plasma & interstitial

allow ventricular filling

space Venules

Bundle of His •

•

Arises from the AV node & conduct impulse to the bundle branch system

•

•

collecting channels between the capillaries & veins Veins

Located at the interventricular septum

•

Small veins that receive blood from capillaries & function as

•

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 depolarization after ventricular contraction

•

Located at the walls of the ventricles for ventricular contraction

2. Myocardial Ischemia: Angina Pectoris 3. Myocardial Necrosis: Myocardial Infarction ATHEROSCLEROSIS •

ATHEROSCLEROSIS Narrowing of artery

•

ARTERIOSCLEROSIS Hardening of artery

•

Lipid or fat deposits

•

Calcium and protein

•

Tunica intima

SA NODE

deposits •

Tunica media

AV NODE

Predisposing Factors

1. Sex: male BUNDLE OF HIS

PURKINJE FIBERS

2. Race: black 3.

Smoking

4.

Obesity

5.

Hyperlipidemia

6.

Sedentary lifestyle

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

•

T wave (ventricular repolarization)

2.

Dyspnea

•

Insert pacemaker if there is complete heart block

3.

Tachycardia

•

Most common pacemaker is the metal pacemaker and lasts

4.

Palpitations

5.

Diaphoresis

up to 2 – 5 years Abnormal ECG Tracing

Treatment 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

•

T wave inversion: Myocardial Infarction

A - Arterial

•

Widening of QRS complexes: Arrythmia

B - Bypass

C - Coronary

A - And Vascular System •

Major function of the blood vessels isto supply the tissue

G - Graft 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

41

42 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 •

•

Transient paroxysmal chest pain produced by insufficient

minutes interval

blood flow to the myocardium resulting to myocardial ischemia •

Give 3rd & last dose of NTG: if pain still persist at 3-5

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

•

temporary myocardial ischemia

Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug

•

Predisposing Factors

Relax for 15 minutes after taking a tablet: to prevent dizziness

1.

Sex: male

2.

Race: black

3.

Smoking

•

Orthostatic hypotension

4.

Obesity

•

Transient headache & dizziness: frequent side

5.

Hyperlipidemia

6.

Sedentary lifestyle

7.

Diabetes Mellitus

8.

Hypertension

•

effect

2.

9. CAD: Atherosclerosis

•

Instruct the client to rise slowly from sitting position

•

Assist or supervise in ambulation

NTG Nitrol or Transdermal patch •

10. Thromboangiitis Obliterans

•

12. Aortic Insufficiency: heart valve that fails to open & close

•

13. Hypothyroidism

important thing to remember)

15. Type A personality

b.

Precipitating Factors 4 E’s of Angina Pectoris c.

1. Excessive physical exertion: heavy exercises, sexual activity

d.

3. Extreme emotional response: fear, anxiety, excitement,

•

Propanolol: side effects PNS

•

Not given to COPD cases: it causes bronchospasm

ACE Inhibitors Enalapril

Calcium Antagonist •

strong emotions

Nefedipine

4.

Administer oxygen inhalation

5.

Place client on semi-to high fowlers position

6.

Monitor strictly V/S, I&O, status of cardiopulmonary fuction & ECG tracing

1. Levine’s Sign: initial sign that shows the hand clutching the 2. Chest pain: characterized by sharp stabbing pain located at

Beta-blockers

•

2. Exposure to cold environment: vasoconstriction

chest

Avoid placing near microwave ovens or during defibrillation as it may lead to burns (most

14. Diet: increased saturated fats

S/sx

Avoid rotating transdermal patches as it may decrease drug absorption

efficiently

Excessive intake of foods or heavy meal

Avoid placing near hairy areas as it may decrease drug absorption

11. Severe Anemia

4.

Monitor side effects:

7.

Provide decrease saturated fats sodium and caffeine

8.

Provide client health teachings and discharge planning

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 1.

Dress warmly in cold weather

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

3. Stress test / treadmill test: reveal abnormal ECG during exercise 4.

Increase serum lipid levels

5.

Serum cholesterol & uric acid is increased

Medical Management

The importance of follow up care 9.

occurs & persists despite rest & medication administration Myocardial Infarction •

2.

Nitrates: Nitroglycerine (NTG)

•

Beta-adrenergic blocking agent: Propanolol

•

Calcium-blocking agent: nefedipine

•

Ace Inhibitor: Enapril

Modification of diet & other risk factors

3. Surgery: Coronary artery bypass surgery

Death of myocardial cells from inadequate oxygenation, often caused by sudden complete blockage of a coronary

1. Drug Therapy: if cholesterol is elevated •

Instruct the client to notify the physician immediately if pain

artery

•

Characterized by localized formation of necrosis (tissue destruction) with subsequent healing by scar formation & fibrosis

•

Heart attack

•

Terminal stage of coronary artery disease characterized by malocclusion, necrosis & scarring.

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

3. Administer medications as ordered:

2. Subendocardial Myocardial Infarction: characterized by occlusion of either right or left coronary artery

42

43 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

respiratory arrest or dyspnea & prevent arrhythmias

3. Enforce CBR in semi-fowlers position without bathroom

arrhythmia leading to premature ventricular contractions

privileges (use bedside commode): to decrease cardiac

(PVC)

workload 4.

Instruct client to avoid forms of valsalva maneuver

Predisposing Factors

5.

Place client on semi fowlers position

1. Sex: male

6.

Monitor strictly V/S, I&O, ECG tracing & hemodynamic procedures

2. Race: black 3.

Smoking

7.

4.

Obesity

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

5. CAD: Atherosclerotic

Perform complete lung / cardiovascular assessment hr: indicates decrease cardiac output

9. Provide a full liquid diet with gradual increase to soft diet:

6.

Thrombus Formation

7.

Genetic Predisposition

8.

Hyperlipidemia

10. Maintain quiet environment

9.

Sedentary lifestyle

11. Administer stool softeners as ordered: to facilitate bowel

10. Diabetes Mellitus 11. Hypothyroidism

12. Diet: increased saturated fats 13. Type A personality

low in saturated fats, Na & caffeine

evacuation & prevent straining

12. Relieve anxiety associated with coronary care unit (CCU) environment

13. Administer medication as ordered: a. Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate,

S/sx 1.

Isodil (ISD): sublingual

Chest pain

• •

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 •

b. Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium

Not usually relieved by rest or by nitroglycerine

2.

N/V

3.

Dyspnea

f.

Urokinase, Tissue Plasminogen Activating Factor (TIPAF)

4. Increase in blood pressure & pulse, with gradual drop in blood pressure (initial sign)

Thrombolytics / Fibrinolytic Agents: Streptokinase,

g.

•

Side Effects: allergic reaction, urticaria, pruritus

•

Nursing Intervention: Monitor for bleeding time

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

•

Split S1 & S2

•

Antidote: Vitamin K

•

Rales or Crackles upon auscultation

•

Nursing Intervention: Check for Prothrombin

•

S4 or atrial gallop

•

Caumadin (Warfarin)

Time (PT)

h. Anti Platelet: PASA (Aspirin): Anti thrombotic effect Dx 1.

•

CPK-MB: elevated

•

Creatinine phosphokinase (CPK): elevated

•

Heart only, 12 – 24 hours

•

Lactic acid dehydrogenase (LDH): is increased

•

Serum glutamic pyruvate transaminase (SGPT): is increased

•

Serum glutamic oxal-acetic transaminase (SGOT): is increased

2. Troponin Test: is increased 3.

•

Cardiac Enzymes

ECG tracing reveals •

ST segment elevation

•

T wave inversion

•

Widening of QRS complexes: indicates that there is

Dyspepsia

•

14. Provide client health teaching & discharge planning concerning: a.

Effects of MI healing process & treatment regimen

b.

Medication regimen including time name purpose, schedule, dosage, side effects

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

d. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy: to induce vasodilation e.

Avoidance of modifiable risk factors

f.

Prevent Complication

•

5. CBC: increased WBC Nursing Intervention Goal: Decrease myocardial oxygen demand

•

Cardiogenic shock: late sign is oliguria

•

Left Congestive Heart Failure

•

Thrombophlebitis: homan’s sign

•

Stroke / CVA

•

Dressler’s Syndrome (Post MI Syndrome): client is resistant to pharmacological agents: administer

1. Decrease myocardial workload (rest heart) Establish a patent IV line

•

Administer narcotic analgesic as ordered: Morphine Sulfate IV: provide pain relief (given IV because after an infarction there is poor peripheral perfusion & because serum enzyme would be affected by IM injection as ordered)

•

Side Effects: Respiratory Depression

•

Antidote: Naloxone (Narcan)

•

Side Effects of Naloxone Toxicity: is tremors

Arrhythmia: caused by premature ventricular contraction

4. Serum Cholesterol & uric acid: are both increased

•

Contraindication: Dengue, Peptic Ulcer Disease, Unknown cause of headache

arrhythmia in MI

•

Side Effects: Tinnitus, Heartburn, Indigestion /

150,000-450,000 units of streptokinase as ordered g.

Importance of participation in a progressive activity program

h. Resumption of ADL particularly sexual intercourse: is 4-6 weeks post cardiac rehab, post CABG & instruct to: •

Make sex as an appetizer rather than dessert

•

Instruct client to assume a non weight bearing position

•

Client can resume sexual intercourse: if can climb or use the staircase

43

44 i.

•

Need to report the ff s/sx: •

Increased persistent chest pain

pulmonary system: systemic venous congestion occurs as

•

Dyspnea

pressure builds up

•

Weakness

•

Fatigue

•

Persistent palpitation

•

Light headedness

j.

Enrollment of client in a cardiac rehabilitation program

k.

Strict compliance to mediation & importance of follow

Predisposing Factors

up care Congestive Heart Failure •

Inability of the heart to pump an adequate supply of blood to meet the metabolic needs of the body

•

Inability of the heart to pump blood towards systemic

Types of Heart Failure 1.

Left Sided Heart Failure

2.

Right Sided Heart Failure

3.

High-Output Failure

1.

Right ventricular infarction

2.

