MEDICAL-SURGICAL NURSING

By: Anthony T. Villegas R.N.

Overview of structures and functions:

NERVOUS SYSTEM

The functional unit of the nervous system is the

nerve cells or neurons

The nervous system is composed of the ff:

Central Nervous System

Brain

Spinal Cord – serves as a connecting link

between the brain & the periphery.

Peripheral Nervous System

Cranial Nerves –12 pairs; carry impulses to &

from the brain.

Spinal Nerves – 31 pairs; carry impulses to &

from spinal cord.

Autonomic Nervous System

subdivision of the PNS that automatically controls

body function such as breathing & heart beat.

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

Sympathetic nervous system – generally

accelerate some body functions in response to

stress.

Parasympathetic nervous system – controls

normal body functioning.

CELLS

A. NEURONS

Primary component of nervous system

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

dendrites

Basic cells for nerve impulse and conduction.

Axon

Elongated process or fiber extending from the

cell body

Transmits impulses (messages) away from the

cell body to dendrites or directly to the cell

bodies of other neurons

Neurons usually has only one axon

Dendrites

Short, blanching fibers that receives impulses

and conducts them toward the nerve cell body.

Neurons may have many dendrites.

Synapse

Junction between neurons where an impulse is

transmitted

Neurotransmitter

Chemical agent (ex. Acetylcholine,

norepinephrine) involved in the transmission of

impulse across synapse.

Myelin Sheath

A wrapping of myelin (whitish, fatty material)

that protects and insulates nerve fibers and

enhances the speed of impulse conduction.

o Both axons and dendrites may or may not

have a myelin sheath

(myelinated/unmyelinated)

o Most axons leaving the CNS are heavily

myelinated by schwann cells

Functional Classification

1. Afferent (sensory) neurons

Transmit impulses from peripheral receptors

to the CNS

2. Efferent (motor) neurons

Conduct impulses from CNS to muscle and

glands

3. Internuncial neurons (interneurons)

Connecting links between afferent and

efferent neurons

Properties

1. Excitability – ability of neuron to be affected by

changes in external environment.

2. Conductility – ability of neuron to transmit a

wave of excitetation from one cell to another.

3. Permanent Cell – once destroyed not capable of

regeneration.

TYPES OF CELLS BASED ON REGENERATIVE CAPACITY

1. Labile

Capable of regeneration.

Epidermal cells, GIT cells, GUT cells, cells of

lungs.

2. Stable

Capable of regeneration with limited time,

survival period.

Kidney cells, Liver cells, Salivary cells,

pancreas.

3. Permanent

Not capable of regeneration.

Myocardial cells, Neurons, Bone cells,

Osteocytes, Retinal Cells.

B. NEUROGLIA

Support and protection of neurons.

TYPES

1. Astrocytes

maintains blood brain barrier semi-permiable.

majority of brain tumors (90%) arises from

called astrocytoma.

integrity of blood brain barrier.

2. Oligodendria

produces myelin sheath in CNS.

act as insulator and facilitates rapid nerve

impulse transmission.

3. Microglia

stationary cells that carry on phagocytosis

(engulfing of bacteria or cellular debris,

eating), pinocytosis (cell drinking).

4. Epindymal

secretes a glue called chemo attractants that

concentrate the bacteria.

MACROPHAGE ORGA

N

Microglia

Monocytes

Kupffers

Histiocytes

Alveolar

Macrophage

Brain

Blood

Kidney

Skin

Lung

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Central Nervous System

Composition Of Brain

80% brain mass

10% blood

10% CSF

Brain Mass

Parts Of The Brain

1. Cerebrum

largest part of the brain

outermost area (cerebral cortex) is gray

matter

deeper area is composed of white matter

function of cerebrum: integration, sensory,

motor

composed of two hemisphere the Right

Cerebral Hemisphere and Left Cerebral

Hemisphere enclosed in the Corpus Callosum.

Each hemisphere divided into four lobes;

many of the functional areas of the cerebrum

have been located in these lobes:

Lobes of Cerebrum

1. Frontal Lobe

controls personality, behavior

higher cortical thinking, intellectual

functioning

precentral gyrus: controls motor function

Broca’s Area: specialized motor speech area -

when damaged results to garbled speech.

2. 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.

Postcentral gyrus: registered general

sensation (ex. Touch, pressure)

4. Occipital Lobe

for vision

Insula (Island of Reil)

visceral function activities of internal organ

like gastric motility.

Limbic System (Rhinencephalon)

controls smell - if damaged results to anosmia

(absence of smell).

controls libido

controls long term memory

Corpus Callosum

large fiber tract that connects the two

cerebral hemisphere

Basal Ganglia

island of gray matter within white matter of

cerebrum

regulate & integrate motor activity originating

in the cerebral cortex

part of extrapyramidal system

area of gray matter located deep within each

cerebral hemisphere.

release dopamine (controls gross voluntary

movement).

2. Diencephalon/interbrain

Connecting part of the brain, between the

cerebrum & the brain stem

Contains several small structures: the

thalamus & hypothalamus are most important

Thalamus

acts as relay station for discrimination of

sensory signals (ex. Pain, temperature, touch)

controls primitive emotional responses (ex.

Rage, fear)

Hypothalamus

found immediately beneath the thalamus

plays a major role in regulation/controls of

vital function: blood pressure, thirst, appetite,

sleep & wakefulness, temperature

(thermoregulatory center)

acts as controls center for pituitary gland and

affects both divisions of the autonomic

nervous system.

controls some emotional responses like fear,

anxiety and excitement.

androgenic hormones promotes secondary

sex characteristics.

early sign for males are testicular and penile

enlargement

late sign is deepening of voice.

early sign for females telarch and late sign is

menarch.

3. Mesencephalon/Midbrain

acts as relay station for sight and hearing.

size of pupil is 2 – 3 mm.

equal size of pupil is isocoria.

unequal size of pupil is anisocoria.

hearing acuity is 30 – 40 dB.

positive PERRLA

4. Brain Stem

located at lowest part of brain.

contains midbrain, pons, medulla oblongata.

extends from the cerebral hemispheres to the

foramen magnum at the base of the skull.

contains nuclei of the cranial nerves and the

long ascending and descending tracts

connecting the cerebrum and the spinal cord.

contains vital center of respiratory,

vasomotor, and cardiac functions.

Pons

pneumotaxic center controls the rate, rhythm

and depth of respiration.

Medulla Oblongata

controls respiration, heart rate, swallowing,

vomiting, hiccup, vasomotor center (dilation

and constriction of bronchioles).

5. Cerebellum

smallest part of the brain, lesser brain.

coordinates muscle tone and movements and

maintains position in space (equilibrium)

controls balance, equilibrium, posture and

gait.

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2

Spinal Cord

serves as a connecting link between the brain

and periphery

extends from foramen magnum to second

lumbar vertebra

H-shaped gray matter in the center (cell

bodies) surrounded by white matter (nerve

tract and fibers)

Gray Matter

1. Anterior Horns

Contains cell bodies giving rise to efferent

(motor) fibers

2. Posterior Horns

Contains cell bodies connecting with

afferent (sensory) fibers from dorsal root

ganglion

3. Lateral Horns

In thoracic region, contain cells giving rise

to autonomic fibers of sympathetic

nervous system

White Matter

1. Ascending Tracts (sensory pathways)

a. Posterior Column

Carry impulses concerned with

touch, pressure, vibration, &

position sense

b. Spinocerebellar

Carry impulses concerned with

muscle tension & position

sense to cerebellum

c. Lateral Spinothalamic

Carry impulses resulting in pain

& temperature sensations

d. Anterior Spinothlamic

Carry impulses concerned with

crude touch & pressure

2. Descending Tracts (motor pathways)

a. Corticospinal (pyramidal, upper motor

neurons)

Conduct motor impulses from

motor cortex to anterior horn

cells (cross in the medulla)

b. Extrapyramidal

Help to maintain muscle tone &

to control body movement,

especially gross automatic

movements such as walking

Reflex Arc

Reflex consists of an involuntary response to

a stimulus occurring over a neural pathway

called a reflex arc.

Not relayed to & from brain: take place at

cord levels

Components

a. Sensory Receptors

Receives/reacts to stimulus

b. Afferent Pathways

Transmits impulses to spinal cord

c. Interneurons

Synapses with a motor neuron (anterior

horn cell)

d. Efferent Pathways

Transmits impulses from motor neuron to

effector

e. Effectors

Muscle or organ that responds to stimulus

Supporting Structures

1. Skull

Rigid; numerous bones fused together

Protects & support the brain

2. Spinal Column

Consists of 7 cervical, 12 thoracic, & 5 lumbar

vertebrae as well as sacrum & coccyx

Supports the head & protect the spinal cord

3. Meninges

Membranes between the skull & brain & the

vertebral column & spinal cord

3 fold membrane that covers brain and spinal

cord.

For support and protection; for nourishment;

blood supply

Area between arachnoid & pia mater is called

subarachnoid space: CSF aspiration is done

Subdural space between the dura and

arachnoid

Layers:

Dura Mater

outermost layer, tough, leathery

Arachnoid Mater

middle layer, weblike

Pia Mater

innermost layer, delicate, clings to surface

of brain

4. Ventricles

Four fluid-filled cavities connecting with

one another & spinal canal

Produce & circulate cerebrospinal fluid

5. Cerebrospinal Fluid (CSF)

Surrounds brain & spinal cord

Offer protection by functioning as a shock

absorber

Allows fluid shifts from the cranial cavity to

the spinal cavity

Carries nutrient to & waste product away from

nerve cells

Component of CSF: CHON, WBC, Glucose

6. Vascular Supply

Two internal carotid arteries anteriorly

Two vertebral arteries leading to basilar

artery posteriorly

These arteries communicate at the base of

the brain through the circle of willis

Anterior, middle, & posterior cerebral arteries

are the main arteries for distributing blood to

each hemisphere of the brain

Brain stem & cerebellum are supplied by

branches of the vertebral & basilar arteries

Venous blood drains into dural sinuses & then

into jugular veins

7. Blood-Brain-Barrier (BBB)

Protective barrier preventing harmful agents

from entering the capillaries of the CNS;

protect brain & spinal cord

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Substance That Can Pass Blood-Brain Barrier

1. Amonia

Cerebral toxin

Hepatic Encephalopathy (Liver Cirrhosis)

Ascites

Esophageal Varices

Early Signs of Hepatic Encephalopathy

Asterexis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy

Headache

Dizziness

Confusion

Fetor hepaticus (amonia like breath)

decrease LOC

2. Carbon Monoxide and Lead Poisoning

Can lead to Parkinson’s Disease.

Epilepsy

Treated with calcium EDTA.

3. Type 1 DM (IDDM)

Causes diabetic ketoacidosis.

And increases breakdown of fats.

And free fatty acids

Resulting to cholesterol and positive to

ketones (CNS depressant).

Resulting to acetone breath odor/fruity odor.

And kusshmauls respiration a rapid shallow

respiration.

Which may lead to diabetic coma.

4. Hepatitis

Signs of jaundice (icteric sclerae).

Caused by bilirubin (yellow pigment)

5. Bilirubin

Increase bilirubin in brain (kernicterus).

Causing irreversible brain damage.

Peripheral Nervous System

Spinal Nerves

31 pairs: carry impulses to & from spinal cord

Each segment of the spinal cord contains a pair

of spinal nerves (one of each side of the body)

Each nerve is attached to the spinal by two roots:

1. Dorsal (posterior) roots

contains afferent (sensory) nerve

whose cell body is in the dorsal roots

ganglion

2. Ventral (anterior) roots

Contains efferent (motor) nerve whose

nerve fibers originate in the anterior

horn cell of the spinal cord (lower

motor neuron)

Cranial Nerves

12 pairs: carry impulses to & from the brain.

May have sensory, motor, or mixed functions.

Name & Number Function

Olfactory : CN I Sensory: carries

impulses for sense of smell.

Optic : CN II Sensory: carries impulses for

vision.

Oculomotor : CN III Motor: muscles for

papillary constriction, elevation of upper eyelid;

4 out of 6 extraocular

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 of eye

Facial : CN VII Mixed: impulses for

taste from anterior tongue; muscles for facial

Movement.

Acoustic : CN VIII Sensory:

impulses for 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

Movement of soft

palate, pharynx, & larynx.

Spinal Accessory : CN XI Motor:

movement of sternomastoid muscles & upper

part of trapezius

Muscles.

Hypoglossal : CN XII Motor: movement of

tongue.

Autonomic Nervous System

Part of the peripheral nervous system

Include those peripheral nerves (both cranial &

spinal) that regulates smooth muscles, cardiac

muscles, & glands.

Component:

1. Sympathetic Nervous System

Generally accelerates some body function

in response to stress.

2. Parasympathetic Nervous System

Controls normal body functioning

Sympathetic Nervous

System

(Adrenergic) Effect

Parasympathetic Nervous

System

(Cholinergic) Effect, Vagal,

Sympatholytic

- Involved in fight or

aggression response.

- Release of

Norepinephrine

(cathecolamines) from

adrenal glands and

causes vasoconstriction.

- Increase all bodily

activity except GIT

EFFECTS OF SNS

- Dilation of pupils

(mydriasis) in order to be

aware.

- Involved in flight or

withdrawal response.

- Release of Acetylcholine.

- Decreases all bodily

activities except GIT.

EFFECTS OF PNS

- Constriction of pupils

(miosis).

- Increase salivation.

- Decrease BP and Heart

Rate.

- Bronchoconstriction,

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- Dry mouth (thickened

saliva).

- Increase BP and Heart

Rate.

- Bronchodilation,

Increase RR

- Constipation.

- Urinary Retention.

- Increase blood supply to

brain, heart and skeletal

muscles.

- SNS

I. Adrenergic Agents

- Give Epinephrine.

SE:

- SNS effect

Contraindication:

- Contraindicated to

patients suffering from

COPD (Broncholitis,

Bronchoectasis,

Emphysema, Asthma).

II. Beta-adrenergic

Blocking Agents

- Also called Beta-

blockers.

- all ending with “lol”

- Propranolol, Atenelol,

Metoprolol.

Effect of Beta-blockers

B – broncho spasm

E – elicits a decrease in

myocardial contraction.

T – treats hypertension.

A – AV conduction slows

down.

- Should be given to

patients with Angina,

Myocardial Infarction,

Hypertension

ANTI- HYPERTENSIVE

AGENTS

1. Beta-blockers – “lol”

2. Ace Inhibitors –

Angiotensin “pril”

(Captopril, Enalapril)

3. Calcium Antagonist –

Nifedipine (Calcibloc)

- In chronic cases of

arrhythmia give Lidocane,

Xylocane.

Decrease RR.

- Diarrhea

- Urinary frequency.

I. Cholinergic Agents

- Mestinon, Neostignin.

SE:

- PNS effect

II. Anti-cholinergic Agents

- To counter cholinergic

agents.

- Atrophine Sulfate

SE:

- SNS effect

Effectors Sympathetic (Adrenergic) Effect

Parasympathetic (Cholinergic) Effect

Eye dilate pupil (mydriasis)

constrict pupil (miosis)

Gland of Head

Lacrimal no effect

stimulate secretions

Salivary scanty thick, viscous secretions

copious thin, watery secretions

Dry mouth

Heart increase rate & force of contraction

decrease rate

Blood Vessel constrict smooth muscles of the skin, no

effect

Abdominal blood vessels, and

Cutaneous blood vessels

Dilates smooth muscles of bronchioles,

Blood vessels of the heart & skeletal

muscles

Lungs bronchodilation

bronchoconstriction

GI Tract decrease motility

increase motility

Constrict sphincters

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

& no effect

Norepinephrine

Urinary Tract relaxes detrusor muscles

contract detrusor muscles

Contract trigone sphincter (prevent

voiding) relaxes trigone sphincter (allows voiding)

NEURO

TRANSMITTER

Decrease Increase

Acethylcholine Myesthenia

Gravis

Bi-polar Disorder

Dopamine Parkinson’s

Disease

Schizophrenia

Physical Examination

Comprehensive Neuro Exam

Neuro Check

1. Level of Consciousness (LOC)

a. Orientation to time, place, person

b. Speech: clear, garbled, rambling

c. Ability to follow command

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

painful stimulus (ex. Pressure on the nailbeds,

squeeze trapezius muscle); note response to

pain

Appropriate: withdrawal, moaning

Inappropriate: non-purposeful

e. Abnormal posturing (may occur

spontaneously or in response to stimulus)

Decorticate Posturing: extension of leg,

internal rotation & abduction of arms with

flexion of elbows, wrist, & finger: (damage

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to corticospinal tract; cerebral

hemisphere)

Decerebrate Posturing: back arched, rigid

extension of all four extremities with

hyperpronation of arms & plantar flexion

of feet: (damage to upper brain stem,

midbrain, or pons)

2. Glasgow Coma Scale

Objective measurement of LOC sometimes

called as the quick neuro check

Objective evaluation of LOC, motor / verbal

response

A standardized system for assessing the

degree of neurologic impairment in critically

ill client

Components

1. Eye opening

2. Verbal response

3. Motor response

GCS Grading / Scoring

1. Conscious 15 – 14

2. Lethargy 13 – 11

3. Stupor 10 – 8

4. Coma 7

5. Deep Coma 3

3. Pupillary Reaction & Eye Movement

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

size in millimeter)

b. Reaction to light: pupillary constriction

c. Corneal reflex: blink reflex in response to light

stroking of cornea

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

unconscious client with intact brainstem

4. Motor Function

a. Movement of extremities (paralysis)

b. Muscle strength

5. Vital Signs: respiratory patterns (may help

localize possible lesion)

a. Cheyne-Stokes Respiration: regular rhythmic

alternating between hyperventilation &

apnea; may be caused by structural cerebral

dysfunction or by metabolic problems such as

diabetic coma

b. Central Neurogenic Hyperventilation:

sustained, rapid, regular respiration (rate of

25/min) with normal O2 level; usually due to

brainstem dysfunction

c. Apneustic Breathing: prolonged inspiratory

phase, followed by a 2-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

Neurologic Exam

1. Mental status and speech (Cerebral Function)

a. General appearance & behavior

b. LOC

c. Intellectual Function: memory (recent &

remote), attention span, cognitive skills

d. Emotional status

e. Thought content

f. Language / speech

2. Cranial nerve assessment

3. Cerebellar Function: posture, gait, balance,

coordination

a. Romberg’s Test: 2 nurses, positive for ataxia

b. Finger to Nose Test: positive result mean

dimetria (inability of body to stop movement

at desired point)

4. Sensory Function: light touch, superficial pain,

temperature, vibration & position sense

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

abnormal or involuntary movements

6. Reflexes

a. Deep tendon reflex: grade from 0 (no

response); to 4 (hyperactive); 2 (normal)

b. Superficial

c. Pathologic: babinski reflex (dorsiflexion of the

great toe with fanning of toes): indicates

damage to corticospinal tracts

Level Of Consciouness (LOC)

1. Conscious: awake

2. Lethargy: lethargic (drowsy, sleepy, obtunded)

3. Stupor

Stuporous: (awakened by vigorous

stimulation)

Generalized body weakness

Decrease body reflex

4. Coma

Comatose

light coma: positive to all forms of painful

stimulus

deep coma: negative to all forms of painful

stimulus

Different Painful Stimulation

1. Deep sternal stimulation / deep sternal pressure

2. Orbital pressure

3. Pressure on great toes

4. Corneal or blinking reflex

Conscious Client: use a wisp of cotton

Unconscious Client: place 1 drop of saline

solution

Test of Memory

1. Short term memory

Ask most recent activity

Positive result mean anterograde amnesia

and damage to temporal lobe

2. Long term memory

Ask for birthday and validate on profile sheet

Positive result mean retrograde amnesia and

damage to limbic system

Consider educational background

Level of Orientation

1. Time: first asked

2. Person: second asked

3. Place: third asked

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Cranial Nerves

Cranial Nerves Function

1. Olfactory S

2. Optic S

3. Oculomotor M

4. Trochlear M

(smallest

)

5. Trigeminal B

(largest)

6. Abducens M

7. Facial B

8. Acoustic S

9. Glossopharengeal B

10.Vagus B

(longest)

11.Spinal Accessory M

12.Hypoglossal M

CRANIAL NERVE I: OLFACTORY

Sensory function for smell

Material Used

Don’t use alcohol, ammonia, perfume because it

is irritating and highly diffusible.

Use coffee granules, vinegar, bar of soap,

cigarette

Procedure

Test each nostril by occluding each nostril

Abnormal Findings

1. Hyposnia: decrease sensitivity to smell

2. Dysosmia: distorted sense of smell

3. Anosmia: absence of smell

Either of the 3 may indicate head injury damaging the

cribriform plate of ethmoid bone where olfactory cells

are located may indicate inflammatory conditions

(sinusitis)

CRANIAL NERVE II: OPTIC

Sensory function for vision or sight

Functions

1. Test visual acuity or central vision or distance

Use Snellen’s Chart

Snellen’s Alphabet chart: for literate client

Snellen’s E chart: for illiterate client

Snellen’s Animal chart: for pediatric client

Normal visual acuity 20/20

Numerator: is constant, it is the distance of

person from the chart (6-7 m, 20 feet)

Denominator: changes, indicates distance by

which the person normally can see letter in

the chart.

20/200 indicates blindness

20/20 visual acuity if client is able to read

letters above the red line.

2. Test of visual field or peripheral vision

a. Superiorly

b. Bitemporaly

c. Nasally

d. Inferiorly

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

ABDUCENS

Controls or innervates the movement of extrinsic

ocular muscle (EOM)

6 muscles:

Superior Rectus Superior

Oblique

Lateral Rectus

Medial Rectus

Inferior Oblique

Inferior Rectus

Trochlear: controls superior oblique

Abducens: controls lateral rectus

Oculomotor: controls the 4 remaining EOM

Oculomotor

Controls the size and response of pupil

Normal pupil size is 2 – 3 mm

Equal size of pupil: Isocoria

Unequal size of pupil: Anisocoria

Normal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINAL

Largest cranial nerve

Consists of ophthalmic, maxillary, mandibular

Sensory: controls sensation of face, mucous

membrane, teeth, soft palate and corneal reflex

Motor: controls the muscle of mastication or

chewing

Damage to CN V leads to Trigeminal Neuralgia /

Tic Douloureux

Medication: Carbamezapine (Tegretol)

CRANIAL NERVE VII: FACIAL

Sensory: controls taste, anterior 2/3 of tongue

Pinch of sugar and cotton applicator placed on tip

of tongue

Motor: controls muscle of facial expression

Instruct client to smile, frown and if results are

negative there is facial paralysis or Bell’s Palsy

and the primary cause is forcep delivery.

CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR

Controls balance particularly kinesthesia or

position sense, refers to movement and

orientation of the body in space.

CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS

Glosopharenageal: controls taste, posterior 1/3 of

tongue

Vagus: controls gag reflex

Uvula should be midline and if not indicative of

damage to cerebral hemisphere

Effects of vagal stimulation is PNS

CRANIAL NERVE XI: SPINAL ACCESSORY

Innervates with sternocleidomastoid (neck) and

trapezius (shoulder)

CRANIAL NERVE XII: HYPOGLOSSAL

Controls the movement of tongue

Let client protrude tongue and it should be

midline and if unable to do indicative of damage

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to cerebral hemisphere and/or has short

frenulum.

Pathognomonic Signs:

1. PTB – low grade afternoon fever

2. PNEUMONIA – rusty sputum.

3. ASTHMA – wheezing on expiration.

4. EMPHYSEMA – barrel chest.

5. KAWASAKI SYNDROME – strawberry tongue

6. PERNICIOUS ANEMIA – red beefy tongue

7. DOWN SYNDROME – protruding tongue

8. CHOLERA – rice watery stool.

9. MALARIA – step ladder like fever with chills.

10.TYPHOID – rose spots in abdomen.

11.DIPTHERIA – pseudo membrane.

12.MEASLES – koplick’s spots

13.SLE – butterfly rashes.

14.LIVER CIRRHOSIS – spider like varices

15.LEPROSY – lioning face

16.BOLIMIA – chipmunk face.

17.APPENDICITIS – rebound tenderness

18.DENGUE – petichae or positive herman’s sign.

19.MENINGITIS – kernig’s sign (leg pain), brudzinski

sign (neck pain).

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

carpopedal spasm/ (+) chvostek sign (facial

spasm).

21.TETANUS – risus sardonicus

22.PANCREATITIS – cullen’s sign (echymosis of

umbilicus) / (+) grey turners spots.

23.PYLORIC STENOSIS – olive like mass.

24.PDA – machine like murmur

25.ADDISON’S DISEASE – bronze like skin

pigmentation.

26.CUSHING’S SYNDROME – moon face appearance

and buffalo hump.

27.HYPERTHYROIDSM/GRAVES DISEASE –

exopthalmus.

DEMYELINATING DISORDERS

Alzheimer’s disease

Atrophy of brain tissue due to deficiency of

acetylcholine.

S/sx

4 A’s of Alzheimer

a. Amnesia – loss of memory.

b. Agnosia – unable to recognized

inanimate/familiar objects.

c. Apraxia – unable to determine purpose/

function of objects.

d. Aphasia – no speech (nodding).

*Expressive aphasia

“motor speech center” unable to speak

Broca’s Aphasia

*Receptive aphasia

inability to understand spoken words.

Common to Alzheimer’s

Wernike’s Aphasia

General Knowing Gnostic Area or General

Interpretative Area.

DOC

Aricept (taken at bedtime)

Cognex

Management

1. Palliative & supportive

Multiple Sclerosis (MS)

Chronic intermittently progressive disorder

of CNS characterized by scattered white

patches of demyelination in brain and

spinal cord.

Characterized by remission and

exacerbation.

S/sx are varied & multiple, reflecting the

location of demyelination within the CNS.

Cause unknown: maybe a slow growing

virus or possibly autoimmune disorders.

Incident: Affects women more than men

ages 20-40 are prone & more frequent in

cool or temperate climate.

Ig G - only antibody that pass placental

circulation causing passive immunity, short term

protection

Ig A - present in all bodily secretions (tears,

saliva, colostrums).

Ig M - acute in inflammation.

Ig E - for allergic reaction

Ig D - for chronic inflammation.

* Give palliative or supportive care.

S/sx

1. Visual disturbances

blurring of vision (primary)

diplopia (double vision)

scotomas (blind spots)

2. Impaired sensation

touch, pain, pressure, temperature, or

position sense

paresthesia such as tingling sensation,

numbness

3. Mood swings or euphoria (sense of elation)

4. Impaired motor function

weakness

spasticity

paralysis

5. Impaired cerebral function

scanning speech

ataxic gait

nystagmus

dysarthria

intentional tremor

6. Bladder

Urinary retention or incontinence

7. Constipation

8. Sexual impotence in male / decrease sexual

capacity

TRIAD SIGNS OF MS

Ataxia

CHARCOTS TRIAD

8

8

(unsteady

gait, positive

romberg’s test)

Intentional tremors

Nystagmus

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.

Nursing Intervention

1. Assess the client for specific deficit related to

location of demyelination

2. Promote optimum mobility

a. Muscles stretching & strengthening exercises

b. Walking exercises to improve gait: use wide-

base gait

c. Assistive devices: canes, walker, rails,

wheelchair as necessary

3. Administer medications as ordered

a. ACTH (adreno chorticotropic hormone),

Corticosteroids (prednisone) for acute

exacerbations: to reduce edema at site of

demyelination to prevent paralysis.

b. Baclofen (Lioresal), Dantrolene (Dantrium),

Diazepam (Valium) - muscle relaxants: for

spacity

c. Beta Interferons - Immunosuppresants: alter

immune response.

4. Encourage independence in self-care activities

5. Prevent complications of immobility

6. Institute bowel program

7. Maintain side rails to prevent injury related to

falls.

8. Institute stress management techniques.

a. Deep breathing exercises

b. Yoga

9. Increase fluid intake and increase fiber to

prevent constipation.

10.Maintain urinary elimination

1. Urinary Retention

a. perform intermittent catheterization as

ordered: to prevent retention.

b. Bethanecol Chloride (Urecholine) as

ordered

Nursing Management

only given subcutaneous.

monitor side effects bronchospasm and

wheezing.

monitor breath sounds 1 hour after

subcutaneous administration.

2. Urinary Incontinence

a. Establish voiding schedule

b. Anti spasmodic agent Prophantheline

Bromide (Pro-banthine) if ordered

3. Force fluid to 3000 ml/day.

4. Promote use of acid ash diet like cranberry

juice, plums, prunes, pineapple, vitamin C and

orange: to acidify urine and prevent bacterial

multiplication.

11.Prevent injury related to sensory problems.

a. Test bath water with thermometer.

b. Avoid heating pads, hot water bottles.

c. Inspect body parts frequently for injury.

d. Make frequent position changes.

12.Prepare client for plasma exchange if indicated:

to remove antibodies

13.Provide psychologic support to client/significant

others.

a. Encourage positive attitude & assist client in

setting realistic goals.

b. Provide compassion in helping client adapt to

changes in body image & self-concept.

c. Do not encourage false hope during

remission.

d. Refer to MS societies & community agencies.

14.Provide client teaching & discharge planning

concerning:

a. General measures to ensure optimum health.

Balance between activity & rest

Regular exercise such as walking,

swimming, biking in mild case.

Use energy conservation techniques

Well-balance diet

Fresh air & sunshine

Avoiding fatigue, overheating or

chilling, stress, infection.

b. Use of medication & side effects.

c. Alternative methods for sexual counseling if

indicated.

COMMON CAUSE OF UTI

Female

- short urethra (3-5 cm, 1-1 ½ inches)

- poor perineal hygiene

- vaginal environment is moist

Nursing Management

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

- avoid use of tissue papers

- avoid using talcum powder and perfume.

Male

- urethra (20 cm, 8 inches)

- do not urinate after intercourse

INTRACRANIAL PRESSURE ICP

Monroe Kelly Hypothesis

Skull is a closed container

Any alteration or increase in one of the intracranial

components

Increase intracranial pressure

(normal ICP is 0 – 15 mmHg)

Cervical 1 – also known as atlas.

Cervical 2 – also known as axis.

9

9

Foramen Magnum

Medulla Oblongata

Brain Herniation

Increase intra cranial pressure

Nursing Intervention

1. alternate hot and cold compress to prevent

hematoma

CSF cushions brain (shock absorber)

Obstruction of flow of CSF will lead to

enlargement of skull posteriorly called

hydrocephalus.

Early closure of posterior fontanels causes

posterior enlargement of skull in hydrocephalus.

DISORDERS

Increase Intracranial Pressure (IICP)

Increase in intracranial bulk brought due to an

increase in any of the 3 major intracranial

components: Brain Tissue, CSF, Blood.

Untreated increase ICP can lead to displacement

of brain tissue (herniation).

Present life threatening situation because of

pressure on vital structures in the brain stem,

nerve tracts & cranial nerve.

Increase ICP may be caused:

head trauma/injury

localized abscess

cerebral edema

hemorrhage

inflammatory condition (stroke)

hydrocephalus

tumor (rarely)

S/sx

(Early signs)

1. Decrease LOC

2. Irritability / agitation

3. Progresses from restlessness to confusion &

disorientation to lethargy & coma

(Late signs)

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

a. Systolic blood pressure increases while

diastolic pressure remains the same

(widening pulse pressure)

b. Pulse rate decrease

c. Abnormal respiratory patterns (cheyne-

stokes respiration)

d. temperature increase directly proportional

to blood pressure.

2. Pupillary Changes

a. Ipsilateral (same side) dilatation of

pupil with sluggish reaction to light

from compression of cranial nerve III

b. unilateral dilation of pupils called uncal

herniation

c. bilateral dilation of pupils called

tentorial herniation

d. Pupil eventually becomes fixed &

dilated

3. Motor Abnormalities

a. Contralateral (opposite side)

hemiparesis from compression of

corticospinal tract

b. abnormal posturing

c. decorticate posturing (damage to

cortex and spinal cord).

d. decerebrate posturing (damage to

upper brain stem that includes pons,

cerebellum and midbrain).

4. Headache

5. Projective Vomiting

6. Papilledema (edema of optic disc)

7. Possible seizure activity

Nursing Intervention

1. Maintain patent airway and adequate ventilation

by:

a. Prevention of hypoxia (decrease O2) and

hypercarbia (increase CO2) important:

Hypoxia may cause brain swelling

which increase ICP

Early signs of hypoxia:

Restlessness

Tachycardia

Agitation

Late signs of hypoxia:

Extreme restlessness

Bradycardia

Dyspnea

Cyanosis

Hypercarbia may cause cerebral

vasodilation which increase ICP

Hypercabia

Increase CO2 (most powerful

respiratory stimulant) retention.

In chronic respiratory distress

syndrome decrease O2 stimulates

respiration.

b. Before and after suctioning hyperventilate

the client with resuscitator bag connected

to 100% O2 & limit suctioning to 10 – 15

seconds only.

c. Assist with mechanical hyperventilation as

indicated: produces hypocarbia (decease

CO2) causing cerebral constriction &

decrease ICP.

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

frequently to detect increase in ICP

3. Maintain fluid balance: fluid restriction to 1200-

1500 ml/day may be ordered

4. Position the client with head of bed elevated to

30-45o angle with neck in neutral position unless

contraindicated to improve venous drainage from

brain.

5. 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)

10

10

Excessive vomiting: administer anti-

emetics as ordered (Plasil - Phil only,

Phenergan)

Excessive coughing: administer anti-

tussive (dextromethorphan)

Avoid stooping/bending

Avoid lifting heavy objects

e. Avoid clustering of nursing care activity

together.

6. Prevent complications of immobility.

7. Administer medications as ordered:

a. Hyperosmotic agent / Osmotic Diuretic

[Mannitol (Osmitrol)]: to reduce cerebral

edema

Nursing Management

Monitor V/S especially BP: SE hypotension.

Monitor strictly input and output every

hour: (output should increase): notify

physician if output is less 30 cc/hr.

Administered via side drip

Regulate fast drip to prevent crystal

formation.

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

reduce cerebral edema

drug of choice for CHF (pulmonary edema)

loop of henle in kidneys.

Nursing Management

Monitor V/S especially BP: SE hypotension.

Monitor strictly input and output every

hour: (output should increase): notify

physician if output is less 30 cc/hr.

Administered IV push or oral.

Given early morning

Immediate effect of 10-15 minutes.

Maximum effect of 6 hours.

c. Corticosteroids [Dexamethasone (Decadron)]:

anti-inflammatory effect reduces cerebral

edema

d. Analgesics for headache as needed:

Small dose of Codein SO4

Strong opiates may be contraindicated

since they potentiate respiratory

depression, alter LOC, & cause papillary

changes.

e. Anti-convulsants [Phenytoin (Dilantin)]: to

prevent seizures.

8. Assist with ICP monitoring when indicated:

a. ICP monitoring records the pressure exerted

within the cranial cavity by the brain, cerebral

blood, & CSF

b. Types of monitoring devices:

Intraventricular Catheter: inserted in

lateral ventricle to give direct

measurement of ICP; also allows for

drainage of CSF if needed.

Subarachnoid screw (bolt): inserted

through the skull & dura matter into

subarachnoid space.

Epidural Sensor: least invasive method;

placed in space between skull & dura

matter for indirect measurement of ICP.

c. Monitor ICP pressure readings frequently &

prevent complications:

Normal ICP reading is 0-15 mmHg; a

sustained increase above 15 mmHg is

considered abnormal.

Use strict aseptic technique when handling

any part of the monitoring system.

Check insertion site for signs of infection;

monitor temperature.

Assess system for CSF leakage, loose

connections, air bubbles in he line, &

occluded tubing.

9. Provide intensive nursing care for clients treated

with barbiturates therapy or administration of

paralyzing agents.

a. Intravenous administration of barbiturates

may be ordered: to induce coma artificially in

the client who has not responded to

conventional treatment.

b. Paralytic agents such as [vercuronium

bromide (Norcuron)]: may be administered to

paralyzed the client

c. Reduces metabolic demand that may protect

the brain from further injury.

d. Constant monitoring of the client’s ICP,

arterial blood gas, serum barbiturates level, &

ECG is necessary.

e. EEG monitoring as necessary

f. Provide appropriate nursing care for the client

on a ventilator

10.Observe for hyperthermia secondary to

hypothalamus damage.

