Professional Documents
Culture Documents
MedicalSurgical Nursing Review PDF
MedicalSurgical Nursing Review PDF
Somatic NS
C- 8
T- 12
L- 5
S- 5
C- 1
SE:
B broncho spasm (bronchoconstriction)
E elicits a decrease in myocardial contraction
T treats HPN
A AV conduction slows down
Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic)
- Involved in fly or withdrawal response 1. Meiosis contraction of pupils
- Release of acetylcholine (ACTH) 2. Increase salivation
- Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased
4. RR decrease broncho constriction
I Cholinergic agents 5. Diarrhea increased GI motility
ex 1. Mestinon 6. Urinary frequency
Antidote anti cholinergic agents Atropine Sulfate S/E SNS
1
2. transient headache & dizziness.
-Mgt. Rise slowly. Assist in ambulation.
CNS (brain & spinal cord)
I. Cells A. neurons
Properties and characteristics
a. Excitability ability of neuron to be affected in external environment.
b. Conductivity ability of neuron to transmit a wave of excitation from one cell to another
c. Permanent cells once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
Regenerative capacity
A. Labile once destroyed cant regenerate
- Epidermal cells, GIT cells, resp (lung cells). GUT
B. Stable capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cells
C. Permanent cells retina, brain, heart, osteocytes cant regenerate.
3.) Neuroglia attached to neurons. Supports neurons. Where brain tumors are found.
Types:
1. Astrocyte
2. Oligodendria
Astrocytoma 90 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.
Astrocyte maintains integrity of blood brain barrier (BBB).
BBB semi permeable / selective
-Toxic substance that destroys astrocyte & destroy BBB.
Toxins that can pass in BBB:
1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide seizure & parkinsons.
3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. 4. Ketones DM.
OLIGODENDRIA Produces myelin sheath wraps around a neuron acts as insulator facilitates rapid nerve impulse transmission.
No myelin sheath degenerates neurons
DEMYELLENATING DSE
1.)ALZHEIMERS DISEASE atrophy of brain tissue due to a deficiency of acetylcholine.
S&Sx:
A amnesia loss of memory
A apraxia unable to determine function & purpose of object
A agnosia unable to recognize familiar object
A aphasia
- Expressive broccas aphasia unable to speak
- Receptive wernickes aphasia unable to understand spoken words
Common to Alzheimer receptive aphasia
Drug of choice ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.
2
1. Cerebrum largest - Connects R & L cerebral hemisphere
- Corpus collusum
Rt cerebral hemisphere, Lt cerebral hemisphere
Function:
1. Sensory
2. Motor
3. Integrative
Lobes
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reflexes are inhibited
d. Site of development of sense of umor
e. Broccas area speech center
Damage - expressive aphasia
2.) Temporal
a. Hearing
b. Short term memory
c. Wernickes area gen interpretative or knowing Gnostic area
Damage receptive aphasia
3.) Parietal lobe appreciation & discrimation of sensory imp
- Pain, touch, pressure, heat & cold
4.) Occipital - vision
5.) Insula/island of reil/ Central lobe- controls visceral fx
Function: - activities of internal organ
6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory
Basal Ganglia areas of gray matte located deep within a cerebral hemisphere
- Extra pyramidal tract
- Releases dopamine-
- Controls gross voluntary unit
MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12
3
Cerebellar Tests:
a.) R Rombergs test- needs 2 RNs to assist
- Normal anatomical position 5 10 min
(+) Rombergs test (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test
(+) To FTNT dymetria inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to cerebellum dymentrium
INCREASED ICP increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis
c.) Uncal herniation unilateral dilation of pupil. (Bilateral dilation of pupil tentorial herniation.)
d.) Possible seizure.
4
Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).
Nursing Mgt:
1.) Administer K supplements ex Kalium Durule, K chloride
Potassium Rich food:
ABCs of K
Vegetables Fruits
A - asparagus A apple
B broccoli (highest) B banana green
C carrots C cantalope/ melon
O orange (highest) for digitalis toxicity also.
Vit A squash, carrots yellow vegetables & fruits, spinach, chesa
Iron raisins,
Food appropriate for toddler spaghetti! Not milk increase bronchial secretions
Dont give grapes may choke
S/E of Lasix:
1.) Hypokalemia
2.) Hypocalcemia (Normal level Ca = 8.5 11mg/100ml) or Tetany:
S&Sx
weakness
Paresthesia
(+) Trousseau sign pathognomonic or carpopedal spasm. Put bp cuff on arm=hand spasm.
(+) Chevosteks sign
Arrhythmia
Laryngospasm
Administer Ca gluconate IV slowly
Nsg Mgt:
a. Monitor FBS (N=80 120 mg/dl)
5.) Hyperurecemia increase serum uric acid. Tophi- urate crystals in joint.
6
Gou ty arthritis kidney stones- renal colic (pain)
Cool moist skin
Sx joint pain & swelling usually at great toe.
7
e. Photophobia
f. Changes in color perception yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)
MAOI antidepressant
m AR plan
n AR dil can lead to CVA or hypertensive crisis
p AR nate
3 4 weeks - before MAOI will take effect
Anti Parkinsonian agents Vit B6 Pyridoxine reverses effect of Levodopa
Dilantin toxicity:
S/Sx:
G gingival hyperplasia swollen gums
i. Oral hygiene soft toothbrush
ii. Massage gums
H hairy tongue
A - ataxia
N nystagmus abnormal movement of eyeballs
A acetaminophen/ Tylenol non-opoid analgesic & antipyretic febrile pts
Acetaminophen toxicity :
1. Hepato toxicity
2. Monitor liver enzymes
SGPT (ALT) Serum Glutamic Piruvate Tyranase
SGOT- Serum Glutamic Acetate Tyranase
3. Monitor BUN (10 20)
Crea (.8-1)
Acetaminophen toxicity can lead to hypoglycemia
8
T tremors, Tachycardia
I irritability
R restlessness
E extreme fatigue
D depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity Acetylcesteine = causes outporing of secretions. Suction.
Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:
a. Nightmares
b. Extreme thirst hyperglycemia symptoms
c. Weakness d. Diaphoresis
PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine
producing cells in substancia nigra at mid brain & basal ganglia
- Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
2. Hypoxia
3. Arteriosclerosis
4. Encephalitis
10
4. Impaired motor function:
a. Weakness
b. Spasiticity tigas
c. Paralysis major problem
5. Impaired cerebellar function
Triad Sx of MS
I intentional tremors
N nystagmus abnormal rotation of eyes Charcots triad
A Ataxia
& Scanning speech
6. Urinary retention or incontinence
7. Constipation
8. Decrease sexual ability
Dx MS
1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG
2. MRI reveals site & extent of demyelination
3. Lhermittes response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS
- Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH adenocorticotopic
Steroids to reduce edema at the site of demyelination to prevent paralysis
Spinal Cord Injury
Administer drug to prevent paralysis due to edema
a. Give ACTH steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)
To decrease muscle spasticity
c. Interferone to alter immune response
d. Immunosuppresants
2. Maintain siderails
3. Assist passive ROMexercises promote proper body alignment
4. Prevent complications of immobility
5. Encourage fluid intake & increase fiber diet to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence give Prophantheline bromide (probanthene)
MYASTHENIA GRAVIS (MG) disturbance in transmission of impulses from nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 40 yo, unknown cause or idiopathic
Autoimmune release of cholenesterase enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness
(Ascending muscle weakness Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
1.) Ptosis drooping of upper lid ( initial sign)
Check Palpebral fissure opening of upper & lower lids = to know if (+) of MG.
