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Overview of structures and functions:
CentraI Nervous System
Brain
Spinal Cord
PeripheraI Nervous System
Cranial Nerves
Spinal Nerves
Autonomic Nervous System
Sympathetic nervous system
Parasympathetic nervous system

AUTONOMIC NERVOUS SYSTEM
Sympathetic Nervous System
(ADRENERGIC)
Parasympathetic Nervous System
(CHOLINERGIC, VAGAL, SYMPATHOLYTIC)
- nvolved in fight or aggression response.
- Release of Norepinephrine (cathecolamines)
from adrenaI gIands and causes
vasoconstriction.
- ncrease all bodily activity except GT

EFFECTS OF SNS
- Dilation of pupils(mydriasis) in order to be aware.
- Dry mouth (thickened saliva).
- ncrease BP and Heart Rate.
- Bronchodilation, ncrease RR
- Constipation.
- Urinary Retention. FLUID VOLUME EXCESS
- ncrease blood supply to brain, heart and skeIetaI
muscIes.
- SNS

I. Adrenergic Agents
- Give Epinephrine. [ADRENALIN]
Signs and Symptoms:
- SNS
Contraindication:
- Contraindicated to patients suffering from COPD
(Broncholitis, Bronchoectasis, Emphysema, Asthma).

II. Anti-choIinergic Agents
- To counter cholinergic agents.
- Atropine Sulfate decreased mucus production
Side Effects
- SNS
Antipsychotics:
! Haloperidol [Haldol], chlorpromazine
! Thorazine, etc.
Side effect of THORAZNE: atopic
dermatitis and foul smelling odor.
Side effect of all antipsychotic: signs of
PARKNSON'S DSEASE, therefore
antipsychotic are given together with
antiparkinson drugs
Anti-parkinson drugs:
! C.A.P.A.B.L.E.S
- nvolved in fight or withdrawal response.
- Release of Acetylcholine.
- vasodilation bronchoconstriction

- Decreases all bodily activities except GT.

EFFECTS OF PNS
- Constriction of pupils (meiosis).
- ncrease salivation.
- Decrease BP and Heart Rate.
- Bronchoconstriction, Decrease RR.
- Diarrhea
- Urinary frequency. FLUID VOLUME DEF.
- antihypertension

I. ChoIinergic Agents
- Mestinon, Neostigmine.
Side Effects
- PNS

II. Beta-adrenergic BIocking Agents
- Also called Beta-bIockers.
- All ending with "IoI
- PropranoIoI [InderaI], AteneIoI, MetoproIoI.

Effects of Beta-blockers
B roncho spasm
E licits a decrease in myocardial contraction.
T reats hypertension.
A V conduction slows down.
" Should be given to patients with Angina
Pectoris, MyocardiaI Infarction, and
Hypertension.

ANTI- HYPERTENSIVE AGENTS
1. Beta-blockers "lol
2. Ace nhibitors Angiotensin, "pril (Captopril,
Enalapril)
3. Calcium Antagonist Nifedipine (Calcibloc)
" n chronic cases of arrhythmia give
Lidocaine(XyIocaine)

CENTRAL NERVOUS SYSTEM
Brain and Spinal Cord.
[SpinaI cord terminates at L
1
to L
2
therefore a LUMBAR TAP is performed at L
3 ,
L
4
or L
5
no risk for
spinaI cord damage]
I. CELLS
A. NEURONS
Basic cells for nerve impulse and conduction.
PROPERTIES
ExcitabiIity ability of neuron to be affected by changes in external environment.
Conductivity ability of neuron to transmit a wave of excitation from one cell to another.
Permanent CeII once destroyed not capable of regeneration.

TYPES OF CELLS BASED ON REGENERATIVE CAPACITY
1. LabiIe
Capable of regeneration.
Epidermal cells, GT cells, GUT cells, cells of lungs.
2. StabIe
Capable of regeneration with limited time, survival period.
Kidney cells, Liver cells, salivary cells, pancreas.
3. Permanent
Not capable of regeneration.
Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
B. NEUROGLIA
" Support and protection of neurons.
TYPES
1. Astrocytes - maintains bIood brain barrier semi-permeable.
# Majority of brain tumors (90%) arises from called astrocytoma.
2. OIigodendria Produces myeIin sheath in CNS. Act as insulator and facilitates rapid nerve impulse transmission
3. MicrogIia
4. EpindymaI

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER
1. Ammonia
" Cerebral toxin
" Hepatic Encephalopathy (Liver Cirrhosis)
" Ascites
" Esophageal Varices
EarIy Signs of Hepatic EncephaIopathy
" asterixis (flapping hand tremors).
Late Signs of Hepatic EncephaIopathy
" Headache
" Dizziness
" Confusion
" Fetor hepaticus (ammonia like breath)
" Decrease LOC [hepatic coma]
[ARWAY FOR HEPATC COMA]
2. Carbon Monoxide and Lead Poisoning
" Can lead to Parkinson's disease.
[PILL ROLLING TREMORS]
" Epilepsy
" Treat with ANTIDOTE: CaIcium EDTA
For Lead poisoning
Hyperbaric oxygenation (100% O
2
)
For carbon monoxide poisoning

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1. PTB - Low-grade afternoon fever.
2. PNEUMONIA - Rusty sputum.
3. ASTHMA - Wheezing on expiration.
4. EMPHYSEMA - BarreI chest.
5. KAWASAKI DISEASE - Strawberry tongue.
6. PERNICIOUS ANEMIA - Red beefy tongue.
7. DOWN SYNDROME - Protruding tongue / semian crease on paIm
8. CHOLERA - Rice watery stooI.
9. MALARIA - StepIadder Iike fever and chiIIs.
10. TYPHOID - Rose spots in abdomen.
11. DIPTHERIA - pseudo membrane formation (pharynx, tonsiIs, nasaI)
12. MEASLES - KopIik's spots.
13. SLE - ButterfIy rashes.
14. LIVER CIRRHOSIS - spider angioma, due to esophageaI varices
15. LEPROSY - Iioning face
16. BULIMIA NERVOSA - Chipmunk face. Parotid gIand sweIIing
17. APPENDICITIS. - rebound tenderness
18. DENGUE - petechiae or (+) Herman's sign
19. MENINGITIS - Kernig's sign (Ieg pain), Brudzinski sign (neck pain).
20. TETANY - HYPOCALCEMIA (+) Trousseau's sign/carpopedaI spasm; Chvostek sign (faciaI spasm).
21. TETANUS - risus sardonicus.
22. PANCREATITIS - CuIIen's sign (ecchymosis of umbiIicus); (+) Grey turners spots.
23. PYLORIC STENOSIS - oIive SHAPE mass on the abdomen
24. PDA - machine Iike murmur
25. ADDISON'S DISEASE - Bronze Iike skin pigmentation.
26. CUSHING'S SYNDROME - Moon face appearance and buffaIo hump.
27. HYPERTHYROIDISM/GRAVE'S DISEASE - ExopthaImus
28. INTUSSUSCEPTION - sausage shaped mass
29. PARKINSON'S DISEASE - PiII roIIing tremors
30. HEPATITIS - Jaundice
31. THROMBOPHEBITIS - Homan's sign
32. CATARACT - Hazy vision / Ioss of centraI vision
33. GLAUCOMA - TunneI vision / Ioss of peripheraI vision
34. RETINAL DETACHMENT - Curtain veiI-Iike vision / fIashes and fIoaters
35. CHOLECYSTITIS - Murphy's sign (pain on deep inspiration, a infIammation of the gaIIbIadder
36. ANGINA PECTORIS - Levine's sign [hand cIutching in the chest]
37. MYASTHENIA GRAVIS - Ptosis [drooping of the upper eyeIid]
38. TETRALOGY OF FALLOT - CIubbing of fingers

3. Type 1 DM (IDDM) [KETONES]
" Causes diabetic ketoacidosis.
" And increases breakdown of fats.
" And free fatty acids
" Resulting to choIesteroI and (+) to Ketones (CNS depressant).
" Resulting to acetone breath odor/fruity odor.
" KUSSMAUL'S respiration, a rapid shallow respiration.
" This may lead to diabetic coma.
4. Hepatitis
" Signs of jaundice (icteric sclerae).
" Caused by bilirubin (yellow pigment)
5. BiIirubin
" ncrease bilirubin in brain (Kernicterus).
" Causing irreversible brain damage.

DEMYELINATING DISORDERS
1. ALZHEIMER'S DISEASE
" Atrophy of brain tissues. Progressive, irreversible, degenerative neurologic disease characterized by
gradual losses of cognitive fx. And disturbances in behavior and affect.
Sign and Symptoms
4 A's of Alzheimer
a. Amnesia partial or total loss of memory.
b. Agnosia no recognition of inanimate objects.
c. Apraxia no recognition of objects function.
d. Aphasia no speech (nodding).
*Expressive aphasia (Broca's Aphasia) frontal lobe
" "motor speech center
" Nursing mgt. provide PCTURE BOARD
*Receptive aphasia (Wernicke's Aphasia) temporal lobe
" nability to understand spoken words.
" rrational thoughts/illogical
" General Knowing Gnostic Area or General nterpretative Area.
DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. [increasing acetylcholine]

2. MULTIPLE SCLEROSIS [Autoimmune process]
" Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord.
" Characterized by remission and exacerbation.
" Women ages 15-35 are prone
" Unknown Cause
" Slow growing virus
" Autoimmune disorders
" Pernicious anemia
" Myasthenia gravis
" Lupus
" Hypothyroidism
" GBS

Ig G - only antibody that pass placental
circulation causing passive immunity.
- Short term protection.
- mmediate action.
Ig A present in all bodily secretions
(tears, saliva, colostrums).
Ig M acute in inflammation.
Ig E for allergic reaction.
Ig D for chronic inflammation.

* Give palliative or supportive care.
Signs and Symptoms
1. VisuaI disturbances
" blurring of vision (primary)
" Diplopia (double vision)
" scotomas (blind spots)

2. Impaired sensation
" Pain, pressure, heat and cold. [do not give hot packs b'coz of dec. sensation to heat which can lead to burns.]
" tingling sensation
" paresthesia
" numbness
3. Mood swings
" euphoria (sense of well being)
4. Impaired motor function
" weakness
" spasticity
" paralysis
5. Impaired cerebraI function
" scanning speech
TRIAD SIGNS OF MS
Ataxia
(Unsteady gait, (+) Romberg's test)

IntentionaI tremors Nystagmus

6. Urinary retention/incontinence
7. Constipation
8. Decrease sexuaI capacity

DIAGNOSTIC PROCEDURE
" CSF analysis (increase in IgG and Protein).
" MR (reveals site and extent of demyelination).
" (+) Lhermitte's sign a continuous and increase contraction of spinal column/cord following laminotomy.

NURSING MANAGEMENT
1. Administer medications as ordered
a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site
of demyelination to prevent paralysis. [Best given in Morning to mimic body normal rhythm]
b. BacIofen (DioresaI)/ DantroIene Sodium (Dantrene) muscle relaxants.
c. Interferons alter immune response.
d. Immunosupresants
2. Maintain side rails to prevent injury related to falls.
3. nstitute stress management techniques.
a. Deep breathing exercises
b. Yoga
4. ncrease fluid intake and increase fiber to prevent constipation.
5. Catheterization to prevent retention.
a. Diuretics
b. BethanicoI ChIoride (UrechoIine) - treat urinary retention
Nursing Management
" Only given subcutaneous.
" Monitor side effects bronchospasm and wheezing.
" Monitor breath sounds 1 hour after subcutaneous administration.
c. For Urinary Incontinence
Anti spasmodic agent
a. ProphantheIine Bromide (Probanthine) antispasmodic drug to treat urinary incontinence
" Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.
" To acidify urine and prevent bacterial multiplication.
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COMMON CAUSE OF UTI
FemaIe
" 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.
MaIe
" Urethra (20 cm, 8 inches)
" urinate after intercourse

MICROGLIA
" stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating), pinocytosis
(cell drinking).
MACROPHAGE ORGAN
MicrogIia
Monocytes
Kupffers ceIIs
Histiocytes
AIveoIar
Macrophage
Brain
BIood
Kidney
Skin
Lung
EPINDYMAL CELLS
" Secretes a glue called chemo attractants that concentrate the bacteria.
COMPOSITION OF BRAIN
" 80% brain mass
" 10% blood
" 10% CSF
I. Brain Mass
PARTS OF THE BRAIN
1. CEREBRUM
" largest part
" Composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus
Callosum.
Functions of Cerebrum
" integrative
" sensory
" motor
Lobes of Cerebrum
1. FrontaI
" higher cortical thinking
" controls personality
" controls motor activity
" Broca's Area (motor speech area) when damaged results to garbled speech.

2. TemporaI
" hearing
" short term memory
3. ParietaI
" for appreciation
" Discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.
4. OccipitaI
" for vision
Insula (Island of Reil)
" Visceral function activities of internal organ like gastric motility.
Limbic System (Rhinencephalon)
" controls smell and if damaged results to Anosmia (absence of smell).
" controIs Iibido [the true sense of sexual arousal is when you smelled the fumes of the natural body]
" controls long term memory

2. BASAL GAGLIA
" areas of grey matter located deep within each cerebral hemisphere.
" release dopamine (controls gross voluntary movement.)

NEURO TRANSMITTER DECREASE INCREASE
AcethyIchoIine Myasthenia Gravis Bi-poIar Disorder
Dopamine Parkinson's Disease Schizophrenia

3. MIDBRAIN/ MESENCEPHALON
" acts as relay station for sight and hearing.
" size of pupil is 2 - 3 mm.
" equal size of pupil is isocoria.
" unequal size of pupil is anisocoria.
" hearing acuity is 30 - 40 dB.
" positive PERRLA [Pupils equal, round, reactive to light and accommodation]

4. INTERBRAIN/ DIENCEPHALON
Parts of Diencephalon
A. ThaIamus
" Acts as relay station for sensation.
B. HypothaIamus
" Controls temperature (thermoregulatory center).
" controls blood pressure
" controls thirst
" appetite/satiety
" sleep and wakefulness
" Controls some emotional responses like fear, anxiety and excitement.
" controls pituitary functions
" Androgenic hormones promote secondary sex characteristics.
" early sign for males are testicular and penile enlargement
" late sign is deepening of voice.
" early sign for females telarche and late sign is menarche.

5. BRAIN STEM
" located at lowest part of brain
Parts of Brain Stem
1. Pons
" pneumotaxic center controls the rate, rhythm and depth of respiration.
2. MeduIIa ObIongata
" Controls respiration, heart rate, and swallowing, vomiting, hiccup, vasomotor center (dilation and
constriction of bronchioles).
[damage to medulla is most life threatening]

3. CerebeIIum
" Smallest part of the brain.
" Lesser brain.
" Controls balance, equilibrium, posture and gait.
INTRA CRANIAL PRESSURE

Monroe Kellie Hypothesis

Skull is a closed container

Any alteration or increase in one of the intracranial components

ncrease intra-cranial pressure
(normaI ICP is 0 - 15 mmHg)

CervicaI 1 also known as ATLAS.
CervicaI 2 also known as AXS.
Foramen Magnum

Medulla Oblongata

Brain Herniation

ncrease intra cranial pressure
* Alternate hot and cold compress to prevent HEMATOMA
" CSF cushions brain (shock absorber)
" Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephaIus.
" Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.
NEUROLOGIC DISORDERS
INCREASE INTRACRANIAL PRESSURE increase in intra-cranial bulk brought about by an increase in one of the 3
major intra cranial components. NORMAL ICP: 0-15 mmhg
Causes:
" head trauma/injury
" localized abscess
" cerebral edema
" hemorrhage
" inflammatory condition (stroke)
" hydrocephalus
" tumor (rarely)
Signs and Symptoms (EarIy)
" decrease LOC
" restlessness/agitation
" irritability
" lethargy/stupor
" coma
Signs and Symptoms (Late)
" changes in vital signs
" Blood pressure (systoIic bIood pressure increases but diastoIic remains the same).
" Widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).
" heart rate decrease
" respiratory rate decrease
" Temperature increase directly proportional to blood pressure.
" projective vomiting
" headache
" papiIIedema (edema of optic disc)
" abnormal posturing, [may positive to babinski reflex]
" Decorticate posturing (damage to cortex and spinal cord).
" decerebrate posturing (damage to upper brain stem
that includes pons, cerebellum and midbrain).
" uniIateraI diIation of pupiIs called uncaI herniation
" biIateraI diIation of pupiIs called tentoriaI herniation
" resulting to mild headache
" possible seizure activity
Nursing Management
1. Maintain patent and adequate ventilation by:
a. Prevention of hypoxia and hypercarbia
EarIy signs of hypoxia
" Restlessness
" Agitation
" Tachycardia
Late signs of hypoxia
" Bradycardia
" Extreme restlessness
" Dyspnea
" Cyanosis

HYPERCARBIA
" ncrease CO
2
(most powerful respiratory stimulant) retention.
" n chronic respiratory distress syndrome decrease O
2
stimulates respiration.
b. Before and after suctioning hyper oxygenate cIient 100% and done 10 - 15 seconds onIy.
c. Assist in mechanicaI ventiIation
2. Elevate bed of client 30 35
o
angle with neck in neutral position unless contraindicated to promote venous drainage.
3. Limit fluid intake to 1200 1500 ml/day (in force fluids 2000 3000 ml/day).
4. Monitor strictly input and output and neuro check
5. Prevent complications of
6. Prevent further increase CP by:
a. provide an comfortable and quite environment.
b. avoid use of restraints.
c. maintain side rails.
d. instruct client to avoid forms of vaIsaIva maneuver like:
straining stool
excessive vomiting (use anti emetics)
excessive coughing (use anti tussive like dextromethorphan)
avoid stooping/bending
avoid lifting heavy objects
e. avoid clustering of nursing activity together.

7. Administer medications like:
a. Osmotic diuretic (MannitoI)
for cerebral diuresis
Nursing Management
monitor vital signs especially BP (hypotension).
monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.
administered via side drip
Regulated fast drip to prevent crystal formation.
b. Loop diuretic (Lasix, Furosemide)
" Drug of choice for CHF (puImonary edema)
" Loop of Henle in kidneys.
Nursing Management
" Monitor vital signs especially BP (hypotension).
" monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.
" Administered V push or oral.
" given early morning
" Immediate effect of 10 - 15 minutes.
" maximum effect of 6 hours. [monitor for potassium depletion]

c. Corticosteroids
" Dexamethasone (Decadron)
" Hydrocortisone
" Prednisone (to reduce edema that may lead to increase CP)
" Mild Analgesics (Codeine Sulfate for respiratory depression)
" Anti Convulsants (Dilantin, Phenytoin)

*CONGESTIVE HEART FAILURE
Signs and Symptoms
" dyspnea
" orthopnea
" paroxysmal nocturnal dyspnea
" productive cough
" frothy salivation
" cyanosis
" rales/crackles
" bronchial wheezing
" puIsus aIternans
" anorexia and general body malaise
" PM (point of maximum impulse/apical pulse rate) is displaced laterally
" S3 (ventricular gallop)
" Predisposing Factors/Mitral Valve
# RHD
# Aging
TREATMENT
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor

RIGHT CONGESTIVE HEART FAILURE (Venous congestion)
Signs and Symptoms
" jugular vein distention (neck)
" ascites
" pitting edema
" weight gain
" hepatosplenomegaly
" jaundice
" pruritus
" esophageal varices
" anorexia and general body malaise

Signs and Symptoms of Lasix in terms of electrolyte imbalances
1. HypokaIemia
" decrease potassium IeveI
" normaI vaIue is 3.4 - 5.5 meq/L
Sign and Symptoms
" weakness and fatigue
" constipation
" positive U wave on ECG tracing
Nursing Management
" administer potassium supplements as ordered (KaIium DuruIe, OraI Potassium ChIoride)
" increase intake of foods rich in potassium
FRUITS VEGETABLES
AppIe
Banana
CantaIope
Oranges
Asparagus
BrocoIIi
Carrots
Spinach

2. HypocaIcemia/ Tetany
" decrease caIcium IeveI
" normaI vaIue is 8.5 - 10.5 mg/100 mI
Signs and Symptoms
" tingling sensation
" paresthesia
" numbness
" (+) Trousseau's sign/ CarpopedaI spasm
" (+) Chvostek's sign
CompIications
# Arrhythmia
# Seizures
Nursing Management
" Calcium Gluconate per V slowly as ordered
* CaIcium GIuconate toxicity - resuIts to SEIZURE

Magnesium Sulfate

Magnesium SuIfate toxicity [B.U.R.P]
S/S
BP
Urine output DECREASE
Respiratory rate
Patellar relfex absent

3. Hyponatremia
" decrease sodium IeveI
" normaI vaIue is 135 - 145 meq/L
Signs and Symptoms
" hypotension
" dehydration signs (nitial sign in adult is THIRST, in infant TACHYCARDIA)
" agitation
" dry mucous membrane
" poor skin turgor
" weakness and fatigue

Nursing Management
" force fluids
" administer isotonic fIuid soIution as ordered

4. HypergIycemia
" normaI FBS is 80 - 100 mg/dI
Signs and Symptoms - 3 P's
" polyuria
" polydypsia
" polyphagia
Nursing Management
" monitor FBS
5. Hyperuricemia
" increase uric acid (purine metabolism)
" foods high in uric acid (sardines, organ meats and anchovies)
" *Increase in tophi deposit Ieads to Gouty arthritis.
Signs and Symptoms
" joint pain (great toes)
" swelling
Nursing Management
" force fluids
" administer medications as ordered
a. AIIopurinoI (ZyIoprim)
" Drug of choice for gout.
" Mechanism of action: inhibits synthesis of uric acid.
b. CoIchecine
" Acute gout
" Mechanism of action: promotes excretion of uric acid.