*CONGESTIVE HEART FAILURE

Signs and Symptoms

- dyspnea

- orthopnea

- paroxysmal nocturnal dyspnea

- productive cough

- frothy salivation

- cyanosis

- rales/crackles

- bronchial wheezing

- pulsus alternans

- anorexia and general body malaise

- PMI (point of maximum impulse/apical pulse

rate) is displaced laterally

- S3 (ventricular gallop)

- Predisposing Factors/Mitral Valve

o RHD

o Aging

Treatment

Morphine Sulfate

Aminophelline

Digoxin

Diuretics

Oxygen

Gases, blood monitor

RIGHT CONGESTIVE HEART FAILURE (venous

congestion)

Signs and Symptoms

11

11

- jugular vein distention (neck)

- ascites

- pitting edema

- weight gain

- hepatosplenomegaly

- jaundice

- pruritus

- esophageal varices

- anorexia and general body malaise

Signs and Symptoms of Lasix in terms of

electrolyte imbalances

1. Hypokalemia

- decrease potassium level

- normal value is 3.4 – 5.5 meq/L

Sign and Symptoms

- weakness and fatigue

- constipation

- positive U wave on ECG tracing

Nursing Management

- administer potassium supplements as ordered

(Kalium Durule, Oral Potassium Chloride)

- increase intake of foods rich in potassium

FRUITS VEGETABL

ES

Apple

Banana

C

antalope

Oranges

Asparagus

Brocolli

Carrots

Spinach

2. Hypocalcemia/Tetany

- decrease calcium level

- normal value is 8.5 – 11 mg/100 ml

Signs and Symptoms

- tingling sensation

- paresthesia

- numbness

- (+) Trousseus sign/Carpopedal spasm

- (+) 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

- polyphagia

Nursing Management

- monitor FBS

5. Hyperuricemia

- increase uric acid (purine metabolism)

- foods high in uric acid (sardines, organ meats and

anchovies)

*Increase in tophi deposit leads to gouty

arthritis.

Signs and Symptoms

- joint pain (great toes)

- swelling

Nursing Management

- force fluids

- administer medications as ordered

a. Allopurinol (Zylopril)

- drug of choice for gout.

- mechanism of action: inhibits synthesis of

uric acid.

b. Colchesine

- acute gout

- mechanism of action: promotes excretion of

uric acid.

* Kidney stones

Signs and Symptoms

- renal cholic

- cool moist skin

Nursing Management

- force fluids

- administer medications as ordered

a. Narcotic Analgesic

- Morphine Sulfate

- antidote: Naloxone (Narcan) toxicity leads to

tremors.

12

12

Multiple loss causes suicide

b. Allopurinol (Zylopril)

Side Effects

- respiratory depression (check for RR)

Parkinson’s Disease/ Parkinsonism

Chronic progressive disorder of CNS

characterized by degeneration of dopamine

producing cells in the substantia nigra of the

midbrain and basal ganglia.

Progressive disorder with degeneration of the

nerve cell in the basal ganglia resulting in

generalized decline in muscular function

Disorder of the extrapyramidal system

Usually occurs in the older population

Cause Unknown: predominantly idiopathic, but

sometimes disorder is postencephalitic, toxic,

arteriosclerotic, traumatic, or drug induced

(reserpine, methyldopa (aldomet) haloperidol

(haldol), phenothiazines).

Pathophysiology

Disorder causes degeneration of dopamine

producing neurons in the substantia nigra in the

midbrain

Dopamine: influences purposeful movement

Depletion of dopamine results in degeneration of

the basal ganglia

Predisposing Factors

1. Poisoning (lead and carbon monoxide)

2. Arteriosclerosis

3. Hypoxia

4. Encephalitis

5. Increase dosage of the following drugs:

a. Reserpine (Serpasil)

b. Methyldopa (Aldomet) Antihypertensive

c. Haloperidol (Haldol) _______

d. Phenothiazine ___________________

Antipsychotic

Side Effects Reserpine: Major depression lead to

suicide

Aloneness

Loss of spouse

Loss of Job

Nursing Intervention for Suicide

direct approach towards the client

close surveillance is a nursing priority

time to commit suicide is on weekends early

morning

S/sx

1. Tremor: mainly of the upper limbs “pill rolling

tremors” of extremities especially the hands;

resting tremor: most common initial symptoms

2. Bradykinesia: slowness of movement

3. Rigidity: cogwheel type

4. Stooped posture: shuffling, propulsive gait

5. Fatigue

6. Mask like facial expression with decrease blinking

of the eyes.

7. Difficulty rising from sitting position.

8. Quite, monotone speech

9. Emotional lability: state of depression

10.Increase salivation: drooling type

11.Cramped, small handwriting

12.Autonomic Symptoms

a. excessive sweating

b. increase lacrimation

c. seborrhea

d. constipation

e. decrease sexual capacity

Nursing Intervention

1. Administer medications as ordered

Anti-Parkinson Drug

a. Levodopa (L-dopa) short acting

MOA: Increase level of dopamine in the

brain; relieves tremors; rigidity;

bradykinesia

SE: GIT irritation (should be taken with

meal); anorexia; N/V; postural

hypotension; mental changes: confusion,

agitation, hallucination; cardiac

arrhythmias; dyskinesias.

CI: narrow-angled glaucoma; client taking

MAOI inhibitor; reserpine; guanethidine;

methyldopa; antipsychotic; acute

psychoses

Avoid multi-vitamins preparation

containing vitamin B6 & food rich in

vitamin B6 (Pyridoxine): reverses the

therapeutic effects of Levodopa

Urine and stool may be darkened

Be aware of any worsening of symptoms

with prolonged high-dose therapy: “on-off”

syndrome.

b. Carbidopa-levodopa (Sinemet)

Prevents breakdown of dopamine in the

periphery & causes fewer side effects.

c. Amantadine Hydrochloride (Symmetrel)

Used in mild cases or in combination with

L-dopa to reduce rigidity, tremors, &

bradykinesia

Anti-Cholinergic Drug

a. Benztropine Mesylate (Cogentin)

b. Procyclidine (Kemadrine)

c. Trihexyphenidyl (Artane)

MOA: inhinit the action of acetylcholine;

used in mild cases or in combination with

L-dopa; relived tremors & rigidity

SE: dry mouth; blurred vision;

constipation; urinary retention; confusion;

hallucination; tachycardia

Anti-Histamines Drug

a. Diphenhydramine (benadryl)

MOA: decrease tremors & anxiety

SE: Adult: drowsiness Children: CNS

excitement (hyperactivity) because blood

brain barrier is not yet fully developed.

b. Bromocriptine (Parlodel)

MOA: stimulate release of dopamine in the

substantia nigra

13

13

Often employed when L-dopa loses

effectiveness

MAOI Inhibitor

a. Eldepryl (Selegilene)

MOA: inhibit dopamine breakdown & slow

progression of disease

Anti-Depressant Drug

a. Tricyclic

MOA: given to treat depression commonly

seen in Parkinson’s disease

2. Provide safe environment

Side rails on bed

Rails & handlebars in the toilet, bathtub, &

hallways

No scattered rugs

Hard-back or spring-loaded chair to make

getting up easier

3. Provide measures to increase mobility

Physical Therapy: active & passive ROM

exercise; stretching exercise; warm baths

Assistive devices

If client “freezes” suggest thinking of

something to walk over

4. Encourage independence in self-care activities:

alter clothing for ease in dressing

use assistive device

do not rush the client

5. Improve communication abilities:

Instruct the client to practice reading a loud

Listen to own voice & enunciate each syllable

clearly

6. Refer for speech therapy when indicated.

7. Maintain adequate nutrition.

Cut food into bite-size pieces

Provide small frequent feeding

Allow sufficient time for meals, use warming

tray

8. Avoid constipation & maintain adequate bowel

elimination

9. Provide significant support to client/ significant

others:

Depression is common due to changes in

body image & self-concept

10.Provide client teaching & discharge planning

concerning:

a. Nature of the disease

b. Use prescribed medications & side effects

c. Importance of daily exercise as tolerated:

balanced activity & rest

walking

swimming

gardening

d. Activities/ methods to limit postural

deformities:

Firm mattress with small pillow

Keep head & neck as erected as possible

Use broad-based gait

Raise feet while walking

e. Promotion of active participation in self-care

activities.

* Increase Vitamin B when taking INH (Isoniazid),

Isonicotinic Acid Hydrazide

* Dopamine Agonist relieves tremor rigidity

MAGIC 2’s IN DRUG MONITORING

DRUG NORMAL

RANGE

TOXICIT

Y

LEVEL

INDICATI

ON

CLASSIFICAT

ION

Digoxin/Lanoxin

(increase force of

cardiac output)

.5 – 1.5 meq/L 2 CHF Cardiac

Glycoside

Lithium/Lithane

(decrease level of

Ach/NE/Serotonin)

.6 – 1.2 meq/L 2 Bipolar Anti-Manic

Agents

Aminophelline

(dilates bronchial

tree)

10 – 19

mg/100 ml

20 COPD Bronchodilat

ors

Dilantin/

Phenytoin

10 – 19

mg/100 ml

20 Seizures Anti-

Convulsant

Acetaminophen/

Tylenol

10 – 30

mg/100 ml

200 Osteo

Arthritis

Non-narcotic

Analgesic

1. Digitalis Toxicity

Signs and Symptoms

- nausea and vomiting

- diarrhea

- confusion

- photophobia

- changes in color perception (yellowish spots)

Antidote: Digibind

2. Lithium Toxicity

Signs and Symptoms

- anorexia

- nausea and vomiting

- diarrhea

- dehydration causing fine tremors

- hypothyroidism

Nursing Management

- force fluids

- increase sodium intake to 4 – 10 g% daily

3. Aminophelline Toxicity

Signs and Symptoms

- tachycardia

- palpitations

- CNS excitement (tremors, irritability, agitation and

restlessness)

Nursing Management

- only mixed with plain NSS or 0.9 NaCl to prevent

development of crystals of precipitate.

- administered sandwich method

- avoid taking alcohol because it can lead to severe CNS

depression

- avoid caffeine

4. Dilantin Toxicity

Signs and Symptoms

- gingival hyperplasia (swollen gums)

- hairy tongue

- ataxia

- nystagmus

Nursing Management

- provide oral care

- massage gums

5. Acetaminophen Toxicity

Signs and Symptoms

- hepatotoxicity (monitor for liver enzymes)

- SGPT/ALT (Serum Glutamic Pyruvate Transaminace)

14

14

- SGOT/AST (Serum Glutamic Oxalo-Acetil

Transaminace)

- nephrotoxicity monitor BUN (10 – 20) and Creatinine

(.8 – 1)

- hypoglycemia

Tremors, tachycardia

Irritability

Restlessness

Extreme fatigue

Diaphoresis, depression

Antidote: Acetylceisteine (mucomyst) prepare suction

apparatus as bedside.

MYASTHENIA GRAVIS (MG)

neuromuscular disorder characterized by a

disturbance in the transmission of impulses from

nerve to muscle cells at the neuromuscular

junction leading to descending muscle weakness.

Incidence rate:

highest between 15 & 35 years old for

women, over 40 for men.

Affects women more than men

Cause:

Unknown/ idiopathic

Thought to be autoimmune disorder whereby

antibodies destroy acetylcholine receptor

sites on the postsynaptic membrane of the

neuromuscular junction.

Voluntary muscles are affected, especially those

muscles innervated by the cranial nerve.

Pathophysiology

Autoimmune = Release of Cholinesterase

Enzymes = Cholinesterase destroy Acetylcholine

(ACH) = Decrease of Acetylcholine (ACH)

Acetylcholine: activate muscle contraction

Autoimmune: it involves release of

cholinesterase an enzyme that destroys Ach

Cholinesterase: an enzyme that destroys ACH

S/sx

1. Initial sign is ptosis a clinical parameter to

determine ptosis is palpebral fissure: cracked or

cleft in the lining or membrane of the eyelids

2. Diplopia

3. Dysphagia

4. Mask like facial expression

5. Hoarseness of voice, weakness of voice

6. Respiratory muscle weakness that may lead to

respiratory arrest

7. Extreme muscle weakness especially during

exertion and morning; increase activity &

reduced with rest.

Dx

1. Tensilon Test (Edrophonium Hydrochloride): IV

injection of tensilon provides temporary relief of

S/sx for about 5-10 minutes and a maximum of

15 minutes.

If there is no effect there is no damage to

occipital lobe and midbrain and is negative for

M.G.

2. Electromyography (EMG): amplitudes of evoked

potentials decrease rapidly.

3. Presence of anti-acetlycholine receptors

antibodies in the serum.

Medical Management

1. Drug Therapy

a. Anti-cholinesterase Drugs: [Ambenonium

(Mytelase), Neostigmine (Prostigmin),

Pyridostigmine (Mestinon)]

MOA: block the action of cholinesterase &

increase the level of acetylcholine at the

neuromuscular junction.

SE: excessive salivation & sweating,

abdominal cramps, N/V, diarrhea,

fasciculations (muscle twitching).

b. Corticosteroids: Prednisone

MOA: suppress autoimmune response

Used if other drugs are not effective

2. Surgery (Thymectomy)

a. Surgical removal of thymus gland: thought to

be involve in the production of acetylcholine

receptor antibodies.

b. May cause remission in some clients

especially if performed early in the disease.

3. Plasma Exchange (Plasmapheresis)

a. Removes circulating acetylcholine receptor

antibodies.

b. Use in clients who do not respond to other

types of therapy.

Nursing Interventions

1. Administer anti-cholinesterase drugs as ordered:

a. Give medication exactly on time.

b. Give with milk & crackers to decrease GI

upset

c. Monitor effectiveness of drugs: assess muscle

strength & vital capacity before & after

medication.

d. Avoid use of the ff drugs:

Morphine SO4 & Strong Sedatives:

respiratory depressant effects

Quinine, Curare, Procainamide,

Neomycin, Streptomycine, Kanamycine

& other aminoglycosides: skeletal

muscle blocking effect

e. Observe for side effects

2. Promote optimal nutrition:

a. Mealtime should coincide with the peak effect

of the drugs: give medication 30 minutes

before meals.

b. Check gag reflex & swallowing ability before

feeding.

c. Provide mechanical soft diet.

d. If the client has difficulty in chewing &

swallowing, do not leave alone at mealtime;

keep emergency airway & suctioning

equipment nearby.

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 CHOLINERGIC CRISIS

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Abrupt onset of severe,

generalized muscle weakness

with inability to swallow, speak,

or maintain respirations.

Symptoms will improve

temporarily with tensilon test.

Causes:

under medication

physical or emotional stress

infection

Signs and Symptoms

the client is unable to see,

swallow, speak, breathe

Treatment

administer cholinergic agents as

ordered

Symptoms similar to myasthenic

crisis & in addition the side effect

of anti-cholinesterase drugs

(excessive salivation & sweating,

abdominal carmp, N/V, diarrhea,

fasciculation)

Symptoms worsen with tensilon

test: keep Atropine Sulfate &

emergency equipment on hand.

Cause:

over medication with the

cholinergic drugs

cholinesterase)

Signs and Symptoms

PNS

Treatment

administer

agents (Atrophine Sulfate)

Nursing Care in Crisis:

a. Maintain tracheostomy set or endotracheal

tube with mechanical ventilation as indicated.

b. Monitor ABG & Vital Capacity

c. Administer medication as ordered:

Myasthenic Crisis: increase doses of

anti-cholinesterase drug as ordered.

Cholinergic Crisis: discontinue anti-

cholinesterase drugs as ordered until

the client recovers.

d. Established method of communication

e. Provide support & reassurance.

6. Provide nursing care for the client with

thymectomy.

7. Provide client teaching & discharge planning

concerning:

a. Nature of the disease

b. Use of prescribe medications their side effects

& sign of toxicity

c. Importance of checking with physician before

taking any new medication including OTC

drugs

d. Importance of planning activities to take

advantage of energy peaks & of scheduling

frequent rest period

e. Need o avoid fatigue, stress, people with

upper respiratory infection

f. Use of eye patch for diplopia (alternate eyes)

g. Need to wear medic-alert bracelet

h. Myasthenia Gravis foundation & other

community agencies

Guillain-Barre Syndrome

a disorder of the CNS characterized by bilateral,

symmetrical, peripheral polyneuritis

characterized by ascending muscle paralysis.

Can occur at any age; affects women and men

equally

Progression of disease is highly individual; 90%

of clients stop progression in 4 weeks; recovery

is usually from 3-6 months; may have residual

deficits.

Causes:

1. Unknown / idiopathic

2. May be autoimmune process

Predisposing Factors

1. Immunization

2. Antecedent viral infections such as LRT infections

S/sx

1. Mild Sensory Changes: in some clients severe

misinterpretation of sensory stimuli resulting to

extreme discomfort

2. Clumsiness (initial sign)

3. Progressive motor weakness in more than one

limb (classically is ascending & symmetrical)

4. Dysphagia: cranial nerve involvement

5. Ascending muscle weakness leading to paralysis

6. Ventilatory insufficiency if paralysis ascends to

respiratory muscles

7. Absence or decreased deep tendon reflex

8. Alternate hypotension to hypertension

9. Arrythmia (most feared complication)

10.Autonomic disfunction: symptoms that includes

a. increase salivation

b. increase sweating

c. constipation

Dx

1. CSF analysis: reveals increased in IgG and

protein

2. EMG: slowed nerve conduction

Medical Management

1. Mechanical Ventilation: if respiratory problems

present

2. Plasmapheresis: to reduce circulating antibodies

3. Continuous ECG monitoring to detect alteration

in heart rate & rhythm

4. Propranolol: to prevent tachycardia

5. Atropine SO4: may be given to prevent episodes

of bradycardia during endotracheal suctioning &

physical therapy

Nursing Intervention

1. Maintain patent airway & adequate ventilation:

a. Monitor rate & depth of respiration; serial vital

capacity

b. Observe for ventilatory insufficiency

c. Maintain mechanical ventilation as needed

d. Keep airway free of secretions & prevent

pneumonia

2. Check individual muscle groups every 2 hrs in

acute phase to check progression of muscle

weakness

3. Assess cranial nerve function:

a. Check gag reflex

b. Swallowing ability

c. Ability to handle secretion

d. Voice

4. Monitor strictly the following:

a. Vital signs

b. Input and output

c. Neuro check

d. ECG: due to arrhythmia

e. Observe signs of autonomic dysfunction:

acute period of hypertension fluctuating with

hypotension

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f. Tachycardia

g. Arrhythmias

5. Maintain side rails to prevent injury related to fall

6. Prevent complications of immobility: turning the

client every 2 hrs

7. 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

9. Promote optimum nutrition:

a. Check gag reflex before feeding

b. Start with pureed food

c. Assess need for NGT feeding: if unable to

swallow; to prevent aspiration

10.Administer medications as ordered

a. Corticosteroids: suppress immune response

b. Anti Cholinergic Agents:

Atrophine Sulfate

c. Anti Arrythmic Agents:

Lidocaine (Xylocaine)

Bretylium: blocks release of

norepinephrine; to prevent increase of BP

11.Assist in plasmapheresis (filtering of blood to

remove autoimmune anti-bodies)

12.Prevent complications:

a. Arrythmia

b. Paralysis of respiratory muscles / respiratory

arrest

13.Provide psychologic support & encouragement to

client / significant others

14.Refer for rehabilitation to regain strength & treat

any residual deficits.

INFLAMMATORY CONDITIONS OF THE BRAIN

Meningitis

Inflammation of the meninges of the brain &

spinal cord.

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

Etiology / Most Common M.O.

1. Meningococcus: most dangerous

2. Pneumococcus

3. Streptococcus: cause of adult meningitis

4. Hemophilus Influenzae: cause of pediatric

meningitis

Mode of transmission

1. Airborne transmission (droplet nuclei)

2. Via blood, CSF, lymph

3. By direct extension from adjacent cranial

structures (nasal, sinuses, mastoid bone, ear,

skull fracture)

4. By oral or nasopharyngeal route

Signs and Symptoms

2. Headache, photophobia, general body malaise,

irritability,

3. Projectile vomiting: due to increase ICP

4. Fever & chills

5. Anorexia & weight loss

6. Possible seizure activity & decrease LOC

7. Abnormal posturing: (decorticate and

decerebrate)

8. Signs of Meningeal Irritation:

a. Nuchal rigidity or stiff neck: initial sign

b. Opisthotonos (arching of back): head & heels

bent backward & body arched forward

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

pain in the hamstring muscles when

attempting to extend the leg when the hip is

flexed

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

hip & knee in response to forward flexion of

the neck

Dx

1. Lumbar Puncture:

Measurement & analysis of CSF shows

increased pressure, elevated WBC & CHON,

decrease glucose & culture positive for

specific M.O.

A hollow spinal needle is inserted in the

subarachnoid space between the L3-L4 or L4-

L5.

Nursing Management Before Lumbar Puncture

1. 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

2. Force fluids

3. Check punctured site for any discoloration,

drainage and leakage to tissues.

4. Assess for movement and sensation of

extremities.

CSF analysis reveals

1. Increase CHON and WBC

2. Decrease glucose

3. Increase CSF opening pressure (normal

pressure is 50 – 100 mmHg)

4. (+) cultured microorganism (confirms

meningitis)

CBC reveals

1. Increase WBC

Nursing Management

1. Administer large doses of antibiotic IV as

ordered:

a. Broad spectrum antibiotics (Penicillin,

Tetracycline)

b. Mild analgesics: for headaches

c. Antipyretics: for fever

2. Enforced strict respiratory isolation 24 hours

after initiation of anti biotic therapy (for some

type of meningitis)

3. Provide nursing care for increase ICP, seizure &

hyperthermia if they occur

4. Provide nursing care for delirious or unconscious

client as needed

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5. Enforce complete bed rest

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

headache & photophobia

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

8. Maintain fluid & electrolyte balance

9. Prevent complication of immobility

10.Provide client teaching & discharge planning

concerning:

a. Importance of good diet: high CHON, high

calories with small frequent feedings.

b. Rehabilitation program for residual deficit

mental retardation

delayed psychomotor development

c. Prevent complications

most feared is hydrocephalus

hearing loss/nerve deafness is second

complication

consult audiologist

Cerebrovascular Accident (CVA) (Stroke/Brain

Attack/Apoplexy/Cerebral Thrombosis)

Destruction (infarction) of brain cells caused by a

reduction in cerebral blood flow and oxygen

A partial or complete disruption in the brains

blood supply.

2 largest & most common cerebral artery

affected by stroke:

a. Mid Cerebral Artery

b. Internal Cerebral Artery

Incidence Rate:

a. Affects men more than women; Men are 2-3

times high risk; Incidence increase with age

Causes:

a. Thrombosis (attached)

b. Embolism (detached): most dangerous

because it can go to the lungs & cause

pulmonary embolism or the brain & cause

cerebral embolism.

c. Hemorrhage

d. Compartment Syndrome: compression of

nerves & arteries

S/sx Pulmonary Embolism

1. Sudden sharp chest pain

2. Unexplained dyspnea

3. SOB

4. Tachycardia

5. Palpitations

6. Diaphoresis

7. Mild restlessness

S/sx of Cerebral Embolism

1. Headache

2. disorientation

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.

Yellow bone marrow are produced from

the medullary cavity of the long bones

and produces fat cells.

If there is bone fracture there is

hemorrhage and there would be escape

of the fat cells in the circulation.

Risk Factors

Disease:

1. Hypertension

2. Diabetes Mellitus

3. Atherosclerosis / Arteriosclerosis

4. Myocardial Infarction

5. Mitral valve replacement

6. Valvular Disease / replacement

7. Chronic atrial Fibrillation

8. Post Cardiac Surgery

Lifestyle:

1. Smoking

2. Sedentary lifestyle

3. Obesity (increase 20% ideal body weight)

4. Hyperlipidemia more on genetics/genes that

binds to cholesterol

5. Type A personality

a. Deadline driven

b. Can do multiple tasks

c. Usually fells guilty when not doing anything

6. Related to diet: increase intake of saturated fats

like whole milk

7. Related stress physical and emotional

8. Prolong use of oral contraceptives: promotes

lypolysis (breakdown of lipids) leading to

atherosclerosis that will lead to hypertension &

eventually CVA.

Pathophysiology

1. Interruption of cerebral blood flow for 5 min or

more causes death of neurons in affected area

with irreversible loss of function.

2. Modifying Factors:

a. Cerebral Edema:

Develops around affected area causing

further impairment

b. Vasospasm:

Constriction of cerebral blood vessel may

occur, causing further decrease in blood

flow

c. Collateral Circulation:

May help to maintain cerebral blood flow

when there is compromise of main blood

supply

Stages of Development

1. Transient Ischemic Attack (TIA)

a. Initial / warning signs of impending CVA /

stroke

b. Brief period of neurologic deficit:

Visual loss / Visual disturbance

Hemiparesis

Slurred Speech / Speech disturbance

Vertigo

Aphasia

Headache: initial sign

Dizziness

Tinnitus

Possible Increase ICP

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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

3. Complete Stroke

Neurologic deficit remains unchanged for 2-3-

days period

S/sx

1. Headache

2. Generalized Signs:

Vomiting

Seizure

Confusion

Disorientation

Decrease LOC

Nuchal Rigidity

Fever

Hypertension

Slow Bounding Pulse

Cheyne-Strokes Respiration

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

hemorrhagic stroke

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

Hemiplegia

Homonymous hemianopsia: loss of half of

visual field

Sensory loss

Aphasia

Dysarthia: inability to articulate words

Alexia: difficulty reading

Agraphia: difficulty writing

Dx

1. CT & Brain Scan: reveals brain lesions

2. EEG: abnormal changes

3. Cerebral Arteriography: invasive procedure due

to injection of dye (iodine based); Uses dye for

visualization

May show occlusion or malformation of blood

vessels

Reveals the site and extent of malocclusion

Nursing Management Post Cerebral

Arteriography

Allergy Test (shellfish)

Force fluids to release dye because it is

nephro toxic

Check for peripheral pulse: distal (femoral)

Check for hematoma formation

Nursing Intervention: Acute Stage

1. Maintain patent airway and adequate ventilation

by:

a. Assist in mechanical ventilation

b. Administer O2 inhalation

2. Monitor strictly V/S, I & O, neuro check & observe

signs of increase ICP, shock, hyperthermia, &

seizure

3. Provide CBR as ordered

4. Maintain fluid & electrolyte balance & ensure

adequate nutrition:

a. IV therapy for the first few days

b. NGT for feeding the client who is unable to

swallow

c. Fluid restriction as ordered: to decrease

cerebral edema & might also increase ICP

5. Maintain proper positioning & body alignment:

a. Elevate head 30-45 degree to decrease ICP

b. Turn & reposition every 2 hrs (20 min only on

the affected side)

c. Passive ROM exercise every 4 hrs: prevent

contractures; promote body alignment

6. Promote optimum skin integrity: turn client &

apply lotion every 2 hrs

7. Prevent complications of immobility by:

a. Turn client to side

b. Provide egg crate mattresses or water bed

c. Provide sand bag or food board.

8. Maintain adequate elimination:

a. Offer bed pan or urinal every 2 hrs;

catheterized only if necessary

b. Administer stool softener & suppositories as

ordered: to prevent constipation & fecal

impaction

9. Provide quiet, restful environment

10. Provide alternative means of communication to

the client:

a. Non verbal cues

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

c. If positive to hemianopsia: approach client on

unaffected side

11.Administer medications as ordered:

a. Hyperosmotic agent: to decrease cerebral

edema

Osmotic Diuretics (Mannitol)

Loop Diuretics Furosemide (Lasix)

Corticosteroids (Dexamethazone)

b. Anti-convulsants: to prevent or treat seizures

c. Thrombolytic / Fibrinolytic Agents: given to

dissolve clot (hemorrhage must be ruled out)

Tissue Plasminogen Activating Factor (tPA,

Alteplase): SE: allergic Reaction

Streptokinase, Urokinase: SE: chest pain

d. Anticoagulants: for stroke in evolution or

embolic stroke (hemorrhage must be ruled

out)

Heparin: short acting

Check for Partial Thromboplastin Time

(PTT): if prolonged there is a risk for

bleeding

Antidote: Protamine SO4

Warfarin (Comadin): long acting / long

term therapy

Give simultaneously with Heparin

cause Warfarin (Coumadin) will take

effect after 3 days

Check for Prothrombin Time (PT): if

prolonged there is a risk for bleeding

Antidote: Vitamin K (Aqua Mephyton)

Anti Platelet: to inhibit platelet aggregation

in treating TIA’s

PASA (Aspirin)

Contraindicated for dengue, ulcer and

unknown cause of headache because it

may potentiate bleeding

e. Antihypertensive: if indicated for elevated BP

f. Mild Analgesics: for pain

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12.Provide client health teachings and discharge

planning concerning

a. Avoid modifiable risk factors (diet,

exercise, smoking)

b. Prevent complication (subarachnoid

hemorrhage is the most feared

complication)

c. Dietary modification (decrease salt,

saturated fats and caffeine)

d. Importance of follow up care

Nursing Intervention: Rehabiltation

1. Hemiplegia: results from injury to cell in the

cerebral motor cortex or to corticospinal tract

(causes contralateral hemiplegia since tracts

crosses medulla)

a. Turn every 2 hrs (20 min only on affected

side)

b. Use proper positioning & repositioning to

prevent deformities (foot drop, external

rotation of hips, flexion of fingers, wrist drop,

abduction of shoulder & arms)

c. Support paralyzed arm on pillow or use sling

while out of bed to prevent subluxation of

shoulders

d. Elevate extremities to prevent dependent

edema

e. Provide active & passive ROM exercises every

4 hrs

2. Susceptibility to hazard

a. Keep side rails up at all times

b. Institute safety measures

c. Inspect body parts frequently for signs of

injury

3. Dysphagia: difficulty of swallowing

a. Check for gag reflex before feeding client

b. Maintain a calm, unhurried approach

c. Place client in upright position

d. Place food in unaffected side of the mouth

e. Offer soft foods

f. Give mouth care before & after meals

4. Homonymous Hemianopsia: loss of right or left

half of each visual field

a. Approach the client on unaffected side

b. Place personal belongings, food etc., on

unaffected side

c. Gradually teach the client to compensate by

scanning (ex. Turning the head to see things

on affected side)

5. Emotional Lability: mood swings, frustrations

a. Create a quiet, restful environment with a

reduction in excessive sensory stimuli

b. Maintain a calm, non-threatening manner

c. Explain to family that client’s behavior is not

purposeful

6. Aphasia: most common in right hemiplegics; may

be receptive / expressive

a. Receptive Aphasia

Give simple, slow directions

Give one command at a time; gradually

shift topics

Use non-verbal techniques of

communication (ex. Pantomime,

demonstration)

b. Expressive Aphasia

Listen & watch very carefully when the

client attempts to speak

Anticipate client’s needs to decrease

frustrations & feeling of helplessness

Allow sufficient time for client to answer

7. Sensory / Perceptual Deficit: more common in

left hemiplegics; characterized by impulsiveness

unawareness of disabilities, visual neglect

(neglect of affected side & visual space on

affected side)

a. Assist with self-care

b. Provide safety measures

c. Initially arrange objects in environment on

unaffected side

d. Gradually teach client to take care of the

affected & turn frequently & look at affected

side

8. Apraxia: loss of ability to perform purposeful,

skilled acts

a. Guide client through intended movement (ex.

Take object such as wash cloth & guide client

through movement of washing)

b. Keep repeating the movement

9. Generalizations about the clients with left

hemiplegia vs. right hemiplegia & nursing care

a. Left Hemiplegia

Perceptual, sensory deficits: quick &

impulsive behavior

Use safety measures, verbal cues,

simplicity in all area of care

b. Right Hemiplegia

Speech-language deficits: slow & cautious

behavior

Use pantomime & demonstration

CONVULSIVE DISORDER/CONVULSION

disorder of CNS characterized by paroxysmal

seizure with or without loss of consciousness

abnormal motor activity alternation in sensation

and perception and changes in behavior.

Seizure: first convulsive attack

Epilepsy: second or series of attacks

Febrile seizure: normal in children age below 5

years

Predisposing Factors

1. Head injury due to birth trauma

2. Genetics

3. Presence of brain tumor

4. Toxicity from the ff:

a. Lead

b. Carbon monoxide

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) & Glucose

S/sx

Dependent on stages of development or types

of seizure

1. Generalized Seizure

Initial onset in both hemisphere, usually

involves loss of consciousness & bilateral

motor activity.

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a. Major Motor Seizure (Grand mal Seizure):

tonic-clonic seizure

Signs or aura with auditory, olfactory,

visual, tactile, sensory experience

Epileptic cry: is characterized by fall and

loss of consciousness for 3-5 minutes

Tonic Phase:

Limbs contract or stiffens

Pupils dilated & eye roll up to one side

Glottis closes: causing noise on

exhalation

May be incontinent

Occurs at same time as loss of

consciousness last 20-40 sec

Tonic contractions: direct symmetrical

extension of extremities

Clonic Phase:

repetitive movement

increase mucus production

slowly tapers

Clonic contractions: contraction of

extremities

Postictal sleep: unresponsive sleep

Seizure ends with postictal period of

confusion, drowsiness

b. Absence Seizure (Petit mal Seizure):

Usually non-organic brain damage present

Must be differentiated from daydreaming

Sudden onset with twitching & rolling of eyes

that last 20-40 sec

Common among pediatric clients

characterized by:

Blank stare

Decrease blinking of eyes

Twitching of mouth

Loss of consciousness (5 – 10 seconds)

2. Partial or Localized Seizure

Begins in focal area of brain & symptoms are

related to a dysfunction of that area

May progress into a generalized seizure

a. Jacksonian Seizure (focal seizure)

characterized by tingling and jerky

movement of index finger and thumb that

spreads to the shoulder and other side of

the body.

b. Psychomotor Seizure (focal motor seizure)

May follow trauma, hypoxia, drug use

Purposeful but inappropriate repetitive

motor acts

Aura is present: daydreaming like

Automatism: stereotype repetitive and non

propulsive behavior

Clouding of consciousness: not in contact

with environment

Mild hallucinatory sensory experience

3. Status Epilepticus

Usually refers to generalized grand mal

seizure

Seizure is prolong (or there are repeated

seizures without regaining consciousness) &

unresponsive to treatment

Can result in decrease in O2 supply & possible

cardiac arrest

A continuous uninterrupted seizure activity

If left untreated can lead to hyperpyrexia and

lead to coma and eventually death.