2.) Diplopia double vision
11
3.) Mask like facial expression
4.) Dysphagia risk for aspiration!
5.) Weakening of laryngeal muscles hoarseness of voice
6.) Resp muscle weakness lead respiratory arrest. Prepare at bedside tracheostomy set
7.) Extreme muscle weakness during activity especially in the morning.
Dx test
1. Tensilon test (Edrophonium Hcl) temporarily strengthens muscles for 5 10 mins. Short term- cholinergic. PNS effect.
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent attach to ventilator
b.) Monitor pulmonary function test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr.
5. NGT feeding
Administer meds
a.) Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) Long term
- Increase acetylcholine
s/e PNS
b.) Corticosteroids to suppress immune resp
Decadron (dexamethasone)
S&Sx
Initial :
1. Clumsiness
2. Ascending muscle weakness lead to paralysis
3. Dysphagia
4. Decrease or diminished DTR (deep tendon reflexes)
- Paralysis
5. Alternate HPN to hypotension lead to arrhythmia - complication
6. Autonomic changes increase sweating, increase salivation.
Increase lacrimation
12
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)
Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding due dysphagia
S&Sx
- Stiff neck or nuchal rigidity (initial sign)
- Headache
- Projectile vomiting due to increase ICP
- Photophobia
- Fever chills, anorexia
- Gen body malaise
- Wt loss
- Decorticate/decerebration abnormal posturing
- Possible seizure
Sx of meningeal irritation nuchal rigidity or stiffness
Opisthotonus- rigid arching of back
13
Leg pain neck pain
Dx:
1. Lumbar puncture lumbar/ spinal tap use of hallow spinal needle sub arachnoid space L3 & L4 or L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture invasive
1. Consent / explain procedure to pt
- RN dx procedure (lab)
- MD operation procedure
2. Empty bladder, bowel promote comfort
3. Arch back to clearly visualize L3, L4
Result
1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose
b. Decrease glucose
Confirms meningitis c. increase CSF opening pressure
N 50 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
1. GIT irritation take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection alteration in normal bacterial flora
- N flora throat streptococcus
- N flora intestine e coli
Sx of superinfection of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapy
A Cushings synd reverse isolation - due to increased corticosteroid in body.
B Aplastic anemia reverse isolation - due to bone marrow depression.
C Cancer anytype reverse isolation immunocompromised.
D Post liver transplant reverse isolation takes steroids lifetime.
E Prolonged use steroids reverse isolation
F Meningitis strict respiratory isolation safe after 24h of antibiotic therapy
G Asthma not to be isolated
Predisposing factor:
1. Thrombosis clot (attached)
2. Embolism dislodged clot pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness
Femur fracture complications: fat embolism most feared complication w/in 24hrs
Yellow bone marrow produces fat cells at meduallary cavity of long bone
Red bone marrow provides WBC, platelets, RBC found at epiphisis
2.) Hemorrhage
3.) Compartment syndrome compression of nerves/ arteries
Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery mitral valve replacement
15
e.) Increase BP
f.) (+) Kernigs & Brudzinski sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria inability to vocalize, articulate words
3. Aphasia
4. Agraphia diff writing
5. Alesia diff reading
6. Homoninous hemianopsia loss of half of field of vision
Left sided hemianopsia approach Right side of pt the unaffected side
Dx
1. CT Scan reveals brain lesion
2. Cerebral arteriography site & extent of mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All graphy invasive due to iodine dye
Post
1.) Force fluid to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal
Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
- To prevent decubitus ulcer
- To prevent hypostatic pneumonia after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding if pt cant swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia approach on unaffected side
9. Meds
Osmotic diuretics Mannitol
Loop diuretics Lasix/ Furosemide
Corticosteroids dextamethazone
Mild analgesic
Thrombolytic/ fibrolitic agents tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants Heparin & Coumadin sabay
Coumadin will take effect after 3 days
Heparin monitor PTT partial thromboplastin time if prolonged bleeding give Protamine SO4- antidote.
Coumadin Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K Aquamephyton- antidote.
Antiplatelet PASA aspirin paraanemo aspirin, dont give to dengue, ulcer, and unknown headache.
Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking
2. Dietary modification
16
- Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit physical therapy
1. Mental retardation
2. Delay in psychomotor development
CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of
consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior.
Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attack
Febrile seizure Normal if < 5 yo Epilepsy 2nd and with history of seizure
Pathologic if > 5 yo
Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide
Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus drug of choice: Diazepam & glucose
S & Sx
I. Generalized Seizure
a.) Grand mal / tonic clonic seizures
With or without aura warning symptoms of impending seizure attack- Epigastric pain- associated with
olfactory, tactile, visual, auditory sensory experience
- Epileptic cry fall
- Loss of consciousness 3 5 min
- Tonic clonic contractions
- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
- Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching of mouth
- Loss of consciousness 5 10 secs (quick & short)
HALLUCINATIONS
1. Auditory schitzo paranoid type
2. Visual korsakoffs psychosis chronic alcoholism
3. Tactile addict substance abuse
III. Status epilecticus continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia coma death
Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2.
Tx:Diazepam (drug of choice), glucose
17
Dx-Convulsion- get health history!
1. CT scan brain lesion
2. EEG electroencephalography
- Hyperactivity brain waves
Nsg Mgt
Priority Airway & safety
1. Maintain patent a/w & promote safety
Before seizure:
1. Remove blunt/sharp objects
2. Loosen clothing
3. Avoid restraints
4. Maintain siderails
5. Turn head to side to prevent aspiration
6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at home.
7. Avoid precipitating stimulus bright glaring lights & noises
8. Administer meds
a. Dilantin (Phenytoin) ( toxicity level 20 )
SE Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Dont give alcohol lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations
2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration
- Type of seizure
- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status
epilepticus!
4. Assist in surgical procedure. Cortical resection
5. Complications: Subarachnoid hemorrhage and encephalitis
Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale obj measurement of LOC or quick neuro check
3 components of ECS
M motor 6
V verbal resp 5
E eye opening 4
15
15 14 conscious
13 11 lethargy
10 8 stupor
7 coma
3 deep coma lowest score
18
2.) Levels of orientation
3.) CN assessment
4.) Motor assessment
5.) Sensory assessment
6.) Cerebral test Romhberg, finger to nose
7.) DTR
8.) Autonomics
Graphesthesia- can identify numbers or letters written on palm with a blunt object.
Agraphesthesia cant identify numbers or letters written on palm with a blunt object.