Atherosclerotic heart disease

3.

Tricuspid valve stenosis

4.

Pulmonary embolism

5.

Related to COPD

6.

Pulmonic valve stenosis

7.

Left sided heart failure

S/sx

circulation

Left Sided Heart Failure

•

Weakened right ventricle is unable to pump blood into he

1.

Anorexia

2.

Nausea

3.

Weight gain

4.

Neck / jugular vein distension

5.

Pitting edema

6.

Bounding pulse

7.

Hepatomegaly / Slenomegaly

8.

Cool extremities

9.

Ascites

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 lungs which result pulmonary congestion.

Dx

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 mitral valve due to invasion of Group A beta-hemolytic streptococcus 2.

Myocardial Infarction

3.

Ischemic heart disease

4.

Hypertension

5.

Aortic valve stenosis

•

Measure pressure in right atrium: 4-10 cm of water

•

If CVP is less than 4 cm of water: Hypovolemic shock: increase IV flow rate

•

Administer loop diuretics as ordered •

S/sx 1.

Dyspnea

Nursing Intervention: •

When reading CVP patient should be flat on bed

•

Upon insertion place client in trendelendberg position: to promote ventricular filling and prevent

2. Paroxysmal nocturnal dyspnea (PND): client is awakened at night due to difficulty of breathing

If CVP is more than 10 cm of water: Hypervolemic shock:

pulmonary embolism

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

7.

Tachycardia

8.

Frothy salivation

9.

Cyanosis

10. Pallor 11. Rales / Crackles

Medical Management 1.

2. Drug therapy: digitalis preparations, diuretics, vasodilators 3. Sodium-restricted diet: to decrease fluid retention 4. If medical therapies unsuccessful: mechanical assist devices (intra-aortic balloon pump), cardiac transplantation, or

12. Bronchial wheezing

13. Pulsus Alternans: weak pulse followed by strong bounding pulse

Determination & elimination / control of underlying cause

mechanical heart may be employed

5. Treatment for Left Sided Heart Failure Only:

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 systolic and dyastolic pressure: increased

4. Central Venous Pressure (CVP): indicates fluid or hydration

Nursing Intervention Goal: Increase cardiac contractility thereby increasing cardiac output of 3-6 L / min

status

•

Increase CVP: decreased flow rate of IV

•

Decrease CVP: increased flow rate of IV

1. Monitor respiratory status & provide adequate ventilation (when HF progress to pulmonary edema)

a. Administer O2 therapy: high inflow 3-4 L / min delivered

5. Swan-Ganz catheterization: cardiac catheterization

via nasal cannula

6. Echocardiography: shows increased sized of cardiac

b. Maintain client in semi or high fowlers position:

chamber (cardiomyopathy): dependent on extent of heart

maximize oxygenation by promoting lung expansion

failure c.

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

d. Assess for breath sounds: noting any changes

increased (respiratory acidosis) 2. Right Sided Heart Failure

Monitor ABG

Provide physical & emotional rest a.

Constantly assess level of anxiety

b.

Maintain bed rest with limited activity

44

45

3.

c.

Maintain quiet & relaxed environment

d.

Organized nursing care around rest periods

S/sx

1. Intermittent claudication: leg pain upon walking

Increase cardiac output a.

2. Cold sensitivity & changes in skin color 1st white (pallor)

Administer digitalis as ordered & monitor effects

•

Cardiac glycosides: Digoxin (Lanoxin)

•

Action: Increase force of cardiac contraction

•

Contraindication: If heart rate is decreased do not

changing to blue (cyanosis) then red (rubor)

3. Decreased or absent peripheral pulses (posterior tibial & dorsalis pedis) 4.

5. Ulceration & Gangrene formation (advanced)

give b.

Monitor ECG & hemodynamic monitoring

c.

Administer vasodilators as ordered

• d. 4.

Vasodilators: Nitroglycerine (NTG)

Monitor V/S

Reduce / eliminate edema a.

Administer diuretics as ordered

•

Loop Diuretics: Lasix (Furosemide)

b.

Daily weight

c.

Maintain accurate I&O

d.

Assess for peripheral edema

e.

Measure abdominal girth daily

f.

Monitor electrolyte levels

g.

Monitor CVP & Swan-Ganz reading

h.

Provide Na restricted diet as ordered

i.

Provide meticulous skin care

Trophic changes

Dx

1. Oscillometry: may reveal decrease in peripheral pulse volume

2. Doppler (UTZ): reveals decrease blood flow to the affected extremity

3. Angiography: reveals location & extent of obstructive process Medical Management 1.

Drug Therapy

a. Vasodilators: to improve arterial circulation (effectiveness ?)

5. If acute pulmonary edema occurs: For Left Sided Heart Failure only a.

b.

c.

Administer Narcotic Analgesic as ordered

•

Narcotic analgesic: Morphine SO4

•

Action: to allay anxiety & reduce preload & afterload

•

Papaverine

•

Isoxsuprine HCL (Vasodilan)

•

Nylidrin HCL (Arlidin)

•

Nicotinyl Alcohol (Roniacol)

•

Cyclandelate (Cyclospasmol)

•

Tolazoline HCL (Priscoline)

b. Analgesic: to relieve ischemic pain

Administer Bronchodilator as ordered

c. Anti-coagulant: to prevent thrombus formation

•

Bronchodilators: Aminophylline IV

•

Action: relieve bronchospasm, increase urinary

a.

Bypass Grafting

output & increase cardiac output

b.

Endarterectomy

Administer Anti-arrythmic as ordered

c.

Balloon Catheter Dilation

•

d. Lumbar Sympathectomy: to increase blood flow

2.

Anti-arrythmic: Lidocaine (Xylocane)

Surgery

e.

6. Assist in bloodless phlebotomy: rotating tourniquet, rotated

Amputation: may be necessary

clockwise every 15 minutes: to promote decrease venous return or reducing preload 7.

Provide client teaching & discharge planning concerning:

Nursing Intervention 1.

a. Need to monitor self daily for S/sx of Heart Failure (pedal edema, weight gain, of 1-2 kg in a 2 day period, dyspnea, loss of appetite, cough)

2.

b. Medication regimen including name, purpose, dosage, frequency & side effects (digitalis, diuretics)

c. Prescribe diet plan (low Na, cholesterol, caffeine: small frequent meals) d.

Need to avoid fatigue & plan for rest periods

e.

Prevent complications

f.

3.

Encourage a slow progressive physical activity •

Walking at least 2 times / day

•

Out of bed at least 3-4 times / day

Administer medications as ordered •

Analgesics

•

Vasodilators

•

Anti-coagulants

Foot care management: •

Need to avoid trauma to the affected extreminty

4.

Importance of stop smoking

5.

Need to maintain warmth especially in cold weather

•

Arrythmia

•

Shock

6. Prepare client for surgery: below knee amputation (BKA)

•

Right ventricular hypertrophy

7.

•

MI

•

Thrombophlebitis

Importance of follow-up care

Raynaud’s Phenomenon Intermittent episodes of arterial spasm most frequently

Importance of follow-up care

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) 2.

Raynaud’s Phenomenon

40 years old & above 2.

Smoking

3.

Collagen diseases

a. Systemic Lupus Erythematosus (SLE): butterfly rash

Venous Ulcer 1.

Varicose Veins

2. Thrombophlebitis (deep vein thrombosis)

b. 4.

Thromboangiitis Obliterans (Buerger’s Disease) •

Acute inflammatory disorder affecting the small / medium

Rheumatoid Arthritis

Direct hand trauma a.

Piano playing

b.

Excessive typing

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 1.

High risk groups - men 25-40 years old

2.

High incident among smokers

4. Pain: usually precipitated by exposure to cold, Emotional upset & Tobacco use

5. Intermittent color changes: pallor (white), cyanosis (blue), rubor (red)

45

46 •

6. Small ulceration & gangrene a tips of digits (advance)

Assess for increase of bleeding particularly in groin area

7.

Dx

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 1.

(thrombus), may affect superficial or deep veins

Administer medications as ordered a.

b.

Inflammation of the vessel wall with formation of clot

Catecholamine-depliting antihypertinsive drugs:

•

Inflammation of the veins with thrombus formation

•

Reserpine

•

Most frequent veins affected are the saphenous, femoral &

•

Guanethidine Monosulfate (Ismelin)

popliteal •

Vasodilators

Can result in damage to the surrounding tissue, ischemia & necrosis

Nursing Intervention 1.

Importance of stop smoking

2.

Need to maintain warmth especially in cold weather

3.

Need to wear gloves when handling cold object / opening a

1.

Obesity

freezer or refrigerator door

2.

Smoking

3.

Related to pregnancy

4.

Severe anemia

Predisposing Factors

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

2.

Congenital weakness of the veins

1.

3.

Thrombophlebitis

2. Superficial vein: Tenderness, redness induration along

4.

Cardiac disorder

5.

Pregnancy

6.

Obesity

•

Swelling

7.

Prolonged standing or sitting

•

Venous distention of limb

•

Tenderness over involved vein

•

Positive homan’s sign: pain at the calf or leg muscle

S/sx

course of the vein 3.

S/sx

1. Pain after prolonged standing: relieved by elevation 2.

Swollen dilated tortuous skin veins

3.

Warm to touch

4.

Heaviness in legs

Pain in the affected extremity

Deep vein:

upon dorsi flexion of the foot •

Cyanosis

Dx

1. Venography (Phlebography): increased uptake of radioactive

Dx 1.

material

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

1. Vein Ligation: involves ligating the saphenous vein where it joins the femoral vein & stripping the saphenous vein system fro groin to ankles

Medical Management 1.

Anti-coagulant therapy a.

Heparin

•

& reduces formation or extension of thrombus

2. Sclerotherapy: can recur & only done in spider web varicosities & danger of thrombosis (2-3 years for embolism)

•

Nursing Intervention

1. Elevate legs above heart level: to promote increased venous return by placing 2-3 pillows under the legs 2.

Measure the circumference of ankle & calf muscle daily: to determine if swollen

3.