KIDNEY STONES
Signs and Symptoms
" renal colic
" Cool moist skin
Nursing Management
" force fluids
" administer medications as ordered
a. Narcotic Analgesic
" Morphine Sulfate
" ANTDOTE: NaIoxone (Narcan)
toxicity leads to tremors.
b. Allopurinol (Zyloprim)
Side Effects
" Respiratory depression (check for RR)

PARKINSON'S DISEASE/ PARKINSONISM
" Chronic progressive disorder of CNS
characterized by degeneration of dopamine producing ceIIs in the
SUBSTANCIA NIGRA of the midbrain and basaI gangIia.
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
2. Arteriosclerosis
3. Hypoxia
4. Encephalitis
5. ncrease dosage of the following drugs:
a. Reserpine(Serpasil)
b. Methyldopa(Aldomet) AntihypertensiveS
c. Haloperidol(Haldol)
d. Phenothiazine AntipsychoticS
(/012304 0566
78/646 6/27294
SIDE EFFECTS RESERPINE $ Major depression leading to suicide

AIoneness

Loss of spouse Loss of Job

" direct approach towards the client
" close surveillance is a nursing priority
" time to commit suicide is on weekends early morning

Signs and Symptoms for Parkinson's
" piII roIIing tremors of extremities especially the hands.
" bradykinesia (slowness of movement)
" rigidity (cogwheeI type)
" stooped posture
" shuffling and propulsive gait
" over fatigue
" mask Iike facial expression with decrease blinking of the eyes.
" difficulty rising from sitting position.
" Dysphonia soft slurred Monotone type speech
" mood lability (in state of depression)
" Micrographia-shrinking slow handwriting
" increase salivation (drooIing type)
" autonomic changes
a. increase sweating
b. increase lacrimation
c. seborrhea
d. constipation
e. decrease sexual capacity
Nursing Management
Anti Parkinsonian agents
" Levodopa (L-dopa) short acting
" Amantadine Hydrochloride (Symmetrel)
" Carbidopa (Sinemet)
Mechanism of Action
" increase level of dopamine
Side Effects
" GT irritation (should be taken with meals
" orthostatic hypotension (CBQ)
" arrhythmia
" hallucinations
Contraindications
" clients with narrow angle closure glaucoma
" clients taking MAO's (no foods with tryptophan and thiamine: cheese, beer, avocado, wine)
" urine and stool may be darkened
" no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa

* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide

Anti ChoIinergic Agents (ARTANE and COGENTIN) - to reIieve tremors
Mechanism of Action
" inhibits action of acethylcholine
Side Effects
" SNS

Anti Histamine (Dipenhydramine HydrochIoride)
Side Effects
Adult: drowsiness
Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.
Dopamine Agonist - reIieves tremor rigidity
Bromocriptene HydrochIoride (ParIodeI)
Side Effects
" Respiratory depression
2. Maintain side rails to prevent injury
3. Prevent complications of immobility
4. Decrease protein in morning and increase protein in afternoon to induce sleep
5. Encourage increase fluid intake and fiber.
6. Assist/supervise in ambulation
7. Assist in Stereotaxic ThaIamotomy a portion of thalamus is destroyed to reduce tremors

MAGIC 2's IN DRUG MONITORING [D.L.A.D.A]
DRUG NORMAL RANGE
TOXICITY
LEVEL
INDICATION CLASSIFICATION
Digoxin/ Lanoxin
(ncrease force of
cardiac output)
.5 - 1.5 meq/L 2 CHF Cardiac GIycoside
Lithium/ Lithane
(Decrease level of
Ach/NE/Serotonin)
.6 - 1.2 meq/L 2 BipoIar Anti-Manic Agents
AminophyIIine
(Dilates bronchial tree)
10 - 19 mg/100 mI 20 COPD BronchodiIators
DiIantin/ Phenytoin 10 - 19 mg/100 mI 20 Seizures Anti-ConvuIsant
Acetaminophen/TyIenoI 10 - 30 mg/100 mI 200 Osteoarthritis
Non-narcotic
AnaIgesic

1. DigitaIis Toxicity
Signs and Symptoms
" nausea and vomiting / anorexia
" diarrhea
" confusion / fatigue / depression / malaise
" photophobia
" changes in color perception (yellowish or green halo around lights or "snowy vision)
Antidote: Digibind digoxin immune FAB
2. Lithium Toxicity anti-manic agent/ mood stabilizing agent
Signs and Symptoms
" anorexia
" nausea and vomiting
" diarrhea
" dehydration causing fine tremors
" hypothyroidism (cretinism the only endocrine disorder that can lead to mental retardation)
Nursing Management
" force fluids
" increase sodium intake to 4 10 g% daily

3. AminophyIIine 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 or precipitate.
" administered sandwich method
" avoid taking alcohol because it can lead to severe CNS depression
" avoid caffeine

4. DiIantin phenytoin Toxicity
Signs and Symptoms
" gingival hyperplasia (swollen & tender 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)
" hypogIycemia
Tremors, tachycardia
Irritability
Restlessness
Extreme fatigue
Diaphoresis, depression
Antidote: AcetyIcisteine (mucomyst) prepare suction apparatus at bedside.

MYASTHENIA GRAVIS
" Neuromuscular disorder characterized by a disturbance in the transmission of impulses from nerve to
muscle cells at the neuromuscular junction leading to descending muscIe weakness.
Incidence rate: women 20 40 years old
Predisposing factors
" unknown
" Autoimmune: it involves release of cholinesterase an enzyme that destroys Acetylcholine
Signs and Symptoms
" initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. (drooping of eyelid)
" diplipia
" mask like facial expression
" dysphagia
" hoarseness of voice [dysphonia-voice impairment]
" respiratory muscle weakness that may lead to respiratory arrest (tracheostomy at bed side)
" extreme muscle weakness especially during activity or exertion
Diagnostic Procedure
" TensiIon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms for about 5
- 10 minutes and a maximum of 15 minutes.
" if there is no effect there is damage to occipital lobe and midbrain and is negative for M.G.
Nursing Management
1. Airway
2. Aspiration maintain patent airway and adequate ventilation
3. mmobility
* assist in mechanical ventilation and monitor pulmonary function test
* monitor strictly vital signs, input and output and neuro check
* monitor strength or motor grading scale
4. Maintain side rails to prevent injury related to falls
5. nstitute NGT feeding
a. ChoIinergic (Mestinon) - pyridostigmine bromide
b. Anti ChoIenisterase (Prostigmin) - neostigmine bromide
Mechanism of Action
" increase level of Ach
Side Effects
" PNS
" Cortocosteroids suppress immune response
" monitor for 2 types of crisis:
MYASTHENIC CRISIS CHOLINERGIC CRISIS
Causes:
under medication
stress (disease exacerbation, high temp.)
infection
Signs and Symptoms
The client is unable to see, swallow, speak,
breathe
Treatment
administer cholinergic agents as ordered
Cause:
over medication
Signs and Symptoms
PNS
Tensilon test doesn't improve MG

Treatment
Administer anti cholinergic agents (Atropine
Sulfate)

7. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.G.
8. Assist in plasma paresis and removing auto immune anti bodies
9. Prevent complications

INFLAMMATORY CONDITIONS OF THE BRAIN
MENINGITIS
Meninges
" 3 fold membrane that covers brain and spinal cord.
" for support and protection
" for nourishment
" blood supply
LAYERS OF THE MENINGES
1. Dura matter outer layer
2. Arachnoid middle layer
3. Pia matter inner layer
" subduraI space between the dura and arachnoid
" Subarachnoid space between the arachnoid and pia, CSF aspiration is done.

A. EtioIogy
1. Meningococcus most dangerous
2. Pneumococcus
3. Streptococcus - causes adult meningitis
4. Hemophilus nfluenzae causes pediatric meningitis

B. Mode of transmission
" airborne transmission (droplet nuclei)

C. Signs and Symptoms
" headache
" photophobia
" projectiIe vomiting
" fever & chills, anorexia, generalized body malaise and weight loss
" Possible increase in CP and seizure activity
" Abnormal posturing (decorticate and decerebrate)
" Signs of meningeal irritation
a. NuchaI rigidity or stiff neck
b. Opisthotonus (arching of back)
c. (+) Kernig's sign (Ieg pain)
d. (+) Brudzinski sign (neck pain)

D. Diagnostic Procedures
" Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 L4 to
L5.
Nursing Management for LP
Before Lumbar Puncture. [note all surgery procedure explain by the doctor, diagnostic procedure is by the nurse]
1. Secure informed consent and explain procedure.
2. Empty bladder and bowel to promote comfort.
3. Encourage to arch back to clearly visualize L3-L4. (fetal position)
Post Lumbar Puncture
1. Place flat on bed 12 24
o

2. Force fluids
3. Check punctured site for any discoloration, drainage and leakage to tissues.
4. Assess for movement and sensation of extremities.
CSF anaIysis reveaIs
1. ncrease CHON and WBC
2. Decrease glucose
3. ncrease CSF opening pressure (normal pressure is 50 100 mmHg)
4. (+) cultured microorganism (confirms meningitis)

CBC reveals notes on hematology:
1. ncrease wbc

E. Nursing Management
1. Enforce complete bed rest
a. Broad spectrum antibiotics (Penicillin, Tetracycline)
b. Mild analgesics
c. Anti pyretics
3. nstitute strict respiratory isolation 24 hours after initiation of anti biotic therapy
4. Elevate head 30-45
o
5. Monitor strictly V/S, input and output and neuro check
6. nstitute measures to prevent increase CP and seizure.
7. Provide a comfortable and darkened environment.
8. Maintain fluid and electrolyte balance.
9. Provide client health care and discharge planning concerning:
a. Maintain good diet of increase CHO, CHON, calories with small frequent feedings.
b. Prevent complications
" most feared is hydrocephaIus
" hearing Ioss/nerve deafness is second complication
" consult audioIogist
c. Rehabilitation for neurological deficit
" mental retardation
" delayed psychomotor development

INCREASED DECREASED
RBC PoIycythemia Anemia
WBC Leukocytosis Leukopenia
PLATELETS Thrombocytosis Thrombocytopenia
CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)
" a partial or complete disruption in the brains blood supply.
" 2 most common cerebral artery affected by stroke
a. Mid Cerebral Artery
b. nternal Cerebral Artery the 2 largest artery
A. Incidence Rate
" men are 2-3 times high risk

B. Predisposing Factors
" thrombus (attached)
" embolus (detached and most dangerous because it can go to the Iungs and cause puImonary
emboIism or the brain and cause cerebraI emboIism.

Signs and Symptoms of PuImonary EmboIism
" Sudden sharp chest pain
" Unexplained dyspnea
" Tachycardia
" Palpitations
" Diaphoresis
" Mild restlessness
Signs and Symptoms of CerebraI EmboIism
" Headache and dizziness
" Confusion
" Restlessness
" Decrease LOC

# Fat embolism is the most feared complications after femur fracture.
# Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells.
# f there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation.
# Compartment syndrome (compression of arteries and nerves)
Notes:
!"#$%&'( - paralysis
Ex: Hemiplegia - paralysis of one side of
the body.

!"')$*&*( - weakness
Ex: Hemiparesis - weakness of one side
of the body.

C. Risk Factors
1. Hypertension, Diabetes Mellitus, Myocardial nfarction, Atherosclerosis, Valvular Heart Disease, Post Cardiac Surgery
(mitral valve replacement)
2. Lifestyle (smoking), sedentary lifestyle
3. Obesity (increase 20% ideal body weight)
4. Hyperlipidemia more on genetics/genes that binds to cholesterol
5. Type A personality
a. deadline driven
b. can do multiple tasks
c. usually fells guilty when not doing anything
6. Related to diet: increase intake of saturated fats like whole milk
7. Related stress physical and emotional
8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to
hypertension and eventually CVA.

D. Signs and Symptoms
" dependent on stages of development
1. TIA
" nitial sign of stroke or warning sign
Signs and Symptoms
" headache and dizziness
" tinnitus
" visual and speech disturbances
" paresis to plegia
" possible increase CP
2. Stroke in evoIution
-progression of signs and symptoms of stroke
3. CompIete stroke
" resolution phase characterized by:
Signs and Symptoms
" headache and dizziness
" Cheyne Stokes Respiration
" anorexia, nausea and vomiting
" dysphagia
" (+) Kernig's sign and Brudzinski sign
which may lead to hemorrhagic stroke
" focal neurological deficits
a. phlegia
b. aphasia
c. dysarthria (inability to articulate words)
d. alexia (difficulty reading)
e. agraphia (difficulty writing)
f. homonymous hemianopsia (loss of half of visual field)
E. Diagnostic Procedure
1. CT Scan reveals brain lesions
2. CerebraI Arteriography
" reveals the site and extent of malocclusion
" uses dye for visualization
" most of dye are iodine based
" check for shellfish allergy
" after diagnostic exam force fluids to release dye because it is nephro toxic
" check for distal pulse (femoral)
" check for hematoma formation

F. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. administrate O2 inhalation
2. Restrict fluids to prevent cerebral edema that might increase CP
3. Elevate head 30 45
o

4. Monitor strictly vitals signs, & O and neuro check
5. Prevent complications of immobility by:
a. turn client to side
b. provide egg crate mattresses or water bed
c. provide sand bag or foot board.
6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures
7. nstitute NGT feeding
8. Provide alternative means of communication
a. non verbal cues
b. magic slate
9. f positive to hemianopsia approach client on unaffected side
a. Osmotic Diuretics (MannitoI)
b. Loop Diuretics (Lasix, Furosemide)
c. Cortecosteroids
d. Mild Analgesics
e. Thrombolytic/Fibrinolytic Agents dissolves thrombus
" Streptokinase
# Side Effect: Allergic Reaction
" Urokinase
" Tissue PIasminogen Activating Factor
# Side Effect: Chest Pain
f. Anti Coagulants
" Heparin (short acting)
# check for partial thromboplastin time if prolonged there is a risk for bleeding.
# give Protamine Sulfate
" Comadin/ Warfarin (Iong acting)
# give simultaneously because Coumadin will take effect after 3 days
# check for prothrombin time if prolonged there is a risk for bleeding
# give Vit. K (Aqua Mephyton)
g. Anti Platelet
" PASA (Aspirin)
" Contraindicated for dengue, ulcer and unknown cause of headache because it may potentiate
bleeding
11. Provide client health teachings and discharge planning concerning
a. avoidance of modifiable risk factors (diet, exercise, smoking)
b. prevent complication (subarachnoid hemorrhage is the most feared complication)
c. dietary modification (decrease salt, saturated fats and caffeine)
d. importance of follow up care

GUILLAIN BARRE SYNDROME
(Acute Ediopathic PoIyneuropathy)
" a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscIe
paraIysis/weakness.

A. Predisposing Factors
1. Autoimmune
2. Antecedent viral infections such as LRT infections
B. Signs and Symptoms
1. CIumsiness (initiaI sign)
2. Dysphagia
3. Ascending muscle weakness leading to paralysis
4. Decreased of diminished deep tendon reflex
5. Alternate hypotension to hypertension
** ARRYTHMIA (most feared compIication)
6. Autonomic symptoms that includes
a. increase salivation
b. increase sweating
c. constipation

C. Diagnostic Procedures
1. CSF analysis reveals increase in gG and protein

D. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. monitor pulmonary function test
2. Monitor strictly the following
a. vital signs
b. intake and output
c. neuro check
d. ECG
3. Maintain side rails to prevent injury related to fall
4. Prevent complications of immobility by turning the client every 2 hours
5. nstitute NGT feeding to prevent aspiration
6. Assist in passive ROM exercise
a. Corticosteroids suppress immune response
b. Anti Cholinergic Agents Atrophine Sulfate
c. Anti Arrythmic Agents
" Lidocaine, Zylocaine
" Bretylium blocks release of norepinephrine to prevent increase of BP
8. Assist in pIasma pharesis (filtering of blood to remove autoimmune anti-bodies)
a. Arrythmia
b. Paralysis or respiratory muscles / Respiratory arrest

* Sengstaken BIakemore Tube
" for liver cirrhosis
" to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing
to release air in the balloon
" for hemodialysis prepare buIIdog cIips to prevent air embolism.

CONVULSIVE DISORDER/ CONVULSION
" Disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness abnormal
motor activity alternation in sensation and perception and changes in behavior.
" Seizure first convulsive attack
" EpiIepsy second or series of attacks
" FebriIe seizure normal in children age below 5 years

1. Head injury due to birth trauma
2. Genetics
3. Presence of brain tumor
4. Toxicity from
a. lead
b carbon monoxide
5. Nutritional and Metabolic deficiencies
6. Physical and emotional stress
7. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam,
Valium)

" Dependent on stages of development or types of seizure

I. GeneraIized Seizure
1. Grand maI Seizure (tonic-clonic seizure)
a. Signs or aura with auditory, olfactory, visual, tactile, sensory experience
b. Epileptic cry is characterized by fall and loss of consciousness for 3 5 minutes
c. Tonic contractions - direct symmetrical extension of extremities
CIonic contractions - contraction of extremities
d. Post ictal sleep unresponsive sleep
2. Petit maI Seizure absence of seizure common among pediatric clients characterized by
a. blank stare
b. decrease blinking of eyes
c. twitching of mouth
d. loss of consciousness (5 10 seconds)

II. PartiaI or LocaIized Seizure
1. Jacksonian Seizure (focal seizure)
" Characterized by tingling and jerky movement of index finger and thumb that spreads to the shoulder and other side
of the body.
2. Psychomotor Seizure (focal motor seizure)
a. automatism stereotype repetitive and non propulsive behavior
b. clouding of consciousness not in contact with environment
c. mild hallucinatory sensory experience

III. Status EpiIepticus
" A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and lead to coma
and eventually death.
" Drug of choice: Diazepam, Valium and Glucose

1. CT Scan reveals brain lesions
2. EEG reveals hyper activity of electrical brain waves

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
a. Anti convulsants (Dilantin, Phenytoin)
b. Diazepam, Valium
c. Carbamazepine (Tegretol) Trigeminal neuralgia
d. Phenobarbital, Luminal
4. nstitute seizure and safety precaution post seizure attack
a. administer O2 inhalation
b. provide suction apparatus
5. Document and monitor the following
a. onset and duration
b. types of seizures
c. duration of post ictal sleep may lead to status epilepticus
d. assist in surgical procedure cortical resection

COMPREHENSIVE NEURO EXAM
GLASGOW COMA SCALE
" objective measurement of LOC sometimes called as the quick neuro check
Components
1. Motor response
2. Verbal response
3. Eye opening

" Survey of mental status and speech
a. LOC
b. Test of memory
" Levels of orientation
" Cranial nerve assessment
" Sensory nerve assessment
" Motor nerve assessment
" Deep tendon reflex
" Autonimics
" Cerebellar test
a, Romberg's test 2 nurses, positive for ataxia
b. Finger to nose test positive result mean dimetria
(inability of body to stop movement at desired point)
c. Alternate supination and pronation positive result mean dimetria

I. LEVEL OF CONSCIOUSNESS
1. Conscious - awake
2. Lethargy lethargic (drowsy, sleepy, obtunded)
3. Stupor
" stuporous (awakened by vigorous stimulation)
" generalized body weakness
" decrease body reflex
4. Coma
" comatose
" light coma (positive to all forms of painful stimulus)
" deep coma (negative to all forms of painful stimulus)

Conscious 15 14
Lethargy 13 11
Stupor 10 8
Coma 7
Deep Coma 3
DIFFERENT PAINFUL STIMULATION
1. Deep sternal stimulation/ deep sternal pressure
2. Orbital pressure
3. Pressure on great toes
4. Corneal or blinking reflex
# Conscious client use a wisp of cotton
# Unconscious client place 1 drop of saline solution

II. TEST OF MEMORY
1. Short term memory
" ask most recent activity
" positive result mean anterograde amnesia and damage to temporal lobe
2. Long term memory
" ask for birthday and validate on profile sheet
" positive result mean retrograde amnesia and damage to limbic system
" consider educational background

III. LEVELS OF ORIENTATION
1. Time first asked
2. Person second asked
3. Place third asked

CRANIAL NERVES

CRANIAL NERVE I: OLFACTORY
" sensory function for smell
MateriaI Used
" don't use alcohol, ammonia, perfume because it is irritating
and highly diffusible.
" use coffee granules, vinegar, bar of soap, cigarette
Procedure
" test each nostril by occluding each nostril
AbnormaI Findings
1. Hyposnia decrease sensitivity to smell
2. Dysosmia distorted sense of smell
3. Anosmia absence of smell
Indicative of
1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located
2. may indicate inflammatory conditions (sinusitis)

CRANIAL NERVE II: OPTIC
" sensory function for vision or sight
Functions
1. Test visual acuity or central vision or distance
" use SneIIen's Chart
" Snellen's Alphabet chart: for literate clients
" Snellen's E chart: for illiterate clients
" Snellen's Animal chart: for pediatric clients
" normal visual acuity 20/20
" numerator is constant, it is the distance of person from the chart (6 7 m, 20 feet)
" denominator changes, indicates distance by which the person normally can see letter in the chart.
" - 20/200 indicates blindness
" 20/20 visual acuity if client is able to read letters above the red line.
2. Test of visual field or peripheral vision

CRANIAL NERVES

FUNCTION

I. OLFACTORY

S
II. OPTIC S
III OCCULOMOTOR M
IV. TROCHLEAR
M
(SmaIIest)
V. TRIGEMINAL
B
(Largest)
VI. ABDUCENSE M
VII. FACIAL B
VIII. ACOUSTIC S
IX. GLOSSOPHARYNGEAL B
X. VAGUS
B
(Longest)
XI. SPINAL ACCESSORY M
XII. HYPOGLOSSAL M
a. Superiorly
b. Bitemporaly
c. Nasally
d. nferiorly

COMMON VISUAL DISORDERS
1. GIaucoma
" increase OP
" normal OP is 12 - 21 mmHg
" preventable but not curable
" Common among 40 years old and above
" Hereditary
" Hypertension
" Obesity
1. Loss of peripheral vision
" pathognomonic sign is tunneI vision
2. Headache, nausea, vomiting, eye pain (haIos around Iight)
" steamy cornea
" may lead to blindness

1. Tonometry
2. Perimetry
3. Gonioscopy

D. Treatment
1. Miotics constricts pupil
a. PiIocarpine Sodium, CarbachoI
2. Epinephrine eyedrops decrease formation of aqueous humor
3. Carbonic Anhydrase Inhibitors
a. AcetazoIamide (Diamox) promotes increase outflow of aqueous humor or drainage
4. Timoptics (TimoIoI MaIeate)

E. SurgicaI Procedures
1. TRABECULECTOMY (Peripheral ndectomy) drain aqueous humor

2. CATARACT
" Decrease opacity of lens
A. Predisposing Factor
1. Aging 65 years and above
2. Related to congenital
3. Diabetes Mellitus
4. Prolonged exposure to UV rays

1. Loss of central vision

C. Pathognomonic Signs
1. BIurring or hazy vision
2. Milky white appearance at center of pupils
3. Decrease perception to colors
" Complication is blindness
D. Diagnostic Procedure
1. Opthalmoscopic exam

E. Treatment
1. Mydriatics (MydriacyI) dilating pupils
2. CycIopegics (CycIogyI) paralyses cilliary muscle

F. SurgicaI Procedure
Extra Intra
Capsular Capsular
Cataract Cataract
Lens Lens
Extraction Extraction
- Partial removal - Total removal of cataract with its surrounding capsules
" Most feared compIication post op is RETINAL DETACHMENT

3. RetinaI Detachment
" Separation of epithelial surface of retina

1. Post Lens Extraction
2. Myopia (near sightedness)

1. Curtain veil like vision
2. Floaters

C. SurgicaI Procedures
1. ScIeraI BuckIing
2. Cryosurgery cold application
3. Diathermy heat application

4. MacuIar Degeneration
" Degeneration of the macuIa Iutea (yellowish spot at the center of retina)

A. Signs and Symptoms
1. Black Spots

CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS
" Controls or innervates the movement of extrinsic ocular muscle (EOM)
" 6 muscles

Superior Rectus Superior Oblique

Lateral Rectus Medial Rectus

nferior Oblique nferior Rectus

A. normal retina
B. wet" macular degeneration
c. dry" macular degeneration
" trochlear controls superior oblique
" abducens controls lateral rectus
" oculomotor controls the 4 remaining EOM

OcuIomotor
" controls the size and response of pupil
" normal pupil size is 2 3 mm
" equal size of pupil: Isocoria
" Unequal size of pupil: Anisocoria
" Normal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINAL
" largest cranial nerve
" consists of ophthalmic, maxillary, mandibular
" sensory: controls sensation of face, mucous membrane, teeth, soft palate and corneal reflex)
" motor: controls the muscle of mastication or chewing
" damage to CN V leads to trigeminal neuralgia/tic douloureux (nerve pain)
" medication: Carbamezapine(Tegretol) - anticonvulsant

CRANIAL NERVE VII: FACIAL
" Sensory: controls taste, anterior 2/3 of tongue
" pinch of sugar and cotton applicator placed on tip of tongue
" Motor: controls muscle of facial expression
" nstruct client to smile, frown and if results are negative there is facial paralysis or Bell's palsy and the
primary cause is forceps delivery.

CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR
" Controls balance particularly kinesthesia or position sense, refers to movement and orientation of the
body in space.
Parts of the Ear
1. Outer Ear
" Pinna
" Eardrum
2. MiddIe Ear
" Hammer Malleus
" Anvil Incus
" Stirrup Stapes
3. Inner Ear
" Vestibule: Meinere's Disease
" Cochlea
" Mastoid Cells
" Endolymph and Perilymph
# COCHLEA: controls hearing, contains the Organ of Corti (the true organ of hearing)
# Let client repeat words uttered

CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE
" Glosopharyngeal: controls taste, posterior 1/3 of tongue
" Vagus: controls gag reflex
" Uvula should be midline and if not indicative of damage to cerebral hemisphere
" Effects of vagal stimulation is PNS

CRANIAL NERVE XI: SPINAL ACCESSORY
" nnervates with sternocleidomastoid (neck) and trapezius (shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL
" Controls the movement of tongue
" Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral
hemisphere and/or has short frenulum.

ENDOCRINE SYSTEM
Overview of the structures and functions
1. Pituitary GIand (Hypophysis Cerebri)
! Located at base of brain particularly at seIIa turcica
! Master gland or master clock
! Controls all metabolic function of body
PARTS OF THE PITUITARY GLAND
1. Anterior Pituitary GIand
! called as adenohypophysis
2. Posterior Pituitary GIand
! called as neurohypophysis
! secretes hormones oxytocin -promotes uterine contractions preventing bleeding/ hemorrhage
! administrate oxytocin immediately after delivery to prevent uterine atony.
! initiates milk let down reflex with help of hormone prolactin
2. Antidiuretic Hormone
! Pitressin (Vasopressin)
! Function: prevents urination thereby conserving water
! Diabetes nsipidus/ Syndrome of nappropriate Anti Diuretic
Hormone

DIABETES INSIPIDUS (DaIas Ihi)
! Decrease production of anti diuretic hormone
A. Predisposing Factor
! Related to pituitary surgery
! Trauma
! nflammation
! Presence of tumor
1. Polyuria
2. Signs of dehydration
a. Adult: thirst
b. Agitation
c. Poor Skin turgor
d. Dry mucous membrane
3. Weakness and fatigue
4. Hypotension
5. Weight loss (payat)
6. f left untreated results to hypovolemic shock (sign is anuria)
1. Urine Specific Gravity
! Normal value: 1.015 - 1.030
! Ph 4 8
2. Serum Sodium
! ncrease resulting to hypernatremia
1. Force fluids
2. Monitor strictly vital signs and intake and output
a. Pitressin (Vasopresin Tannate) administered M Z-tract
4. Prevent complilcations HYPOVOLEMIC SHOCK is the most feared complication
Anterior pituitary Posterior pituitary
ADH
OXYTOCIN

GH
ACTH
TSH
FSH & LH
PROLACTIN
MSH
SIADH lunod sa tubig
! hypersecretion of antidiuretic hormone

1. Head injury
2. Related to presence of bronchogenic cancer
! initial sign of lung cancer is non productive cough
! non invasive procedure is chest x-ray
3. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary gland.

1. Fluid retention
a. Hypertension
b. Edema
c. Weight gain (mataba)
2. Water intoxication may lead to cerebral edema and lead to increase CP may lead to seizure activity

C. Diagnostic Procedure
1. Urine specific gravity is increased
2. Serum Sodium is decreased (hyponatremia 135 mg/dl)

1. Restrict fluid
a. Loop diuretics (Lasix)
b. Osmotic diuretics (Mannitol)
3. Monitor strictly vital signs, intake and output and neuro check
4. Weigh patient daily and assess for pitting edema
5. Provide meticulous skin care

ANTERIOR PITUITARY GLAND
! also called ADENOHYPOPHYSIS secretes
1. Growth hormones (somatotropic hormone)
! Promotes elongation of long bones
! Hyposecretion of GH among children results to Dwarfism
! Hypersecretion of GH results to Gigantism
! Hypersecretion of GH among adults results to AcromegaIy (square face)
! Drug of choice: Ocreotide (Sandostatin)

2. MeIanocyte StimuIating hormone
! for skin pigmentation
! Hyposecretion of MSH results to AIbinism
! Most feared complications of albinism
a. Lead to bIindness due to severe photophobia
b. Prone to skin cancer
! Hypersecretion of MSH results to VitiIigo

3. Adrenochorticotropic hormone (ACTH)
! promotes development of adrenal cortex

4. Lactogenic homone (ProIactin)
! promotes development of mammary gland
! with help of oxytocin it initiates milk let down reflex
5. Leutinizing hormone
! secretes estrogen
6. FoIIicIe stimuIating hormone
! secretes progesterone

PINEAL GLAND
! secretes meIatonin
! inhibits LH secretion
! it controls/regulates circadian rhythm (body clock)

THYROID GLAND
! located anterior to the neck
3 Hormones secreted
1. T3 (Tri iodothyronine) - 3 molecules of iodine (more potent)
2. T4 (tetra iodothyronine, Thyroxine)
! T3 and T4 are metabolic or calorigenic hormone
! promotes cerebration (thinking)
3. ThyrocaIcitonin antagonizes the effects of parathormone to promote calcium resorption.

HYPOTHYROIDISM thyroid deficiency
! all are decrease except weight and menstruation
! memory impairment
Signs and Symptoms
! there is loss of appetite but there is weight gain
! menorrhagia or amenorrhea
! cold intolerance
! constipation
! can lead to Myxedema
! extreme fatigue
! babagsak sa exam (mental proc. Decreased)
! weight gain
! hypothermic
HYPERTHYROIDISM
! all are increase except weight and menstruation
Signs and Symptoms
! increase appetite but there is weight loss
! amenorrhea
! exophthalmos
! Tachycardia, palpitations
! insomnia
! restlessness agitation
! Heat intolerance
! HPN

THYROID DISORDERS
SIMPLE GOITER
! enlargement of thyroid gland due to iodine deficiency
1. Goiter belt area
a. places far from sea
b. Mountainous regions
2. ncrease intake of goitrogenic foods
! contains pro-goitrin an anti thyroid agent that has no iodine.
! cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts
(:;494<8 75<8
Severe hypothyroidism
- !ncreased
lethargic
- Hypothermic
- Stupor
- coma
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Synthetic levothyroxine
(syndroid or levothroid)
! soil erosion washes away iodine
! goitrogenic drugs
a. Anti Thyroid Agent Prophylthiuracil (PTU)
b. Lithium Carbonate d. Cobalt
c. PASA (Aspirin) e. Phenylbutazones (NSADs) - if goiter is caused by
1. Enlarged thyroid gland
2. Mild dysphagia
3. Mild restlessness

1. Serum T3 and T4 reveals normal or below normal
2. Thyroid Scan reveals enlarged thyroid gland.
3. Serum Thyroid Stimulating Hormone (TSH)
is increased (confirmatory diagnostic test)

a. LugoI's SoIution/SSKI ( Saturated Solution of Potassium odine)
! color purple or violet and administered via straw to prevent staining of teeth.
! 4 Medications to be taken via straw: Lugol's, ron, Tetracycline, Nitrofurantoin (drug of choice for
pyelonephritis)
b. Thyroid Hormones
! Levothyroxine (Synthroid)
! Liothyronine (Cytomel)
! Thyroid Extracts
Nursing Management when giving Thyroid Hormones
1. nstruct client to take in the morning to prevent insomnia
2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations
3. Monitor side effects
! insomnia
! tachycardia and palpitations
! hypertension
! heat intolerance
4. ncrease dietary intake of foods rich in iodine
! seaweeds
! seafood's like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of
iodine.
! iodized salt, best taken raw because it it is easily destroyed by heat
5. Assist in surgical procedure of subtotaI thyroidectomy

HYPOTHYROIDISM
! hyposecretion of thyroid hormone
! aduIts: MYXEDEMA non pitting edema
! chiIdren: CRETINISM the onIy endocrine disorder that can Iead to mentaI retardation

1. Iatrogenic Cause disease caused by medical intervention such as surgery
2. Related to atrophy of thyroid gland due to trauma, presence of tumor, infIammation
3. odine deficiency
4. Autoimmune (Hashimotos Disease)

(EarIy Signs)
2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and M
3. Dry skin
4. CoId intoIerance
5. Constipation
(Late Signs)
1. Brittleness of hair and nails
2. Non pitting edema (Myxedema)
3. Hoarseness of voice
4. Decrease libido
5. Decrease in all vital signs hypotension, bradycardia, bradypnea, hypothermia
6. CNS changes
! lethargy
! memory impairment (forgetfulness)
! psychosis
! menorrhagia

1. Serum T3 and T4 is decreased
2. Serum Cholesterol is increased
3. RAU (Radio Active odine Uptake) is decreased

1. Monitor strictly vital signs and intake and output to determine presence of
! Myxedema coma is a complication of hypothyroidism and an emergency case a severe form of
hypothyroidism is characterized by severe hypotension, bradycardia, bradypnea, hypoventilation,
hyponatremia, hypoglycemia, hypothermia leading to pregressive stupor and coma.
Nursing Management for Myxedema Coma
! Assist in mechanical ventilation
! Administer thyroid hormones as ordered
! Force fluids
2. Force fluids
3. Administer isotonic fluid solution as ordered
Thyroid Hormones
a. Levothyroxine
b. Leothyronine
c. Thyroid Extracts
5. Provide dietary intake that is low in calories due to wt. gain
6. Provide comfortable and warm environment due to cold intolerance
8. Provide client health teaching and discharge planning concerning
a. Avoid precipitating factors leading to myxedema coma
! stress
! infection
! cold intolerance
! use of anesthetics, narcotics, and sedatives
! prevent complications (myxedema coma, hypovolemic shock
! hormonal replacement therapy for lifetime
! importance of follow up care
HYPERTHYROIDISM - grave's disease or thyroid toxicosis (everything is up except wt. and mens.
! increase in T3 and T4
! Grave's Disease or Thyrotoxicosis
! developed by Robert Graves

1. Autoimmune it involves release of long acting thyroid stimulator causing exopthaImus (protrusion of
eyeballs) enopthaImus (late sign of dehydration among infants)
2. Excessive iodine intake
3. Related to hyperplasia of TG (increase size)

1. ncrease appetite (hyperphagia) but there is weight loss due to increased metabolism
2. Moist skin
3. Heat intolerance
4. Diarrhea
5. All vital signs are increased
6. CNS involvement
a. rritability and agitation
b. Restlessness
c. Tremors
d. nsomnia
e. Hallucinations
7. Goiter
8. Exopthalmus (Pathognomonic sign)
9. Amenorrhea

1. Serum T3 and T4 is increased
2. RAU (Radio Active odine Uptake) is increased
3. Thyroid Scan- reveals an enlarged thyroid gland

1. Monitor strictly vital signs and intake and output - determine thyroid storm or most feared complication:
Thyrotoxicosis
Anti Thyroid Agent
a. Prophythioracill (PTU)
b. Methymazole (Tapazole)
Most toxic Side Effects AgranuIocytosis
! increase lymphocytes and monocytes
! fever and chills
! sore throat (throat swab/culture)
! leukocytosis (CBC)
! Nost feared complication : Thrombosis - stroke CvS
3. Provide dietary intake that is increased in caIories.
5. Comfortable and cold environment
6. Maintain side rails - due to agitation/restlessness
7. Provide bilateral eye patch to prevent drying of the eyes.
8. Assist in surgical procedures known as subtotal thyroidectomy
* Before thyroidectomy administer LugoI's SoIution (SSK) to decrease vascularity of the thyroid
gland to prevent bleeding and hemorrhage.

#-)". ,)&',

POST OPERATIVELY,
1. Watch out for signs of thyroid storm/ thyrotoxicosis

Agitation

Hyperthermia Tachycardia
! administer medications as ordered
a. Anti Pyretics
b. Beta-blockers tachycardia
! Monitor strictly vital signs, input and output and neuro check.
! maintain side rails
! offer TSB

2. Watch out for accidentaI removaI of parathyroid gIand (secretes parathormone) that may Iead to
HypocaIcemia (tetany)
Signs and Symptoms
! (+) trousseau's sign
! (+) chvostek sign
! Watch out for arrhythmia, seizure give Calcium Gluconate V slowly as ordered
Ca gluconate toxicity - antidote - NgSO+
3. Watch out for accidentaI LaryngeaI (voice box) damage which may Iead to hoarseness of voice
Nursing Management
! encourage client to talk/speak immediately after operation and notify physician

4. Signs of bIeeding (feeIing of fuIIness at incisionaI site)
Nursing Management
! Check the soiled dressings at the back or nape area.
! Sign of laryngeal spasm DOB, SOB (tracheostomy at bed side)
5. HormonaI repIacement therapy for Iifetime
6. mportance of follow up care

PARATHYROID GLAND
! A pair of small nodules behind the thyroid gland
! Secretes parathormone
! Promotes calcium reabsorption
! #=:>57807215A2A - antagonises secretion of parathyroid hormone
! Hypoparathyroidism
! Hyperparathyroidism

HYPOPARATHYROIDISM
! Decrease secretion of parathormone leading to hypocaIcemia (tetany)
! Resulting to Hyperphosphatemia
[!f Ca decreases, phosphate increases|
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to:
a. inflammation
B)#C .
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b. tumor
c. trauma
1. Acute tetany
a. tingling sensation
b. paresthesia
c. numbness
d. dysphagia
e. positive trousseau's sign/carpopedal spasm
f. positive chvostek sign
g. laryngospasms / broncospasm
h. seizure feared compIications
i. arrhythmia
2. Chronic tetany
a. photophobia and cataract formation
b. loss of tooth enamel
c. anorexia, nausea and vomiting
d. agitation and memory impairment (irritable)

1. Serum Calcium is decreased (normaI vaIue: 8.5 - 10.5 mg/100 mI)
2. Serum Phosphate is increased (normaI vaIue: 2.5 - 4.5 mg/100 mI)
3. X-ray of long bones reveals a decrease in bone density
4. CT Scan reveals degeneration of basal ganglia

1. Administer medications as ordered such as:
a. Acute Tetany
! Calcium Gluconate V slowly
b. Chronic Tetany
! Oral Calcium supplements
! Calcium Gluconate
! Calcium Lactate
! Calcium Carbonate
c. Vitamin D (Cholecalciferol) for absorption of calcium

d. Phosphate binder
! Aluminum Hydroxide Gel (AmpogeI)
! Side effect: constipation
ANTACID

A.A.C MAD
* *
AIuminum Containing Magnesium Containing
Antacids Antacids
* *
AIuminum E;C (20K 5@ <8?A4628
Hydroxide
GeI (Naalox - magnesium 8 aluminum - Less sfe)
*
Side Effect: Constipation Side Effect: Diarrhea
2. Avoid precipitating stimulus such as glaring lights and noise
3. Encourage increase intake of foods rich in calcium (decreased phosphorus)
a. anchovies - increase Ca, decrease phosphorus + inc uric acid. Tuna 8 green turnips- !nc Ca.
b. salmon
c. green turnips
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4. nstitute seizure and safety precaution
5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.
6. Prepare trachea set at bedside for presence of laryngospasm
8. Hormonal replacement therapy for lifetime
9. mportance of follow up care.

HYPERPARATHYROIDISM
! Decrease parathormone
! HypercaIcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood)
! Kidney stones
(parathormone pullout the Ca in from the bone to the blood)
1. Hyperplasia of parathyroid gland
2. over compensation of parathyroid gland due to vitamin D deficiency
a. Children: Rickets - the bone do not hardened
b. Adults: OsteomaIacia - softening of the bone
1. Bone pain especially at back (bone fracture)
2. Kidney stones
a. renal cholic
b. cool moist skin
3. Anorexia, nausea and vomiting
4. Agitation and memory impairment

1. Serum Calcium is increased
2. Serum Phosphate is decreased
3. X-ray of long bones reveals bone demineralization
1. Force fluids to prevent kidney stones
2. Strain all the urine using gauze pad for stone analysis
3. Provide warm sitz bath
a. Morphine Sulfate (Demerol)
5. Encourage increase intake of foods rich in phosphate but decrease in calcium
6. Provide acid ash in the diet to acidify urine and prevent bacterial growth
7. Assist/supervise in ambulation
8. Maintain side rails
9. Prevent complications (seizure and arrhythmia) most feared renal failure
10. Assist in surgical procedure known as parathyroidectomy
11. HormonaI repIacement therapy for Iifetime

ADRENAL GLAND
! Located atop of each kidney
! 2 layers of adrenal gland
a. Adrenal Cortex outermost
b. Adrenal Medulla innermost (secretes catechoIamine's a power hormone)

2 Types of CatechoIamines
! Epinephrine and Norepinephrine (vasoconstrictor) increased BP
! Pheochromocytoma (adrenal medulla)
! ncrease secretion of norepinephrine
! Leading to hypertension which is resistant to pharmacological agents leading to CVA
! Use beta-blockers

!"#$%"&$'$%()$'*+ presence of tumor at adrenal medulla
ncrease norepinephrine. HPN with pounding headache.
with HPN and resistant to drugs
drug of choice: beta bIockers
complication: HPN crisis = Iead to stroke
no valsalva maneuver. Don't smoke. No caffeine.

ADRENAL CORTEX
3 Zones/Layers
1. Zona FascicuIata
- secretes glucocortocoids (cortisol)
- function: controls glucose metabolism
- Sugar
2. Zona ReticuIaris
- secretes traces of glucocorticoids and androgenic hormones
- function: promotes secondary sex characteristics
- Sex
3. Zona GIumeruIosa
- secretes mineralocorticoids (aldosterone)
- function: promotes sodium and water reabsorption and excretion of potassium
- Salt

ADDISON'S DISEASE - payat
! Hyposecretion of adreno cortical hormone leading to
ex - secondary sex disturbances / decreased libido
ugar - metabolic disturbance / hypoglycemia
aIt - fluid & electrolytes imbalance

1. Related to atrophy of adrenal glands
2. Fungal infections

1. HypogIycemia TRED
2. Decrease tolerance to stress
3. Hyponatremia
- hypotension
- signs of dehydration
- weight loss
4. HyperkaIemia
- agitation
- diarrhea
- arrhythmia
5. Decrease libido
6. Loss of pubic and axillary hair
7. Bronze Iike skin pigmentation
s
! #$%& '&()))

1. FBS is decreased (normal value: 80 100 mg/dl)
2. Plasma Cortisol is decreased
3. Serum Sodium is decrease (normal value: 135 145 meq/L)
4. Serum Potassium is increased (normal value: 3.5 4.5 meq/L)

1. Monitor strictly vital signs, input and output to determine presence of Addisonian crisis (complication of addison's
disease)
! Addisonian crisis results from acute exacerbation of addison's disease characterized by
a. severe hypotension
b. hypovolemic shock
c. hyponatremia leading to progressive stupor and coma
Nursing Management for Addisonian Crisis
1. Assist in mechanical ventilation,
- administer steroids as ordered
- force fluids
2. Administer isotonic fIuid soIution as ordered
3. Force fluids
"99265A28A 7>2626L
Cyanosis
Classic sign of circulatory shock: pallor,
apprehension, rapid weak pulse, rapid
RR, low BP

nydrocort|sone (So|u-Cortef) adm|n. IV, fo||owed
w] S D
S
NS.
Corticosteroids
a. Dexamethasone (Decadrone)
b. Prednisone
c. Hydrocortisone (Cortison)
Nursing Management when giving steroids
1. nstruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm
2. Taper dose (withdraw gradually from drug)
a. hypertension
b. edema
c. hirsutism
d. increase susceptibility to infection
e. moon face appearance
4. Mineralocorticoids (Flourocortisone)
5. Provide dietary intake, increase calories, carbohydrates, protein but decrease in potassium
7. Provide client health teaching and discharge planning
a. avoid precipitating factor Ieading to addisonian crisis Ieading to
- stress
- infection
- sudden withdrawal to steroids
b. prevent compIications
- addisonian crisis
- hypovolemic shock
c. hormonaI repIacement for Iifetime
d. importance of follow up care

CUSHING SYNDROME - mataba
! Hypersecretion of adenocortical hormones

1 Related to hyperplasia of adrenal gland
2. ncrease susceptibility to infections
3. Hypernatremia
a. hypertension
b. edema
c. weight gain
d. moon face appearance and buffaIo hump
e. obese trunk
f. pendulous abdomen
g. thin extremities
4. Hypokalemia
a. weakness and fatigue
b. constipation
c. U wave upon ECG (T wave hyperkalemia)
5. Hirsutism
6. Acne and striae
7. Easy bruising
8. Increase mascuIinity among femaIes

B. Diagnostic Procedures
1. FBS is increased
2. Plasma Cortisol is increased
Cushing's syndrome.
A. Client prior to syndrome.
B. Client 4 months after diagnosis of syndrome.