CN assessment:
I Olfactory s
II Optic s
III Oculomotor m
IV Trocheal m smallest CN
V Trigeminal b largest CN
VI Abducens m
VII Facial b
VIII Acustic/auditory s
IX Glassopharyngeal b
X Vagus b longest CN
XI Spinal accessory m
XII Hypoglossal m
I. Olfactory dont use ammonia, alcohol, cologne irritating to mucosa use coffee, bar soap, vinegar, cigarette tar
- Hyposmia decrease sensitivity to smell
- Diposmia distorted sense of smell
19
- Anosmia absence of sense of smell
Either of 3 might indicate head injury damage to cribriform plate of ethmoid bone where olfactory cells are located
or indicate inflammation condition sinusitis
Common Disorders see page 85-87 for more info on glaucoma, etc.
1. Glaucoma Normal 12 21 mmHg pressure
- Increase IOP - Loss of peripheral vision tunnel vision
2. Cataract opacity of lens - Loss of central vision, Blurring or hazy vision
3. Retinal detachment curtain veil like vision & floaters
4. Macular degeneration black spots
3 4 EOM
IV sup oblique
VI lateral rectus
Normal response PERRLA (isocoria equal pupil)
Anisocoria unequal pupil
Oculomotor
1. Raising of eyelid Ptosis
2. Controls pupil size 2 -3 cm or 1.5 2 mm
20
VI Facial: Sensory controls taste ant 2/3 of tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group 40 yrs old
Motor- controls muscles of facial expression, smile frown, raise eyebrow
Damage Bells palsy facial paralysis
Cause bells palsy pedia R/T forcep delivery
Temporary only
Most evident clinical sign of facial symmetry: Nasolabial folds
VIII Acoustic/ vestibule cochlear (controls hearing) controls balance (kenesthesia or position sense)
- Movement & orientation of body in space
- Organ of Corti for hearing true sense organ of hearing
Test 9 10
Pt say ah check uvula should be midline
Damage cerebral hemisphere is L or R
Gag reflex place tongue depression post part of tongue
Dont touch uvula
XI Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)
- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia
XII Hypoglossal controls movement of tongue say ah. Assess tongue position=midline
L or R deviation
- Push tongue against cheek
- Short frenulum lingue
Tongue tied bulol
ENDOCRINE
21
Anterior pituitary gland adenohypophysis
Posterior pituitary gland neurohypophysis
Posterior pituitary:
1.) Oxytocin a.) Promotes uterine contraction preventing bleeding/ hemorrhage.
- Give after placental delivery to prevent uterine atony.
b.) Milk letdown reflex with help of prolactin.
2.) ADH antidiuretic hormone (vasopressin) -Prevents urination conserve H2O
S & Sx:
1. Polyuria
2. Sx of dehydration (1st sx of dehydration in children-tachycardia)
- Excessive thirst (adult)
- Agitation
- Poor skin turgor
- Dry mucus membrane
3. Weakness & fatigue
4. Hypotension if left untreated -
5. Hypovolemic shock
Anuria late sign hypovolemic shock
Dx Proc:
1. Decrease urine specific gravity- concentrated urine
N= 1.015 1.035
2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia
Mgt:
1. Force fluid 2,000 3,000ml/day
2. Administer IV fluid replacement as ordered
3. Monitor VS, I&O
4. Administer meds as ordered
a.) Pitresin (vasopressin) IM
5. Prevent complications
Most feared complication Hypovolemic shock
Predisposing factor
1. Head injury
2. Related to Bronchogenic cancer or lung caner-
Early Sign of Lung Ca - Cough 1. non productive 2. productive
3. Hyperplasia of Pit gland
Increase size of organ
22
S&Sx
1. Fluid retention
2. Increase BP HPN
3. Edema
4. Wt gain
5. Danger of H2O intoxication Complications: 1. cerebral edema increase ICP 2. seizure
Dx Proc:
1. Urine specific gravity increase diluted urine
2. Hyponatremia Decreased Na
Nsg Mgt:
1. Restrict fluid
2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
3. Monitorstrictly V/S, I&O, neuro check increase ICP
4. Weigh daily
5. Assess for presence edema
6. Provide meticulous skin care
7. Prevent complications increase ICP & seizures activity
Square face
Square jaw
PINEAL GLAND
1. Secretes Melatonin inhibits lutenizing hormone (LH) secretion
TG hormones:
T3 T4 Thyrocalcitonin
- Triodothyronine -Tetraiodothyronine/ Tyroxine FX antagonizes effects of parathormone
Increase metabolism brain inc cerebration, inc v/s all v/s down, constipation
HYPOTHYROIDISM all decreased except wt & menstruation, loss of appetite but with wt gain
menorrhagia increase in mens
HYPERTHYROIDISM - Increase appetite wt loss, amenorrhea
S & Sx enlarged TG
Mild restlessness
Mild dysphagia
Dx Proc.
1. Thyroid scan reveals enlarged TG
2. Serum TSH increase (confirmatory)
3. Serum T3, T4 N or below N
Nsg Mgt:
1. Administer meds
a.) Iodine solution Logols solution or saturated sol of K iodide SSKI
B. Thyroid h / Agents
1. Levothyroxine (Synthroid)
2. Liothyronine (cytomel)
3. Thyroid extract
24
Tachycardia, palpitations
Signs of insomnia
Hyperthyroidism restlessness agitation
Heat intolerance
HPN
Dx:
1. Serum T3 T4 decrease
2. Serum cholesterol increase can lead to MI
3. RA IU radio iodine uptake decrease
Nsg Mgt:
1. Monitor strictly V/S. I&O to determine presence of myxedema coma!
Myxedema Coma - Severe form of hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia
Might lead to progressive stupor & coma
Impt mgt for Myxedema coma
1. Assist mech vent priority a/w
2. Adm thyroid hormone
3. Adm IVF replacement force fluid
25
Mgt myxedema coma
1. Monitor VS, I&O
2. Provide dietary intake low in calories due to wt gain
3. Skin care due to dry skin
4. Comfortable & warm environment due to cold intolerance
5. Administer IVF replacements
6. Force fluid
7. Administer meds take AM SE insomia. Monitor HR.
Thyroid hormones
Levothyroxine(Synthroid), Liothyronine (cytomel)
Thyroid extracts
8. Health teaching & discharge plan
a. Avoidance precipitating factors leading to myxedema coma:
1. Exposure to cold environment
2. Stress 3. Infection
4. Use of sedative, narcotics, anesthetics not allowed CNS depressants V/S already down
Complications:
9. Hypovolemic shock, myxedema coma
10. Hormonal replacement therapy - lifetime
11. Importance of follow up care
S&Sx:
1. Increase in appetite hyperphagia wt loss due to increase metabolism
2. Skin is moist - perspiration
3. Heat intolerance
4. Diarrhea increase motility
5. All VS increase = HPN, tachycardia, tachypnea, hyperthermia
6. CNS changes
8. Irritability & agitation, restlessness, tremors, insomnia, hallucinations
7. Goiter
8. Exopthalmos pathognomonic sx
9. Amenorrhea
Dx:
1. Serum T3 & T4 - increased
2. Radio iodine uptake increase
3. Thyroid scan reveals enlarged TG
Nsg Mgt:
1. Monitor VS & I & O determine presence of thyroid storm or most feared complication: Thyrotoxicosis
2. Administer meds
a. Antithyroid agents
1. Prophylthiuracil (PTU)
2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture
Most feared complication : Thrombosis stroke CVS
26
3. Diet increase calorie to correct wt loss
4. Skin care
5. Comfy & cool environment
6. Maintain siderails- due agitation/restlessness
7. Provide bilateral eye patch to prevent drying of eyes- exopthalmos
8. Assist in surgery subtotal thyroidectomy
27
11. Secrets parathyroid hormone promotes Ca reabsorption
Hypocalcemia Hyperphosphatemia
(Or tetany)
A. Predisposing, factors:
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to
a. Irradiation
b. Trauma
S&Sx:
1. Acute tetany
a. Tingling sensation
b. Paresthesia
c. Dysphagia
d. Laryngospasm
e. Bronchospasm
2. Chronic tetany
a. Loss of tooth enamel
b. Photophobia & cataract formation
c. GIT changes anorexia, n/v, general body malaise
d. CNS changes memory impairment, irritability
Dx:
1. Serum calcium decrease (N 8.5 11 mg/100ml)
2. Serum phosphate increase (N 2.5 4.5 mg/100ml)
3. X-ray of long bone decrease bone density
4. CT Scan reveals degeneration of basal ganglia
Nsg Mgt:
1. Administration of meds:
a.) Acute tetany
Ca gluconate IV, slowly
b.) Chronic tetany
1. Oral Ca supplements
Ex. Ca gluconate
28
Ca carbonate
Ca lactate
Vit D (Cholecalceferol)
2. Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC MAD
Aluminum containing acids Mg containing antacids
Ex. Milk or magnesia
Aluminum OH gel Diarrhea
Ca 99% bones
1% serum blood
Predisposing Factors:
1. Hyperplasia parathyroid gland (PTG)
2. Over compensation of PTG due to Vit D deficiency
Children Rickets Vit D
Adults Osteomalacia deficiency
S/Sx:
Bone fracture
1. Bone pain (especially at back), bone fracture
29
2. Kidney stone
a. Renal colic
b. Cool moist skin
3. GIT changes anorexia, n/v, ulcerations
4. CNS involvement irritability, memory impairment
Dx Proc:
1. Serum Ca increase
2. Serum phosphorus decreases
3. X-ray long bones reveals bone demineralization
ADRENAL GLAND
12. Atop of @ kidney
13. 2 parts
Adrenal cortex outermost layer
Adrenal medulla - innermost layer
14. Secrets cathecolamines
a.) Epinephrine / Norephinephrine potent vasoconstrictor adrenaline=Increase BP
Adrenal Cortex
1. Zona fasiculata secrets glucocorticoids
Ex. Cortisol - Controls glucose metabolism (SUGAR)
2. Zona reticularis secrets traces of glucocorticoids & androgenic hormones
M testosterone
F estrogen & progesterone
30
Fx promotes development of secondary sexual characteristics
3. Zona glomerulosa - secretes mineralcortisone
Ex. Aldosterone
Fx: promotes Na & H2O reabsorption & excretion of potassium (SALT)
Predisposing Factors:
1. Atrophy of adrenal gland
2. Fungal infections
3. Tubercular infections
S/Sx:
1. Decrease sugar Hypoglycemia Decreased glucocorticoids - cortisol
T tremors, tachycardia
I - irritability
R - restlessness
E extreme fatigue
D diaphoresis, depression
Dx Proc:
1. FBS decrease FBS (N 80 120 mg/dL)
2. Plasma cortisol decreased
Serum Na decreased (N 135 145 meg/L)
3. Serum K increased (N 3.5 5.5 meg/L)
Nsg Mgt:
1. Monitor VS, I&O to determine presence of Addisonian crisis
15. Complication of Addisons dse : Addisonian crisis
16. Results the acute exacerbation of Addisons dse characterized by :
Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia
31
17. Lead to progressive stupor & coma
2. Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone
32
Obese trunk classic signs
Pendulous abdomen
Thin extremities
4. Hypokalemia
a. Weakness & fatigue
b. Constipation
c. ECG (+) U wave
5. Hirsutism increase sex
6. Acne & striae
7. Increase muscularity of female
Dx:
1. FBS increase (N: 80-120mg/dL)
2. Plasma cortisol increase
3. Na increase (135-145 meq/L)
4. K- decrease (3.5-5.5 meq/L)
Nsg Mgt:
1. Monitor VS, I&O
2. Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone
- promotes excretion of NA while conserving potassium
3. Restrict Na
4. Provide Dietary intake low in CHO, low in Na & fats
High in CHON & K
5. Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc.
6. Reverse isolation
7. Skin care due acne & striae
8. Prevent complication
- Most feared arrhythmia & DM
(Endocrine disorder lead to MI Hypothyroidism & DM)
9. Surgical bilateral Adrenolectomy
10. Hormonal replacement therapy lifetime due to adrenal gland removal- no more corticosteroid!
PANCREAS behind the stomach, mixed gland both endocrine and exocrine gland
Acinar cells (exocrine gland) Islets of Langerhans (endocrine gland ductless)
Cells
Secrets insulin
Fxn: hypoglycemia
Delta Cells
33
Secrets somatostatin
Overview only:
PANCREATITIS (check page 72) acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion self-digestion
Cause: unknown/idiopathic
18. Or alcoholism
Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turners sign ecchymosis of flank area
DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism
Classification:
I. Type I DM (IDDM) Juvenile onset, common in children, non-obese brittle dse
-Insulin dependent diabetes mellitus
Incidence rate
1.) 10% of population with DM have Type I
Predisposing Factor:
1. 90% hereditary total destruction of pancreatic dells
2. Virus
3. Toxicity to carbon tetrachloride
4. Drugs Steroids both cause hyperglycemia
Lasix - loop diuretics
S/Sx:
3 PS + G
1.) Polyuria
2.) Poydipsia
3.) Polyphagia
4.) Glycosuria
5.) Weight loss
34
6.) Anorexia
7.) N/V
8.) Blurring of vision
9.) Increase susceptibility to infection
10.) Delayed/ poor wound healing
Mgt:
1. Insulin Therapy
Diet
Exercise
Predisposing Factor:
1. Obesity obese people lack insulin receptors binding site
2. Hereditary
S/Sx:
1. Asymptomatic
2. 3 Ps and 1G
Tx:
1. Oral Hypoglycemic Agents (OHA)
2. Diet
3. Exercise
Complication: HONKC
H hyper
O osmolar
N non
K ketotic
C coma
III. GESTATIONAL DM occurs during pregnancy & terminates upon delivery of child
Predisposing Factors:
1. Unknown/ idiopathic
2. Influence of maternal hormones
S/Sx :
Same as type II
1. Asymptomatic
2. 3 Ps & 1G
35
2. Poor sucking reflex
IV. DM ASSOCIATED WITH OTHER DISORDER
a.) Pancreatic tumor
b.) Cancer
c.) Cushings syndrome
Hyperglycemia pancreas will not release insulin. Glucose cant go to cell, stays at circulation causing hyperglycemia.