Apply anti-embolic / knee-length stockings

4.

Provide adequate rest

5.

Administer medications as ordered

a. Analgesics: for pain 6. Prepare client for vein ligation if necessary a.

• • •

Keep affected extremity elevated above the level of

Side effects: •

Spontaneous bleeding

•

Injection site reaction

•

Ecchymoses

•

Tissue irritation & sloughing

•

Reversible transient alopecia

•

Cyanosis

•

Pan in the arms or legs

•

Thrombocytopenia

b. Warfarin (Coumadin) •

Action: block prothrombin synthesis by interfering with vit. K synthesis

Provide routine pre-op care: usually OPD

b. In addition to routine post-op care:

Action: block conversion of prothrombin to thrombin

•

Side effects:

•

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:

46

47

•

2.

•

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 a.

Other:

Pulmonary Embolism •

Sudden sharp chest pain

•

Unexplained dyspnea

•

Tachycardia

Surgery

•

Palpitations

a.

•

Diaphoresis

•

Restlessness

•

Transient hair loss

•

Burning sensation of feet

•

Bleeding complication

Vein ligation & stripping

b. Venous thrombectomy: removal of cloth in the 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 conduction system, include the nose, pharynx & larynx. Air

Nursing Intervention

is filtered warmed & humidified in the upper airway before

1. Elevate legs above heart level: to promote increase venous

passing to lower airway.

return & decreased edema

2. Apply warm moist pack: to reduce lymphatic congestion 3.

Administer anti-coagulant as ordered: a.

1. External nose is a frame work of bone & cartilage , internally

Heparin

•

divided into two passages or nares (nasal cavity) by the

Monitor PTT: dosage should be adjusted to keep PTT between 1.5-2.5 times normal control level

•

Use infusion pump to administer heparin

•

Ensure proper injection technique •

Use 26 or 27 gauge syringe with ½-5/8 inch needle, inject into fatty layer of abdomen above iliac crest

•

Nose

septum: air enters the system through the nares

2. The septum is covered with mucous membrane, where the olfactory receptors are located. Turbinates, located internally, assist in warming & moistening the air 3.

The major function of the nose are warming, moistening & filtering air.

4. Consist of anastomosis of capillaries known as Keissel Rach

•

Avoid injecting within 2 inches of umbilicus

•

Insert needle at 45-90o to skin

•

Do not withdraw plunger to assess blood return

•

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

3.

Serves as a muscular passageway for both food and air

Assess for increased bleeding tendencies

Plexus: the site of nose bleeding Pharynx

(hematuria, hematemesis, bleeding gums, petechiae of soft palate, conjunctiva retina, ecchymoses, epistaxis, bloody spumtum, melena) &

Composed of three section

1. Nasopharynx: located above the soft palate of the mouth, contains the adenoids & opening to the eustachian tubes

instruct the client to observe for & report these

•

Have antidote (Protamine Sulfate) available

•

Instruct the client to avoid aspirin, antihistamines 7 cough preparations containing glyceryl guaiacolate & obtain MD permission before using other OTC

2. Oropharynx: located directly behind the mouth & tongue, contains the palatine tonsils; air & food enter the body through oropharynx

3. Laryngopharynx: extends from the epiglotitis to the sixth cervical level

drugs

b. Warfarin (Coumadin) •

Assess PT daily: dosage should be adjusted to maintain PT at 1.5-2.5 times normal control level; INR of 2

•

•

Have antidote (Vitamin K) available

•

Alert client to factors that may affect the anticoagulant response (high-fat diet or sudden

4.

airways 2. 3.

Larynx opens to allow respiration & closes to prevent aspiration when food passes through the pharynx

4.

Vocal cords of larynx permit speech & are involved in the cough reflex

5. For phonation (voice production) Glottis

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

3.

Closes to allow passage of food going to the esophagus

4.

The initial sign of complete airway obstruction is the

Assess V/S every 4 hours

5. Monitor chest pain or shortness of breath: possible

inability to cough

pulmonary embolism 6.

Measure thigh, calves, ankles & instep every morning

7.

Provide client teaching & discharge planning a.

Framework is formed by the hyoid bone, epiglotitis & thyroid, cricoid & arytenoids cartilages

Advise client to withhold dose & notify MD immediately if bleeding occur

•

1. Sometimes called “voice Box” connects upper & lower

Obtain careful medication history (there are many drug-drug interaction)

•

Larynx

Lower Respiratory System

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

•

rings

Begin with dorsiflexion of the feet while sitting or lying down

47

48

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 Decrease surface tension

Bronchi

Prevent collapse of alveoli

Right main bronchus

Composed of lecithin and spingomyelin

Larger & straighter than the left Divided into three lobar branches (upper, middle &

Lecitin / Spingomyelin ratio: to determine lung maturity

lower bronchi) to supply the three lobes of right lung

Normal Lecitin / Spingomyelin ratio: is 2:1 In premature infants: 1:2

Left main bronchus Divides into the upper & lower lobar bronchi to supply

Give oxygen of less 40% in premature: to prevent

the left lobes

atelectasis and retrolental fibroplasias Retinopathy & blindness: in premature

Bronchioles In the bronchioles, airway patency is primarily dependent

Pulmonary Circulation

upon elastic recoil formed by network of smooth muscles

Provides for reoxygenation of blood & release of CO2

The tracheobronchial tree ends at the terminal bronchials.

Gas transfers occurs in the pulmonary capillary bed

Distal to the terminal bronchioles the major function is no longer air conduction but gas exchange between blood &

Respiratory Distress Syndrome

alveolar air

Decrease oxygen stimulates breathing

The respiratory bronchioles serves as the transition to the

Increase carbon dioxide is a powerful stimulant for breathing

alveolar epithelium 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 Broad area of lungs resting on diaphragm is called the base

Etiologic Agents

1. Streptococcus Pneumonae: causing pneumococal

& the narrow superior portion called the apex

pneumonia

2. Hemophylus Influenzae: causing broncho pneumonia

Pleura Serous membranes covering the lungs, continuous with the

3.

Diplococcus Pneumoniae

parietal pleura that lines the chest wall

4.

Klebsella Pneumoniae

5.

Escherichia Pneumoniae

6.

Pseudomonas

Parietal Pleura Lines the chest walls & secretes small amounts of lubricating fluid into the intrapleural space (space between

High Risk Groups

the parietal pleura & visceral pleura) this fluid holds the lungs & chest wall together as a single unit while allowing them to move separately

Includes the ribs cage, intercostal muscles & diaphragm Chest is a C shaped & supported by 12 pairs of ribs & costal

2.

Elderly

1.

Smoking

2.

Air pollution

3.

Immuno compromised

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

The internal intercoastal muscles tends to pull ribs down

Children below 5 years old

Predisposing Factors

Chest Wall

of the thoracic cavity

1.

S/sx

& in & play a role in forced expiration Diaphragm A major muscle of ventilation (the exchange of air between the atmosphere & the alveoli). Alveoli Are functional cellular unit of the lungs; about half arise

1.

Productive cough with greenish to rusty sputum

2.

Rapid shallow respiration with expiratory grunt

3.

Nasal flaring

4.

Intercostal rib retraction

5.

Use of accessory muscles of respiration

6.

Dullness to flatness upon auscultation

7.

Possible pleural friction rub

8.

High-pitched bronchial breath sound

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 16. Cyanosis

Surfactant A phospholipids substance found in the fluid lining the

17. Chest pain

alveolar epithelium

18. Abdominal distention leading to paralytic ileus (absence of peristalsis)

Reduces surface tension & increase stability of the alveoli & prevents their collapse Dx Alveolar Ducts Arises from the respiratory bronchioles & lead to the alveoli

1. Sputum Gram Staining & Culture Sensitivity: positive to cultured microorganisms

2. Chest x-ray: reveals pulmonary consolidation over affected Alveolar Sac

area

48

49 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 1.

Persistent fatigue

Facilitate adequate ventilation Administer O2 as needed & assess its effectiveness: low

f.

Avoid smoking

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

2.

Histoplasmosis

Auscultate breath sound every 2-4 hour

Systemic fungal disease caused by inhalation of dust

Monitor ABG

contaminated by histoplasma capsulatum which is transmitted to bird manure

Facilitate removal of secretions 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 Administer Mucolytic or Expectorant as ordered

S/sx

Aerosol treatment via nebulizer Humidification of inhaled air Chest physiotherapy (Postural Drainage): tends to promote expectoration

3. Observe color characteristics of sputum & report any

4.

Similar to PTB or Pneumonia

2.

Productive cough

3.

Fever, chills, anorexia, general body malaise

4.

Chest and joint pains

5.

Dyspnea

6.

Cyanosis

changes: encourage client to perform good oral hygiene

7.

Hemoptysis

after expectoration

8.

Sometimes asymptomatic

Provide adequate rest & relief control of pain Enforce CBR with limited activity

5.

1.

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

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 7.

Nursing Intervention 1.

Monitor respiratory status

Monitor temperature A

2.

Enforce CBR

Administer antipyretic as ordered

3.

Administer oxygen inhalation

4.

Administer medications as ordered

Control fever & chills:

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

Fever: acetaminophen given prophylactically

to stimulate the movement of secretions

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.

f.

Provide oral care after procedure

g.

Contraindicated with Unstable V/S

Prevent the spread of infection by spraying of breeding places

Chronic Obstructive Pulmonary Disease (COPD)

Hemoptysis Clients with increase intra ocular pressure (Normal

9.

Chronic Bronchitis

IOP 12 – 21 mmHg)

Excessive production of mucus in the bronchi with

Increase ICP

accompanying persistent cough Characteristic include hypertrophy / hyperplasia of the

Provide increase CHO, calories, CHON & vitamin C

mucus secreting gland in the bronchi, decreased ciliary

10. Provide client teaching & discharge planning 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

Need to continue deep breathing & coughing exercise

narrowing of smaller airways

for at least 6-8 weeks after discharge

AKA “Blue Bloaters”

c. 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

49

50 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

Nursing Intervention

6.

Slight Cyanosis

7.