DOC: Diazepam (Valium) & Glucose

C. Diagnostic Procedures

1. CT Scan – reveals brain lesions

2. EEG – reveals hyper activity of electrical brain waves

D. Nursing Management

1. Maintain patent airway and promote safety before

seizure activity

a. clear the site of blunt or sharp objects

b. loosen clothing of client

c. maintain side rails

d. avoid use of restrains

e. turn clients head to side to prevent aspiration

f. place mouth piece of tongue guard to prevent

biting or tongue

2. Avoid precipitating stimulus such as bright/glaring

lights and noise

3. Administer medications as ordered

a. Anti convulsants (Dilantin, Phenytoin)

b. Diazepam, Valium

c. Carbamazepine (Tegnetol) – trigeminal

neuralgia

d. Phenobarbital, Luminal

4. Institute seizure and safety precaution post seizure

attack

a. administer O2 inhalation

b. provide suction apparatus

5. Document and monitor the following

a. onset and duration

b. types of seizures

c. duration of post ictal sleep may lead to status

epilepticus

d. assist in surgical procedure cortical resection

Overview Anatomy & Physiology of the Eye

External Structure of Eye

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

from foreign particles

b. Conjunctiva:

Palpebral Conjunctiva: pink; lines inner

surface of eyelids

Bulbar Conjunctiva: white with small blood

vessels, covers anterior sclera

c. Lacrimal Apparatus (lacrimal gland & its ducts &

passage): produces tears to lubricate the eye &

moisten the cornea; tears drain into the

nasolacrimal duct, which empties into nasal

cavity

d. The movement of the eye is controlled by 6

extraocular muscles (EOM)

Internal Structure of Eye

A. 3 layers of the eyeball

1. Outer Layer

a. Sclera: tough, white connective tissue

(“white of the eye”); located anteriorly &

posteriorly

b. Cornea: transparent tissue through which

light enters the eye; located anteriorly

2. Middle Layer

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a. Choroid: highly vascular layer, nourishes

retina; located posteriorly

b. Ciliary Body: anterior to choroid, secrets

aqueous humor; muscle change shape of

lens

c. Iris: pigmented membrane behind cornea,

gives color to eye; located anteriorly

d. Pupil: is circular opening in the middle of

the iris that constrict or dilates to regulate

amount of light entering the eye

3. Inner Layer

a. Light-sensitive layer composed of rods &

cones (visual cell)

Cones: specialized for fine

discrimination & color vision;

(daylight / colored vision)

Rods: more sensitive to light than

cones, aid in peripheral vision;

(night twilight vision)

b. Optic Disk: area in retina for entrance of

optic nerve, has no photoreceptors

B. Lens: transparent body that focuses image on

retina

C. Fluid of the eye

1. Aqueous Humor: clear, watery fluid in anterior

& posterior chambers in anterior part of eye;

serves as refracting medium & provides

nutrients to lens & cornea; contribute to

maintenance of intraocular pressure

2. Vitreous Humor: clear, gelatinous material

that fills posterior cavity of eye; maintains

transparency & form of eye

Visual Pathways

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

neural impulses that travel over the optic nerves

b. Optic nerves for each eye meet at the optic

chiasm

Fibers from median halves of the retinas

cross here & travel to the opposite side of

the brain

Fibers from lateral halves of retinas remain

uncrossed

c. Optic nerves continue from optic chiasm as optic

tracts & travels to the cerebrum (occipital lobe)

where visual impulses are perceived &

interpreted

Canal of schlemm: site of aqueous humor drainage

Meibomian gland: secrets a lubricating fluid inside

the eyelid

Maculla lutea: yellow spot center of retina

Fovea centralis: area with highest visual acuity or

acute vision

2 muscles of iris:

Circular smooth muscle fiber: Constricts the pupil

Radial smooth muscle fiber: Dilates the pupil

Physiology of vision

4 Physiological processes for vision to occur:

1. Refraction of light rays: bending of light rays

2. Accommodation of lens

3. Constriction & dilation of pupils

4. Convergence of eyes

Unit of measurements of refraction: diopters

Normal eye refraction: emmetropia

Normal IOP: 12-21 mmHg

Error of Refraction

1. Myopia: nearsightedness: Treatment: biconcave

lens

2. Hyperopia: farsightedness: Treatment: biconvex

lens

3. Astigmatisim: distorted vision: Treatment:

cylindrical

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

aging: Treatment: bifocal lens or double vista

Accommodation of lenses: based on thelmholtz

theory of accommodation

Near Vision: Ciliary muscle contracts: Lens bulges

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

Convergence of the eye:

Error:

1. Exotropia:1 eye normal

2. Esophoria: corrected by

corrective eye surgery

3. Strabismus: squint eye

4. Amblyopia: prolong squinting

Common Visual Disorder

Glaucoma

Characterized by increase intraocular pressure

resulting in progressive loss of vision

May cause blindness if not recognized & treated

Early detection is very important

preventable but not curable

Regular eye exam including tonometry for person

over age 40 is recommended

Predisposing Factors

1. Common among 40 years old and above

2. Hereditary

3. Hypertension

4. Obesity

5. History of previous eye surgery, trauma,

inflammation

Types of Glaucoma:

1. Chronic (open-angle) Glaucoma:

Most common form

Due to obstruction of the outflow of aqueous

humor, in trabecular meshwork or canal of

schlemm

2. Acute (close-angle) Glaucoma:

Due to forward displacement of the iris

against the cornea, obstructing the outflow of

the aqueous humor

Occurs suddenly & is an emergency situation

If untreated it will result to blindness

3. Chronic (close-angle) Glaucoma:

similar to acute (close-angle) glaucoma, with

the potential for an acute attack

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S/sx

1. Chronic (open-angle) Glaucoma: symptoms

develops slowly

Impaired peripheral vision (PS: tunnel vision)

Halos around light

Mild discomfort in the eye

Loss of central vision if unarrested

2. Acute (close-angle) Glaucoma

Severe eye pain

Blurred cloudy vision

Halos around light

N/V

Steamy cornea

Moderate pupillary dilation

3. Chronic (close-angle) Glaucoma

Transient blurred vision

Slight eye pain

Halos around lights

Dx

1. Visual Acuity: reduced

2. Tonometry: reading of 24-32 mmHg suggest

glaucoma; may be 50 mmHg of more in acute

(close-angle) glaucoma

3. Ophthalmoscopic exam: reveals narrowing of

small vessels of optic disk, cupping of optic disk

4. Perimetry: reveals defects in visual field

5. Gonioscopy: examine angle of anterior chamber

Medical Management

1. Chronic (open-angle) Glaucoma

a. Drug Therapy: one or a combination of the

following

Miotics eye drops (Pilocarpine): to increase

outflow of aqueous humor

Epinephrine eye drops: to decrease

aqueous humor production & increase

outflow

Carbonic Anhydrase Inhibitor:

Acetazolamide (Diamox): to decrease

aqueous humor production

Timolol Maleate (Timoptic): topical beta-

adrenergic blocker: to decrease intraocular

pressure (IOP)

b. Surgery (if no improvement with drug)

Filtering procedure (Trabeculectomy /

Trephining): to create artificial openings

for the outflow of aqueous humor

Laser Trabeculoplasty: non-invasive

procedure performed with argon laser that

can be done on an out-client basis;

procedure similar result as trabeculectomy

2. Acute (close-angle) Glaucoma

a. Drug Therapy: before surgery

Miotics eye drops (Pilocarpine): to cause

pupil to contract & draw iris away from

cornea

Osmotic Agent (Glycerin oral, Mannitol IV):

to decrease intraocular pressure (IOP)

Narcotic Analgesic: for pain

b. Surgery

Peripheral Iridectomy: portion of the iris is

excised to facilitate outflow of aqueous

humor

Argon Laser Beam Surgery: non-invasive

procedure using laser produces same

effect as iridectomy; done in out-client

basis

Iridectomy: usually performed on second

eye later since a large number of client

have an acute acute attack in the other

eye

3. Chronic (close-angle) Glaucoma

a. Drug Therapy:

miotics (pilocarpine)

b. Surgery:

bilateral peripheral iridectomy: to prevent

acute attacks

Nursing Intervention

1. Administer medication as ordered

2. Provide quite, dark environment

3. Maintain accurate I & O with the use of osmotic

agent

4. Prepare client for surgery if indicated

5. Provide post-op care

6. Provide client teaching & discharge planning

a. Self-administration of eye drops

b. Need to avoid stooping, heavy lifting or

pushing, emotional upsets, excessive fluid

intake, constrictive clothing around the neck

c. Need to avoid the use antihistamines or

sympathomimetic drugs (found in cold

preparation) in close-angle glaucoma since

they may cause mydriasis

d. Importance of follow-up care

e. Need to wear medic-alert tag

Cataract

Decrease opacity of ocular lens

Incidence increases with age

Predisposing Factor

1. Aging 65 years and above

2. May caused by changes associated with aging

(“senile” cataract)

3. Related to congenital

4. May develop secondary to trauma, radiation,

infection, certain drugs (corticosteroids)

5. Diabetes Mellitus

6. Prolonged exposure to UV rays

S/sx

1. Loss of central vision

2. Blurring or hazy vision

3. Progressive decrease of vision

4. Glare in bright lights

5. Milky white appearance at center of pupils

6. Decrease perception to colors

Diagnostic Procedure

1. Ophthalmoscopic exam: confirms presence of

cataract

Nursing Intervention

1. Prepare client for cataract surgery:

a. Performed when client can no longer remain

independent because of reduced vision

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b. Surgery performed on one eye at a time;

usually in a same day surgery unit

c. Local anesthesia & intravenous sedation

usually used

d. Types of cataract surgery:

Extracapsular Extraction: lens capsule is

excised & the lens is expressed; posterior

capsule is left in place (may be used to

support new artificial lens implant); partial

removal of lens

Phacoemulsification: type of extracapsular

extraction; a hollow needle capable of

ultrasonic vibration is inserted into lens,

vibrations emulsify the lens, which is

aspirated

Intracapsular Extraction: lens is totally

removed within its capsules, may be

delivered from eye by cryoextraction (lens

is frozen with metal probe & removed);

total removal of lens & surrounding

capsules

e. Peripheral Iridectomy: may be performed at

the time of surgery; small hole cut in iris to

prevent development of secondary glaucoma

f. Intraocular Lens Implant: often performed at

the time of surgery

2. Nursing Intervention Pre-op

a. Assess vision in the unaffected eye since the

affected eye will be patched post-op

b. Provide pre-op teaching regarding measures

to prevent intraocular pressure (IOP) post-op

c. Administer medication as ordered:

Topical Mydriatics (Mydriacyl) &

Cyclopegics (Cyclogyl): to dilate the pupil

Topical antibiotics: to prevent infection

Acetazolamide (Diamox) & osmotic agent

(Oral Glycerin or Mannitol IV): to decrease

intraocular pressure to provide soft eyeball

for surgery

3. Nursing Intervention Post-op

a. Reorient the client to surroundings

b. Provide safety measures:

Elevate side rails

Provide call bells

Assist with ambulation when fully

recovered from anesthesia

c. Prevent intraocular pressure & stress on the

suture line:

Elevate head of the bed 30-40 degree

Have the client lie on back or unaffected

side

Avoid having the client cough, sneeze,

bend over, or move head too rapidly

Treat nausea with anti-emetics as ordered:

to prevent vomiting

Give stool softener as ordered: to prevent

straining

Observe for & report signs of intraocular

pressure (IOP):

Severe eye pain

Restlessness

Increased pulse

4. 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

5. Administer medication as ordered:

a. Topical mydriatics & cycloplegic: to decrease

spasm of ciliary body & relieve pain

b. Topical antibiotics & corticosteroids

c. Mild analgesic as needed

6. Provide client teaching & discharge planning

concerning:

a. Technique of eyedrop administration

b. Use of eye shield at night

c. No bending, stooping, or lifting

d. Report signs & symptoms of complication

immediately to physician:

Severe eye pain

Decrease vision

Excessive drainage

Swelling of eyelid

e. Cataract glasses / contact lenses

If a lens implant has not been performed

the client will need glasses or contact

lenses

Temporary glasses are worn for 1-4 weeks

then permanent glasses fitted

Cataract glasses magnify object by 1/3 &

distortion peripheral vision

Have the client practice manual

coordination with assistance until new

spatial relationship becomes familiar

Have client practice walking, using

stairs, reaching for articles

Contact lenses cause less distortion of

vision; prescribe at one month

Retinal Detachment

Separation of epithelial surface of retina

Detachment or the sensory retina from the

pigment epithelium of the retina

Predisposing Factors

1. Trauma

2. Aging process

3. Severe diabetic retinopathy

4. Post-cataract extraction

5. Severe myopia (near sightedness)

Pathophysiology

Tear in the retina allows vitreous humor to seep

behind the sensory retina & separate it from the

pigment epithelium

S/sx

1. Curtain veil like vision coming across field of

vision

2. Flashes of light

3. Visual field loss

4. Floaters

5. Gradual decrease of central vision

Dx

1. Ophthalmoscopic exam: confirms diagnosis

Medical Management

1. Bed rest with eye patched & detached areas

dependent to prevent further detachment

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2. Surgery: necessary to repair detachment

a. Photocoagulation: light beam (argon laser)

through dilated pupil creates an inflammatory

reaction & scarring to heal the area

b. Cryosurgery or diathermy: application of

extreme cold or heat to external globe;

inflammatory reaction causes scarring &

healing of area

c. Scleral buckling: shortening of sclera to force

pigment epithelium close to retina

Nursing Intervention Pre-op

1. Maintain bed rest as ordered with head of bed

flat & detached area in a dependent position

2. Use bilateral eye patches as ordered; elevate

side rails to prevent injury

3. Identify yourself when entering the room

4. Orient the client frequently to time of date &

surroundings; explain procedures

5. Provide diversional activities to provide sensory

stimulation

Nursing Intervention Post-op

1. Check orders for positioning & activity level:

a. May be on bed rest for 1-2 days

b. May need to position client so that detached

area is in dependent position

2. Administer medication as ordered:

a. Topical mydriatics

b. Analgesic as needed

3. Provide client teaching & discharge planning

concerning:

a. Techniques of eyedrop administration

b. Use eye shield at night

c. No bending from waist; no heavy work or

lifting for 6 weeks

d. Restriction of reading for 3 weeks or more

e. May watch TV

f. Need to check to physician regarding

combing & shampooing hair & shaving

g. Need to report complications such as

recurrence of detachment

Overview of Anatomy & Physiology Of Ear (Hearing)

External Ear

1. Auricle (Pinna): outer projection of ear composed

of cartilage & covered by skin; collects sound

waves

2. External Auditory Canal: lined with skin; glands

secretes cerumen (wax), providing protection;

transmits sound waves to tympanic membrane

3. Tympanic Membrane (Eardrum): at end of

external canal; vibrates in response to sound &

transmits vibrations to middle ear

Middle Ear

1. Ossicles

a. 3 small bones: malleus (Hammer) attached

to tympanic membrane, incus (anvil), stapes

(stirrup)

b. 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 between the middle ear & the

inner ear)

2. Eustachian Tube: connects nasopharynx &

middle ear; bring air into middle ear, thus

equalizing pressure on both sides of eardrum

Inner Ear

1. Cochlea

Controls hearing

Contains Organ of Corti (the true organ of

hearing): the receptor end-organ for

hearing

Transmit sound waves from the oval

window & initiates nerve impulses carried

by cranial nerve VIII (acoustic branch) to

the brain (temporal lobe of cerebrum)

2. Vestibular Apparatus

Organ of balance

Composed of three semicircular canals & the

utricle

3. Endolymph & Perilymph

For static equilibrium

4. Mastoid air cells Air filled spaces in temporal bone in skull

Disorder of the Ear

Otosclerosis

Formation of new spongy bone in the

labyrinth of the ear causing fixation of the

stapes in the oval window

This prevent transmission of auditory

vibration to the inner ear

Predisposing Factor

1. Found more often in women

Cause

1. Unknown / idiopathic

2. There is familial tendency

3. Ear trauma & surgery

S/sx

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

Removal of diseased portion of stapes &

replacement with prosthesis to conduct

vibrations from the middle ear to inner ear

Usually performed under local anesthesia

Used to treat otoscrlerosis

Nursing Intervention Pre-op

1. Provide general pre-op nursing care, including

an explanation of post-op expectation

2. Explain to the client that hearing may

improve during surgery & then decrease due

to edema & packing

Nursing Intervention Post-op

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1. Position the client according to the surgeon’s

orders (possibly with operative ear uppermost

to prevent displacement of the graft)

2. Have the client deep breathe every 2 hours

while in bed, but no coughing

3. Elevate side rails; assist the client with

ambulation & move slowly: may have some

vertigo

4. Administer medication as ordered:

Analgesic

Antibiotics

Anti-emetics

Anti-motion sickness drug: Meclesine Hcl

(Bonamine)

5. Check for dressing frequently for excessive

drainage or bleeding

6. Assess facial nerve function: Ask the client to

do the ff:

Wrinkle forehead

Close eyelids

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

8. 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 tract infection is present

d. Placement of cotton balls in auditory

meatus after packing is removed; change

twice daily

Meniere’s Disease

Disease of the inner ear resulting from dilatation

of the endolymphatic system & increase volume

of endolymph

Characterized by recurrent & usually progressive

triad of symptoms: vertigo, tinnitus, hearing loss

Predisposing Factor

1. Incidence highest between ages 30 & 60

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:

Atropine (decreases autonomic nervous

system activity)

Diazepam (Valium)

Fentanyl & Droperidol (Innovar)

2. Chronic:

a. Drug Therapy:

Vasodilators (nicotinic Acid)

Diuretics

Mild sedative or tranquilizers:

Diazepam (Valium)

Antihistamines: Diphenhydramine

(Benadryl)

Meclizine (antivert)

b. Diet:

Low sodium diet

Restricted fluid intake

Restrict caffeine & nicotine

3. Surgery:

a. Surgical destruction of labyrinth causing

loss of vestibular & cochlear function (if

disease is unilateral)

b. Intracranial division of vestibular portion of

cranial nerve VIII

c. Endolymphatic sac decompression or

shunt to equalize pressure in

endolymphatic space

Nursing Intervention

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:

a. Use of medication & side effects

b. Low sodium diet & decrease fluid intake

c. Importance of eliminating smoking

Overview of Anatomy & Physiology of Endocrine

System

Endocrine System

Is composed of an interrelated complex of glands

(Pituitary G, Adrenal G, Thyroid G, Parathyroid G,

Islets of langerhans of the pancreas, Ovaries &

Testes) that secretes a variety of hormones

directly into the bloodstream.

Its major function, together with the nervous

system: is to regulate body function

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Hormones Regulation

1. Hormones: chemical substance that acts s

messenger to specific cells & organs (target

organs), stimulating & inhibiting various

processes

Two Major Categories

a. Local: hormones with specific effect in the

area of secretion (ex. Secretin,

cholecystokinin, panceozymin [CCK-PZ])

b. General: hormones transported in the blood

to distant sites where they exert their effects

(ex. Cortisol)

2. Negative Feedback Mechanisms: major means of

regulating hormone levels

a. Decreased concentration of a circulating

hormones triggers production of a stimulating

hormones from pituitary gland; this hormones

in turn stimulates its target organ to produce

hormones

b. Increased concentration of a hormones

inhibits production of the stimulating

hormone, resulting in decreased secretion of

the target organ hormone

3. Some hormones are controlled by changing

blood levels of specific substances (ex. Calcium,

glucose)

4. Certain hormones (ex. Cortisol or female

reproductive hormones) follow rhythmic patterns

of secretion

5. Autonomic & CNS control (pituitary-hypothalamic

axis): hypothalamus controls release of the

hormones of the anterior pituitary gland through

releasing & inhibiting factors that stimulate or

inhibits hormone secretions

Hormone Function

Endocrine G Hormone Functions

Pituitary G

Anterior lobe : TSH : stimulate

thyroid G to release thyroid hormones

: ACTH : stimulate

adrenal cortex to

produce &

release

adrenocoticoids

: FSH, LH : stimulate

growth, maturation, & function of primary

& secondary sex

organ

: GH, Somatotropin : stimulate

growth of body tissues & bones

: Prolactin or LTH : stimulate

development of mammary gland &

Lactation

Posterior lobe : ADH : regulates H2O

metabolism; release during stress

Or in response to

an increase in plasma

osmolality

To stimulate

reabsorption of H2O &

decrease urine

Output

: Oxytocin : stimulate

uterine contractions during delivery & the

Release of milk

in lactation

Intermediate lobe : MSH : affects

skin pigmentation

Adrenal G

Adrenal Cortex : Mineralocorticoid : regulate fluid &

electrolyte balance; stimulate

(ex. Aldosterone)

reabsoption of sodium,

chloride, & H2O; stimulate

potassium

excretion

: Glucocorticoids : increase

blood glucose level by increasing rate of

(ex. Cortisol,

glyconeogenesis; increase CHON catabolism;

increase

corticosterone)

mobilization of fatty acid; promote sodium & H2O

retention;

anti-inflammatory effect; aid body in coping

with stress

: Sex Hormones : influence

development of secondary sex

(androgens, estrogens

characeristics

progesterones)

Adrenal Medulla: Epinephrine, : function

in acute stress; increase HR, BP; dilates

Norepinephrine

bronchioles; convert glycogen

to glucose when

Needed by the

muscles for energy

Thyroid G : T3, T4 : regulate

metabolic rate; CHO, fats, & CHON

Metabolism; aid

in regulating physical & mental

Growth &

development

: Thyrocalcitonin : lowers

serum calcium & phosphate levels

Parathyroid G : PTH : regulates

serum calcium & phosphate levels

Pancreas (islets of

Langerhans)

Beta Cells : Insulin :

allows glucose to diffuse across cell membrane;

Converts glucose

to glycogen

Alpha Cells : Glucagon : increase

blood glucose by causing glyconeogenisis

& glycogenolysis

in the liver;

secreted in

response to

low blood sugar

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Ovaries : Estrogen, Progesterone :

development of secondary sex characteristics in the

Female,

maturation of sex organ, sexual functioning

Maintenance of

pregnancy

Testes : Testosterone :

development of secondary sex characteristics in the

Male maturation

of the sex organs, sexual functioning

Pituitary Gland (Hypophysis)

Located in sella turcica at the base of brain

“Master Gland” or master clock

Controls all metabolic function of body

3 Lobes of Pituitary Gland

1. Anterior Lobe PG (Adenohypophysis)

a. Secretes tropic hormones (hormones that

stimulate target glands to produce their

hormones): adrenocorticotropic H (ACTH),

thyroid-stimulating H (TSH), follicle-

stimulating H (FSH), luteinizing H (LH)

ACTH: promotes development of

adrenal cortex

LH: secretes estrogen

FSH: secretes progesterone

b. Also secretes hormones that have direct

effects on tissues: somatotropic or growth H,

prolactin

Somatotropic / GH: promotes

elongation of long bones

Hyposecretion of GH: among children

results to dwarfism

Hypersecretion of GH: among children

results to gigantism

Hypersecretion of GH: among adults

results to acromegaly (square face)

DOC: Ocreotide (Sandostatin)

Prolactin: promotes development of

mammary gland; with help of oxytocin

it initiates milk let down reflex

c. Regulated by hypothalamic releasing &

inhibiting factors & by negative feedback

system

2. Posterior Lobe PG (Neurohypophysis)

Does not produce hormones

Store & release anti-diuretic hormones (ADH)

& oxytocin produced by hypothalamus

Secretes hormones oxytocin (promotes

uterine contractions preventing bleeding or

hemorrhage)

Administer oxytocin immediately after

delivery to prevent uterine atony.

Initiates milk let down reflex with help of

hormone prolactin

3. Intermediate Lobe PG

Secretes melanocytes stimulating H (MSH)

MSH: for skin pigmentation

Hyposecretion of MSH: results to albinism

Hypersecretion of MSH: results to vitiligo

2 feared complications of albinism:

1. Lead to blindness due to severe

photophobia

2. Prone to skin cancer

Adrenal Glands

Two small glands, one above each kidney;

Located at top of each kidney

2 Sections of Adrenal Glands

1. Adrenal Cortex (outer portion): produces

mineralocorticoids, glucocorticoids, sex

hormones

3 Zones/Layers

Zona Fasciculata: secretes glucocortocoids

(cortisol): controls glucose metabolism:

Sugar

Zona Reticularis: secretes traces of

glucocorticoids & androgenic hormones:

promotes secondary sex characteristics:

Sex

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 Pheochromocytoma (adrenal medulla):

Increase secretion of norepinephrine:

Leading to hypertension which is

resistant to pharmacological agents

leading to CVA: Use beta-blockers

Thyroid Gland

Located in anterior portion of the neck

Consist of 2 lobes connected by a narrow

isthmus

Produces thyroxine (T4), triiodothyronine (T3),

thyrocalcitonin

3 Hormones Secreted:

T3: 3 molecules of iodine (more potent)

T4: 4 molecule of iodine

T3 and T4 are metabolic hormone:

increase brain activity; promotes

cerebration (thinking); increase V/S

Thyrocalcitonin: antagonizes the effects of

parathormone to promote calcium

reabsorption.

Parathyroid Gland

4 small glands located in pairs behind the thyroid

gland

Produce parathormone (PTH)

Promotes calcium reabsorption

Pancreas

Located behind the stomach

Has both endocrine & exocrine function (mixed

gland)

Consist of Acinar Cells (exocrine gland): which

secretes pancreatic juices: that aids in digestion

Islets of langerhans (alpha & beta cells) involved

in endocrine function:

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Alpha Cell: produce glucagons: (function:

hyperglycemia)

Beta Cell: produce insulin: (function:

hypoglycemia)

Delta Cells: produce somatostatin: (function:

antagonizes the effects of growth hormones)

Gonads

Ovaries: located in pelvic cavity; produce

estrogen & progesterone

Testes: located in scrotum; produces

testosterone

Pineal Gland

Secretes melatonin

Inhibits LH secretion

It controls & regulates circadian rhythm (body

clock)

Diabetes Incipidus (DI)

DI: dalas-ihi

Decrease of anti-diuretic hormone (ADH)

Hyposecretion of ADH

Hypofunction of the posterior pituitary gland

(PPG) resulting in deficiency of ADH

Characterized by excessive thirst & urination

Anti-diuretic Hormone: Pitressin (Vasopressin)

Function: prevents urination thereby conserving water

Note: Alcohol inhibits release of ADH

Predisposing Factor

1. Related to pituitary surgery

2. Trauma

3. Inflammation

4. Presence of tumor

S/sx

1. Severe polyuria with low specific gravity

2. Polydipsia (excessive thirst)

3. Fatigue

4. Muscle weakness

5. Irritability

6. Weight loss

7. Hypotension

8. Signs of dehydration

a. Adult: thirst; Children: tachycardia

b. Agitation

c. Poor Skin turgor

d. Dry mucous membrane

9. Tachycardia, eventually shock if fluids is not

replaced

10.If left untreated results to hypovolemic shock

(late sign anuria)

Dx

1. Urine Specific Gravity (NV: 1.015 – 1.030): less

than 1.004

2. Serum Na: increase resulting to hypernatremia

3. H2O deprivation test: reveals inability to

concentrate urine

Nursing Intervention

1. 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

2. Monitor strictly V/S & observe for signs of

dehydration & hypovolemia

3. Administer hormone replacement as ordered:

a. Vasopressin (Pitressin) & Vasopressin Tannate

(Pitressin Tannate Oil): administered by IM

injection

Warm to body temperature before

giving

Shake tannate suspension to ensure

uniform dispersion

b. Lypressin (Diapid): nasal spray

4. Prevent complications: hypovolemic shock is the

most feared complication

5. Provide client teaching & discharge planning

concerning:

a. Lifelong hormone replacement: Lypressin

(Diapid) as needed to control polyuria &

polydipsia

b. Need to wear medic-alert bracelet

Syndrome of Inappropriate Anti-diuretic Hormone

Secretion (SIADH)

Hypersecretion of anti-diuretic hormone (ADH)

from the PPG even when the client has abnormal

serum osmolality

Predisposing Factors

1. Head injury

2. Related to presence of bronchogenic cancer

Initial sign of lung cancer is non productive

cough

Non invasive procedure is chest x-ray

3. Related to hyperplasia of pituitary gland

(increase size of organ brought about by increase

of number of cells)

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

Dx

1. Urine specific gravity: is increase

2. Serum Sodium: is decreased

Medical Management

1. Treat underlying cause if possible

2. Diuretics & fluid restriction

Nursing Intervention

1. Restrict fluid: to promote fluid loss & gradual

increase in serum Na

2. Administer medications as ordered:

a. Loop diuretics (Lasix)

b. Osmotic diuretics (Mannitol)

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

4. Weigh patient daily and assess for pitting edema

5. Monitor serum electrolytes & blood chemistries

carefully

6. Provide meticulous skin care

7. Prevent complications

HYPOTHYROIDISM

- all are decrease except weight and menstruation

- memory impairment

Signs and Symptoms

- there is loss of appetite but there is weight gain

- menorrhagia

- cold intolerance

- constipation

HYPERTHYROIDISM

- all are increase except weight and menstruation

Signs and Symptoms

- increase appetite but there is weight loss

- amenorrhea

- exophthalmos

Thyroid Disorder

Simple Goiter

Enlargement of thyroid gland due to iodine

deficiency

Enlargement of the thyroid gland not caused by

inflammation of neoplasm

Low level of thyroid hormones stimulate

increased secretion of TSH by pituitary; under

TSH stimulation the thyroid increases in size to

compensate & produce more thyroid hormone

Predisposing Factors

1. Endemic: caused by nutritional iodine deficiency,

most common in the “goiter belt” area, areas

where soil & H2O are deficient in iodine; occurs

most frequently during adolescence & pregnancy

Goiter belt area:

a. Midwest, northwest & great lakes region

b. Places far from sea

c. Mountainous regions

2. Sporadic: caused by

Increase intake of goitrogenic foods (contains

agent that decrease the thyroxine production:

pro-goitrin an anti-thyroid agent that has no

iodine). Ex. cabbage, turnips, radish,

strawberry, carrots, sweet potato, rutabagas,

peaches, peas, spinach, broccoli, all nuts

Soil erosion washes away iodine

Goitrogenic drugs:

a. Anti-Thyroid Agent: Propylthiouracil (PTU)

b. Large doses of iodine

c. Phenylbutazone

d. Para-amino salicylic acid

e. Lithium Carbonate

f. PASA (Aspirin)

g. Cobalt

3. Genetic defects that prevents synthesis of

thyroid hormones

S/sx

1. Enlarged thyroid gland

2. Dysphagia

3. Respiratory distress

4. Mild restlessness

Dx

1. Serum T4: reveals normal or below normal

2. Thyroid Scan: reveals enlarged thyroid gland.

3. Serum Thyroid Stimulating Hormone (TSH): is

increased (confirmatory diagnostic test)

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

increased

Medical Management

1. Drug Therapy:

Hormone replacement with levothyroxine

(Synthroid) (T4), dessicated thyroid, or

liothyronine (Cytomel) (T3)

Small dose of iodine (Lugol’s or potassium

iodide solution): for goiter resulting from

iodine deficiency

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

Nursing Intervention

1. Administer Replacement therapy as ordered:

a. Lugol’s Solution / SSKI (Saturated Solution of

Potassium Iodine)

Color purple or violet and administered via

straw to prevent staining of teeth.

4 Medications to be taken via straw:

Lugol’s, Iron, Tetracycline, Nitrofurantoin

(DOC: for pyelonephritis)

b. Thyroid Hormones:

Levothyroxine (Synthroid)

Liothyronine (Cytomel)

Thyroid Extracts

Nursing Intervention when giving Thyroid

Hormones:

1. Instruct client to take in the morning to

prevent insomnia

2. Monitor vital signs especially heart rate

because drug causes tachycardia and

palpitations

3. Monitor side effects:

Insomnia

Tachycardia and palpitations

Hypertension

Heat intolerance

2. Increase dietary intake of foods rich in iodine:

Seaweeds

Seafood’s like oyster, crabs, clams and

lobster but not shrimps because it contains

lesser amount of iodine.

Iodized salt: best taken raw because it is

easily destroyed by heat

3. Assist in surgical procedure of subtotal

thyroidectomy

30

30

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 medications; infection; trauma;

exposure to cold; use of sedatives, narcotics

or anesthetics

Predisposing Factors

1. Primary hypothyroidism: atrophy of the gland

possibly caused by an autoimmune process

2. Secondary hypothyroidism: caused by

decreased stimulation from pituitary TSH

3. Iatrogenic: surgical removal of the gland or

over treatment of hyperthyroidism with drugs

or radioactive iodine; disease caused by

medical intervention such as surgery

4. Related to atrophy of thyroid gland due to

trauma, presence of tumor, inflammation

5. Iodine deficiency

6. Autoimmune (Hashimotos Disease)

7. Occurs more often to women ages 30 & 60

S/sx

1. Loss of appetite: but there is wt gain

2. Anorexia

3. Weight gain: which promotes lipolysis leading

to atherosclerosis and MI

4. Constipation

5. Cold intolerance

6. Dry scaly skin

7. Spares hair

8. Brittleness of nails

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

a. Hypotension

b. Bradycardia

c. Bradypnea

d. Hypothermia

10.Weakness and fatigue

11.Slowed mental processes

12.Dull look

13.Slow clumsy movement

14.Lethargy

15.Generalized interstitial non-pitting edema

(Myxedema)

16.Hoarseness of voice

17.Decrease libido

18.Memory impairment

19.Psychosis

20.Menorrhagia

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)

Dessicated thyroid

Liothyronine (Cytomel)

2. Myxedema coma is a medical emergency:

IV thyroid hormones

Correction of hypothermina

Maintenance of vital function

Treatment of precipitating cause

Nursing Intervention

1. Monitor strictly V/S & I&O, daily weights;

observe for edema & signs of cardiovascular

complication & to determine presence of

myxedema coma

2. Administer thyroid hormone replacement

therapy as ordered & monitor effects:

a. Observe signs of thyrotoxicosis:

Tachycardia & palpitation

N/V

Diarrhea

Sweating

Tremors

Agitation

Dyspnea

b. Increase dosage gradually, especially in

clients with cardiac complication

3. Provide comfortable and warm environment:

due to cold intolerance

4. Provide a low calorie diet

5. Avoid the use of sedatives; reduce the dose of

any sedatives, narcotics, or anesthetic agent

by half as ordered

6. Provide meticulous skin care: to prevent skin

breakdown

7. Increase fluid & food high in fiber: to prevent

constipation; administer stool softener as

ordered

8. Observe for signs of myxedema coma;

provide appropriate nursing care

a. Administer medication as ordered

b. Maintain vital functions:

Correct hypothermia

Maintain adequate ventilation

9. Myxedema coma:

A complication of hypothyroidism & an

emergency case

A severe form of hypothyroidism is

characterized by:

Severe hypotension

Bradycardia

Bradypnea

Hypoventilation

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31

Hyponatremia

Hypoglycemia

Hypothermia

Leading to progressive stupor and

coma

Nursing Management for Myxedema Coma

1. Assist in mechanical ventilation

2. Administer thyroid hormones as ordered

3. Administer IVF replacement isotonic fluid

solution as ordered / Force fluids

10.Provide client health teaching and discharge

planning concerning:

a. Thyroid hormone replacement

b. Importance of regular follow-up care

c. Need in additional protection in cold

weather

d. Measures to prevent constipation

e. Avoid precipitating factors leading to

myxedema coma & hypovolemic shock

f. Stress & infection

g. Use of anesthetics, narcotics, and

sedatives

Hyperthyroidism

Secretion of excessive amounts of thyroid

hormone in the blood causes an increase in

metabolic process

Increase in T3 and T4

Grave’s Disease or Thyrotoxicosis

Increase in all V/S except wt & menses

Predisposing Factors

1. More often seen in women between ages 30

& 50

2. Autoimmune: involves release of long acting

thyroid stimulator causing exopthalmus

(protrusion of eyeballs) enopthalmus (late

sign of dehydration among infants)

3. Excessive iodine intake

4. Related to hyperplasia (increase size of TG)

S/sx

1. Increase appetite (hyperphagia): but there is

weight loss

2. Heat intolerance

3. Weight loss

4. Diarrhea: increase motility

5. Increased in all V/S: except wt & menses

a. Tachycardia

b. Increase systolic BP

c. Palpitation

6. Warm smooth skin

7. Fine soft hair

8. Pliable nails

9. CNS involvement

a. Irritability & agitation

b. Restlessness

c. Tremors

d. Insomnia

e. Hallucinations

f. Sweating

g. Hyperactive movement

10.Goiter

11.PS: Exopthalmus (protrusion of eyeballs)

12.Amenorrhea

Dx

1. Serum T3 and T4: is increased

2. RAIU (Radio Active Iodine Uptake): is

increased

3. Thyroid Scan: reveals an enlarged thyroid

gland

Medical Management

1. Drug Therap:

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

methimazole (Tapazole): blocke synthesis

of thyroid hormone; toxic effect include

agranulocytosis

b. Adrenergic Blocking Agent: Propranolol

(Inderal): used to decrease sympathetic

activity & alleviate symptoms such as

tachycardia

2. Radioactive Iodine Therapy

a. Radioactive isotope of iodine (ex. 131I):

given to destroy the thyroid gland, thereby

decreasing production of thyroid hormone

b. Used in middle-aged or older clients who

are resistant to, or develop toxicity from

drug therapy

c. Hypothyroidism is a potential complication

3. Surgery: Thyroidectomy performed in younger

client for whom drug therapy has not been

effective

Nursing Intervention

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

2. Administer anti-thyroid medications as

ordered:

a. Propylthiouracil (PTU)

b. Methimazole (Tapazole)

3. Provide for period of uninterrupted rest:

a. Assign a private room away from

excessive activity

b. Administer medication to promote sleep as

ordered

4. Provide comfortable and cold environment

5. Minimized stress in the environment

6. Encourage quiet, relaxing diversional

activities

7. Provide dietary intake that is high in CHO,

CHON, calories, vitamin & minerals with

supplemental feeding between meals & at

bedtime; omit stimulant

8. Observe for & prevent complication

a. Exophthalmos: protects eyes with dark

glasses & artificial tears as ordered

b. Thyroid Storm

9. Provide meticulous skin care

10.Maintain side rails

11.Provide bilateral eye patch to prevent drying

of the eyes

12.Assist in surgical procedures subtotal

Thyroidectomy:

13.Provide client teaching & discharge planning

concerning:

a. Need to recognized & report S/sx of

agranulocytosis (fever, sore throat, skin

rash): if taking anti-thyroid drugs

32

32

TRIAD SIGNS

b. S/sx of hyperthyroidism & hypothyroidism

Thyroid Storm

Uncontrolled & potentially life-threatening

hyperthyroidism caused by sudden & excessive

release of thyroid hormone into the bloodstream

Precipitating Factors

1. Stress

2. Infection

3. unprepared thyroid surgery

S/sx

1. Apprehension

2. Restlessness

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

4. Tahchycardia

5. HF

6. Respiratory Distress

7. Delirium

8. Coma

Nursing Intervention

1. Maintain patent airway & adequate

ventilation; administer O2 as ordered

2. Administer IV therapy as ordered

3. Administer medication as ordered:

a. Anti-thyroid drugs

b. Corticosteroids

c. Sedatives

d. Cardiac Drugs

Thyroidectomy

Partial or total removal of thyroid gland

Indication:

Subtotal Thyroidectomy: hyperthyroidism

Total Thyroidectomy: thyroid cancer

Nursing Intervention Pre-op

1. Ensure that the client is adequately prepared

for surgery

a. Cardiac status is normal

b. Weight & nutritional status is normal

2. Administer anti-thyroid drugs as ordered: to

suppressed the production of thyroid

hormone & to prevent thyroid storm

3. Administer iodine preparation Lugol’s Solution

(SSKI) or Potassium Iodide Solution: to

decrease vascularity of the thyroid gland & to

prevent hemorrhage.