3. Serum Sodium is increased
4. Serum Potassium is decreased
5. Dexamethasone suppression test
C. Nursing Management
1. Monitor strictly vital signs and intake and output
2. Weigh patient daily and assess for pitting edema
3. Measure abdominal girth daily and notify physician
4. Restrict sodium intake
a. Spinarolactone potassium sparring diuretics
7. Prevent complications (DM)
8. Assist in surgical procedure (bilateral adrenoraphy)
9. Hormonal replacement for lifetime

PANCREAS
- Located behind the stomach
- Mixed gIand (exocrine and endocrine)
- Consist of acinar ceIIs which secretes pancreatic juices that aids in digestion thus it is an exocrine gland

Type 1 (IDDM) Type 2 (NIDDM)
- Juvenile onset type
- BrittIe disease

A. Incidence Rate
- 10% general population has type 1 DM
1. Hereditary (total destruction of pancreatic cells)
2. Related to viruses
3. Drugs
a. Lasix
b. Steroids
4. Related to carbon tetrachIoride toxicity

1. Polyuria
2. Polydypsia
3. Polyphagia
4. Glycosuria
5. Weight Ioss
7. Blurring of vision
8. ncrease susceptibility to infection
9. Delayed/poor wound healing
D. Treatment
1. nsulin therapy
2. Diet
3. Exercise

E. CompIication
1. Diabetic Ketoacidosis

- Adult onset
- Maturity onset type
- Obese over 40 years old
A. Incidence Rate
- 90% of general population has type 2 DM
1. Obesity because obese persons lack insulin
receptor binding sites

1. Usually asymptomatic
2. Polyuria
3. Polydypsia
4. Polyphagia
5. Glucosuria
6. Weight gain

D. Treatment
1. Oral Hypoglycemic agents
2. Diet
3. Exercise

E. CompIications
1. Hyper
2. Osmolar
3. Non
4. Ketotic
5. Coma

Best example of *H,$)'& ,M'.-%(E is
no other than
N%DD)OEE + moon face 8 big body with
thin extremities
- Consist of isIets of Iangerhans
- Has alpha cells that secretes glucagons (function: hyperglycemia)
- Beta cells secretes insulin (function: hypoglycemia)
- Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones)
3 Main Disorders of Pancreas
1. Pancreatic Tumor/Cancer
3. Pancreatitis

DIABETES MELLITUS
- Metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism

MAIN
FOODSTUFF
ANABOLISM CATABOLISM

1. Carbohydrates
2. Protein
3. Fats

GIucose
Amino Acids
Fatty Acids

GIycogen
Nitrogen
Free Fatty Acids
- ChoIesteroI
- Ketones

HYPERGLYCEMIA
ncrease osmotic diuresis

Glycosuria Polyuria

Cellular starvation weight loss Cellular dehydration

Stimulates the appetite/satiety center Stimulates the thirst center
(Hypothalamus) (Hypothalamus)
PoIyphagia PoIydypsia

* Liver has gIycogen that undergo gIycogenesis/ gIycogenoIysis

GLUCONEOGENESIS
Formation of glucose from non-CHO sources
ncrease protein formation
*
Negative Nitrogen balance
*
Tissue wasting (Cachexia)
*
INCREASE FAT CATABOLISM
*
Free fatty acids

Cholesterol Ketones
* *
Atherosclerosis Diabetic Keto Acidosis
*
Hypertension
Acetone Breath Kussmaul's Respiration
odor
M CVA

Death Diabetic Coma

DIABETIC KETOACIDOSIS
- Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression

1. Hyperglycemia
2. Stress number one precipitating factor
3. nfection

1. Polyuria
2. Polydypsia
3. Polyphagia
4. Glucosuria
5. Weight loss
7. Blurring of vision
8. Acetone breath odor
9. KussmauI's Respiration (rapid shallow breathing)
10 CNS depression leading to coma

1. FBS is increased
2. BUN (normal value: 10 20)
3. Creatinine (normal value: .8 1)
4. Hct (normal value: female 36 42, male 42 48) due to severe dehydration

1. Assist in mechanical ventilation
2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock
3. Monitor strictly vital signs, intake and output and blood sugar levels
a. nsulin therapy (regular acting insulin/rapid acting insulin peak action of 2 4 hours)
b. Sodium Bicarbonate to counteract acidosis
c. Antibiotics to prevent infection

HYPER OSMOLAR NON KETOTIC COMA
- Hyperosmolar: increase osmolarity (severe dehydration)
- Non ketotic: absence of lypolysis (no ketones)

1. Headache and dizziness
2. Restlessness
3. Seizure activity
4. Decrease LOC diabetic coma

B. Nursing Management
1. Assist in mechanical ventilation
2. Administer 0.9 NaCl followed by .45 NaCl
(hypotonic solutions) to counteract dehydration and shock
a. nsulin therapy (regular acting insulin peak action of 2 4 hours)
- for DKA use rapid acting insulin
b. Antibiotics to prevent infection
INSULIN THERAPY
A. Sources of InsuIin
1. AnimaI sources
- Rarely used because it can cause severe allergic reaction
- Derived from beef and pork
2. Human Sources
- Frequently used type because it has less antigenicity property thus less allergic reaction
3. ArtificiaIIy Compound InsuIin

B. Types of InsuIin

1. Rapid Acting InsuIin (cIear)
- Regular acting insulin (V only)
- Peak action is 2 4 hours
2. Intermediate Acting InsuIin (cIoudy)
- Non Protamine Hagedorn nsulin (NPH)
3. Long Acting InsuIin (cIoudy)
- Ultra Lente

C. Nursing Management for InsuIin Injections
1. Administer at room temperature to prevent development of Iipodystrophy (atrophy, hypertrophy of subcutaneous
tissues)
2. Place in refrigerator once opened
3. Avoid shaking insulin vial vigorously instead gently roll vial between palms to prevent formation of bubbles
4. Use gauge 25 - 26 needIe
5. Administer insulin either 45
o
90
o
depending on amount of clients tissue deposit
6. No need to aspirate upon injection
7. Rotate insulin injection sites to prevent development of lipodystrophy
8. Most accessible route is abdomen
9. When mixing 2 types of insulin aspirate first the cIear insuIin before cIoudy to prevent contaminating the clear
insulin and promote proper calibration.
10. Monitor for signs of local complications such as
a. Allergic reactions
b. Lipodystrophy
c. Somogyi Phenomenon rebound effect of insulin characterized by hypoglycemia to hyperglycemia

ORAL HYPOGLYCEMIC AGENTS - OHA
- Stimulates the pancreas to secrete insulin
A. CIasssification
1. First Generation SuIfonyIureas
a. Chlorpropamide (Diabenase)
b. Tolbutamide (Orinase)
c. Tolamazide (Tolinase)
2. Second Generation SuIfonyIureas
a. Glipzide (Glucotrol)
b. Diabeta (Micronase)
Nursing Management when giving OHA
1. nstruct the client to take it with meals to lessen GT irritation and prevent hypoglycemia
2. nstruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse)
toxicity symptoms

#:346 5@ )A6/02A *505> P 75A62614A7: !48K
Rapid CIear 2-4
Intermediate CIoudy 6-12
Long acting CIoudy 12-24
B. Diagnostic Procedures for DM
1. FBS is increased (3 consecutive times with signs or
poIyuria, poIydypsia, poIyphagia and gIucosuria confirmatory for DM)
2. Random Blood Sugar is increased
3. Oral glucose tolerance test is increased most sensitive test
4. Alpha Glycosylated Hemoglobin is increased

1. Monitor for peak action of insulin and OHA and notify physician
2. Administer insulin and OHA therapy as ordered
4. Monitor for signs of hypoglycemia and hyperglycemia
- administer simple sugars
- for hypoglycemia (cold and clammy skin) give simple sugars
- for hyperglycemia (dry and warm skin)
5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% and fats 20% or offer
alternative food substitutes
6. nstruct client to exercise best after meals when blood
glucose is rising
7. Monitor signs for complications
a. Atherosclerosis (HPN, M, CVA)
b. Microangiopathy (affects small minute blood vessels of eyes and kidneys)
c. HPN and DM major cause of renal failure
d. Gangrene formation
e. Shock due to dehydration
- peripheral neuropathy
- diarrhea/constipation
- sexual impotence
8. nstitute foot care management
a. instruct client to avoid walking barefooted
b. instruct client to cut toenails straight
c. instruct client to avoid wearing constrictive garments
d. encourage client to apply lanolin lotion to
prevent skin breakdown
e. assist in surgical wound debriment
(give analgesics 15 30 mins prior)
9. nstruct client to have an annual eye and kidney exam
10. Monitor for signs of DKA and HONKC
11. Assist in surgical procedure

%"&$-.% "#'$&&"*/.% !*-%&#*).).0- bangugot
Predisposing Iactors - unknown
Risk Iactor:
History oI hepatobiliary disorder
Alcohol
Drugs thiazide diuretics, oral contraceptives, aspirin, penthan
Obesity
Hyperlipidemia
Hyperthyroidism
High intake oI Iatty Iood saturated Iats

Overview only:
!*-%&#*).).0 + acute inIlammation oI pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion selI-digestion
Cause: unknown/idiopathic
alcoholism
Pathognomonic sign- () Cullens sign - Ecchymosis oI umbilicus (bluish color)- pasa
(+) Grey turner`s sign - ecchymosis of flank area
EYES KIDNEY
-PREMATURE CATARACT
- BIindness
-RECURRENT PYELONEPHRITIS
- RenaI faiIure
HEMATOLOGICAL SYSTEM

. Blood . Blood Vessels . Blood Forming Organs

1. Arteries 1. Liver
55% Plasma 45% Formed 2. Veins 3. Spleen
4. Lymphoid Organ
Serum Plasma CHON 5. Lymph Nodes
(formed in liver) 6. Bone Marrow
1. Albumin
2. Globulins
3. Prothrombin and Fibrinogen

ALBUMIN
- Largest and numerous plasma CHON
- Maintains osmotic pressure preventing edema

GLOBULINS
- Alpha globulins - transport steroids, bilirubin and hormones
- Beta globulins iron and copper
- Gamma globulins
a. anti-bodies and immunoglobulins
b. prothrombin and fibrinogen clotting factors

FORMED ELEMENTS
1. RBC (ERYTHROCYTES)
- normal value: 4 - 6 miIIion/mm
3
- onIy unnucIeated ceII
- biconcave discs
- consist of molecules of hgb (red pigment) biIirubin (yeIIow pigment) biIiverdin (green pigment) hemosiderin (goIden
brown pigment)
- transports and carries oxygen to tissues
- hemogIobin: normal value femaIe 12 - 14 gms% maIe 14 - 16 gms%
- hematocrit red cell percentage in wholeblood
- normal value: femaIe 36 - 42% maIe 42 - 48%
- substances needed for maturation of RBC
a. folic acid
b. iron
c. vitamin c
d. vitamin b
12
(cyanocobalamin)
e. vitamin b
6
(pyridoxine)
f. intrinsic factor
- NormaI Iife span of RBC is 80 - 120 days and is kiIIed in red puIp of spIeen

2. WBC (LEUKOCYTES)
- normal value: 5000 - 10000/mm
3
A. Granulocytes
1. PoIymorpho NeutrophiIs
- 60 70% of WBC
- involved in short term phagocytosis for acute infIammation
2. PoIymorphonucIear BasophiIs
- for parasite infections
- responsible for the release of chemical mediation for inflammation
3. PoIymorphonucIear EosinophiIs
- for allergic reaction
B. Non Granulocytes
1. Monocytes
- macrophage in blood
- largest WBC
- involved in long term phagocytosis for chronic inflammation
2. Lymphocytes

B-ceII T-ceII NaturaI kiIIer ceII
- bone marrow - thymus - anti viral and anti tumor property
for immunity

HIV
- 6 months 5 years incubation period
- 6 months window period
- western blot opportunistic
- ELSA
- drug of choice AZT (Zidon Retrovir)

2 Common fungaI opportunistic infection in AIDS
1. Kaposi's Sarcoma
2. Pneumocystis Carinii Pneumonia

3. PIateIets (THROMBOCYTES)
- Normal value: 150,000 - 450,000/mm
3
- Promotes hemostasis (prevention of blood loss)
- Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus
- NormaI Iife span of pIateIet is 9 - 12 days

Signs of PIateIet Dysfunction
1. Petechiae
2. Echhymosis
3. Oozing of blood from venipunctured site

BLOOD DISORDERS
Iron Deficiency Anemia
- A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury
A. Incidence Rate
1. Common among developed countries
2. Common among tropical zones
3. Common among women 15 35 years old
4. Related to poor nutrition
1. Chronic blood loss due to trauma
a. Heavy menstruation
b. Related to GT bleeding resulting to hematemesis and meIena (sign for upper GT bleeding)
c. fresh blood per rectum is called hematochezia
2. nadequate intake of iron due to
a. Chronic diarrhea
b. Related to malabsorption syndrome
c. High cereal intake with low animal protein digestion
d. Subtotal gastrectomy
4. Related to improper cooking of foods
1. Usually asymptomatic
2. Weakness and fatigue (initial signs)
4. Pallor and cold sensitivity
5. Dyspnea
6. Palpitations
7. Brittleness of hair and spoon shape nails (koiIonychias)
8. Atropic Glossitis (inflammation of tongue)
- Stomatitis PLUMBER VINSON'S SYNDROME
- Dysphagia
9. PCA (abnormal appetite or craving for non edible foods
D. Diagnostic Procedures
1. RBC is decreased
2. Hgb is decreased
3. Hct is deceased
4. ron is decreased
5. Reticulocyte is decreased
6. Ferritin is decreased
1. Monitor for signs of bleeding of all hema test including urine, stool and GT
2. Enforce CBR so as not to over tire client
3. nstruct client to take foods rich in iron
a. Organ meat
b. Egg (yolk)
c. Raisin
d. Sweet potatoes
e. Dried fruits
f. Legumes
g. Nuts
4. nstruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption
OraI Iron Preparations
a. Ferrous Sulfate
b. Ferrous Fumarate
c. Ferrous Gluconate
- 300 mg/day
Nursing Management when taking oraI iron preparations
1. nstruct client to take with meals to lessen GT irritation
2. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth
Medications administered via straw
Lugol's solution
ron
Tetracycline
Nitrofurantoin (Macrodentin)
3. Administer with Vitamin C or orange juice for absorption
4. Monitor and inform client of side effects
a. Anorexia
b. Nausea and vomiting
c. Abdominal pain
d. Diarrhea/constipation
e. Melena
5. f client cant tolerate/no compliance administer parenteral iron preparation
a. ron Dextran (M, V)
b. Sorbitex (M)
Nursing Management when giving parenteraI iron preparations
1. Administer Z tract technique to prevent discomfort, discoloration and leakage to tissues
2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption
a. Pain at injection site
b. Localized abscess
c. Lymphadenopathy
d. Fever and chills
e. Skin rashes
f. Pruritus/orticaria
g. Hypotension (anaphylactic shock)

PERNICIOUS ANEMIA
- Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric
acid secretion)

1. Subtotal gastrectomy
2. Hereditary factors
3. nflammatory disorders of the ileum
4. Autoimmune
5. Strictly vegetarian diet

STOMACH
*
PareitaI ceIIs/ Argentaffin or Oxyntic ceIIs

Produces intrinsic factors Secretes hydrochloric acid
* *
Promotes reabsorption of Vit B
12
Aids in digestion
*
Promotes maturation of RBC

3. Pallor and cold sensitivity
4. Dyspnea and palpitations as part of compensation
5. GT changes that includes
a. mouth sore
b. red beefy tongue
c. indigestion/dyspepsia
d. weight loss
e. jaundice
6. CNS changes
a. tingling sensation
b. numbness
c. paresthesia
d. positive to Romberg's test damage to cerebellum resulting to ataxia
e. result to psychosis

SchiIIing's Test reveals inadequate/decrease absorption of Vitamin B
12

1. Enforce CBR
2. Administer Vitamin B
12
injections at monthly intervals for Iifetime as ordered
- Never given orally because there is possibility of developing tolerance
- Site of injection for Vitamin B
12
is dorsogIuteaI and ventrogIuteaI
- No side effects
3. Provide a dietary intake that is high in carbohydrates, protein, vitamin c and iron
4. nstruct client to avoid irritating mouth washes instead use soft bristled toothbrush
5. Avoid heat application to prevent burns

APLASTIC ANEMIA
- Stem cell disorder leading to bone marrow depression leading to pancytopenia

PANCYTOPENIA

Decrease RBC Decrease WBC Decrease Platelet
(anemia) (leucopenia) (thrombocytopenia)

1. Chemicals (Benzine and its derivatives)
2. Related to irradiation/exposure to x-ray
3. mmunologic injury
4. Drugs
Broad Spectrum Antibiotics
a. Chloramphenicol (Sulfonamides)
Chemotherapeutic Agents
a. Methotrexate (Alkylating Agent)
b. Vincristine (Plant Alkaloid)
c. Nitrogen Mustard (Antimetabolite)
PhenyIbutazones (NSADS)

1. Anemia
a. Weakness and fatigue
b. Headache and dizziness
c. Pallor and cold sensitivity
d. Dyspnea and palpitations
2. Leukopenia
a. ncrease susceptibility to infection
3. Thrombocytopenia
a. Petechiae (multiple petechiae is called purpura)
b. Ecchymosis
c. Oozing of blood from venipunctured sites
1. CBC reveals pancytopenia
2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) reveals fat necrosis in bone marrow

1. Removal of underlying cause
2. nstitute BT as ordered
3. Administer oxygen inhalation
4. Enforce CBR
5. nstitute reverse isolation
6. Monitor for signs of infection
a. fever
b. cough
When all of the blood elements
are depressed, the term
"pancytopenia" is used. "Pan
meaning everything.
7. Avoid M, subcutaneous, venipunctured sites
8 nstead provide Heplock
9. nstruct client to use electric razor when shaving
a. Corticosteroids caused by immunologic injury
b. mmunosuppressants

Anti Lymphocyte Globulin
*
Given via central venous catheter
*
Given 6 days to 3 weeks to achieve
Maximum therapeutic effect of drug

DISSEMINATED INTRAVASCULAR COAGULATION
Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin
and fibrinogen

1. Related to rapid blood transfusion
2. Massive burns
3. Massive trauma
4. Anaphylaxis
5. Septicemia
6. Neoplasia (new growth of tissue)
7. Pregnancy

1. Petechiae (widespread and systemic) eye, lungs and lower extremities
2. Ecchymosis
3. Oozing of blood from punctured sites
4. Hemoptysis
6. Oliguria (Iate sign)

1. CBC reveals decreased platelets
2. Stool occult blood positive
3. ABG analysis reveals metabolic acidosis
4. Opthamoscopic exam reveals sub retinal hemorrhages

1. Monitor for signs of bleeding of all hema test including stool and GT
2. Administer isotonic fluid solution as ordered
4. Force fluids
a. Vitamin K
b. Pitressin/ Vasopresin to conserve fluids
c. Heparin/Coumadin is ineffective
6. Provide heparin lock
7. nstitute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 1000 ml
8. Monitor NGT output
9. Prevent complication
a. Hypovolemic shock
b. Anuria late sign

!"##$ &'()*+,*-#)
GoaIs/Objectives
1. Replace circulating blood volume
2. ncrease the oxygen carrying capacity of blood
3. Prevent infection in there is a decrease in WBC
4. Prevent bleeding if there is platelet deficiency

PrincipIes of bIood transfusion
1. Proper refrigeration
- Expiration of packed RBC is 3 6 days
- Expiration of platelet is 3 5 days
2. Proper typing and cross matching
a. Type O universal donor
b. Type AB universal recipient
c. 85% of population is RH positive
3. AsepticaIIy assembIe aII materiaIs needed for BT
a. Filter set
b. Gauge 18 19 needle
c. sotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis
4. Instruct another RN to re check the foIIowing
a. Client name
b. Blood typing and cross matching
c. Expiration date
d. Serial number
5. Check the bIood unit for bubbIes cIoudiness, sediments and darkness in coIor because it indicates bacteriaI
contamination
- Never warm blood as it may destroy vital factors in blood.
- Warming is only done during emergency situation and if you have the warming device
- Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood.
6. BT should be completed Iess than 4 hours because blood that is exposed at room temperature more
than 2 hours causes blood deterioration that can lead to BACTERAL CONTAMNATON
7. Avoid mixing or administering drugs at BT line to prevent HEMOLYSS
8. Regulate BT 10 - 15 gtts/min or KVO rate or equivaIent to 100 cc/hr to prevent circulatory overload
9. Monitor strictly vital signs before, during and after BT especially every 15 minutes for first hour
because majority of transfusion reaction occurs during this period
a. Hemolytic reaction
b. Allergic reaction
c. Pyrogenic reaction
d. Circulatory overload
e. Air embolism
f. Thrombocytopenia
g. Cytrate intoxication
h. Hyperkalemia Q78/649 R: 4;32>49 R0559G

,2?A6 8A9 ,:<315<6 5@ $4<50:127 >487125A
2. Dyspnea
3. Diarrhea/Constipation
4. Hypotension
5. Flushed skin
6. Lumbar/sternal/ Flank pain
7. Urine is color red/ portwine urine

Nursing Management
1. Stop BT
2. Notify physician
3. Flush with plain NSS
4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis
5. Send the blood unit to blood bank for re examination
6. Obtain urine and blood sample and send to laboratory for re examination
7. Monitor vital signs and intake and output

SIGNS AND SYMPTOMS OF ALLERGIC REACTION
1. Fever
2. Dyspnea
3. Broncial wheezing
4. Skin rashes
5. Urticaria
6. Laryngospasm and Broncospasm
Nursing Management
1. Stop BT
2. Notify physician
a. Anti Histamine (BenadryI) - if positive to hypotension, anaphylactic shock treat with Epinephrine

SIGNS AND SYMPTOMS PYROGENIC REACTIONS (FEVER)
1. Fever and chills
2. Headache
3. Tachycardia
4. PaIpitations
5. Diaphoresis
6. Dyspnea
Nursing Management
1. Stop BT
2. Notify physician
a. Antipyretic
b. Antibiotic
8. Render TSB
SIGNS AND SYMPTOMS OF CIRCULATORY REACTION
1. Orthopnea
2. Dyspnea
3. RaIes/CrackIes upon auscultation
4. Exertional discomfort
Nursing Management
1. Stop BT
2. Notify physician
a. Loop diuretic (Lasix
CARDIOVASCULAR SYSTEM
OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART

HEART
- Muscular pumping organ 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
2 Iayers of pericardium
a. Parietal outer layer
b. Visceral inner layer
- n between is the pericardiaI space fiIIed w/ fIuid
which is 10 - 30 cc lubricates the surface to reduces
friction during systole.
- Common among M, pericarditis, Cardiac tamponade

A. Layers of Heart
1. Epicardium outer layer
2. Myocardium middle layer
3. Endocardium inner layer
- Myocarditis can lead to cardiogenic shock and rheumatic heart disease

B. Chambers of the Heart
1. Upper Chamber (connecting or receiving)
a. Atria
2. Lower Chamber (contracting or pumping)
a. VentricIes
- Left ventricle has increased pressure which is 120 180 mmHg
- n order to propel blood to the systemic circulation
- Right atrium has decreased pressure which is 60 80 mmHg

C. VaIves
- To promote unidimensional flow or prevent backflow

1. AtrioventricuIar VaIves guards opening between
a. tricuspid valve
b. mitral valve
- Closure of AV valves give rise to first heart sound (S
1
'lub")

2. Semi - Iunar VaIves
a. pulmonic
b. aortic
- Closure of SV valve give rise to second heart sound (S
2
'dub")

Extra Heart Sounds
1. S
3
ventricular gallop usually seen in Left Congestive Heart FaiIure sound occurring during rapid ventricular filling
2. S
4
atrial gallop usually seen in MyocardiaI Infarction and Hypertension sound head during atrial contraction (often
heard when the ventricle is enlarged or hypertrophied

D. Coronary Arteries
- Arises from base of the aorta
Types of Coronary Arteries
1. Right Main Coronary Artery
2. Left Main Coronary Arterying
- Supplies the myocardium

E. Cardiac Conduction System
1. Sino - AtriaI Node (SA or Keith FIack Node)
- Located at the junction of superior vena cava and right atrium
- Acts as primary pacemaker of the heart
- nitiates electrical impulse of 60 100 bpm

2. Atrio - VentricuIar Node (AV or Tawara Node)
- Located at the inter atrial septum
- Delay of electrical impulse for about .08 milliseconds to allow ventricular filling

3. BundIe of His
- Right Main Bundle of His
- Left Main Bundle of His
- Located at the interventricular septum

4. Purkinje Fibers terminal point in the conduction system
(point which the myocardiaI ceIIs are stimuIated causing ventricuIar contraction)
- Located at the walls of the ventricles for ventricular contraction
- P WAVE (atrial depolarization) contraction
- QRS WAVE (ventricular depolarization)
- T WAVE (ventricular repolarization)
! nsert pacemaker if there is complete heart block
! Most common pacemaker is the metal pacemaker and lasts up to 2 5 years

Cardiac electrical activity is the result of the movement of ions (charged particles such as SODIUM, POTASSIUM,
AND CALCIUM) across the cell membrane.