increase osmotic diuresis glycosuria
Lead to cellular starvation
Polydipsia
Atherosclerosis coma
HPN death
MI stroke
Predisposing factor:
36
1. Stress between stress and infection, stress causes DKA more.
2. Hyperglycemia
3. Infection
S/Sx: 3 Ps & 1G
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glycosuria
5. Wt loss
6. Anorexia, N/V
7. (+) Acetone breath odor- fruity odor pathognomonic DKA
8. Kussmaul's resp-rapid shallow respiration
9. CNS depression
10. Coma
Dx Proc:
1. FBS increase, Hct increase (compensate due to dehydration)
N =BUN 10 -20 mg/100ml --increased due to severe dehydration
Crea - .8 1 mg/100ml
Nsg Mgt:
1. Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3. Monitor VS, I&O, blood sugar levels
4. Administer meds as ordered:
a.) Insulin therapy IV push
Regular Acting Insulin clear (2-4hrs, peak action)
b.) To counteract acidosis Na HCO3
c.) Antibiotic to prevent infection
Insulin Therapy
A. Sources:
1. Animal source beef/ pork-rarely used. Causes severe allergic reaction.
2. Human has less antigenecity property
Cause less allergic reaction. Humulin
If kid is allergic to chicken dont give measles vaccine due it comes from chicken embryo.
3. Artificially compound
B. Types of Insulin
1. Rapid Acting Insulin - Ex. Regular acting I
2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)
3. Long acting I - Ex. Ultra lente
Types of Insulin color & consistency onset peak duration
1. Rapid clear - 2-4h -
2. Intermediate cloudy - 6-12h -
3. Long acting cloudy - 12-24h -
250 mg/dl
Adm 5 units of RA I
37
Peak 7-9am monitor hypoglycemic reaction at this time- TIRED
- - 1 cc = 100 units
- - .5cc = 50 units
- - .1 cc = 10 units
6 units RA
Classifications of OHA
1. First generation Sulfonylurear
a. Chlorpropamide (diabenase)
b. Tolbutamide (orinase)
c. Tolazamide (tolinase)
38
2. 2nd generation sulfonylurear
a. Diabeta (Micronase)
b. Glipside (Glucotrol)
Nsg Mgt;
1. Monitor for PEAK action of OHA & insulin
Notify Doc
2. Monitor VS, I&O, neurocheck, blood sugar levels.
3. Administer insulin & OHA therapy as ordered.
4. Monitor signs of hyper & hypoglycemia.
Pt DM hinimatay
20. You dont know if hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain cant tolerate low sugar!)
Cold, clammy skin hypo Orange Juice or simple sugar / warm to touch hyper adm insulin
5. Provide nutritional intake of diabetic diet:
CHO 50%
CHON 30%
Fats 20%
-Or offer alternative food products or beverage.
-Glass of orange juice.
6. Exercise after meals when blood glucose is rising.
7. Monitor complications of DM
a. Atherosclerosis HPN, MI, CVA
b. Microangiopathy small blood vessels
Eyes diabetic retinopathy , premature cataract & blindness
Kidneys recurrent pyelonephritis & Renal Failure
(2 common causes of Renal Failure : DM & HPN)
c. Gangrene formation
d. Peripheral neuropathy
1. Diarrhea/ constipation
2. Sexual impotence
e. Shock due to cellular dehydration
8. Foot care mgt
a. Avoid waking barefooted
b. Cut toe nails straight
c. Apply lanolin lotion prevent skin breakdown
d. Avoid wearing constrictive garments
Blood 45% formed elements 55% plasma fluid portion of vlood. Yellow color.
SICKLE CELL ANEMIA sickle shaped RBC. Should be round. Impaired circulation of RBC.
-immature cells=hemolysis of RBC=decreased hgb
3 Nsg priority
1. a/w avoid deoxygenating activities
- High altitude is bad
2. Fluid deficit promote hydration
3. Pain & comfort
Hgb ( hemoglobin)
F= 12 14 gms %
M = 14-16 gms %
Hct 3x hgb 12 x 3 = 36
(hamatocrit) F 36 42% 14 x 3 = 42
M 42 48%
Average 42%
- Red cell percentage in whole red
40
Substances needed for maturation of RBC
a.) Folic acid
b.) Iron
c.) Vit C
d.) Vit B12 (cyanocobalamin)
e.) Vit B6 (Pyridoxine)
f.) Intrinsic factor
3.Platelets (thrombocytes)
N- 150,000 450, 000/ mm3
it promotes hemostasis prevention of blood loss by activating clotting
- Consists of immature or baby platelets known as megakaryocytes target of virus
dengue
- Normal lifespan 9 12 days
ANEMIA
Iron deficiency Anemia chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption of iron leading to
hypoxemic injury.
Incidence rate:
1. Common developed country due to high cereal intake
Due to accidents common on adults
2. Common tropical countries blood sucking parasites
3. Women 15 35yo reproductive yrs
4. Common among the poor poor nutritional intake
41
Suicide - common in teenager
Poisoning common in children (aspirin)
Aspiration common in infant
Accidents common in adults
Choking common in toddler
SIDS common in infant in US
22. Common in tropical zone Phil due blood sucks
Predisposing factor:
1. Chronic blood loss
a. Trauma
b. Mens
c. GIT bleeding:
i. Hematemesis-
ii. Melena upper GIT duodenal cancer
iii. Hematochezia lower GIT large intestine fresh blood from rectum
2. Inadequate intake of food rich in iron
3. Inadequate absorption of iron due to :
a. Chronic diarrhea
b. Malabsorption syndrome celiac disease-gluten free diet. Food for celiac pts- sardines
c. High cereal intake with low animal CHON ingestion
d. Subtotal gastrectomy
4. Improper cooking of food
S/Sx:
1. Asymptomatic
2. Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
3. Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells
4. Atropic glossitis, dysphagia, stomatitis
5. Pica abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior)
Dx Proc:
1. RBC
2. Hgb
3. Reticulocyte
4. Hct
5. Iron
6. Ferritin
Nsg Mgt
1. Monitor signs of bleeding of all hema test including urine & stool
2. Complete bed rest dont overtire pt =weakness and fatigue=activity intolerance
3. Encourage iron rich food
23. Raisins, legumes, egg yolk
4. Instruct the pt to avoid taking tea - impairs iron absorption
5. Administer meds
a.) Oral iron preparation
Ferrous SO4
Fe gluconate
Fe Fumarate
Nsg Mgt oral iron meds:
42
1. Administer with meals to lessen GIT irritation
2. If diluting in iron liquid prep adm with straw
Straw
1. Lugols
2. Tetracycline
3. Oral iron
4. Macrodantine
If pt cant tolerate oral iron prep administer parenteral iron prep example:
1. Iron dextran (IV, IM)
2. Sorbitex (IM)
PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to
Hypochlorhydria decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement.