Distended neck veins

1.

8.

Ankle edema

2. O2 inhalation: low flow 2-3 L/min: to prevent respiratory

9.

Prolonged expiratory grunt

Enforce CBR distress

10. Anorexia and generalized body malaise

3.

Administer medications as ordered

11. Pulmonary hypertension

4.

Force fluids 2-3 L/day

5.

Semi fowlers position: to promote lung expansion

6.

Nebulize & suction when needed

7.

Provide client health teachings and discharge planning

a.

Leading to peripheral edema

b. Cor Pulmonale (right ventricular hypertrophy) 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 cause poor controlled asthma

Immunologic / allergic reaction results in histamine release 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 Predisposing Factors (Depending on Types)

d.

Importance of follow up care

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

1.

Productive cough with mucopurulent sputum

2.

Dyspnea in exertion

Causes Hereditary

Sx

Drugs (aspirin, penicillin, beta blocker) 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

2.

Dyspnea

3.

Wheezing on expiration

4.

Cyanosis

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

1.

Pulmonary Function Test Incentive spirometer: reveals

1.

Feeding initiated upon return of gag reflex

decrease vital lung capacity

3. Bronchoscopy: reveals sources & sites of secretion: direct visualization of bronchus using fiberscope Nursing Management before Bronchoscopy

Dx

Post Bronchoscopy 2.

Avoid talking, coughing and smoking, may cause irritation

2. ABG analysis: PO2 decrease

3.

Monitor for signs of gross

3.

4. Monitor for signs of laryngeal spasm: prepare tracheostomy

Before ABG test for positive Allens Test, apply direct pressure to ulnar & radial artery to determine presence of

set

collateral circulation Medical Management 1.

Drug Therapy

a. Bronchodilators: given via inhalation or metered dose inhaler or MDI for 5 minutes

b. Steroids: decrease inflammation: given 10 min after bronchodilator

Medical Management 1.

Surgery Pneumonectomy: 1 lung is removed & position on affected side Segmental Wedge Lobectomy: promote re-expansion of lungs Unaffected lobectomy: facilitate drainage

50

51 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 abdomen to help produce more expulsive cough)

Inelasticity of alveoli

d. Employ pursed-lip breathing techniques (prolonged slow

Air trapping

relaxed expiration against pursed lips)

Maldistribution of gases e.

Overdistention of thoracic cavity (barrel chest)

Institute pulmonary toilet

6. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung

Predisposing Factors 1.

expansion

Smoking

2. Inhaled irritants: air pollution 3.

Allergy or allergic factor

4.

High risk: elderly

5. Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to

7.

Provide comfortable & humid environment

8.

Provide high carbohydrates, protein, calories, vitamins and minerals

9.

Provide client teachings and discharge planning concerning a.

release elastase for recoil of alveoli

Prevention of recurrent infection 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 tightness of chest, fatigue, increased dyspnea)

5. Flaring of nostrils (alai nares) b.

Control of environment

6.

Use of accessory muscles

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 Panacinar/centriacinar

f.

Strict compliance to medication

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)

•

growths, but malignant cells behave very differently from

Theophylline

normal cells & have special features characteristics of the

Isoetharine (Bronkosol) b.

Corticosteroids: Prednisone

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

d.

The term neoplasia refers to both benign & malignant

cancer process.

•

Since the growth control mechanism of normal cells is not entirely understood, it is not clear what allows the

Tetracycline

uncontrolled growth, therefore no definitive cure has

Ampicilline

been found.

Mucolytics / expectorants

51

52 Characteristics of Malignant Cells •

Cancer cells are mutated stem cells that have undergone structural changes so that they are unable to perform the normal functions of specialized tissues.

•

They may function is a disorderly way to crease normal function completely, only functioning for their own survival

1.

Rate of Growth Cancer cells have uncontrolled growth or cell division

•

Rate at which a tumor grows involves both increased cell Malignant cells do not form orderly layers, but pile on top of each other to eventually form tumors.

•

•

Definitely cancer

Seven warning signs of cancer

3.

Importance of retal exam for those over age 40

4.

Hazards of smoking

5.

Oral self – examination as well as annual exam of mouth

6.

Hazards of excess sun exposure

7.

Importance of pap smear

8.

P.E. with lab work – up: every 3 years ages 20-40; yearly

9. TSE – testicular self – examination •

Testicular Cancer i.

•

Some cancers shows familial pattern

•

Maybe caused by inherited genetics defects

Most common cancer in men between the age of 15 & 34

•

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 groin

V – Viral o 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

Viruses

(

HTLV-I,

Epstein

Barr

Virus,

o

Oncovirus (RNA – Type Viruses) thought to be culprit

of

the

C: change in bowel or bladder habits A: a sore that doesn’t heal

Majority (over 80%) of human cancer related to

U: unusual bleeding or discharge

environmental carcinogens o

tenderness

7 Warning Signs of Cancer

E – Environmental o

or

breasts

Human

Papilloma Virus) linked to human tumors •

Probably cancer or precancerous

G – Genetics

• •

•

for age 40 & over

Pre-disposing Factors

•

Doubtful (more severe changes)

& teeth

division & increased survival time of cells. •

•

2. BSE – breast self – examination

The most undifferentiated cells are also called anaplastic.

•

Probably normal (slight changes)

Client Factors

& growth. •

•

T: thickening of lump in breast or elsewhere

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,

•

urethane •

Cigarette smoke

•

hormones

Ability of the drug to kill cancer cells; normal cells may also be damaged, producing side effects.

•

Different drug act on tumor cell in different stages of the cell growth cycle.

Classification of Cancer Types of Chemotherapeutic Drugs

Tissue Typing:

•

Carcinoma – arises from surface, glandular, or parenchymal epithelium

1. Antimetabolites o

1. Squamous Cell Carcinoma – surface epithelium

Foster cancer cell death by interfering with cellular metabolic process.

2. Adenocarcinoma – glandular or parenchymal tissue 2.

Alkylating Agent

•

Sarcoma – arises from connective tissue

•

Leukemia – from blood

•

Lymphoma – from lymph glands

o

obtained from periwinkle plant.

•

Multiple Myeloma – from bone marrow

o

makes the host’s body a less favorable environment

o 3.

Plant Alkaloids

for the growth of cancer cells.

Stages of Tumor Growth A. Staging System:

•

4.

Antitumor Antibiotics o

TNM System: uses letters & numbers to designate the T– stands for primary growth; 1-4 with increasing

5.

Steroids & Sex Hormones o

size; T1S indicates carcinoma in situ

o

affect RNA to make environment less favorable for cancer growth.

extent of tumors

o

act with DNA to hinder cell growth & division.

alter the endocrine environment to make it less conducive to growth of cancer cells.

N – stands for lymph nodes involvement: 0-4 indicates progressively advancing nodal disease

o

M – stands for metastasis; 0 indicates no distant metastases, 1 indicates presence of metastases

•

Stages 0 – IV: all cancers divided into five stages incorporating size, nodal involvement & spread

B. Cytologic Diagnosis of Cancer

1. Involves in the study of shed cells (ex. Pap smear) 2.

Classified by degree of cellular abnormality •

Normal

Major Side Effects & Nursing Intervention A. GI System •

Nausea & Vomiting o

Administer antiemetics routinely q 4-6 hrs as well as prophylactically before chemotherapy is initiated.

o

Withhold food/fluid 4-6 hrs before chemotherapy

o

Provide bland food in small amounts after treatment

52

53 •

Diarrhea o

Administer antidiarrheals.

o

Maintain good perineal care.

o

Give clear liquids as tolerated.

o

Monitor K, Na, Cl levels.

•

Plant alkaloids (vincristine) cause neurologic damage with repeated doses

•

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

Radiation Therapy

•

Stomatitis (mouth sore) o

o

•

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

Perform a cleansing rinse with plain H2O or dilute a

cells including normal cells will be injured causing side

H2O soluble lubricant such as hydrogen peroxide

effects.

after meal. o

cells, maybe internal or external.

Rinse with viscous lidocaine before meals to provide analgesic effect.

o

Uses ionizing radiation to kill or limit the growth of cancer

Provide & teach the client good oral hygiene, including avoidance of commercial mouthwashes.

o

•

•

Localized effects are related to the area of the body being

Apply H2O lubricant such as K-Y jelly to lubricate

treated; generalized effects maybe related to cellular

cracked lips.

breakdown products.

Advice client to suck on Popsicles or ice chips to provide moisture.

B. Hematologic System

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 •

Thrombocytopenia

isotopes, used for internal source.

o

Avoid bumping or bruising the skin.

o

Protect client from physical injury.

common form of external radiotherapy (ex. Electromagnetic

o

Avoid aspirin or aspirin products.

or X-ray)

o

Avoid giving IM injections.

o

Monitor blood counts carefully.

o

Assess for signs of increase bleeding tendencies

•

Gamma – penetrate more deeper areas of the body, most

Methods of Delivery

•

External Radiation Therapy – beams high energy rays

(epistaxis, petechiae, ecchymoses)

directly to the affected area. Ex. Cobalt therapy

• •

Internal Radiation Therapy – radioactive material is injected

Leukopenia o

Use careful handwashing technique.

o

Maintain reverse isolation if WBC count drops below

or implanted in the client’s body for designated period of time.

o

Sealed Implants – a radioisotope enclosed in a

1000/mm

container so it does not circulate in the body;

o

Assess for signs of respiratory infection

client’s body fluids should not be contaminated.

o

Avoid crowds/persons with known infection

o

Unsealed source – a radioisotope that is not encased in a container & does circulate in the body &

•

Anemia

contaminate body fluids.

o

Provide adequate rest period

o

Monitor hemoglobin & hematocrit

o

Protect client from injury

o

Administer O2 if needed

Factors Controlling Exposure

•

Half-life – time required for half of radioactive atoms to decay.

Alopecia o

Explain that hair loss is not permanent

o

Offer support & encouragement

o

Scalp tourniquets or scalp hypothermia via ice pack

Each radioisotope has different half-life.

2.

At the end of half-life the danger from exposure decreases.