Nursing Intervention Post-Op

1. Monitor V/S & I&O

2. Check dressing for signs of hemorrhage:

check for wetness behind the neck

3. Place client in semi-fowlers position & support

head with pillow

4. Observe for respiratory distress secondary to

hemorrhage, edema of glottis, laryngeal

nerve damage, or tetany: keep tracheostomy

set, O2 & suction nearby

5. Assess for signs of tetany: due to

hypocalcemia: due to secondary accidental

removal of parathyroid glands: keep Calcium

Gluconate available:

Watch out for accidental removal of

parathyroid which may lead to

hypocalcemia (tetany)

Classic S/sx of Tetany

Positive trousseu’s sign

Positive chvostek sign

Observe for arrhythmia, seizure: give

Calcium Gluconate IV slowly as ordered

6. Ecourage clients voice to rest:

a. Some hoarseness is common

b. Check every 30-60 min for extreme

hoarseness or any accompanying

respiratory distress

7. Observe for signs of thyroid storm /

thyrotoxicosis: due to release of excessive

amount of thyroid hormone during surgery

Agitation

Hyperthermia

Tachycardia

Administer medications as ordered:

Anti Pyretics

Beta-blockers

Monitor strictly vital signs, input and

output and neuro check.

Maintain side rails

Offer TSB

8. Administer IV fluids as ordered: until the client

is tolerating fluids by mouth

9. Administer analgesics as ordered: for

incisional pain

10.Relieve discomfort from sore throat:

a. Cool mist humidifier to thin secretions

b. Administer analgesic throat lozenges

before meals prn as ordered

11.Encourage coughing & deep breathing every

hour

12.Assist the client with ambulation: instruct the

client to place the hands behind the neck: to

decrease stress on suture line if added

support is necessary

13.Hormonal replacement therapy for lifetime

14.Watch out for accidental laryngeal damage

which may lead to hoarseness of voice:

encourage client to talk/speak immediately

after operation and notify physician

15.Provide client teaching& discharge planning

concerning:

a. S/sx of hyperthyroidism & hypothyroidism

b. Self administration of thyroid hormone: if

total thyroidectomy is performed

c. Application of lubricant to the incision once

suture is removed

d. Perform ROM neck exercise 3-4 times a

day

e. Importance of follow up care with periodic

serum calcium level

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33

Hypoparathyroidism

Disorder characterized by hypocalcemia resulting

from a deficiency of parathormone (PTH)

production

Decrease secretion of parathormone: leading to

hypocalcemia: resulting to hyperphospatemia

If calcium decreases phosphate increases

Predisposing Factors

1. May be hereditary

2. Idiopathic

3. Caused by accidental damage to or removal

of 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

e. Seizure: feared complications

f. Cardiac arrhythmia: feared complications

g. Numbness

h. Positive trousseu’s sign: carpopedal spasm

i. Positive chvostek sign

2. Chronic hypocalcemia (tetany)

a. Fatigue

b. Weakness

c. Muscle cramps

d. Personality changes

e. Irritability

f. Memory impairment

g. Agitation

h. Dry scaly skin

i. Hair loss

j. Loss of tooth enamel

k. Tremors

l. Cardiac arrhythmias

m. Cataract formation

n. Photophobia

o. Anorexia

p. N/V

Diagnostic Procedures

1. Serum Calcium level: decreased (normal

value: 8.5 – 11 mg/100 ml)

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

Nursing Management

1. Administer medications as ordered such as:

a. Acute Tetany: Calcium Gluconate slow IV

drip as ordered

b. Chronic Tetany:

Oral calcium preparation: Calcium

Gluconate, Calcium Lactate, Calcium

Carbonate (Os-Cal)

Large dose of vitamin D (Calciferol): to

help absorption of calcium

CHOLECALCIFEROL ARE DERIVED FROM

Drug Diet (Calcidiol)

Sunlight (Calcitriol)

Phosphate Binder: Aluminum Hydroxide

Gel (Amphogel) or aluminum carbonate

gel, basic (basaljel): to decrease

phosphate levels

ANTACID

A.A.C

MAD

Aluminum

Magnesium

Containing

Containing

Antacids

Antacids

Aluminum

Hydroxide

Gel

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. Monitor signs of hoarseness or stridor; check

for signs for Chvostek’s & Trousseau’s sign

6. Keep emergency equipment (tracheostomy

set, injectable Calcium Gluconate) at bedside:

for presence of laryngospasm

7. For tetany or generalized muscle cramp: may

use rebreathing bag or paper bag to produce

mild respiratory acidosis: to promote increase

ionized Ca levels

8. Monitor serum calcium & phosphate level

9. Provide high-calcium & low-phosphorus diet

10.Provide client teaching & discharge planning

concerning:

a. Medication regimen: oral calcium

preparation & vit D to be taken with meal

to increase absorption

b. Need to recognized & report S/sx of

hypo/hypercalcemia

c. Importance of follow-up care with periodic

serum calcium level

d. Prevent complications

e. Hormonal replacement therapy for lifetime

Hyperparathyroidism

34

34

Increase secretion of PTH that results in an

altered state of calcium, phosphate & bone

metabolism

Decrease parathormone

Hypercalcemia: bone demineralization leading to

bone fracture (calcium is stored 99% in bone and

1% blood)

Kidney stones

Predisposing Factors

1. Most commonly affects women between ages

35 & 65

2. Primary Hyperparathyroidism: caused by

tumor & hyperplasia of parathyroid gland

3. Secondary Hyperparathyroidism: cause by

compensatory over secretion of PTH in

response to hypocalcemia from:

a. Children: Ricketts

b. Adults: Osteomalacia

c. Chronic renal disease

d. Malabsorption syndrome

S/sx

1. Bone pain (especially at back); Bone

demineralization; Pathologic fracture

2. Kidney stones; Renal colic; Polyuria;

Polydipsia; Cool moist skin

3. Anorexia; N/V; Gastric Ulcer; Constipation

4. Muscle weakness; Fatigue

5. Irritability / Agitation; Personality changes;

Depression; Memory impairment

6. Cardiac arrhythmias; HPN

Dx

1. Serum Calcium: is increased

2. Serum Phosphate: is decreased

3. Skeletal X-ray of long bones: reveals bone

demineralization

Nursing Intervention

1. Administer IV infusions of normal saline

solution & give diuretics as ordered:

2. Monitor I&O & observe fluid overload &

electrolytes imbalance

3. Assist client with self care: Provide careful

handling, Moving, Ambulation: to prevent

pathologic fracture

4. Monitor V/S: report irregularities

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

kidney stones

6. Provide acid-ash juices (ex. Cranberry, orange

juice): to acidify urine & prevent bacterial

growth

7. Strain urine: using gauze pad: for stone

analysis

8. Provide low-calcium & high-phosphorus diet

9. Provide warm sitz bath: for comfort

10.Administer medications as ordered: Morphine

Sulfate (Demerol)

11.Maintain side rails

12.Assist in surgical procedure:

Parathyroidectomy

13.Provide client teaching & discharge planning

concerning:

a. Need to engage in progressive ambulatory

activities

b. Increase fluid intake

c. Use of calcium preparation & importance

of high-calcium diet following a

parathyroidectomy

d. Prevent complications: renal failure

e. Hormonal replacement therapy for lifetime

f. Importance of follow up care

Addison’s Disease

Primary adrenocortical insufficiency;

hypofunction of the adrenal cortex causes

decrease secretion of the mineralcorticoids,

glucocorticoids, & sex hormones

Hyposecretion of adrenocortical hormone leading

to:

Metabolic disturbance: Sugar

Fluid and electrolyte imbalance: Na, H2O, K

Deficiency of neuromascular function: Salt,

Sex

Predisposing Factors

1. Relatively rare disease caused by:

Idiopathic atrophy of the adrenal cortex:

due to an autoimmune process

Destruction of the gland secondary to TB

or fungal infections

S/sx

1. Fatigue, Muscle weakness

2. Anorexia, N/V, abdominal pain, weight loss

3. History of hypoglycemic reaction /

Hypoglycemia: tremors, tachycardia,

irritability, restlessness, extreme fatigue,

diaphoresis, depression

4. Hyponatremia: hypotension, signs of

dehydration, weight loss, weak pulse

5. Decrease tolerance to stress

6. Hyperkalemia: agitation, diarrhea, arrhythmia

7. Decrease libido

8. Loss of pubic and axillary hair

9. Bronze like skin pigmentation

Dx

1. FBS: is decreased (normal value: 80 – 100

mg/dl)

2. Plasma Cortisol: is decreased

3. Serum Sodium: is decrease (normal value:

135 – 145 meq/L)

4. Serum Potassium: is increased (normal value:

3.5 – 4.5 meq/L)

Nursing Intervention

1. Administer hormone replacement therapy as

ordered:

a. Glucocorticoids: stimulate diurnal rhythm

of cortisol release, give 2/3 of dose in early

morning & 1/3 of dose in afternoon

Corticosteroids: Dexamethasone

(Decadrone)

Hydrocortisone: Cortisone (Prednisone)

b. Mineralocorticoids:

Fludrocortisone Acetate (Florinef)

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35

Nursing Management when giving steroids

1. Instruct client to take 2/3 dose in the

morning and 1/3 dose in the afternoon to

mimic the normal diurnal rhythm

2. Taper dose (withdraw gradually from drug)

3. Monitor side effects:

Hypertension

Edema

Hirsutism

Increase susceptibility to infection

Moon face appearance

2. Monitor V/S

3. Decrease stress in the environment

4. Prevent exposure to infection

5. Provide rest period: prevent fatigue

6. Weight daily

7. Provide small frequent feeding of diet:

decrease in K, increase cal, CHO, CHON, Na:

to prevent hypoglycemia, & hyponatremia &

provide proper nutrition

8. Monitor I&O: to determine presence of

addisonian crisis (complication of addison’s

disease)

9. Provide meticulous skin care

10.Provide client teaching & discharge planning

concerning:

a. Disease process: signs of adrenal

insufficiency

b. Use of prescribe medication for lifelong

replacement therapy: never omit

medication

c. Need to avoid stress, trauma & infection:

notify the physician if these occurs as

medication dosage may need to be

adjusted

d. Stress management technique

e. Diet modification

f. Use of salt tablet (if prescribe) or ingestion

of salty foods (potato chips): if

experiencing increase sweating

g. Importance of alternating regular exercise

with rest periods

h. Avoidance of strenuous exercise especially

in hot weather

i. Avoid precipitating factor: leading to

addisonian crisis: stress, infection, sudden

withdrawal to steroids

j. Prevent complications: addisonian crisis,

hypovolemic shock

k. Importance of follow up care

Addisonian Crisis

Severe exacerbation of addison’s diseasecaused

by acute adrenal insufficiency

Predisposing Factors

1. Strenuous activity

2. Stress

3. Trauma

4. Infection

5. Failure to take prescribe medicine

6. Iatrogenic:

Surgery of pituitary gland or adrenal

gland

Rapid withdrawal of exogenous steroids

in a client on long-term steroid therapy

S/sx

1. Generalized muscle weakness

2. Severe hypotension

3. Hypovolemic shock: vascular collapse

4. Hyponatremia: leading to progressive

stupor and coma

Nursing Intervention

1. Assist in mechanical ventilation

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

plasma) as ordered: to treat vascular

collapse

3. Administer IV glucocorticoids:

Hydrocortisone (Solu-Cortef) &

vasopressors as ordered

4. Force fluids

5. If crisis precipitate by infection: administer

antibiotics as ordered

6. Maintain strict bed rest & eliminate all

forms of stressful stimuli

7. Monitor V/S, I&O & daily weight

8. Protect client from infection

9. Provide client teaching & discharge

planning concerning: same as addison’s

disease

Cushing Syndrome

Condition resulting from excessive secretion of

corticosteroids, particularly glucocorticoid

cortisol

Hypersecretion of adrenocortical hormones

Predisposing Factors

1. Primary Cushing’s Syndrome: caused by

adrenocortical tumors or hyperplasia

2. Secondary Cushing’s Syndrome (also called

Cushing’s disease): caused by functioning

pituitary or nonpituitary neoplasm secreting

ACTH, causing increase secretion of

glucocorticoids

3. Iatrogenic: cause by prolonged use of

corticosteroids

4. Related to hyperplasia of adrenal gland

5. Increase susceptibility to infections

S/sx

1. Muscle weakness

2. Fatigue

3. Obese trunk with thin arms & legs

4. Muscle wasting

5. Irritability

6. Depression

7. Frequent mood swings

8. Moon face

9. Buffalo hump

10.Pendulous abdomen

11.Purple striae on trunk

12.Acne

13.Thin skin

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36

14.Signs of masculinization in women: menstrual

dysfunction, decrease libido

15.Osteoporosis

16.Decrease resistance to infection

17.Hypertension

18.Edema

19.Hypernatremia

20.Weight gain

21.Hypokalemia

22.Constipation

23.U wave upon ECG (T wave hyperkalemia)

24.Hirsutis

25.Easy bruising

Dx

1. FBS: is increased

2. Plasma Cortisol: is increased

3. Serum Sodium: is increased

4. Serum Potassium: is decreased

Nursing Intervention

1. Maintain muscle tone

a. Provide ROM exercise

b. Assist in ambulation

2. Prevent accidents fall & provide adequate rest

3. Protect client from exposure to infection

4. Maintain skin integrity

a. Provide meticulous skin care

b. Prevent tearing of the skin: use paper tape

if necessary

5. Minimize stress in the environment

6. Monitor V/S: observe for hypertension &

edema

7. Monitor I&O & daily weight: assess for pitting

edema: Measure abdominal girth: notify

physician

8. Provide diet low in Calorie & Na & high in

CHON, K, Ca, Vitamin D

9. Monitor urine: for glucose & acetone;

administer insulin as ordered

10.Provide psychological support & acceptance

11.Prepare client for hypophysectomy or

radiation: if condition is caused by a pituitary

tumor

12.Prepare client for Adrenalectomy: if condition

is caused by an adrenal tumor or hyperplasia

13.Restrict sodium intake

14.Administer medications as ordered:

Spironolactone (Aldactone): potassium

sparring diuretics

15.Provide client teaching & discharge planning

concerning:

a. Diet modification

b. Importance of adequate rest

c. Need to avoid stress & infection

d. Change in medication regimen (alternate

day therapy or reduce dosage): if caused

of condition is prolonged corticosteroid

therapy

e. Prevent complications (DM)

f. Hormonal replacement for lifetime:

lifetime due to adrenal gland removal: no

more corticosteroid!

g. Importance of follow up care

Diabetes Mellitus (DM)

Represent a heterogenous group of chronic

disorders characterized by hyperglycemia

Hyperglycemia: due to total or partial insulin

deficiency or insensitivity of the cells to insulin

Characterized by disorder in the metabolism of

CHO, fats, CHON, as well as changes in the

structure & function of blood vessels

Metabolic disorder characterized by non

utilization of carbohydrates, protein and fat

metabolism

Pathophysiology

Lack of insulin causes hyperglycemia (insulin is

necessary for the transport of glucose across the cell

membrane) = Hyperglycemia leads to osmitic diuresis

as large amounts of glucose pass through the kidney

result polyuria & glycosuria = Diuresis leads to cellular

dehydration & F & E depletion causing polydipsia

(excessive thirst) = Polyphagia (hunger & increase

appetite) result from cellular starvation = The body

turns to fat & CHON for energy but in the absence of

glucose in the cell fat cannot be completely

metabolized & ketones (intermediate products of fat

metabolism) are produced = This leads to ketonemia,

ketonuria (contributes to osmotic diuresis) & metabolic

acidosis (ketones are acid bodies) = Ketone sacts as

CNS depressants & can cause coma = Excess loss of F

& E leads to hypovolemia, hypotension, renal failure &

decease blood flow to the brain resulting in coma &

death unless treated.

MAIN

FOODSTUFF

ANABOLIS

M

CATABOLISM

1. CHO

2. CHON

3. Fats

Glucose

Amino

Acids

Fatty Acids

Glycogen

Nitrogen

Free Fatty

Acids

: cholesterol

: ketones

HYPERGLYCEMIA

Increase osmotic diuresis

Glycosuria

Polyuria

Cellular starvation: weight loss Cellular dehydration

Stimulates the appetite / satiety center

Stimulates the thirst center

(Hypothalamus)

(Hypothalamus)

Polyphagia

Polydypsia

* liver has glycogen that undergo

glycogenesis/glycogenolysis

GLUCONEOGENESIS

Formation of glucose from non-CHO sources

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37

Increase protein formation

Negative Nitrogen balance

Tissue wasting (Cachexia)

INCREASE FAT CATABOLISM

Free fatty acids

Cholesterol

Ketones

Atherosclerosis

Diabetic Keto Acidosis

Hypertension

Acetone Breath Kussmaul’s Respiration

odor MI CVA

DeathDiabetic Coma

Classification Of DM

1. Type I Insulin-dependent Diabetes Mellitus

(IDDM)

Secondary to destruction of beta cells in the

islets of langerhans in the pancreas resulting

in little of no insulin production

Non-obese adults

Requires insulin injection

Juvenile onset type (Brittle disease)

Incidence Rate

1. 10% general population has Type I DM

Predisposing Factors

1. Autoimmune response

2. Genetics / Hereditary (total destruction of

pancreatic cells)

3. Related to viruses

4. Drugs: diuretics (Lasix), Steroids, oral

contraceptives

5. Related to carbon tetrachloride toxicity

S/sx

1. Polyuria

2. Polydipsia

3. Polyphagia

4. Glucosuria

5. Weight loss

6. Fatigue

7. Anorexia

8. N/V

9. Blurring of vision

10.Increase susceptibility to infection

11.Delayed / poor wound healing

Dx

1. FBS:

a. A level of 140 mg/dl of greater on at two

occasions confirms DM

b. May be normal in Type II DM

2. Postprandial Blood Sugar: elevated

3. Oral Glucose Tolerance Test (most sensitve

test): elevated

4. Glycosolated Hemoglobin (hemoglobin A1c):

elevated

Medical Management

1. Insulin therapy

2. Exercise

3. Diet:

a. Consistency is imperative to avoid

hypoglycemia

b. High-fiber, low-fat diet also recommended

4. Drug therapy:

a. Insulin:

Short Acting: used in treating

ketoacidosis; during surgery, infection,

trauma; management of poorly

controlled diabetes; to supplement

long-acting insulins

Intermediate: used for maintenance

therapy

Long Acting: used for maintenance

therapy in clients who experience

hyperglycemia during the night with

intermediate-acting insulin

b. Insulin preparation can consist of mixture

of pure pork, pure beef, or human insulin.

Human insulin is the purest insulin & has

the lowest antigenic effect

c. Human Insulin: is recommended for all

newly diagnosed Type I & Type II DM who

need short-term insulin therapy; the

pregnant client & diabetic client with

insulin allergy or severe insulin resistance

d. Insulin Pumps: externally worn device that

closely mimic normal pancreatic

functioning

5. Exercise: helpful adjunct to therapy as

exercise decrease the body’s need for insulin

Characteristics of Insulin Preparation

Drug Synonym Appearance Onset Peak

Duration Compatible Mixed

Rapid Acting

Insulin Injection Regular Ins Clear ½-1 2-4

6-8 All insulin prep

except lente

Insulin, Zinc Semilente Ins Cloudy ½-1

4-6 12-16 Lente prep

suspension,

prompt

Intermediate Acting

Isophane Ins NPH Ins Cloudy

1-1 ½ 8-12 18-24 Regular Ins

injection

injection

Insulin Zinc Lente Ins Cloudy 1-1 ½ 8-

12 18-24 Regular Ins &

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Suspension

semilente prep

Long Acting

Insulin Zinc Ultralente Ins Cloudy 4-8

16-20 30-36 Regular Ins &

suspension,

semilente prep

extended

Complication

1. Diabetic Ketoacidosis (DKA)

2. Type II Non-insulin-dependent Diabetes Mellitus

(NIDDM)

May result to partial deficiency of insulin

production &/or an insensitivity of the cells to

insulin

Obese adult over 40 years old

Maturity onset type

Incidence Rate

1. 90% of general population has Type II DM

Predisposing Factors

1. Genetics

2. Obesity: because obese persons lack insulin

receptor binding sites

S/sx

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

10.Delayed / poor wound healing

Dx

5. FBS:

c. A level of 140 mg/dl of greater on at two

occasions confirms DM

d. May be normal in Type II DM

6. Postprandial Blood Sugar: elevated

7. Oral Glucose Tolerance Test (most sensitve

test): elevated

8. Glycosolated Hemoglobin (hemoglobin A1c):

elevated

Medical Management

1. Ideally manage by diet & exercise

2. Oral Hypoglycemic agents or occasionally

insulin: if diet & exercise are not effective in

controlling hyperglycemia

3. Insulin is needed in acute stress: ex. Surgery,

infection

4. Diet: CHO 50%, CHON 30% & Fats 20%

a. Weight loss is important since it decreases

insulin resistance

b. High-fiber, low-fat diet also recommended

5. Drug therapy:

a. Occasional use of insulin

b. Oral hypoglycemic agent:

Used by client who are not controlled

by diet & exercise

Increase the ability of islet cells of the

pancreas to secret insulin; may have

some effect on cell receptors to

decrease resistance to insulin

6. Exercise: helpful adjunct to therapy as

exercise decrease the body’s need for insulin

Oral Hypoglycemic Agent

Drug Onset Peak Duration

Comments

Oral Sulfonylureas

Acetohexamide (Dymelor) 1 4-6

12-24

Chlorpropamide (Diabinase) 1 4-6 40-

60

Glyburide (Micronase, Diabeta) 15 min- 1 hr 2-8 10-

24

Oral Biguanides

Metformin (Glucophage) 2-2.5 10-

16 :Decrease glucose

production in liver

:Decrease intestinal

absorption of glucose &

improves insulin sensitivity

Oral Alpha-glucosidose Inhibitor

Acarbose (Precose) Unknown 1 Unknown

:Delay glucose absorption

& digestion of CHO,

lowering blood sugar

Miglitol (Glyset) 2-3

Troglitazone (Rezulin) Rapid 2-3

Unknown :Reduce plasma glucose &

insulin

:Potetiates action of insulin

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 ordered: monitor hypoglycemia especially

during period of drug peak action

2. Provide special diet as ordered:

a. Ensure that the client is eating all meals

b. If all food is not ingested: provide

appropriate substitute according to the

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exchange list or give measured amount of

orange juice to substitute for leftover food;

provide snack later in the day

3. Monitor urine sugar & acetone (freshly voided

specimen)

4. Perform finger sticks to monitor blood glucose

level as ordered (more accurate than urine

test)

5. Observe signs of hypo/hyperglycemia

6. Provide meticulous skin care & prevent injury

7. Maintain I&O; weight daily

8. Provide emotional support: assist client in

adapting change in lifestyle & body image

9. Observe for chronic complications & plan of

care accordingly:

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

Peripheral Vascular Disease

b. Microangiopathy: most commonly affects

eyes & kidneys

c. Kidney Disease

Recurrent Pyelonephritis

Diabetic Nephropathy

d. Ocular Disorder

Premature Cataracts

Diabetic Retinopathy

e. Peripheral Neuropathy

Affects PNS & ANS

Cause diarrhea, constipation,

neurogenic bladder, impotence,

decrease sweating

10.Provide client teaching & discharge planning

concerning:

a. Disease process

b. Diet

Client should be able to plan a meal

using exchange lists before discharge

Emphasize importance of regularity of

meals; never skip meals

c. Insulin

How to draw up into syringe

Use insulin at room temp

Gently roll the vial between palms

Draw up insulin using sterile

technique

If mixing insulin, draw up clear

insulin, before cloudy insulin

Injection technique

Systematically rotate the site: to

prevent lipodystrophy: (hypertrophy

or atrophy of tissue)

Insert needle at a 45 (skinny clients)

or 90 (fat or obese clients) degree

angle depending on amount of

adipose tissue

May store current vial of insulin at

room temperature; refrigerate extra

supplies

Somogyi’s phenomenon: hypoglycemia

followed by periods of hyperglycemia

or rebound effect of insulin.

Provide many opportunities for return

demonstration

d. Oral hypoglycemic agent

Stress importance of taking the drug

regularly

Avoid alcohol intake while on

medication: it can lead to severe

hypoglycemia reaction

Instruct the client to take it with meals:

to lessen GIT irritation & prevent

hypoglycemia

e. Urine testing (not very accurate reflection

of blood glucose level)

May be satisfactory for Type II diabetics

since they are more stable

Use clinitest, tes-tape, diastix, for

glucose testing

Perform test before meals & at bedtime

Use freshly voided specimen

Be consistent in brand of urine test

used

Report results in percentage

Report result to physician if results are

greater that 1%, especially if

experiencing symptoms of

hyperglycemia

Urine testing for ketones should be

done by Type I diabetic clients when

there is persistent glycosuria, increase

blood glucose level or if the client is not

feeling well (acetest, ketostix)

f. Blood glucose monitoring

Use for Type I diabetic client: since it

gives exact blood glucose level & also

detects hypoglycemia

Instruct client in finger stick technique:

use of monitor device (if used), &

recording & utilization of test results

g. General care

Perform good oral hygiene & have

regular dental exam

Have regular eye exam

Care for “sick days” (ex. Cold or flu)

Do not omit insulin or oral

hypoglycemic agent: since infection

causes increase blood sugar

Notify physician

Monitor urine or blood glucose level

& urine ketones frequently

If N/V occurs: sip on clear liquid with

simple sugar

h. Foot care

Wash foot with mild soap & water & pat

dry

Apply lanolin lotion to feet: to prevent

drying & cracking

Cut toenail straight across

Avoid constrictive garments such as

garters

Wear clean, absorbent socks (cotton or

wool)

Purchase properly fitting shoes & break

new shoes in gradually

Never go barefoot

Inspect foot daily & notify physician: if

cut, blister, or break in skin occurs

i. Exercise

Undertake regular exercise; avoid

sporadic, vigorous exercise

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Food intake may need to be increased

before exercising

Exercise is best performed after meals

when the blood sugar is rising

j. Complication

Learn to recognized S/sx of

hypo/hyperglycemia: for hypoglycemia

(cold and clammy skin), for

hyperglycemia (dry and warm skin):

administer simple sugars

Eat candy or drink orange juice with

sugar added for insulin reaction

(hypoglycemia)

Monitor signs of DKA & HONKC

k. Need to wear a Medic-Alert bracelet

Diabetic Ketoacidosis (DKA)

Acute complication of DM characterized by

hyperglycemia & accumulation of ketones in the

body: cause metabolic acidosis

Acute complication of Type I DM: due to severe

hyperglycemia leading to severe CNS depression

Occurs in insulin-dependent diabetic clients

Onset slow: maybe hours to days

Predisposing Factors

1. Undiagnosed DM

2. Neglect to treatment

3. Infection

4. cardiovascular disorder

5. Hyperglycemia

6. Physical & Emotional Stress: number one

precipitating factor

S/sx

1. Polyuria

2. Polydipsia

3. Polyphagia

4. Glucosuria

5. Weight loss

6. Anorexia

7. N/V

8. Abdominal pain

9. Skin warm, dry & flushed

10.Dry mucous membrane; soft eyeballs

11.Blurring of vision

12.PS: Acetone breath odor

13.PS: Kussmaul’s Respiration (rapid shallow

breathing) or tachypnea

14.Alteration in LOC

15.Hypotension

16.Tachycardia

17.CNS depression leading to coma

Dx

1. FBS: is increased

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

6. Serum Na: decrease

7. Serum K: maybe normal or elevated at first

8. ABG: metabolic acidosis with compensatory

respiratory alkalosis

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 5% dextrose to IV

Potassium will be added: when the

urine output is adequate

b. Observe for F&E imbalance, especially

fluid overload, hyperkalemia &

hypokalemia

4. Administer insulin as ordered: regular acting

insulin/rapid acting insulin

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

subcutaneously (SC)

b. If given IV drip: give small amount of

albumin since insulin adheres to IV tubing

c. Monitor blood glucose level frequently

5. Administer medications as ordered:

a. Sodium Bicarbonate: to counteract

acidosis

b. Antibiotics: to prevent infection

6. Check urine output every hour

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

8. Assist client with self-care

9. Provide care for unconscious client if in a

coma

10.Discuss with client the reasons ketosis

developed & provide additional diabetic

teaching if indicated

Hyperglycemic Hyperosmolar Non-Ketotic Coma

(HHNKC)

Characterized by hyperglycemia & a

hyperosmolar state without ketosis

Occurs in non-insulin-dependent diabetic or non-

diabetic persons (typically elderly clients)

Hyperosmolar: increase osmolarity (severe

dehydration)

Non-ketotic: absence of lypolysis (no ketones)

Predisposing Factors

1. Undiagnosed diabetes

2. Infection or other stress

3. Certain medications (ex. dilantin, thiazide,

diuretics)

4. Dialysis

5. Hyperalimentation

6. Major burns

7. Pancreatic disease

S/sx

1. Polyuria 2. Polydipsia

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3. Polyphagia

4. Glucosuria

5. Weight loss

6. Anorexia

7. N/V

8. Abdominal pain

9. Skin warm, dry & flushed

10.Dry mucous membrane; soft eyeballs

11.Blurring of vision

12.Hypotension

13.Tachycardia

14.Headache and dizziness

15.Restlessness

16.Seizure activity

17.Alteration / Decrease LOC: diabetic coma

Dx

1. Blood glucose level: extremely elevated

2. BUN: elevated: due to dehydration

3. Creatinine: elevted: due to dehydration

4. Hct: elevated: due to dehydration

5. Urine: (+) for glucose

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 5% dextrose to IV

Potassium will be added: when the

urine output is adequate

b. Observe for F&E imbalance, especially

fluid overload, hyperkalemia &

hypokalemia

4. Administer insulin as ordered:

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

subcutaneously (SC)

b. If given IV drip: give small amount of

albumin since insulin adheres to IV tubing

c. Monitor blood glucose level frequently

5. Administer medications as ordered:

a. Antibiotics: to prevent infection

6. Check urine output every hour

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

8. Assist client with self-care

9. Provide care for unconscious client if in a

coma

10.Discuss with client the reasons ketosis

developed & provide additional diabetic

teaching if indicated

Overview of Anatomy & Physiology of Hematologic

System

The structure of the hematological of

hematopoietic system includes the blood, blood

vessels, & blood forming organs (bone marrow,

spleen, liver, lymph nodes, & thymus gland).

The major function of blood: is to carry necessary

materials (O2, nutrients) to cells & remove CO2

& metabolic waste products.

The hematologic system also plays an important

role in hormone transport, the inflammatory &

immune responses, temperature regulation, F&E

balance & acid-base balance.

HEMATOLOGICAL SYSTEM

I. Blood II. Blood VesselsIII. Blood Forming Organs

1. Arteries 1. Liver 55% Plasma 45% Formed 2. Veins

2. Thymus (Fluid) cellular elements 3. Capillaries

3. Spleen4.

Lymphoid Organ Serum Plasma CHON

5. Lymph Nodes (formed in liver)

6. Bone Marrow1. Albumin2. Globulins3. Prothrombin and Fibrinogen

Bone Marrow

Contained inside all bones, occupies interior of

spongy bones & center of long bones; collectively

one of the largest organs in the body (4-5% of

total body weight)

Primary function is Hematopoiesis: the formation

of blood cells

All blood cells start as stem cells in the bone

marrow; these mature into different, specific

types of cells, collectively referred to as Formed

Elements of Blood or Blood Components:

1. Erythrocytes

2. Leukocytes

3. Thrombocytes

Two kinds of Bone Marrow:

1. Red Marrow

Carries out hematopoiesis; production site

of erythroid, myeloid, & thrombocytic

component of blood; one source of

lymphocytes & macrophages

Found in the ribs, vertebral column, other

flat bones

2. Yellow Marrow

Red marrow that has changed to fats;

found in long bone; does not contribute to

hematopoiesis

Blood

Composed of plasma (55%) & cellular

components (45%)

Hematocrit

1. Reflects portion of blood composed of red

blood cells

2. Centrifugation of blood results in separation

into top layer of plasma, middle layer of

leukocytes & platelets, & bottom layer of

erythrocytes

3. Majority of formed elements is erythrocytes;

volume of leukocytes & platelets is negligible

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Distribution

1. 1300 ml in pulmonary circulation

a. 400 ml arterial

b. 60 ml capillary

c. 840 ml venous

2. 3000 ml in systemic circulation

a. 550 ml arterial

b. 300 ml capillary

c. 2150 ml venous

Plasma

Liquid part of the blood; yellow in color because

of pigments

Consists of serum (liquid portion of plasma) &

fibrinogen

Contains plasma CHON such as albumin, serum,

globulins, fibrinogen, prothrombin, plasminogen

1. Albumin

Largest & numerous plasma CHON

Involved in regulation of intravascular

plasma volume

Maintains osmotic pressure: preventing

edema

2. Serum Globulins

a. Alpha: role in transport steroids, lipids,

bilirubin & hormones

b. Beta: role in transport of iron & copper

c. Gamma: role in immune response,

function of antibodies

3. Fibrinogens, Prothrombin, Plasminogens:

clotting factors to prevent bleeding

Cellular Components or Formed Elements

1. Erythrocytes (RBC)

a. Normal value: 4 – 6 million/mm3

b. No nucleus, Biconcave shape discs, Chiefly

sac of hemoglobin

c. Call membrane is highly diffusible to O2 &

CO2

d. Responsible for O2 transport via hemoglobin

(Hgb)

Two portion: iron carried on heme portion;

second portion is CHON

Normal blood contains 12-18 g Hgb/100 ml

blood; higher (14-18 g) in men than in

women (12-14 g)

e. Production

Start in bone marrow as stem cells,

release as reticulocytes (immature cells),

mature into erythrocytes

Erythropoietin stimulates differentiation;

produced by kidneys & stimulated by

hypoxia

Iron, vitamin B12, folic acid, pyridoxine

vitamin B6, & other factors required for

erythropoiesis

f. Hemolysis (Destruction)

Normal life span of RBC is 80 – 120 days

and is killed in red pulp of spleen

Immature RBCs destroyed in either bone

marrow or other reticuloendothelial organs

(blood, connective tissue, spleen, liver,

lungs and lymph nodes)

Mature cells remove chiefly by liver and

spleen

Bilirubin (yellow pigment): by product of

Hgb (red pigment) released when RBCs

destroyed, excreted in bile

Biliverdin (green pigment)

Hemosiderin (golden brown pigment)

Iron: feed from Hgb during bilirubin

formation; transported to bone marrow via

transferring and and reclaimed for new

Hgb production

Premature destruction: may be caused by

RBC membrane abnormalities, Hgb

abnormalities, extrinsic physical factors

(such as the enzyme defects found in

G6PD)

Normal age RBCs may be destroyed by

gross damage as in trauma or

extravascular hemolysis (in spleen, liver,

bone marrow)

g. Hemoglobin: normal value female 12 – 14

gms% male 14 – 16 gms%

h. Hematocrit red cell percentage in wholeblood

(normal value: female 36 – 42% male 42 –

48%)

i. Substances needed for maturation of RBC:

a. Folic acid

b. Iron

c. Vitamin c

d. Vitamin b12 (Cyanocobalamin)

e. Vitamin b6 (Pyridoxine)

f. Intrinsic factor

2. Leukocytes (WBC)

a. Normal value: 5000 – 10000/mm3

b. Granulocytes and mononuclear cells: involved

in the protection from bacteria and other

foreign substances

c. Granulocytes:

Polymorphonuclear Neutrophils

- 60 – 70% of WBC

- Involved in short term phagocytosis for

acute inflammation

- Mature neutrophils: polymorphonuclear

leukocytes

- Immature neutrophils: band cells

(bacterial infection usually produces

increased numbers of band cells)

Polymorphonuclear Basophils

- For parasite infections

- Responsible for the release of chemical

mediation for inflammation

- Involved in prevention of clotting in

microcirculation and allergic reactions

Polymorphonuclear Eosinophils

- Involved in phagocytosis and allergic

reaction

Eosinophils & Basophils: are reservoirs of

histamine, serotonin & heparin

d. Non Granulocytes

Mononuclear cells: large nucleated cells

a. Monocytes:

Involved in long-term phagocytosis

for chronic inflammation

Play a role in immune response

Macrophage in blood

Largest WBC

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Produced by bone marrow: give rise

to histiocytes (kupffer cells of liver),

macrophages & other components

of reticuloendothelial system

b. Lymphocytes: immune cells; produce

substances against foreign cells;

produced primarily in lymph tissue (B

cells) & thymus (T cells)

Lymphocytes

B-cell T-cell Natural killer cell- bone marrow - thymus - anti-viral and anti-tumor property

for immunity

HIV

c. Thrombocytes (Platelets)

Normal value: 150,000 –

450,000/mm3

Normal life span of platelet is 9 – 12

days

Fragments of megakaryocytes

formed in bone marrow

Production regulated by

thrombopoietin

Essential factors in coagulation via

adhesion, aggregation & plug

formation

Release substances involved in

coagulation

Promotes hemostasis (prevention of

blood loss)

Consist of immature or baby

platelets or megakaryocytes which

is the target of dengue virus

Signs of Platelet Dysfunction

1. Petechiae

2. Echhymosis

3. Oozing of blood from

venipunctured site

Blood Groups

Erythrocytes carry antigens, which determine the

different blood group

Blood-typing system are based on the many

possible antigens, but the most important are the

antigens of the ABO & Rh blood groups because

they are most likely to be involved in transfusion

reactions

1. ABO Typing

a. Antigens of systems are labeled A & B

b. Absence of both antigens results in type O

blood

c. Presence of both antigen is type AB

d. Presence of either type A or B results in type

A & type B, respectively

e. Type O: universal donor

f. Antibodies are automatically formed against

ABO antigens not on persons own RBC

2. Rh Typing

a. Identifies presence or absence of Rh antigens

(Rh + or Rh -)

b. Anti-Rh antibodies not automatically formed

in Rh (-) persons, but if Rh (+) blood is given,

antibody formation starts & second exposure

to Rh antigen will trigger a transfusion

reaction

c. Important for Rh (-) woman carrying Rh (+)

baby; 1st pregnancy not affected, but

subsequent pregnancy with an Rh (+) baby,

mother’s antibodies attack baby’s RBC

Complication of Blood Transfusion

Type Causes Mechanism

Occurrence S/sx Intervention

Hemolytic ABO Antibodies in Acute:

Headache, Stop transfusion.

