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MEDICAL-SURGICAL NURSING
MEDICAL-SURGICAL NURSING
NERVOUS SYSTEM
Overview of structures and functions:
Central Nervous System
Brain
Spinal Cord
Peripheral Nervous System
Cranial Nerves
Spinal Nerves
Autonomic Nervous System
Sympathetic nervous system
Parasympathetic nervous system
AUTONOMIC NERVOUS SYSTEM
Sympathetic Nervous System
(Adrenergic)Parasympathetic Nervous System
(Cholinergic, 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.
- 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.Signs and Symptoms:
- SNS
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.
Effects of Beta-blockers
B roncho spasm
E licits a decrease in myocardial contraction.
T reats hypertension.
A V conduction slows down.
Should be given to patients with Angina Pectoris, 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 Lidocaine(Xylocaine)- Involved in fight or withdrawal response.
- Release of Acetylcholine.
- Decreases all bodily activities except GIT.
EFFECTS OF PNS
- Constriction of pupils (meiosis).
- Increase salivation.
- Decrease BP and Heart Rate.
- Bronchoconstriction, Decrease RR.
- Diarrhea
- Urinary frequency.
I. Cholinergic Agents
- Mestinon, Neostigmine.
Side Effects
- PNS
II. Anti-cholinergic Agents
- To counter cholinergic agents.
- Atropine Sulfate
Side Effects
- SNS
CENTRAL NERVOUS SYSTEM
Brain and Spinal Cord.
I. CELLS
A. NEURONS
Basic cells for nerve impulse and conduction.
Properties
Excitability ability of neuron to be affected by changes in external environment.
Conductivity ability of neuron to transmit a wave of excitation from one cell to another.
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-permeable.
Majority of brain tumors (90%) arises from called astrocytoma.
2. Oligodendria
3. Microglia
4. Epindymal
SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER
1. Ammonia
Cerebral toxin
Hepatic Encephalopathy (Liver Cirrhosis)
Ascites
Esophageal Varices
Early Signs of Hepatic Encephalopathy
asterixis (flapping hand tremors).
Late Signs of Hepatic Encephalopathy
Headache
Dizziness
Confusion
Fetor hepaticus (ammonia like breath)
Decrease LOC
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 stepladder like fever with chills.10. TYPHOID rose spots in abdomen.
11. DIPTHERIA pseudo membrane formation
12. MEASLES kopliks spots.
13. SLE butterfly rashes.
14. LIVER CIRRHOSIS spider like varices.
15. LEPROSY lioning face.
16. BULIMIA chipmunk face.
17. APPENDICITIS rebound tenderness.
18. DENGUE petechiae or (+) Hermans sign.
19. MENINGITIS Kernigs sign (leg pain), Brudzinski sign (neck pain).
20. TETANY hypocalcemia (+) Trousseaus sign/carpopedal spasm; Chvostek sign (facial spasm).
21. TETANUS risus sardonicus.
22. PANCREATITIS Cullens sign (ecchymosis of umbilicus); (+) Grey turners spots.
23. PYLORIC STENOSIS olive like mass.
24. PDA machine like murmur.
25. ADDISONS DISEASE bronze like skin pigmentation.
26. CUSHINGS SYNDROME moon face appearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVES DISEASE exopthalmus.
28. INTUSSUSCEPTION sausage shaped mass
2. Carbon Monoxide and Lead Poisoning
Can lead to Parkinsons Disease.
Epilepsy
Treat with ANTIDOTE: Calcium EDTA.
3. Type 1 DM (IDDM)
Causes diabetic ketoacidosis.
And increases breakdown of fats.
And free fatty acids
Resulting to cholesterol and (+) to Ketones (CNS depressant).
Resulting to acetone breath odor/fruity odor.
KUSSMAULS 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.
DEMYELINATING DISORDERS
1. Alzheimers disease
Atrophy of brain tissues.
Sign and Symptoms
4 As of Alzheimer
a. Amnesia loss of memory.
b. Agnosia no recognition of inanimate objects.
c. Apraxia no recognition of objects function.
d. Aphasia no speech (nodding).
*Expressive aphasia
motor speech center
Brocas Aphasia
*Receptive aphasia
inability to understand spoken words.
Wernickes Aphasia
General Knowing Gnostic Area or General Interpretative Area.
Drug of choice: Aricept (taken at bedtime) and Cognex.
2. Multiple Sclerosis
Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord.
Characterized by remission and exacerbation.
Women ages 15-35 are prone
Unknown Cause
Slow growing virus
Autoimmune disorders
Pernicious anemia
Myasthenia gravis
Lupus
Hypothyroidism
GBS
Ig G only antibody that pass placental circulation causing passive immunity.
- short term protection.
- Immediate action.
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.
Signs and Symptoms
1. Visual disturbances
blurring of vision (primary)
diplopia (double vision)
scotomas (blind spots)
2. Impaired sensation
to touch, pain, pressure, heat and cold.
tingling sensation
paresthesia
numbness
3. Mood swings
euphoria (sense of well being)
4. Impaired motor function
weakness
spasticity
paralysis
5. Impaired cerebral function
scanning speech
TRIAD SIGNS OF MS
Ataxia
(Unsteady gait, (+) Rombergs test)
Intentional tremors
Nystagmus
6. Urinary retention/incontinence
7. Constipation
8. Decrease sexual capacity
DIAGNOSTIC PROCEDURE
CSF analysis (increase in IgG and Protein).
MRI (reveals site and extent of demyelination).
(+) Lhermittes sign a continuous and increase contraction of spinal column.
NURSING MANAGEMENT1. Administer medications as ordered
a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site
of demyelination to prevent paralysis.
b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) muscle relaxants.
c. Interferons alter immune response.
d. Immunosupresants
2. Maintain side rails to prevent injury related to falls.
3. Institute stress management techniques.
a. Deep breathing exercises
b. Yoga
4. Increase fluid intake and increase fiber to prevent constipation.
5. Catheterization to prevent retention.
a. Diuretics
b. Bethanicol Chloride (Urecholine)
Nursing Management
Only given subcutaneous.
Monitor side effects bronchospasm and wheezing.
Monitor breath sounds 1 hour after subcutaneous administration.
c. For Urinary Incontinence
Anti spasmodic agent
a. Prophantheline Bromide (Promanthene)
Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.
To acidify urine and prevent bacterial multiplication.
COMMON CAUSE OF UTI
Female
short urethra (3-5 cm, 1-1 inches)
poor perineal hygiene
vaginal environment is moist
Nursing Management
avoid bubble bath (can alter Ph of vagina).
avoid use of tissue papers
avoid using talcum powder and perfume.
Male
Urethra (20 cm, 8 inches)
urinate after intercourse
MICROGLIA
stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating), pinocytosis (cell drinking).
MACROPHAGEORGAN
Microglia
Monocytes
Kupffers cells
Histiocytes
Alveolar MacrophageBrain
Blood
Kidney
Skin
Lung
EPINDYMAL CELLS
Secretes a glue called chemo attractants that concentrate the bacteria.
COMPOSITION OF BRAIN
80% brain mass
10% blood
10% CSF
I. Brain Mass
PARTS OF THE BRAIN
1. Cerebrum largest part
composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum.
Functions of Cerebrum
integrative
sensory
motor
Lobes of Cerebrum
1. Frontal
higher cortical thinking
controls personality
controls motor activity
Brocas Area (motor speech area) when damaged results to garbled speech.
2. Temporal
hearing
short term memory
3. Parietal
for appreciation
discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.
4. Occipital
for vision
Insula (Island of Reil)
visceral function activities of internal organ like gastric motility.
Limbic System (Rhinencephalon)
controls smell and if damaged results to Anosmia (absence of smell).
controls libido
controls long term memory
2. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere.
release dopamine (controls gross voluntary movement.
