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Med Surg Notes
Med Surg Notes
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: B. NEUROGLIA Support and protection of neurons. 3. Capable of regeneration with limited time, survival period. Kidney cells, Liver cells, Salivary cells, pancreas.
Permanent Not capable of regeneration. Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
Central Nervous System Brain Spinal Cord serves as a connecting link between the brain & the periphery. Peripheral Nervous System
TYPES 1. Astrocytes maintains blood brain barrier semi-permiable. majority of brain tumors (90%) arises from called astrocytoma. 2. integrity of blood brain barrier.
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
Oligodendria
3.
produces myelin sheath in CNS. act as insulator and facilitates rapid nerve impulse transmission.
Sympathetic nervous system generally accelerate some body functions in response to stress. Parasympathetic nervous system controls normal body functioning.
Microglia stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating), pinocytosis (cell drinking).
4. CELLS A. NEURONS Primary component of nervous system Composed of cell body (gray matter), axon, and dendrites Basic cells for nerve impulse and conduction.
Epindymal
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
Central Nervous System Composition Of Brain 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: 80% brain mass 10% blood 10% CSF
Dendrites Short, blanching fibers that receives impulses and conducts them toward the nerve cell body. Neurons may have many dendrites.
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 o
Both axons and dendrites may or may not have a myelin sheath (myelinated/unmyelinated) Most axons leaving the CNS are heavily myelinated by schwann cells
Functional Classification 1. Afferent (sensory) neurons 2. 3. Transmit impulses from peripheral receptors to the CNS Lobes of Cerebrum 1. Frontal Lobe controls personality, behavior higher cortical thinking, intellectual functioning precentral gyrus: controls motor function Brocas Area: specialized motor speech area - when damaged results to garbled speech. 2. Temporal Lobe hearing, taste, smell short term memory Wernickes 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.
Efferent (motor) neurons Conduct impulses from CNS to muscle and glands
Internuncial neurons (interneurons) Connecting links between afferent and efferent neurons
Properties
Stable
2
4. controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation and constriction of bronchioles). 5. Insula (Island of Reil) visceral function activities of internal organ like gastric motility. Limbic System (Rhinencephalon) Spinal Cord serves as a connecting link between the brain and periphery extends from foramen magnum to second lumbar vertebra 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.
controls smell - if damaged results to anosmia (absence of smell). controls libido controls long term memory
Corpus Callosum
H-shaped gray matter in the center (cell bodies) surrounded by white matter (nerve tract and fibers)
Basal Ganglia island of gray matter within white matter of cerebrum regulate & integrate motor activity originating in the cerebral cortex part of extrapyramidal system area of gray matter located deep within each cerebral hemisphere. 2.
Posterior Horns
2.
Contains cell bodies connecting with afferent (sensory) fibers from dorsal root ganglion
Diencephalon/interbrain Connecting part of the brain, between the cerebrum & the brain stem
Lateral Horns In thoracic region, contain cells giving rise to autonomic fibers of sympathetic nervous system
Contains several small structures: the thalamus & hypothalamus are most important
White Matter
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.
3.
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.
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.
Reflex consists of an involuntary response to a stimulus occurring over a neural pathway called a reflex arc. Not relayed to & from brain: take place at cord levels
Brain Stem 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
Interneurons
d. e.
3
2. 3. Protects & support the brain
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.
Spinal Column Consists of 7 cervical, 12 thoracic, & 5 lumbar vertebrae as well as sacrum & coccyx Supports the head & protect the spinal cord 4.
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
Hepatitis
5.
Bilirubin
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
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:
4.
Ventricles Four fluid-filled cavities connecting with one another & spinal canal Produce & circulate cerebrospinal fluid
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 Substance That Can Pass Blood-Brain Barrier 1. Amonia Cerebral toxin Hepatic Encephalopathy (Liver Cirrhosis) Ascites Esophageal Varices
Late Signs of Hepatic Encephalopathy Headache Dizziness Confusion Fetor hepaticus (amonia like breath) decrease LOC
2.
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 2. accelerates some body function in response to stress. Parasympathetic Nervous System
3.
Type 1 DM (IDDM) Causes diabetic ketoacidosis. And increases breakdown of fats. And free fatty acids
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Blood Vessel constrict smooth muscles of the skin, Abdominal blood vessels, and Cutaneous blood vessels Sympathetic Nervous System (Adrenergic) Effect - 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. 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. Effectors Sympathetic (Adrenergic) Effect Components 1. Eye pupil (miosis) Gland of Head Lacrimal Salivary no effect scanty thick, viscous secretions Dry mouth Heart increase rate & force of contraction decrease rate 3. stimulate secretions copious thin, watery secretions dilate pupil (mydriasis) constrict 2. 3. Eye opening Verbal response Motor response 2. II. Anti-cholinergic Agents - To counter cholinergic agents. - Atrophine Sulfate SE: - SNS effect I. Cholinergic Agents - Mestinon, Neostignin. SE: - PNS effect Urinary Tract EFFECTS OF PNS - Constriction of pupils (miosis). - Increase salivation. - Decrease BP and Heart Rate. - Bronchoconstriction, Decrease RR. - Diarrhea - Urinary frequency. Parasympathetic Nervous System (Cholinergic) Effect, Vagal, Sympatholytic - Involved in flight or withdrawal response. - Release of Acetylcholine. - Decreases all bodily activities except GIT. GI Tract decrease motility increase motility Constrict sphincters 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 & Norepinephrine relaxes detrusor muscles Contract trigone sphincter (prevent voiding) relaxes trigone sphincter (allows voiding) NEURO TRANSMITTER Acethylcholine Dopamine Physical Examination Comprehensive Neuro Exam Neuro Check Decrease Myesthenia Gravis Parkinsons Disease Increase Bi-polar Disorder Schizophrenia no effect relaxed Dilates smooth muscles of bronchioles, Blood vessels of the heart & skeletal muscles Lungs bronchodilation bronchoconstriction no effect
CRANIAL NERVE I: OLFACTORY Sensory function for smell Material Used Dont use alcohol, ammonia, perfume because it is irritating (recent & remote), 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 Snellens Chart Snellens Alphabet chart: for literate client Snellens E chart: for illiterate client Snellens 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. b. c. d. Superiorly Bitemporaly Nasally Inferiorly
3. Cerebellar Function: posture, gait, balance, coordination 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)
CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS Controls or innervates the movement of extrinsic ocular muscle (EOM) 6 muscles: Superior Rectus Superior Oblique
Medial
21. TETANUS risus sardonicus 22. PANCREATITIS cullens sign (echymosis 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.
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 koplicks 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 hermans sign. 19. MENINGITIS kernigs sign (leg pain), brudzinski sign (neck
pain). 2. 1. S/sx
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.
Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) Impaired sensation
touch, pain, pressure, temperature, or position sense paresthesia such as tingling sensation, numbness 2.
monitor breath sounds 1 hour after subcutaneous administration. Urinary Incontinence a. Establish voiding schedule banthine) if ordered 3. Force fluid to 3000 ml/day. prunes, pineapple, vitamin C and orange: to acidify urine and prevent bacterial multiplication. 11. Prevent injury related to sensory problems. a. b. c. d. Test bath water with thermometer. Avoid heating pads, hot water bottles. Inspect body parts frequently for injury. Make frequent position changes.
CHARCOTS TRIAD
Well-balance diet Fresh air & sunshine Avoiding fatigue, overheating or chilling, stress, infection. b. c. Use of medication & side effects. Alternative methods for sexual counseling if indicated.
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
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) - 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. Foramen Magnum Medulla Oblongata Brain Herniation Increase intra cranial pressure Nursing Intervention 1. alternate hot and cold compress to prevent hematoma
b. Walking exercises to improve gait: use wide-base gait c. Assistive devices: canes, walker, rails, wheelchair as
necessary 3. Administer medications as ordered
Increase
constipation. 10. Maintain urinary elimination 1. Urinary Retention a. b. perform intermittent catheterization as ordered: to prevent retention. Bethanecol Chloride (Urecholine) as ordered Nursing Management only given subcutaneous. monitor side effects bronchospasm and wheezing. 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. 2. 3. Decrease LOC Irritability / agitation Progresses from restlessness to confusion & disorientation to lethargy & coma (Late signs) 5. b.
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. Before and after suctioning hyperventilate the client with resuscitator bag connected to 100% O2 & limit suctioning to 10 15 seconds only.
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 respiration) d. 2. temperature increase directly proportional to blood pressure. Pupillary Changes
c. decorticate posturing (damage to cortex and d. decerebrate posturing (damage to upper brain
stem that includes pons, cerebellum and midbrain). 4. 5. Headache Projective Vomiting
a. Prevention
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 b. 8. a.
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.