Incompatibility; recipient plasma first

5 min lumbar or continue saline IV

Rh react w/ antigen after

completion sternal pain, send blood unit

&

Incompatibility; in donor cells. of

transfusion diarrhea, fever, client blood

Use of dextrose Agglutinated cell

chills, flushing, sample to lab.

solutions; block capillary Delayed:

heat along vein, Watch for

Wide temp blood flow to days to 2

restlessness, hemoglobinuria.

fluctuation organs. weeks

after anemia, jaundice, Treat or prevent

Hemolysis (Hgb

dyspnea, signs shock, DIC, &

into plasma &

of shock, renal renal shutdown

urine)

shutdown, DIC

Complication of Blood Transfusion

Type Causes Mechanism

Occurrence S/sx Intervention

Allergic Transfer of an Immune

Within 30 min Uticaria, larygeal Stop

transfusion.

antigen & sensitivity tostart of

edema, wheezing Administer

antibody from foreign serum

transfusion dyspnea, antihistamine &

donor to CHON

bronchospasm, or epinephrine.

recipient;

headache, Treat

Allergic donor

anaphylaxis life-threatening

reaction

________________________________________________________

_______________________________

Pyrogenic Recipient Leukocytes Within 15-90

Fever, chills, Stop transfusion.

possesses agglutination min after

flushing, Treat temp.

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44

antibodies bacterial initiation of

palpitation, Transfuse with

directed against organism

transfusion tachycardia, leukocytes-poor

WBC; bacterial

occasional blood of washed

contamination;

lumbar pain RBC.

Multitransfused

Administer

client;

antibiotics prn

multiparous

client

________________________________________________________

_______________________________

Circulatory Too rapid Fluid volumeDuring & after

Dyspnea, Slow infusion rate

Overload infusion in overload

transfusion increase BP, Used packed cells

Susceptible

tachycardia, instead of whole

Client

orthopnea, blood.

cyanosis, anxiety Monitor CVP

t

hr

ou

gh

a

separate line.

________________________________________________________

_______________________________

Air Embolism Blood given Bolus of air Anytime

Dyspnea, Clamp tubing.

under air blocks pulmonary

increase pulse, Turn client on

pressure artery outflow

wheezing, chest left side

following severe

pain, decrease BP,

blood loss

apprehension

________________________________________________________

_______________________________Thrombo- Used of

large Platelets When large Abnormal Assess for

signs

cytopenia amount of deteriorate amount of blood

bleeding of bleeding.

banked blood rapidly in stored

given over 24 hr Initiate bleeding

blood

precautions.

Use fresh blood.

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_______________________________

Citrate Large amount Citrate binds

After large Neuromascular Monitor/treat

Intoxication of citrated blood ionic calcium

amount of irritability hypocalcemia.

in client with banked blood

Bleeding due to Avoid large

decrease liver

decrease calcium amounts of

function

citrated blood.

Monitor liver fxn

________________________________________________________

_______________________________

Hyperkalemia Potassium level Release of In

client with Nausea, colic, Administer blood

increase in potassium into renal

diarrhea, muscle less than 5-7

stored blood plasma with insufficiency

spasm, ECG days old in client

red cell lysis

changes (tall with impaired

peaked T-waves, potassium

short Q-T excretion

seg

ments)

Blood Coagulation

Conversion of fluid blood into a solid clot to

reduce blood loss when blood vessels are

ruptured

System that Initiating Clotting

1. Intrinsic System: initiated by contact activation

following endothelial injury (“intrinsic” to vessel

itself)

a. Factor XII: initiate as contact made between

damaged vessel & plasma CHON

b. Factors VIII, IX & XI activated

2. Extrinsic System:

a. Initiated by tissue thromboplastins released

from injured vessels (“extrinsic” to vessel)

b. Factor VII activated

Common Pathways: activated by either intrinsic or

extrinsic pathways

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

X & V

2. Prothrombin converted to thrombin via

thromboplastin

3. Thrombin acts on fibrinogens, forming soluble

fibrin

4. Soluble fibrin polymerized by factor XIII to

produce a stable, insoluble fibrin clot

Clot Resolution: takes place via fibrinolytic system

by plasmin & proteolytic enzymes; clots dissolves as

tissue repairs.

Spleen

Largest Lymphatic Organ: functions as blood

filtration system & reservoir

Vascular bean shape; lies beneath the

diaphragm, behind & to the left of the stomach;

composed of fibrous tissue capsule surrounding a

network of fiber

Contains two types of pulp:

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a. Red Pulp: located between the fibrous

strands, composed of RBC, WBC &

macrophages

b. White Pulp: scattered throughout the red

pulp, produces lymphocytes & sequesters

lymphocytes, macrophages, & antigens

1%-2% of red cell mass or 200 ml blood/minute

stored in the spleen; blood comes via splenic

artery to the pulp for cleansing, then passes into

splenic venules that are lined with phagocytic

cells & finally to the splenic vein to the liver.

Important hematopoietic site in fetus; postnatally

procedures lymphocytes & monocytes

Important in phagocytosis; removes misshapen

erythrocytes, unwanted parts of erythrocytes

Also involved in antibody production by plasma

cells & iron metabolism (iron released from Hgb

portion of destroyed erythrocytes returned to

bone marrow)

In the adult functions of the spleen can be taken

over by the reticuloendothelial system.

Liver

Involved in bile production (via erythrocyte

destruction & bilirubin production) &

erythropoeisis (during fetal life & when bone

marrow production is insufficient).

Kupffer cells of liver have reticuloendothelial

function as histiocytes; phagocytic activity &

iron storage.

Liver also involved in synthesis of clotting

factors, synthesis of antithrombins.

Blood Tranfusion

Purpose

1. RBC: Improve O2 transport

2. Whole Blood, Plasma, Albumin: volume

expansion

3. Fresh Frozen Plasma, Albumin, Plasma Protein

Fraction: provision of proteins

4. Cryoprecipitate, Fresh Frozen Plasma, Fresh

Whole Blood: provision of coagulation factors

5. Platelet Concentration, Fresh Whole Blood:

provision of platelets

Blood & Blood Products

1. Whole Blood: provides all components

a. Large volume can cause difficulty: 12-24

hr for Hgb & Hct to rise

b. Complications: volume overload,

transmission of hepatitis or AIDS,

transfusion reacion, infusion of excess

potassium & sodium, infusion of

anticoagulant (citrate) used to keep stored

blood from clotting, calcium binding &

depletion (citrate) in massive transfusion

therapy

2. Red Blood Cell (RBC)

a. Provide twice amount of Hgb as an

equivalent amount of whole blood

b. Indicate in cases of blood loss, pre-op &

post-op client & those with incipient

congestive failure

c. Complication: transfusion reaction (less

common than with whole blood: due to

removal of plasma protein)

3. 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

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

5. Factor VIII Fractions (Cryoprecipitate):

contains factor VIII, fibrinogens & XIII

6. Granulocytes

a. Do not increase WBC: increase marginal

pool (at tissue level) rather than

circulating pool

b. Premedication with steroids, antihistamine

& acetaminophen

c. Respiratory distress with shortness of

breath, cyanosis & chest pain may occur;

requires cessation of transfusion &

immediate attention

d. Shaking chills or rigors common, require

brief cessation of therapy, administration

of meperdine IV until rigors are diminished

& resumption of transfusion when

symptoms relieved

7. Volume Expander: albumin; percentage

concentration varies (50-100 ml/unit);

hyperosmolar solution should not be used in

dehydrated clients

Goals / Objectives

1. Replace circulating blood volume

2. Increase the O2 carrying capacity of blood

3. Prevent infection: if there is a decrease in

WBC

4. Prevent bleeding: if there is platelet

deficiency

Principles of blood transfusion

1. Proper refrigeration

a. Expiration of packed RBC is 3-6 days

b. Expiration of platelet is 3-5 days

2. Proper typing and cross matching

a. Type O: universal donor

b. Type AB: universal recipient

c. 85% of population is RH positive

3. Aseptically assemble all materials needed for

BT

a. Filter set

b. Gauge 18-19 needle

c. Isotonic solution (0.9 NaCl / plain NSS): to

prevent hemolysis

4. Instruct another RN to re check the following

a. Client name

b. Blood typing & cross matching

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c. Expiration date

d. Serial number

5. Check the blood unit for bubbles cloudiness,

sediments and darkness in color because it

indicates bacterial contamination

a. Never warm blood: it may destroy vital

factors in blood.

b. Warming is only done: during emergency

situation & if you have the warming device

c. Emergency rapid BT is given after 30

minutes & let natural room temperature

warm the blood.

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 bacterial

contamination

7. Avoid mixing or administering drugs at BT

line: to 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 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

h. Hyperkalemia (caused by expired blood)

S/sx of Hemolytic reaction

1. Headache and dizziness

2. Dyspnea

3. Diarrhea / Constipation

4. Hypotension

5. Flushed skin

6. Lumbasternal / Flank pain

7. Urine is color red / portwine urine

Nursing Management

1. Stop BT

2. Notify physician

3. Flush with plain NSS

4. Administer isotonic fluid solution: to prevent

shock and acute tubular necrosis

5. Send the blood unit to blood bank for re-

examination

6. Obtain urine & blood sample & send to

laboratory for re-examination

7. Monitor vital signs & I&O

S/sx of Allergic reaction

1. 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-examination

7. Monitor vital signs and intake and output

S/sx Pyrogenic reactions

1. Fever and chills

2. Headache

3. Tachycardia

4. Palpitations

5. Diaphoresis

6. Dyspnea

Nursing Management

1. Stop BT

2. Notify physician

3. Flush with plain NSS

4. Administer medications as ordered

a. Antipyretic

b. Antibiotic

5. Send the blood unit to blood bank for re

examination

6. Obtain urine & blood sample & send to

laboratory for re-examination

7. Monitor vital signs & I&O

8. Render TSB

S/sx of Circulatory reaction

1. Orthopnea

2. Dyspnea

3. Rales / Crackles upon auscultation

4. Exertional discomfort

Nursing Management

1. Stop BT

2. Notify physician

3. Administer medications as ordered

a. Loop diuretic (Lasix)

Nursing Care

1. Assess client for history of previous blood

transfusions & any adverse reaction

2. Ensure that the adult client has an 18-19

gauge IV catheter in place

3. Use 0.9% sodium chloride

4. At least two nurse should verify the ABO

group, RH type, client & blood numbers &

expiration date

5. Take baseline V/S before initiating transfusion

6. Start transfusion slowly (2 ml/min)

7. Stay with the client during the first 15 min of

the transfusion & take V/S frequently

8. Maintain the prescribed transfusion rate:

a. Whole Blood: approximately 3-4 hr

b. RBC: approximately 2-4 hr

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c. Fresh Frozen Plasma: as quickly as

possible

d. Platelet: as quickly as possible

e. Cryoprecipitate: rapid infusion

f. Granulocytes: usually over 2 hr

g. Volume Expander: volume-dependent rate

9. Monitor for adverse reaction

10.Document the following:

a. Blood component unit number (apply

sticker if available)

b. Date of infusion starts & end

c. Type of component & amount transfused

d. Client reaction & vital signs

e. Signature of transfusionist

HIV

- 6 months – 5 years incubation period

- 6 months window period

- western blot opportunistic

- ELISA

- drug of choice AZT (Zidon Retrovir)

2 Common fungal opportunistic infection in AIDS

1. Kaposis Sarcoma

2. Pneumocystic Carini Pneumonia

Blood Disorder

Iron Deficiency Anemia (Anemias)

A chronic microcytic anemia resulting from

inadequate absorption of iron leading to

hypoxemic tissue injury

Chronic microcytic, hypochromic anemia caused

by either inadequate absorption or excessive loss

of iron

Acute or chronic bleeding principal cause in

adults (chiefly from trauma, dysfunctional uterine

bleeding & GI bleeding)

May also be caused by inadequate intake of iron-

rich foods or by inadequate absorption of iron

In iron-deficiency states, iron stores are depleted

first, followed by a reduction in Hgb formation

Incidence Rate

1. Common among developed countries &

tropical zones (blood-sucking parasites)

2. Common among women 15 & 45 years old &

children affected more frequently, as are the

poor

3. Related to poor nutrition

Predisposing Factors

1. Chronic blood loss due to:

a. Trauma

b. Heavy menstruation

c. Related to GIT bleeding resulting to

hematemasis and melena (sign for upper

GIT bleeding)

d. Fresh blood per rectum is called

hematochezia

2. Inadequate intake or absorption of iron due

to:

a. Chronic diarrhea

b. Related to malabsorption syndrome

c. High cereal intake with low animal CHON

digestion

d. Partial or complete gastrectomy

e. Pica

3. Related to improper cooking of foods

S/sx

1. Usually asymptomatic (mild cases)

2. Weakness & fatigue (initial signs)

3. Headache & dizziness

4. Pallor & cold sensitivity

5. Dyspnea

6. Palpitations

7. Brittleness of hair & nails, spoon shape nails

(koilonychias)

8. Atrophic Glossitis (inflammation of tongue)

a. Stomatitis

PLUMBER VINSON’S SYNDROME

b. Dysphagia

9. PICA: abnormal appetite or craving for non

edible foods

Dx

1. RBC: small (microcytic) & pale (hypochromic)

2. RBC: is decreased

3. Hgb: decreased

4. Hct: moderately decreased

5. Serum iron: decreased

6. Reticulocyte count: is decreased

7. Serum ferritin: is decreased

8. Hemosiderin: absent from bone marrow

Nursing Intervention

1. Monitor for s/sx of bleeding through hematest

of all elimination including urine, stool &

gastrict content

2. Enforce CBR / Provide adequate rest: plan

activities so as not to over tire the client

3. Provide thorough explanation of all diagnostic

exam used to determine sources of possible

bleeding: help allay anxiety & ensure

cooperation

4. Instruct client to take foods rich in iron

a. Organ meat

b. Egg yolk

c. Raisin

d. Sweet potatoes

e. Dried fruits

f. Legumes

g. Nuts

5. Instruct the client to avoid taking tea and

coffee: because it contains tannates which

impairs iron absorption

6. Administer iron preparation as ordered:

a. Oral Iron Preparations: route of choice

Ferrous Sulfate

Ferrous Fumarate

Ferrous Gluconate

Nursing Management when taking oral

iron preparations

Instruct client to take with meals: to

lessen GIT irritation

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Dilute in liquid preparations well &

administer using a straw: to prevent

staining of teeth

When possible administer with orange

juice as vitamin C (ascorbic acid): to

enhance iron absorption

Warn clients that iron preparations will

change stool color & consistency (dark

& tarry) & may cause constipation

Antacid ingestion will decrease oral iron

effectiveness

b. Parenteral: used in clients intolerant to

oral preparations, who are noncompliant

with therapy or who have continuing blood

losses

Nursing Management when giving

parenteral iron preparation

Use one needle to withdraw & another

to administer iron preparation as tissue

staining & irritation are a problem

Use Z-track injection technique: to

prevent leakage into tissue

Do not massage injection site but

encourage ambulation as this will

enhance absorption; advice against

vigourous exercise & constricting

garments

Observe for local signs of complication:

Pain at the injection site

Development of sterile abscesses

Lymphadenitis

Fever & chills

Headache

Urticaria

Pruritus

Hypotension

Skin rashes

Anaphylactic shock

Medications administered via straw

Lugol’s Solution

Iron

Tetracycline

Nitrofurantoin (Macrodentin)

7. Administer with Vitamin C or orange juice for

absorption

8. Monitor & inform client of side effects

a. Anorexia

b. N/V

c. Abdominal pain

d. Diarrhea / constipation

e. Melena

9. If client can’t tolerate / no compliance

administer parenteral iron preparation

a. Iron Dextran (IM, IV)

b. Sorbitex (IM)

10.Provide dietary teaching regarding food high

in iron

11.Encourage ingestion of roughage & increase

fluid intake: to prevent constipation if oral

iron preparation are being taken

Pernicious Anemia

Chronic progressive, macrocytic anemia caused

by a deficiency of intrinsic factor; the result is

abnormally large erythrocytes & hypochlorhydria

(a deficiency of hydrochloric acid in gastric

secretion)

Chronic anemia characterized by a deficiency of

intrinsic factor leading to hypochlorhydria

(decrease hydrochloric acid secretion)

Characterized by neurologic & GI symptoms;

death usually resuls if untreated

Lack of intrinsic factor is caused by gastric

mucosal atrophy (possibly due to heredity,

prolonged iron deficiency, or an autoimmune

disorder); can also results in clients who have

had a total gastrctomy if vitamin B12 is not

administer

Pathophysiology

1. Intrinsic factor is necessary for the absorbtion

of vitamin B12 into small intestines

2. B12 deficiency diminished DNA synthesis,

which results in defective maturation of cell

(particularly rapidly dividing cells such as

blood cells & GI tract cells)

3. B12 deficiency can alter structure & function of

peripheral nerves, spinal cord, & the brain

STOMACH

Pareital cells/Argentaffin or Oxyntic cells

Produces intrinsic factors

Secretes hydrochloric acid

Promotes reabsorption of Vit B12

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

2. Subtotal gastrectomy

3. Hereditary factors

4. Inflammatory disorders of the ileum

5. Autoimmune

6. Strictly vegetarian diet

S/sx

1. Anemia

2. Weakness & fatigue

3. Headache and dizziness

4. Pallor & cold sensitivity

5. Dyspnea & palpitations: as part of

compensation

6. GIT S/sx:

a. Mouth sore

b. PS: Red beefy tongue

c. Indigestion / dyspepsia

d. Weight loss

e. Constipation / diarrhea

f. Jaundice

7. CNS S/sx:

a. Tingling sensation

b. Numbness

c. Paresthesias of hands & feet

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d. Paralysis

e. Depression

f. Psychosis

g. Positive to Romberg’s test: damage to

cerebellum resulting to ataxia

Dx

1. Erythrocytes count: decrease

2. Blood Smear: oval, macrocytic erythrocytes

with a proportionate amount of Hgb

3. Bilirubin (indirect): elevated unconjugated

fraction

4. Serum LDH: elevated

5. Bone Marrow:

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

a. Measures absorption of radioactive vitamin

B12 bothe before & after parenteral

administration of intrinsic factor

b. Definitive test for pernicious anemia

c. Used to detect lack of intrinsic factor

d. Fasting client is given radioactive vitamin

B12 by mouth & non-radioactive vitamin B12

IM to permit some excretion of radioactive

vitamin B12 in the urine if it os absorbed

e. 24-48 hour urine collection is obtained:

client is encourage to drink fluids

f. If indicated, second stage schilling test

performed 1 week after first stage. Fasting

client is given radioactive vitamin B12

combined with human intrinsic factor &

test is repeated

7. Gastric Analysis: decrease free hydrochloric

acid

8. Large number of reticulocytes in the blood

following parenteral vitamin B12

administration

Medical Management

1. Drug Therapy:

a. Vitamin B12 injection: monthly

maintenance

b. Iron preparation: (if Hgb level inadequate

to meet increase numbers of erythrocytes)

c. Folic Acid

Controversial

Reverses anemia & GI symptoms but

may intensify neurologic symptoms

May be safe if given in small amounts

in addition to vitamin 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

Never given orally because there is

possibility of developing tolerance

Site of injection for Vitamin B12 is

dorsogluteal and ventrogluteal

No side effects

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 carrying hot item)

6. Instruct client to avoid irritating mouth

washes instead use soft bristled toothbrush

7. Avoid heat application to prevent burns

8. Provide client teaching & discharge planning

concerning:

a. Dietery instruction

b. Importance of lifelong vitamin B12 therapy

c. Rehabilitation & physical therapy for

neurologic deficit, as well as instruction

regarding safety

Aplastic Anemia

Stem cell disorder leading to bone marrow

depression leading to pancytopenia

Pancytopenia or depression of granulocytes,

platelets & erythrocytes production: due to fatty

replacement of the bone marrow

Bone marrow destruction may be idiopathic or

secondary

PANCYTOPENIA

Decrease RBC Decrease WBC Decrease Platelet

(anemia) (leukopenia)

(thrombocytopenia)

Predisposing Factors

1. Chemicals (Benzene and its derivatives)

2. Related to radiation / exposure to x-ray

3. Immunologic injury

4. Drugs:

a. Broad Spectrum Antibiotics:

Chloramphenicol (Sulfonamides)

b. Cytotoxic agent / Chemotherapeutic

Agents:

Methotrexate (Alkylating Agent)

Vincristine (Plant Alkaloid)

Nitrogen Mustard (Antimetabolite)

Phenylbutazones (NSAIDS)

S/sx

1. Anemia

a. Weakness & fatigue

b. Headache & dizziness

c. Pallor & cold sensitivity

d. Dyspnea & palpitations

2. Leukopenia

a. Increase susceptibility to infection

3. Thrombocytopenia

a. Petechiae (multiple petechiae is called

purpura)

b. Ecchymosis

c. Oozing of blood from venipunctured sites

Dx

1. CBC: reveals pancytopenia

2. Normocytic anemia, granulocytopenia,

thrombocytopenia

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3. Bone marrow biopsy: aspiration (site is the

posterior iliac crest): marrow is fatty &

contain very few developing cells; reveals fat

necrosis in bone marrow

Medical Management

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

amenorrhea in female clients

5. Identification & withdrawal of offending agent

or drug

Nursing Intervention

1. 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:

a. Corticosteroids: caused by immunologic

injury

b. Immunosuppressants: Anti Lymphocyte

Globulin

Given via central venous

catheter

Given 6 days to 3 weeks to achieve

maximum therapeutic effect of drug

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

c. Provide mouth care before & after meals

d. Fever

e. Cough

9. Monitor signs of bleeding & provide measures

to minimize risk:

a. Use soft toothbrush when brushing teeth &

electric razor when shaving: prevent

bleeding

b. Avoid IM, subcutaneous, venipunctured

sites: Instead provide heparin lock

c. Hematest urine & stool

d. Observe for oozing from gums, petechiae

or ecchymoses

10.Provide client teaching & discharge planning

concerning:

a. Self-care regimen

b. Identification of offending agent &

importance of avoiding it (if possible) in

future

Disseminated Intravascular Coagulation (DIC)

Diffuse fibrin deposition within arterioles &

capillaries with widespread coagulation all over

the body & subsequent depletion of clotting

factors

Acute hemorrhagic syndrome characterized by

wide spread bleeding and thrombosis due to a

deficiency of prothrombin and fibrinogen

Hemorrhage from kidneys, brain, adrenals, heart

& other organs

May be linked with entry of thromboplasic

substance into the blood

Mortality rate is high usually because underlying

disease cannot be corrected

Pathophysiology

1. Underlying disease (ex. toxemia of

pregnancy, cancer) cause release of

thromboplastic substance that promote the

deposition of fibrin throughout the

microcirculation

2. Microthrombi form in many organs, causing

microinfarcts & tissue necrosis

3. RBC are trapped in fibrin strands & are

hemolysed

4. Platelets, prothrombin & other clotting factors

are destroyed, leading to bleeding

5. Excessive clotting activates the fibrinolytic

system, which inhibits platelet function,

causing futher bleeding.

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. Pregnancy

S/sx

1. Petechiae & Ecchymosis on the skin, mucous

membrane, heart, eyes, lungs & other organs

(widespread and systemic)

2. 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. 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

10.ABG analysis: reveals metabolic acidosis

11.Opthamoscopic exam: reveals sub retinal

hemorrhages

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Medical Management

1. Identification & control the underlying disease

is key

2. Blood Tranfusions: include whole blood,

packed RBC, platelets, plasma,

cryoprecipitites & volume expanders

3. Heparin administration

a. Somewhat controversial

b. Inhibits thrombin thus preventing further

clot formation, allowing coagulation

factors to accumulate

Nursing Intervention

1. Monitor blood loss & attemp to quantify

2. Monitor for signs of additional bleeding or

thrombus formation

3. Monitor all hema test / laboratory data

including stool and GIT

4. Prevent further injury

a. Avoid IM injection

b. Apply pressure to bleeding site

c. Turn & position the client frequently &

gently

d. Provide frequent nontraumatic mouth care

(ex. soft toothbrush or gauze sponge)

5. Administer isotonic fluid solution as ordered:

to prevent shock

6. Administer oxygen inhalation

7. Force fluids

8. Administer medications as ordered:

a. Vitamin K

b. Pitressin / Vasopresin: to conserve fluids

c. Heparin / Comadin is ineffective

9. Provide heparin lock

10.Institute NGT decompression by performing

gastric 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)

13.Provide emotional support to client &

significant other

14.Teach client the importance of avoiding

aspirin or aspirin-containing compounds

Overview of the Structure & Functions of the Heart

Cardiovascular system consists of the heart,

arteries, veins & capillaries. The major function

are circulation of blood, delivery of O2 & other

nutrients to the tissues of the body & removal of

CO2 & other cellular products metabolism

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

Heart Wall / Layers of the Heart

Pericardium

Composed of fibrous (outermost layer) & serous

pericardium (parietal & visceral); a sac that

function to protect the heart from friction

In between is the pericardial fluid which is 10 –

20 cc: Prevent pericardial friction rub

2 layers of pericardium

Parietal: outer layer

Visceral: inner layer

Epicardium

Covers surface of the heart, becomes continuous

with visceral layer of serous pericardium

Outer layer

Myocardium

Middle muscular layer

Myocarditis can lead to cardiogenic shock and

rheumatic heart disease

Endocardium

Thin, inner membrabous layer lining the chamber

of the heart

Inner layer

Papillary Muscle

Arise from the endocardial & myocardial surface

of the ventricles & attach to the chordae

tendinae

Chordae Tendinae

Attach to the tricuspid & mitral valves & prevent

eversion during systole

Chambers of the Heart

Atria

2 chambers, function as receiving chambers, lies

above the ventricles

Upper Chamber (connecting or receiving)

Right Atrium: receives systemic venous blood

through the superior vena cava, inferior vena

cava & coronary sinus

Left Atrium: receives oxygenated blood

returning to the heart from the lungs trough

the pulmonary veins

Ventricles

2 thick-walled chambers; major responsibility for

forcing blood out of the heart; lie below the atria

Lower Chamber (contracting or pumping)

Right Ventricle: contracts & propels

deoxygenated blood into pulmonary

circulation via the aorta during ventricular

systole; Right atrium has decreased pressure

which is 60 – 80 mmHg

Left Ventricle: propels blood into the systemic

circulation via aortaduring ventricular systole;

Left ventricle has increased pressure which is

120 – 180 mmHg in order to propel blood to

the systemic circulation

Valves

To promote unidimensional flow or prevent

backflow

Atrioventricular Valve

Guards opening between

Mitral Valve: located between the left atrium

& left ventricle; contains 2 leaflets attached to

the chordae tandinae

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SA NODE

AV NODE

BUNDLE OF HIS

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Tricuspid Valve: located between the right

atrium & right ventricle; contains 3 leaflets

attached to the chordae tandinae

Functions

Permit unidirectional flow of blood from specific

atrium to specific ventricle during ventricular

diastole

Prevent reflux flow during ventricular systole

Valve leaflets open during ventricular diastole;

Closure of AV valves give rise to first heart sound

(S1 “lub”)

Semi-lunar Valve

Pulmonary Valve

Located between the left ventricle &

pulmonary artery

Aortic Valve

Located between left ventricle & aorta

Function

Pemit unidirectional flow of the blood from

specific ventricle to arterial vessel during

ventricular diastole

Prevent reflux blood flow during ventricular

diastole

Valve open when ventricle contract & close

during ventricular diastole; Closure of SV valve

produces second heart sound (S2 “dub”)

Extra Heart Sounds

S3: ventricular gallop usually seen in Left

Congestive Heart Failure

S4: atrial gallop usually seen in Myocardial

Infarction and Hypertension

Coronary Circulation

Coronary Arteries

Branch off at the base of the aorta & supply

blood to the myocardium & the conduction

system

Arises from base of the aorta

Types of Coronary Arteries

Right Main Coronary Artery

Left Main Coronary Artery

Coronary Veins

Return blood from the myocardium back to the

right atrium via the coronary sinus

Conduction System

Sinoatrial Node (SA node or Keith Flack Node)

Located at the junction of superior vena cava and

right atrium

Acts as primary pacemaker of the heart

Initiates the cardiac impulse which spreads

across the atria & into AV node

Initiates electrical impulse of 60-100 bpm

Atrioventricular Node (AV node or Tawara Node)

Located at the inter atrial septum

Delays the impulse from the atria while the

ventricles fill

Delay of electrical impulse for about .08

milliseconds to allow ventricular filling

Bundle of His

Arises from the AV node & conduct impulse to

the bundle branch system

Located at the interventricular septum

Right Bundle Branch: divided into anterior

lateral & posterior; transmits impulses down

the right side of the interventricular

myocardium

Left Bundle Branch: divided into anterior &

posterior

Anterior Portion: transmits impulses to the

anterior endocardial surface of the left

ventricle

Posterior Portion: transmits impulse over

the posterior & inferior endocardial surface

of the left ventricle

Purkinje Fibers

Transmit impulses to the ventricle & provide for

depolarization after ventricular contraction

Located at the walls of the ventricles for

ventricular contraction

PURKINJE FIBERS

Electrical activity of heart can be visualize by attaching

electrodes to the skin & recording activity by ECG

Electrocadiography (ECG) Tracing

P wave (atrail depolarization) contraction

QRS wave (ventricular depolarization)

T wave (ventricular repolarization)

Insert pacemaker if there is complete heart block

Most common pacemaker is the metal

pacemaker and lasts up to 2 – 5 years

Abnormal ECG Tracing

Positive U wave: Hypokalemia

Peak T wave: Hyperkalemia

ST segment depression: Angina Pectoris

ST segment elevation: Myocardial Infarction

T wave inversion: Myocardial Infarction

Widening of QRS complexes: Arrythmia

Vascular System

Major function of the blood vessels isto supply

the tissue with blood, remove wastes, & carry

unoxygenated blood back to the heart

Types of Blood Vessels

Arteries

Elastic-walled vessels that can stretch during

systole & recoil during diastole; they carry blood

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away from the heart & distribute oxygenated

blood throughout the body

Arterioles

Small arteries that distribute blood to the

capillaries & function in controlling systemic

vascular resistance & therefore arterial pressure

Capilliaries

The following exchanges occurs in the capilliaries

O2 & CO2

Solutes between the blood & tissue

Fluid volume transfer between the plasma &

interstitial space

Venules

Small veins that receive blood from capillaries &

function as collecting channels between the

capillaries & veins

Veins

Low-pressure vessels with thin small & less

muscles than arteries; most contains valves that

prevent retrograde blood flow; they carry

deoxygenated blood back to the heart. When the

skeletal surrounding veins contract, the veins are

compressed, promoting movement of blood back

to the heart.