Predisposing factor
1. Subtotal gastrectomy removal stomach
2. Hereditary
3. Infl dse of ileum
4. Autoimmune
5. Strict vegetable diet
STOMACH
S/Sx:
1. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
43
2. GIT changes
a. Red beefy tongue PATHOGNOMONIC mouth sores
b. Dyspepsia indigestion
c. Wt loss
d. Jaundice
3. CNS
Most dangerous anemia: pernicious due to neuroglogic involvement.
a. Tingling sensation
b. Paresthesia
c. (+) Rombergs test
Ataxia
d. Psychosis
Dx:- Shillings test
APLASTIC ANEMIA stem cell disorder due to bone marrow depression leading to pancytopenia all RBC are decreased
S/Sx:
1. Anemia:
a. Weakness & fatigue
b. Headache, dizziness, dyspnea
c. cold sensitivity, pallor
d. palpitations
2. Leucopenia increase susceptibility to infection
3. Thrombocytopenia
a. Peticchiae
b. Oozing ofblood from venipuncture site
c. ecchymosis
Dx:
1. CBC pancytopenia
2. Bone marrow biopsy/ aspiration at post iliac crest reveals fatty streaks in bone marrow
Nsg Mgt:
1. Removal of underlying cause
2. Blood transfusion as ordered
44
3. Complete bed rest
4. O2 inhalation
5. Reverse isolation due leukopenia
6. Monitor signs of infection
7. Avoid SQ, IM or any venipuncture site = HEPLOCK
8. Use electric razor when shaving to prevent bleeding
9. Administer meds
Immunosuppresants
Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days 3 weeks to achieve max therapeutic effect of
drug.
BLOOD TRANSFUSION:
Objectives:
1. To replace circulating blood volume
2. To increase O2 carrying capacity of blood
3. To combat infection if theres decrease WBC
4. To prevent bleeding if theres platelet deficiency
45
2. Notify Doc
3. Flush with plain NSS
4. Administer isotonic fluid sol to prevent acute tubular necrosis & conteract shock
5. Send blood unit to blood bank for reexamination
6. Obtain urine & blood samples of pt & send to lab for reexamination
7. Monitor VS & Allergic Rxn
Allergic Reaction:
S/Sx
1. Fever/ chills
2. Urticaria/ pruritus
3. Dyspnea
4. Laryngospasm/ bronchospasm
5. Bronchial wheezing
Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antihistamine diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive
If (+) Hypotension anaphylactic shock administer epinephrine
5. Send blood unit to blood bank
6. Obtain urine & blood samples send to lab
7. Monitor VS & IO
8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension indicates anaphylactic shock
24. administer epinephrine
9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB
Pyrogenic Reaction:
S/Sx
a.) Fever/ chills d. tachycardia
b.) Headache e. palpitations
c.) Dyspnea f. diaphoresis
Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antipyretics, antibiotics
5. Send blood unit to blood bank
6. Obtain urine & blood samples send to lab
7. Monitor VS & IO
8. Tepid sponge bath offer hypothermic blanket
Circulatory Overload:
Sx
a. Dyspnea
b. Orthopnea
c. Rales or crackles
d. Exertional discomfort
Nsg Mgt:
1. Stop BT
2. Notify Doc. Dont flush due pt has circulatory overload.
3. Administer diuretics
Priority cases:
Hemolytic Rxn 1st due to hypotension 1st priority attend to destruction of Hgb O2 brain damage
46
Allergic 3rd
Pyrogenic 4th
Circulatory 2nd
Hemolytic 2nd
Anaphylitic 1st priority
Predisposing factor:
1. Rapid BT
2. Massive trauma
3. Massive burns
4. Septicemia
5. Hemolytic reaction
6. Anaphylaxis
7. Neoplasia growth of new tissue
8. Pregnancy
S/Sx
1. Petechiae widespread & systemic (lungs, lower & upper trunk)
2. Ecchymosis widespread
3. Oozing of blood from venipunctured site
4. Hemoptysis cough blood
5. Hemorrhage
6. Oliguria late sx
Dx Proc
1. CBC reveals decrease platelets
2. Stool for occult blood (+)
Specimen stool
3. Opthalmoscopic exam sub retinal hemorrhage
4. ABG analysis metabolic acidosis
pH HCO3
R pH PCO2 respiratory alkalosis
Female
1. Breast cancer 40 yrs old & up mammography 15 20 mins (SBE 7 days after mens)
2. Cervical cancer 90% multi sexual partners
5% early pregnancy
3. Ovarian cancer
Classes of cancer
Tissue typing
1. Carcinoma arises from surface epithelium & glandular tissues
2. Sarcoma- from connective tissue or bones
3. Multiple myeloma from bone marrow
Pathological fracture of ribs & back pain
4. Lymphoma from lymph glands
5. Leukemia from blood
Warning / Danger Sx of CA
C change in bowel /bladder habits
48
A a sore that doesnt heal
U unusual bleeding/ Discharge
T thickening of lump breast or elsewhere
I indigestion? Dysphagia
O obvious change in wart/ mole
N nagging cough/ hoarseness
U unexplained anemia A - anemia
S sudden wt loss L loss of wt
Therapeutic Modality:
1. Chemotherapy use various chemotherapeutic agents that kills cancer cells & kills normal rapidly producing cells GIT,
bone marrow, and hair follicle.
Classification:
a.) Alkylating agents
b.) Plant alkaloids vincristine
c.) Anti metabolites nitrogen mustard
d.) Hormones DES
Steroids
e.) Antineoplastic antibiotics
- Diarrhea
1. Administer anti diarrheal 4 6h before start of chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care offer ice chips/ popsickles
2. Inform pt hair loss temporary alopecia
Hair will grow back after 4 6 months post chemo.
-Bone marrow depression anemia
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding
Repro organ sterility
1. Do sperm banking before start of chemo
Renal system increase uric acid
1. Administer allopurinol/ xyloprin (gout)
27. Inhibits uric acid
28. Acute gout colchicines
29. Increase secretion of uric acid
Neurological changes peristalsis paralytic ileus
Most feared complication ff any abdominal surgery
Vincristine plant alkaloid causes peripheral neuropathy
2. Radiation therapy involves use of ionizing radiation that kills cancer cells & inhibit their growth & kill N rapidly producing
cells.
Layer
1. Epicardium outermost
2. Myocardium inner responsible for pumping action/ most dangerous layer - cardiogenic shock
3. Endocardium innermost layer
Chambers
1. Upper collecting/ receiving chamber - Atria
2. Lower pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
50
Closure of AV valves gives rise to 1st heart sound or S1 or lub
2. Semi lunar valve
a.) Pulmonic
b.) Aortic
Closure of semilunar valve gives rise to 2nd heart sound or S2 or dub
Extra heart Sound
S3 ventricular Gallop CHF
S4 atrial gallop MI, HPN
SA node
AV
Purkenjie Fibers
Bundle of His
ATHEROSCLEROSIS ARTEROSCLEROSIS
- Hardening or artery due to fat/ lipid deposits at tunica - Narrowing or artery due to calcium & CHON deposits at tunica
intima. media.