2. Hypocalcemia/Tetany - decrease calcium level - normal value is 8.5 11 mg/100 ml *CONGESTIVE HEART FAILURE Signs and Symptoms dyspnea orthopnea paroxysmal nocturnal dyspnea productive cough frothy salivation cyanosis rales/crackles bronchial wheezing pulsus alternans anorexia and general body malaise PMI (point of maximum impulse/apical pulse rate) is displaced laterally S3 (ventricular gallop) Predisposing Factors/Mitral Valve o o 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 RHD Aging Signs and Symptoms - tingling sensation - paresthesia - numbness - (+) Trousseus sign/Carpopedal spasm - (+) Chvosteks 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 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 DECREASE
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- polyphagia Nursing Management - monitor FBS 5. Hyperuricemia - increase uric acid (purine metabolism) - foods high in uric acid (sardines, organ meats and anchovies) S/sx *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. b. Allopurinol (Zylopril) Side Effects - respiratory depression (check for RR) Parkinsons 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. 2. 3. 4. 5. Poisoning (lead and carbon monoxide) Arteriosclerosis Hypoxia Encephalitis Increase dosage of the following drugs: a. Reserpine (Serpasil) b. Methyldopa (Aldomet) c. Haloperidol (Haldol) Antihypertensive _______ Anti-Cholinergic Drug a. b. c. Benztropine Mesylate (Cogentin) Procyclidine (Kemadrine) 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 Side Effects Reserpine: Major depression lead to suicide Aloneness b. (hyperactivity) because blood brain barrier is not yet fully developed. Bromocriptine (Parlodel) MOA:
Multiple loss causes suicide
Loss of spouse 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
Loss
8. Quite, monotone speech 9. Emotional lability: state of depression 10. Increase salivation: drooling type
11. Cramped, small handwriting 12. Autonomic Symptoms a. b. c. d. e. excessive sweating increase lacrimation seborrhea constipation decrease sexual capacity
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
stimulate
release
of
dopamine
in
the
substantia nigra Often employed when L-dopa loses effectiveness MAOI Inhibitor
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a. Eldepryl (Selegilene) MOA: inhibit dopamine breakdown & slow progression of disease Anti-Depressant Drug a. Tricyclic MOA: given to treat depression commonly seen in Parkinsons 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. 7. Refer for speech therapy when indicated. Maintain adequate nutrition. Cut food into bite-size pieces Provide small frequent feeding Allow sufficient time for meals, use warming tray 8. 9. Avoid constipation & maintain adequate bowel elimination 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. b. c. Nature of the disease Use prescribed medications & side effects 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. Hydrazide * Dopamine Agonist relieves tremor rigidity MAGIC 2s IN DRUG MONITORING DRUG Digoxin/Lanoxin (increase force of cardiac output) Lithium/Lithane (decrease level of Ach/NE/Serotonin) Aminophelline (dilates bronchial tree) Dilantin/Phenytoin Acetaminophen/Tylen ol 1. Digitalis Toxicity Signs and Symptoms - nausea and vomiting - diarrhea - confusion - photophobia - changes in color perception (yellowish spots) Antidote: Digibind 2. Lithium Toxicity 2. 3. S/sx 10 19 mg/100 ml 10 19 mg/100 ml 10 30 mg/100 ml 20 20 200 COPD Seizures Osteo Arthritis .6 1.2 meq/L 2 Bipolar NORMAL RANGE .5 1.5 meq/L TOXICITY LEVEL 2 INDICATION CHF Promotion of active participation in self-care activities. * Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid 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) - 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 Signs and Symptoms - anorexia - nausea and vomiting - diarrhea - dehydration causing fine tremors - hypothyroidism
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4. 5. Mask like facial expression Hoarseness of voice, weakness of voice arrest
physical or emotional stress infection Signs and Symptoms the client is unable to see, swallow, speak, breathe Treatment administer cholinergic agents as ordered
over medication with the chol drugs (anti-cholinesterase) Signs and Symptoms PNS Treatment
6. Respiratory muscle weakness that may lead to respiratory 7. Extreme muscle weakness especially during exertion and
morning; increase activity & reduced with rest. Dx
administer anti-cholinergic ag (Atrophine Sulfate) Nursing Care in Crisis: a. b. Maintain tracheostomy set or endotracheal tube with mechanical ventilation as indicated. Monitor ABG & Vital Capacity
b. Corticosteroids: Prednisone
MOA: suppress autoimmune response Used if other drugs are not effective
2. Promote optimal nutrition: a. Mealtime should coincide with the peak effect of the
drugs: give medication 30 minutes before meals.
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. 8. Absence or decreased deep tendon reflex Alternate hypotension to hypertension
CHOLINERGIC CRISIS 9. Arrythmia (most feared complication) Symptoms similar to myasthenic crisis & 10. Autonomic disfunction: symptoms that includes in addition the side effect of antia. increase salivation cholinesterase drugs (excessive b. increase sweating salivation & sweating, abdominal carmp, c. constipation N/V, diarrhea, fasciculation) Symptoms worsen with tensilon test: Dx keep Atropine Sulfate & emergency 1. CSF analysis: reveals increased in IgG and protein equipment on hand. 2. EMG: slowed nerve conduction
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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 2.
Mode of transmission
Check individual muscle groups every 2 hrs in acute phase to check progression of muscle weakness Assess cranial nerve function: a. b. c. d. Check gag reflex Swallowing ability Ability to handle secretion Voice Vital signs Input and output Neuro check
a. Nuchal rigidity or stiff neck: initial sign b. Opisthotonos (arching of back): head & heels bent
backward & body arched forward
d. PS: Brudzinski sign (neck pain): flexion at the hip & knee
in response to forward flexion of the neck
4.
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. 2. 3. Secure informed consent and explain procedure. Empty bladder and bowel to promote comfort. Encourage to arch back to clearly visualize L3-L4. Nursing Management Post Lumbar Puncture
3. Increase CSF opening pressure (normal pressure is 50 4. (+) cultured microorganism (confirms meningitis)
CBC reveals 1. Increase WBC
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. 4. 5. Provide nursing care for increase ICP, seizure & hyperthermia if they occur
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. 7. Etiology / Most Common M.O. 8. 9.
Provide nursing care for delirious or unconscious client as needed Enforce complete bed rest photophobia Monitor strictly V/S, I & O & neuro check Maintain fluid & electrolyte balance Prevent complication of immobility
6. Keep room quiet & dark: if the client has headache &
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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. b. Mid Cerebral Artery Internal Cerebral Artery
Incidence Rate: a. Affects men more than women; Men are 2-3 times high risk; Incidence increase with age Causes:
1. 2. 3. 4.
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)
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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. b. 2. 3. 4. Assist in mechanical ventilation Administer O2 inhalation
Monitor strictly V/S, I & O, neuro check & observe signs of increase ICP, shock, hyperthermia, & seizure Provide CBR as ordered Maintain fluid & electrolyte balance & ensure adequate nutrition: a. b. IV therapy for the first few days NGT for feeding the client who is unable to swallow & might also increase ICP
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. Gradually teach the client to compensate by scanning 5. Emotional Lability: mood swings, frustrations
a. b. c. Create a quiet, restful environment with a reduction in excessive sensory stimuli Maintain a calm, non-threatening manner Explain to family that clients behavior is not purposeful
b. Magic slate: not paper & pen tiring for client c. If positive to hemianopsia: approach client on
unaffected side 11. Administer medications as ordered:
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
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) Keep repeating the movement
a. Avoid
modifiable
risk
factors
(diet,
exercise,
smoking)
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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. 2. 3. 4. Head injury due to birth trauma Genetics Presence of brain tumor Toxicity from the ff: a. b. 5. 6. Lead Carbon monoxide 3.
Aura is present: daydreaming like Automatism: stereotype repetitive and non propulsive behavior Clouding of consciousness: not in contact with environment Mild hallucinatory sensory experience 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
Nutritional and Metabolic deficiencies Physical and emotional stress factor for status epilepticus: DOC: Diazepam (Valium) & Glucose S/sx Dependent on stages of development or types of seizure
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
1.
Generalized Seizure Initial onset in both hemisphere, usually involves loss of consciousness & bilateral motor activity.
b. Conjunctiva:
Palpebral Conjunctiva: pink; lines inner surface of eyelids Bulbar Conjunctiva: white with small blood vessels, covers anterior sclera
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Types of Glaucoma:
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:
Unit of measurements of refraction: diopters Normal eye refraction: emmetropia Normal IOP: 12-21 mmHg Error of Refraction
1. Visual Acuity: reduced 2. Tonometry: reading of 24-32 mmHg suggest glaucoma; may
be 50 mmHg of more in acute (close-angle) glaucoma
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
4. Perimetry: reveals defects in visual field 5. Gonioscopy: examine angle of anterior chamber
Medical Management
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b. c. d. Surgery performed on one eye at a time; usually in a same day surgery unit Local anesthesia & intravenous sedation usually used 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
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
f.
Nursing Intervention Pre-op a. Assess vision in the unaffected eye since the affected eye will be patched post-op
prevent vomiting Give stool softener as ordered: to prevent straining Observe for & report signs of intraocular pressure (IOP): Severe eye pain Restlessness Increased pulse Protect eye from injury: a. b. c. Dressing usually removed the day after the surgery Eyeglasses or eye shield used during the day Always use eye shield during the night
Swelling of eyelid Cataract glasses / contact lenses If a lens implant has not been performed the client will need glasses or contact lenses
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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. 2. 3. 4. Trauma Aging process Severe diabetic retinopathy Post-cataract extraction
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. 4.