Cardiac Disorders

Coronary Arterial Disease / Ischemic Heart Disease

Stages of Development of Coronary Artery Disease

1. Myocardial Injury: Atherosclerosis

2. Myocardial Ischemia: Angina Pectoris

3. Myocardial Necrosis: Myocardial Infarction

ATHEROSCLEROSIS

ATHEROSCLEROSIS ARTERIOSCLEROSIS

Narrowing of artery

Lipid or fat deposits

Tunica intima

Hardening of artery

Calcium and protein

deposits

Tunica media

Predisposing Factors

1. Sex: male

2. Race: black

3. Smoking

4. Obesity

5. Hyperlipidemia

6. Sedentary lifestyle

7. Diabetes Mellitus

8. Hypothyroidism

9. Diet: increased saturated fats

10.Type A personality

S/sx

1. Chest pain

2. Dyspnea

3. Tachycardia

4. Palpitations

5. Diaphoresis

Treatment

P - Percutaneous

T - Transluminal

C - Coronary

A – Angioplasty

C - Coronary

A - Arterial

B - Bypass

A - And

G - Graft

S - Surgery

Objectives

1. Revascularize myocardium

2. To prevent angina

3. Increase survival rate

4. Done to single occluded vessels

5. If there is 2 or more occluded blood vessels

CABG is done

3 Complications of CABG

1. Pneumonia: encourage to perform deep

breathing, coughing exercise and use of

incentive spirometer

2. Shock

3. Thrombophlebitis

Angina Pectoris

Transient paroxysmal chest pain produced by

insufficient blood flow to the myocardium

resulting to myocardial ischemia

Clinical syndrome characterized by paroxysmal

chest pain that is usually relieved by rest or

nitroglycerine due to temporary myocardial

ischemia

Predisposing Factors

1. Sex: male

2. Race: black

3. Smoking

4. Obesity

5. Hyperlipidemia

6. Sedentary lifestyle

7. Diabetes Mellitus

8. Hypertension

9. CAD: Atherosclerosis

10.Thromboangiitis Obliterans

11.Severe Anemia

12.Aortic Insufficiency: heart valve that fails to open

& close efficiently

13.Hypothyroidism

14.Diet: increased saturated fats

15.Type A personality

Precipitating Factors

4 E’s of Angina Pectoris

1. Excessive physical exertion: heavy exercises,

sexual activity

2. Exposure to cold environment: vasoconstriction

3. Extreme emotional response: fear, anxiety,

excitement, strong emotions

4. Excessive intake of foods or heavy meal

S/sx

1. Levine’s Sign: initial sign that shows the hand

clutching the chest

2. Chest pain: characterized by sharp stabbing pain

located at sub sterna usually radiates from neck,

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back, arms, shoulder and jaw muscles usually

relieved by rest or taking nitroglycerine (NTG)

3. Dyspnea

4. Tachycardia

5. Palpitations

6. Diaphoresis

Dx

1. History taking and physical exam

2. ECG: may reveals ST segment depression & T

wave 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

1. Drug Therapy: if cholesterol is elevated

Nitrates: Nitroglycerine (NTG)

Beta-adrenergic blocking agent: Propanolol

Calcium-blocking agent: nefedipine

Ace Inhibitor: Enapril

2. Modification of diet & other risk factors

3. Surgery: Coronary artery bypass surgery

4. Percutaneuos Transluminal Coronary Angioplasty

(PTCA)

Nursing Intervention

1. Enforce complete bed rest

2. Give prompt pain relievers with nitrates or

narcotic analgesic as ordered

3. Administer medications as ordered:

a. Nitroglycerine (NTG): when given in small

doses will act as venodilator, but in large

doses will act as vasodilator

Give 1st dose of NTG: sublingual 3-5

minutes

Give 2nd dose of NTG: if pain persist after

giving 1st dose with interval of 3-5 minutes

Give 3rd & last dose of NTG: if pain still

persist at 3-5 minutes interval

Nursing Management when giving NTG

1. NTG Tablets (sublingual)

Keep the drug in a dry place, avoid

moisture and exposure to sunlight as it

may inactivate the drug

Relax for 15 minutes after taking a tablet:

to prevent dizziness

Monitor side effects:

Orthostatic hypotension

Transient headache & dizziness:

frequent side effect

Instruct the client to rise slowly from

sitting position

Assist or supervise in ambulation

2. NTG Nitrol or Transdermal patch

Avoid placing near hairy areas as it may

decrease drug absorption

Avoid rotating transdermal patches as it

may decrease drug absorption

Avoid placing near microwave ovens or

during defibrillation as it may lead to burns

(most important thing to remember)

b. Beta-blockers

Propanolol: side effects PNS

Not given to COPD cases: it causes

bronchospasm

c. ACE Inhibitors

Enalapril

d. Calcium Antagonist

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

7. Provide decrease saturated fats sodium and

caffeine

8. Provide client health teachings and discharge

planning

Avoidance of 4 E’s

Prevent complication (myocardial infarction)

Instruct client to take medication before

indulging into physical exertion to achieve the

maximum therapeutic effect of drug

Reduce stress & anxiety: relaxation

techniques & guided imagery

Avoid overexertion & smoking

Avoid extremes of temperature

Dress warmly in cold weather

Participate in regular exercise program

Space exercise periods & allow for rest

periods

The importance of follow up care

9. Instruct the client to notify the physician

immediately if pain occurs & persists despite rest

& medication administration

Myocardial Infarction

Death of myocardial cells from inadequate

oxygenation, often caused by sudden complete

blockage of a coronary artery

Characterized by localized formation of necrosis

(tissue destruction) with subsequent healing by

scar formation & fibrosis

Heart attack

Terminal stage of coronary artery disease

characterized by malocclusion, necrosis &

scarring.

Types

1. Transmural Myocardial Infarction: most

dangerous type characterized by occlusion of

both right and left coronary artery

2. Subendocardial Myocardial Infarction:

characterized by occlusion of either right or left

coronary artery

The Most Critical Period Following Diagnosis of

Myocardial Infarction

6-8 hours because majority of death occurs due

to arrhythmia leading to premature ventricular

contractions (PVC)

Predisposing Factors

1. Sex: male

2. Race: black

3. Smoking

4. Obesity

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5. CAD: Atherosclerotic

6. Thrombus Formation

7. Genetic Predisposition

8. Hyperlipidemia

9. Sedentary lifestyle

10.Diabetes Mellitus

11.Hypothyroidism

12.Diet: increased saturated fats

13.Type A personality

S/sx

1. Chest pain

Excruciating visceral, viselike pain with

sudden onset located at substernal & rarely in

precordial

Usually radiates from neck, back, shoulder,

arms, jaw & abdominal muscles (abdominal

ischemia): severe crushing

Not usually relieved by rest or by

nitroglycerine

2. N/V

3. Dyspnea

4. Increase in blood pressure & pulse, with gradual

drop in blood pressure (initial sign)

5. Hyperthermia: elevated temp

6. Skin: cool, clammy, ashen

7. Mild restlessness & apprehension

8. Occasional findings:

Pericardial friction rub

Split S1 & S2

Rales or Crackles upon auscultation

S4 or atrial gallop

Dx

1. Cardiac Enzymes

CPK-MB: elevated

Creatinine phosphokinase (CPK): elevated

Heart only, 12 – 24 hours

Lactic acid dehydrogenase (LDH): is increased

Serum glutamic pyruvate transaminase

(SGPT): is increased

Serum glutamic oxal-acetic transaminase

(SGOT): is increased

2. Troponin Test: is increased

3. ECG tracing reveals

ST segment elevation

T wave inversion

Widening of QRS complexes: indicates that

there is arrhythmia in MI

4. Serum Cholesterol & uric acid: are both

increased

5. CBC: increased WBC

Nursing Intervention

Goal: Decrease myocardial oxygen demand

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

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

prevent respiratory arrest or dyspnea & prevent

arrhythmias

3. Enforce CBR in semi-fowlers position without

bathroom privileges (use bedside commode): to

decrease cardiac workload

4. Instruct client to avoid forms of valsalva

maneuver

5. Place client on semi fowlers position

6. Monitor strictly V/S, I&O, ECG tracing &

hemodynamic procedures

7. Perform complete lung / cardiovascular

assessment

8. Monitor urinary output & report output of less

than 30 ml / hr: indicates decrease cardiac

output

9. Provide a full liquid diet with gradual increase to

soft diet: low in saturated fats, Na & caffeine

10.Maintain quiet environment

11.Administer stool softeners as ordered: to

facilitate bowel evacuation & prevent straining

12.Relieve anxiety associated with coronary care

unit (CCU) environment

13.Administer medication as ordered:

a. Vasodilators: Nitroglycirine (NTG), Isosorbide

Dinitrate, Isodil (ISD): sublingual

b. Anti Arrythmic Agents: Lidocaine (Xylocane),

Brithylium

Side Effects: confusion and dizziness

c. Beta-blockers: Propanolol (Inderal)

d. ACE Inhibitors: Captopril (Enalapril)

e. Calcium Antagonist: Nefedipine

f. Thrombolytics / Fibrinolytic Agents:

Streptokinase, Urokinase, Tissue Plasminogen

Activating Factor (TIPAF)

Side Effects: allergic reaction, urticaria,

pruritus

Nursing Intervention: Monitor for bleeding

time

g. Anti Coagulant

Heparin

Antidote: Protamine Sulfate

Nursing Intervention: Check for Partial

Thrombin Time (PTT)

Caumadin (Warfarin)

Antidote: Vitamin K

Nursing Intervention: Check for

Prothrombin Time (PT)

h. Anti Platelet: PASA (Aspirin): Anti thrombotic

effect

Side Effects: Tinnitus, Heartburn,

Indigestion / Dyspepsia

Contraindication: Dengue, Peptic Ulcer

Disease, Unknown cause of headache

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

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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

Arrhythmia: caused by premature

ventricular contraction

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 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

i. Need to report the ff s/sx:

Increased persistent chest pain

Dyspnea

Weakness

Fatigue

Persistent palpitation

Light headedness

j. Enrollment of client in a cardiac rehabilitation

program

k. Strict compliance to mediation & importance

of follow 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 circulation

Types of Heart Failure

1. Left Sided Heart Failure

2. Right Sided Heart Failure

3. High-Output Failure

Left Sided Heart Failure

Left ventricular damage causes blood to back up

through the left atrium & into the pulmonary

veins: Increased pressure causes transudation

into interstitial tissues of the lungs which result

pulmonary congestion.

Predisposing Factors

1. 90% is mitral valve stenosis due to RHD:

inflammation of mitral valve due to invasion of

Group A beta-hemolytic streptococcus

2. Myocardial Infarction

3. Ischemic heart disease

4. Hypertension

5. Aortic valve stenosis

S/sx

1. Dyspnea

2. Paroxysmal nocturnal dyspnea (PND): client is

awakened at night due to difficulty of breathing

3. Orthopnea: use 2-3 pillows when sleeping or

place in high fowlers

4. Tiredness

5. Muscle Weakness

6. Productive cough with blood tinged sputum

7. Tachycardia

8. Frothy salivation

9. Cyanosis

10.Pallor

11.Rales / Crackles

12.Bronchial wheezing

13.Pulsus Alternans: weak pulse followed by strong

bounding pulse

14.PMI is displaced laterally: due to cardiomegaly

15.Possible S3: ventricular gallop

Dx

1. Chest X-ray (CXR): reveals cardiomegaly

2. Pulmonary Arterial Pressure (PAP): measures

pressure in 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 status

Increase CVP: decreased flow rate of IV

Decrease CVP: increased flow rate of IV

5. Swan-Ganz catheterization: cardiac

catheterization

6. Echocardiography: shows increased sized of

cardiac chamber (cardiomyopathy): dependent

on extent of heart failure

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

is increased (respiratory acidosis)

Right Sided Heart Failure

Weakened right ventricle is unable to pump

blood into he pulmonary system: systemic

venous congestion occurs as pressure builds up

Predisposing Factors

1. Right ventricular infarction

2. Atherosclerotic heart disease

3. Tricuspid valve stenosis

4. Pulmonary embolism

5. Related to COPD

6. Pulmonic valve stenosis

7. Left sided heart failure

S/sx

1. 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

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11.Pruritus

12.Esophageal varices

Dx

1. Chest X-ray (CXR): reveals cardiomegaly

2. Central Venous Pressure (CVP): measure fluid

status: elevated

Measure pressure in right atrium: 4-10 cm of

water

If CVP is less than 4 cm of water: Hypovolemic

shock: increase IV flow rate

If CVP is more than 10 cm of water:

Hypervolemic shock: Administer loop diuretics

as ordered

Nursing Intervention:

When reading CVP patient should be flat

on bed

Upon insertion place client in

trendelendberg position: to promote

ventricular filling and prevent pulmonary

embolism

3. Echocardiography: reveals increased size of

cardiac chambers (cardiomyopathy)

4. Liver enzymes: SGPT & SGOT: is increased

5. ABG: decreased pO2

Medical Management

1. Determination & elimination / control of

underlying cause

2. Drug therapy: digitalis preparations, diuretics,

vasodilators

3. Sodium-restricted diet: to decrease fluid

retention

4. If medical therapies unsuccessful: mechanical

assist devices (intra-aortic balloon pump),

cardiac transplantation, or mechanical heart may

be employed

5. Treatment for Left Sided Heart Failure Only:

M – Morphine SO4

A – Aminophylline

D – Digitalis

D – Diuretics

O – O2

G – Gases

Nursing Intervention

Goal: Increase cardiac contractility thereby increasing

cardiac output of 3-6 L / min

1. Monitor respiratory status & provide adequate

ventilation (when HF progress to pulmonary

edema)

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

delivered via nasal cannula

b. Maintain client in semi or high fowlers

position: maximize oxygenation by promoting

lung expansion

c. Monitor ABG

d. Assess for breath sounds: noting any changes

2. Provide physical & emotional rest

a. Constantly assess level of anxiety

b. Maintain bed rest with limited activity

c. Maintain quiet & relaxed environment

d. Organized nursing care around rest periods

3. Increase cardiac output

a. Administer digitalis as ordered & monitor

effects

Cardiac glycosides: Digoxin (Lanoxin)

Action: Increase force of cardiac

contraction

Contraindication: If heart rate is decreased

do not give

b. Monitor ECG & hemodynamic monitoring

c. Administer vasodilators as ordered

Vasodilators: Nitroglycerine (NTG)

d. Monitor V/S

4. 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

5. If acute pulmonary edema occurs: For Left Sided

Heart Failure only

a. Administer Narcotic Analgesic as ordered

Narcotic analgesic: Morphine SO4

Action: to allay anxiety & reduce preload &

afterload

b. Administer Bronchodilator as ordered

Bronchodilators: Aminophylline IV

Action: relieve bronchospasm, increase

urinary output & increase cardiac output

c. Administer Anti-arrythmic as ordered

Anti-arrythmic: Lidocaine (Xylocane)

6. Assist in bloodless phlebotomy: rotating

tourniquet, rotated clockwise every 15 minutes:

to promote decrease venous return or reducing

preload

7. Provide client teaching & discharge planning

concerning:

a. Need to monitor self daily for S/sx of Heart

Failure (pedal edema, weight gain, of 1-2 kg

in a 2 day period, dyspnea, loss of appetite,

cough)

b. Medication regimen including name, purpose,

dosage, frequency & side effects (digitalis,

diuretics)

c. Prescribe diet plan (low Na, cholesterol,

caffeine: small frequent meals)

d. Need to avoid fatigue & plan for rest periods

e. Prevent complications

Arrythmia

Shock

Right ventricular hypertrophy

MI

Thrombophlebitis

f. Importance of follow-up care

Peripheral Vascular Disorder

Arterial Ulcer

1. Thromboangiitis Obliterans (Buerger’s Disease)

2. Raynaud’s Phenomenon

Venous Ulcer

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1. Varicose Veins

2. Thrombophlebitis (deep vein thrombosis)

Thromboangiitis Obliterans (Buerger’s Disease)

Acute inflammatory disorder affecting the small /

medium sized arteries & veins of the lower

extremities

Occurs as focal, obstructive, process; result in

occlusion of a vessel with a subsequent

development of collateral circulation

Predisposing Factors

1. High risk groups - men 25-40 years old

2. High incident among smokers

S/sx

1. Intermittent claudication: leg pain upon walking

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

(pallor) changing to blue (cyanosis) then red

(rubor)

3. Decreased or absent peripheral pulses (posterior

tibial & dorsalis pedis)

4. Trophic changes

5. Ulceration & Gangrene formation (advanced)

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 ?)

Papaverine

Isoxsuprine HCL (Vasodilan)

Nylidrin HCL (Arlidin)

Nicotinyl Alcohol (Roniacol)

Cyclandelate (Cyclospasmol)

Tolazoline HCL (Priscoline)

b. Analgesic: to relieve ischemic pain

c. Anti-coagulant: to prevent thrombus

formation

2. Surgery

a. Bypass Grafting

b. Endarterectomy

c. Balloon Catheter Dilation

d. Lumbar Sympathectomy: to increase blood

flow

e. Amputation: may be necessary

Nursing Intervention

1. Encourage a slow progressive physical activity

Walking at least 2 times / day

Out of bed at least 3-4 times / day

2. Administer medications as ordered

Analgesics

Vasodilators

Anti-coagulants

3. 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

6. Prepare client for surgery: below knee

amputation (BKA)

7. Importance of follow-up care

Raynaud’s Phenomenon

Intermittent episodes of arterial spasm most

frequently involving the fingers or digits of the

hands

Predisposing Factors

1. High risk group: female between the teenage

years & age 40 years old & above

2. Smoking

3. Collagen diseases

a. Systemic Lupus Erythematosus (SLE):

butterfly rash

b. Rheumatoid Arthritis

4. Direct hand trauma

a. Piano playing

b. Excessive typing

c. Operating chainsaw

S/sx

1. Coldness

2. Numbness

3. Tingling in one or more digits

4. Pain: usually precipitated by exposure to cold,

Emotional upset & Tobacco use

5. Intermittent color changes: pallor (white),

cyanosis (blue), rubor (red)

6. Small ulceration & gangrene a tips of digits

(advance)

Dx

1. Doppler UTZ: decrease blood flow to the affected

extremity

2. Angiography: reveals site & extent of

malocclusion

Medical Management

1. Administer medications as ordered

a. Catecholamine-depliting antihypertinsive

drugs:

Reserpine

Guanethidine Monosulfate (Ismelin)

b. Vasodilators

Nursing Intervention

1. Importance of stop smoking

2. Need to maintain warmth especially in cold

weather

3. Need to wear gloves when handling cold object /

opening a freezer or refrigerator door

Varicose Veins

Dilated veins that occurs most often in the lower

extremities & trunk. As the vessel dilates the

valves become stretched & incompetent with

result venous pooling / edema

Abnormal dilation of veins of lower extremities

and trunks due to incompetent valve resulting to

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increased venous pooling resulting to venous

stasis causing decrease venous return

Predisposing Factors

1. Hereditary

2. Congenital weakness of the veins

3. Thrombophlebitis

4. Cardiac disorder

5. Pregnancy

6. Obesity

7. Prolonged standing or sitting

S/sx

1. Pain after prolonged standing: relieved by

elevation

2. Swollen dilated tortuous skin veins

3. Warm to touch

4. Heaviness in legs

Dx

1. Venography

2. Trendelenburg Test: veins distends quickly in

less than 35 seconds

3. Doppler Ultrasound: decreased or no blood flow

heard after 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

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. Provide routine pre-op care: usually OPD

b. In addition to routine post-op care:

Keep affected extremity elevated above

the level of the heart: to prevent edema

Apply elastic bandage & stockings which

should be removed every 8 hours for short

periods & reapplied

Assist out of bed within 24 hours ensuring

the elastic stockings is applied

Assess for increase of bleeding particularly

in groin area

7. Provide client teaching & discharge planning

Thrombophlebitis (Deep vein thrombosis)

Inflammation of the vessel wall with formation of

clot (thrombus), may affect superficial or deep

veins

Inflammation of the veins with thrombus

formation

Most frequent veins affected are the saphenous,

femoral & popliteal

Can result in damage to the surrounding tissue,

ischemia & necrosis

Predisposing Factors

1. Obesity

2. Smoking

3. Related to pregnancy

4. Severe anemia

5. Prolong use of oral contraceptives: promotes

lipolysis

6. Prolonged immobility

7. Trauma

8. Dehydration

9. Sepsis

10.Congestive heart failure

11.Myocardial infarction

12.Post-op complication: surgery

13.Venous cannulation: insertion of various cardiac

catheter

14.Increase in saturated fats in the diet.

S/sx

1. Pain in the affected extremity

2. Superficial vein: Tenderness, redness induration

along course of the vein

3. Deep vein:

Swelling

Venous distention of limb

Tenderness over involved vein

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

muscle upon dorsi flexion of the foot

Cyanosis

Dx

1. Venography (Phlebography): increased uptake of

radioactive material

2. Doppler ultrasonography: impairment of blood

flow ahead of thrombus

3. Venous pressure measurement: high in affected

limb until collateral circulation is developed

Medical Management

1. Anti-coagulant therapy

a. Heparin

Action: block conversion of prothrombin to

thrombin & reduces formation or extension

of thrombus

Side effects:

Spontaneous bleeding

Injection site reaction

Ecchymoses

Tissue irritation & sloughing

Reversible transient alopecia

Cyanosis

Pan in the arms or legs

Thrombocytopenia

b. Warfarin (Coumadin)

Action: block prothrombin synthesis by

interfering with vit. K synthesis

Side effects:

GI:

Anorexia

N/V

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Diarrhea

Stomatitis

Hypersensitivity:

Dermatitis

Urticaria

Pruritus

Fever

Other:

Transient hair loss

Burning sensation of feet

Bleeding complication

2. Surgery

a. Vein ligation & stripping

b. Venous thrombectomy: removal of cloth in

the iliofemoral region

c. Plication of the inferior vena cava: insertion of

an umbrella-like prosthesis into the lumen of

the vena cava: to filter incoming cloth

Nursing Intervention

1. Elevate legs above heart level: to promote

increase venous return & decreased edema

2. Apply warm moist pack: to reduce lymphatic

congestion

3. Administer anti-coagulant as ordered:

a. Heparin

Monitor PTT: dosage should be adjusted to

keep PTT between 1.5-2.5 times normal

control level

Use infusion pump to administer heparin

Ensure proper injection technique

Use 26 or 27 gauge syringe with ½-5/8

inch needle, inject into fatty layer of

abdomen above iliac crest

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: avoid massage

Assess for increased bleeding tendencies

(hematuria, hematemesis, bleeding gums,

petechiae of soft palate, conjunctiva

retina, ecchymoses, epistaxis, bloody

spumtum, melena) & instruct the client to

observe for & report these

Have antidote (Protamine Sulfate)

available

Instruct the client to avoid aspirin,

antihistamines 7 cough preparations

containing glyceryl guaiacolate & obtain

MD permission before using other OTC

drugs

b. Warfarin (Coumadin)

Assess PT daily: dosage should be

adjusted to maintain PT at 1.5-2.5 times

normal control level; INR of 2

Obtain careful medication history (there

are many drug-drug interaction)

Advise client to withhold dose & notify MD

immediately if bleeding occur

Have antidote (Vitamin K) available

Alert client to factors that may affect the

anticoagulant response (high-fat diet or

sudden increased in vit. K-rich food)

Instruct the client to wear medic-alert

bracelet

4. Assess V/S every 4 hours

5. Monitor chest pain or shortness of breath:

possible pulmonary embolism

6. Measure thigh, calves, ankles & instep every

morning

7. Provide client teaching & discharge planning

a. Need to avoid standing, sitting for long

period, constrictive clothing, crossing legs at

the knee, smoking, oral contraceptives

b. Importance of adequate hydration: to prevent

hypercoagubility

c. Use elastic stockings when ambulatory

d. Importance of planned rest periods with

elevation of the feet

e. Drug regimen

f. Plan for exercise / activity

Begin with dorsiflexion of the feet while

sitting or lying down

Swim several times weekly

Gradually increased walking distance

g. Importance of weight reduction: if obese

h. Monitor for signs of complications

a. Pulmonary Embolism

Sudden sharp chest pain

Unexplained dyspnea

Tachycardia

Palpitations

Diaphoresis

Restlessness

Overview of Anatomy & Physiology of the Respiratory

System

Upper Respiratory System

Structure of the respiratory system, primarily an

air conduction system, include the nose, pharynx

& larynx. Air is filtered warmed & humidified in

the upper airway before passing to lower airway.

Nose

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

, internally divided into two passages or nares

(nasal cavity) by the septum: air enters the

system through the nares

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 Plexus: the site of nose bleeding

Pharynx

1. A muscular passageway commonly called the

throat

2. Air passes through the nose to the pharynx

3. Serves as a muscular passageway for both food

and air

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Composed of three section

1. Nasopharynx: located above the soft palate of

the mouth, contains the adenoids & opening to

the eustachian tubes

2. Oropharynx: located directly behind the mouth &

tongue, contains the palatine tonsils; air & food

enter the body through oropharynx

3. Laryngopharynx: extends from the epiglotitis to

the sixth cervical level

Larynx

1. Sometimes called “voice Box” connects upper &

lower airways

2. Framework is formed by the hyoid bone,

epiglotitis & thyroid, cricoid & arytenoids

cartilages

3. Larynx opens to allow respiration & closes to

prevent aspiration when food passes through the

pharynx

4. Vocal cords of larynx permit speech & are

involved in the cough reflex

5. For phonation (voice production)

Glottis

1. Opening of larynx

2. Opens to allow passage of air

3. Closes to allow passage of food going to the

esophagus

4. The initial sign of complete airway obstruction is

the inability to cough

Lower Respiratory System

Consist of trachea, bronchi & branches, & the

lungs & associated structures

For gas exchange

Trachea

AKA “Windpipe”

Air move from the pharynx to larynx to trachea

(length 11-13 cm, diameter 1.5-2.5 cm in adult)

Extend from the larynx to the second costal

cartilage, where it bifurcates & is supported by

16-20 C-shaped cartilage rings

The area where the trachea divides into two

branches is called the carina

Consist of cartilaginous rings

Serves as passageway of air going to the lungs

Site of tracheostomy

Bronchi

Right main bronchus

Larger & straighter than the left

Divided into three lobar branches (upper,

middle & lower bronchi) to supply the three

lobes of right lung

Left main bronchus

Divides into the upper & lower lobar bronchi

to supply the left lobes

Bronchioles

In the bronchioles, airway patency is primarily

dependent upon elastic recoil formed by network

of smooth muscles

The tracheobronchial tree ends at the terminal

bronchials. Distal to the terminal bronchioles the

major function is no longer air conduction but

gas exchange between blood & alveolar air

The respiratory bronchioles serves as the

transition to the alveolar epithelium

Lungs

Right lung (consist of 3 lobes, 10 segments)

Left lung (consist of 2 lobes, 8 segments)

Main organ of respiration, lie within the thoracic

cavity on either side of the heart

Broad area of lungs resting on diaphragm is

called the base & the narrow superior portion

called the apex

Pleura

Serous membranes covering the lungs,

continuous with the parietal pleura that lines the

chest wall

Parietal Pleura

Lines the chest walls & secretes small amounts

of lubricating fluid into the intrapleural space

(space between the parietal pleura & visceral

pleura) this fluid holds the lungs & chest wall

together as a single unit while allowing them to

move separately

Chest Wall

Includes the ribs cage, intercostal muscles &

diaphragm

Chest is a C shaped & supported by 12 pairs of

ribs & costal cartilages, the ribs have several

attached muscles

Contraction of the external intercostal

muscles raises the ribs cage during

inspiration & helps increase the size of the

thoracic cavity

The internal intercoastal muscles tends to pull

ribs down & in & play a role in forced

expiration

Diaphragm

A major muscle of ventilation (the exchange of

air between the atmosphere & the alveoli).

Alveoli

Are functional cellular unit of the lungs; about

half arise directly from alveolar ducts & are

responsible for about 35% of alveolar gas

exchange

Produces surfactants

Site of gas exchange (CO2 and O2)

Diffusion (Dalton’s law of partial pressure of

gases)

Surfactant

A phospholipids substance found in the fluid

lining the alveolar epithelium

Reduces surface tension & increase stability of

the alveoli & prevents their collapse

Alveolar Ducts

Arises from the respiratory bronchioles & lead to

the alveoli

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Alveolar Sac

Form the last part of the airway

Functionally the same as the alveolar ducts they

are surrounded by alveoli & are responsible for

the 65% of the alveolar gas exchange

Type II Cells of Alveoli

Secretes surfactant

Decrease surface tension

Prevent collapse of alveoli

Composed of lecithin and spingomyelin

Lecitin / Spingomyelin ratio: to determine lung

maturity

Normal Lecitin / Spingomyelin ratio: is 2:1

In premature infants: 1:2

Give oxygen of less 40% in premature: to

prevent atelectasis and retrolental

fibroplasias

Retinopathy & blindness: in premature

Pulmonary Circulation

Provides for reoxygenation of blood & release of

CO2

Gas transfers occurs in the pulmonary capillary

bed

Respiratory Distress Syndrome

Decrease oxygen stimulates breathing

Increase carbon dioxide is a powerful stimulant

for breathing

Pneumonia

Inflammation of the alveolar spaces of the lungs,

resulting in consolidation of lung tissue as the

alveoli fill with exudates

Inflammation of the lung parenchyma leading to

pulmonary consolidation as the alveoli is filled

with exudates

Etiologic Agents

1. Streptococcus Pneumonae: causing pneumococal

pneumonia

2. Hemophylus Influenzae: causing broncho

pneumonia

3. Diplococcus Pneumoniae

4. Klebsella Pneumoniae

5. Escherichia Pneumoniae

6. Pseudomonas

High Risk Groups

1. Children below 5 years old

2. Elderly

Predisposing Factors

1. Smoking

2. Air pollution

3. Immuno compromised

4. Related to prolonged immobility (CVA clients):

causing hypostatic pneumonia

5. Aspiration of food: causing aspiration pneumonia

S/sx

1. 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)

10.Fever

11.Chills

12.Anorexia

13.General body malaise

14.Weight loss

15.Bronchial wheezing

16.Cyanosis

17.Chest pain

18.Abdominal distention leading to paralytic ileus

(absence of peristalsis)

Dx

1. Sputum Gram Staining & Culture Sensitivity:

positive to cultured microorganisms

2. Chest x-ray: reveals pulmonary consolidation

over affected area

3. ABG analysis: reveals decrease PO2

4. CBC: reveals increase WBC, erythrocyte

sedimentation rate is increased

Nursing Intervention

1. Facilitate adequate ventilation

Administer O2 as needed & assess its

effectiveness: low inflow

Place client semi fowlers position

Turn & reposition frequently client who are

immobilized

Administer analgesic as ordered: DOC:

codeine: to relieve pain associated with

breathing

Auscultate breath sound every 2-4 hour

Monitor ABG

2. Facilitate removal of secretions

General hydration

Deep breathing & coughing exercise: tends to

promote expectoration

Tracheobronchial suctioning as needed

Administer Mucolytic or Expectorant as

ordered

Aerosol treatment via nebulizer

Humidification of inhaled air

Chest physiotherapy (Postural Drainage):

tends to promote expectoration

3. Observe color characteristics of sputum & report

any changes: encourage client to perform good

oral hygiene after expectoration

4. Provide adequate rest & relief control of pain

Enforce CBR with limited activity

Limit visits & minimized conversation

Plan for uninterrupted rest periods

Maintain pleasant & restful environment

5. Administer antibiotic as ordered: monitor effects

& possible toxicity

Broad Spectrum Antibiotic

Penicillin

Tetracycline

Microlides (Zethromax)

Azethromycin: Side Effect: Ototoxicity

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6. Prevent transmission: respiratory isolation client

with staphylococcal pneumonia

7. Control fever & chills:

Monitor temperature A

Administer antipyretic as ordered

Increased fluid intake

Provide frequent clothing & linen changing

8. Assist in postural drainage: uses gravity &

various position to stimulate the movement of

secretions

Nursing Management for Postural Drainage

a. Best done before meals or 2-3 hours: to

prevent gastro esophageal reflux

b. Monitor vital signs

c. Encourage client deep breathing exercises

d. Administer bronchodilators 20-30 minutes

before procedure

e. Stop if client cannot tolerate procedure

f. Provide oral care after procedure

g. Contraindicated with

Unstable V/S

Hemoptysis

Clients with increase intra ocular pressure

(Normal IOP 12 – 21 mmHg)

Increase ICP

9. Provide increase CHO, calories, CHON & vitamin

C

10.Provide client teaching & discharge planning

a. Medication regimen / antibiotic therapy

b. Need for adequate rest, limited activity, good

nutrition, with adequate fluid intake & good

ventilation

c. Need to continue deep breathing & coughing

exercise for at least 6-8 weeks after discharge

d. Availability of vaccines

e. Need to report S/sx of respiratory infection

Persistent or recurrent fever

Changes in characteristics color of sputum

Chills

Increased pain

Difficulty in breathing

Weight loss

Persistent fatigue

f. Avoid smoking

g. Prevent complications

Atelectasis

Meningitis

h. Importance of follow up care

Histoplasmosis

Systemic fungal disease caused by inhalation of

dust contaminated by histoplasma capsulatum

which is transmitted to bird manure

Acute fungal infection caused by inhalation of

contaminated dust or particles with histoplasma

capsulatum derived from birds manure

S/sx

1. Similar to PTB or Pneumonia

2. Productive cough

3. Fever, chills, anorexia, general body malaise

4. Chest and joint pains

5. Dyspnea

6. Cyanosis

7. Hemoptysis

8. Sometimes asymptomatic

Dx

1. Chest X-ray: often appears similar to PTB

2. Histoplasmin Skin Test: positive

3. ABG analysis: PO2 decrease

Medical Management

1. Anti-fungal Agent: Amphotericin B (Fungizone)

Very toxic: toxicity includes anorexia, chills,

fever, headaches & renal failure

Acetaminophen, Benadryl & Steroids is given

with Amphotericin B: to prevent reaction

Nursing Intervention

1. Monitor respiratory status

2. Enforce CBR

3. Administer oxygen inhalation

4. Administer medications as ordered

a. Antifungal: Amphotericin B (Fungizone)

Observe severe side effects:

Fever: acetaminophen given

prophylactically

Anaphylactic reaction: Benadryl &

Steroids given prophylactically

Abnormal renal function with

hypokalemia & azotemia:

Nephrotoxicity, check for BUN and

Creatinine, Hypokalemia

5. Force fluids to liquefy secretions

6. Nebulize & suction as needed

7. Prevent complications: bronchiectasis

8. Prevent the spread of infection by spraying of

breeding places

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Bronchitis

Excessive production of mucus in the bronchi

with accompanying persistent cough

Characteristic include hypertrophy / hyperplasia

of the mucus secreting gland in the bronchi,

decreased ciliary activity, chronic inflammation &

narrowing of the airway

Inflammation of bronchus resulting to

hypertrophy or hyperplasia of goblet mucous

producing cells leading to narrowing of smaller

airways

AKA “Blue Bloaters”

Predisposing Factors

1. Smoking

2. Air pollution

S/sx

1. Productive copious cough (consistent to all

COPD)

2. Dyspnea on exertion

3. Use of accessory muscle of respiration

4. Scattered rales / rhonchi

5. Feeling of gastric fullness

6. Slight Cyanosis

7. Distended neck veins

8. Ankle edema

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9. Prolonged expiratory grunt

10.Anorexia and generalized body malaise

11.Pulmonary hypertension

a. Leading to peripheral edema

b. Cor Pulmonale (right ventricular hypertrophy)

Dx

1. ABG analysis: reveals PO2 decrease (hypoxemia):

causing cyanosis, PCO2 increase

Bronchial Asthma

Immunologic / allergic reaction results in

histamine release which produces three

mainairway response: Edema of mucus

membrane, Spasm of the smooth muscle of

bronchi & bronchioles, Accumulation of tenacious

secretions

Reversible inflammatory lung condition due to

hypersensitivity to allergens leading to narrowing

of smaller airways

Predisposing Factors (Depending on Types)

1. Extrinsic Asthma (Atopic / Allergic)

Causes

Pollen

Dust

Fumes

Smoke

Gases

Danders

Furs

Lints

2. Intrinsic Asthma (Non atopic / Non allergic)

Causes

Hereditary

Drugs (aspirin, penicillin, beta blocker)

Foods (seafoods, eggs, milk, chocolates,

chicken)

Food additives (nitrates)

Sudden change in temperature, air pressure

and humidity

Physical and emotional stress

3. Mixed Type: 90 – 95%

S/sx

1. Cough that is non productive

2. Dyspnea

3. Wheezing on expiration

4. Cyanosis

5. Mild Stress or apprehension

6. Tachycardia, palpitations

7. Diaphoresis

Dx

1. Pulmonary Function Test Incentive spirometer:

reveals decrease vital lung capacity

2. ABG analysis: PO2 decrease

3. Before ABG test for positive Allens Test, apply

direct pressure to ulnar & radial artery to

determine presence of collateral circulation

Medical Management

1. Drug Therapy

a. Bronchodilators: given via inhalation or

metered dose inhaler or MDI for 5 minutes

b. Steroids: decrease inflammation: given 10

min after bronchodilator

c. Mucomysts (acetylceisteine): at bed side put

suction machine

d. Mucolytics / expectorants

e. Anti histamine

2. Physical Therapy

3. Hyposensitization

4. Execise

Nursing Intervention

1. Enforce CBR

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

respiratory distress

3. Administer medications as ordered

4. Force fluids 2-3 L/day

5. Semi fowlers position: to promote lung expansion

6. Nebulize & suction when needed

7. Provide client health teachings and discharge

planning concerning

a. Avoidance of precipitating factor

b. Prevent complications

Emphysema

Status Asthmaticus: severe attack of

asthma which cause poor controlled

asthma

DOC: Epinephrine

Steroids

Bronchodilators

c. Regular adherence to medications: to prevent

development of status asthmaticus

d. Importance of follow up care

Bronchiectasis

Permanent abnormal dilation of the bronchi with

destruction of muscular & elastic structure of the

bronchial wall

Abnormal permanent dilation of bronchus leading

to destruction of muscular and elastic tissues of

alveoli

Predisposing Factors

1. Caused by bacterial infection

2. Recurrent lower respiratory tract infections

3. Chest trauma

4. Congenital defects (altered bronchial structure)

5. Related to presence of tumor (lung tumor)

6. Thick tenacious secretion

Sx

1. Productive cough with mucopurulent sputum

2. Dyspnea in exertion

3. Cyanosis

4. Anorexia & generalized body malaise

5. Hemoptysis (only COPD with sign)

6. Wheezing

7. Weight loss

Dx

1. CBC: elevation in WBC

2. ABG: PO2 decrease

3. Bronchoscopy: reveals sources & sites of

secretion: direct visualization of bronchus using

fiberscope

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Nursing Management before Bronchoscopy