ABNORMAL ECG TRACING
1. Positive U wave - Hypokalemia
2. Peak T wave Hyperkalemia
3. ST segment depression Angina Pectoris
4. ST segment elevation Myocardial nfarction
5. T wave inversion Myocardial nfarction
6. Widening of QRS complexes Arrhythmias

CARDIAC DISORDERS
Coronary ArteriaI Disease/ Ischemic Heart Disease
Stages of DeveIopment of Coronary Artery Disease
1. Myocardial njury - Atherosclerosis
2. Myocardial schemia Angina Pectoris
3. Myocardial Necrosis Myocardial nfarction

ATHEROSCLEROSIS
ATHEROSCLEROSIS ARTERIOSCLEROSIS
- narrowing of artery
- Iipid or fat deposits (pIaques)
- tunica intima
- hardening of artery, thicken
- caIcium and protein deposits
- tunica media

1. Sex male
2. Race black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
8. Hypothyroidism
9. Diet increased saturated fats

1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis

C. Treatment
Percutaneous Transluminal Coronary Angioplasty
Objectives of PTCA
1. Revascularize myocardium
2. To prevent angina
3. ncrease survival rate
- Done to single occluded vessels
- f there is 2 or more occluded blood vessels CABG is done
Coronary Arterial Bypass And Graft Surgery
3 CompIications of CABG
1. Pneumonia encourage to perform deep breathing, coughing exercise and use of incentive spirometer
2. Shock
3. Thrombophlebitis

ANGINA PECTORIS (SYNDROME)
Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to
temporary myocardial ischemia
1. Sex male
2. Race black
3. Smoking
4. Obesity
5. Hyperlipidemia
8. Hypothyroidism

B. Precipitating Factors
4 E's of Angina Pectoris
1. Excessive physicaI exertion heavy exercises
2. Exposure to coId environment
3. Extreme emotionaI response fear, anxiety, excitement
4. Excessive intake of foods rich in saturated fats skimmed milk

1. Levine's Sign initial sign that shows the hand clutching the chest
2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back, shoulder, arms, axilla
and jaw muscles, usually relieved by rest or taking nitroglycerine
3. Dyspnea
4. Tachycardia
5. Palpitations
6. Diaphoresis

1. History taking and physical exam
2. ECG tracing reveals ST segment depression
3. Stress test treadmill test, reveal abnormal ECG
4. Serum cholesterol and uric acid is increased

a. NitrogIycerine (NTG) when given in smaII doses will act as venodiIator, but in Iarge doses will act as
vasodiIator
- Give first dose of NTG (sublingual) 3 5 minutes
Angina is usually caused by
ATHEROSCLEROTIC Disease.
- lipid or fat deposits
- tunica intima

- Give second dose of NTG if pain persist after giving first dose with interval of 3 - 5 minutes
- Give third and last dose of NTG if pain still persists at 3 5 minutes interval
Nursing Management when giving NTG
- Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug
- Monitor side effects
Orthostatic hypotension
Transient headache and dizziness
- nstruct the client to rise slowly from sitting position
- Assist or supervise in ambulation
- When giving nitroI or transdermaI patch
! Avoid placing near hairy areas as it may decrease drug absorption
! Avoid rotating transdermal patches as it may decrease drug absorption
! Avoid placing near microwave ovens or during defibrillation as it may lead to burns (most important
thing to remember)

b. Beta-bIockers
- (IoI)
- Propanolol - side effects PNS - broncho constriction, vasodiIation
- Not given to COPD cases because it causes Bronchospasm

c. ACE Inhibitors
- (priI)
- Enalapril, captopril, april jane dolo

d. CaIcium Antagonist
- calciblock
- Nifedipine, diltiazem

4. Place client on semi fowler's position
5. Monitor strictly vital signs, intake and output and ECG tracing
6. Provide decrease saturated fats sodium and caffeine
7. Provide client health teachings and discharge planning
a. Avoidance of 4 E's
b. Prevent complication (myocardial infarction)
c. nstruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic
effect of drug
d. The importance of follow up care

MYOCARDIAL INFARCTION - areas in myocardial cells in the heart are permanently destroyed.
Heart attack
Terminal stage of coronary artery disease characterized by malocclusion, necrosis and scarring.

A. Types
1. TransmuraI MyocardiaI Infarction most dangerous type characterized by occlusion of both right and left coronary
artery
2. SubendocardiaI MyocardiaI Infarction characterized by occlusion of either right or left coronary artery

B. The Most CriticaI Period FoIIowing Diagnosis of MyocardiaI Infarction
** 6 - 8 hours because majority of death occurs due to arrhythmia leading to PVC's

C. Predisposing Factors
1. Sex male
2. Race black
3. Smoking
4. Obesity
5. Hyperlipidemia
8. Hypothyroidism

1. Chest pain
- Excruciating visceral, viselike pain Iocated at substernaI and rarely in precordial
- Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles (abdominal ischemia) and hands
- Not usuaIIy reIieved by rest or by nitrogIycerine
2. Dyspnea
3. ncrease in blood pressure (initial sign)
4. Hyperthermia
5. Ashen skin (pale), cool, clammy, diaphoretic
6. Mild restlessness and apprehension, anxiety
7. Occasional findings
a. Pericardial friction rub
b. Split S
1
and S
2

c. Rales/Crackles upon auscultation
d. S
4
or atrial gallop

1. Cardiac Enzymes
a. CPK - MB
- Creatinine phosphokinase is increased
- Heart only, 12 24 hours
b. LDH Lactic dehydroginase is increased
c. SGPT Serum glutamic pyruvate transaminase is increased
d. SGOT Serum glutamic oxal-acetic transaminase is increased
2. Troponin Test is increased (protein in myocardial)
3. ECG tracing reveals
a. ST segment elevation
b. T wave inversion
c. Widening of QRS complexes indicates that there is arrhythmia in M
4. Serum ChoIesteroI and uric acid are both increased
5. CBC increased WBC

GoaI: Decrease myocardial oxygen demand
1. Decrease myocardial workload (rest heart)
- Administer narcotic anaIgesic/morphine suIfate
- Side Effects: respiratory depression
- Antidote: Narcan/NaIoxone
- Side Effects of NaIoxone Toxicity is tremors
2. Administer oxygen low inflow to prevent respiratory arrest at 2 3 L/min
3. Enforce CBR without bathroom privileges
a. Using bedside commode
4. nstruct client to avoid forms of valsalva maneuver
5. Place client on semi fowler's position
7. Provide a general liquid to soft diet that is Iow in saturated fats, sodium and caffeine
8. Encourage client to take 20 - 30 cc/week of wine, whisky and brandy to induce vasodilation
9. Administer medication as ordered :
a. VasodiIators
- Nitroglycerine
- SD (sosorbide Dinitrate, sordil) sublingual

b. Anti Arrythmic Agents
- Lidocaine (Xylocane
- Side Effects: confusion and dizziness
- Brutylium
c. Beta-bIockers
- (-lol)

d. ACE Inhibitors
- (-pril)

e. CaIcium Antagonist
- amlodipine, verapamil, diltiazem
f. ThromboIytics/ FibrinoIytic Agents
- Streptokinase
- Side Effects: allergic reaction, pruritus
- Urokinase
- TPAF (tissue plasminogen activating factor)
- Side Effects: chest pain
- Monitor for bleeding time

g. Anti CoaguIant
- Heparin (check for partial thrombin time)
- Antidote: protamine suIfate
- Coumadin/ Warfarin Sodium (check for prothrombin time)
- Antidote: Vitamin K

h. Anti PIateIet
- PASA (Aspirin)
- Anti thrombotic effect
- Side Effects of Aspirin
# Tinnitus
# Heartburn
# ndigestion/Dyspepsia
- Contraindication
# Dengue
# Peptic Ulcer Disease
# Unknown cause of headache

10. Provide client health teaching and discharge planning concerning
a. Avoidance of modifiable risk factors
- Arrhythmia (caused by premature ventricular contraction)
b. Cardiogenic shock
- Iate sign is oIiguria
c. Left Congestive Heart Failure
d. Thrombophlebitis
- homan's sign
e. Stroke/CVA
f. Post M Syndrome/DressIer's Syndrome
- Client is resistant to pharmacological agents; administer 150,000 - 450,000 units of streptokinase as
ordered
g. Resumption of ADL particularly sexual intercourse is 4 - 6 weeks post cardiac rehab, post CABG and instruct
to
- make sex as an appetizer rather than dessert
- instruct client to assume a non weight bearing position
Client can resume sexual intercourse if can cIimb staircase
- dietary modification
h. Strict compliance to mediation and importance of follow up care

CONGESTIVE HEART FAILURE
nability of the heart to pump blood towards systemic circulation

Types of Heart FaiIure
1. LEFT SIDED HEART FAILURE

1. 90% is mitral valve stenosis due to
a. RHD inflammation of mitral valve due to invasion of Group A beta-hemolytic streptococcus
- Formation of aschoff bodies in the mitraI vaIve
- Common among children (throat infection)
- ASO Titer (Anti streptolysin O titer)
- Penicillin
- Aspirin
b. Aging
2. Myocardial nfarction
3. schemic heart disease
4. Hypertension
5. Aortic valve stenosis
1. Dyspnea
2. ParoxysmaI nocturnaI dyspnea client awakened at night due to DOB (sudden attacks of Orthopnea at night)
3. Orthopnea use 2 3 pillows when sleeping or place in high fowlers
4. Productive cough with bIood tinged sputum (severe pulmonary edema)
5. Frothy salivation
6. Cyanosis
7. Rales/Crackles (bi-basilar lobes that do not clear w/ coughing)
8. Bronchial wheezing
9. PuIsus AIternans weak pulse followed by strong bounding pulse
10. PM is displaced laterally due to cardiomegaly
11. There is anorexia and generalized body malaise
12. S
3
ventricular gallop
13. OIiguria - blood flow to the kidney decreases, causing decreased perfusion and reduce urine output. (Daytime)
14. Nocturia sleeping cardiac workload decreased, improving renal perfusion, which then leads to frequent urination at
Night.

1. Chest x-ray reveals cardiomegaly
2. PAP (pulmonary arterial pressure) measures pressure in right ventricle or cardiac status
PCWP (pulmonary capillary wedge pressure) measures end systolic and dyastolic pressure
- both are increased
- done by cardiac catheterization (insertion of swan ganz catheter)
3. Echocardiography enIarged heart chamber (cardiomyopathy), dependent on extent of heart failure
4. ABG reveals PO
2
is decreased (hypoxemia), PCO
2
is increased (respiratory acidosis)

2. RIGHT SIDED HEART FAILURE - RGHT VENT. FALS.
1. Tricuspid valve stenosis
2. Pulmonary embolism
3. Related to COPD
4. Pulmonic valve stenosis
5. Left sided heart failure

B. Signs and Symptoms (venous congestion)
1. Neck/jugular vein distension
2. Pitting edema (lower extremities)
3. Ascites
4. Weight gain
5. Hepatosplenomegaly
6. Jaundice
7. Pruritus (albumin)
8. Anorexia
9. Esophageal varices

1. Chest x-ray reveals cardiomegaly
2. Central venous pressure (CVP)
- Measure pressure in right atrium (4 10 cm of water)
- CVP fluid status measure
- f CVP is less than 4 cm of water hypovolemic shock
- Do the fluid challenge (increase V flow rate)
- f CVP is more than 10 cm of water hypervolemic shock
- Administer loop diuretics as ordered
- When reading CVP patient should be flat on bed
- Upon insertion place client in TrendeIenburg position to promote ventricular filling and prevent pulmonary
embolism

3. Ecocardiography reveals enlarged heart chambers (cardiomyopathy)
4. Liver enzymes SGPT and SGOT is increased B. hypertrophic cardiomyopathy

GoaI: increase cardiac contractility thereby increasing cardiac output (3 6 L/min)
1. Enforce CBR
a. Cardiac gIycosides B. dilated cardiomyopathy
- Digoxin (Lanoxin) (increases cardiac contraction but lowers the pulse rate)
- ncrease force of cardiac contraction
- f heart rate is decreased do not give
b. Loop Diuretics
- Lasix (Furosemide) peak 1-2 hrs, duration 6-8 hrs (monitor for hyperkalemia)
c. BronchodiIators aminophylline
d. Narcotic anaIgesics
- Morphine Sulfate
e. VasodiIators
- Nitroglycerine
f. Anti Arrhythmic
- Lidocaine (Xylocane)

3. Administer oxygen inhalation with high inflow, 3 4 L/min, delivered via nasal cannula
4. High fowler's position
6. Measure abdominal girth daily and notify physician
7. Provide a dietary intake of Iow sodium, choIesteroI and caffeine
9. Assist in bloodless phlebotomy rotating tourniquet, rotated clockwise every 15 minutes to promote decrease venous
return
a. Prevent complications
- Arrhythmia
- Shock
- Right ventricular hypertrophy
- M
- Thrombophlebitis
b. Dietary modification
c. Strict compliance to medications

PERIPHERAL VASCULAR DISORDER
ArteriaI UIcer
I. ThromboAngIitis ObIiterans (BUERGER'S DISEASE)
# Burger's Disease - <804S @441
# Reynaud's Disease - @4<804S =8A96

Venous UIcer
1. Varicose Veins
2. Thrombophlebitis (deep vein thrombosis)

THROMBOANGIITIS OBLITERANS or BUERGER'S DISEASE (MALE FEET) 20-35 yrs oId
Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities
(Autoimmune disease)

1. High risk groups men 30 years old and above
2. Smoking
3. Thrombus formation and occlusion of the vessels
4. Age 20-35 yrs

B. Signs and Symptoms (pain is the outstanding symptom)
1. ntermittent claudication leg pain upon walking (foot cramps, especially the arch (instep claudication after exercise)
2. Cold sensitivity and changes in skin color rubor (reddish blue discoloration, pallor, and cyanosis)
3. Decreased peripheral pulses
4. Trophic changes
5. Ulceration
6. Gangrene formation
7. Absence of pedal pulse but with normal femoral pulse and popliteal pulses.
8. Radial and ulnar artery pulses are absent or diminished.

1. OsciIIometry decrease in peripheral pulses
2. DoppIer UTZ decrease blood flow to the affected extremity
3. Angiography reveals site and extent of malocclusion
4. Segmental limb blood pressure (alternation of tourniquet)

1. Encourage a slow progressive physical activity
A. walking 3 4 times a day
B. out of bed 3 4 times a day
a. Analgesics
b. Vasodilators
c. Anti coagulants
3. nstitute foot care management
4. nstruct client to avoid smoking and exposure to cold environment
5. Assist in surgical procedure bellow knee amputation (elevate the stump for 24 hrs postop to promote venous return
and minimize edema).
6. Pain is relieve by rest

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1=4 =48>1 04U40 + 2@ 1=4 75A92125A
26 U4A5/6 2A A81/>4

REYNAUD'S DISEASE
Disorder characterized by acute episodes of arterial (small arteries) spasm/vasoconstriction that result in coldness, pain,
and pallor involving the fingers or digits of the hands.

1. High risk group femaIe 16-40 years old and above
2. Smoking
3. Collagen diseases
a. SLE (butterfly rash)
b. Rheumatoid Arthritis
4. Direct hand trauma
a. Piano playing
b. Excessive typing
c. Operating chainsaw
5. Cold climates and during winter

1. ntermittent claudication leg pain upon walking
2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)
3. Trophic changes
4. Ulceration
5. Gangrene formation
6. Raynaud's phenomenon refer to localized, intermittent episodes of vasoconstriction of small arteries of the hands
that causes changes in color and temperature. (as white, bIue, and red)

1. DoppIer UTZ decrease blood flow to the affected extremity
2. Angiography reveals site and extent of malocclusion

a. Analgesics
b. Vasodilators (calcium channel blockers: nifedipine)
2. Encourage to wear gloves
3. nstruct client on importance of cessation of smoking and exposure to cold environment

VARICOSITIES
Dilated, tortuous, superficial veins caused by incompetent venous valves
Abnormal dilation of veins of lower extremities and trunks due to
Incompetent vaIve resulting to
Increased venous pooIing resulting to
Venous stasis causing
Decrease venous return

1. Hereditary
2. Congenital weakness of veins
3. Thrombophlebitis
4. Cardiac disorder
5. Pregnancy
6. Obesity
7. Prolonged standing or sitting
8. Tortuous veins (saphenous veins)

1. Pain after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs

1. Venography
2. Trendelenburg's Test - veins distends quickly in less than 35 seconds

1. Elevate legs above heart level to promote increased venous return by placing 2 3 pillows under the legs
2. Measure the circumference of leg muscle to determine if swollen
3. Wear anti embolic stockings
a. Analgesics
5. Assist in surgical procedure
a. Vein stripping and ligation (most effective)
b. Sclerotherapy can recur and only done small/ spider web varicosities and danger of thrombosis (2 3 years
for embolism)
- scIerosing agent is injected into the vein, irritating the venous endothelium and producing
localized phlebitis and fibrousis, thereby obliterating the lumen of the vein.

THROMBOPHLEBITIS
Deep vein thrombosis
nflammation of the veins with thrombus formation
3 factors known as VIRCHOW'S TRIAD believe to play a significant role in its development:
Stasis of the blood (venous stasis)
Vessel wall injury
Altered blood coagulation

1. Obesity
2. Smoking
3. Related to pregnancy
4. Chronic anemia
5. Prolong use of oral contraceptives promotes lipolysis
6. Diabetes mellitus
7. Congestive heart failure
8. Myocardial infarction
9. Post op complication
10. Post cannulation insertion of various cardiac catheter.
11. ncrease in saturated fats in the diet.