Endolymph & Perilymph For static equilibrium Mastoid air cells Air filled spaces in temporal bone in skull
2. Surgery: necessary to repair detachment a. Photocoagulation: light beam (argon laser) through
dilated pupil creates an inflammatory reaction & scarring to heal the area
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. 2. 3. Unknown / idiopathic There is familial tendency Ear trauma & surgery S/sx 1. 2. Progressive hearing loss Tinnitus Dx
1. Audiometry: reveals conductive hearing loss 2. Webers & Rinnes Test: show bone conduction is greater
than air conduction Medical Management
Provide client teaching & discharge planning concerning: Techniques of eyedrop administration Use eye shield at night No bending from waist; no heavy work or lifting for 6 weeks Restriction of reading for 3 weeks or more May watch TV Need to check to physician regarding combing & shampooing hair & shaving
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1. Provide general pre-op nursing care, including an explanation of post-op expectation
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:
2. Only move the client for essential care (bath may not be
essential)
7. Prepare client for surgery as indicated (pot-op care 8. Provide client care & discharge planning concerning:
a. b. c. Use of medication & side effects Low sodium diet & decrease fluid intake Importance of eliminating smoking
Overview of Anatomy & Physiology of Endocrine System Menieres 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. 3. Unknown / idiopathic Theories include the ff: a. b. c. d. e. f. Allergy Toxicity Localized ischemia Hemorrhage Viral infection Edema 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 Hormones Regulation
S/sx 1. 2. 3. 4. 5. Sudden attacks of vertigo lasting hours or days; attacks occurs several times a year N/V Tinnitus Progressive hearing loss Nystagmus Dx
1. Audiometry: reveals sensorineural hearing loss 2. Vestibular Test: reveals decrease function
Medical Management 1. Acute:
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anterior pituitary gland through releasing & inhibiting factors that stimulate or inhibits hormone secretions Hormone Function Endocrine G Pituitary G Anterior lobe : ACTH : TSH : stimulate : stimulate adrenal cortex to produce & release adrenocoticoids : FSH, LH maturation, & function of primary & secondary sex organ : GH, Somatotropin body tissues & bones : Prolactin or LTH development of mammary gland & Lactation Posterior lobe : ADH : regulates H2O Pituitary Gland (Hypophysis) Or in response to an increase in plasma osmolality To stimulate reabsorption of H2O & decrease urine Output : Oxytocin contractions during delivery & the Release of milk in lactation Intermediate lobe pigmentation Adrenal G Adrenal Cortex : Mineralocorticoid (ex. Aldosterone) : regulate fluid & reabsoption potassium excretion : Glucocorticoids blood glucose level by increasing rate of (ex. Cortisol, increase CHON catabolism; increase corticosterone) acid; promote sodium & H2O retention; anti-inflammatory effect; aid body in coping with stress : Sex Hormones development of secondary sex (androgens, estrogens characeristics progesterones) Adrenal Medulla : Epinephrine, Norepinephrine : function in acute bronchioles; Needed by the muscles for energy Thyroid G : T3, T4 : regulate metabolic Metabolism; regulating physical & mental Growth development : Thyrocalcitonin serum calcium & phosphate levels Parathyroid G : PTH : regulates serum : lowers & aid in : influence c. mobilization of fatty glyconeogenesis; : increase : MSH : affects skin : stimulate uterine 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 the sex organs, sexual functioning : stimulate : stimulate growth of pregnancy Testes : Testosterone : development of secondary sex characteristics in the Male maturation of of sex organ, sexual functioning Maintenance of : stimulate growth, Ovaries : Estrogen, Progesterone Female, : maturation Hormone Functions Alpha Cells : Glucagon
Beta Cells
: Insulin
: allows glucose to Converts glucose to glycogen : increase blood & glycogenolysis in the liver; secreted in response to low blood sugar
Two small glands, one above each kidney; Located at top of each kidney
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2 Sections of Adrenal Glands
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: 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)
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. b. c. 2. Keep accurate I&O Weigh daily Administer IV/oral fluids as ordered to replace fluid loss
Monitor strictly V/S & observe for signs of dehydration & hypovolemia
3. Administer hormone replacement as ordered: a. Vasopressin (Pitressin) & Vasopressin Tannate (Pitressin
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:
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. 2. Head injury Related to presence of bronchogenic cancer Initial sign of lung cancer is non productive cough Non invasive procedure is chest x-ray
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
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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)
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.
2. Sporadic: caused by
Increase intake of goitrogenic foods (contains agent that decrease the thyroxine production: pro-goitrin an antithyroid agent that has no iodine). Ex. cabbage, turnips, radish, strawberry, carrots, sweet potato, rutabagas, peaches, peas, spinach, broccoli, all nuts Soil erosion washes away iodine Goitrogenic drugs:
f.
g. 3.
1.
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6.
9. Myxedema coma:
A complication of hypothyroidism & an emergency case A severe form of hypothyroidism is characterized by: Severe hypotension Bradycardia Bradypnea Hypoventilation Hyponatremia Hypoglycemia Hypothermia Leading to progressive stupor and coma Nursing Management for Myxedema Coma 1. 2. 3. Assist in mechanical ventilation Administer thyroid hormones as ordered Administer IVF replacement isotonic fluid solution as ordered / Force fluids 10. Provide client health teaching and discharge planning concerning: a. b. c. d. e. f. g. Thyroid hormone replacement Importance of regular follow-up care Need in additional protection in cold weather Measures to prevent constipation Avoid precipitating factors leading to myxedema coma & hypovolemic shock Stress & infection Use of anesthetics, narcotics, and sedatives
10. Weakness and fatigue 11. Slowed mental processes 12. Dull look 13. Slow clumsy movement 14. Lethargy
1. Serum T3 and T4: is decreased 2. Serum Cholesterol: is increased 3. RAIU (Radio Active Iodine Uptake): is decreased
Medical Management
Hyperthyroidism Secretion of excessive amounts of thyroid hormone in the blood causes an increase in metabolic process Increase in T3 and T4 Graves Disease or Thyrotoxicosis Increase in all V/S except wt & menses Predisposing Factors 1. More often seen in women between ages 30 & 50 stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 3. Excessive iodine intake
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
4. Related to hyperplasia (increase size of TG) 1. Monitor strictly V/S & I&O, daily weights; observe for
edema & signs of cardiovascular complication & to determine presence of myxedema coma 2. 3. S/sx
Warm smooth skin Fine soft hair Pliable nails CNS involvement a. b. c. Irritability & agitation Restlessness Tremors
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d. e. f. g. Insomnia Hallucinations Sweating Hyperactive movement 1. 2. 3. Dx Nursing Intervention Maintain patent airway & adequate ventilation; administer O2 as ordered Administer IV therapy as ordered Administer medication as ordered: a. b. c. d. 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. b. 2. Cardiac status is normal Weight & nutritional status is normal Anti-thyroid drugs Corticosteroids Sedatives Cardiac Drugs 7. 8. Delirium Coma
10. Goiter
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:
Administer anti-thyroid drugs as ordered: to suppressed the production of thyroid hormone & to prevent thyroid storm Administer iodine preparation Lugols Solution (SSKI) or Potassium Iodide Solution: to decrease vascularity of the thyroid gland & to prevent hemorrhage. Nursing Intervention Post-Op
Provide comfortable and cold environment Minimized stress in the environment Encourage quiet, relaxing diversional activities calories, vitamin & minerals with supplemental feeding between meals & at bedtime; omit stimulant
8.
10. Maintain side rails 11. Provide bilateral eye patch to prevent drying of the eyes
TRIAD SIGNS
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
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10. Relieve discomfort from sore throat: a. b. Cool mist humidifier to thin secretions Administer analgesic throat lozenges before meals prn as ordered 11. Encourage coughing & deep breathing every hour 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 Sunlight (Calcitriol) Diet (Calcidiol)
Phosphate Binder: Aluminum Hydroxide Gel (Amphogel) or aluminum carbonate gel, basic (basaljel): to decrease phosphate levels ANTACID A.A.C MAD
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. 2. 3. May be hereditary Idiopathic Caused by accidental damage to or removal of parathyroid gland during thyroidectomy surgery
Aluminum Hydroxide Gel Side Effect: Constipation Side Effect: Diarrhea 2. Institute seizure & safety precaution Provide quite environment free from excessive stimuli Avoid precipitating stimulus such as glaring lights and noise 5. Monitor signs of hoarseness or stridor; check for signs for Chvosteks & Trousseaus sign 3. 4.
1. Acute hypocalcemia (tetany) a. Paresthesia: tingling sensation of finger & around lip
b. c. d. Muscle spasm laryngospasm/broncospasm Dysphagia
Hyperparathyroidism 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 hyperplasia of parathyroid gland
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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)
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)
1. Serum Calcium: is increased 2. Serum Phosphate: is decreased 3. Skeletal X-ray of long bones: reveals bone
demineralization Nursing Intervention 1. 2. Administer IV infusions of normal saline solution & give diuretics as ordered: Monitor I&O & observe fluid overload & electrolytes imbalance 1.
b. Mineralocorticoids:
Fludrocortisone Acetate (Florinef) Nursing Management when giving steroids Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm
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
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. b. Need to engage in progressive ambulatory activities Increase fluid intake calcium diet following a parathyroidectomy
c. Use of calcium preparation & importance of highd. Prevent complications: renal failure
e. f. Hormonal replacement therapy for lifetime Importance of follow up care
a. Disease process: signs of adrenal insufficiency b. Use of prescribe medication for lifelong replacement
therapy: never omit medication
Addisons 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 g. Predisposing Factors d. e.
f.
i.
j.