NEURO TRANSMITTERDecreaseIncrease
AcethylcholineMyasthenia GravisBi-polar Disorder
DopamineParkinsons DiseaseSchizophrenia
3. MIDBRAIN/ MESENCEPHALON 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. INTERBRAIN/ DIENCEPHALONParts of Diencephalon
A. Thalamus
acts as relay station for sensation.
B. Hypothalamus
controls temperature (thermoregulatory center).
controls blood pressure
controls thirst
appetite/satiety
sleep and wakefulness
controls some emotional responses like fear, anxiety and excitement.
controls pituitary functions
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 telarche and late sign is menarche.
5. BRAIN STEM located at lowest part of brain
Parts of Brain Stem
1. Pons
pneumotaxic center controls the rate, rhythm and depth of respiration.
2. Medulla Oblongata
controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation and constriction of bronchioles).
3. Cerebellum
smallest part of the brain.
lesser brain.
controls balance, equilibrium, posture and gait.
INTRA CRANIAL PRESSURE
Monroe Kellie Hypothesis
Skull is a closed container
Any alteration or increase in one of the intracranial components
Increase intra-cranial pressure
(normal ICP is 0 15 mmHg)
Cervical 1 also known as atlas.
Cervical 2 also known as axis.
Foramen Magnum
Medulla Oblongata
Brain Herniation
Increase intra cranial pressure
* 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.
NEUROLOGIC DISORDERS
Increase intracranial pressure increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components.
Causes:
head trauma/injury
localized abscess
cerebral edema
hemorrhage
inflammatory condition (stroke)
hydrocephalus
tumor (rarely)
Signs and Symptoms (Early)
decrease LOC
restlessness/agitation
irritability
lethargy/stupor
coma
Signs and Symptoms (Late)
changes in vital signs
blood pressure (systolic blood pressure increases but diastolic remains the same).
widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).
heart rate decrease
respiratory rate decrease
temperature increase directly proportional to blood pressure.
projective vomiting
headache
papilledema (edema of optic disc)
abnormal posturing
decorticate posturing (damage to cortex and spinal cord).
decerebrate posturing (damage to upper brain stem that includes pons, cerebellum and midbrain).
unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation
resulting to mild headache
possible seizure activity
Nursing Management
1. Maintain patent and adequate ventilation by:
a. Prevention of hypoxia and hypercarbia
Early signs of hypoxia
restlessness
agitation
tachycardia
Late signs of hypoxia
Bradycardia
Extreme restlessness
Dyspnea
Cyanosis
HypercarBia
Increase CO2 (most powerful respiratory stimulant) retention.
In chronic respiratory distress syndrome decrease O2 stimulates respiration.
b. Before and after suctioning hyper oxygenate client 100% and done 10 15 seconds only.
c. Assist in mechanical ventilation
2. Elevate bed of client 30 35o angle with neck in neutral position unless contraindicated to promote venous drainage.
3. Limit fluid intake to 1200 1500 ml/day (in force fluids 2000 3000 ml/day).
4. Monitor strictly input and output and neuro check
5. Prevent complications of
6. Prevent further increase ICP by:
a. provide an 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
excessive vomiting (use anti emetics)
excessive coughing (use anti tussive like dextromethorphan)
avoid stooping/bending
avoid lifting heavy objects
e. avoid clustering of nursing activity together.
7. Administer medications like:
a. Osmotic diuretic (Mannitol) for cerebral diuresis
Nursing Management monitor vital signs especially BP (hypotension).
monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.
administered via side drip
regulated fast drip to prevent crystal formation.
b. Loop diuretic (Lasix, Furosemide)
Drug of choice for CHF (pulmonary edema)
Loop of Henle in kidneys.
Nursing Management
Monitor vital signs especially BP (hypotension).
monitor strictly input and output every 1 hour 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)
Hydrocortisone
Prednisone (to reduce edema that may lead to increase ICP)
Mild Analgesics (Codeine Sulfate for respiratory depression)
Anti Convulsants (Dilantin, Phenytoin)
*CONGESTIVE HEART FAILURESigns 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
RHD
Aging
Treatment
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (Venous congestion)
Signs and Symptoms
jugular vein distention (neck)
ascites
pitting edema
weight gain
hepatosplenomegaly
jaundice
pruritus
esophageal varices
anorexia and general body malaise
Signs and Symptoms of Lasix in terms of electrolyte imbalances1. 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
FRUITSVEGETABLES
Apple
Banana
Cantalope
OrangesAsparagus
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
(+) Trousseaus sign/ Carpopedal spasm
(+) Chvosteks sign
Complications
Arrhythmia
Seizures
Nursing Management
Calcium Gluconate per IV slowly as ordered
* Calcium Gluconate 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 (Zyloprim)
Drug of choice for gout.
Mechanism of action: inhibits synthesis of uric acid.
b. Colchecine
Acute gout
Mechanism of action: promotes excretion of uric acid.
* Kidney stonesSigns and Symptoms
renal colic
Cool moist skin
Nursing Management
force fluids
administer medications as ordered
a. Narcotic Analgesic
Morphine Sulfate
antidote: Naloxone (Narcan) toxicity leads to tremors.
b. Allopurinol (Zyloprim)
Side Effects
Respiratory depression (check for RR)
PARKINSONS DISEASE/ PARKINSONISM
Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the substancia nigra of the midbrain and 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) AntihypertensiveS
c. Haloperidol(Haldol)
d. Phenothiazine AntipsychoticS
Side Effects Reserpine ( Major depression leading to suicideAloneness
Loss of spouse
Loss of Job
direct approach towards the client
close surveillance is a nursing priority
time to commit suicide is on weekends early morning
Signs and Symptoms for Parkinsons
pill rolling tremors of extremities especially the hands.
bradykinesia (slowness of movement)
rigidity (cogwheel type)
stooped posture
shuffling and propulsive gait
over fatigue
mask like facial expression with decrease blinking of the eyes.
difficulty rising from sitting position.
Monotone type speech mood lability (in state of depression)
increase salivation (drooling type)
autonomic changes
a. increase sweating
b. increase lacrimation
c. seborrhea
d. constipation
e. decrease sexual capacity
Nursing Management
1. Administer medications as ordered
Anti Parkinsonian agents
Levodopa (L-dopa) short acting
Amantadine Hydrochloride (Symmetrel)
Carbidopa (Sinemet)
Mechanism of Action increase level of dopamine
Side Effects
GIT irritation (should be taken with meals
orthostatic hypotension
arrhythmia
hallucinations
Contraindications
clients with narrow angle closure glaucoma
clients taking MAOIs (no foods with triptophan and thiamine)
urine and stool may be darkened
no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide
Anti Cholinergic Agents (Artane and Cogentin) - to relieve tremors Mechanism of Action
inhibits action of acethylcholine
Side Effects
SNS
Anti Histamine (Dipenhydramine Hydrochloride)
Side EffectsAdult: drowsiness
Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.