1. Pain at affected extremity
2. Warm to touch
3. Dilated tortuous skin veins
4. Positive Homan's Signs pain at the calf or leg muscle upon dorsiflexion of the foot

1. Venography
2. Angiography

1. Elevate legs above heart level to promote increase venous return
2. Apply warm moist pack to reduce lymphatic congestion
3. Measure circumference of leg muscle to determine if swollen
4. Encourage to wear anti embolic stockings or knee elastic stockings
a. Analgesics
b. Anti Coagulant take at the same time each day, usually bet. 8-9 am
- Heparin
Note: if any of the ff. sign are appear, report them immediately
Faintness, dizziness, or increased weakness
Severe headaches or abdominal pain
Reddish or brownish urine
Any bleeding nose bleeding, cuts, and unusual
Red black bowel movements
Rash

6. Monitor for signs of complications
EmboIism
a. PuImonary
- Sudden sharp chest pain
- Unexplained dyspnea
- Tachycardia
- Palpitations
- Diaphoresis
- Restlessness

b. CerebraI
- Headache
- Dizziness
- Decrease LOC
MURPHY'S SIGN is seen in clients with cholelithiasis, cholecystitis characterized by pain at the right upper
quadrant with tenderness (inflammation of the gall bladder)

RESPIRATORY SYSTEM

OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM
I. Upper Respiratory System
1. Filtering of air
2. Warming and moistening of air
3. Humidification

A. Nose
- Cartillage
- Right nostril
- Left nostril
- Separated by septum
- Consist of anastomosis of capillaries known as KesseIbach's PIexus (the site of nose bleeding)
B. Pharynx/Throat
- Serves as a muscular passageway for both food and air

C. Larynx
- For phonation (voice production)
- For cough reflex
GIottis
- Opening of larynx
- Opens to allow passage of air
- Closes to allow passage of food going to the esophagus
- The initial sign of complete airway obstruction is the inability to cough

II. Lower Respiratory System
- For gas exchange
A. Trachea/Windpipe
- Consist of cartilaginous rings
- Serves as passageway of air going to the lungs
- Site of tracheostomy
B. Bronchus
- Right main bronchus
- Left main bronchus
C. Lungs
- Right lung (consist of 3 lobes, 10 segments)
- Left lung (consist of 2 lobes, 8 segments)
- Serous membranes
PIeuraI Cavity
a. Pareital
b. Pleural fluid
c. Visceral
With PIeuritic Friction Rub
a. Pneumonia
b. Pleural effusion
c. Hydrothorax (air and blood in pleural space
AIveoIi - acinar cells
- Site of gas exchange (CO
2
and O
2
)
- Diffusion (Dalton's law of partial pressure of gases)

Respiratory Distress Syndrome
- Decrease oxygen stimulates breathing
- Increase carbon dioxide is a powerfuI stimuIant for breathing
VentiIation movement of air in & out of lungs
Respiration movement of air into cells

Type II CeIIs of AIveoIi
- Secretes surfactant
- Decrease surface tension
- Prevent collapse of alveoli
- Composed of Iecithin and spingomyeIin
- L/S ratio to determine lung maturity
- NormaI L/S 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 prematurity

Disorders of Respiratory System
1. PTB/PuImonary TubercuIosis (Koch's Disease)
- nfection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli
- An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight

A. Precipitating Factors
1. Malnutrition
2. Overcrowded places
3. Alcoholism
4. Over fatigue
5. ngestion of infected cattle with mycobacterium bovis
6. Virulence (degree of pathogenecity) of microorganism

B. Mode of Transmission
1. Airborne transmission via droplet nuclei

1. Low grade afternoon fever, night sweats
2. Productive cough (yellowish sputum)
3. Anorexia, generalized body malaise
4. Weight loss
5. Dyspnea
6. Chest pain
7. Hemoptysis (chronic)

1. Mantoux Test (skin test)
- Purified protein derivative
- DOH 8 10 mm induration, 48 72 hours
- WHO 10 14 mm induration, 48 72 hours
- Positive Mantoux test (previous exposure to tubercle bacilli but without active TB)

2. Sputum Acid Fast BaciIIus
- Positive to cultured microorganism

3. Chest X-ray
- Reveals pulmonary infiltrates (chalk thorax)

4. CBC
- Reveals increase WBC

1. Enforce CBR
2. nstitute strict respiratory isolation
4. Force fluids to liquefy secretions
5. Place client on semi fowler's position to promote
expansion of lungs
6. Encourage deep breathing and coughing exercise
7. Nebulize and suction when needed
8. Comfortable and humid environment
9. nstitute short course chemotherapy
a. Intensive phase
- NH (sonicotinic Acid Hydrazide)
- Rifampicin (Rifampin)
- PZA (Pyrazinamide)
- Given everyday simultaneously to prevent resistance
- NH and Rifampicin is given for 4 months, taken before meals to facilitate absorption
- PZA is given for 2 months, taken after meals to facilitate absorption
- Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B
6
/Pyridoxine)
- Side Effect Rifampicin: all bodily secretions turn to red orange color
- Side Effect PZA: allergic reaction, hepatotoxicity, nephrotoxicity
- PZA can be replaced by Ethambutol
- Side Effect EthambutoI: optic neuritis

b. Standard phase
- njection of streptomycin (aminoglycoside)
- Kanamycin
- Amikacin
- Neomycin
- Gentamycin
- Side Effect:
- Ototoxicity damage to the 8
th
cranial nerve resulting to tinnitus leading to hearing loss
- Nephrotoxicity check for BUN and Creatinine
- Give aspirin if there is fever
- Side Effect: tinnitus, dyspepsia, heartburn
10. Provide increase carbohydrates, protein, vitamin C and calories
a. Avoidance of precipitating factors
b. Prevent complications (Atelectasis, military tuberculosis)
PTB
- Bones (potts)
- Meninges
- Eyes
- Skin
- Adrenal gland
c. Strict compliance to medications
d. mportance of follow up care

PNEUMONIA
nflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates

A. EtioIogic Agents
1. Streptococcus Pneumonae causing pneumococal pneumonia
2. HemophyIus InfIuenzae causing broncho pneumonia (children)
3. DipIococcus Pneumoniae
4. KIebseIIa Pneumoniae
5. Escherichia Pneumoniae
6. Pseudomonas

B. High Risk Groups
1. Children below 5 years old bec. Of low resistance
2. Elderly

C. Predisposing Factors
1. Smoking
2. Air pollution
3. mmuno compromised
a. AIDS
- Pneumocystic carini pneumonia
- Drug of choice is Retrovir
b. Bronchogenic Cancer
- nitial sign is non productive cough to productive cough
- Chest x-ray confirms lung cancer
4. Related to prolonged immobility (CVA clients), causing hypostatic pneumonia
5. Aspiration of food causing aspiration pneumonia
1. Productive cough with greenish to rusty sputum
2. Dyspnea with prolong expiratory grunt
3. Fever, chills, anorexia and general body malaise
4. Weight loss
5. Rales/crackles
7. Cyanosis
8. Pleuritic friction rub
9. Chest pain
10. Abdominal distention leading to paralytic ileus (absence of peristalsis)

1. Sputum Gram Staining and Culture Sensitivity positive to cultured microorganisms
2. Chest x-ray reveals pulmonary consolidation
3. ABG analysis reveals decrease PO
2

4. CBC reveals increase WBC, erythrocyte sedimentation rate is increased

1. Enforce CBR
2. Administer oxygen inhalation low inflow
Broad Spectrum Antibiotic
a. Penicillin
b. Tetracycline
c. Microlides (Zethromax)
- Azethromycin (Side Effect: Ototoxicity)
- Antipyretics
- Mucolytics/Expectorants
- Analgesics
4. Force fluid
5. Place on semi fowler's position
6. nstitute pulmonary toilet
(tends to promote expectoration)
- Deep breathing exercises
- Coughing exercises
- Chest physiotherapy
- Turning and reposition
7. Nebulize and suction as needed
8. Assist in postural drainage
- Drain uppermost area of lungs
- Placed on various position

Nursing Management for Postural Drainage
a. Best done before meaIs or 2 - 4 hours after meaIs to prevent gastro esophageal reflux
b. Monitor vital signs
c. Encourage client deep breathing exercises normaI breathe sound bronchovesicuIar
d. Administer bronchodilators 15 - 30 minutes before procedure
e. Stop if client cannot tolerate procedure
f. Provide oral care after procedure
g. Contraindicated with
- Unstable vital signs
- Hemoptysis
- Clients with increase intra ocular pressure (NormaI IOP 12 - 21 mmHg)
- ncrease CP
9. Provide increase carbohydrates, calories, protein and vitamin C
10. Health teaching and discharge planning
a. Avoid smoking
- AteIectasis
- Meningitis (nerve deafness, hydrocephaIus)
c. Regular adherence to medications

HISTOPLASMOSIS
Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from
birds manure

PTB or Pneumonia Iike
1. Productive cough
2. Dyspnea
3. Fever, chills, anorexia, general body malaise
4. Cyanosis
5. Hemoptysis
6. Chest and joint pains

B. Diagnostic Procedures
1. Histoplasmin Skin Test positive
2. ABG analysis PO
2
decrease

1. Enforce CBR
a. Antifungal
- Amphotericin B
- Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia)
b. Steroids
c. Mucolytics
d. Antipyretics
4. Force fluids to liquefy secretions
5. Nebulize and suction as needed
6. Prevent complications bronchiectasis
7. Prevent the spread of infection by spraying of breeding places

COPD (Chronic Obstructive PuImonary/Lung Disease)
Chronic Bronchitis
nflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of
smaller airways

1. Smoking
2. Air pollution
1. Productive cough (consistent to all COPD)
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Anorexia and generalized body malaise
5. Scattered rales/ronchi
6. Cyanosis
7. Pulmonary hypertension
a. Peripheral edema
b. Cor PuImonaIe (right ventricular hypertrophy)

ABG anaIysis reveals PO
2
decrease (hypoxemia), PCO
2
increase, and pH decrease (resp. acidosis)

BronchiaI Asthma
Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways

A. Predisposing Factors (Depending on Types)
1. Extrinsic Asthma (Atopic/ AIIergic)
Causes
a. Pollen
b. Dust
c. Fumes
d. Smoke
e. Gases
f. Danders
g. Furs
h. Lints

2. Intrinsic Asthma (Non atopic/Non aIIergic)
Causes
a. Hereditary
b. Drugs (aspirin, penicillin, beta blocker)
c. Foods (seafoods, eggs, milk, chocolates, chicken
d. Food additives (nitrates)
e. Sudden change in temperature, air pressure and humidity
f. Physical and emotional stress

3. Mixed Type $ 90 95%

1. Cough that is non productive
2. Dyspnea
3. Wheezing on expiration
4. Cyanosis
5. Mild Stress/apprehension
6. Tachycardia, palpitations
7. Diaphoresis

1. Pulmonary Function Test
- ncentive spirometer reveals decrease vital lung capacity
2. ABG analysis PO
2
decrease
- Before ABG test for positive Allens Test, apply direct
pressure to ulnar and radial artery to determine presence
of collateral circulation

1. Enforce CBR
2. Oxygen inhalation, with low inflow of 2 3 L/min
a. Bronchodilators given via inhalation or metered dose inhalaer or MD for 5 minutes
b. Steroids decrease inflammation
c. Mucomysts (acetylceisteine)
d. Mucolytics/expectorants
e. Anti histamine
4. Force fluids
5. Semi fowler's position
7. Provide client health teachings and discharge planning concerning
a. Avoidance of precipitating factor
- Emphysema
- Status Asthmaticus (give drug of choice)
- Epinephrine
- Steroids
- Bronchodilators
c. Regular adherence to medications to prevent development of status asthmaticus
BRONCHIECTASIS
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli

1. Recurrent lower respiratory tract infections
2. Chest trauma
3. Congenital defects
4. Related to presence of tumor

1. Productive cough
2. Dyspnea
3. Cyanosis
5. Hemoptysis (only COPD with sign)

1. ABG PO
2
decrease
2. Bronchoscopy direct visualization of bronchus using fiberscope

Nursing Management PRE Bronchoscopy
1. Secure inform consent and explain procedure to client
2. Maintain NPO 6 8 hours prior to procedure
3. Monitor vital signs and breathe sound

POST Bronchoscopy
1. Feeding initiated upon return of gag reflex
2. Avoid talking, coughing and smoking, may cause irritation
3. Monitor for signs of gross
4. Monitor for signs of laryngeal spasm prepare tracheostomy set
D. Treatment
1. Surgery (pneumonectomy, 1 lung is removed and position on affected side)
2. Segmental Wedge Lobectomy (promote re expansion of lungs)
- Unaffected lobectomy facilitate drainage

EMPHYSEMA
rreversible terminal stage of COPD characterized by
a. nelasticity of alveoli
b. Air trapping
c. Maldistribution of gases
d. Over distention of thoracic cavity (barreI chest)

1. Smoking
2. Air pollution
3. Allergy
4. High risk: elderly
5. Hereditary it involves deficiency of
ALPHA-1 ANTI TRYPSIN
(needed to form Elastase, for recoil of alveoli)

1. Productive cough
2. Dyspnea at rest
3. Prolong expiratory grunt
5. Resonance to hyperresonance
6. Decrease tactile fremitus
7. Decrease or diminished breath sounds
8. Rales or ronchi
10. Barrel chest
11. Flaring of alai nares
12. Purse lip breathing to eliminates excess CO
2

(compensatory mechanism)

1. Pulmonary Function Test reveals decrease vital lung capacity
2. ABG analysis reveals
a. Panlobular/ centrilobular
- Decrease PO
2
(hypoxemia leading to chronic bronchitis, "BIue BIoaters)
- Decrease ph
- ncrease PCO
2
- Respiratory acidosis
b. Panacinar/ centriacinar
- ncrease PO
2
(hyperaxemia, "Pink Puffers)
- Decrease PCO
2
- ncrease ph
- Respiratory alkalosis

1. Enforce CBR
2. Administer oxygen inhalation via low inflow
a. Bronchodilators
b. Steroids
c. Antibiotics
d. Mucolytics/expectorants
4. High fowlers position
5. Force fluids
6. nstitute pulmonary toilet
8. nstitute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion
9. Provide comfortable and humid environment
10. Provide high carbohydrates, protein, calories, vitamins and minerals
11. Health teachings and discharge planning concerning
a. Avoid smoking
- Atelectasis
- Cor Pulmonale
- CO
2
narcosis may lead to coma
- Pneumothorax
c. Strict compliance to medication

-E,#-)*#)BE DH'& .),%-.E-

!'EH(%#$%-"V - partial f or complete collapse of lungs due to entry or air in pleural space.
Types:
1. Spontaneous pneumothorax - entry of air in pleural space without obvious cause.
eg. Rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
2. Open pneumothorax - air enters pleural space through an opening in chest wall
-Stabf gunshot wound
3. Tension Pneumothorax - air enters plural space with @ inspiration 8 can't escape leading to over distension of
thoracic cavity resulting to shifting of mediastinum content to unaffected side.
Eg. Flail chest - paradoxical breathing pattern"
Predisposing factors:
1. Chest trauma
2. !nflammatory lung conditions
3. Tumor
SfSx:
1. Sudden sharp chest pain
2. unexplained Dyspnea or SOB
3. Cyanosis
+. Diminished or decreased breath sound
of affected lung
5. Cool moist skin- initial sign of shock
6. Nild restlessnessf apprehension, anxiety
7. Resonance to hyperresonance
8. decreased tactile fremitus
Diagnosis:
1. ABG - pO2 decrease -
2. CXR - confirms pneumothoraxfcollapse of lung
Nursing Ngt:
1. Assist in endotracheal intubation
2. Assist in thoracenthesis
3. Administer meds - Norphine SO+ - due to pain
- Anti microbial agents- due to bacteria
+. Assist in test tube thoracotomy attached
to H2O sealed drainage system

!f client has a tension pneumothorax, the initial treatment of choice is to insert a large-bore needle into the
second intercostal space midclavicular line to relieve pressure. Next, a chest tube system is placed into the fourth
intercostal space.

A small chest tube(28 french) is inserted near the second intercostal space; this space is used because it is the
thinnest part of the chest wall, minimizes the danger of contracting the thoracic nerve, and leave small scar. !f
the patient has also hemothorax, a large-diameter chest tube (32 french) or greater is inserted usually in the +
th

or 5
th
interscostal space at the midaxillary line.

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1. Reestablish (-) pressure in the lungs-lung 6-12mm Hg
2. Promote re-expansion of the lungs
3. Drain fluid, blood and air
+. To prevent reflux of blood fluid and air

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1. Naintain strict aseptic technique
2. DBE
3. At bedside
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7CG E;1>8 R51104
+. Neds - Norphine SO+
Antimicrobial
5. Nonitor 8 assess for oscillation fluctuations or bubbling
a.) !f (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2O goes down upon expiration
b.) !f (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify ND
c.) !f (-) to bubbling
1. Check for loop, clots, and kink
2. Nilk towards H2O seal
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+. Auscultate for breath sounds, Xrays
5. Removal of CTT

[=4A T200 (. >4<5U4 7=461 1/R4\
1. !f (-) fluctuations
2. (+) Breath sounds
3. CXR - full expansion of lungs

Nursing Ngt of removal of chest tube
1. Encourage DBE
2. !nstruct to perform valsalva maneuver for easy removal, to prevent entry of air in pleural space.
3. Apply vaselinated air occlusive dressing and pressure dressing
- Naintain dressing dry 8 intact
+. Prepare: Extra bottle, excellent clamp, petroleum gauze

Gastro IntestinaI Tract
!. Upper alimentary canal - function for digestion
a. Nouth
b. Pharynx (throat)
c. Esophagus
d. Stomach- site of digestion
e. 1
st
half of duodenum

!!. Niddle Alimentary canal - Function: for absorption
- Complete absorption - large intestine
a. 2
nd
half of duodenum for absorption
b. Jejunum
c. !leum
d. 1
st
half of ascending colon

!!!. Lower Alimentary Canal - Function: elimination
a. 2
nd
half of ascending colon for elimination
b. Transverse for complete absorption- L !
c. Descending colon
d. Sigmoid
e. Rectum

!v. Accessory Organ
a. Salivary gland
b. verniform appendix
c. Liver
d. Pancreas - auto digestion
e. Gallbladder - storage of bile

!. Salivary Glands
1. Parotid - below 8 front of ear
2. Sublingual
3. Submaxillary

- Produces saliva - for mechanical digestion
- 1,200 -1,500 mlfday - saliva produced
Lacrimal gland- depression on the frontal bone
Lacrimal duct- outer canthus

!"-%#)#), - mumps" - inflammation of parotid gland
-Paramyxovirus

SfSx:
1. Fever, chills anorexia, generalized body malaise
2. enlarged parotid gland
3. Swelling of parotid gland
+. Dysphagia
5. Earache - otalgia

Node of transmission: Direct transmission 8 droplet nuclei
!ncubation period: 1+ - 21 days
Period of communicability - 1 week before swelling 8 immediately when swelling begins.

Nursing Ngt:
1. CBR
2. !nstitute a strict respiratory isolation
3. Neds: analgesic
Antipyretic
Antibiotics - to prevent 2 complications
+. Alternate warm 8 cold compress at affected part (vinegar promotes cooling)
5. General liquid to soft diet
6. Complications
Women - cervicitis, vaginitis, oophoritis
Both sexes - meningitis 8 encephalitisf reason why antibiotics is needed
Nen - orchitis might lead to sterility if it occurs during f after puberty.

VERNIFORM APPENDIX Rt. iliac or Rt. inguinal area
- Function lymphatic organ produces WBC during fetal life - ceases to function upon birth of baby

APENDICITIS inflamation of verniform appendix
Predisposing factor:
1. Microbial infection
2. Feacalith undigested food particles tomato seeds, guava seeds
3. ntestinal obstruction

S/Sx:
1. Pathognomonic sign: (+) rebound tenderness
2. Low grade fever, anorexia, n/v
3. Diarrhea &/ or constipation
4. Pain at Rt. iliac region-- MCBURNEY'S point site of surgical incision
5. Late sign due pain tachycardia

Rovsing's sign - elicited by palpating the Ieft Iower quadrant; this paradoxically causes pain to be felt in the right
Iower quadrant.

Diagnosis:
1. CBC mild leukocytosis increase WBC
2. PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area rebound)
3. Urinalysis(+) acetone in urine

Treatment: - appendectomy 24 - 45
Nursing Mgt:
1. Secure consent
2. Routinely nursing measures:
a.) Skin prep
b.) NPO
c.) Avoid enema/Iaxatives lead to rupture of
appendix
3. Meds:
Antipyretic
Antibiotics
*Don't give anaIgesic pre-diagnosis will mask pain
Give anaIgesic - post diagnosis
- Presence of pain means appendix has not ruptured.
4. Avoid heat application will rupture appendix.
5. Monitor VS, &O bowel sound
6. Maintain a patent V line

Complications:
Peritonitis
Septicemia

Nursing Mgt: post op
1. If (+) to Penrose drain indicates rupture of appendix
Position- affected side to drain
2. Meds: analgesic due post op pain
Antibiotics, Antipyretics PRN
3. Monitor VS, &O, bowel sound- N- borborygmy sound
4. Maintain patent V line
5. Complications- peritonitis, septicemia

PEPTIC ULCER DISEASE - (PUD) excoriation / erosion of submucosa & mucosal lining due to:
a.) Hyper secretion of acid pepsin
b.) Decrease resistance to mucosal barrier

ncidence Rate:
1. Men 40 55 yrs old
2. Aggressive persons/ type A personality
3. Hereditary
4. Emotional Stress
1. Hereditary
2. Emotional
3. Smoking vasoconstriction GT ischemia
4. Alcoholism stimulates release of histamine = Parietal cell release Hcl acid = ulceration
5. Caffeine tea, soda, chocolate
6. rregular diet
7. Rapid eating
8. Ulcerogenic drugs NSADS, aspirin, steroids, indomethacin, ibuprofen
ndomethacin - S/E corneal cloudiness. Needs annual eye check up.
NSAD and steroids= gastropathy

9. Gastrin producing tumor or gastrinoma Zollinger Ellisons syndrome
10. Microbial invasion helicobacter pylori. Metronidazole (Flagyl)

Types of uIcers
Ascending to severity
1. Acute affects submucosal lining
2. Chronic affects underlying tissues
heals & forms a scar, deeper

According to Iocation
1. Stress uIcer
2. Gastric uIcer
3. DuodenaI uIcer most common

Stress ulcers common among critically ill clients
2 types
1. CurIing's uIcer cause: trauma & Burns

Hypovolemia

GT schemia

Decrease resistance of mucosal barriers to Hcl acid

Ulcerations

2. Cushing's uIcer cause stroke/CVA/ head injury

ncrease vagal stimulation

Hyperacidity

Ulcerations

Treatment: Vagotomy - done to prevent hemorrhage and shock prior to surgery on the stomach

GASTRIC ULCER DUODENAL ULCER
SITE Antrum or lesser curvature Duodenal bulb
PAIN - 30 min 1 hr after eating
- epigastrium
- gaseous & burning
- not usually relieved by food & antacid

- Eating Ieads to pain
- 2-3 hrs after eating
- mid epigastrium
- cramping & burning pain
- usually relieved by food & antacid
- 12 MN 3am pain
- Eating Iessens pain
HYPERSECRETION Normal gastric acid secretion ncreased gastric acid secretion
VOMITING common Not common
HEMORRHAGE hematemesis Melena
WT Wt loss Wt gain
COMPLICATIONS a. stomach cancer
b. hemorrhage
a. perforation
HIGH RISK 50 or 60 years old and above 20 years old and above
INCIDENCE Male; female = 1:1
15% of peptic ulcers are gastric
Male: Female = 2-3:1
80% of peptic ulcers are duodenal

90-95% is cases of duodenal ulcers - less bicarbonate ions, decrease so increase incidence
Diagnosis:
1. Endoscopic exam
2. Stool from occult blood (+)
3. Gastric analysis Gastric Ulcer: normal gastric acid secretion
Duodenal: increased gastric acid secretion
4. G series confirms presence of ulceration
Nursing Mgt:
1. Diet bland, non irritating, non spicy
2. Avoid caffeine & milk/ milk products ncrease gastric acid secretion
3. Administer meds

a.) Antacids

ACA
AIuminum containing antacids Magnesium containing antacids

ex. aluminum hydroxide gel ex. milk of magnesia
(Amphogel) S/E diarrhea
S/E constipation

Maalox (fever S/E)

b.) H2 receptor antagonist:
1. Ranitidine (Zantac) SE: fever
2. Cimetidine (Tagamet)hastens the effect of oral anticoagulants
3. Famotidine (Pepcid) SE: fever
- Avoid smoking decrease effectiveness of drug

Nursing Mgt:
1. Administer antacid & H2 receptor antagonist (Cimetidine) 1hr apart
-Cemetidine decrease antacid absorption & vise versa
c.) Cytoprotective agents
Ex
1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
2. Misoprostol (Cytotec) SE: menstrual spotting
d.) Sedatives/ Tranquilizers - Valium, lithium
e.) Anticholinergics / Antispasmodic
1. Atropine SO4
2. Prophantheline Bromide (Profanthene)

(Pt has history of hpn crisis with peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na.