C. Integumentary System •

1.

•

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

may be ordered to minimize hair loss with some

gamma rays.

agent o

Advice client to obtain wig before initiating treatment

D. Renal System

•

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.

Encourage fluid & frequent voiding to prevent accumulation of metabolites in bladder; R: may cause direct damage to kidney by excretion of metabolites.

•

Avoid pressure, trauma, infection to skin; use bed cradle.

•

Wash affected areas with plain H2O & pat dry; avoid soap.

•

Increased excretion of uric acid may damage kidney

•

Use cornstarch, olive oil for itching; avoid talcum powder.

•

Administer allopurinol (Zyloprim) as ordered; R: to prevent

•

If sloughing occurs, use sterile dressing with micropore tape

uric acid formation; encourage fluids when administering

•

Avoid exposing skin to heat, cold, or sunlight & avoid constricting irritating clothing.

allopurinol

B. Anorexia, N/V •

E. Reproductive System

Arrange meal time so they do not directly precede or follow therapy.

• • •

Damage may occur to both men & women resulting

•

Encourage bland foods.

infertility &/or mutagenic damage to chromosomes

•

Provide small attractive meals.

Banking sperm often recommended for men before

•

Avoid extreme temperature.

chemotherapy

•

Administer antiemetics as ordered before meals.

Clients & partners advised to use reliable methods of contraception during chemotherapy

F. Neurologic System

C. Diarrhea •

Encourage low residue, bland, high CHON food.

•

Administer antidiarrheal as ordered.

•

Provide good perineal care.

53

54 •

Monitor electrolytes particularly Na, K, Cl

D. Anemia, Leukopenia, Thrombocytopenia

1. Synarthroses: immovable joints 2. Amphiarthroses: partially movable joints

•

Isolate from those with known infection.

•

Provide frequent rest period.

•

Encourage high CHON diet.

•

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

3. Diarthroses (synovial): freely movable joints •

Have a joint cavity (synovial cavity) between the articulating bone surfaces

synovial fluid to lubricate the joint and reduce friction. Muscles

Burns •

direct tissue injury caused by thermal, electric, chemical &

•

smoke inhaled (TECS) Type:

Functions of Muscles •

Provide shape to the body

•

Protect the bones

1.

Thermal

•

Maintain posture

2.

Smoke Inhalation Chemical

•

Cause movement of body parts by contraction

3. 4.

Electrical

•

Classification •

Types of Muscles

•

Cardiac: involuntary; found only in heart

•

Smooth: involuntary; found in walls of hollow structures (e.g. intestines)

Partial Thickness

•

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

origin and to bones at the point of insertion.

Characteristics: erythema, blanching on

•

pressure, no vesicles

thickening of the muscle) and isometric (increased

Depth: epidermis & dermis

muscle tension) movement.

Causes: flash, scalding, or flame burn

•

Sensation: very painful shinny, wet after vesicles ruptures

•

Full Thickness (3rd & 4th degree) 1.

Depth: all skin layers & nerve endings; may involve Causes: flames, chemicals, scalding, electric current

3.

Sensation: little or no pain

4.

Characteristics: wound is dry, white, leathery, or hard

•

A form of connective tissue

•

Major functions are to cushion bony prominences and offer protection where resiliency is required

Tendons and Ligaments •

Composed of dense, fibrous connective tissue

•

Functions

Overview Of Anatomy & Physiology Of Musculoskeletal System • •

To provide a structural framework for the body

•

To provide a means for movement

Ligaments attach bone to bone

2.

Tendons attach muscle to bone

Rheumatoid Arthritis (RA) •

Chronic systemic disease characterized by inflammatory changes in joints and related structures.

•

Joint distribution is symmetric (bilateral): most commonly affects smaller peripheral joints of hands & also commonly

Bones

involves wrists, elbows, shoulders, knees, hips, ankles and

Function of Bones •

Provide support to skeletal framework

•

Assist in movement by acting as levers for muscles

•

Protect vital organ & soft tissue

•

Manufacture RBC in the red bone marrow

jaw.

•

If unarrested, affected joints progress through four stages of deterioration: synovitis, pannus formation, fibrous ankylosis, and bony ankylosis.

Cause

(hematopoiesis)

1.

Cause unknown or idiopathic

Provide site for storage of calcium & phosphorus

2.

Maybe an autoimmune process

Types of Bones

3.

Genetic factors

•

4. Play a role in society (work)

• 1.

1.

Consist of bones, muscles, joints, cartilages, tendons, ligaments, bursae

•

Contraction is innervated by nerve stimulation.

Cartilage

muscles, tendons & bones 2.

Have properties of contraction and extension, as well as elasticity, to permit isotonic (shortening and

2. Deep Partial Thickness (2nd degree)

Characteristics: fluid filled vesicles; red,

Muscles are attached to the skeleton at the point of

Long Bones

•

Central shaft (diaphysis) made of compact bone & two end (epiphyses) composed of cancellous bones (ex. Femur & humerus)

•

ages 35-45.

Cancellous bones covered by thin layer of compact

2.

Fatigue

bone (ex. Carpals & tarsals)

3.

Cold

4.

Emotional stress

5.

Infection

Flat Bones

•

Two layers of compact bone separated by a layer of cancellous bone (ex. Skull & ribs)

•

1. Occurs in women more often than men (3:1) between the

Short Bones •

•

Predisposing factors

Irregular Bones

•

Sizes and shapes vary (ex. Vertebrae & mandible)

Joints

S/sx 1.

Fatigue

2.

Anorexia & body malaise

3.

Weight loss

4.

Slight elevation in temperature

•

Articulation of bones occurs at joints

•

Movable joints provide stabilization and permit a variety of

morning & after a period of inactivity & may show crippling

movements

deformity in long-standing disease.

Classification

5. Joints are painful: warm, swollen, limited in motion, stiff in

6.

Muscle weakness secondary to inactivity

7.

History of remissions and exacerbations

54

55 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.

f.

Prevent complications of immobility.

Dx

6. Provide heat treatments: warm bath, shower or whirlpool;

1. X-rays: shows various stages of joint disease 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.

feelings.

Medical Management 1.

Provide psychologic support and encourage client to express

9.

Drug therapy

Assists clients in setting realistic goals; focus on client strengths.

a. Aspirin: mainstay of treatment: has both analgesic and

10. Provide client teaching & discharge planning & concerning.

anti-inflammatory effect.

b. Nonsteroidal anti-inflammatory drugs (NSAIDs): relieve pain and inflammation by inhibiting the synthesis of

a.

Use of prescribed medications & side effects

b.

Self-help devices to assist in ADL and to increase independence

prostaglandins.

c.

Importance of maintaining a balance between activity &

•

Ibuprofen (Motrin)

•

Indomethacin (Indocin)

d.

Energy conservation methods

•

Fenoprofen (Nalfon)

e.

Performance of ROM, isometric & prescribed exercises

•

Mefenamic acid (Ponstel)

f.

Maintenance of well-balanced diet

•

Phenylbutazone (Butazolidin)

g.

Application of resting splints as ordered

h.

Avoidance of undue physical or emotional stress

•

Piroxicam (Feldene)

i.

Importance of follow-up care

•

Naproxen (Naprosyn)

•

Sulindac (Clinoril)

rest

Osteoarthritis 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

•

Sodium thiomalate (Myochrysine)

•

Aurothioglucose (Solganal)

•

•

interphalangeal joints of fingers most commonly affected Incident Rate

SI: monitor blood studies & urinalysis

1.

Women & men affected equally

frequently

2.

Incidence increases with age

•

Proteinuria

•

Mouth ulcers

•

Skin rash

•

Aplastic anemia.

Predisposing Factors

1. Most important factor in development is aging (wear & tear on joints)

Oral form: smaller doses are effective; take 3-6

2.

Obesity

3.

Joint trauma

months to become effective

•

Auranofin (Ridaura)

•

S/sx

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

SI: blood & urine studies should be

joints

monitored. • d.

2. Heberden’s nodes: bony overgrowths at terminal

Diarrhea

interphalangeal joints

Corticosteroids

•

3. Decreased ROM with possible crepitation (grating sound

Intra-articular injections: temporarily suppress

when moving joints)

inflammation in specific joints.

•

Systemic administration: used only when client does not respond to less potent anti-inflammatory drugs.

e. Methotrexate: given to suppress immune response •

Cytoxan

•

SI: bone marrow suppression.

2. Physical therapy: to minimize joint deformities. 3. Surgery: to remove severely damaged joints (e.g. total hip

Dx

1. X-rays: show joint deformity as disease progresses 2. ESR: may be slightly elevated when disease is inflammatory Nursing Interventions 1.

Assess joints for pain & ROM.

2.

Relieve strain & prevent further trauma to joints.

replacement; knee replacement). Nursing Interventions 1.

Assess joints for pain, swelling, tenderness & limitation of

b.

Use cane or walker when indicated.

c.

Ensure proper posture & body mechanics.

e.

Promote maintenance of joint mobility and muscle strength.

a. Perform ROM exercises several times a day: use of heat

3. Maintain joint mobility and muscle strength.

at the point of pain. b.

Use isometric or other exercise to strengthen muscles.

3. Change position frequently: alternate sitting, standing &

4.

lying.

Ensure balance between activity & rest.

b.

Provide 1-2 scheduled rest periods throughout day.

b.

Ensure proper body alignment.

c.

Change client’s position frequently.

Promote comfort / relief of pain. Administer medications as ordered:

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

b. Apply heat or ice as ordered (e.g. warm baths,

2 times/day for gentle ROM exercises. a.

Provide ROM & isometric exercises.

Aspirin & NSAID: most commonly used

c. Rest & support inflamed joints: if splints used: remove 1Ensure bed rest if ordered for acute exacerbations.

a.

a.

4. Promote comfort & relief / control of pain. a.

Avoid excessive weight-bearing activities & continuous standing.

prior to exercise may decrease discomfort; stop exercise

5.

Encourage rest periods throughout day.

d. Promote weight reduction: if obese

motion. 2.

a.

compresses, hot packs): to reduce pain. 5.