Dopamine Agonist - relieves tremor rigidity
Bromocriptene Hydrochloride (Parlodel)
Side Effects
Respiratory depression
2. Maintain side rails to prevent injury
3. Prevent complications of immobility
4. Decrease protein in morning and increase protein in afternoon to induce sleep
5. Encourage increase fluid intake and fiber.
6. Assist/supervise in ambulation
7. Assist in Stereotaxic Thalamotomy
MAGIC 2s IN DRUG MONITORING
DRUGNORMAL RANGETOXICITY
LEVELINDICATIONCLASSIFICATION
Digoxin/ Lanoxin
(Increase force of
cardiac output).5 1.5 meq/L2CHFCardiac Glycoside
Lithium/ Lithane
(Decrease level of
Ach/NE/Serotonin).6 1.2 meq/L2BipolarAnti-Manic Agents
Aminophylline
(Dilates bronchial tree)10 19 mg/100 ml20COPDBronchodilators
Dilantin/ Phenytoin 10 19 mg/100 ml20SeizuresAnti-Convulsant
Acetaminophen/Tylenol10 30 mg/100 ml200Osteo
ArthritisNon-narcotic Analgesic
1. Digitalis ToxicitySigns and Symptoms
nausea and vomiting
diarrhea
confusion
photophobia
changes in color perception (yellowish spots)
Antidote: Digibind
2. Lithium ToxicitySigns 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. Aminophylline ToxicitySigns 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 or precipitate.
administered sandwich method
avoid taking alcohol because it can lead to severe CNS depression
avoid caffeine
4. Dilantin ToxicitySigns and Symptoms
gingival hyperplasia (swollen gums)
hairy tongue
ataxia
nystagmus
Nursing Management
provide oral care
massage gums
5. Acetaminophen ToxicitySigns and Symptoms
hepatotoxicity (monitor for liver enzymes)
SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
nephrotoxicity monitor BUN (10 20) and Creatinine (.8 1)
hypoglycemia
Tremors, tachycardia
Irritability
Restlessness
Extreme fatigue
Diaphoresis, depression
Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.
MYASTHENIA GRAVIS
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: women 20 40 years old
Predisposing factors
unknown
autoimmune: it involves release of cholinesterase an enzyme that destroys Ach.
Signs and Symptoms
initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.
diplipia
mask like facial expression
dysphagia
hoarseness of voice
respiratory muscle weakness that may lead to respiratory arrest
extreme muscle weakness especially during exertion and morning
Diagnostic Procedure Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms for about 5 10 minutes and a maximum of 15 minutes.
if there is no effect there is damage to occipital lobe and midbrain and is negative for M.G.
Nursing Management
1. airway
2. aspiration maintain patent airway and adequate ventilation
3. mmobility
* assist in mechanical ventilation and monitor pulmonary function test
* monitor strictly vital signs, input and output and neuro check
* monitor strength or motor grading scale
4. maintain side rails to prevent injury related to falls
5. institute NGT feeding
6. administer medications as ordered
a. Cholinergic (Mestinon)
b. Anti Cholenisterase (Neostegmin)
Mechanism of Action increase level of Ach
Side Effects
PNS
Cortocosteroids suppress immune response
monitor for 2 types of crisis:
MYASTHENIC CRISISCHOLINERGIC CRISIS
Causes:
- under medication
- stress
- infection
Signs and Symptoms
- The client is unable to see, swallow, speak, breathe
Treatment
- administer cholinergic agents as orderedCause:
- over medication
Signs and Symptoms
- PNS
Treatment
- Administer anti cholinergic agents
(Atropine Sulfate)
7. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.G.
8. Assist in plasma paresis and removing auto immune anti bodies
9. Prevent complications
INFLAMMATORY CONDITIONS OF THE BRAIN
MENINGITIS
Meninges
3 fold membrane that covers brain and spinal cord.
for support and protection
for nourishment
blood supply
Layers of the meninges
1. Dura matter outer layer
2. Arachnoid middle layer
3. Pia matter inner layer
subdural space between the dura and arachnoid
subarachnoid space between the arachnoid and pia, CSF aspiration is done.
A. Etiology
1. Meningococcus most dangerous
2. Pneumococcus
3. Streptococcus - causes adult meningitis
4. Hemophilus Influenzae causes pediatric meningitis
B. Mode of transmission
airborne transmission (droplet nuclei)
C. Signs and Symptoms
headache
photophobia
projectile vomiting
fever, chills, anorexia, general body malaise and weight loss
Possible increase in ICP and seizure activity
Abnormal posturing (decorticate and decerebrate)
Signs of meningeal irritation
a. Nuchal rigidity or stiff neck
b. Opisthotonus (arching of back)
c. (+) Kernigs sign (leg pain)
d. (+) Brudzinski sign (neck pain)
D. Diagnostic Procedures
Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 L4 to L5.
Nursing Management for LP
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.
Post Lumbar Puncture
1. Place flat on bed 12 24 o2. 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
E. Nursing Management
1. Enforce complete bed rest
2. Administer medications as ordered
a. Broad spectrum antibiotics (Penicillin, Tetracycline)
b. Mild analgesics
c. Anti pyretics
3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy
4. Elevate head 30-45o
5. Monitor strictly V/S, input and output and neuro check
6. Institute measures to prevent increase ICP and seizure.
7. Provide a comfortable and darkened environment.
8. Maintain fluid and electrolyte balance.
9. Provide client health care and discharge planning concerning:
a. Maintain good diet of increase CHO, CHON, calories with small frequent feedings.
b. Prevent complications
most feared is hydrocephalus hearing loss/nerve deafness is second complication
consult audiologist
c. Rehabilitation for neurological deficit
mental retardation
delayed psychomotor development
CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)
a partial or complete disruption in the brains blood supply.
2 most common cerebral artery affected by stroke
a. Mid Cerebral Artery
b. Internal Cerebral Artery the 2 largest artery
A. Incidence Rate
men are 2-3 times high risk
B. Predisposing Factors
thrombus (attached)
embolus (detached and most dangerous because it can go to the lungs and cause pulmonary embolism or the brain and cause cerebral embolism.
Signs and Symptoms of Pulmonary Embolism
Sudden sharp chest pain
Unexplained dyspnea
Tachycardia
Palpitations
Diaphoresis
Mild restlessness
Signs and Symptoms of Cerebral Embolism
Headache and dizziness
Confusion
Restlessness
Decrease LOC
Fat embolism is the most feared complications after 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.
Compartment syndrome (compression of arteries and nerves)
C. Risk Factors
1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular Heart Disease, Post Cardiac Surgery (mitral valve replacement)
2. Lifestyle (smoking), 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 and eventually CVA.
D. Signs and Symptoms
dependent on stages of development
1. TIA Initial sign of stroke or warning sign
Signs and Symptoms
headache and dizziness
tinnitus
visual and speech disturbances
paresis (plegia)
possible increase ICP
2. Stroke in evolution progression of signs and symptoms of stroke
3. Complete stroke resolution phase characterized by:
Signs and Symptoms
headache and dizziness
Cheyne Stokes Respiration
anorexia, nausea and vomiting
dysphagia
(+) Kernigs sign and Brudzinski sign which may lead to hemorrhagic stroke
focal neurological deficits
a. phlegia
b. aphasia
c. dysarthria (inability to articulate words)
d. alexia (difficulty reading)
e. agraphia (difficulty writing)
f. homonymous hemianopsia (loss of half of visual field)
E. Diagnostic Procedure
1. CT Scan reveals brain lesions
2. Cerebral Arteriography reveals the site and extent of malocclusion
uses dye for visualization
most of dye are iodine based
check for shellfish allergy
after diagnostic exam force fluids to release dye because it is nephro toxic
check for distal pulse (femoral)
check for hematoma formation
F. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. administrate O2 inhalation
2. Restrict fluids to prevent cerebral edema that might increase ICP
3. Elevate head 30 45o 4. Monitor strictly vitals signs, I & O and neuro check
5. 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.
6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures
7. Institute NGT feeding
8. Provide alternative means of communication
a. non verbal cues
b. magic slate
9. If positive to hemianopsia approach client on unaffected side
10. Administer medications as ordered
a. Osmotic Diuretics (Mannitol)
b. Loop Diuretics (Lasix, Furosemide)
c. Cortecosteroids
d. Mild Analgesics
e. Thrombolytic/Fibrinolytic Agents dissolves thrombus
Streptokinase
Side Effect: Allergic Reaction
Urokinase
Tissue Plasminogen Activating Factor
Side Effect: Chest Pain
f. Anti Coagulants
Heparin (short acting)
check for partial thromboplastin time if prolonged there is a risk for bleeding.
give Protamine Sulfate
Comadin/ Warfarin (long acting)
give simultaneously because Coumadin will take effect after 3 days
check for prothrombin time if prolonged there is a risk for bleeding
give Vit. K (Aqua Mephyton)
g. Anti Platelet
PASA (Aspirin)
Contraindicated for dengue, ulcer and unknown cause of headache because it may potentiate bleeding
11. Provide client health teachings and discharge planning concerning
a. avoidance of 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
GuillAIn BarRe Syndrome
a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis.