S/sx 1. 2. Fatigue, Muscle weakness Anorexia, N/V, abdominal pain, weight loss tremors, tachycardia, irritability, restlessness, extreme fatigue, diaphoresis, depression k.
Addisonian Crisis
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4. Force fluids antibiotics as ordered Predisposing Factors 1. 2. 3. 4. 5. Strenuous activity Stress Trauma Infection Failure to take prescribe medicine 7. 8. 6. Maintain strict bed rest & eliminate all forms of stressful stimuli Monitor V/S, I&O & daily weight Protect client from infection concerning: same as addisons disease Cushing Syndrome Condition resulting from excessive secretion of corticosteroids, particularly glucocorticoid cortisol Hypersecretion of adrenocortical hormones Predisposing Factors
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. 2. Generalized muscle weakness Severe hypotension
2. Administer IV fluids (5% dextrose in saline, plasma) 3. Administer IV glucocorticoids: Hydrocortisone (SoluCortef) & vasopressors as ordered 1. 2. 3. 4. 5. 6. 7. 8. 9. Muscle weakness Fatigue Obese trunk with thin arms & legs Muscle wasting Irritability Depression Frequent mood swings Moon face Buffalo hump
10. Pendulous abdomen 11. Purple striae on trunk 12. Acne 13. Thin skin
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. b. 2. 3. 4. Provide ROM exercise Assist in ambulation
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 ANABOLISM CATABOLISM
Prevent accidents fall & provide adequate rest Protect client from exposure to infection Maintain skin integrity a. Provide meticulous skin care necessary
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
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1. CHO 2. CHON 3. Fats Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids : cholesterol : ketones Keto Acidosis Hypertension HYPERGLYCEMIA Increase osmotic diuresis Glycosuria Polyuria Cellular starvation: weight loss 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 1. Negative Nitrogen balance Tissue wasting (Cachexia) INCREASE FAT CATABOLISM Free fatty acids 1. 2. 3. 4. 5. 6. Polyuria Polydipsia Polyphagia Glucosuria Weight loss Fatigue 7. 8. 9. 1. Cellular Diabetic Coma Death Acetone Kussmauls Respiration odor MI CVA Breath Atherosclerosis Diabetic Ketones Cholesterol
Classification Of DM
2. Postprandial Blood Sugar: elevated 3. Oral Glucose Tolerance Test (most sensitve test):
elevated
Drug therapy:
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Complication
5. FBS:
c. d. A level of 140 mg/dl of greater on at two occasions confirms DM May be normal in Type II DM
6. Postprandial Blood Sugar: elevated 7. Oral Glucose Tolerance Test (most sensitve test):
elevated
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
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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 Somogyis 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 i. h.
Notify physician Monitor urine or blood glucose level & urine ketones frequently If N/V occurs: sip on clear liquid with simple sugar 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 Exercise Undertake regular exercise; avoid sporadic, vigorous exercise 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 Undiagnosed DM Neglect to treatment Infection cardiovascular disorder Hyperglycemia factor S/sx
1. 2. 3. 4. 5. 6. 7. 8. 9.
Polyuria Polydipsia Polyphagia Glucosuria Weight loss Anorexia N/V Abdominal pain Skin warm, dry & flushed
12. PS: Acetone breath odor 13. PS: Kussmauls Respiration (rapid shallow breathing) or
tachypnea 14. Alteration in LOC 15. Hypotension 16. Tachycardia 17. CNS depression leading to coma
1. FBS: is increased 2. Serum glucose & ketones level: elevated 3. BUN (normal value: 10 20): elevated: due to
dehydration
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Potassium will be added: when the urine output is adequate b. Observe for F&E imbalance, especially fluid overload, hyperkalemia & hypokalemia 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. 2. 3. 4. 5. 6. 7. Undiagnosed diabetes Infection or other stress Certain medications (ex. dilantin, thiazide, diuretics) Dialysis Hyperalimentation Major burns Pancreatic disease S/sx
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 The hematologic system also plays an important role in
Dx
hormone transport, the inflammatory & immune responses, temperature regulation, F&E balance & acid-base balance.
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. 2. Maintain patent airway Assist in mechanical ventilation
HEMATOLOGICAL SYSTEM
I. Blood III. Blood Forming Organs Liver 55% Plasma Thymus (Fluid) Spleen Lymphoid Organ Serum Lymph Nodes Bone Marrow
2. Veins 3. Capillaries
5. 6.
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. 2. 3. 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 Erythrocytes Leukocytes Thrombocytes
2.
Yellow Marrow Red marrow that has changed to fats; found in long bone; does not contribute to hematopoiesis
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. Blood
Composed of plasma (55%) & cellular components (45%) Hematocrit 1. Reflects portion of blood composed of red blood cells
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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 Distribution 1. 1300 ml in pulmonary circulation a. b. c. 2. a. b. c. 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 400 ml arterial 60 ml capillary 840 ml venous 550 ml arterial 300 ml capillary 2150 ml venous i.
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 leukocytes Immature band cells) Polymorphonuclear Basophils For parasite infections Responsible Involved in for the release of of chemical in mediation for inflammation prevention clotting microcirculation and allergic reactions Polymorphonuclear Eosinophils Involved in phagocytosis and allergic reaction neutrophils: neutrophils: polymorphonuclear band cells (bacterial
b. Beta: role in transport of iron & copper c. Gamma: role in immune response, function of
antibodies
1. Erythrocytes (RBC)
a. Normal value: 4 6 million/mm3 hemoglobin c. Call membrane is highly diffusible to O2 & CO2 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 Produced by bone marrow: give rise to histiocytes (kupffer cells of liver), macrophages & other components of reticuloendothelial system
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) HIV B-cell T-cell - bone marrow - thymus and anti-tumor property for immunity Natural killer cell anti-viral
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
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Signs of Platelet Dysfunction 1. 2. 3. 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. b. c. d. Antigens of systems are labeled A & B Absence of both antigens results in type O blood Presence of both antigen is type AB Presence of either type A or B results in type A & type B, respectively Petechiae Echhymosis Oozing of blood from venipunctured site reaction _____________________________________________________________________ __________________ Pyrogenic Recipient possesses flushing, palpitation, tachycardia, occasional lumbar pain antibodies Leukocytes agglutination bacterial Within 15-90 min initiation after of Fever, chills, Stop transfusion. Treat temp. Transfuse with organism transfusion leukocytes-poor blood of washed RBC.
directed against WBC; bacterial contamination; Multitransfused Administer client; antibiotics prn multiparous client
_____________________________________________________________________ __________________ Circulatory Overload transfusion tachycardia, Client orthopnea, blood. Monitor CVP t hro ug ha separate line. _____________________________________________________________________ after __________________ Air Embolism Blood given under air pressure wheezing, chest pain, decrease BP, blood loss apprehension _____________________________________________________________________ __________________ThromboWhen large of cytopenia bleeding banked blood 24 hr amount of Used of large deteriorate of bleeding. rapidly in stored blood precautions. Use fresh blood. Occurrence S/sx _____________________________________________________________________ __________________ Citrate Large amount Citrate binds After large amount of blood Neuromascular Monitor/treat Intoxication of citrated blood hypocalcemia. banked Avoid large amounts of in client with transfusion Bleeding due to decrease liver decrease calcium function citrated blood. Monitor liver fxn ionic calcium irritability given over Initiate bleeding Platelets amount of blood Abnormal Assess for signs Bolus of air Anytime Dyspnea, Clamp tubing. blocks pulmonary artery outflow left side Too rapid Fluid volume During & after Dyspnea, Slow infusion rate infusion in increase BP, Susceptible instead of whole overload Used packed cells
cyanosis, anxiety
Headache,
Incompatibility; in donor cells. diarrhea, fever, Use of dextrose solutions; Wide temp restlessness, fluctuation
following severe
hemoglobinuria.
anemia, jaundice,
Complication of Blood Transfusion Type Causes Intervention Allergic Transfer of an Uticaria, larygeal antigen & edema, wheezing dyspnea, donor to recipient; headache, anaphylaxis Treat life-threatening Allergic donor Immune sensitivity to Administer antihistamine & CHON Within 30 min start of Mechanism
Stop transfusion.
bronchospasm, or epinephrine.
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_____________________________________________________________________ __________________ Hyperkalemia Potassium level Release of Administer blood potassium into renal less than 5-7 plasma with red cell lysis changes (tall with impaired potassium insufficiency increase in diarrhea, muscle stored blood spasm, ECG In client with Blood Tranfusion Purpose Nausea, colic,
1. RBC: Improve O2 transport 2. Whole Blood, Plasma, Albumin: volume expansion 3. Fresh Frozen Plasma, Albumin, Plasma Protein Fraction:
provision of proteins
excretion
1. Whole Blood: provides all components a. Large volume can cause difficulty: 12-24 hr for Hgb
& Hct to rise
Blood Coagulation Conversion of fluid blood into a solid clot to reduce blood loss when blood vessels are ruptured System that Initiating Clotting
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:
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 Proper refrigeration a. b. Expiration of packed RBC is 3-6 days Expiration of platelet is 3-5 days
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a. b. Filter set Gauge 18-19 needle 1. 2. 3. 4. 5. 6. hemolysis 4. Instruct another RN to re check the following a. b. c. d. 5. Client name Blood typing & cross matching Expiration date Serial number Nursing Management 1. 2. 3. 4. Stop BT Notify physician Flush with plain NSS Administer medications as ordered a. b. 5. 6. 7. 8. Antipyretic Antibiotic S/sx Pyrogenic reactions Fever and chills Headache Tachycardia Palpitations Diaphoresis Dyspnea
Check the blood unit for bubbles cloudiness, sediments and darkness in color because it indicates bacterial contamination
Send the blood unit to blood bank for re examination Obtain urine & blood sample & send to laboratory for reexamination Monitor vital signs & I&O Render TSB
S/sx of Circulatory reaction 1. 2. 3. 4. Orthopnea Dyspnea Rales / Crackles upon auscultation Exertional discomfort Nursing Management 1. 2. 3. Stop BT Notify physician Administer medications as ordered
a. Whole Blood: approximately 3-4 hr b. RBC: approximately 2-4 hr c. Fresh Frozen Plasma: as quickly as possible d. Platelet: as quickly as possible e. Cryoprecipitate: rapid infusion f.