ATHEROSCLEROSIS
Predisposing Factor
1. Sex male
2. Black race
51
3. Hyperlipidemia
4. Smoking
5. HPN
6. DM
7. Oral contraceptive- prolonged use
8. Sedentary lifestyle
9. Obesity
10. Hypothyroidism
Signs & Symptoms
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P percutaneous
T tansluminar
C coronary
A angioplasty
Obj:
1. To revascularize the myocardium
2. To prevent angina
3. Increase survival rate
ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT
nitroglycerin, resulting fr temp myocardial ischemia.
Predisposing Factor:
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10.hypothyroidism
Precipitating factors
4 Es
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake of food saturated fats.
Signs & Symptoms
52
1. Initial symptoms Levines sign hand clutching of chest
2. Chest pain sharp, stabbing excruciating pain. Location substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT
3. Dyspnea
4. Tachycardia
5. Palpitation
6.diaphoresis
Diagnosis
1.History taking & PE
2. ECG ST segment depression
3. Stress test treadmill = abnormal ECG
4. Serum cholesterol & uric acid - increase.
Nursing Management
1.) Enforce CBR
2.) Administer meds
NTG small doses venodilator
Large dose vasodilator
1st dose NTG give 3 5 min
2nd dose NTG 3 5 min
3rd & last dose 3 5 min
Still painful after 3rd dose notify doc. MI!
Venodilator veins of lower ext increase venous pooling lead to decrease venous return.
Meds:
A. NTG- Nsg Mgt:
1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug.
2. Monitor S/E:
orthostatic hypotension dec bp
transient headache
dizziness
3. Rise slowly from sitting position
4. Assist in ambulation.
5. If giving NTG via patch:
i. avoid placing it near hairy areas-will dec drug absorption
ii. avoid rotating transdermal patches- will dec drug absorption
iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch
53
Types:
Nursing Management
1. Narcotic analgesics Morphine SO4 to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias PVC
2. Shock cardiogenic shock. Late signs of cardiogenic shock in MI oliguria
3. thrombophlebitis - deep vein
4. CHF left sided
5. Dresslers syndrome post MI syndrome
-Resistant to medications
-Administer 150,000 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. Isordil
- Antiarrythmic
1. Lydocaine blocks release of norepenephrine
2. Brithylium
- Beta-blockers lol
1. Propanolol (inderal)
- ACE inhibitors - pril
54
1. Captopril (enalapril)
- Ca antagonist
1. Nifedipine
- Thrombolitics or fibrinolytics to dissolve clots/ thrombus
PTT PT
When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet decrease Na, Saturated fats, and caffeine
f.) Follow up care.
CHF CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.
- Backflow
1.) Left sided heart failure:
Predisposing factors:
1.) 90% mitral valve stenosis due RHD, aging
RHD affects mitral valve streptococcal infection
Dx: - Aso titer anti streptolysine O > 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis
S/Sx
Pulmonary congestion/ Edema
1. Dyspnea
2. Orthopnea (Diff of breathing sitting pos platypnea)
3. Paroxysmal nocturnal dysnea PNO- nalulunod
4. Productive cough with blood tinged sputum
5. Frothy salivation (from lungs)
6. Cyanosis
7. Rales/ crackles due to fluid
8. Bronchial wheezing
55
9. PMI displaced lateral due cardiomegaly
10. Pulsus alternons weak-strong pulse
11. Anorexia & general body malaise
12. S3 ventricular gallop
Dx
1. CXR cardiomegaly
2. PAP Pulmonary Arterial Pressure
PCWP Pulmonary CapillaryWedge Pressure
Predisposing factor
1. 90% - tricuspid stenosis
2. COPD
3. Pulmonary embolism
4. Pulmonic stenosis
5. Left sided heart failure
S/Sx
Venous congestion
- Neck or jugular vein distension
- Pitting edema
- Ascites
- Wt gain
- Hepatomegalo/ splenomegaly
- Jaundice
- Pruritus
- Esophageal varies
- Anorexia, gen body malaise
Diagnosis:
1. CXR cardiomegaly
2. CVP measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 hypervolemia
Decrease CVP < 4 hypovolemia
Flat on bed post of pt when giving CVP
Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote ventricular
filling.
56
Nsg mgt: Increase force of myocardial contraction = increase CO
3 6L of CO
1. Administer meds:
Tx for LSHF: M morphine SO4 to induce vasodilatation
A aminophylline & decrease anxiety
D digitalis (digoxin)
D - diuretics
O - oxygen
G - gases
1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small to medium sized
arteries & veins of lower extremities. Male/ feet
Predisposing factors:
- Male
- Smokers
57
S/Sx
1. Intermittent claudication leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes
Dx:
1. Oscillometry decrease peripheral pulse volume.
2. Doppler UTZ decrease blood flow to affected extremities.
3. Angiography reveals site & extent of mal-occulsion.
5.
Nsg Mgt:
1. Encourage a slow progression of physical activity
a.) Walk 3 -4 x / day
b.) Out of bed 2 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM
a.) Avoid walking barefoot
b.) Cut toe nails straight
c.) Apply lanolin lotion prevent skin breakdown
d.) Avoid wearing constrictive garments
4. Avoid smoking & exposure to cold environment
5. Surgery: BKA (Below the knee amputation)
2.)REYNAUDS PHENOMENON acute episodes of arterial spasm affecting digits of hands & fingers
Predisposing factors:
1. Female, 40 yrs
2. Smoking
3. Collagen dse
a.) SLE pathognomonic sign butterfly rash on face
Chipmunk face bulimia nervosa
Cherry red skin carbon monoxide poisoning
Spider angioma liver cirrhosis
Caput medusae leg & trunk umbilicus- Liver cirrhosis
Lion face leprosy
Nsg Mgt:
58
a. Analgesics
b. Vasodilators
c. Encourage to wear gloves especially when opening a refrigerator.
d. Avoid smoking & exposure to cold environment
VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return
Predisposing factors:
a. Hereditary
b. Congenital weakness of veins
c. Thrombophlebitis
d. Heart dse
e. Pregnancy
f. Obesity
g. Prolonged immobility - Prolonged standing
S/Sx:
1. Pain especially after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs
Dx:
1. Venography
2. Trendelenbergs test vein distend quickly < 35 secs
Nsg Mgt:
1. Elevate legs above heart level to promote venous return 1 to 2 pillows
2. Measure circumference of leg muscles to determine if swollen.
3. Wear anti embolic or knee high stockings. Women panty hose
4. Meds: Analgesics
5. Surgery: vein sweeping & ligation
Sclerotherapy spider web varicosities
S/E thrombosis
S/Sx:
1. Pain at affected extremities
2. Cyanosis
3. (+) Homans sign - Pain at leg muscles upon dorsiflexion of foot.