A. Predisposing Factors
1. Autoimmune
2. Antecedent viral infections such as LRT infections
B. Signs and Symptoms
1. Clumsiness (initial sign)2. Dysphagia
3. Ascending muscle weakness leading to paralysis
4. Decreased of diminished deep tendon reflex
5. Alternate hypotension to hypertension
** Arrythmia (most feared complication)
6. Autonomic symptoms that includes
a. increase salivation
b. increase sweating
c. constipation
C. Diagnostic Procedures
1. CSF analysis reveals increase in IgG and protein
D. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. monitor pulmonary function test
2. Monitor strictly the following
a. vital signs
b. intake and output
c. neuro check
d. ECG
3. Maintain side rails to prevent injury related to fall
4. Prevent complications of immobility by turning the client every 2 hours
5. Institute NGT feeding to prevent aspiration
6. Assist in passive ROM exercise
7. Administer medications as ordered
a. Corticosteroids suppress immune response
b. Anti Cholinergic Agents Atrophine Sulfate
c. Anti Arrythmic Agents
Lidocaine, Zylocaine
Bretylium blocks release of norepinephrine to prevent increase of BP
8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies)
9. Prevent complications
a. Arrythmia
b. Paralysis or respiratory muscles/Respiratory arrest
* Sengstaken Blakemore Tube
for liver cirrhosis
to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing to release air in the balloon
for hemodialysis prepare bulldog clips to prevent air embolism.
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
A. Predisposing Factors
1. Head injury due to birth trauma
2. Genetics
3. Presence of brain tumor
4. Toxicity from
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 (drug of choice is Diazepam, Valium)
B. Signs and Symptoms
Dependent on stages of development or types of seizure
I. Generalized Seizure1. Grand mal Seizure (tonic-clonic seizure)
a. Signs or aura with auditory, olfactory, visual, tactile, sensory experience
b. Epileptic cry is characterized by fall and loss of consciousness for 3 5 minutes
c. Tonic contractions - direct symmetrical extension of extremities
Clonic contractions - contraction of extremities
d. Post ictal sleep unresponsive sleep
2. Petit mal Seizure absence of seizure common among pediatric clients characterized by
a. blank stare
b. decrease blinking of eyes
c. twitching of mouth
d. loss of consciousness (5 10 seconds)
II. Partial or Localized Seizure1. 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.
2. Psychomotor Seizure (focal motor seizure)
a. automatism stereotype repetitive and non propulsive behavior
b. clouding of consciousness not in contact with environment
c. mild hallucinatory sensory experience
III. Status Epilepticus A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and lead to coma and eventually death.
Drug of choice: Diazepam, Valium and 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 (Tegretol) 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
COMPREHENSIVE NEURO EXAM
GLASGOW COMA SCALE objective measurement of LOC sometimes called as the quick neuro check
Components
1. Motor response
2. Verbal response
3. Eye opening
Survey of mental status and speech
a. LOC
b. Test of memory
Levels of orientation
Cranial nerve assessment
Sensory nerve assessment
Motor nerve assessment
Deep tendon reflex
Autonimics
Cerebellar test
a, Rombergs test 2 nurses, positive for ataxia
b. Finger to nose test positive result mean dimetria
(inability of body to stop movement at desired point)
c. Alternate supination and pronation positive result mean dimetria
I. LEVEL OF CONSCIOUSNESS
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
II. 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
III. LEVELS OF ORIENTATION
1. Time first asked
2. Person second asked
3. Place third asked
CRANIAL NERVES
CRANIAL NERVESFUNCTION
I. OLFACTORYS
II. OPTICS
III OCCULOMOTORM
IV. TROCHLEARM (Smallest)
V. TRIGEMINALB (Largest)
VI. ABDUCENSEM
VII. FACIALB
VIII. ACOUSTICS
IX. GLOSSOPHARYNGEALB
X. VAGUSB (Longest)
XI. SPINAL ACCESSORYM
XII. HYPOGLOSSALM
CRANIAL NERVE I: OLFACTORY sensory function for smell
Material Used
dont use alcohol, ammonia, perfume because it is irritating and highly diffusible.
use coffee granules, vinegar, bar of soap, cigarette
Procedure
test each nostril by occluding each nostril
Abnormal Findings
1. Hyposnia decrease sensitivity to smell
2. Dysosmia distorted sense of smell
3. Anosmia absence of smell
Indicative of
1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located
2. 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 Snellens Chart
Snellens Alphabet chart: for literate clients
Snellens E chart: for illiterate clients
Snellens Animal chart: for pediatric clients
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
COMMON VISUAL DISORDERS
1. Glaucoma increase IOP
normal IOP is 12 21 mmHg
preventable but not curable
A. Predisposing Factors
Common among 40 years old and above
Hereditary
Hypertension
Obesity
B. Signs and Symptoms
1. Loss of peripheral vision
pathognomonic sign is tunnel vision2. Headache, nausea, vomiting, eye pain (halos around light)
steamy cornea
may lead to blindness
C. Diagnostic Procedures
1. Tonometry
2. Perimetry
3. Gonioscopy
D. Treatment
1. Miotics constricts pupil
a. Pilocarpine Sodium, Carbachol2. Epinephrine eyedrops decrease formation of aqueous humor
3. Carbonic Anhydrase Inhibitors
a. Acetazolamide (Diamox) promotes increase outflow of aqueous humor or drainage
4. Timoptics (Timolol Maleate)
E. Surgical Procedures
1. Trabeculectomy (Peripheral Indectomy) drain aqueous humor
2. Cataract Decrease opacity of lens
A. Predisposing Factor
1. Aging 65 years and above
2. Related to congenital
3. Diabetes Mellitus
4. Prolonged exposure to UV rays
B. Signs and Symptoms
1. Loss of central vision
C. Pathognomonic Signs
1. Blurring or hazy vision
2. Milky white appearance at center of pupils
3. Decrease perception to colors
Complication is blindness
D. Diagnostic Procedure
1. Opthalmoscopic exam
E. Treatment
1. Mydriatics (Mydriacyl) constricts pupils
2. Cyclopegics (Cyclogyl) paralyses cilliary muscle
F. Surgical Procedure
Extra
Intra
Capsular
Capsular
Cataract
Cataract
Lens
Lens
Extraction
Extraction
- Partial removal
- Total removal of cataract with its surrounding capsules
Most feared complication post op is retinal detachment3. Retinal Detachment Separation of epithelial surface of retina
A. Predisposing Factors
1. Post Lens Extraction
2. Myopia (near sightedness)
B. Signs and Symptoms
1. Curtain veil like vision
2. Floaters
C. Surgical Procedures
1. Scleral Buckling2. Cryosurgery cold application
3. Diathermy heat application
4. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina)
A. Signs and Symptoms
1. Black Spots
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/thickdolorum
medication: Carbamezapine(Tegretol)
CRANIAL NERVE VII: FACIAL Sensory: controls taste, anterior 2/3 of tongue
pinch of sugar and cotton applicator placed on tip of tongue
Motor: controls muscle of facial expression
instruct client to smile, frown and if results are negative there is facial paralysis or Bells Palsy and the primary cause is forcep delivery.
CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense, refers to movement and orientation of the body in space.