9. Granulocytes: usually over 2 hr
- 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)
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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
c. Related to GIT bleeding resulting to hematemasis d. Fresh blood per rectum is called hematochezia
2. Inadequate intake or absorption of iron due to: a. b. c. d. e. 3. Chronic diarrhea Related to malabsorption syndrome High cereal intake with low animal CHON digestion Partial or complete gastrectomy Pica
7. Brittleness of hair & nails, spoon shape nails 8. Atrophic Glossitis (inflammation of tongue) a. Stomatitis
VINSONS SYNDROME b. Dysphagia PLUMBER
Fever & chills Headache Urticaria Pruritus Hypotension Skin rashes Anaphylactic shock Medications administered via straw Lugols Solution Iron Tetracycline Nitrofurantoin (Macrodentin) 7. 8. Administer with Vitamin C or orange juice for absorption Monitor & inform client of side effects a. b. c. d. e. 9. Anorexia N/V Abdominal pain Diarrhea / constipation Melena
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
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erythrocytes & hypochlorhydria (a deficiency of hydrochloric acid in gastric secretion) Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) Characterized by neurologic & GI symptoms; death usually resuls if untreated 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 e. b. c.
f.
Pathophysiology
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
7. CNS S/sx:
a. b. c. d. e. f. Tingling sensation Numbness Paresthesias of hands & feet Paralysis Depression Psychosis resulting to ataxia Dx
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Leukopenia Thrombocytopenia
3. Administer O2 inhalation
4. 5. 6. 7. Enforce CBR Institute reverse isolation Provide nursing care for client with bone marrow transplant Administer medications as ordered:
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
Medical Management 1. Identification & control the underlying disease is key platelets, plasma, cryoprecipitites & volume expanders 3. Heparin administration a. b. Somewhat controversial Inhibits thrombin thus preventing further clot formation, allowing coagulation factors to accumulate Nursing Intervention 1. Monitor blood loss & attemp to quantify
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2. 3. 4. Monitor for signs of additional bleeding or thrombus formation Monitor all hema test / laboratory data including stool and GIT Prevent further injury a. b. c. Avoid IM injection Apply pressure to bleeding site Turn & position the client frequently & gently toothbrush or gauze sponge) 2 chambers, function as receiving chambers, lies above the ventricles
Right Atrium: receives systemic venous blood through the superior vena cava, inferior vena cava & coronary sinus
Ventricles
Left Atrium: receives oxygenated blood returning to the heart from the lungs trough the pulmonary veins
d. Provide frequent nontraumatic mouth care (ex. soft 5. Administer isotonic fluid solution as ordered: to prevent
shock 6. 7. 8. Administer oxygen inhalation Force fluids Administer medications as ordered: a. Vitamin K
2 thick-walled chambers; major responsibility for forcing blood out of the heart; lie below the atria
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
Provide heparin lock lavage: by using ice or cold saline solution of 500-1000 ml
Mitral Valve: located between the left atrium & left ventricle; contains 2 leaflets attached to the chordae tandinae
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
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
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
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
Epicardium
S3: ventricular gallop usually seen in Left Congestive Heart Failure S4: atrial gallop usually seen in Myocardial Infarction and Hypertension
Covers surface of the heart, becomes continuous with visceral layer of serous pericardium Outer layer
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
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
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
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Initiates the cardiac impulse which spreads across the atria & into AV node Initiates electrical impulse of 60-100 bpm Small arteries that distribute blood to the capillaries & function in controlling systemic vascular resistance & therefore arterial pressure Capilliaries 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 Venules Bundle of His Arises from the AV node & conduct impulse to the bundle branch system Located at the interventricular septum 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. Small veins that receive blood from capillaries & function as collecting channels between the capillaries & veins The following exchanges occurs in the capilliaries O2 & CO2 Solutes between the blood & tissue Fluid volume transfer between the plasma & interstitial space
Right Bundle Branch: divided into anterior lateral & posterior; transmits impulses down the right side of the interventricular myocardium
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
Cardiac Disorders Coronary Arterial Disease / Ischemic Heart Disease Stages of Development of Coronary Artery Disease
Purkinje Fibers Transmit impulses to the ventricle & provide for depolarization after ventricular contraction Located at the walls of the ventricles for ventricular contraction
1. Myocardial Injury: Atherosclerosis 2. Myocardial Ischemia: Angina Pectoris 3. Myocardial Necrosis: Myocardial Infarction
ATHEROSCLEROSIS
SA NODE AV NODE
Predisposing Factors
1. Sex: male
BUNDLE OF HIS
2. Race: black
3. 4. 5. 6. 7. 8. Smoking Obesity Hyperlipidemia Sedentary lifestyle Diabetes Mellitus Hypothyroidism
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
Treatment P - Percutaneous T - Transluminal C - Coronary A Angioplasty C - Coronary A - Arterial B - Bypass A - And G - Graft S - Surgery
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
Objectives Types of Blood Vessels Arteries Elastic-walled vessels that can stretch during systole & recoil during diastole; they carry blood away from the heart & distribute oxygenated blood throughout the body Arterioles 3 Complications of CABG 1. 2. 3. 4. 5. Revascularize myocardium To prevent angina Increase survival rate Done to single occluded vessels If there is 2 or more occluded blood vessels CABG is done
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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
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. 2. 3. 4. 5. 6. 7. 8. Sex: male Race: black Smoking Obesity Hyperlipidemia Sedentary lifestyle Diabetes Mellitus Hypertension 2.
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
9. CAD: Atherosclerosis
10. Thromboangiitis Obliterans 11. Severe Anemia
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
12. Aortic Insufficiency: heart valve that fails to open & close
efficiently 13. Hypothyroidism
Avoid placing near microwave ovens or during defibrillation as it may lead to burns (most important thing to remember)
Beta-blockers Propanolol: side effects PNS Not given to COPD cases: it causes bronchospasm
c. d. 4. 5. 6. 7. 8.
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
Administer oxygen inhalation Place client on semi-to high fowlers position Monitor strictly V/S, I&O, status of cardiopulmonary fuction & ECG tracing Provide decrease saturated fats sodium and caffeine Provide client health teachings and discharge planning Avoidance of 4 Es 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
S/sx
1. Levines Sign: initial sign that shows the hand clutching the
chest
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
2. ECG: may reveals ST segment depression & T wave 3. Stress test / treadmill test: reveal abnormal ECG during
exercise 4. 5. Increase serum lipid levels Serum cholesterol & uric acid is increased
Medical Management
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.
3. Surgery: Coronary artery bypass surgery 4. Percutaneuos Transluminal Coronary Angioplasty (PTCA)
Types Nursing Intervention 1. 2. Enforce complete bed rest Give prompt pain relievers with nitrates or narcotic analgesic as ordered
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6-8 hours because majority of death occurs due to arrhythmia leading to premature ventricular contractions (PVC)
Predisposing Factors
8. Monitor urinary output & report output of less than 30 ml / 9. Provide a full liquid diet with gradual increase to soft diet:
low in saturated fats, Na & caffeine 10. Maintain quiet environment
5. CAD: Atherosclerotic
6. 7. 8. 9. Thrombus Formation Genetic Predisposition Hyperlipidemia Sedentary lifestyle
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
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)
2. 3. N/V
Side Effects: allergic reaction, urticaria, pruritus Nursing Intervention: Monitor for bleeding time
4. Increase in blood pressure & pulse, with gradual drop in 5. Hyperthermia: elevated temp
6. 7. 8. Skin: cool, clammy, ashen Mild restlessness & apprehension Occasional findings: Pericardial friction rub Split S1 & S2 Rales or Crackles upon auscultation S4 or atrial gallop
Antidote: Protamine Sulfate Nursing Intervention: Check for Partial Thrombin Time (PTT)
Caumadin (Warfarin)
Dx 1.
Side Effects: Tinnitus, Heartburn, Indigestion / Dyspepsia Contraindication: Dengue, Peptic Ulcer Disease, Unknown cause of headache
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
Arrhythmia: caused by premature ventricular contraction Cardiogenic shock: late sign is oliguria Left Congestive Heart Failure Thrombophlebitis: homans sign Stroke / CVA Dresslers Syndrome (Post MI Syndrome): client is resistant to pharmacological agents: administer 150,000-450,000 units of streptokinase as ordered
4. Serum Cholesterol & uric acid: are both increased 5. CBC: increased WBC
Nursing Intervention
g.