1. Secure inform consent and explain procedure to

client

2. Maintain NPO 6-8 hours prior to procedure

3. Monitor vital signs & breath sound

Post Bronchoscopy

1. Feeding initiated upon return of gag reflex

2. Avoid talking, coughing and smoking, may cause

irritation

3. Monitor for signs of gross

4. Monitor for signs of laryngeal spasm: prepare

tracheostomy set

Medical Management

1. Surgery

Pneumonectomy: 1 lung is removed &

position on affected side

Segmental Wedge Lobectomy: promote re-

expansion of lungs

Unaffected lobectomy: facilitate drainage

Emphysema

Enlargement & destruction of the alveolar,

bronchial & bronchiolar tissue with resultant loss

of recoil, air tapping, thoracic overdistension,

sputum accumulation & loss of diaphragmatic

muscle tone

These changes cause a state of CO2 retention,

hypoxia & respiratory acidosis

Irreversible terminal stage of COPD characterized

by

Inelasticity of alveoli

Air trapping

Maldistribution of gases

Overdistention of thoracic cavity (barrel

chest)

Predisposing Factors

1. Smoking

2. Inhaled irritants: air pollution

3. Allergy or allergic factor

4. High risk: elderly

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

trypsin: to release elastase for recoil of alveoli

S/sx

1. Productive cough

2. Sputum production

3. Anorexia & generalized body malaise

4. Weight loss

5. Flaring of nostrils (alai nares)

6. Use of accessory muscles

7. Dyspnea at rest

8. Increased rate & depth of breathing

9. Decrease respiratory excursion

10.Resonance to hyper resonance

11.Decrease or diminished breath sounds with

prolong expiration

12.Decrease tactile fremitus

13.Prolong expiratory grunt

14.Rales or rhonchi

15.Bronchial wheezing

16.Barrel chest

17.Purse lip breathing: to eliminates excess CO2

(compensatory mechanism)

Dx

1. Pulmonary Function Test: reveals decrease vital

lung capacity

2. ABG analysis: reveals

Panlobular/centrilobular

Decrease PO2 (hypoxemia leading to

chronic bronchitis, “Blue Bloaters”)

Decrease ph

Increase PCO2

Respiratory acidosis

Panacinar/centriacinar

Increase PO2 (hyperaxemia, “Pink Puffers”)

Decrease PCO2

Increase ph

Respiratory alkalosis

Nursing Intervention

1. Enforce CBR

2. Administer oxygen inhalation via low inflow

3. Administer medications as ordered

a. Bronchodilators: used to treat bronchospam

Aminophylline

Isoproterenol (Isuprel)

Terbutalin (Brethine)

Metaproterenol (Alupent)

Theophylline

Isoetharine (Bronkosol)

b. Corticosteroids:

Prednisone

c. Anti-microbial / Antibiotics: to treat bacterial

infection

Tetracycline

Ampicilline

d. Mucolytics / expectorants

4. Facilitate removal of secretions:

a. Force fluids at least 3 L/day

b. Provide chest physiotherapy, coughing &

deep breathing

c. Nebulize & suction when needed

d. Provide oral hygiene after expectoration of

sputum

5. Improve ventilation

a. Position client to semi or high fowlers

b. Instruct the client diaphragmatic muscles to

breathe

c. Encourage productive cough after all

treatment (splint abdomen to help produce

more expulsive cough)

d. Employ pursed-lip breathing techniques

(prolonged slow relaxed expiration against

pursed lips)

e. Institute pulmonary toilet

6. Institute PEEP (positive end expiratory pressure)

in mechanical ventilation promotes maximum

alveolar lung expansion

7. Provide comfortable & humid environment

8. Provide high carbohydrates, protein, calories,

vitamins and minerals

9. Provide client teachings and discharge planning

concerning

a. Prevention of recurrent infection

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Avoid crowds & individual with known

infection

Adhere to high CHON, CHO & increased vit

C diet

Received immunization for influenza &

pneumonia

Report changes in characteristic & color of

sputum immediately

Report of worsening of symptoms

(increased tightness of chest, fatigue,

increased dyspnea)

b. Control of environment

Use home humidifier at 30-50%

Wear scarf over nose & mouth in cold

weather: to prevent bronchospasm

Avoid smoking & contact with

environmental smoke

Avoid abrupt change in temperature

c. Avoidance of inhaled irritants

Stay indoor: if pollution level is high

Use air conditioner with efficiency

particulate air filter: to remove particles

from air

d. Increase activity tolerance

Start with mild exercise: such as walking &

gradual increase in amount & duration

Used breathing techniques: (pursed lip,

diaphragmatic) during activities / exercise:

to control breathing

Have O2 available as needed to assist with

activities

Plan activities that require low amount of

energy

Plan rest period before & after activities

e. Prevent complications

Atelectasis

Cor Pulmonale: R ventricular hypertrophy

CO2 narcosis: may lead to coma

Pneumothorax: air in the pleural space

f. Strict compliance to medication

g. Importance of follow up care

Oncology Nursing

Pathophysiology & Etiology of Cancer

Evolution of Cancer Cells All cells constantly change through growth,

degeneration, repair, & adaptation. Normal cells

must divide & multiply to meet the needs of the

organism as a whole, & this cycle of cell growth

& destruction is an integral part of life processes.

The activities of the normal cell in the human

body are all coordinated to meet the needs of

the organism as a whole, but when the

regulatory control mechanisms of normal fail, &

growth continues in excess of the body needs,

neoplasia results.

The term neoplasia refers to both benign &

malignant growths, but malignant cells behave

very differently from normal cells & have special

features characteristics of the cancer process.

Since the growth control mechanism of normal

cells is not entirely understood, it is not clear

what allows the uncontrolled growth, therefore

no definitive cure has been found.

Characteristics of Malignant Cells

Cancer cells are mutated stem cells that have

undergone structural changes so that they are

unable to perform the normal functions of

specialized tissues.

They may function is a disorderly way to crease

normal function completely, only functioning for

their own survival & growth.

The most undifferentiated cells are also called

anaplastic.

Rate of Growth

Cancer cells have uncontrolled growth or cell

division

Rate at which a tumor grows involves both

increased cell division & increased survival time

of cells.

Malignant cells do not form orderly layers, but

pile on top of each other to eventually form

tumors.

Pre-disposing Factors

G – Genetics

Some cancers shows familial pattern

Maybe caused by inherited genetics defects

I – Immunologic

Failure of the immune system to respond &

eradicate cancer cells

Immunosuppressed individuals are more

susceptible to cancer

V – Viral

o Viruses have been shown to be the cause

of certain tumors in animals

o Viruses ( HTLV-I, Epstein Barr Virus,

Human Papilloma Virus) linked to human

tumors

o Oncovirus (RNA – Type Viruses) thought to

be culprit

E – Environmental

o Majority (over 80%) of human cancer

related to environmental carcinogens

o Types:

Physical

Radiation: X – ray, radium,

nuclear explosion & waste,

UV

Trauma or chronic irritation

Chemical

Nitrates, & food additives,

polycyclic hydrocarbons,

dyes, alkylating agents

Drugs: arsenicals, stilbestol,

urethane

Cigarette smoke

hormones

Classification of Cancer

Tissue Typing:

Carcinoma – arises from surface, glandular, or

parenchymal epithelium

1. Squamous Cell Carcinoma – surface

epithelium

2. Adenocarcinoma – glandular or

parenchymal tissue

Sarcoma – arises from connective tissue

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Leukemia – from blood

Lymphoma – from lymph glands

Multiple Myeloma – from bone marrow

Stages of Tumor Growth

A. Staging System:

TNM System: uses letters & numbers to

designate the extent of tumors

o T– stands for primary growth; 1-4 with

increasing size; T1S indicates carcinoma in

situ

o N – stands for lymph nodes involvement:

0-4 indicates progressively advancing

nodal disease

o M – stands for metastasis; 0 indicates no

distant metastases, 1 indicates presence

of metastases

Stages 0 – IV: all cancers divided into five stages

incorporating size, nodal involvement & spread

B. Cytologic Diagnosis of Cancer

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

smear)

2. Classified by degree of cellular abnormality

Normal

Probably normal (slight changes)

Doubtful (more severe changes)

Probably cancer or precancerous

Definitely cancer

Client Factors

1. Seven warning signs of cancer

2. BSE – breast self – examination

3. Importance of retal exam for those over age

40

4. Hazards of smoking

5. Oral self – examination as well as annual

exam of mouth & teeth

6. Hazards of excess sun exposure

7. Importance of pap smear

8. P.E. with lab work – up: every 3 years ages

20-40; yearly for age 40 & over

9. TSE – testicular self – examination

Testicular Cancer

i. Most common cancer in men

between the age of 15 & 34

Warning signs that men should look for:

i. Painless swelling

ii. Feeling of heaviness

iii. Hard lump (size of a pea)

iv. Sudden collection fluid in the

scrotum

v. Dull ache in the lower abdomen

or in the groin

vi. Pain in the testicle or in the

scrotum

vii. Enlargement or tenderness of

the breasts

7 Warning Signs of Cancer

C: change in bowel or bladder habits

A: a sore that doesn’t heal

U: unusual bleeding or discharge

T: thickening of lump in breast or elsewhere

I: indigestion or dysphagia

O: obvious change in wart or mole

N: nagging cough or hoarseness

Treatment of Cancer

Therapeutic Modality

Chemotherapy

Ability of the drug to kill cancer cells; normal

cells may also be damaged, producing side

effects.

Different drug act on tumor cell in different

stages of the cell growth cycle.

Types of Chemotherapeutic Drugs

1. Antimetabolites

o Foster cancer cell death by interfering with

cellular metabolic process.

2. Alkylating Agent

o act with DNA to hinder cell growth &

division.

3. Plant Alkaloids

o obtained from periwinkle plant.

o makes the host’s body a less favorable

environment for the growth of cancer cells.

4. Antitumor Antibiotics

o affect RNA to make environment less

favorable for cancer growth.

5. Steroids & Sex Hormones

o alter the endocrine environment to make it

less conducive to growth of cancer cells.

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

Diarrhea

o Administer antidiarrheals.

o Maintain good perineal care.

o Give clear liquids as tolerated.

o Monitor K, Na, Cl levels.

Stomatitis (mouth sore)

o Provide & teach the client good oral

hygiene, including avoidance of

commercial mouthwashes.

o Rinse with viscous lidocaine before meals

to provide analgesic effect.

o Perform a cleansing rinse with plain H2O

or dilute a H2O soluble lubricant such as

hydrogen peroxide after meal.

o Apply H2O lubricant such as K-Y jelly to

lubricate cracked lips.

o Advice client to suck on Popsicles or ice

chips to provide moisture.

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B. Hematologic System

Thrombocytopenia

o Avoid bumping or bruising the skin.

o Protect client from physical injury.

o Avoid aspirin or aspirin products.

o Avoid giving IM injections.

o Monitor blood counts carefully.

o Assess for signs of increase bleeding

tendencies (epistaxis, petechiae,

ecchymoses)

Leukopenia

o Use careful handwashing technique.

o Maintain reverse isolation if WBC count

drops below 1000/mm

o Assess for signs of respiratory infection

o Avoid crowds/persons with known infection

Anemia

o Provide adequate rest period

o Monitor hemoglobin & hematocrit

o Protect client from injury

o Administer O2 if needed

C. Integumentary System

Alopecia

o Explain that hair loss is not permanent

o Offer support & encouragement

o Scalp tourniquets or scalp hypothermia via

ice pack may be ordered to minimize hair

loss with some agent

o Advice client to obtain wig before initiating

treatment

D. Renal System

Encourage fluid & frequent voiding to prevent

accumulation of metabolites in bladder; R: may

cause direct damage to kidney by excretion of

metabolites.

Increased excretion of uric acid may damage

kidney

Administer allopurinol (Zyloprim) as ordered; R:

to prevent uric acid formation; encourage fluids

when administering allopurinol

E. Reproductive System

Damage may occur to both men & women

resulting infertility &/or mutagenic damage to

chromosomes

Banking sperm often recommended for men

before chemotherapy

Clients & partners advised to use reliable

methods of contraception during chemotherapy

F. Neurologic System

Plant alkaloids (vincristine) cause neurologic

damage with repeated doses

Peripheral neuropathies, hearing loss, loss of

deep tendon reflex, & paralytic ileus may occur.

Radiation Therapy

Uses ionizing radiation to kill or limit the growth

of cancer cells, maybe internal or external.

It not only injured cell membrane but destroy &

alter DNA so that the cell cannot reproduce.

Effects cannot be limited to cancer cells only; all

exposed cells including normal cells will be

injured causing side effects.

Localized effects are related to the area of the

body being treated; generalized effects maybe

related to cellular breakdown products.

Types of Energy Emitted

Alpha – particles cannot passed through skin,

rarely used.

Beta – particle cannot passed through skin, more

penetrating than alpha, generally emitted from

radioactive isotopes, used for internal source.

Gamma – penetrate more deeper areas of the

body, most common form of external

radiotherapy (ex. Electromagnetic or X-ray)

Methods of Delivery

External Radiation Therapy – beams high energy

rays directly to the affected area. Ex. Cobalt

therapy

Internal Radiation Therapy – radioactive material

is injected or implanted in the client’s body for

designated period of time.

o Sealed Implants – a radioisotope enclosed

in a container so it does not circulate in

the body; client’s body fluids should not be

contaminated.

o Unsealed source – a radioisotope that is

not encased in a container & does

circulate in the body & contaminate body

fluids.

Factors Controlling Exposure

Half-life – time required for half of radioactive

atoms to decay.

1. Each radioisotope has different half-life.

2. At the end of half-life the danger from

exposure decreases.

Time – the shorter the duration the less the

exposure.

Distance – the greater the distance from the

radiation source the less the exposure.

Shielding – all radiation can be blocked; rubber

gloves for alpha & usually beta rays; thick lead or

concrete stop gamma rays.

Side Effects of Radiation Therapy & Nursing

Intervention

A. Skin - itching, redness, burning, oozing, sloughing.

Keep skin free from foreign substances.

Avoid use of medicated solution, ointment, or

powders that contain heavy metals such as zinc

oxide.

Avoid pressure, trauma, infection to skin; use

bed cradle.

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Wash affected areas with plain H2O & pat dry;

avoid soap.

Use cornstarch, olive oil for itching; avoid talcum

powder.

If sloughing occurs, use sterile dressing with

micropore tape

Avoid exposing skin to heat, cold, or sunlight &

avoid constricting irritating clothing.

B. Anorexia, N/V

Arrange meal time so they do not directly

precede or follow therapy.

Encourage bland foods.

Provide small attractive meals.

Avoid extreme temperature.

Administer antiemetics as ordered before

meals.

C. Diarrhea

Encourage low residue, bland, high CHON food.

Administer antidiarrheal as ordered.

Provide good perineal care.

Monitor electrolytes particularly Na, K, Cl

D. Anemia, Leukopenia, Thrombocytopenia

Isolate from those with known infection.

Provide frequent rest period.

Encourage high CHON diet.

Avoid injury.

Assess for bleeding.

Monitor CBC, WBC, & platelets.

Burns

direct tissue injury caused by thermal, electric,

chemical & smoke inhaled (TECS)

Type:

1. Thermal

2. Smoke Inhalation

3. Chemical

4. Electrical

Classification

Partial Thickness

1. Superficial partial thickness (1st degree)

Depth: epidermis only

Causes: sunburn, splashes of hot

liquid

Sensation: painful

Characteristics: erythema,

blanching on pressure, no vesicles

2. Deep Partial Thickness (2nd degree)

Depth: epidermis & dermis

Causes: flash, scalding, or flame

burn

Sensation: very painful

Characteristics: fluid filled vesicles;

red, shinny, wet after vesicles

ruptures

Full Thickness (3rd & 4th degree)

1. Depth: all skin layers & nerve endings;

may involve muscles, tendons & bones

2. Causes: flames, chemicals, scalding,

electric current

3. Sensation: little or no pain

4. Characteristics: wound is dry, white,

leathery, or hard

Overview Of Anatomy & Physiology Of Musculoskeletal

System

Consist of bones, muscles, joints, cartilages,

tendons, ligaments, bursae

To provide a structural framework for the body

To provide a means for movement

Bones

Function of Bones

Provide support to skeletal framework

Assist in movement by acting as levers for

muscles

Protect vital organ & soft tissue

Manufacture RBC in the red bone marrow

(hematopoiesis)

Provide site for storage of calcium &

phosphorus

1. Types of Bones

Long Bones

Central shaft (diaphysis) made of compact

bone & two end (epiphyses) composed of

cancellous bones (ex. Femur & humerus)

Short Bones

Cancellous bones covered by thin layer of

compact bone (ex. Carpals & tarsals)

Flat Bones

Two layers of compact bone separated by

a layer of cancellous bone (ex. Skull &

ribs)

Irregular Bones

Sizes and shapes vary (ex. Vertebrae &

mandible)

Joints

Articulation of bones occurs at joints

Movable joints provide stabilization and permit a

variety of movements

Classification

1. Synarthroses: immovable joints

2. Amphiarthroses: partially movable joints

3. Diarthroses (synovial): freely movable joints

Have a joint cavity (synovial cavity) between

the articulating bone surfaces

Articular cartilage covers the ends of the

bones

A fibrous capsule encloses the joint

Capsule is lined with synovial membrane that

secretes synovial fluid to lubricate the joint

and reduce friction.

Muscles

Functions of Muscles

Provide shape to the body

Protect the bones

Maintain posture

Cause movement of body parts by contraction

Types of Muscles

Cardiac: involuntary; found only in heart

Smooth: involuntary; found in walls of hollow

structures (e.g. intestines)

Striated (skeletal): voluntary

1. Characteristics of skeletal muscles

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Muscles are attached to the skeleton at

the point of origin and to bones at the

point of insertion.

Have properties of contraction and

extension, as well as elasticity, to permit

isotonic (shortening and thickening of the

muscle) and isometric (increased muscle

tension) movement.

Contraction is innervated by nerve

stimulation.

Cartilage

A form of connective tissue

Major functions are to cushion bony prominences

and offer protection where resiliency is required

Tendons and Ligaments

Composed of dense, fibrous connective tissue

Functions

1. Ligaments attach bone to bone

2. Tendons attach muscle to bone

Rheumatoid Arthritis (RA)

Chronic systemic disease characterized by

inflammatory changes in joints and related

structures.

Joint distribution is symmetric (bilateral): most

commonly affects smaller peripheral joints of

hands & also commonly involves wrists, elbows,

shoulders, knees, hips, ankles and jaw.

If unarrested, affected joints progress through

four stages of deterioration: synovitis, pannus

formation, fibrous ankylosis, and bony ankylosis.

Cause

1. Cause unknown or idiopathic

2. Maybe an autoimmune process

3. Genetic factors

4. Play a role in society (work)

Predisposing factors

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

between the ages 35-45.

2. Fatigue

3. Cold

4. Emotional stress

5. Infection

S/sx

1. Fatigue

2. Anorexia & body malaise

3. Weight loss

4. Slight elevation in temperature

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

motion, stiff in morning & after a period of

inactivity & may show crippling deformity in long-

standing disease.

6. Muscle weakness secondary to inactivity

7. History of remissions and exacerbations

8. Some clients have additional extra-articular

manifestations: subcutaneous nodules; eye,

vascular, lung, or cardiac problems.

Dx

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

2. CBC: anemia is common

3. ESR: elevated

4. Rheumatoid factor positive

5. ANA: may be positive

6. C-reactive protein: elevated

Medical Management

1. Drug therapy

a. Aspirin: mainstay of treatment: has both

analgesic and anti-inflammatory effect.

b. Nonsteroidal anti-inflammatory drugs

(NSAIDs): relieve pain and inflammation by

inhibiting the synthesis of prostaglandins.

Ibuprofen (Motrin)

Indomethacin (Indocin)

Fenoprofen (Nalfon)

Mefenamic acid (Ponstel)

Phenylbutazone (Butazolidin)

Piroxicam (Feldene)

Naproxen (Naprosyn)

Sulindac (Clinoril)

c. Gold compounds (Chrysotherapy)

Injectable form: given IM once a week;

take 3-6 months to become effective

Sodium thiomalate (Myochrysine)

Aurothioglucose (Solganal)

SI: monitor blood studies &

urinalysis frequently

Proteinuria

Mouth ulcers

Skin rash

Aplastic anemia.

Oral form: smaller doses are effective;

take 3-6 months to become effective

Auranofin (Ridaura)

SI: blood & urine studies should be

monitored.

Diarrhea

d. Corticosteroids

Intra-articular injections: temporarily

suppress inflammation in specific joints.

Systemic administration: used only when

client does not respond to less potent anti-

inflammatory drugs.

e. Methotrexate: given to suppress immune

response

Cytoxan

SI: bone marrow suppression.

2. Physical therapy: to minimize joint deformities.

3. Surgery: to remove severely damaged joints (e.g.

total hip replacement; knee replacement).

Nursing Interventions

1. Assess joints for pain, swelling, tenderness &

limitation of motion.

2. Promote maintenance of joint mobility and

muscle strength.

a. Perform ROM exercises several times a day:

use of heat prior to exercise may decrease

discomfort; stop exercise at the point of pain.

b. Use isometric or other exercise to strengthen

muscles.

3. Change position frequently: alternate sitting,

standing & lying.

4. Promote comfort & relief / control of pain.

a. Ensure balance between activity & rest.

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b. Provide 1-2 scheduled rest periods throughout

day.

c. Rest & support inflamed joints: if splints used:

remove 1-2 times/day for gentle ROM

exercises.

5. Ensure bed rest if ordered for acute

exacerbations.

a. Provide firm mattress.

b. Maintain proper body alignment.

c. Have client lie prone for ½ hour twice a day.

d. Avoid pillows under knees.

e. Keep joints mainly in extension, not flexion.

f. Prevent complications of immobility.

6. Provide heat treatments: warm bath, shower or

whirlpool; warm, moist compresses; paraffin dips

as ordered.

a. May be more effective in chronic pain.

b. Reduce stiffness, pain & muscle spasm.

7. Provide cold treatments as ordered: most

effective during acute episodes.

8. Provide psychologic support and encourage

client to express feelings.

9. Assists clients in setting realistic goals; focus on

client strengths.

10.Provide client teaching & discharge planning &

concerning.

a. Use of prescribed medications & side effects

b. Self-help devices to assist in ADL and to

increase independence

c. Importance of maintaining a balance between

activity & rest

d. Energy conservation methods

e. Performance of ROM, isometric & prescribed

exercises

f. Maintenance of well-balanced diet

g. Application of resting splints as ordered

h. Avoidance of undue physical or emotional

stress

i. Importance of follow-up care

Osteoarthritis

Chronic non-systemic disorder of joints

characterized by degeneration of articular

cartilage

Weight-bearing joints (spine, knees and hips) &

terminal interphalangeal joints of fingers most

commonly affected

Incident Rate

1. Women & men affected equally

2. Incidence increases with age

Predisposing Factors

1. Most important factor in development is aging

(wear & tear on joints)

2. Obesity

3. Joint trauma

S/sx

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

stiffness of joints

2. Heberden’s nodes: bony overgrowths at terminal

interphalangeal joints

3. Decreased ROM with possible crepitation (grating

sound when moving joints)

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.

a. Encourage rest periods throughout day.

b. Use cane or walker when indicated.

c. Ensure proper posture & body mechanics.

d. Promote weight reduction: if obese

e. Avoid excessive weight-bearing activities &

continuous standing.

3. Maintain joint mobility and muscle strength.

a. Provide ROM & isometric exercises.

b. Ensure proper body alignment.

c. Change client’s position frequently.

4. Promote comfort / relief of pain.

a. Administer medications as ordered:

Aspirin & NSAID: most commonly used

Corticosteroids (Intra-articular injections):

to relieve pain & improve mobility.

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

compresses, hot packs): to reduce pain.

5. Prepare client for joint replacement surgery if

necessary.

6. Provide client teaching and discharge planning

concerning

a. Used of prescribed medications and side

effects

b. Importance of rest periods

c. Measures to relieve strain on joints

d. ROM and isometric exercises

e. Maintenance of a well-balanced diet

f. Use of heat/ice as ordered.

Gout

A disorder of purine metabolism; causes high

levels of uric acid in the blood & the precipitation

of urate crystals in the joints

Inflammation of the joints caused by deposition

of urate crystals in articular tissue

Incident Rate

1. Occurs most often in males

2. Familial tendency

S/sx

1. Joint pain

2. Redness

3. Heat

4. Swelling

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

commonly affected (acute gouty arthritis stage)

6. Headache

7. Malaise

8. Anorexia

9. Tachycardia

10.Fever

11.Tophi in outer ear, hands & feet (chronic

tophaceous stage)

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Dx

1. CBC: uric acid elevated

Medical Management

1. Drug therapy

a. Acute attack:

Colchicine IV or PO: discontinue if diarrhea

occurs

NSAID: Indomethacin (Indocin)

Naproxen (Naprosyn)

Phenylbutazone (Butazolidin)

b. Prevention of attacks

Uricosuric agents: increase renal excretion

of uric acid

Probenecid (Benemid)

Sulfinpyrazone (Anturanel)

Allopurinal (Zyloprim): inhibits uric acid

formation

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. Administer analgesics as ordered: for pain

5. Increased fluid intake to 2000-3000 ml/day: to

prevent formation of renal calculi.

6. Apply local heat or cold as ordered: to reduce

pain

7. Apply bed cradle: to keep pressure of sheets off

joints.

8. Provide client teaching and discharge planning

concerning

a. Medications & their side effects

b. Modifications for low-purine diet: avoidance of

shellfish, liver, kidney, brains, sweetbreads,

sardines, anchovies

c. Limitation of alcohol use

d. Increased in fluid intake

e. Weight reduction if necessary

f. Importance of regular exercise

Systemic Lupus Erythematosus (SLE)

Chronic connective tissue disease involving

multiple organ systems

Incident Rate

1. Occurs most frequently in young women

Predisposing Factors

1. Cause unknown

2. Immune

3. Genetic & viral factors have all been suggested

Pathophysiology

1. A defect in body’s immunologic mechanisms

produces autoantibodies in the serum directed

against components of the client’s own cell

nuclei.

2. Affects cells throughout the body resulting in

involvement of many organs, including joints,

skin, kidney, CNS & cardiopulmonary system.

S/sx

1. Fatigue

2. Fever

3. Anorexia

4. Weight loss

5. Malaise

6. History of remissions & exacerbations

7. Joint pain

8. Morning stiffness

9. Skin lesions

Erythematous rash on face, neck or

extremities may occur

Butterfly rash over bridge of nose & cheeks

Photosensitivity with rash in areas exposed to

sun

10.Oral or nasopharyngeal ulcerations

11.Alopecia

12.Renal system involvement

Proteinuria

Hematuria

Renal failure

13.CNS involvement

Peripheral neuritis

Seizures

Organic brain syndrome

Psychosis

14.Cardiopulmonary system involvement

Pericarditis

Pleurisy

15.Increase susceptibility to infection

Dx

1. ESR: elevated

2. CBC: RBC anemia, WBC & platelet counts

decreased

3. Anti-nuclear antibody test (ANA): positive

4. Lupus Erythematosus (LE prep): positive

5. Anti-DNA: positive

6. Chronic false-positive test for syphilis

Medical Management

1. Drug therapy

a. Aspirin & NSAID: to relieve mild symptoms

such as fever & arthritis

b. Corticosteroids: to suppress the inflammatory

response in acute exacerbations or severe

disease

c. Immunosuppressive agents: to suppress the

immune response when client unresponsive

to more conservative therapy

Azathioprine (Imuran)

Cyclophosphamide (Cytoxan)

2. Plasma exchange: to provide temporary

reduction in amount of circulating antibodies.

3. Supportive therapy: as organ systems become

involved.

Nursing Interventions

1. Assess symptoms to determine systems

involved.

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

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3. Administer medications as ordered.

4. Institute seizure precautions & safety measures:

with CNS involvement.

5. Provide psychologic support to client / significant

others.

6. Provide client teaching & discharge planning

concerning

a. Disease process & relationship to symptoms

b. Medication regimen & side effects.

c. Importance of adequate rest.

d. Use of daily heat & exercises as prescribed:

for arthritis.

e. Need to avoid physical or emotional stress

f. Maintenance of a well-balanced diet

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

Osteomyelitis

Infection of the bone and surrounding soft

tissues, most commonly caused by S. aureus.

Infection may reach bone through open wound

(compound fracture or surgery), through the

bloodstream, or by direct extension from infected

adjacent structures.

Infections can be acute or chronic; both cause

bone destruction.

S/sx

1. 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.

Dx

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.

3. Maintain proper body alignment & change

position frequently: to prevent deformities.

4. Provide immobilization of affected part as

ordered.

5. Provide psychologic support & diversional

activities (depression may result from prolonged

hospitalization)

6. Prepare client for surgery if indicated.

Incision & drainage: of bone abscess

Sequestrectomy: removal of dead, infected

bone & cartilage

Bone grafting: after repeated infections

Leg amputation

7. Provide client teaching and discharge planning

concerning

Use of prescribed oral antibiotic therapy &

side effects

Importance of recognizing & reporting signs &

complications (deformity, fracture) or

recurrence

FRACTURES

A. General information

1.

B. Medical management

C. Assessment findings

D. Nursing interventions

Overview of Anatomy & Physiology Gastro Intestinal

Track System

The primary function of GIT are the movement of

food, digestion, absorption, elimination &

provision of a continuous supply of the nutrients

electrolytes & H2O.

Upper alimentary canal: function for digestion

Mouth

Consist of lips & oral cavity

Provides entrance & initial processing for

nutrients & sensory data such as taste, texture &

temperature

Oral Cavity: contains the teeth used for

mastication & the tongue which assists in

deglutition & the taste sensation &

mastication

Salivary gland: located in the mouth produce

secretion containing pyalin for starch

digestion & mucus for lubrication

Pharynx: aids in swallowing & functions in

ingestion by providing a route for food to pass

from the mouth to the esophagus

Esophagus

Muscular tube that receives foods from the

pharynx & propels it into the stomach by

peristalsis

Stomach

Located on the left side of the abdominal cavity

occupying the hypochondriac, epigastric &

umbilical regions

Stores & mixes food with gastric juices & mucus

producing chemical & mechanical changes in the

bolus of food

The secretion of digestive juice is stimulated

by smelling, tasting & chewing food which is

known as cephalic phase of digestion

The gastric phase is stimulated by the

presence of food in the stomach & regulated

by neural stimulation via PNS & hormonal

stimulation through secretion of gastrin by

the gastric mucosa

After processing in the stomach the food

bolus called chyme is released into the small

intestine through the duodenum

Two sphincters control the rate of food passage

Cardiac Sphincter: located at the opening

between the esophagus & stomach

Pyloric Sphincter: located between the

stomach & duodenum

Three anatomic division

Fundus

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Body

Antrum

Gastric Secretions:

Pepsinogen: secreted by the chief cells

located in the fundus aid in CHON digestion

Hydrocholoric Acid: secreted by parietal cells,

function in CHON digestion & released in

response to gastrin

Intrinsic Factor: secreted by parietal cell,

promotes absorption of Vit B12

Mucoid Secretion: coat stomach wall &

prevent auto digestion

1st half of duodenum

Middle Alimentary canal: Function for absorption;

Complete absorption: large intestine

Small Intestines

Composed of the duodenum, jejunum & ileum

Extends from the pylorus to the ileocecal valve

which regulates flow into the large intestines to

prevent reflux to the into the small intestine

Major function: digestion & absorption of the end

product of digestion

Structural Features:

Villi (functional unit of the small intestines):

finger like projections located in the mucous

membrane; containing goblet cells that

secrets mucus & absorptive cells that absorb

digested food stuff

Crypts of Lieberkuhn: produce secretions

containing digestive enzymes

Brunner’s Gland: found in the submucosaof

the duodenum, secretes mucus

2nd half of duodenum

Jejunum

Ileum

1st half of ascending colon

Lower Alimentary Canal: Function: elimination

Large Intestine

Divided into four parts:

Cecum (with appendix)

Colon (ascending, transverse, descending,

sigmoid)

Rectum

Anus

Serves as a reservoir for fecal material until

defecation occurs

Function: to absorb water & electrolytes

MO present in the large intestine: are responsible

for small amount of further breakdown & also

make some vitamins

Amino Acids: deaminated by bacteria

resulting in ammonia which is converted to

urea in the liver

Bacteria in the large intestine: aid in the

synthesis of vitamin K & some of the vitamin

B groups

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

anus

Anus: contains internal sphincter (under

involuntary control) & external sphincter

(voluntary control)

Fecal matter: usually 75% water & 25% solid

wastes (roughage, dead bacteria, fats, CHON,

inorganic matter)

a. 2nd half of ascending colon

b. Transverse

c. Descending colon

d. Sigmoid

e. Rectum

Accessory Organ

Liver

Largest internal organ: located in the right

hypochondriac & epigastric regions of the

abdomen

Liver Loobules: functional unit of the liver

composed of hepatic cells

Hepatic Sinusoids (capillaries): are lined with

kupffer cells which carry out the process of

phagocytosis

Portal circulation brings blood to the liver from

the stomach, spleen, pancreas & intestines

Function:

Metabolism of fats, CHO & CHON: oxidizes

these nutrient for energy & produces

compounds that can be stored

Production of bile

Conjugation & excretion (in the form of

glycogen, fatty acids, minerals, fat-soluble &

water-soluble vitamins) of bilirubin

Storage of vitamins A, D, B12 & iron

Synthesis of coagulation factors

Detoxification of many drugs & conjugation of

sex hormones

Salivary gland

Verniform appendix

Liver

Pancreas: auto digestion

Gallbladder: storage of bile

Biliary System

Consist of the gallbladder & associated ductal

system (bile ducts)

Gallbladder: lies under the surface of the liver

Function: to concentrate & store bile

Ductal System: provides a route for bile to reach

the intestines

Bile: is formed in the liver & excreted into

hepatic duct

Hepatic Duct: joins with the cystic duct (which

drains the gallbladder) to form the common

bile duct

If the sphincter of oddi is relaxed: bile enters the

duodenum, if contracted: bile is stored in

gallbladder

Pancreas

Positioned transversely in the upper abdominal

cavity

Consist of head, body & tail along with a

pancreatic duct which extends along the gland &

enters the duodenum via the common bile duct

Has both exocrine & endocrine function

Function in GI system: is exocrine

Exocrine cells in the pancreas secretes:

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Trypsinogen & Chymotrypsin: for protein

digestion

Amylase: breakdown starch to disacchardes

Lipase: for fat digestion

Endocrine function related to islets of langerhas

Physiology of Digestion & Absorption

Digestion: physical & chemical breakdown of

food into absorptive substance

Initiate in the mouth where the food mixes

with saliva & starch is broken down

Food then passes into the esophagus where it

is propelled into the stomach

In the stomach food is processed by gastric

secretions into a substance called chyme

In the small intestines CHO are hydrolyzed to

monosaccharides, fats to glycerol & fatty acid

& CHON to amino acid to complete the

digestive process

When chymes enters the duodenum,

mucus is secreted to neutralized

hydrocholoric acid, in response to release

secretin, pancreas releases bicarbonate to

neutralized acid chyme

Cholecystokinin & Pancreozymin (CCKPZ)

Are produced by the duodenal mucosa

Stimulate contraction of the gallbladder

along with relaxation of the sphincter of

oddi (to allow bile flow from common

bile duct into the duodenum) &

stimulate release of the pancreatic

enzymes

Salivary Glands

1. Parotid – below & front of ear

2. Sublingual

3. Submaxillary

- Produces saliva – for mechanical digestion

- 1200 -1500 ml/day - saliva produced

Disorder of the GIT

Peptic Ulcer Disease (PUD)

Gastric Ulcer

Ulceration of the mucosal lining of the stomach

Most commonly found in the antrum

Excoriation / erosion of submucosa & mucosal

lining due to:

Hypersecretion of acid: pepsin

Decrease resistance to mucosal barrier

Caused by bacterial infection: Helicobacter Pylori

Doudenal Ulcer

Most commonly found in the first 2 cm of the

duodenum

Characterized by gastric hyperacidity & a

significant rate of gastric emptying

Predisposing factor

Smoking: vasoconstriction: effect GIT ischemia

Alcohol Abuse: stimulates release of histamine:

Parietal cell release Hcl acid = Ulceration

Emotional Stress

Drugs:

Salicylates (Aspirin)

Steroids

Butazolidin

S/sx

Gastric Ulcer

Duodenal Ulcer

Site Antrum or lesser

curvature

Duodenal bulb

Pain 30 min-1

hr after

eating

Left

epigastriu

m

Gaseous

& burning

Not

usually

relieved

by food &

antacid

2-3 hrs

after

eating

Mid

epigastri

um

Crampin

g &

burning

Usually

relieved

by food

& antacid

12 MN –

3am pain

Hypersecret

ion

Normal

gastric

acid

secretion

Increase

d gastric

acid

secretion

Vomiting Common Not

common

Hemorrhage Hematem

eis

Melena

Weight Weight

loss

Weight

gain

Complicatio

ns

Stomach

cause

Hemorrha

ge

Perforati

on

High Risk 60 years

old

20 years

old

Dx

Hgb & Hct: decrease (if anemic)

Endoscopy: reveals ulceration & differentiate

ulceration from gastric cancer

Gastric Analysis: normal gastric acidity

Upper GI series: presence of ulcer confirm

Medical Management

1. Supportive:

Rest

Bland diet

Stress management

2. Drug Therapy:

Antacids: neutralizes gastric acid

Aluminum hydroxide: binds phosphate in

the GIT & neutralized gastric acid &

inactivates pepsin

Magnesium & aluminum salt: neutralized

gastric acid & inactivate pepsin if pH is

raised to >=4

Aluminum containing Antacids

Magnesium containing Antacids

Ex. Aluminum OH gel (Amphojel) Ex. Milk of

Magnesia

SE: Constipation SE:

Diarrhea

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Maalox

SE: fever

Histamines (H2) receptor antagonist: inhibits

gastric acid secretion of parietal cells

Ranitidine (Zantac): has some antibacterial

action against H. pylori

Cimetidine (Tagamet)

Famotidine (Pepcid)

Anticholinergic:

Atropine SO4: inhibit the action of

acetylcholine at post ganglionic site

(secretory glands) results decreases GI

secretions

Propantheline: inhibit muscarinic action of

acetylcholine resulting decrease GI

secretions

Proton Pump Inhibitor: inhibit gastric acid

secretion regardless of acetylcholine or

histamine release

Omeprazole (Prilosec): diminished the

accumulation of acid in the gastric lumen

& healing of duodenal ulcer

Pepsin Inhibitor: reacts with acid to form a

paste that binds to ulcerated tissue to prevent

further destruction by digestive enzyme

pepsin

Sucralfate (Carafate): provides a paste like

subs that coats mucosal lining of stomach

Metronidazole & Amoxacillin: for ulcer caused

by Helicobacter Pylori

3. Surgery:

Gastric Resection

Anastomosis: joining of 2 or more hollow

organ

Subtotal Gastrectomy: Partial removal of

stomach

Before surgery for BI or BII

Do Vagotomy (severing or cutting of

vagus nerve) & Pyloroplasty (drainage)

first

Billroth I

(Gastroduodenostomy)

Removal of ½ of

stomach &

anastomoses of

gastric stump to the

duodenum.