Parts of the Ear
1. Outer Ear
Pinna
Eardrum
2. Middle Ear
HammerMalleus
Anvil
Incus
Stirrup
Stapes
3. Inner Ear
Vestibule: Meineres Disease
Cochlea
Mastoid Cells
Endolymph and Perilymph
Cochlea: controls hearing, contains the Organ of Corti (the true organ of hearing)
Let client repeat words uttered
CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE Glosopharyngeal: controls taste, posterior 1/3 of tongue
Vagus: controls gag reflex
Uvula should be midline and if not indicative of damage to cerebral hemisphere
Effects of vagal stimulation is PNS
CRANIAL NERVE XI: SPINAL ACCESSORY Innervates with sternocleidomastoid (neck) and trapezius (shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL Controls the movement of tongue
Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral hemisphere and/or has short frenulum.
ENDOCRINE SYSTEM
Overview of the structures and functions
1. Pituitary Gland (Hypophysis Cerebri)
Located at base of brain particularly at sella turcica Master gland or master clock
Controls all metabolic function of bodyPARTS OF the Pituitary Gland
1. Anterior Pituitary Gland called as adenohypophysis
2. Posterior Pituitary Gland
called as neurohypophysis
secretes hormones oxytocin -promotes uterine contractions preventing bleeding/ hemorrhage
administrate oxytocin immediately after delivery to prevent uterine atony.
initiates milk let down reflex with help of hormone prolactin
2. Antidiuretic Hormone
Pitressin (Vasopressin)
Function: prevents urination thereby conserving water
Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone
DIABETES INSIPIDUS
Decrease production of anti diuretic hormone
A. Predisposing Factor
Related to pituitary surgery
Trauma
Inflammation
Presence of tumor
B. Signs and Symptoms
1. Polyuria
2. Signs of dehydration
a. Adult: thirst
b. Agitation
c. Poor Skin turgor
d. Dry mucous membrane
3. Weakness and fatigue
4. Hypotension
5. Weight loss
6. If left untreated results to hypovolemic shock (sign is anuria)
C. Diagnostic Procedures
1. Urine Specific Gravity
Normal value: 1.015 1.030 Ph 4 8
2. Serum Sodium
Increase resulting to hypernatremia
D. Nursing Management
1. Force fluids
2. Monitor strictly vital signs and intake and output
3. Administer medications as ordered
a. Pitressin (Vasopresin Tannate) administered IM Z-tract
4. Prevent complilcations hypovolemic shock is the most feared complication
SIADH
hypersecretion of anti diuretic hormone
A. 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 (increase size of organ brought about by increase of number of cells) of pituitary gland.
B. Signs and Symptoms
1. Fluid retention
a. Hypertension
b. Edema
c. Weight gain
2. Water intoxication may lead to cerebral edema and lead to increase ICP may lead to seizure activity
C. Diagnostic Procedure
1. Urine specific gravity is increased2. Serum Sodium is decreased
D. Nursing Management
1. Restrict fluid
2. Administer medications as ordered
a. Loop diuretics (Lasix)
b. Osmotic diuretics (Mannitol)
3. Monitor strictly vital signs, intake and output and neuro check
4. Weigh patient daily and assess for pitting edema
5. Provide meticulous skin care
6. Prevent complications
ANTERIOR PITUITARY GLAND also called adenohypophysis secretes
1. Growth hormones (somatotropic hormone)
Promotes elongation of long bones
Hyposecretion of GH among children results to Dwarfism
Hypersecretion of GH results to Gigantism Hypersecretion of GH among adults results to Acromegaly (square face)
Drug of choice: Ocreotide (Sandostatin)2. Melanocyte Stimulating hormone
for skin pigmentation
Hyposecretion of MSH results to Albinism
Most feared complications of albinism
a. Lead to blindness due to severe photophobia
b. Prone to skin cancer Hypersecretion of MSH results to Vitiligo
3. Adrenochorticotropic hormone (ACTH)
promotes development of adrenal cortex
4. Lactogenic homone (Prolactin)
promotes development of mammary gland
with help of oxytocin it initiates milk let down reflex
5. Leutinizing hormone secretes estrogen
6. Follicle stimulating hormone
secretes progesterone
PINEAL GLAND secretes melatonin inhibits LH secretion
it controls/regulates circadian rhythm (body clock)
THYROID GLAND located anterior to the neck
3 Hormones secreted
1. T3 (Tri iodothyronine) - 3 molecules of iodine (more potent)
2. T4 (tetra iodothyronine, Thyroxine)
T3 and T4 are metabolic or calorigenic hormone
promotes cerebration (thinking)
3. Thyrocalcitonin antagonizes the effects of parathormone to promote calcium resorption.
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 DISORDERSSimple Goiter
enlargement of thyroid gland due to iodine deficiency
A. Predisposing Factors
1. Goiter belt area
a. places far from sea
b. Mountainous regions
2. Increase intake of goitrogenic foods
contains pro-goitrin an anti thyroid agent that has no iodine.
cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts
soil erosion washes away iodine
goitrogenic drugs
a. Anti Thyroid Agent Prophylthiuracil (PTU)
b. Lithium Carbonate
c. PASA (Aspirin)
d. Cobalt
e. Phenylbutazones (NSAIDs)
- if goiter is caused by
B. Signs and Symptoms
1. Enlarged thyroid gland
2. Mild dysphagia
3. Mild restlessness
C. Diagnostic Procedures
1. Serum T3 and T4 reveals normal or below normal
2. Thyroid Scan reveals enlarged thyroid gland.
3. Serum Thyroid Stimulating Hormone (TSH) is increased (confirmatory diagnostic test)
D. Nursing Management
1. Enforce complete bed rest
2. Administer medications as ordered
a. Lugols Solution/SSKI ( Saturated Solution of Potassium Iodine)
color purple or violet and administered via straw to prevent staining of teeth.
4 Medications to be taken via straw: Lugols, Iron, Tetracycline, Nitrofurantoin (drug of choice for pyelonephritis)
b. Thyroid Hormones
Levothyroxine (Synthroid)
Liothyronine (Cytomel)
Thyroid Extracts
Nursing Management 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
4. Increase dietary intake of foods rich in iodine
seaweeds
seafoods like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of iodine.
iodized salt, best taken raw because it it is easily destroyed by heat
5. Assist in surgical procedure of subtotal thyroidectomy
HYPOTHYROIDISM
hyposecretion of thyroid hormone
adults: myxedema non pitting edema
children: cretinism the only endocrine disorder that can lead to mental retardation
A. Predisposing Factors
1. Iatrogenic Cause disease caused by medical intervention such as surgery
2. Related to atrophy of thyroid gland due to trauma, presence of tumor, inflammation3. Iodine deficiency
4. Autoimmune (Hashimotos Disease)
B. Signs and Symptoms
(Early Signs)
1. Weakness and fatigue
2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI
3. Dry skin
4. Cold intolerance
5. Constipation
(Late Signs)
1. Brittleness of hair and nails
2. Non pitting edema (Myxedema)
3. Hoarseness of voice
4. Decrease libido
5. Decrease in all vital signs hypotension, bradycardia, bradypnea, hypothermia
6. CNS changes
lethargy
memory impairment
psychosis
menorrhagia
C. Diagnostic Procedures
1. Serum T3 and T4 is decreased
2. Serum Cholesterol is increased
3. RAIU (Radio Active Iodine Uptake) is decreased
D. Nursing Management
1. Monitor strictly vital signs and intake and output to determine presence of
Myxedema coma is a complication of hypothyroidism and an emergency case
a severe form of hypothyroidism is characterized by severe hypotension, bradycardia, bradypnea, hypoventilation, hyponatremia, hypoglycemia, hypothermia leading to pregressive stupor and coma.