Prepare client for joint replacement surgery if necessary.

Provide firm mattress.

55

56 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

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.

Predisposing Factors

Pathophysiology 1. Gout

A defect in body’s immunologic mechanisms produces autoantibodies in the serum directed against components of the client’s own cell nuclei.

A disorder of purine metabolism; causes high levels of uric 2.

acid in the blood & the precipitation of urate crystals in the

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 1.

Fatigue

Occurs most often in males

2.

Fever

Familial tendency

3.

Anorexia

4.

Weight loss

5.

Malaise

Incident Rate 1. 2. S/sx 1.

Joint pain

6.

History of remissions & exacerbations

2.

Redness

7.

Joint pain

3.

Heat

8.

Morning stiffness

4.

Swelling

9.

Skin lesions Erythematous rash on face, neck or extremities may

5. Joints of foot (especially great toe) & ankle most commonly 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 1.

Seizures

Drug therapy a.

Organic brain syndrome

Acute attack:

Psychosis

Colchicine IV or PO: discontinue if diarrhea occurs

14. Cardiopulmonary system involvement

NSAID: Indomethacin (Indocin)

Pericarditis

Naproxen (Naprosyn)

Pleurisy

Phenylbutazone (Butazolidin) b.

15. Increase susceptibility to infection

Prevention of attacks Uricosuric agents: increase renal excretion of uric acid

Dx

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 2.

Low-purine diet may be recommended

3.

Joint rest & protection

4.

Heat or cold therapy

Nursing Interventions 1.

Assess joints for pain, motion & appearance.

2.

Provide bed rest & joint immobilization as ordered.

3.

Administer anti-gout medications as ordered.

4. Lupus Erythematosus (LE prep): positive 5. Anti-DNA: positive 6.

Medical Management 1.

& arthritis

b. Corticosteroids: to suppress the inflammatory response 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)

Provide client teaching and discharge planning concerning a.

Cyclophosphamide (Cytoxan)

Medications & their side effects

b. Modifications for low-purine diet: avoidance of shellfish,

2. Plasma exchange: to provide temporary reduction in amount of circulating antibodies.

liver, kidney, brains, sweetbreads, sardines, anchovies c.

Limitation of alcohol use

d.

Increased in fluid intake

e.

Weight reduction if necessary

f.

Importance of regular exercise

Systemic Lupus Erythematosus (SLE) Chronic connective tissue disease involving multiple organ

3. Supportive therapy: as organ systems become involved. Nursing Interventions 1.

Assess symptoms to determine systems involved.

2.

Monitor vital signs, I&O, daily weights.

3.

Administer medications as ordered.

4. Institute seizure precautions & safety measures: with CNS involvement.

systems Incident Rate

Drug therapy

a. Aspirin & NSAID: to relieve mild symptoms such as fever

4. Administer analgesics as ordered: for pain

8.

Chronic false-positive test for syphilis

5.

Provide psychologic support to client / significant others.

6.

Provide client teaching & discharge planning concerning

56

57 •

a.

Disease process & relationship to symptoms

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.

•

Salivary gland: located in the mouth produce secretion

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 h.

Need to avoid exposure to persons with infections

i.

Importance of regular medical follow-up

j.

Availability of community agencies

Esophagus •

Muscular tube that receives foods from the pharynx & propels it into the stomach by peristalsis

Stomach • Osteomyelitis Infection of the bone and surrounding soft tissues, most

Located on the left side of the abdominal cavity occupying the hypochondriac, epigastric & umbilical regions

•

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

•

fracture or surgery), through the bloodstream, or by direct

The secretion of digestive juice is stimulated by 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

•

destruction.

The gastric phase is stimulated by the presence of food in the stomach & regulated by neural stimulation via PNS & hormonal stimulation through secretion of gastrin

S/sx

by the gastric mucosa

1.

Malaise

2.

Fever

3.

Pain & tenderness of bone

4.

Redness & swelling over bone

5.

Difficulty with weight-bearing

6.

Drainage from wound site may be present.

•

After processing in the stomach the food bolus called chyme is released into the small intestine through the duodenum

•

Two sphincters control the rate of food passage

•

Cardiac Sphincter: located at the opening between the esophagus & stomach

•

Dx

duodenum

1. CBC: WBC elevated 2. Blood cultures: may be positive

•

3. ESR: may be elevated Nursing Interventions 1.

Administer analgesics & antibiotics as ordered.

2.

Use sterile techniques during dressing changes.

•

•

Fundus

•

Body

•

Antrum

Gastric Secretions:

•

Provide immobilization of affected part as ordered.

Hydrocholoric Acid: secreted by parietal cells, function in CHON digestion & released in response to gastrin

5. Provide psychologic support & diversional activities

•

(depression may result from prolonged hospitalization)

Intrinsic Factor: secreted by parietal cell, promotes absorption of Vit B12

Prepare client for surgery if indicated.

•

Incision & drainage: of bone abscess

Mucoid Secretion: coat stomach wall & prevent auto digestion

Sequestrectomy: removal of dead, infected bone & cartilage

Pepsinogen: secreted by the chief cells located in the fundus aid in CHON digestion

frequently: to prevent deformities.

6.

Three anatomic division

•

3. Maintain proper body alignment & change position 4.

Pyloric Sphincter: located between the stomach &

1st half of duodenum

Bone grafting: after repeated infections Leg amputation 7.

Provide client teaching and discharge planning concerning Use of prescribed oral antibiotic therapy & side effects

Middle Alimentary canal: Function for absorption; Complete absorption: large intestine Small Intestines

Importance of recognizing & reporting signs &

•

Composed of the duodenum, jejunum & ileum

complications (deformity, fracture) or recurrence

•

Extends from the pylorus to the ileocecal valve which regulates flow into the large intestines to prevent reflux to

FRACTURES A.

the into the small intestine

General information 1.

B. Medical management C. Assessment findings

•

Major function: digestion & absorption of the end product of digestion

•

Structural Features:

•

D. Nursing interventions

projections located in the mucous membrane; containing goblet cells that secrets mucus & absorptive

Overview of Anatomy & Physiology Gastro Intestinal Track System •

Villi (functional unit of the small intestines): finger like

cells that absorb digested food stuff

The primary function of GIT are the movement of food,

•

digestion, absorption, elimination & provision of a

Crypts of Lieberkuhn: produce secretions containing digestive enzymes

continuous supply of the nutrients electrolytes & H2O.

•

Brunner’s Gland: found in the submucosaof the duodenum, secretes mucus

Upper alimentary canal: function for digestion Mouth •

Consist of lips & oral cavity

•

Provides entrance & initial processing for nutrients & sensory data such as taste, texture & temperature

•

Oral Cavity: contains the teeth used for mastication & the tongue which assists in deglutition & the taste sensation & mastication

2nd half of duodenum Jejunum Ileum 1st half of ascending colon Lower Alimentary Canal: Function: elimination Large Intestine •

Divided into four parts:

•

Cecum (with appendix)

57

58

•

•

Colon (ascending, transverse, descending, sigmoid)

•

Trypsinogen & Chymotrypsin: for protein digestion

•

Rectum

•

Amylase: breakdown starch to disacchardes

•

Anus

•

Lipase: for fat digestion

Serves as a reservoir for fecal material until defecation

•

Endocrine function related to islets of langerhas

occurs

•

Function: to absorb water & electrolytes

•

MO present in the large intestine: are responsible for small

Physiology of Digestion & Absorption

•

Digestion: physical & chemical breakdown of food into

amount of further breakdown & also make some vitamins

absorptive substance

•

•

Amino Acids: deaminated by bacteria resulting in

starch is broken down

ammonia which is converted to urea in the liver

•

•

Bacteria in the large intestine: aid in the synthesis of

•

Feces (solid waste): leave the body via rectum & anus

•

•

to amino acid to complete the digestive process

(roughage, dead bacteria, fats, CHON, inorganic matter)

•

a. 2nd half of ascending colon Transverse

c.

Descending colon

d.

Sigmoid

e.

Rectum

In the small intestines CHO are hydrolyzed to monosaccharides, fats to glycerol & fatty acid & CHON

Fecal matter: usually 75% water & 25% solid wastes

b.

In the stomach food is processed by gastric secretions into a substance called chyme

Anus: contains internal sphincter (under involuntary control) & external sphincter (voluntary control)

•

Food then passes into the esophagus where it is propelled into the stomach

vitamin K & some of the vitamin B groups

•

Initiate in the mouth where the food mixes with saliva &

When chymes enters the duodenum, mucus is secreted to neutralized hydrocholoric acid, in response to release secretin, pancreas releases bicarbonate to neutralized acid chyme

•

Accessory Organ

Cholecystokinin & Pancreozymin (CCKPZ) •

Are produced by the duodenal mucosa

•

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

•

Hepatic Sinusoids (capillaries): are lined with kupffer cells which carry out the process of phagocytosis

•

Portal circulation brings blood to the liver from the stomach, spleen, pancreas & intestines

•

Function: •

Metabolism of fats, CHO & CHON: oxidizes these nutrient for energy & produces compounds that can be stored

Salivary Glands 1. Parotid – below & front of ear 2. Sublingual 3. Submaxillary -

Produces saliva – for mechanical digestion

-

1200 -1500 ml/day - saliva produced

Disorder of the GIT Peptic Ulcer Disease (PUD)

•

Production of bile

•

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

•

Excoriation / erosion of submucosa & mucosal lining due to:

bilirubin •

Storage of vitamins A, D, B12 & iron

•

Synthesis of coagulation factors

•

Detoxification of many drugs & conjugation of sex hormones

Salivary gland

Gastric Ulcer

•

•

Hypersecretion of acid: pepsin

•

Decrease resistance to mucosal barrier

Caused by bacterial infection: Helicobacter Pylori

Doudenal Ulcer

Verniform appendix

•

Most commonly found in the first 2 cm of the duodenum

Liver

•

Characterized by gastric hyperacidity & a significant rate of gastric emptying

Pancreas: auto digestion Gallbladder: storage of bile

Predisposing factor Biliary System

•

Consist of the gallbladder & associated ductal system (bile

•

Smoking: vasoconstriction: effect GIT ischemia

•

Alcohol Abuse: stimulates release of histamine: Parietal cell

ducts)

•

•

•

Emotional Stress

•

•

Drugs:

Function: to concentrate & store bile

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

•

release Hcl acid = Ulceration

Gallbladder: lies under the surface of the liver

S/sx Gastric Ulcer

If the sphincter of oddi is relaxed: bile enters the duodenum,

Duodenal Ulcer

if contracted: bile is stored in gallbladder Site Pancreas •

Positioned transversely in the upper abdominal cavity

•

Consist of head, body & tail along with a pancreatic duct which extends along the gland & enters the duodenum via the common bile duct

•

Has both exocrine & endocrine function

•

Function in GI system: is exocrine

•

Exocrine cells in the pancreas secretes:

•

Pain

Antrum or lesser •

curvature 30 min-1 hr

Duodenal bulb •

after eating •

Left

eating •

epigastrium •

Gaseous & Not usually relieved by

Mid epigastrium

•

burning •

2-3 hrs after

Cramping & burning

•

Usually relieved by

58

59

•

Hypersecreti

•

on • • • •

• • • •

s •

antacid

antacid

stomach &

stomach & duodenal bulb

•

12 MN –

anastomoses of gastric

& anastomostoses of

•

3am pain Increased

stump to the

gastric stump to jejunum.