3. Surgery: subtotal gastrectomy - Partial removal of stomach

BiIIroth I (Gastroduodenostomy)

% RemovaI of of stomach & anastomoses of
gastric stump to the duodenum.
BiIIroth II (Gastrojejunostomy)

% RemovaI of -3/4 of stomach & duodenaI buIb &
anastomostoses of gastric stump to jejunum.

Before surgery for B or B - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.

Nursing Mgt:
1. Monitor NGT output or drainage immediately post op- bright red
a.) mmediately post op should be bright red
b.) Within 36- 48h output is yeIIow green
c.) After 48h output is dark red due to HCl acid
2. Administer meds:
a.) Analgesic
b.) Antibiotic
c.) Antiemetics
3. Maintain patent V line
4. VS, &O & bowel sounds
5. Complications:
a.) Hemorrhage hypovolemic shock
Late signs anuria
b.) Peritonitis
c.) ParaIytic iIeus most feared
d.) Hypokalemia
e.) Thrombophlebitis
f.) Pernicious anemia
g.) Septicemia

7.) Dumping syndrome common complication rapid gastric
emptying of hypertonic food solutions CHYME leading to hypovolemia.
Sx of Dumping syndrome:
1. Dizziness
2. Diaphoresis
3. Diarrhea
4. Palpitations

Nursing mgt:
1. Avoid fluids in chilled solutions, sweets
(fluids must be taken after meals)
2. Small frequent feedings-6 equally divided feedings
3. Diet decrease CHO, moderate fats & CHON
4. FIat on bed 15 -30 minutes after q feeding

DIVERTICULITIS/DIVERTICULOSIS
1. Diverticulum- an outpouching of the intestinal mucosa particularly the sigmoid colon
2. Diverticulosis- multiple diverticulum
3. Diverticulitis- inflammation of diverticula
1. High Risk Groups- men (40-45yo)
2. Congenital weakness of muscle fibers of the intestine.
3. Low roughage and fiber in the diet
S/S:
1. ntermittent lower left abdominal quadrant pain, particularly in the rectosigmoid area
2. tenderness
3. alternating bouts of constipation or diarrhea with blood or mucous

Dx:
1. Barium enemareveals inflammatory process
2. CBC reveals: decreased hematocrit and hemoglobin
Nsg Mgt:
1. Administer meds as ordered:
a. antibiotics
b. bulk laxatives
c. stool softeners
d. anti spasmodic agents
2. nstruct clients to take foods high in fiber if there is diverticulosis
3. Monitor for signs of infection
Feared complications: Peritonitis
4. Assists in surgical procedure
Resection of the diseased bowel and creation of a colostomy

Liver - Iargest gIand
- Occupies most of right hypochondriac region
- Color: scarlet red, brown shiny and transparent
- Covered by a fibrous capsule Glisson's capsule
- Functional unit liver lobules

Function:
1. Produces bile
Bile emulsifies fatsH2O and bile salts= cholesterol
Right sided pain: ChoIeIithiasis- easy bruising
Left sided pain: Pancreatitis
- Composed of H2O & bile salts
-Gives color to urine urobilin
Stool color stechobilin
2. Detoxifies drugs
3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins (needs fat for absorption)

Hypervitaminosis vit D & K
Vit A retinol (Def Vit A night blindness)
Vit D cholecalciferon
- Helps calcium
- Rickets, osteoarthritis

4. t destroys excess estrogen hormone
5. for metabolism
A. CHO
1. GIycogenesis synthesis of glycogens
2. GIycogenoIysis breakdown of glycogen
3. GIuconeogenesis formation of glucose from CHO sources
B. CHON-
1. Promotes synthesis of albumin & globulin
Liver Cirrhosis decrease albumin; ascites and edema
AIbumin maintains osmotic pressure, prevents edema
2. Promotes synthesis of prothrombin & fibrinogen
3. Promotes conversion of ammonia to urea.
Ammonia like breath fetor hepaticus - a sweet, slightly fecal odor to the breath presumed 2 be intestinal orig.
C. FATS promotes synthesis of cholesterol to neutral fats called triglycerides

LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Laennac Cirrhosis- loss of architectural design of the liver leading to fat necrosis and scarring

Early sign hepatic encephaIopathy - accumulation of ammonia and other toxic substance in the blood
1. Asterixis flapping hand tremors
Late signs headache, restlessness, disorientation, decrease LOC hepatic coma.
Nursing priority assist in mechanical ventilation

Decrease Laennac's cirrhosis caused by alcoholism
1. Chronic alcoholism- major cause
2. Malnutrition decreaseVit B, thiamin - primary cause
3. Virus
4. Toxicity- eg. Carbon tetrachloride (CCL4)
5. Use of hepatotoxic agents
S/Sx:
1. EarIy signs:
a.) Weakness, fatigue
b.) Anorexia, n/v
c.) Stomatitis
d.) Urine tea color
Stool clay color
e.) Amenorrhea
f.) Decrease sexual urge
g.) Loss of pubic, axilla hair
h.) Hepatomegaly
i.) Jaundice
j.) Pruritus or urticaria (palmar erythema)
k.) Decrease bowel sounds

2. Late signs
a.) Hematological changes all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- bleeding tendencies
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusae, Palmar erythema, loss of tortousity of the umbilicus

c.) GT changes
Ascites, bleeding esophageaI varices due to portal HPN
d.) Neurological changes:
hepatic encephalopathy

Hepatic encephaIopathy - ammonia (cerebraI toxin)
Late signs: EarIy signs:
Headache and dizziness asterexis - flapping hand tremors
Fetor hepaticus Minor mental changes and motor disturbances
Confusion hyperactive deep tendon reflexes
Restlessness
Hypoactive deep tendon reflexes fIaccid
Decrease LOC

Hepatic coma

Diagnosis:
1. Liver enzymes- increase

SGPT (ALT)
SGOT (AST)
2. Serum cholesterol & ammonia increase
3. ndirect or conjugated bilirubin increase
4. CBC - pancytopenia
5. PTT prolonged bleeding
6. Hepatic ultrasonogram fat necrosis of liver globules

Nursing Mgt
1. CBR
2. Restrict Na!
3. Monitor VS, &O
4. Weigh pt daily & assess pitting edema
5. Measure abdominal girth daily notify MD
6. Meticulous skin care
7. Diet increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
8. Complications of liver cirrhosis:
a.) Ascites fluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics 10 15 min effect or potassium sparing diuretic
2. Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted

b.) BIeeding esophageaI varices
- Dilation of esophageal veins
1. Meds: Vit K
Pitressin or Vasopressin (IM)
2. NGT decompression- lavage
- Give before lavage ice or cold saline solution
- Monitor NGT output
3. Assist in mechanical decompression
- nsertion of Sengstaken-BIackemore tube - to decompress veins of esophagus-to prevent
esophageal varices
- 3 lumen typed catheter
- Scissors at bedside to deflate/decompress balloon. Prep scissors when pt complains of DOB
c.) Hepatic encephalopathy
1. Assist in mechanical ventilation due coma
2. Monitor VS, neuro check
3. Siderails due restless
4. Meds Laxatives to excrete ammonia (Lactulose)

HEPATITIS - jaundice (icteric sclera)

Bilirubin

Kernicterus/ hyperbilirubinia

rreversible brain damage

Hepatitis A

Hepatitis A virus (HAV) is a virus that causes liver disease. ncubation is about 30 days, and the virus is excreted in the
stool for about 2 weeks before the illness and about a week after it. The mortality rate is low. Children are typically
asymptomatic. Adults generally have a more severe illness. The disease is not chronic and is not "carried: FECAL ORAL
TRANSMISSION

INFECTION CONTROL
Hand hygiene to prevent the spread of HAV.
Vaccine before traveling to places where HAV is endemic.
Standard precautions, when caring for this client.
Contact precautions, for incontinent clients (cannot control bladder/bowel).

Hepatitis B

Hepatitis B (HBV) is one of the five hepatitis viruses that infect the liver. This virus has a complex structure capable of
attacking and destroying liver cells, resulting in illness or disease. Cellular destruction results in architectural changes of
the normal structure, of the liver which leads to a disruption in the flow of blood and bile. llness can range from mild signs
and symptoms to chronic disease, such as fatal cirrhosis or liver cancer. BLOOD CARRIER

Pancreas mixed gland (exocrine & endocrine gland); found behind the stomach

PANCREATITIS acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
auto digestion (self-digestion).
Bleeding of pancreas - CuIIen's sign on umbilical area

1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs Thiazide diuretics,aspirin, pills, Pentamidine HCL (Pentam) for clients with ADS,
7. Diet increase saturated fats
S/Sx:
1. Severe Midepigastrium epigastric pain radiates from back & flank area (left upper quadrant)
- 24-48 hrs. Aggravated by heavy meals/eating, accompanied by DOB
2. N/V
3. Tachycardia
4. Palpitation due to pain (abdominal guarding)
5. Dyspepsia /indigestion (rigid board like abdomen)
6. Decrease bowel sounds
7. (+) CuIIen's sign - ecchymosis of umbilicus hemorrhage
8. (+) Grey Turner's spots ecchymosis of flank area
9. Hypocalcemia
Diagnosis:
1. Serum amylase & lipase increase
2. Urine lipase increase
3. Serum Ca decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine HcI (DemeroI)
Don't give Morphine SO4 will cause spasm of the sphincter of ODD.
b.) Smooth muscle relaxant/ anticholinergic
- Ex. Papavarine Hcl
Prophantheline Bromide (Profanthene)
c.) Vasodilator NTG
d.) Antacid Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation
f.) Ca gluconate

2. Withold food & fluid aggravates pain (totaI NPO)

3. Assist in TotaI ParenteraI Nutrition (TPN) or hyperalimentation
Complications of TPN
1. Infectionmaintain a strict aseptic technique
2. Pulmonary Embolismcheck all connection to system
3. Hyperglycemia
4. Hyperkalemia
4. nstitute stress mgt tech
a.) DBE
b.) Biofeedback
5. Comfy position - Knee chest or fetaI Iie position
6. f pt can tolerate food, give increase CHO, decrease fats, and moderate CHON
7. Complications: Chronic hemorrhagic pancreatitis, Peritonitis, Septicemia, Shock

GALLBLADDER storage of bile made up of cholesterol.

CHOLECYSTITIS / CHOLELITHIASIS inflammation of gallbladder with gallstone formation.

1. High risk women 40 years old
2. Post menopausal women undergoing estrogen therapy
3. Obesity
4. Sedentary lifestyle, prolonged immobility
5. Hyperlipidemia
6. Neoplasm
7. Obstruction

S/Sx:
1. Severe Right abdominaI pain (after eating fatty food). Occurring especially at night
= epigastric or right abdominal quadrant after eating a heavy meal
2. Fat intolerance
3. Anorexia, n/v, feeling of fullness
4. Jaundice
5. Pruritus
6. Easy bruising
7. Tea colored urine
8. Steatorrhea

Diagnosis:
1. OraI choIecystogram (or gallbladder series) - confirms presence of gall stones
2. ncreased indirect bilirubin
3. ncreased alkaline phosphatase
4. increased serum and amylase
Nursing Mgt:
1. Meds a.) Narcotic analgesic - Meperdipine HcI - DemeroI
b.) Anti cholinergic/Anti-spasmodic - Atropine SO4
c.) Anti emetic
Phenergan Phenothiazide with anti emetic properties
d) Broad spectrum antibiotics
2. Diet increase CHO, moderate CHON, decrease fats
3. Meticulous skin care
4. Surgery: Cholecystectomy
Nursing Mgt post cholecystectomy
-Maintain patency of T-tube intact & prevent infection

Stomach widest section of alimentary canal
- J shaped structures
1. Anthrum
2. Pylorus
3. Fundus
Valves prevent GERD
1. cardiac sphincter valve
2. Pyloric sphincter valve- stomach and first half of duodenum

Cells
1. Chief/ Zymogenic cells secrets
a.) Gastric amyIase - digest CHO / sugars
b.) Gastric Iipase digest fats
c.) Pepsin CHON
d.) Rennin digests milk products

Definition of terms: BiIiary
ChoIecystitis nflammation of the gallbladder
ChoIeIithiasis The presence of calculi in the gallbladder
ChoIecystectomy Removal of the gallbladder
ChoIecystostomy Opening and drainage of the gallbladder
ChoIedochotomy Opening into the common duct
ChoIedochoIithiasis Stones in the common duct
ChoIedochoIithoIithotomy ncision of common bile duct for removal of stones
ChoIedochoduodenostomy Anastomosis of common duct to duodenum
ChoIedochojejunostomy Anastomosis of common duct to jejunum
Lithotripsy Disintegration of gallstones by shock waves
Laparoscopic choIecystectomy Removal of gallbladder through endoscopic
procedure
Laser choIecystectomy Removal of gallbladder using laser rather than
scalpel and traditional surgical instruments
2. Parietal / Argentaffin / oxyntic cells
Function:
a.) Produces intrinsic factor promotes reabsorption of vit B12 cyanocobalamin promotes maturation of
RBC
b.) Secrets Hcl acid aids in digestion
3. Endocrine cells - Secretes gastrin increase Hcl acid secretion

Function of the stomach
1. Mechanical digestion
2. Chem.
3. Storage of food
-CHO, CHON- stored 1 -2 hrs. Fats stored 2 3 hrs

BURNS direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority infection (all kinds of burns)
Head burn-priority - Airway
2
nd
priority for 1
st
& 2
nd
burn - pain
2
nd
priority for 3
rd
burn - FIuid and eIectroIytes

ThermaI - direct contact flames, hot grease, sunburn.
EIectric, wires
ChemicaI direct contact corrosive materials acids
Smoke gas / fume inhalation

Stages:
Emergent phase Removal of pt from cause of burn. Determine source or location of burn
Shock phase 48 - 72 . Characterized by shifting of fluids from intravascular to interstitial space (HypovoIemia)

S/Sx:
- BP decrease
- Urine output
- HR increase
- Hct. increase
- Serum Na decrease
- Serum K increase
- Met acidosis

Diuretic/ FIuid remobiIization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space

Recovery/ convaIescent phase complete diuresis. Wound heaIing starts immediateIy after tissue injury.

Class:
I. PartiaI Burn

1. 1
st
degree superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure
with no fluid filled vesicles
2. 2
nd
degree deep burns
- Affects epidermis & dermis
- Cause chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)

II FuII thickness Burns

1. Third & 4
th
degrees burn
- Affects all layers of skin, muscles, bones
- Cause electrical
- Less painful
- Dry, thick, leathery wound surface known as ESCHAR devitalized or necrotic tissue.

Assessment findings:
RuIe of nines
Head & neck = 9%
Ant chest = 18%
Post chest = 18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum = 1%
TotaI 100%

Nursing Mgt:
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth Claustridium tetany

Tetany

Tetanolysin tetanospasmin

Hemolysis muscle spasm

b.) Morphine SO4
c.) Systemic antibiotics
1. Ampicillin
2. Cephalosporin
3. Tetracyclin
4. Topical antibiotic:
1. Silver Sulfadiazene (silvadene)
2. Sulfamylon
3. Silver nitrate
4. Povidone iodine (betadine)

2. Administer isotonic fluid sol & CHON replacements
3. Strict aseptic technique
4. Diet increase CHO, increase CHON, increase Vit C, and increase K- orange
5. f (+) to burns on head, neck, face - Assist in intubation
6. Assist in hydrotherapy
7. Assist in surgical wound debridement. Administer analgesic 15 30 minutes before debridement
8. Complications:
a.) nfection
b.) Shock
c.) ParaIytic iIeus - due to hypovolemia & hypokalemia
d.) Curling's ulcer H2 receptor antagonist
e.) Septicemia blood poisoning
f.) Surgery: skin grafting

GUT - genito-urinary tract

Function:
1. Promote excretion of nitrogenous waste products
2. Maintain F&E & acid base balance

1. Kidneys pair of bean shaped organ
- Located retroperitonially (back of peritoneum) on either side of vertebral column. Encased in Bowmans's capsule.

Parts:
1. Renal pelvis Pyelonephritis inflammation of the renal pelvis
2. Cortex
3. Medulla

Nephrons basic living unit of the kidneys consisting of glomerulus
GIomeruIus filters blood going to kidneys

Function of kidneys:
1. Urine formation
2. Regulation of BP

Urine formation 25% of total CO (Cardiac Output) is
received by kidneys (3,000-6,000 ml.)
125ml/ min filtered by the glomerulus >
GIomeruIar fiItration rate
1. Filtration
2. Tubular Reabsorption124ml of ultra filtered are
reabsorbed in the blood
3. Tubular Secretion- 1 ml is excreted in the urine

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

Causes of CRF:
1. HPN
2. DM
Regulation of BP:
Ex CS Hypovolemia decrease BP going to kidneys
Activation of RAAS

Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus

Angiotensin mild vasoconstrictor

Angiotensin vasoconstrictor

Adrenal cortex increase CO increase PR

Aldosterone
ncrease BP
ncrease Na &
H2O reabsorption

Hypervolemia

Ureters 25 35 cm long, passageway of urine to bladder
Bladder loc behind symphisis pubis. Muscular & elastic tissue that is distensible
- Function reservoir of urine
1200 1800 ml Normal adult can hold
200 500 ml needed to initiate micturition reflex (voiding)

Color amber
Odor aromatic
Consistency clear or slightly turbid
pH 4.5 8
Specific gravity 1.015 1.030
WBC/ RBC (-)
Albumin (-)
E coli (-)
Mucus threads few
Amorphous urate (-)

Urethra extends to external surface of body. Passage of urine, seminal & vaginal fluids.
- Women 3 5 cm or 1 to 1 "
- Male 20cm or 8
UTI

CYSTITIS inflammation of bladder

1. Microbial invasion E. coli
2. High risk women
3. Obstruction
4. Urinary retention
5. ncrease estrogen levels
6. Sexual intercourse
S/Sx:
1. Pain flank area
2. Urinary frequency & urgency
3. Burning upon urination
4. Dysuria & hematuria
5. Fever, chills, anorexia, gen body malaise
6. Nocturia
*8/646 5@ #>8A624A1 )A75A12A4A74L .)"!!E-,
.elirium
)nfection of urinary tract
"trophic vaginitis, urethritis
!harmacologic agents (anticholinergic)
!sychological factors (depression, regression)
Excessive urine production (D!, diabetic keto, inc. intake)
-estricted activity
,tool imfaction

n the older adult, the most
common signs & symptoms of
cystitis or UT:
1. Fatigue.
2. Change in cognitive status.
Diagnosis: Urine culture & sensitivity - 80% of the cases are (+) to E. coli
Nursing Mgt:
1. Force fluid 2000 ml= to prevent bacterial multiplication
2. Warm sitz bath to promote comfort
3. Monitor & assess for gross hematuria
4. Monitor and assess urine for color, odor, and bleeding N pH: 4.8
5. Acid ash diet cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
6. Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides cotrimoxazole (Bactrim)
- Gantrism (ganthanol)
Aminoglycosides: Gentamycin
Urinary antiseptics Nitrofurantoin (Macrodantin)
Urinary analgesic- Pyridum
7. Ht
a.) mportance of Hydration
b.) Void after sex (male and female)
c.) Female avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications: Pyelonephritis

PYELONEPHRITIS acute/ chronic inflammation of 1 or 2 renal pelvis of kidneys leading to tubular destruction,
interstitial abscess formation.
- Lead to Renal Failure

1. Microbial invasion (Bacterial)
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins or nephrotoxic agents
S/Sx:
Acute pyeIonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary frequency, urgency
d.) Nocturia, dysuria, hematuria
e.) Burning upon urination
f.) FLANK PAIN
g.) Enlarged kidney

Chronic PyeIonephritis
a.) Fatigue, wt loss, weakness
b.) Polyuria, polydypsia
c.) HPN

Diagnosis:
1. Urine culture & sensitivity (+) E. coli & streptococcus
2. Urinalysis
(+) WBC, (+)RBC, (+) Pus cells
3. Cystoscopic exam urinary obstruction

Nursing Mgt:
1. Provide CBR especially during acute phase
2. Force fluid
3. Acid ash diet
4. Provide a warm sitz bath for comfort
5. Meds:
a.) Urinary antiseptic nitrofurantoin (macrodantin)
SE: peripheral neuropathy
G irritation
Hemolytic anemia
Staining of teeth
b.) Urinary analgesic Pyridium
6. Complication - Renal Failure

NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract

- calcium , oxalate, uric acid

milk cabbage anchovies
cranberries organ meat
nuts tea nuts
chocolates sardines

1. Diet increase Ca & oxalate
2. Hereditary gout
3. Obesity
5. Hyperparathyroidism

S/Sx:
1. Renal colic
2. Cool moist skin (shock)
4. Hematuria
5. Anorexia, n/v
Diagnosis:
1. VP intravenous pyelography. Reveals location of stone
2. KUB reveals location of stone
3. Cytoscopic exam- urinary obstruction
4. Stone analysis composition & type of stone
5. Urinalysis increase EBC, increase CHON
6. X-ray
Nursing Mgt:
1. Force fluid
2. Strain urine using gauze pad
3. Warm sitz bath for comfort
4. Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent V line
d.) Diet if + Ca stones acid ash diet
f + oxalate stone alkaline ash diet - (Ex milk/ milk products)
f + uric acid stones decrease organ meat / anchovies sardines
6. Surgery
a.) Nephectomy removal of affected kidney
LithoIapoxy removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones
b.) Extracorporeal shock wave lithotripsy
- Non - invasive
- Dissolve stones by shock wave
7. Complications: Renal Failure

BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to
a.) Hydro ureters dilation of ureters
b.) Hydronephrosis dilation of renal pelvis
c.) Kidney stones Stone formation--$ Renal failure
d.) Renal failure
% encircles the neck of the bladder
% decreased form of urinary stream
% Cause is unknown

1. High risk 50 years old & above
60 70 (3 to 4 x at risk)
Prostate cancer: 40 years old & above
2. nfluence of male hormone
S/Sx:
1. Decrease force of and amount of urinary stream
2. Dysuria
3. Hematuria
5. TerminaI dribbIing-earIy sign of BPH
6. Backache
7. Sciatica
8. Hesitancy
Diagnosis:
1. Digital rectal exam enlarged prostate gland
2. KUB urinary obstruction
3. Cystoscopic exam obstruction
4. Urinalysis increase WBC, CHON, RBC

Nursing Mgt:
1. Prostatic message promotes evacuation of prostatic fluid
2. Limit fluid intake
3. Provide catheterization
4. Provide a warm sitz bath for comfort
5. Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter, relaxes the smooth muscle of urinary sphincter
S/E: HA, hypotension
b. Fenasteride (Proscar) - Atrophy of Prostate Gland (given after meaIs)
S/E: N&V, Anorexia

5. Surgery: Prostatectomy TURP- Transurethral resection of Prostate- No incision
Without incision: for debilitated clients
-Assist in cystocIysis or continuous bladder irrigation.
Complication:
1. Hemorrhage
2. Urinary obstruction
3. Penile dysfunction

Nursing mgt:
c. Monitor signs and symptoms of infection
d. Monitor symptoms gross/ frank bleeding. Normal bleeding within 24h.
3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention

ACUTE RENAL FAILURE sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E
balance due to a decrease in GFR. (N 125 mI/min)

Pre renaI cause- decrease blood flow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension decrease bIood fIow to the kidneys
4. CHF
5. Hemorrhage
6. Dehydration (chronic diarrhea)

Intra-renaI cause involves renal pathology= kidney probIem
1. Acute tubular necrosis 3. HPN
2. Pyelonephritis 4. Acute Glom.