Side Effects: Respiratory Depression Antidote: Naloxone (Narcan) Side Effects of Naloxone Toxicity: is tremors
Client can resume sexual intercourse: if can climb or use the staircase
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i. Need to report the ff s/sx: j. k. Increased persistent chest pain Dyspnea Weakness Fatigue Persistent palpitation Light headedness Predisposing Factors 1. 2. 3. 4. 5. 6. 7. S/sx 1. 2. 3. 4. Types of Heart Failure 1. 2. 3. Left Sided Heart Failure Right Sided Heart Failure High-Output Failure 5. 6. 7. 8. 9. Left Sided Heart Failure Anorexia Nausea Weight gain Neck / jugular vein distension Pitting edema Bounding pulse Hepatomegaly / Slenomegaly Cool extremities Ascites Right ventricular infarction Atherosclerotic heart disease Tricuspid valve stenosis Pulmonary embolism Related to COPD Pulmonic valve stenosis Left sided heart failure
Weakened right ventricle is unable to pump blood into he pulmonary system: systemic venous congestion occurs as pressure builds up
Enrollment of client in a cardiac rehabilitation program 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
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.
1. Chest X-ray (CXR): reveals cardiomegaly 2. Central Venous Pressure (CVP): measure fluid status:
elevated
Predisposing Factors
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
2. Paroxysmal nocturnal dyspnea (PND): client is awakened at 3. Orthopnea: use 2-3 pillows when sleeping or place in high
fowlers 4. 5. 6. 7. 8. 9. Tiredness Muscle Weakness Productive cough with blood tinged sputum Tachycardia Frothy salivation Cyanosis
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
14. PMI is displaced laterally: due to cardiomegaly 15. Possible S3: ventricular gallop
Dx
D Diuretics
1. Chest X-ray (CXR): reveals cardiomegaly 2. Pulmonary Arterial Pressure (PAP): measures pressure in
right ventricle or cardiac status: increased
O O2 G Gases Nursing Intervention Goal: Increase cardiac contractility thereby increasing cardiac output of 3-6 L / min
Increase CVP: decreased flow rate of IV Decrease CVP: increased flow rate of IV
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c. d. 3. a. Maintain quiet & relaxed environment Organized nursing care around rest periods Administer digitalis as ordered & monitor effects 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)
b. c.
Cardiac glycosides: Digoxin (Lanoxin) Action: Increase force of cardiac contraction Contraindication: If heart rate is decreased do not give
d. 4. a.
b. c. d. e. f. g. h. i.
Daily weight Maintain accurate I&O Assess for peripheral edema Measure abdominal girth daily Monitor electrolyte levels Monitor CVP & Swan-Ganz reading Provide Na restricted diet as ordered Provide meticulous skin care
b.
Narcotic analgesic: Morphine SO4 Action: to allay anxiety & reduce preload & afterload
c.
Bronchodilators: Aminophylline IV Action: relieve bronchospasm, increase urinary output & increase cardiac output
Nursing Intervention 1. Encourage a slow progressive physical activity 2. 3. 4. 5. Walking at least 2 times / day Out of bed at least 3-4 times / day
Raynauds Phenomenon Intermittent episodes of arterial spasm most frequently involving the fingers or digits of the hands
1. High risk group: female between the teenage years & age
40 years old & above 2. 3. Smoking Collagen diseases
4. Pain: usually precipitated by exposure to cold, Emotional 5. Intermittent color changes: pallor (white), cyanosis (blue),
rubor (red)
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1. Doppler UTZ: decrease blood flow to the affected extremity 2. Angiography: reveals site & extent of malocclusion
Thrombophlebitis (Deep vein thrombosis) Medical Management 1. Administer medications as ordered a. Catecholamine-depliting antihypertinsive drugs: b. 1. 2. 3. Reserpine Guanethidine Monosulfate (Ismelin)
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
Vasodilators
Nursing Intervention Importance of stop smoking Need to maintain warmth especially in cold weather Need to wear gloves when handling cold object / opening a freezer or refrigerator door
Abnormal dilation of veins of lower extremities and trunks due to incompetent valve resulting to increased venous pooling resulting to venous stasis causing decrease venous return
12. Post-op complication: surgery 13. Venous cannulation: insertion of various cardiac catheter
14. Increase in saturated fats in the diet.
Predisposing Factors 1. 2. 3. 4. 5. 6. 7. S/sx Hereditary Congenital weakness of the veins Thrombophlebitis Cardiac disorder Pregnancy Obesity Prolonged standing or sitting 3. S/sx 1. Pain in the affected extremity course of the vein Deep vein: Swelling Venous distention of limb Tenderness over involved vein Positive homans sign: pain at the calf or leg muscle upon dorsi flexion of the foot Dx Cyanosis
2. Trendelenburg Test: veins distends quickly in less than 35 3. Doppler Ultrasound: decreased or no blood flow heard after
calf or thigh compression Medical Management
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:
Hypersensitivity:
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Dermatitis Urticaria Pruritus Fever Swim several times weekly Gradually increased walking distance
2.
b. Venous thrombectomy: removal of cloth in the 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
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
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 -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 3.
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)
4.
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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
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
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 (Daltons 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 Dx Alveolar Ducts Arises from the respiratory bronchioles & lead to the alveoli Alveolar Sac
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
4. Related to prolonged immobility (CVA clients): causing 5. Aspiration of food: causing aspiration pneumonia
S/sx 1. 2. 3. 4. 5. 6. 7. 8. Productive cough with greenish to rusty sputum Rapid shallow respiration with expiratory grunt Nasal flaring Intercostal rib retraction Use of accessory muscles of respiration Dullness to flatness upon auscultation Possible pleural friction rub High-pitched bronchial breath sound
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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 S/sx 1. 2. 3. 4. 5. 6. 7. 8. Dx Similar to PTB or Pneumonia Productive cough Fever, chills, anorexia, general body malaise Chest and joint pains Dyspnea Cyanosis Hemoptysis Sometimes asymptomatic 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 h. f. g.
Chills Increased pain Difficulty in breathing Weight loss Persistent fatigue Avoid smoking Prevent complications Atelectasis Meningitis Importance of follow up care
1. Chest X-ray: often appears similar to PTB 2. Histoplasmin Skin Test: positive 3. ABG analysis: PO2 decrease
Medical Management
prophylactically Abnormal renal function with hypokalemia & azotemia: Nephrotoxicity, check for BUN and Creatinine, Hypokalemia 5. 6. Force fluids to liquefy secretions Nebulize & suction as needed
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. 2. Smoking Air pollution
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Physical Therapy Hyposensitization Execise Enforce CBR distress Administer medications as ordered Force fluids 2-3 L/day Semi fowlers position: to promote lung expansion Nebulize & suction when needed Provide client health teachings and discharge planning concerning a. b. Avoidance of precipitating factor Prevent complications Emphysema Status Asthmaticus: severe attack of asthma which cause poor controlled asthma DOC: Epinephrine Steroids Bronchodilators
Nursing Intervention
10. Anorexia and generalized body malaise 11. Pulmonary hypertension a. Leading to peripheral edema
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. 2. 3. Caused by bacterial infection Recurrent lower respiratory tract infections Chest trauma
4. Congenital defects (altered bronchial structure) 5. Related to presence of tumor (lung tumor)
6. Sx 1. 2. 3. 4. Productive cough with mucopurulent sputum Dyspnea in exertion Cyanosis Anorexia & generalized body malaise Thick tenacious secretion
1. CBC: elevation in WBC 2. ABG: PO2 decrease 3. Bronchoscopy: reveals sources & sites of secretion: direct
visualization of bronchus using fiberscope Nursing Management before Bronchoscopy 1. 2. 3. Secure inform consent and explain procedure to client Maintain NPO 6-8 hours prior to procedure Monitor vital signs & breath sound Post Bronchoscopy 1. 2. 3. Feeding initiated upon return of gag reflex Avoid talking, coughing and smoking, may cause irritation Monitor for signs of gross 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
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Improve ventilation
c. Encourage productive cough after all treatment (splint d. Employ pursed-lip breathing techniques (prolonged slow
relaxed expiration against pursed lips) Institute pulmonary toilet
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
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. g. Strict compliance to medication 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.
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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.
Client Factors 1.
Probably normal (slight changes) Doubtful (more severe changes) Probably cancer or precancerous Definitely cancer
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 o o Viruses have been shown to be the cause of certain tumors in animals Viruses ( HTLV-I, Papilloma Virus) linked to human tumors Oncovirus (RNA Type Viruses) thought to be culprit
E Environmental o o Majority (over 80%) of human cancer related to environmental carcinogens Types: Physical Radiation: X ray, radium, nuclear explosion & waste, UV Trauma or chronic irritation
Chemical Nitrates, & food additives, polycyclic hydrocarbons, agents Classification of Cancer Tissue Typing: Drugs: urethane Cigarette smoke hormones arsenicals,
1. Antimetabolites
o 2. 3. Foster cancer cell death by interfering with cellular metabolic process. Alkylating Agent o o o 4. act with DNA to hinder cell growth & division. obtained from periwinkle plant. makes the hosts body a less favorable environment for the growth of cancer cells. Antitumor Antibiotics o 5. affect RNA to make environment less favorable for cancer growth. 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 o o Administer antiemetics routinely q 4-6 hrs as well as prophylactically before chemotherapy is initiated. Withhold food/fluid 4-6 hrs before chemotherapy Provide bland food in small amounts after treatment Plant Alkaloids
TNM System: uses letters & numbers to designate the extent of tumors
o o o
T stands for primary growth; 1-4 with increasing size; T1S indicates carcinoma in situ N stands for lymph nodes involvement: 0-4 indicates progressively advancing nodal disease 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
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Diarrhea o o o o Administer antidiarrheals. Maintain good perineal care. Give clear liquids as tolerated. Monitor K, Na, Cl levels. 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. Plant alkaloids (vincristine) cause neurologic damage with repeated doses Peripheral neuropathies, hearing loss, loss of deep tendon reflex, & paralytic ileus may occur.