Nursing Management for Myxedema Coma
Assist in mechanical ventilation
Administer thyroid hormones as ordered
Force fluids
2. Force fluids
3. Administer isotonic fluid solution as ordered
4. Administer medications as ordered
Thyroid Hormones
a. Levothyroxine
b. Leothyronine
c. Thyroid Extracts
5. Provide dietary intake that is low in calories
6. Provide comfortable and warm environment
7. Provide meticulous skin care
8. Provide client health teaching and discharge planning concerning
a. Avoid precipitating factors leading to myxedema coma
stress
infection
cold intolerance
use of anesthetics, narcotics, and sedatives
prevent complications (myxedema coma, hypovolemic shock
hormonal replacement therapy for lifetime
importance of follow up care
HYPERTHYROIDISM
increase in T3 and T4
Graves Disease or Thyrotoxicosis
developed by Robert Grave
A. Predisposing Factors
1. Autoimmune it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants)
2. Excessive iodine intake
3. Related to hyperplasia (increase size)
B. Signs and Symptoms
1. Increase appetite (hyperphagia) but there is weight loss
2. Moist skin
3. Heat intolerance
4. Diarrhea
5. All vital signs are increased
6. CNS involvement
a. Irritability and agitation
b. Restlessness
c. Tremors
d. Insomnia
e. Hallucinations
7. Goiter
8. Exopthalmus
9. Amenorrhea
C. Diagnostic Procedures
1. Serum T3 and T4 is increased
2. RAIU (Radio Active Iodine Uptake) is increased
3. Thyroid Scan- reveals an enlarged thyroid gland
D. Nursing Management
1. Monitor strictly vital signs and intake and output
2. Administer medications as ordered
Anti Thyroid Agent
a. Prophythioracill (PTU)
b. Methymazole (Tapazole)
Side Effects of Agranulocytosis increase lymphocytes and monocytes
fever and chills
sore throat (throat swab/culture)
leukocytosis (CBC)
3. Provide dietary intake that is increased in calories.
4. Provide meticulous skin care
5. Comfortable and cold environment
6. Maintain side rails
7. Provide bilateral eye patch to prevent drying of the eyes.
8. Assist in surgical procedures known as subtotal thyroidectomy
** Before thyroidectomy administer Lugols Solution (SSKI) to decrease vascularity of the thyroid
gland to prevent bleeding and hemorrhage.
POST OPERATIVELY,
1. Watch out for signs of thyroid storm/ thyrotoxicosis
Agitation
Hyperthermia
Tachycardia
administer medications as ordered
a. Anti Pyretics
b. Beta-blockers
monitor strictly vital signs, input and output and neuro check.
maintain side rails
offer TSB
2. Watch out for accidental removal of parathyroid gland that may lead to
Hypocalcemia (tetany)
Signs and Symptoms
(+) trousseaus sign
(+) chvostek sign
Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered
3. Watch out for accidental Laryngeal damage which may lead to hoarseness of voice
Nursing Management
encourage client to talk/speak immediately after operation and notify physician
4. Signs of bleeding (feeling of fullness at incisional site)
Nursing Management
Check the soiled dressings at the back or nape area.
5. Hormonal replacement therapy for lifetime
6. Importance of follow up care
PARATHYROID GLAND A pair of small nodules behind the thyroid gland
Secretes parathormone
Promotes calcium reabsorption
Hypoparathyroidism
Hyperparathyroidism
HYPOPARATHYROIDISM
Decrease secretion of parathormone leading to hypocalcemia
Resulting to hyperphospatemia
A. Predisposing Factors
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to:
a. inflammation
b. tumor
c. trauma
B. Signs and Symptoms
1. Acute tetany
a. tingling sensation
b. paresthesia
c. numbness
d. dysphagia
e. positive trousseus sign/carpopedal spasm
f. positive chvostek sign
g. laryngospasm/broncospasm
h. seizurefeared complications
i. arrhythmia
2. Chronic tetany
a. photophobia and cataract formation
b. loss of tooth enamel
c. anorexia, nausea and vomiting
d. agitation and memory impairment
C. Diagnostic Procedures
1. Serum Calcium is decreased (normal value: 8.5 11 mg/100 ml)
2. Serum Phosphate is decreased (normal value: 2.5 4.5 mg/100 ml)
3. X-ray of long bones reveals a decrease in bone density
4. CT Scan reveals degeneration of basal ganglia
D. Nursing Management
1. Administer medications as ordered such as:
a. Acute Tetany
Calcium Gluconate IV slowly
b. Chronic Tetany
Oral Calcium supplements
Calcium Gluconate
Calcium Lactate
Calcium Carbonate
c. Vitamin D (Cholecalciferol) for absorption of calcium
CHOLECALCIFEROL ARE DERIVED FROM
Drug
Diet (Calcidiol)
Sunlight (Calcitriol)
d. Phosphate binder
Aluminum Hydroxide Gel (Ampogel)
Side effect: constipation
ANTACID
A.A.C
MAD
Aluminum Containing
Magnesium Containing
Antacids
Antacids
Aluminum
Hydroxide
Gel
Side Effect: Constipation
Side Effect: Diarrhea
2. Avoid precipitating stimulus such as glaring lights and noise
3. Encourage increase intake of foods rich in calcium
a. anchovies
b. salmon
c. green turnips
4. Institute seizure and safety precaution
5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.
6. Prepare trache set at bedside for presence of laryngo spasm
7. Prevent complications
8. Hormonal replacement therapy for lifetime
9. Importance of follow up care.
HYPERTHYROIDISM
Decrease parathormone
Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood)
Kidney stones
A. Predisposing Factors
1. Hyperplasia of parathyroid gland
2. Over compensation of parathyroid gland due to vitamin D deficiency
a. Children: Ricketts
b. Adults: Osteomalacia
B. Signs and Symptoms
1. Bone pain especially at back (bone fracture)
2. Kidney stones
a. renal cholic
b. cool moist skin
3. Anorexia, nausea and vomiting
4. Agitation and memory impairment
C. Diagnostic Procedures
1. Serum Calcium is increased
2. Serum Phosphate is decreased
3. X-ray of long bones reveals bone demineralization
D. Nursing Management
1. Force fluids to prevent kidney stones
2. Strain all the urine using gauze pad for stone analysis
3. Provide warm sitz bath
4. Administer medications as ordered
a. Morphine Sulfate (Demerol)
5. Encourage increase intake of foods rich in phosphate but decrease in calcium
6. Provide acid ash in the diet to acidify urine and prevent bacterial growth
7. Assist/supervise in ambulation
8. Maintain side rails
9. Prevent complications (seizure and arrhythmia)
10. Assist in surgical procedure known as parathyroidectomy11. Hormonal replacement therapy for lifetime
12. Importance of follow up care
ADRENAL GLAND Located atop of each kidney
2 layers of adrenal gland
a. Adrenal Cortex outermost
b. Adrenal Medulla innermost (secretes catecholamines a power hormone)
2 Types of Catecholamines
Epinephrine and Norepinephrine (vasoconstrictor)
Pheochromocytoma (adrenal medulla)
Increase secretion of norepinephrine
Leading to hypertension which is resistant to pharmacological agents leading to CVA
Use beta-blockers
ADRENAL CORTEX
3 Zones/Layers
1. Zona Fasciculata
- secretes glucocortocoids (cortisol)
- function: controls glucose metabolism
- Sugar
2. Zona Reticularis
- secretes traces of glucocorticoids and androgenic hormones
- function: promotes secondary sex characteristics
- Sex
3. Zona Glumerulosa
- secretes mineralocorticoids (aldosterone)
- function: promotes sodium and water reabsorption and excretion of potassium
- Salt
ADDISONS DISEASE
Hyposecretion of adreno cortical hormone leading to
a. metabolic disturbance Sugar
b. fluid and electrolyte imbalance Salt
c. deficiency of neuromuscular function Salt/Sex
A. Predisposing Factors
1. Related to atrophy of adrenal glands
2. Fungal infections
B. Signs and Symptoms
1. Hypoglycemia TIRED