Post renaI cause involves mechanical obstruction
Causes:
1. Urinary strictures
2. Urolithiasis
3. BPH
4. Presence of tumors

Stages: Initiation period begins with the initial insult and ends when oliguria develops.
I. OLIGURIC STAGE (1-2 weeks)
- involves passage of urine < 400ml/day
- S/S:
a. Hyperkalemia- arrhythmia
b. Hypernatremia
c. Hyperphosphatemia
d. Hypocalcemia
e. High BUN 10-20 and creatinine .8-1
f. Metabolic acidosis 1-2wks
II. DIURETIC PHASE 2-3 weeks Increased amount of urine
a. Hypokalemia
b. Hyponatremia
c. Metabolic Acidosis
d. ncreased Creatinine and BUN

III. CONVALESCENT/RECOVERY PHASE3-12 months

CHRONIC RF irreversible loss of kidney function
1. DM
2. HPN
3. Recurrent UT/ nephritis/ pyelonephritis
4. Exposure to renal toxins

Stages of CRF
1. Diminished Reserve Volume asymptomatic
Normal BUN & Crea, GFR < 10 30%
2. Renal nsufficiency
3. End Stage Renal disease

!ncreased serum concentration:
Urea
Creatinine
Uric acid
Organic acids
!ntra cellular cations
Potassium
Nagnesium
S/Sx:

1.) Urinary System
a.) poIyuria
b.) nocturia
c.) hematuria
d.) Dysuria
e.) oIiguria
2.) MetaboIic disturbances
a.) azotemia (increase BUN & Crea)
b.) hypergIycemia
c.) hyperinuIinemia
3.) CNS
a.) headache
b.) Iethargy
c.) disorientation
d.) restIessness
e.) memory impairment
4.) GIT
a.) n/v
b.) stomatitis
c.) uremic breath
d.) diarrhea/ constipation
5.) Respiratory
a.) KassmauI's resp
b.) decrease cough refIex
c.) crackIes
6.) hematoIogicaI
a.) Normocytic anemia
bIeeding tendencies
7.) FIuid & EIectroIytes
a.) hyperkaIemia
b.) hypernatermia
c.) hypermagnesemia
d.) hyperposphatemia
e.) hypocaIcemia
f.) met acidosis
8.) Integumentary
a.) itchiness/ pruritus
b.) uremic frost
9.) CardiovascuIar changes
a. HPN
b. CHF
c. Pericarditis

Nursing Mgt:
1. Enforce CBR, reverse isolation
2. Monitor strictly VS, &O, neurocheck, monitor for signs of hypocaIcemia (increased phosphate)
3. Meticulous skin care. Uremic frost assist in bathing pt
4. Meds:
a.) Na HCO3 due Hyperkalemia
b.) KayexeIate enema
c.) Anti HPN Hydralazine (Apresoline)
d.) Vit & minerals (Multivitamins)
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
2.) Weigh patient
3.) Obtain baseline data & monitor VS before and during q30mins, &O, wt, blood exam
4.) Encourage patient to void
5.) Strict aseptic technique
6.) Monitor for signs of complications:
B bleeding (due to heparin)
E embolism
D disequilibrium syndrome
S septicemia
S shock decrease in tissue perfusion

DisequiIibrium syndrome from rapid removal of urea & nitrogenous waste product leading to:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) Paresthesia

5. Avoid BP taking, blood extraction, V, at side of shunt or fistula. Can lead to compression of fistula.
6. Maintain patency of shunt by:
i. PaIpate for thriIIs & auscuItate for bruits if (+) patent shunt!
ii. Bedside- buIIdog cIip
f with accidental removal of fistula to prevent embolism.
nfersole (diastole) common dialisate used
7. Complication
- Peritonitis (most feared)
- Shock
nflow time: 10-20mins
ndwelling time: 30-45 mins

8. Assist in surgery:
Renal transplantation: Complication rejection (feared complication). Reverse isolation
Rejection time in acute6mos to 1 year
Rejection time in chronic5-10 years

EYES

External parts
1. Orbital cavity made up of connective tissue protects eye form trauma.
2. EOM extrinsic ocular muscles involuntary muscles of eye needed for gazing movement.
3. Eyelashes/ eyebrows esthetic purposes
4. Eyelids paIpebraI fissure opening upper & lower lid. Protects eye from direct sunlight

Meibomean gIand secrets a lubricating fluid inside eyelid
b.) Stye/ sty or Hordeolum- inflamed Meibomean gland
5. Conjunctiva
6. Lacrimal apparatus tears

Process of grieving
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance

Intrinsic coat
. sclerotic coat outer most
a.) Sclera white. Occupies post of eye. Refracts light rays
b.) Canal of schlera site of aqueous humor drainage
c.) Cornea transparent structure of eye

. Uveal tract nutritive care
Uveitis infl of uveal tract
Consist of:
a.) ris colored muscular ring of eye
2 muscles of iris:
1. Circular smooth muscle fiber - Constricts the pupil
2.radial smooth muscle fiber - Dilates the pupil

2 chambers of the eye
1. Anterior
a.) Vitreous Humor maintains spherical shape of the eye
b.) Aqueous Humor maintains intrinsic ocular pressure
NormaI IOP= 12-21 mmHg

. Retina (innermost layer)
i. Optic discs or blind spot nerve fibers only

No auto receptors

cones (daylight/ colored vision) rods night twilight vision

phototopic vision "scotopic vision = vit A deficiency rods insufficient

ii. Maculla lutea yellow spot center of retina
iii. Fovea centralis area with highest visual acuity or acute vision
PhysioIogy of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes

Unit of measurements of refraction diopters
Normal eye refraction emmetropia

ERROR of refraction
1. Myopia near sightedness Treatment: biconcave lens
2. Hyperopia/ or farsightedness Treatment: biconvex lens
3. Astigmatisim distorted vision Treatment: cylindrical
4. Presbyopia "old slight inelasticity of lens due to aging Treatment: bifocal lens or double vista
Accommodation of lenses based on Helmholtz theory of accommodation

Near vision = far vision=
Ciliary muscle contracts= ciliary muscle dilates / relaxes=
Lens bulges lens is flat

Convergence of the eye:
Error:
1. Exotropia 1 eye n.
2. Esophoria corrected by corrective eye surgery
3. Strabismus- squint
4. Amblyopia prolong squinting
GLAUCOMA increase OP if untreated, atrophy of optic nerve disc blindness
1. High risk group 40 & above (nearsightedness)
2. HPN
3. DM
4. Hereditary
5. Obesity
6. Recent eye trauma, infl, surgery

Type:
1. Chronic - (open angIe G.) most common type Obstruct in flow of aqueous humor at trabecular meshwork of
canal of schlema
2. Acute (cIose angIe G.) Most dangerous type Forward displacement of iris to cornea leading to blindness.
3. Chronic (cIosed - angIe) - Precipitated by acute attack

S/Sx:
1. Loss of peripheraI vision - tunneI vision
2. HaIos around Iights
3. Headache
4. n/v
5. Steamy cornea
6. Eye discomfort
7. f untreated gradual loss of central vision blindness

Diagnosis:
1. Tonometry increase OP >12- 21 mmHg
2. Perimetry decrease peripheral vision
3. Gonioscopy abstruction in anterior chamber

Nursing mgt:
1. Enforce CBR
2. Maintain siderails
3. Administer meds
a.) Miotics - Iifetime - contracts ciliary muscles & constricts pupil. Ex PiIocarpine Na (Carbachol)
b.) Epinephrine eye drops decrease secretion of aqueous humor
c.) Carbonic anhydrase inhibitors. Ex. Acetazolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- ncrease outflow of aquaous humor
4. Surgery:
Invasive:
a.) Trabeculectomy eyetrephining removal of trabelar meshwork of canal or schlera to drain aqueous
humor
b.) Peripheral ridectomy portion of iris is excised to drain aqueous humor

Non-invasive:
Trabeculoctomy (eye laser surgery)

Nursing Mgt pre op- aII types surgery
1. Apply eye patch on unaffected eye to force weaker eye to become stronger.

Nursing Mgt post op - aII types of surgery
1. Position unaffected/ unoperated side - to prevent tension on suture line.
2. Avoid valsalva maneuver
3. Monitor for symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
4. Eye patch - both eyes - post op

CATARACT partial/ complete opacity of lens
1. 90-95% - aging (degenerative/ senile cataract)
2. Congenital
3. Prolonged exposure to UV rays
4. DM

S/Sx:
1. Loss of centraI vision - "Hazy or blurring of vision
2. PainIess bIurry vision
3. Milky white appearance at center of pupil
4. Decrease perception of coIors
5. DipIopia

Diagnosis: Opthalmoscopic exam (+) opacity of lens

Nsg Mgt:

1. Reorient pt to environment due opacity
2. Side rails
3. Meds: a.) Mydriatics dilate pupil not lifetime (SNS)
Ex. Mydriacyl
c.) CysIopegics paralyzes ciliary muscle. Ex. Cyclogye

4. Surgery

E extra
C - capsular
C cataract partial removal of lens
L - lens
E extraction

- intra
C - capsular
C cataract total removal of lens & surrounding capsules
L - lens
E extraction

Nursing Mgt:

1. Position unaffected/ unoperated side - to prevent tension on suture line.
2. Avoid valsalva maneuver

3. Monitor symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
4. Eye patch - both eyes - post op

RETINAL DETACHMENT- separation of 2 layers of retina

1. Severe myopia - nearsightedness
2. Diabetic Retinopathy
3. Trauma
4. FoIIowing Iens extraction
5. HPN

S/Sx:
1. "Curtain -veiI" Iike vision
2. FIashes of Iights
3. FIoaters
4. Gradual decrease in central vision
5. Headache
6. Cobwebs

Diagnosis: ophthalmoscopic exam
Nursing Mgt:
1. Side rails (all visual disease)
2. Surgery:
a.) Cryosurgery cold application
(Diathermy heat application)
b.) ScIeraI buckIing

EAR
1. Hearing
2. Balance (Kinesthesia or position sense)

Parts:
1. Outer-
a.) Pinna / auricle protects ear from direct trauma
b.) Ext. auditory meatus has ceruminous gland. Cerumen
c.) Tympanic membrane transmits sound waves to middle ear

Disorders of outer ear
Entry of insects put flashlight to give route of exit
Foreign objects beans (bring to MD)
H2O - drain
2. Middle ear
a.) Ear osssicle

1. Hammer -malleus
2. Anvil -ncus for bone conduction disorder conductive hearing loss
3. Stirrups -stapes

b. Eustachian tube - Opens to allow equalization of pressure on both ears
- Yawn, chew, and swallow
ChiIdren - straight, wide, short
c.) Otitis media

AduIt - Iong, narrow & sIanted

c. Muscles
1. Stapedius
2. Tensor tympani
3. nner ear
a. Bony labyrinth for balance, vestibule

Utricle & succule

Otolithe or ear stone has Ca carbonate

Movement of head = Righting reflex = Kinesthesia
b. Membranous Labyrinth
1. Cochlea ( function for hearing) has organ of corti
2. Endolymph & perilymph for static equilibrium
3. Mastoid air cells air filled spaces in temporal bone in skull

Complications of Mastoditis meningitis

Types of hearing Ioss:
1. Conductive hearing loss transmission hearing loss
Causes:
a.) mpacted cerumen tinnitus & conduction hearing loss- assist in ear irrigation
b.) mmobility of stapes OTOSCLEROSS
d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes
e.) Stapes can't transmit sound waves

Surgery
Stapedectomy removal of stapes, spongy bone & implantation of graft/ ear prosthesis

1. Familiar tendency
2. Ear trauma & surgery

S/Sx:
1. Tinnitus
2. Conductive hearing loss

Diagnosis:
1. Audiometry various sound stimulates (+) conductive hearing loss
2. Weber's test Normal AC> BC
result BC > AC
Stapedectomy
Nursing Mgt post op
1. Position pt unaffected side
2. DBE
No coughing & blowing of nose
- Night lead to removal of graft
3. Meds:
a.) Analgesic
b.) Antiemetic
c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)
4. Assess motor function facial nerve - (Smile, frown, raise eyebrow)
5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap

SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS
Cause:
1. Tumor on cocheal
2. Loud noises (gun shot)
3. Presbycusis bilateral progressive hearing loss especially at high frequencies elderly
Face elderly to promote lip reading
4. Meniere's disease endolymphatic hydrops
f.) nner ear disease char by dilation of endolympathic system leading to increase volume of endolin

Predisposing factor of MENIERE'S DISEASE
! Smoking
! Hyperlipidemia
! 30 years old
! Obesity (+) chosesteatoma
! Allergy
! Ear trauma & infection

S/Sx:
1. TRIAD symptoms of Meniere's disease
a.) Tinnitus
b.) Vertigo
c.) Sensory neural hearing loss
2. Nystagmus
3. n/v
4. Mild apprehension, anxiety
5. Tachycardia
6. Palpitations
7. Diaphoresis

Diagnosis:
1. Audiometry (+) sensory hearing loss

Nursing mgt:
1. Comfy & darkened environment
2. Siderails
3. Emetic basin
4. Meds:
a.) Diuretics to remove endolymph
b.) Vasodilator
c.) Antihistamine
d.) Antiemetic
e.) Antimotion sickness agent
f.) Sedatives/ tranquilizers

5. Restrict Na
6. Limit fluid intake
7. Avoid smoking
8. Surgery endolymphatic sac decompression - Shunt

OTITIS MEDIA - nflammation of the middle ear. (last less than 6 wks)

Sign and symptoms:
Pain
Temporary hearing loss
Tugging at the affected ear
Difficulty sleeping
Draining fluid / pus
Frequent pulling of the ear (children)
Fever

Nursing management:
Usually self limiting and resolved spontaneously
Antibiotic
Drainage (lean on the affected side to facilitate drainage)

Complication:
% Hearing loss
% Mastoiditis
% Delayed speech and language development
% Perforation of the TM

OTHER MNEMONICS

IV NOTES
Clindamycin, KCl===NOT for V pushit may cause arrhythmia
Chloramphenicol===NOT for M
Procaine, Penicillin, Benzatine, Pen G, Vancomycin HCl, Acyclovir (Zovirax) ===NOT for V

Opened bottles must be used in 8 hours
HepLock- flush with NSS

KCl < 80meq/L
Epinephrine 1:10,000
Lidocaine- 4 mg /ml (1g/250ml)

COMPATIBLE WITH PNSS ONLY
! Phenytoin
! Vit K
! Vit B6
! Vit C
! Hydralazine
! Furosemide

COMPATIBLE WITH D5W ONLY
! Epinephrine
! Norepinephrine
! Ephedrine
! Dopamine
! Dobutamine
! Nitroprusside
! NaHCO3

Not to be diIuted in LR
Penicillin G
Ampicillin
Cephalosporin
NaHCO3

PRBCto be infused within 2-4hours
FFP1-1.
5 hours
PIateIet concentratesinfuses immediately and quickly

NEURO TRANSMITTER DECREASE INCREASE
AcethyIchoIine
Myasthenia Gravis /
AIzheimer
Bi-poIar Disorder
Dopamine Parkinson's Disease Schizophrenia

Autoimmune diseases

MuItipIe ScIerosis
Hypothyroidism
Acute GIomeruIonephritis
Myasthenia Gravis
Hyperthyroidism
GBS
Pernicious Anemia

Apparatus needed at bedside

Acetaminophen toxicity-
AcetyIcisteine
Prepare suction apparatus-
acetylcysteine causes outpouring of
secretions
Myasthenia Gravis tracheostomy set. For respiratory
arrest
HemodyaIisis bulldog clip
Senkstaken tube scissors to deflate balloon
GuiIIain Barre Syndrome tracheostomy set. For respiratory
arrest
ConvuIsion- suction apparatus ncreased secretions
Hyperthyroidism tracheostomy set. For laryngeal
spasm post subtotal thyroidectomy
complication
Goiter tracheostomy set. For laryngeal
spasm post subtotal thyroidectomy
complication
Hypoparathyroidism tracheostomy set. For laryngeal
spasm
L<1BC< (:B12MN<O G) PQRQ

!"#$%&'%(%')* ,)&',

1. PTB
- Low-grade afternoon fever.
2. PNEUMONIA
- Rusty sputum.
3. ASTHMA - Wheezing on expiration.
4. EMPHYSEMA - BarreI chest.
5. KAWASAKI DISEASE - Strawberry tongue.
6. PERNICIOUS ANEMIA - Red beefy tongue.
7. DOWN SYNDROME - Protruding tongue / semian crease on paIm
8. CHOLERA - Rice watery stooI.
9. MALARIA
- StepIadder Iike fever and chiIIs.
10. TYPHOID - Rose spots in abdomen.
11. DIPTHERIA - pseudo membrane formation (pharynx, tonsiIs, nasaI)
12. MEASLES - KopIik's spots.
13. SLE
- ButterfIy rashes.
14. LIVER CIRRHOSIS - spider angioma, due to esophageaI varices
15. LEPROSY - Iioning face
16. BULIMIA NERVOSA - Chipmunk face. Parotid gIand sweIIing
17. APPENDICITIS. - rebound tenderness
18. DENGUE
- petechiae or (+) Herman's sign
19. MENINGITIS - Kernig's sign (Ieg pain), Brudzinski sign (neck pain).
20. TETANY - HYPOCALCEMIA (+) Trousseau's sign/carpopedaI spasm; Chvostek sign (faciaI spasm).
21. TETANUS - risus sardonicus.
22. PANCREATITIS
- CuIIen's sign (ecchymosis of umbiIicus); (+) Grey turners spots.
23. PYLORIC STENOSIS - oIive SHAPE mass on the abdomen
24. PDA - machine Iike murmur
25. ADDISON'S DISEASE
- Bronze Iike skin pigmentation.
26. CUSHING'S SYNDROME
- Moon face appearance and buffaIo hump.
27. HYPERTHYROIDISM/GRAVE'S DISEASE - ExopthaImus
28. INTUSSUSCEPTION - sausage shaped mass
29. PARKINSON'S DISEASE
- PiII roIIing tremors
30. HEPATITIS - Jaundice
31. THROMBOPHEBITIS
- Homan's sign
32. CATARACT
- Hazy vision / Ioss of centraI vision
33. GLAUCOMA - TunneI vision / Ioss of peripheraI vision
34. RETINAL DETACHMENT
- Curtain veiI-Iike vision / fIashes and fIoaters
35. CHOLECYSTITIS
- Murphy's sign (pain on deep inspiration, a infIammation of the gaIIbIadder
36. ANGINA PECTORIS - Levine's sign [hand cIutching in the chest]
37. MYASTHENIA GRAVIS - Ptosis [drooping of the upper eyeIid]
38. TETRALOGY OF FALLOT - CIubbing of fingers


ATHEROSCLEROSIS ARTERIOSCLEROSIS
- Iipid or fat deposits (pIaques)
- tunica intima
- hardening of artery, thicken
- caIcium and protein deposits
- tunica media

THE 5 MOST COMMON DRUG GIVEN IN BOARD EXAM: D.L.A.D.A MAJIC 2's

DRUG NORMAL RANGE
TOXICITY
LEVEL
INDICATION CLASSIFICATION
Digoxin/ Lanoxin
(ncrease force of
cardiac output)
.5 - 1.5 meq/L 2 CHF Cardiac GIycoside
Lithium/ Lithane
(Decrease level of
Ach/NE/Serotonin)
.6 - 1.2 meq/L 2 BipoIar Anti-Manic Agents
AminophyIIine
(Dilates bronchial tree)
10 - 19 mg/100 mI 20 COPD BronchodiIators
DiIantin/ Phenytoin 10 - 19 mg/100 mI 20 Seizures Anti-ConvuIsant
Acetaminophen/TyIenoI 10 - 30 mg/100 mI 200 Osteoarthritis Non-narcotic AnaIgesic

PITUITARY SECRETIONS
Anterior pituitary Posterior pituitary

ADH
OXYTOCIN

GH
ACTH
TSH
FSH & LH
PROLACTIN
MSH

GASTRIC ULCER

DUODENAL ULCER
SITE Antrum or lesser curvature Duodenal bulb

PAIN
- 30 min 1 hr after eating
- epigastrium
- gaseous & burning
- not usually relieved by food & antacid

- Eating Ieads to pain
- 2-3 hrs after eating
- mid epigastrium
- cramping & burning pain
- usually relieved by food & antacid
- 12 MN 3am pain
- Eating Iessens pain
HYPERSECRETION Normal gastric acid secretion ncreased gastric acid secretion
VOMITING common Not common
HEMORRHAGE hematemesis Melena
WT Wt loss Wt gain
COMPLICATIONS
a. stomach cancer
b. hemorrhage
a. perforation
HIGH RISK 50 or 60 years old and above 20 years old and above
INCIDENCE
Male; female = 1:1
15% of peptic ulcers are gastric
Male: Female = 2-3:1
80% of peptic ulcers are duodenal

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