Stomatitis (mouth sore) o o o Provide & teach the client good oral hygiene, including avoidance of commercial mouthwashes. Rinse with viscous lidocaine before meals to provide analgesic effect. Perform a cleansing rinse with plain H2O or dilute a H2O soluble lubricant such as hydrogen peroxide after meal. o o Apply H2O lubricant such as K-Y jelly to lubricate cracked lips. Advice client to suck on Popsicles or ice chips to provide moisture.
Localized effects are related to the area of the body being treated; generalized effects maybe related to cellular breakdown products.
B. Hematologic System Thrombocytopenia o o o o o o Avoid bumping or bruising the skin. Protect client from physical injury. Avoid aspirin or aspirin products. Avoid giving IM injections. Monitor blood counts carefully. Assess for signs of increase bleeding tendencies (epistaxis, petechiae, ecchymoses)
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 clients body for designated period of time.
Leukopenia o o o o Use careful handwashing technique. Maintain reverse isolation if WBC count drops below 1000/mm Assess for signs of respiratory infection Avoid crowds/persons with known infection
Sealed Implants a radioisotope enclosed in a container so it does not circulate in the body; clients body fluids should not be contaminated.
Unsealed source a radioisotope that is not encased in a container & does circulate in the body & contaminate body fluids.
Anemia o o o o Provide adequate rest period Monitor hemoglobin & hematocrit Protect client from injury Administer O2 if needed
Half-life time required for half of radioactive atoms to decay. 1. 2. Each radioisotope has different half-life. At the end of half-life the danger from exposure decreases.
C. Integumentary System
Alopecia o o o Explain that hair loss is not permanent Offer support & encouragement 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
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.
Encourage fluid & frequent voiding to prevent accumulation of metabolites in bladder; R: may cause direct damage to kidney by excretion of metabolites.
Avoid pressure, trauma, infection to skin; use bed cradle. Wash affected areas with plain H2O & pat dry; avoid soap. 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.
Increased excretion of uric acid may damage kidney Administer allopurinol (Zyloprim) as ordered; R: to prevent uric acid formation; encourage fluids when administering allopurinol
B. Anorexia, N/V 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 Arrange meal time so they do not directly precede or follow therapy. Encourage bland foods. Provide small attractive meals. Avoid extreme temperature. Administer antiemetics as ordered before meals.
C. Diarrhea Encourage low residue, bland, high CHON food. Administer antidiarrheal as ordered. Provide good perineal care.
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Monitor electrolytes particularly Na, K, Cl
1. Synarthroses: immovable joints 2. Amphiarthroses: partially movable joints 3. Diarthroses (synovial): freely movable joints
Muscles 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.
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 Type: 1. 2. 3. 4. Thermal Smoke Inhalation Chemical Electrical direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Functions of Muscles Provide shape to the body Protect the bones Maintain posture Cause movement of body parts by contraction
Types of Muscles
1.
Cardiac: involuntary; found only in heart Smooth: involuntary; found in walls of hollow structures (e.g. intestines) Striated (skeletal): voluntary
Characteristics of skeletal muscles 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.
Full Thickness (3rd & 4th degree) 1. 2. 3. 4. Depth: all skin layers & nerve endings; may involve muscles, tendons & bones Causes: flames, chemicals, scalding, electric current Sensation: little or no pain Characteristics: wound is dry, white, leathery, or hard
A form of connective tissue Major functions are to cushion bony prominences and offer protection where resiliency is required
Tendons and Ligaments Composed of dense, fibrous connective tissue Functions 1. Ligaments attach bone to bone Tendons attach muscle to bone 2.
Overview Of Anatomy & Physiology Of Musculoskeletal System 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) 1. Provide site for storage of calcium & phosphorus Cause 1. 2. 3. Consist of bones, muscles, joints, cartilages, tendons, ligaments, bursae To provide a structural framework for the body To provide a means for movement
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 unknown or idiopathic Maybe an autoimmune process Genetic factors
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
Joints
Articulation of bones occurs at joints Movable joints provide stabilization and permit a variety of movements
Classification
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1. X-rays: shows various stages of joint disease 2. CBC: anemia is common 3. ESR: elevated
4. Rheumatoid factor positive
Ibuprofen (Motrin) Indomethacin (Indocin) Fenoprofen (Nalfon) Mefenamic acid (Ponstel) Phenylbutazone (Butazolidin) Piroxicam (Feldene) Naproxen (Naprosyn) Sulindac (Clinoril)
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. 2. Women & men affected equally Incidence increases with age
SI: monitor blood studies & urinalysis frequently Proteinuria Mouth ulcers Skin rash Aplastic anemia.
Predisposing Factors
Oral form: smaller doses are effective; take 3-6 months to become effective
Auranofin (Ridaura)
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. Dx
1. X-rays: show joint deformity as disease progresses 2. ESR: may be slightly elevated when disease is inflammatory
Nursing Interventions 1. 2. Assess joints for pain & ROM. Relieve strain & prevent further trauma to joints. a. b. c. Encourage rest periods throughout day. Use cane or walker when indicated. Ensure proper posture & body mechanics.
2. Physical therapy: to minimize joint deformities. 3. Surgery: to remove severely damaged joints (e.g. total hip
replacement; knee replacement). Nursing Interventions 1. 2. Assess joints for pain, swelling, tenderness & limitation of motion. Promote maintenance of joint mobility and muscle strength.
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6. Provide client teaching and discharge planning concerning a. b. c. d. e. f. Used of prescribed medications and side effects Importance of rest periods Measures to relieve strain on joints ROM and isometric exercises Maintenance of a well-balanced diet Use of heat/ice as ordered. Pathophysiology 1. 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 S/sx Incident Rate 1. 2. S/sx 1. 2. 3. 4. Joint pain Redness Heat Swelling affected (acute gouty arthritis stage) 6. 7. 8. 9. Headache Malaise Anorexia Tachycardia Occurs most often in males Familial tendency 1. 2. 3. 4. 5. 6. 7. 8. 9. Fatigue Fever Anorexia Weight loss Malaise History of remissions & exacerbations Joint pain Morning stiffness 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 Dx Renal failure 2. A defect in bodys immunologic mechanisms produces autoantibodies in the serum directed against components of the clients own cell nuclei. Affects cells throughout the body resulting in involvement of many organs, including joints, skin, kidney, CNS & cardiopulmonary system. Predisposing Factors 1. 2. 3. Cause unknown Immune Genetic & viral factors have all been suggested 1. Occurs most frequently in young women
10. Fever
11. Tophi in outer ear, hands & feet (chronic tophaceous stage)
13. CNS involvement Peripheral neuritis Seizures Organic brain syndrome Psychosis 14. Cardiopulmonary system involvement Pericarditis Pleurisy 15. Increase susceptibility to infection
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
Nursing Interventions 1. 2. 3. Assess joints for pain, motion & appearance. Provide bed rest & joint immobilization as ordered. 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 liver, kidney, brains, sweetbreads, sardines, anchovies c. d. e. f. Limitation of alcohol use Increased in fluid intake Weight reduction if necessary Importance of regular exercise
Systemic Lupus Erythematosus (SLE) Chronic connective tissue disease involving multiple organ systems Incident Rate
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a. b. c. Disease process & relationship to symptoms Medication regimen & side effects. Importance of adequate rest.
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
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
Cardiac Sphincter: located at the opening between the esophagus & stomach Pyloric Sphincter: located between the stomach & duodenum
1. CBC: WBC elevated 2. Blood cultures: may be positive 3. ESR: may be elevated
Nursing Interventions 1. 2. Administer analgesics & antibiotics as ordered. Use sterile techniques during dressing changes. frequently: to prevent deformities. 4. Provide immobilization of affected part as ordered. (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.