2. Decrease tolerance to stress
3. Hyponatremia- hypotension
- signs of dehydration
- weight loss
4. Hyperkalemia
- agitation
- diarrhea
- arrhythmia
5. Decrease libido
6. Loss of pubic and axillary hair
7. Bronze like skin pigmentationC. Diagnostic Procedures
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)
D. Nursing Management
1. Monitor strictly vital signs, input and output to determine presence of Addisonian crisis (complication of addisons disease)
Addisonian crisis results from acute exacerbation of addisons disease characterized by
a. severe hypotension
b. hypovolemic shock
c. hyponatremia leading to progressive stupor and coma
Nursing Management for Addisonian Crisis
1. Assist in mechanical ventilation,
- administer steroids as ordered
- force fluids
2. Administer isotonic fluid solution as ordered
3. Force fluids
4. Administer medications as ordered
Corticosteroids
a. Dexamethasone (Decadrone)
b. Prednisone
c. Hydrocortisone (Cortison)
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
a. hypertension
b. edema
c. hirsutism
d. increase susceptibility to infection
e. moon face appearance4. Mineralocorticoids (Flourocortisone)
5. Provide dietary intake, increase calories, carbohydrates, protein but decrease in potassium
6. Provide meticulous skin care
7. Provide client health teaching and discharge planning
a. avoid precipitating factor leading to addisonian crisis leading to
- stress
- infection
- sudden withdrawal to steroids
b. prevent complications
- addisonian crisis
- hypovolemic shock
c. hormonal replacement for lifetime
d. importance of follow up care
CUSHING SYNDROME
Hypersecretion of adenocortical hormones
A. Predisposing Factors
1 Related to hyperplasia of adrenal gland
2. Increase susceptibility to infections
3. Hypernatremia
a. hypertension
b. edema
c. weight gain
d. moon face appearance and buffalo hump
e. obese trunk
f. pendulous abdomen
g. thin extremities
4. Hypokalemia
a. weakness and fatigue
b. constipation
c. U wave upon ECG (T wave hyperkalemia)
5. Hirsutism
6. Acne and striae
7. Easy bruising
8. Increase masculinity among femalesB. Diagnostic Procedures
1. FBS is increased
2. Plasma Cortisol is increased
3. Serum Sodium is increased
4. Serum Potassium is decreased
C. Nursing Management
1. Monitor strictly vital signs and intake and output
2. Weigh patient daily and assess for pitting edema
3. Measure abdominal girth daily and notify physician
4. Restrict sodium intake
5. Provide meticulous skin care
6. Administer medications as ordered
a. Spinarolactone potassium sparring diuretics
7. Prevent complications (DM)
8. Assist in surgical procedure (bilateral adrenoraphy)
9. Hormonal replacement for lifetime
10. Importance of follow up care
PANCREAS- Located behind the stomach
- Mixed gland (exocrine and endocrine)
- Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland
- Consist of islets of langerhans
- Has alpha cells that secretes glucagons (function: hyperglycemia)
- Beta cells secretes insulin (function: hypoglycemia)
- Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones)
3 Main Disorders of Pancreas
1. Pancreatic Tumor/Cancer
2. Diabetes Mellitus
3. Pancreatitis
DIABETES MELLITUS
- metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism
CLASSIFICATION OF DM
Type 1 (IDDM)- Juvenile onset type
- Brittle disease
A. Incidence Rate
- 10% general population has type 1 DM
B. Predisposing Factors
1. Hereditary (total destruction of pancreatic cells)
2. Related to viruses
3. Drugs
a. Lasix
b. Steroids
4. Related to carbon tetrachloride toxicity
C. Signs and Symptoms
1. Polyuria
2. Polydypsia
3. Polyphagia
4. Glucosuria
5. Weight loss6. Anorexia, nausea and vomiting
7. Blurring of vision
8. Increase susceptibility to infection
9. Delayed/poor wound healing
D. Treatment
1. Insulin therapy
2. Diet
3. Exercise
E. Complication
1. Diabetic Ketoacidosis
Type 2 (NIDDM)- Adult onset
- Maturity onset type
- Obese over 40 years old
A. Incidence Rate
- 90% of general population has type 2 DM
B. Predisposing Factors
1. Obesity because obese persons lack insulin receptor binding sites
C. Signs and Symptoms
1. Usually asymptomatic
2. Polyuria
3. Polydypsia
4. Polyphagia
5. Glucosuria
6. Weight gain
D. Treatment
1. Oral Hypoglycemic agents
2. Diet
3. Exercise
E. Complications
1. Hyper
2. Osmolar
3. Non
4. Ketotic
5. Coma
MAIN FOODSTUFFANABOLISMCATABOLISM
1. Carbohydrates
2. Protein
3. FatsGlucose
Amino Acids
Fatty AcidsGlycogen
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
Increase protein formation
Negative Nitrogen balance
Tissue wasting (Cachexia)
INCREASE FAT CATABOLISM
Free fatty acids
Cholesterol
Ketones
Atherosclerosis
Diabetic Keto Acidosis
Hypertension
Acetone Breath Kussmauls Respiration
odor
MI
CVA
Death
Diabetic Coma
DIABETIC KETOACIDOSIS
- Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression
A. Predisposing Factors
1. Hyperglycemia
2. Stress number one precipitating factor3. Infection
B. Signs and Symptoms
1. Polyuria
2. Polydypsia
3. Polyphagia
4. Glucosuria
5. Weight loss
6. Anorexia, nausea and vomiting
7. Blurring of vision
8. Acetone breath odor
9. Kussmauls Respiration (rapid shallow breathing)
10 CNS depression leading to coma
C. Diagnostic Procedures
1. FBS is increased
2. BUN (normal value: 10 20)
3. Creatinine (normal value: .8 1)
4. Hct (normal value: female 36 42, male 42 48) due to severe dehydration
D. Nursing Management
1. Assist in mechanical ventilation
2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock
3. Monitor strictly vital signs, intake and output and blood sugar levels
4. Administer medications as ordered
a. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 4 hours)
b. Sodium Bicarbonate to counteract acidosis
c. Antibiotics to prevent infection
HYPER OSMOLAR NON KETOTIC COMA
- Hyperosmolar: increase osmolarity (severe dehydration)
- Non ketotic: absence of lypolysis (no ketones)
A. Signs and Symptoms
1. Headache and dizziness
2. Restlessness
3. Seizure activity
4. Decrease LOC diabetic coma
B. Nursing Management
1. Assist in mechanical ventilation
2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock
3. Monitor strictly vital signs, intake and output and blood sugar levels
4. Administer medications as ordered
a. Insulin therapy (regular acting insulin peak action of 2 4 hours)
- for DKA use rapid acting insulin
b. Antibiotics to prevent infection
INSULIN THERAPYA. Sources of Insulin1. Animal sources
- Rarely used because it can cause severe allergic reaction
- Derived from beef and pork
2. Human Sources
- Frequently used type because it has less antigenicity property thus less allergic reaction
3. Artificially Compound Insulin
B. Types of Insulin1. Rapid Acting Insulin (clear)
- Regular acting insulin (IV only)
- Peak action is 2 4 hours
2. Intermediate Acting Insulin (cloudy)
- Non Protamine Hagedorn Insulin (NPH)
- Peak action is 8 16 hours
3. Long Acting Insulin (cloudy)
- Ultra Lente
- Peak action is 16 24 hours
C. Nursing Management for Insulin Injections1. Administer at room temperature to prevent development of lipodystrophy (atrophy, hypertrophy of subcutaneous tissues)
2. Place in refrigerator once opened
3. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles
4. Use gauge 25 26 needle
5. Administer insulin either 45o 90o depending on amount of clients tissue deposit
6. No need to aspirate upon injection
7. Rotate insulin injection sites to prevent development of lipodystrophy
8. Most accessible route is abdomen
9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration.