Billroth II

(Gastrojejunostomy)

Removal of ½ -3/4

of stomach &

duodenal bulb &

anastomostoses of

gastric stump to

jejunum.

Nursing Intervention Post op

1. Monitor NGT output

Immediately post op should be bright red

Within 36-42 hrs: output is yellow green

After 42 hrs: output is dark red

2. Administer medication

Analgesic

Antibiotic

Antiemetics

3. Maintain patent IV line

4. Monitor V/S, I&O & bowel sounds

5. Complications:

Hemorrhage: Hypovolemic shock: Late signs:

anuria

Peritonitis

Paralytic ileus: most feared

Hypokalemia

Thromobphlebitis

Pernicious anemia

Nursing Intervention

1. Administer medication as ordered

2. Diet: bland, non irritating, non spicy

3. Avoid caffeine & milk / milk products: Increase

gastric acid secretion

4. Provide client teaching & discharge planning

a. Medical Regimen

Take medication at prescribe time

Have antacid available at all times

Recognized situation that would increase

the need for antacids

Avoid ulcerogenic drugs: salicylates,

steroids

Know proper dosage, action & SE

b. Proper Diet

Bland diet consist of six meals / day

Eat slowly

Avoid acid producing substance: caffeine,

alcohol, highly seasoned food

Avoid stressfull situation at mealtime

Plan rest period after meal

Avoid late bedtime snacks

c. Avoidance of stress-producing situation &

development of stress production methods

Relaxation techniques

Exercise

Biofeedback

Dumping syndrome

Abrupt emptying of stomach content into the

intestine

Rapid gastric emptying of hypertonic food

solutions

Common complication of gastric surgery

Appears 15-20 min after meal & last for 20-60

min

Associated with hyperosmolar CHYME in the

jejunum which draws fluid by osmosis from the

extracellular fluid into the bowel. Decreased

plasma volume & distension of the bowel

stimulates increased intestinal motility

S/sx

1. Weakness

2. Faintness

3. Feeling of fullness

4. Dizziness

5. Diaphoresis

6. Diarrhea

7. Palpitations

Nursing Intervention

1. Avoid fluids in chilled solutions

2. Small frequent feeding: six equally divided

feedings

3. Diet: decrease CHO, moderate fats & CHON

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4. Flat on bed 15-30 min after q feeding

Disorders of the Gallbladder

Cholecystitis / Cholelithiasis

Cholecystitis:

Acute or chronic inflammation of the

gallbladder

Most commonly associated with gallstones

Inflammation occurs within the walls of the

gallbladder & creates thickening accompanied

by edema

Consequently there is impaired circulation,

ischemia & eventually necrosis

Cholelithiasis:

Formation of gallstones & cholesterol stones

Inflammation of gallbladder with gallstone

formation.

Predisposing Factor:

1. High risk: women 40 years old

2. Post menopausal women: undergoing estrogen

therapy

3. Obesity

4. Sedentary lifestyle

5. Hyperlipidemia

6. Neoplasm

S/sx:

1. Severe Right abdominal pain (after eating fatty

food): 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

9. Steatorrhea

Dx

1. Direct Bilirubin Transaminase: increase

2. Alkaline Phosphatase: increase

3. WBC: increase

4. Amylase: increase

5. Lipase: increase

6. Oral cholecystogram (or gallbladder series):

confirms presence of stones

Medical Management

1. Supportive Treatment: NPO with NGT & IV fluids

2. Diet modification with administration of fat

soluble vitamins

3. Drug Therapy

Narcotic analgesic: DOC: Meperdipine Hcl

(Demerol): for pain

(Morpine SO4: is contraindicated because

it causes spasm of the Sphincter of Oddi)

Antocholinergic: (Atrophine SO4): for pain

(Anticholinergic: relax smooth muscles &

open bile ducts)

Antiemetics: Phenothiazide (Phenergan): with

anti emetic properties

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 edema, fat necrosis or hemorrhage

Proteolytic & lipolytic pancreatic enzymes are

activated in the pancreas rather than in the

duodenum resulting in tissue damage & auto

digestion of pancreas

Acute or chronic inflammation of pancreas

leading to pancreatic edema, hemorrhage &

necrosis due to auto digestion

Bleeding of Pancreas: Cullen’s sign at umbilicus

Predisposing factors:

1. Chronic alcoholism

2. Hepatobilary disease

3. Trauma

4. Viral infection

5. Penetrating duodenal ulcer

6. Abscesses

7. Obesity

8. Hyperlipidemia

9. Hyperparathyroidism

10.Drugs: Thiazide, steroids, diuretics, oral

contraceptives

S/Sx:

1. Severe left upper epigastric pain radiates from

back & flank area: aggravated by eating with

DOB

2. N/V

3. Tachycardia

4. Palpitation: due to pain

5. Dyspepsia: indigestion

6. Decrease bowel sounds

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

Hemorrhage

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

9. Hypocalcemia

Dx

1. Serum amylase & lipase: increase

2. Urinary amylase: increase

3. Blood Sugar: increase

4. Lipids Level: increase

5. Serum Ca: decrease

6. CT Scan: shows enlargement of the pancreas

Medical Management

1. Drug Therapy

Narcotic Analgesic: for pain

Meperidine Hcl (Demerol)

Don’t give Morphine SO4: will cause spasm

of Sphincter of Oddi

Smooth muscle relaxant: to relieve pain

Papaverine Hcl

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78

Anticholinergic: to decrease pancreatic

stimulation

Atrophine SO4

Propantheline Bromide (Profanthene)

Antacids: to decrease pancreatic stimulation

Maalox

H2 Antagonist: to decrease pancreatic

stimulation

Ranitidin (Zantac)

Vasodilators: to decrease pancreatic

stimulation

Nitroglycerine (NTG)

Ca Gluconate: to decrease pancreatic

stimulation

2. 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

Infection

Embolism

Hyperglycemia

4. Institute non-pharmacological measures: to

decrease pain

Assist client to comfortable position: Knee

chest or fetal like position

Teach relaxation techniques & provide quiet,

restful environment

5. Provide client teaching & discharge planning

Dietary regimen when oral intake permitted

High CHO, CHON & decrease fats

Eat small frequent meal instead of three

large ones

Avoid caffeine products

Eliminate alcohol consumption

Maintain relaxed atmosphere after meals

Report signs of complication

Continued N/V

Abdominal distension with feeling of

fullness

Persistent weight loss

Severe epigastric or back pain

Frothy foul smelling bowel movement

Irritability, confusion, persistent elevation

of temperature (2 day)

Apendicitis

Inflammation of the appendix that prevents

mucus from passing into the cecum

Inflammation of verniform appendix

If untreated: ischemia, gangrene, rupture &

peritonitis

May cause by mechanical obstruction (fecalith,

intestinal parasites) or anatomic defect

May be related to decrease fiber in the diet

Predisposing factor:

1. Microbial infection

2. Feacalith: undigested food particles like tomato

seeds, guava seeds etc.

3. Intestinal obstruction

S/Sx:

1. Pathognomonic sign: (+) rebound tenderness

2. Low grade fever

3. N/V

4. Decrease bowel sound

5. Diffuse pain at lower Right iliac region

6. Late sign: tachycardia: due to pain

Dx

1. CBC: mild leukocytosis: increase WBC

2. PE: (+) rebound tenderness (flex Right leg,

palpate Right iliac area: rebound)

3. Urinalysis: elevated acetone in urine

Medical Management

Surgery: Appendectomy 24-45 hrs

Nursing Intervention

1. Administer antibiotics / antipyretic as ordered

2. Routinary pre-op nursing measures:

Skin prep

NPO

Avoid enema, cathartics: lead to rupture of

appendix

3. 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

Nursing Intervention post op

1. If (+) Pendrose drain (rubber drain inserted at

surgical wound for drainage of blood, pus etc):

indicates rupture of appendix

2. Position the client semi-fowlers or side lying on

right: to facilitate drainage

3. Administer Meds:

Analgesic: due post op pain

Antibiotics: for infection

Antipyretics: for fever (PRN)

4. Monitor VS, I&O, bowel sound

5. Maintain patent IV line

6. Complications: Peritonitis, Septicemia

Liver Cirrhosis

Chronic progressive disease characterized by

inflammation, fibrosis & degeneration of the liver

parenchymal cell

Destroyed liver cell are replaced by scar tissue,

resulting in architectural changes & malfunction

of the liver

Lost of architectural design of liver leading to fat

necrosis & scarring

Types

Laennec’s Cirrhosis:

Associated with alcohol abuse & malnutrition

Characterized by an accumulation of fat in the liver

cell progressing to widespread scar formation

Postnecrotic Cirrhosis

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79

Result in severe inflammation with massive necrosis

as a complication of viral hepatitis

Cardiac Cirrhosis

Occurs as a consequence of right sided heart failure

Manifested by hepatomegaly with some fibrosis

Biliary Cirrhosis

Associated with biliary obstruction usually in the

common bile duct

Results in chronic impairment of bile excretion

S/sx

Fatigue

Anorexia

N/V

Dyspepsia: Indigestion

Weight loss

Flatulence

Change (Irregular) bowel habit

Ascites

Peripheral edema

Hepatomegaly: pain located in the right upper

quadrant

Atrophy of the liver

Fetor hepaticus: fruity, musty odor of chronic

liver disease

Aterixis: flapping of hands & tremores

Hard nodular liver upon palpation

Increased abdominal girth

Changes in moods

Alertness & mental ability

Sensory deficits

Gynecomastia

Decrease of pubic & axilla hair in males

Amenorrhea in female

Jaundice

Pruritus or urticaria

Easy bruising

Spider angiomas on nose, cheeks, upper

thorax & shoulder

Palmar erythema

Muscle atrophy

Dx

Liver enzymes: increase

SGPT (ALT)

SGOT (AST)

LDH Alkaline Phosphate

Serum cholesterol & ammonia: increase

Indirect bilirubin: increase

CBC: pancytopenia

PT: prolonged

Hepatic Ultrasonogram: fat necrosis of liver

lobules

Nursing Intervention

CBR with bathroom privileges

Encourage gradual, progressive, increasing

activity with planned rest period

Institute measure to relieve pruritus

Do not use soap & detergent

Bathe with tepid water followed by application of

emollient lotion

Provide cool, light, non-constrictive clothing

Keep nail short: to avoid skin excoriation from

scratching

Apply cool, moist compresses to pruritic area

Monitor VS, I & O

Prevent Infection

Prevent skin breakdown: by turning & skin care

Provide reverse isolation for client with severe

leukopenia: handwashing technique

Monitor WBC

Diet:

Small frequent meals

Restrict Na!

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

fats with supplemental Vit A, B-complex, C, D, K

& folic acid

Monitor / prevent bleeding

Measure abdominal girth daily: notify MD

With pt daily & assess pitting edema

Administer diuretics as ordered

Provide client teaching & discharge planning

Avoidance of hepatotoxicity drug: sedative, opiates

or OTC drugs detoxified by liver

How to assess weight gain & increase abdominal

girth

Avoid person with upper respiratory infection

Reporting signs of reccuring illness (liver

tenderness, increase jaundice, increase fatigue,

anorexia)

Avoid all alcohol

Avoid straining stool vigorous blowing of nose &

coughing: to decrease incidence of bleeding

Complications:

Ascites: accumolation of free fluid in abdominal

cavity

Nursing Intervention

Meds: Loop diuretics: 10-15 min effect

Assist in abdominal paracentesis: aspiration of

fluid

Void before paracentesis: to prevent accidental

puncture of bladder as trochar is inserted

Bleeding esophageal varices: Dilation of

esophageal veins

Nursing Intervention

Administer meds:

Vit K

Pitrisin or Vasopresin (IM)

NGT decompression: lavage

Give before lavage: ice or cold saline solution

Monitor NGT output

Assist in mechanical decompression

Insertion of sengstaken-blackemore tube

3 lumen typed catheter

Scissors at bedside to deflate balloon.

Hepatic encephalopathy

Nursing Intervention

Assist in mechanical ventilation: due coma

Monitor VS, neuro check

Siderails: due restless

Administer meds

Laxatives: to excrete ammonia

Overview of Anatomy & Physiology Of GUT System

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80

GUT: Genito-urinary tract

GUT includes the kidneys, ureters, urinary bladder,

urethra & the male & female genitalia

Function:

Promote excretion of nitrogenous waste

products

Maintain F&E & acid base balance

Kidneys

Two of bean shaped organ that lie in the

retroperitonial space on either side of the

vertebral column

Retroperitonially (back of peritoneum) on

either side of vertebral column

Adrenal gland is on top of each kidneys

Encased in Bowmans’s capsule

Renal Parenchyma

Cortex

Outermost layer

Site of glomeruli & proximal & distal tubules of

nephron

Medulla

Middle layer

Formed by collecting tubules & ducts

Renal Sinus & Pelvis

Papillae

Projection of renal tissues located at the tip of the

renal pyramids

Calices

Minor Calyx: collects urine flow from collecting ducts

Major Calyx: directs urine from renal sinus to renal

pelvis

Urine flows from renal pelvis to ureters

Nephron

Functional unit of the kidney

Basic living unit

Renal Corpuscle (vascular system of nephron)

Bowman’s Capsule:

Portion of the proximal tubule surrounds the

glomerulus

Glomerulus:

Capillary network permeable to water,

electrolytes, nutrients & waste

Impermeable to large CHON molecules

Filters blood going to kidneys

Renal Tubule

Divided into proximal convoluted tubule,

descending loop of Henle, acending loop of

Henle, distal convoluted tubule &

collecting ducts

Ureters

Two tubes approximately 25-35 cm long

Extend from the renal pelvis to the pelvic cavity

where they enter the bladder, convey urine from

the kidney to the bladder

Passageway of urine to bladder

Ureterovesical valve: prevent backflow of urine into

ureters

Bladder

Located behind the symphisis pubis

Composed of muscular elastic tissue that makes it

distensible

Serve s as reservoir of urine (capable of holding

1000-1800 ml & 500 ml moderately full)

Internal & external urethral sphincter controls the

flow of urine

Urge to void stimulated by passage of urine past the

internal sphincter (involuntary) to the upper

urethra

Relaxation of external sphincter (voluntary)

produces emptying of the bladder (voiding)

Urethra

Small tube that extends from the bladder to the

exterior of the body

Passage of urine, seminal & vaginal fluids.

Females: located behind the symphisis pubis &

anterior vagina & approximately 3-5 cm

Males: extend the entire length of the penis &

approximately 20 cm

Function of kidneys

Kidneys remove nitrogenous waste &

regulates F & E balance & acid base

balance

Urine is the end product

Urine formation: 25 % of total cardiac output is

received by kidneys

Glomerular Filtration

Ultrafiltration of blood by the glomerulus,

beginning of urine formation

Requires hydrostatic pressure & sufficient circulating

volume

Pressure in 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

Filtrate formed has essentially same composition

as blood plasma without the CHON; blood

cells & CHON are usually too large to pass the

glomerular membrane

Tubular Function

Tubules & collecting ducts carry out the

function of reabsorption, secretion &

excretion

Reabsorption of H2O & electrolytes is

controlled by anitdiuretics hormones

(ADH) released by the pituitary &

aldosterone secreted by the adrenal

glands

Proximal Convoluted Tubule

Reabsorb the ff:

80% of F & E

H2O

Glucose

Amino acids

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81

Bicarbonate

Secretes the ff:

Organic substance

Waste

Loop of Henli

Reabsorb the ff:

Na & Chloride in the ascending limb

H2O in the descending limb

Concentrate / dilutes urine

Distal Convoluted Tubule

Secretes the ff:

Potassium

Hydrogen ions

Ammonia

Reabsorb the ff:

H2O

Bicarbonate

Regulate the ff:

Ca

Phosphate concentration

Collecting Ducts

Received urine from distal convoluted tubules &

reabsorb H2O (regulated by ADH)

Normal Adult: produces 1 L /day of urine

Regulation of BP

Through maintenance of volume (formation /

excretion of urine)

Rennin-angiotensin system is the kidneys controlled

mechanism that can contribute to rise the BP

When the BP drops the cells of the glomerulus

release rennin which then activates angiotensin

to cause vasoconstriction.

Filtration – Normal GFR/ min is 125 ml of blood

Tubular reabsorption – 124ml of ultra infiltrates (H2O &

electrolytes is for reabsorption)

Tubular secretion – 1 ml is excreted in urine

Regulation of BP:

Predisposing factor:

Ex CS – hypovolemia – decrease BP going to kidneys

Activation of RAAS

Release of Renin (hydrolytic enzyme) at

juxtaglomerular apparatus

Angiotensin I mild vasoconstrictor

Angiotensin II vasoconstrictor

Adrenal cortex increase CO increase PR

Aldosterone

Increase BP

Increase Na &

H2O reabsorption

Hypervolemia

Color – amber

Odor – aromatic

Consistency – clear or slightly turbid

pH – 4.5 – 8

Specific gravity – 1.015 – 1.030

WBC/ RBC – (-)

Albumin – (-)

E coli – (-)

Mucus thread – few

Amorphous urate (-)

UTI

CYSTITIS

Inflammation of bladder due to bacterial infection

Predisposing factors:

Microbial invasion: E. coli

High risk: women

Obstruction

Urinary retention

Increase estrogen levels

Sexual intercourse

S/Sx:

Pain: flank area

Urinary frequency & urgency

Burning pain upon urination

Dysuria

Hematuria

Nocturia

Fever

Chills

Anorexia

Gen body malaise

Dx

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

Nursing Intervention

Force fluid: 3000 ml

Warm sitz bath: to promote comfort

Monitor & assess urine for gross odor, hematuria &

sediments

Acid Ash Diet: cranberry, vit C: OJ: to acidify urine &

prevent bacterial multiplication

Administer Medication as ordered:

Systemic Antibiotics

Ampicillin

Cephalosporin

Aminoglycosides

Sulfonamides

Co-trimaxazole (Bactrim)

Gantrism (Gantanol)

Antibacterial

Nitrofurantoin (Macrodantin)

Methenamine Mandelate (Mandelamine)

Nalixidic Acid (NegGram)

Urinary Tract Anagesic

Urinary antiseptics: Mitropurantoin

(Macrodantin)

Urinary analgesic: Pyridium

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Provide client teachings & discharge planning

Importance of Hydration

Void after sex: to avoid stagnation

Female: avoids cleaning back & front (should be

front to back)

Bubble bath, Tissue paper, Powder, perfume

Complications: Pyelonephritis

Pyelonephritis

Acute / chronic inflammation of 1 or 2 renal

pelvis of kidneys leading to tubular

destruction & interstitial abscess formation

Acute: infection usually ascends from lower

urinary tract

Chronic: a combination of structural alteration

along with infection major cause is

ureterovesical reflux with infected urine

backing up into ureters & renal pelvis

Recurrent infection will lead to renal

parenchymal deterioration & Renal Failure

Predisposing factor:

Microbial invasion

E. Coli

Streptococcus

Urinary retention /obstruction

Pregnancy

DM

Exposure to renal toxins

S/sx:

Acute Pyelonephritis

Severe flank pain or dull ache

Costovertibral angle pain / tenderness

Fever

Chills

N/V

Anorexia

Gen body malaise

Urinary frequency & urgency

Nocturia

Dsyuria

Hematuria

Burning sensation on urination

Chronic Pyelonephritis: client usually not

aware of disease

Bladder irritability

Slight dull ache over the kidney

Chronic Fatigue

Weight loss

Polyuria

Polydypsia

HPN

Atrophy of the kidney

Medical Management

Urinary analgesic: Peridium

Acute

Antibiotics

Antispasmodic

Surgery: removal of any obstruction

Chronic

Antibiotics

Urinary Antiseptics

Nitrofurantoin (macrodantin)

SE: peripheral neuropathy

GI irritation

Hemolytic anemia

Staining of teeth

Surgery: correction of structural abnormality if

possible

Dx

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

streptococcus

Urinalysis: increase WBC, CHON & pus cells

Cystoscopic exam: urinary obstruction

Nursing Intervention

Provide CBR: acute phase

Monitor I & O

Force fluid

Acid ash diet

Administer medication as ordered

Chronic: possibility of dialysis & transplant if has

renal deterioration

Complication: Renal Failure

Nephrolithiasis / Urolithiasis

Presence of stone anywhere in the urinary tract

Formation of stones at urinary tract

Frequent composition of stones

Calcium

Oxalate

Uric acid

Calcium Oxalate Uric Acid

Milk Cabbage Anchovies

Cranberries Organ meat

Nuts tea Nuts

Chocolates Sardines

Predisposing factors:

Diet: increase Ca & oxalate

Increase uric acid level

Hereditary: gout or calculi

Immobility

Sedentary lifestyle

Hyperparathyroidism

S/sx

Abdominal or flank pain

Renal colic

Cool moist skin (shock)

Burning sensation upon urination

Hematuria

Anorexia

N/V

Dx

Intravenous Pyelography (IVP): identifies site of

obstruction & presence of non-radiopaque stones

KUB: reveals location, number & size of stone

Cytoscopic Exam: urinary obstruction

Stone Analysis: composition & type of stone

Urinalysis: indicates presence of bacteria, increase

WBC, RBC & CHON

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Medical Management

Surgery

Percutaneous Nephrostomy:

Tube is inserted through skin & underlying tissue

into renal pelvis to remove calculi

Percutaneous Nephrostolithotomy

Delivers ultrasound wave through a probe placed

on the calculus

Extracorporeal Shockwave Lithotripsy:

Non-invasive

Delivers shockwaves from outside of the body to the

stone causing pulverization

Pain management & diet modification

Nursing Intervention

Force fluid: 3000-4000 ml / day

Strain urine using gauze pad: to detect stones &

crush all cloths

Encourage ambulation: to prevent stasis

Warm sitz bath: for comfort

Administer narcotic analgesic as ordered: Morphine

SO4: to relieve pain

Application warm compress at flank area: to relieve

pain

Monitor I & O

Provide modified diet depending upon the stone

consistency

Calcium Stones

Limit milk & dairy products

Provide acid ash diet (cranberry or prune juice,

meat, fish, eggs, poultry, grapes, whole

grains): to acidify urine

Take vitamin C

Oxalate Stone

Avoid excess intake of food / fluids high in

oxalate (tea, chocolate, rhubarb,

spinach)

Maintain alkaline-ash diet (milk, vegetable,

fruits except cranberry, plums &

prune): to alkalinize urine

Uric Acid Stone

Reduce food high in purine (liver, brain,

kidney, venison, shellfish, meat soup,

gravies, legumes)

Maintain alkaline urine

Administer Allopurinol (Zyloprim) as ordered: to

decrease uric acid production: push fluids when

giving allopurinol

Provide client teaching & discharge planning

Prevention of urinary stasis: increase fluid intake

especially during hot weather & illness

Mobility

Voiding whenever the urge is felt & at least twice

during night

Adherence to prescribe diet

Complications: Renal Failure

Benign Prostatic Hypertrophy (BPH)

Mild to moderate glandular enlargement,

hyperplsia & over growth of the smooth

muscles & connective tissue

As the gland enlarges it compresses the urethra:

resulting to urinary retention

Enlarged prostate gland leading to

Hydroureters: dilation of urethers

Hydronephrosis: dilation of renal pelvis

Kidney stones

Renal failure

Predisposing factor:

High risk: 50 years old & above & 60-70 (3-4x at

risk)

Influence of male hormone

S/sx

Urgency, frequency & hesitancy

Nocturia

Enlargement of prostate gland upon palpation

by digital rectal exam

Decrease force & amount of urinary stream

Dysuria

Hematuria

Burning sensation upon urination

Terminal bubbling

Backache

Sciatica: severe pain in the lower back &

down the back of thigh & leg

Dx

Digital rectal exam: enlarged prostate gland

KUB: urinary obstruction

Cystoscopic Exam: reveals enlargement of

prostate gland & obstruction of urine flow

Urinalysis: alkalinity increase

Specific Gravity: normal or elevated

BUN & Creatinine: elevated (if longstanding BPH)

Prostate-specific Antigen: elevated (normal is < 4

ng /ml)

Nursing Intervention

Prostate message: promotes evacuation of

prostatic fluid

Force fluid intake: 2000-3000 ml unless

contraindicated

Provide catheterization

Administer medication as ordered:

Terazosine (Hytrin): relaxes bladder sphincter

& make it easier to urinate

Finasteride (Proscar): shrink enlarge prostate

gland

Surgery: Prostatectomy

Transurethral Resection of Prostate (TURP): insertion

of a resectoscope into urethra to excise prostatic

tissue

Assist in cystoclysis or continuous bladder irrigation.

Nursing Intervention

Monitor symptoms of infection

Monitor symptoms gross / flank bleeding.

Normal bleeding within 24h

Maintain irrigation or tube patent to flush out

clots: to prevent bladder spasm &

distention

Acute Renal Failure

Sudden inability of the kidney to regulate fluid &

electrolyte balance & remove toxic products from

the body

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Sudden immobility of kidneys to excrete nitrogenous

waste products & maintain F&E balance due to a

decrease in GFR (N 125 ml/min)

Causes

Pre-renal cause: interfering with perfusion &

resulting in decreased blood flow & glomerular

filtrate

Inter-renal cause: condiion that cause damage to

the nephrons

Post-renal cause: mechanical obstruction anywhere

from the tubules to the urethra

Pre renal cause: decrease blood flow & glomerular

filtrate

Ischemia & oliguria

Cardiogenic shock

Acute vasoconstriction

Septicemia

Hypovolemia Decrease

flow to kidneys

Hypotension

CHF

Hemorrhage

Dehydration

Intra-renal cause: involves renal pathology: kidney

problem

Acute tubular necrosis

Endocarditis

DM

Tumors

Pyelonephritis

Malignant HPN

Acute Glomerulonephritis

Blood transfision reaction

Hypercalemia

Nephrotoxin (certain antibiotics, X-ray, dyes,

pesticides, anesthesia)

Post renal cause: involves mechanical obstruction

Tumors

Stricture

Blood cloths

Urolithiasis

BPH

Anatomic malformation

S/sx

Oliguric Phase: caused by reduction in glomerular

filtration rate

Urine output less than 400 ml / 24 hrs; duration

1-2 weeks

S/sx

Hypernatremia

Hyperkalemia

Hyperphosphotemia

Hypermagnesemia

Hypocalcemia

Metabolic acidosis

Dx

BUN & Creatinine: elevated

Diuretic Phase: slow gradual increase in daily urine

output

Diuresis may occur (output 3-5 L / day): due to

partially regenerated tubules inability to

concentrate urine

Duration: 2-3 weeks

S/sx

Hyponatremia

Hypokalemia

Hypovolemia

Dx

BUN & Creatinine: elevated

Recovery or Covalescent Phase: renal function

stabilized with gradual improvement over next 3-

12 mos

Nursing Intervention

Monitor / maintain F&E balance

Obtain baseline data on usual appearance &

amount of client’s urine

Measure I&O every hour: note excessive

losses

Administer IV F&E supplements as ordered

Weight daily

Monitor lab values: assess / treat F&E & acid

base imbalance as needed

Monitor alteration in fluid volume

Monitor V/S. PAP, PCWP, CVP as needed

Monitor I&O strictly

Assess every hour fro hypervolemia

Maintain ventilation

Decrease fluid intake as ordered

Administer diuretics, cardiac glycosides &

hypertensive agent as ordered

Assess every hour for hypovolemia: replace

fluid as ordered

Monitor ECG

Check urine serum osmolality / osmolarity &

urine specific gravity as ordered

Promote optimal nutrition

Administer TPN as ordered

Restrict CHON intake

Prevent complication from impaired mobility

Pulmonary Embolism

Skin breakdown

Contractures

Atelectesis

Prevent infection / fever

Assess sign of infection

Use strict aseptic technique for wound & catheter

care

Take temperature via rectal

Administer antipyretics as ordered & cooling

blankets

Support clients / significant others: reduce level

of anxiety

Provide care for client receiving dialysis

Provide client teaching & discharge planning

Adherence to prescribed dietary regime

S/sx of recurrent renal disease

Importance of planned rest period

Use of prescribe drugs only

S/sx of UTI or respiratory infection: report to MD

Chronic Renal Failure

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Progressive, irreversible destruction of the kidneys

that continues until nephrons are replaced by

scar tissue

Loss of renal function gradual

Irreversible loss of kidney function

Predisposing factors:

DM

HPN

Recurrent UTI/ nephritis

Urinary Tract obstruction

Exposure to renal toxins

Stages of CRF

Diminished Reserve Volume – asymptomatic

Normal BUN & Crea, GFR < 10 – 30%

2. Renal Insufficiency

3. End Stage Renal disease

S/Sx:

N/V

Diarrhea / constipation

Decreased urinary output

Dyspnea

Stomatitis

Hypotension (early)

Hypertension (late)

Lethargy

Convulsion

Memory impairment

Pericardial Friction Rub

HF

Urinary System

Polyuria

Nocturia

Hematuria

Dysuria

Oliguria

Metabolic Disturbance

Azotemia

(increase BUN

& Creatinine)

Hyperglycemia

Hyperinsulinemia

CNS

Headache

Lethargy

Disorientation

Restlessness

Memory

impairment

GIT

N/V

Stomatitis

Uremic breath

Diarrhea /

constipatio

n

Respiratory

Kassmaul’s resp

Decrease cough

reflex

Hematological

Normocytic

anemia

Bleeding

tendencies

Fluid & Electrolytes

Hyperkalemia

Hypernatermia

Hypermagnese

mia

Hyperposphate

mia

Hypocalcemia

Metabolic

acidosis

Integumentary

Itchiness /

pruritus

Uremic

frost

Dx

Urinalysis: CHON, Na & WBC: elevated

Specific gravity: decrease

Platelets: decrease

Ca: decrease

Medical Management

Diet restriction

Multivitamins

Hematinics

Aluminum Hydroxide Gels

Antihypertensive

Nursing Intervention

Prevent neurologic complication

Monitor for signs of uremia

Fatigue

Loss of appetite

Decreased urine output

Apathy

Confusion

Elevated BP

Edema of face & feet

Itchy skin

Restlessness

Seizures

Monitor for changes in mental functioning

Orient confused client to time, place, date &

person

Institute safety measures to protect the client

from falling out of bed

Monitor serum electrolytes, BUN & creatinine

as ordered

Promote optimal GI function

Provide care for stomatitis

Monitor N/V & anorexia: administer

antiemetics as ordered

Monitor signs of GI bleeding

Monitor & prevent alteration in F&E balance

Monitor for hyperphosphatemia: administer

aluminum hydroxides gel (amphojel,

alternagel) as ordered

Paresthesias

Muscle cramps

Seizures

Abnormal reflex

Maintenance of skin integrity

Provide care for pruritus

Monitor uremic frost (urea crystallization on the

skin): bathe in plain water

Monitor for bleeding complication & prevent

injury to client

Monitor Hgb, Hct, platelets, RBC

Hematest all secretions

Administer hematinics as ordered

Avoid IM injections

Maintain maximal cardiovascular function

Monitor BP

Auscultate for pericardial friction rub

Perform circulation check routinely

Administer diuretics as ordered & monitor I&O

Modify digitalis dose as ordered (digitalis is

excreted in kidneys)

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Provide care for client receiving dialysis

Disequilibrium syndrome: from rapid removal of

urea & nitrogenous waste prod leading to:

N/V

HPN

Leg cramps

Disorientation

Paresthes

Enforce CBR

Monitor VS, I&O

Meticulous skin care. Uremic frost – assist

in bathing pt

4. Meds:

a.) Na HCO3 – due Hyperkalemia

b.) Kagexelate enema

c.) Anti HPN – hydralazine

d.) Vit & minerals

e.) Phosphate binder

(Amphogel) Al OH gel - S/E

constipation

f.) Decrease Ca – Ca gluconate

5. Assist in hemodialysis

Consent/ explain procedure

Obtain baseline data & monitor VS,

I&O, wt, blood exam

Strict aseptic technique

Monitor for signs of complications:

B – bleeding

E – embolism

D – disequilibrium syndrome

S – septicemia

S – shock – decrease in tissue perfusion

Disequilibrium syndrome – from rapid removal of urea

& nitrogenous waste prod leading to:

n/v

HPN

Leg cramps

Disorientation

Paresthesia

Avoid BP taking, blood extraction, IV, at side

of shunt or fistula. Can lead to

compression of fistula.

Maintain patency of shunt by:

Palpate for thrills & auscultate for

bruits if (+) patent shunt!

Bedside- bulldog clip

- If with accidental removal of fistula to

prevent embolism.

- Infersole (diastole) – common dialisate

used

7. Complication

- Peritonitis

- Shock

8. Assist in surgery:

Renal transplantation : Complication –

rejection. Reverse isolation

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