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 Brunners Gland: found in the submucosaof the duodenum, secretes mucus
Upper alimentary canal: function for digestion Mouth Consist of lips & oral cavity Provides entrance & initial processing for nutrients & sensory data such as taste, texture & temperature
2nd half of duodenum Jejunum Ileum 1st half of ascending colon Lower Alimentary Canal: Function: elimination Large Intestine Divided into four parts:
Oral Cavity: contains the teeth used for mastication & the tongue which assists in deglutition & the taste sensation & mastication
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Trypsinogen & Chymotrypsin: for protein digestion Amylase: breakdown starch to disacchardes Lipase: for fat digestion
Function: to absorb water & electrolytes MO present in the large intestine: are responsible for small amount of further breakdown & also make some vitamins
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
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
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
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)
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
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 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:
Salivary gland Verniform appendix Liver Pancreas: auto digestion Gallbladder: storage of bile
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
Biliary System
Smoking: vasoconstriction: effect GIT ischemia Alcohol Abuse: stimulates release of histamine: Parietal cell release Hcl acid = Ulceration Emotional Stress Drugs:
Consist of the gallbladder & associated ductal system (bile ducts) Gallbladder: lies under the surface of the liver
S/sx
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 Site
Gastric Ulcer Duodenal Ulcer Antrum or lesser curvature 30 min-1 hr after eating Left epigastrium Gaseous & burning Not usually relieved by Duodenal bulb 2-3 hrs after eating Mid epigastrium Cramping & burning Usually relieved by
Pancreas Positioned transversely in the upper abdominal cavity Consist of head, body & tail along with a pancreatic duct which extends along the gland & enters the duodenum via the common bile duct Has both exocrine & endocrine function Function in GI system: is exocrine Exocrine cells in the pancreas secretes:
Pain
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food & antacid Hypersecreti on Vomiting Hemorrhage Weight Complication s Dx High Risk Normal gastric acid secretion Common Hematemeis Weight loss Stomach cause Hemorrhage 60 years old 20 years old 2. food & antacid 12 MN 3am pain Increased gastric acid secretion Not common Melena Weight gain Perforation 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
Removal of -3/4 of stomach & duodenal bulb & anastomostoses of gastric stump to jejunum.
3. 4. 5.
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
Maintain patent IV line Monitor V/S, I&O & bowel sounds Complications:
Hemorrhage: Hypovolemic shock: Late signs: anuria Peritonitis Paralytic ileus: most feared Hypokalemia Thromobphlebitis Pernicious anemia
Drug Therapy:
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
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
Aluminum containing Antacids containing Antacids Ex. Aluminum OH gel (Amphojel) SE: Constipation
Avoid ulcerogenic drugs: salicylates, steroids Know proper dosage, action & SE
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
Histamines (H2) receptor antagonist: inhibits gastric acid secretion of parietal cells
Ranitidine (Zantac): has some antibacterial action against H. pylori Cimetidine (Tagamet) Famotidine (Pepcid) c.
Avoidance of stress-producing situation & development of stress production methods Relaxation techniques Exercise Biofeedback
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 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. 2. 3. 4. 5. 6. 7. Weakness Faintness Feeling of fullness Dizziness Diaphoresis Diarrhea Palpitations
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
3.
Sucralfate (Carafate): provides a paste like subs that coats mucosal lining of stomach
Surgery: Gastric Resection Anastomosis: joining of 2 or more hollow organ Subtotal Gastrectomy: Partial removal of stomach Before surgery for BI or BII
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1. Severe left upper epigastric pain radiates from back & flank
area: aggravated by eating with DOB 2. 3. N/V Tachycardia
Predisposing Factor:
1. High risk: women 40 years old 2. Post menopausal women: undergoing estrogen therapy
3. 4. 5. 6. S/sx: Obesity Sedentary lifestyle Hyperlipidemia Neoplasm
7. (+) Cullens sign: ecchymosis of umbilicus 8. (+) Grey Turners spots: ecchymosis of flank area
9. Dx Hypocalcemia
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. 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. 2. 3. Supportive Treatment: NPO with NGT & IV fluids Diet modification with administration of fat soluble vitamins Drug Therapy
1.
Drug Therapy
Meperidine Hcl (Demerol) Dont give Morphine SO4: will cause spasm of Sphincter of Oddi
Ranitidin (Zantac)
2.
Nitroglycerine (NTG)
Diet Modification
3. NPO (usually)
4. 5. Peritoneal Lavage Dialysis
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
2. Withhold food & fluid & eliminate odor: to decrease 3. Assist in Total Parenteral Nutrition (TPN) or
hyperalimentation Complication of TPN Infection Embolism Hyperglycemia
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
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5. Teach relaxation techniques & provide quiet, restful environment 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 Types Laennecs Cirrhosis: Associated with alcohol abuse & malnutrition Characterized by an accumulation of fat in the liver cell progressing to widespread scar formation Postnecrotic Cirrhosis 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 Predisposing factor: 1. 2. 3. S/Sx: Microbial infection Feacalith: undigested food particles like tomato seeds, guava seeds etc. Intestinal obstruction 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 Medical Management Easy bruising Spider angiomas on nose, cheeks, upper thorax & shoulder Nursing Intervention 1. 2. Administer antibiotics / antipyretic as ordered Routinary pre-op nursing measures: Skin prep NPO Avoid enema, cathartics: lead to rupture of appendix Dx Liver enzymes: increase SGPT (ALT) SGOT (AST) LDH Alkaline Phosphate Serum cholesterol & ammonia: increase Indirect bilirubin: increase CBC: pancytopenia PT: prolonged Nursing Intervention post op Hepatic Ultrasonogram: fat necrosis of liver lobules 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 Palmar erythema Muscle atrophy 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
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
1. CBC: mild leukocytosis: increase WBC 2. PE: (+) rebound tenderness (flex Right leg, palpate Right
iliac area: rebound)
4. 5.
Analgesic: due post op pain Antibiotics: for infection Antipyretics: for fever (PRN)
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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 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 Bowmanss capsule Renal Parenchyma Cortex Outermost layer Site of glomeruli & proximal & distal tubules of nephron Medulla Middle layer Tubular Function 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 bowmans 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 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 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) 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 Renal Corpuscle (vascular system of nephron) Bowmans 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 Nephron Functional unit of the kidney Basic living unit 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 Formed by collecting tubules & ducts
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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 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) Dx 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. 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 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 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 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 Adrenal cortex Aldosterone Increase BP Increase Na & H2O reabsorption Hypervolemia increase CO increase PR 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 Color amber S/Sx: Pain: flank area Urinary frequency & urgency Burning pain upon urination Dysuria Hematuria Nocturia Fever Chills Anorexia Gen body malaise Predisposing factors: Microbial invasion: E. coli High risk: women Obstruction Urinary retention Increase estrogen levels Sexual intercourse UTI CYSTITIS Inflammation of bladder due to bacterial infection Odor Consistency pH WBC/ RBC Albumin E coli aromatic clear or slightly turbid 4.5 8 (-) (-) (-)
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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 Milk Oxalate Cabbage Cranberries Nuts tea Nuts Uric Acid Anchovies Organ meat Benign Prostatic Hypertrophy (BPH) 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 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 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 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 S/sx Abdominal or flank pain Renal colic Cool moist skin (shock) Burning sensation upon urination Hematuria Anorexia N/V Predisposing factors: Diet: increase Ca & oxalate Increase uric acid level Hereditary: gout or calculi Immobility Sedentary lifestyle Hyperparathyroidism Chocolates Sardines
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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 Nursing Intervention Monitor / maintain F&E balance Obtain baseline data on usual appearance & amount of clients urine Measure I&O every hour: note excessive losses Administer IV F&E supplements as ordered Weight daily Acute Renal Failure Sudden inability of the kidney to regulate fluid & electrolyte balance & remove toxic products from the body Sudden immobility of kidneys to excrete nitrogenous waste 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 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 Dx BUN & Creatinine: elevated Recovery or Covalescent Phase: renal function stabilized with gradual improvement over next 3-12 mos 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 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 Post renal cause: involves mechanical obstruction Tumors Stricture Blood cloths Urolithiasis BPH Anatomic malformation 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) Hypovolemia flow to kidneys Hypotension CHF Hemorrhage Dehydration Decrease
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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 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 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 S/Sx: N/V Diarrhea / constipation Decreased urinary output Dyspnea Stomatitis Hypotension (early) Hypertension (late) Lethargy Convulsion Memory impairment Pericardial Friction Rub HF 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 Urinary System Polyuria Nocturia Hematuria Dysuria Oliguria CNS Headache Lethargy Disorientation Restlessness Memory impairment Respiratory Kassmauls resp Decrease cough reflex Fluid & Electrolytes Hyperkalemia Hypernatermia Hypermagnese mia Hyperposphate mia Hypocalcemia Metabolic acidosis GIT N/V Stomatitis Uremic breath Diarrhea / constipation Hematological Normocytic anemia Bleeding tendencies Integumentary Itchiness / pruritus Uremic frost Metabolic Disturbance Azotemia (increase BUN & Creatinine) Hyperglycemia Hyperinsulinemia 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) 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 Nursing Intervention Prevent neurologic complication Monitor for signs of uremia Fatigue Loss of appetite Decreased urine output Medical Management Diet restriction Multivitamins Hematinics Aluminum Hydroxide Gels Antihypertensive Dx Urinalysis: CHON, Na & WBC: elevated Specific gravity: decrease Platelets: decrease Ca: decrease
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f.) Decrease Ca Ca gluconate 5. Assist in hemodialysis Consent/ explain procedure Obtain baseline data & monitor VS, I&O, wt, blood exam Strict aseptic technique Monitor for signs of complications: B bleeding E embolism D disequilibrium syndrome S septicemia S shock decrease in tissue perfusion Disequilibrium syndrome from rapid removal of urea & nitrogenous waste prod leading to: n/v HPN Leg cramps Disorientation Paresthesia Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula. Maintain patency of shunt by: Palpate for thrills & auscultate for bruits if (+) patent shunt! Bedside- bulldog clip - If with accidental removal of fistula to prevent embolism. - Infersole (diastole) common dialisate used 7. Complication - Peritonitis - Shock 8. Assist in surgery: Renal transplantation : Complication rejection. Reverse isolation
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