Normal

High Risk

Removal of ½ of

duodenum.

secretion Common Hematemeis Weight loss Stomach

• • • •

secretion Not common Melena Weight gain Perforation

Nursing Intervention Post op 1.

Hemorrhage 60 years old

•

20 years old

2.

Dx

Monitor NGT output •

Immediately post op should be bright red

•

Within 36-42 hrs: output is yellow green

•

After 42 hrs: output is dark red

Administer medication •

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

•

Upper GI series: presence of ulcer confirm

5.

Complications:

•

Hemorrhage: Hypovolemic shock: Late signs: anuria

•

Peritonitis

Supportive:

•

Paralytic ileus: most feared

•

Rest

•

Hypokalemia

•

Bland diet

•

Thromobphlebitis

•

Stress management

•

Pernicious anemia

Medical Management 1.

2.

Removal of ½ -3/4 of

gastric acid

cause • •

•

food &

gastric acid

Vomiting Hemorrhage Weight Complication

•

food &

Drug Therapy:

•

Nursing Intervention

Antacids: neutralizes gastric acid

•

Aluminum hydroxide: binds phosphate in the GIT & neutralized gastric acid & inactivates pepsin

•

Magnesium & aluminum salt: neutralized gastric acid & inactivate pepsin if pH is raised to >=4

Aluminum containing Antacids

1.

Administer medication as ordered

2. Diet: bland, non irritating, non spicy 3. Avoid caffeine & milk / milk products: Increase gastric acid secretion 4.

Provide client teaching & discharge planning a.

Magnesium

•

Take medication at prescribe time

Ex. Milk of Magnesia

•

Have antacid available at all times

SE: Diarrhea

•

Recognized situation that would increase the need

containing Antacids Ex. Aluminum OH gel (Amphojel)

Medical Regimen

SE: Constipation

for antacids

Maalox

b.

SE: fever

•

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

•

against H. pylori

•

Cimetidine (Tagamet)

•

Famotidine (Pepcid)

c.

•

Bland diet consist of six meals / day

•

Eat slowly

•

Avoid acid producing substance: caffeine, alcohol,

•

Avoid stressfull situation at mealtime

•

Plan rest period after meal

•

Avoid late bedtime snacks

Avoidance of stress-producing situation & development

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 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

3.

Proper Diet

•

• •

Know proper dosage, action & SE

of stress production methods

acetylcholine resulting decrease GI secretions

•

•

Anticholinergic:

• •

Avoid ulcerogenic drugs: salicylates, steroids

highly seasoned food

Ranitidine (Zantac): has some antibacterial action

•

•

S/sx

Metronidazole & Amoxacillin: for ulcer caused by

1.

Weakness

Helicobacter Pylori

2.

Faintness

Surgery:

3.

Feeling of fullness

•

Gastric Resection

4.

Dizziness

•

Anastomosis: joining of 2 or more hollow organ

5.

Diaphoresis

•

Subtotal Gastrectomy: Partial removal of stomach

6.

Diarrhea

7.

Palpitations

•

Before surgery for BI or BII

•

Do Vagotomy (severing or cutting of vagus nerve) & Pyloroplasty (drainage) first

Nursing Intervention 1.

Avoid fluids in chilled solutions

2. Small frequent feeding: six equally divided feedings Billroth I (Gastroduodenostomy)

Billroth II (Gastrojejunostomy)

59

60 •

3. Diet: decrease CHO, moderate fats & CHON 4.

Bleeding of Pancreas: Cullen’s sign at umbilicus

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

8.

Hyperlipidemia

9.

Hyperparathyroidism

•

& creates thickening accompanied by edema •

Consequently there is impaired circulation, ischemia & eventually necrosis

•

• •

10. Drugs: Thiazide, steroids, diuretics, oral contraceptives

Cholelithiasis: Formation of gallstones & cholesterol stones

Inflammation of gallbladder with gallstone formation.

S/Sx:

1. Severe left upper epigastric pain radiates from back & flank area: aggravated by eating with DOB

Predisposing Factor:

1. High risk: women 40 years old 2. Post menopausal women: undergoing estrogen therapy 3.

Obesity

4.

Sedentary lifestyle

5.

Hyperlipidemia

6.

Neoplasm

2.

N/V

3.

Tachycardia

4. Palpitation: due to pain 5. Dyspepsia: indigestion 6.

Decrease bowel sounds

7. (+) Cullen’s sign: ecchymosis of umbilicus Hemorrhage

8. (+) Grey Turner’s spots: ecchymosis of flank area

S/sx:

1. Severe Right abdominal pain (after eating fatty food):

9.

Hypocalcemia

Occurring especially at night 2.

Intolerance of fatty food

3.

Anorexia

4.

N/V

5.

Jaundice

6.

Pruritus

7.

Easy bruising

8.

Tea colored urine

5. Serum Ca: decrease

9.

Steatorrhea

6. CT Scan: shows enlargement of the pancreas

Dx

1. Serum amylase & lipase: increase 2. Urinary amylase: increase 3. Blood Sugar: increase 4. Lipids Level: increase

Medical Management

Dx

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

•

presence of stones

•

Medical Management 1.

Supportive Treatment: NPO with NGT & IV fluids

2.

Diet modification with administration of fat soluble vitamins

3.

Drug Therapy

•

•

•

Narcotic analgesic: DOC: Meperdipine Hcl (Demerol): for

•

(Morpine SO4: is contraindicated because it causes spasm of the Sphincter of Oddi)

•

•

•

(Anticholinergic: relax smooth muscles & open bile

Antiemetics: Phenothiazide (Phenergan): with anti emetic properties

4. Surgery: Cholecystectomy / Choledochostomy Nursing Intervention 1.

Administer pain medication as ordered & monitor effects

2.

Administer IV fluids as ordered

3. Diet: increase CHO, moderate CHON, decrease fats 4. Meticulous skin care: to relieved priritus Disorders of the Pancreas Pancreatitis •

•

An inflammatory process with varying degrees of pancreatic

•

Propantheline Bromide (Profanthene)

Antacids: to decrease pancreatic stimulation

• 2.

Maalox

H2 Antagonist: to decrease pancreatic stimulation Ranitidin (Zantac)

Vasodilators: to decrease pancreatic stimulation Nitroglycerine (NTG)

Ca Gluconate: to decrease pancreatic stimulation

Diet Modification

3. NPO (usually) 4.

Peritoneal Lavage

5.

Dialysis

Nursing Intervention 1.

Administer medication as ordered

2. Withhold food & fluid & eliminate odor: to decrease pancreatic stimulation / aggravates pain

3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation •

Complication of TPN

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

•

Atrophine SO4

•

ducts)

•

•

•

Antocholinergic: (Atrophine SO4): for pain

Papaverine Hcl

Anticholinergic: to decrease pancreatic stimulation

•

pain

•

Smooth muscle relaxant: to relieve pain

Acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto

4. Institute non-pharmacological measures: to decrease pain •

Assist client to comfortable position: Knee chest or fetal like position

digestion

60

61 •

Teach relaxation techniques & provide quiet, restful environment

5.

Liver Cirrhosis Chronic progressive disease characterized by inflammation,

Provide client teaching & discharge planning •

•

fibrosis & degeneration of the liver parenchymal cell

Dietary regimen when oral intake permitted •

High CHO, CHON & decrease fats

•

Eat small frequent meal instead of three large ones

•

Avoid caffeine products

•

Eliminate alcohol consumption

•

Maintain relaxed atmosphere after meals

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

Report signs of complication

Laennec’s Cirrhosis:

•

Continued N/V

Associated with alcohol abuse & malnutrition

•

Abdominal distension with feeling of fullness

Characterized by an accumulation of fat in the liver cell

•

Persistent weight loss

•

Severe epigastric or back pain

•

Frothy foul smelling bowel movement

•

Irritability, confusion, persistent elevation of

progressing to widespread scar formation Postnecrotic Cirrhosis Result in severe inflammation with massive necrosis as a complication of viral hepatitis 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 •

Inflammation of verniform appendix

•

If untreated: ischemia, gangrene, rupture & peritonitis

•

May cause by mechanical obstruction (fecalith, intestinal

•

duct Results in chronic impairment of bile excretion S/sx

parasites) or anatomic defect

Fatigue

May be related to decrease fiber in the diet

Anorexia N/V Dyspepsia: Indigestion

Predisposing factor: 1.

Microbial infection

Weight loss

2.

Feacalith: undigested food particles like tomato seeds,

Flatulence

guava seeds etc.

Change (Irregular) bowel habit

Intestinal obstruction

Ascites

3.