10. Monitor for signs of local complications such as
a. Allergic reactions
b. Lipodystrophy
c. Somogyis Phenomenon rebound effect of insulin characterized by hypoglycemia to hyperglycemia
ORAL HYPOGLYCEMIC AGENTS- Stimulates the pancreas to secrete insulin
A. Classsification1. First Generation Sulfonylureas
a. Chlorpropamide (Diabenase)
b. Tolbutamide (Orinase)
c. Tolamazide (Tolinase)
2. Second Generation Sulfonylureas
a. Glipzide (Glucotrol)
b. Diabeta (Micronase)
Nursing Management when giving OHA
1. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia
2. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms
B. Diagnostic Procedures1. FBS is increased (3 consecutive times with signs or polyuria, polydypsia, polyphagia and glucosuria confirmatory for DM)
2. Random Blood Sugar is increased
3. Oral glucose tolerance test is increased most sensitive test
4. Alpha Glycosylated Hemoglobin is increased
C. Nursing Management
1. Monitor for peak action of insulin and OHA and notify physician
2. Administer insulin and OHA therapy as ordered
3. Monitor strictly vital signs, intake and output and blood sugar levels
4. Monitor for signs of hypoglycemia and hyperglycemia
- administer simple sugars
- for hypoglycemia (cold and clammy skin) give simple sugars
- for hyperglycemia (dry and warm skin)
5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% and fats 20% or offer alternative food substitutes
6. Instruct client to exercise best after meals when blood glucose is rising
7. Monitor signs for complications
a. Atherosclerosis (HPN, MI, CVA)
b. Microangiopathy (affects small minute blood vessels of eyes and kidneys)
EYESKIDNEY
-PREMATURE CATARACT
- Blindness-RECURRENT PYELONEPHRITIS
- Renal failure
c. HPN and DM major cause of renal failure
d. Gangrene formation
e. Shock due to dehydration
- peripheral neuropathy
- diarrhea/constipation
- sexual impotence
8. Institute foot care management
a. instruct client to avoid walking barefooted
b. instruct client to cut toenails straight
c. instruct client to avoid wearing constrictive garments
d. encourage client to apply lanolin lotion to prevent skin breakdown
e. assist in surgical wound debriment (give analgesics 15 30 mins prior)
9. Instruct client to have an annual eye and kidney exam
10. Monitor for signs of DKA and HONKC
11. Assist in surgical procedure
HEMATOLOGICAL SYSTEM
I. Blood
II. Blood Vessels
III. Blood Forming Organs
1. Arteries
1. Liver
55% Plasma 45% Formed2. Veins
3. Spleen
4. Lymphoid Organ
Serum
Plasma CHON
5. Lymph Nodes
(formed in liver)
6. Bone Marrow
1. Albumin
2. Globulins
3. Prothrombin and Fibrinogen
ALBUMIN- Largest and numerous plasma CHON
- Maintains osmotic pressure preventing edema
GLOBULINS
- Alpha globulins - transport steroids, bilirubin and hormones
- Beta globulins iron and copper
- Gamma globulins
a. anti-bodies and immunoglobulins
b. prothrombin and fibrinogen clotting factors
FORMED ELEMENTS
1. RBC (erythrocytes)- normal value: 4 6 million/mm3
- only unnucleated cell
- biconcave discs
- consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment)
- transports and carries oxygen to tissues
- hemoglobin: normal value female 12 14 gms% male 14 16 gms%- hematocrit red cell percentage in wholeblood
- normal value: female 36 42% male 42 48%
- substances needed for maturation of RBC
a. folic acid
b. iron
c. vitamin c
d. vitamin b12 (cyanocobalamin)
e. vitamin b6 (pyridoxine)
f. intrinsic factor
- Normal life span of RBC is 80 120 days and is killed in red pulp of spleen
2. WBC (leukocytes)- normal value: 5000 10000/mm3
A. Granulocytes1. Polymorpho Neutrophils
- 60 70% of WBC
- involved in short term phagocytosis for acute inflammation
2. Polymorphonuclear Basophils
- for parasite infections
- responsible for the release of chemical mediation for inflammation
3. Polymorphonuclear Eosinophils
- for allergic reaction
B. Non Granulocytes1. Monocytes
- macrophage in blood
- largest WBC
- involved in long term phagocytosis for chronic inflammation
2. Lymphocytes
B-cell
T-cell
Natural killer cell- bone marrow
- thymus
- anti viral and anti tumor property
for immunity
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. Pneumocystis Carinii Pneumonia
3. Platelets (thrombocytes)- Normal value: 150,000 450,000/mm3
- Promotes hemostasis (prevention of blood loss)
- Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus
- Normal life span of platelet is 9 12 days
Signs of Platelet Dysfunction
1. Petechiae
2. Echhymosis
3. Oozing of blood from venipunctured site
BLOOD DISORDERS
Iron Deficiency Anemia
- A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury
A. Incidence Rate
1. Common among developed countries
2. Common among tropical zones
3. Common among women 15 35 years old
4. Related to poor nutrition
B. Predisposing Factors
1. Chronic blood loss due to trauma
a. Heavy menstruation
b. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding)
c. fresh blood per rectum is called hematochezia
2. Inadequate intake of iron due to
a. Chronic diarrhea
b. Related to malabsorption syndrome
c. High cereal intake with low animal protein digestion
d. Subtotal gastrectomy
4. Related to improper cooking of foods
C. Signs and Symptoms
1. Usually asymptomatic
2. Weakness and fatigue (initial signs)
3. Headache and dizziness
4. Pallor and cold sensitivity
5. Dyspnea
6. Palpitations
7. Brittleness of hair and spoon shape nails (koilonychias)
8. Atropic Glossitis (inflammation of tongue)
- Stomatitis
PLUMBER VINSONS SYNDROME- Dysphagia
9. PICA (abnormal appetite or craving for non edible foods
D. Diagnostic Procedures
1. RBC is decreased
2. Hgb is decreased
3. Hct is deceased
4. Iron is decreased
5. Reticulocyte is decreased
6. Ferritin is decreased
E. Nursing Management
1. Monitor for signs of bleeding of all hema test including urinw, stool and GIT
2. Enforce CBR so as not to over tire client
3. 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
4. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption
5. Administer medications as ordered
Oral Iron Preparations
a. Ferrous Sulfate
b. Ferrous Fumarate
c. Ferrous Gluconate
- 300 mg/day
Nursing Management when taking oral iron preparations
1. Instruct client to take with meals to lessen GIT irritation
2. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth
Medications administered via straw
- Lugols solution
- Iron
- Tetracycline
- Nitrofurantoin (Macrodentin)
3. Administer with Vitamin C or orange juice for absorption
4. Monitor and inform client of side effects
a. Anorexia
b. Nausea and vomiting
c. Abdominal pain
d. Diarrhea/constipation
e. Melena
5. If client cant tolerate/no compliance administer parenteral iron preparation
a. Iron Dextran (IM, IV)
b. Sorbitex (IM)
Nursing Management when giving parenteral iron preparations
1. Administer Z tract technique to prevent discomfort, discoloration and leakage to tissues
2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption
3. Monitor side effects
a. Pain at injection site
b. Localized abscess
c. Lymphadenopathy
d. Fever and chills
e. Skin rashes
f. Pruritus/orticaria
g. Hypotension (anaphylactic shock)
PERNICIOUS ANEMIA
- Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion)
A. Predisposing Factors
1. Subtotal gastrectomy
2. Hereditary factors
3. Inflammatory disorders of the ileum
4. Autoimmune
5. Strictly vegetarian diet
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
B. Signs and Symptoms
1. Weakness and fatigue
2. Headache and dizziness
3. Pallor and cold sensitivity
4. Dyspnea and palpitations as part of compensation
5. GIT changes that includes
a. mouth sore
b