Peripheral edema Hepatomegaly: pain located in the right upper quadrant

S/Sx:

1. Pathognomonic sign: (+) rebound tenderness

Atrophy of the liver

2.

Low grade fever

Fetor hepaticus: fruity, musty odor of chronic liver

3.

N/V

4.

Decrease bowel sound

Aterixis: flapping of hands & tremores

5.

Diffuse pain at lower Right iliac region

Hard nodular liver upon palpation

disease

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 1.

Administer antibiotics / antipyretic as ordered

2.

Routinary pre-op nursing measures: •

Skin prep

•

NPO

•

Avoid enema, cathartics: lead to rupture of appendix

3. Don’t give analgesic: will mask pain •

Presence of pain means appendix has not ruptured

4. Avoid heat application: will rupture appendix 5.

Monitor VS, I&O bowel sound

Palmar erythema Muscle atrophy Dx Liver enzymes: increase SGPT (ALT) SGOT (AST) LDH Alkaline Phosphate Serum cholesterol & ammonia: increase Indirect bilirubin: increase 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 appendix

2. Position the client semi-fowlers or side lying on right: to facilitate drainage 3.

Nursing Intervention CBR with bathroom privileges Encourage gradual, progressive, increasing activity with planned rest period

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

•

Antipyretics: for fever (PRN)

4.

Monitor VS, I&O, bowel sound

5.

Maintain patent IV line

6. Complications: Peritonitis, Septicemia

lotion Provide cool, light, non-constrictive clothing Keep nail short: to avoid skin excoriation from scratching Apply cool, moist compresses to pruritic area Monitor VS, I & O

61

62 Prevent Infection

Formed by collecting tubules & ducts

Prevent skin breakdown: by turning & skin care Provide reverse isolation for client with severe leukopenia:

Renal Sinus & Pelvis

handwashing technique Monitor WBC

Papillae Projection of renal tissues located at the tip of the renal

Diet:

pyramids

Small frequent meals

Calices

Restrict Na!

Minor Calyx: collects urine flow from collecting ducts

High calorie, low to moderate CHON, high CHO, low fats with

Major Calyx: directs urine from renal sinus to renal pelvis

supplemental Vit A, B-complex, C, D, K & folic acid

Urine flows from renal pelvis to ureters

Monitor / prevent bleeding Measure abdominal girth daily: notify MD

Nephron

With pt daily & assess pitting edema

Functional unit of the kidney

Administer diuretics as ordered

Basic living unit

Provide client teaching & discharge planning Avoidance of hepatotoxicity drug: sedative, opiates or OTC drugs detoxified by liver

Renal Corpuscle (vascular system of nephron) Bowman’s Capsule:

How to assess weight gain & increase abdominal girth Avoid person with upper respiratory infection

Portion of the proximal tubule surrounds the glomerulus Glomerulus:

Reporting signs of reccuring illness (liver tenderness, increase

Capillary network permeable to water, electrolytes,

jaundice, increase fatigue, anorexia)

nutrients & waste

Avoid all alcohol Avoid straining stool vigorous blowing of nose & coughing: to decrease incidence of bleeding

Impermeable to large CHON molecules Filters blood going to kidneys Renal Tubule

Complications:

Divided into proximal convoluted tubule, descending

Ascites: accumolation of free fluid in abdominal cavity

loop of Henle, acending loop of Henle, distal convoluted tubule & collecting ducts

Nursing Intervention Meds: Loop diuretics: 10-15 min effect

Ureters

Assist in abdominal paracentesis: aspiration of fluid

Two tubes approximately 25-35 cm long

Void before paracentesis: to prevent accidental puncture of

Extend from the renal pelvis to the pelvic cavity where they

bladder as trochar is inserted

enter the bladder, convey urine from the kidney to the bladder

Bleeding esophageal varices: Dilation of esophageal veins

Passageway of urine to bladder Ureterovesical valve: prevent backflow of urine into ureters

Nursing Intervention Administer meds:

Bladder

Vit K

Located behind the symphisis pubis

Pitrisin or Vasopresin (IM)

Composed of muscular elastic tissue that makes it distensible

NGT decompression: lavage

Serve s as reservoir of urine (capable of holding 1000-1800 ml &

Give before lavage: ice or cold saline solution Monitor NGT output Assist in mechanical decompression

500 ml moderately full) Internal & external urethral sphincter controls the flow of urine Urge to void stimulated by passage of urine past the internal

Insertion of sengstaken-blackemore tube 3 lumen typed catheter

sphincter (involuntary) to the upper urethra Relaxation of external sphincter (voluntary) produces emptying

Scissors at bedside to deflate balloon. Hepatic encephalopathy

of the bladder (voiding) 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 Administer meds Laxatives: to excrete ammonia Overview of Anatomy & Physiology Of GUT System

vagina & approximately 3-5 cm Males: extend the entire length of the penis & approximately 20 cm Function of kidneys Kidneys remove nitrogenous waste & regulates F & E

GUT: Genito-urinary tract GUT includes the kidneys, ureters, urinary bladder, urethra & the

balance & acid base balance 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 space on either side of the vertebral column Retroperitonially (back of peritoneum) on either side of vertebral column Adrenal gland is on top of each kidneys Encased in Bowmans’s capsule

Pressure in bowman’s capsule opposes hydrostatic pressure & filtration If glomerular pressure insufficient to force substance out of the blood into the tubules filtrate formation stops Glomerular Filtration Rate (GFR) Amount of blood filtered by the glomeruli in a given time Normal: 125 ml / min

Renal Parenchyma Cortex Outermost layer

Filtrate formed has essentially same composition as blood plasma without the CHON; blood cells & CHON are usually too large to pass the glomerular membrane

Site of glomeruli & proximal & distal tubules of nephron Medulla

Tubular Function

Middle layer

62

63 Tubules & collecting ducts carry out the function of reabsorption, secretion & excretion Reabsorption of H2O & electrolytes is controlled by

Odor –

aromatic

Consistency –

clear or slightly turbid

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 Regulation of BP

Urine culture & sensitivity: (+) to E. coli 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 When the BP drops the cells of the glomerulus release rennin which then activates angiotensin to cause vasoconstriction.

Monitor & assess urine for gross odor, hematuria & sediments Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent bacterial multiplication Administer Medication as ordered: Systemic Antibiotics

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 juxtaglomerular apparatus

Urinary antiseptics: Mitropurantoin (Macrodantin) 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

Aldosterone

Complications: Pyelonephritis 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

63

64 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 disease

Stone Analysis: composition & type of stone 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 Formation of stones at urinary tract

Administer Allopurinol (Zyloprim) as ordered: to decrease uric 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

Nuts tea

Nuts

Benign Prostatic Hypertrophy (BPH)

64

65 Mild to moderate glandular enlargement, hyperplsia & over

Hypovolemia

growth of the smooth muscles & connective tissue

Decrease

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 Dx

Anatomic malformation 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 fluid Force fluid intake: 2000-3000 ml unless contraindicated

BUN & Creatinine: elevated Diuretic Phase: slow gradual increase in daily urine output 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 Surgery: Prostatectomy Transurethral Resection of Prostate (TURP): insertion of a resectoscope into urethra to excise prostatic tissue Assist in cystoclysis or continuous bladder irrigation. Nursing Intervention

Hypokalemia Hypovolemia Dx BUN & Creatinine: elevated Recovery or Covalescent Phase: renal function stabilized with gradual improvement over next 3-12 mos

Monitor symptoms of infection Monitor symptoms gross / flank bleeding. Normal bleeding within 24h Maintain irrigation or tube patent to flush out clots: to prevent bladder spasm & distention

Nursing Intervention Monitor / maintain F&E balance Obtain baseline data on usual appearance & amount of client’s urine Measure I&O every hour: note excessive losses Administer IV F&E supplements as ordered Weight daily

Acute Renal Failure Sudden inability of the kidney to regulate fluid & electrolyte balance & remove toxic products from the body Sudden immobility of kidneys to excrete nitrogenous waste

Monitor lab values: assess / treat F&E & acid base imbalance as needed Monitor alteration in fluid volume Monitor V/S. PAP, PCWP, CVP as needed

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 decreased blood flow & glomerular filtrate Inter-renal cause: condiion that cause damage to the nephrons Post-renal cause: mechanical obstruction anywhere from the tubules to the urethra

Administer diuretics, cardiac glycosides & hypertensive agent as ordered Assess every hour for hypovolemia: replace fluid as ordered Monitor ECG Check urine serum osmolality / osmolarity & urine

Pre renal cause: decrease blood flow & glomerular filtrate Ischemia & oliguria

specific gravity as ordered Promote optimal nutrition

Cardiogenic shock

Administer TPN as ordered

Acute vasoconstriction

Restrict CHON intake

Septicemia

Prevent complication from impaired mobility

65

66 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 continues until nephrons are replaced by scar tissue

Decreased urine output 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 Polyuria

Metabolic Disturbance Azotemia (increase BUN

Nocturia

& Creatinine)

Maintain maximal cardiovascular function Monitor BP Auscultate for pericardial friction rub

Hematuria

Hyperglycemia

Perform circulation check routinely

Dysuria

Hyperinsulinemia

Administer diuretics as ordered & monitor I&O Modify digitalis dose as ordered (digitalis is excreted in

Oliguria 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 Respiratory

constipation Hematological

Kassmaul’s resp

Normocytic anemia

Decrease cough

Bleeding tendencies

reflex Fluid & Electrolytes Hyperkalemia

Integumentary Itchiness /

Hypernatermia

pruritus

Hypermagnese

Uremic frost

mia Hyperposphate mia

HPN Leg cramps Disorientation Paresthes Enforce CBR Monitor VS, I&O Meticulous skin care. Uremic frost – assist in bathing pt 4. Meds: a.) Na HCO3 – due Hyperkalemia b.) Kagexelate enema

Hypocalcemia

c.) Anti HPN – hydralazine

Metabolic

d.) Vit & minerals

acidosis

e.) Phosphate binder (Amphogel) Al OH gel - S/E constipation

66

67 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

67