59
Dx:
1. Angiography
2. Doppler UTZ
Nsg Mgt:
1. Elevate legs above heart level.
2. Apply warm, moist packs to decrease lymphatic congestion.
3. Measure circumference of leg muscles to detect if swollen.
4. Use anti embolic stockings.
5. Meds: Analgesics.
Anticoagulant: Heparin
6. Complication:
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
- Mild restlessness
Glottis opening
Opens to allow passage of air
Closes to allow passage of food
60
- diffusion: Daltons law of partial pressure of gases
If 1:2 adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.
I. PNEUMONIA inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.
Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Hemophilus pneumoniae(Bronchopneumonia)
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.
Predisposing factors:
1. Smoking
2. Air pollution
3. Immuno-compromised
a. AIDS PLP
b. Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue
S/Sx:
1. Productive cough pathognomonic: greenish to rusty sputum
2. Dyspnea with prolonged respiratory grunt
3. Fever, chills, anorexia, gen body malaise
4. Wt loss
5. Pleuritic friction rub
6. Rales/ crackles
7. Cyanosis
8. Abdominal distension leading to paralytic ileus
Dx:
1. Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism.
2. CXR pulmo consolidation
3. CBC increase WBC
Erythrocyte sedimentation rate
4. ABG PO2 decrease
61
Nsg Mgt:
1. Enforce CBR
2. Strict respiratory isolation
3. Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
4. Force fluids 2 to 3 L/day
5. Institute pulmonary toilet-
a.) Deep breathing exercise
b.) Coughing exercise
c.) Chest physiotherapy cupping
d.) Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfy & humid environment
9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt for postural drainage:
a.) Best done before meals or 2 4 hrs after meals to prevent Gastroesophageal Reflux
b.) Monitor VS & breath sounds
Normal breath sound bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 30 min before procedure
e.) Stop if pt cant tolerate procedure
f.) Provide oral care it may alter taste sensation
g.) C/I pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)
Normal IOP 12 21 mmHg
11. HT:
a.) Avoidance of precipitating factors
b.) Complication: Atelectacies & meningitis
c.) Compliance to meds
PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB or
tubercle bacilli or acid fast bacilli gram (+) aerobic, motile & easily destroyed by heat or sunlight.
Predisposing factors:
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle (mycobacterium BOVIS)
5. Virulence
6. Over fatigue
S/Sx:
1. Productive cough yellowish
2. Low fever
3. Night sweats
4. Dyspnea
5. Anorexia, general body malaise, wt loss
6. Chest/ back pain
7. Hempotysis
Diagnosis:
1. Skin test mantoux test infection of Purified CHON Derivative PPD
DOH 8-10 mm induration
WHO 10-14 mm induration
Result within 48 72h
62
(+) Mantoux test previous exposure to tubercle bacilli
Nursing Mgt:
1. CBR
2. Strict resp isolation
3. O2 inhalation
4. Semi fowler
5. Force fluid to liquefy secretions
6. DBCE
7. Nebulize & suction
8. Comfy & humid environment
9. Diet increase CHO & calories, CHON, Vit, minerals
10. Short course chemotherapy
- Intensive phase
PZA Pyrazinamide given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity
Standard regimen
1. Injection of streptomycin aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
a.) Ototoxicity damage CN # 8 tinnitus hearing loss
b.) Nephrotoxicicity monitor BUN & Crea
HT:
a.) Avoid pred factors
b.) Complications:
1.) Atelectasis
2.) Miliary TB spread of Tb to other system
b.) Compliance to meds
- Religiously take meds
HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted
to birds manure.
S/Sx: Same as pneumonia & PTB like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis
Dx:
1. Histoplasmin skin test = (+)
2. ABG pO2 decrease
63
Nsg Mgt:
1. CBR
2. Meds:
a.) Anti fungal agents
Amphotericin B (Fungizone)
S/E :
a.) Nephrotoxcicity check BUN
b.) Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.
CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet
mucus producing cells leading to narrowing of smaller airways.
Predisposing factors:
1. Smoking all COPD types
2. Air pollution
S/Sx:
1. Prod cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmo HPN a.)Leading to peripheral edema
b.) Cor pulmonary respiratory in origin
7. Anorexia, gen body malaise
Dx:
1. ABG
PO2 PCO2 Resp acidosis
2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller
airway.
Predisposing factor:
1. Extrinsic Asthma called Atropic/ allergic asthma
a.) Pallor
b.) Dust
c.) Gases
d.) Smoke
64
e.) Dander
f.) Lints
2. Intrinsic Asthma-
Cause:
Herediatary
Drugs aspirin, penicillin, blockers
Food additives nitrites
Foods seafood, chicken, eggs, chocolates, milk
Physical/ emotional stress
Sudden change of temp, humidity &air pressure
3. mixed type: combi of both ext & intr. Asthma
90% cause of asthma
S/Sx:
1. C cough non productive to productive
2. D dyspnea
3. W wheezing on expiration
4. Cyanosis
5. Mild apprehension & restlessness
6. Tachycardia & palpitation
7. Diaphoresis
Dx:
1. Pulmo function test decrease lung capacity
2. ABG PO2 decrease
Nsg Mgt:
1. CBR all COPD
2. Meds-
a.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids
b.) Corticosteroids due inflammatory. Given 10 min after adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist at bedside put suction machine.
e.) Antihistamine
2. Force fluid
3. O2 all COPD low inflow to prevent resp distress
4. Nebulize & suction
5. Semifowler all COPD except emphysema due late stage
6. HT
a.) Avoid pred factors
b.) Complications:
- Status astmaticus- give epinephrine & bronchodilators
- Emphysema
c.) Adherence to med
BRONCHIECTASIS abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.
Predisposing factors:
1. Recurrent upper & lower RI
2. Congenital anomalies
3. Tumors
4. Trauma
S/Sx:
1. Productive cough
2. Dyspnea
3. Anorexia, gen body malaise- all energy are used to increase respiration.
4. Cyanosis
5. Hemoptisis
65
Dx:
1. ABG PO2 decrease
2. Bronchoscopy direct visualization of bronchus using fiberscope.
Nsg Mgt: before bronchoscopy
1. Consent, explain procedure MD/ lab explain RN
2. NPO
3. Monitor VS
Nsg Mgt after bronchoscopy
1. Feeding after return of gag reflex
2. Instruct client to avoid talking, smoking or coughing
3. Monitor signs of frank or gross bleeding
4. Monitor of laryngeal spasm
- DOB
- Prepare at bedside tracheostomy set
Diagnosis:
1. Pulmonary function test decrease vital lung capacity
2. ABG
a.) Panlobular / centrolobular emphysema
pCO2 increase
pO2 decrease hypoxema resp acidosis Blue bloaters
b.) Panacinar/ Centracinar
pCO2 decrease
pO2 increase hyperaxemia resp alkalosis Pink puffers
Nursing Mgt:
1. CBR
2. Meds
a.) Bronchodilators
66
b.) Corticosteroids
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
3. O2 Low inflow
4. Force fluids
5. High fowlers
6. Neb & suction
7. Institute
P posture
E end
E expiratory to prevent collapse of alveoli
P pressure
8. HT
a.) Avoid smoking
b.) Prevent complications
1.) Cor pulmonary R ventricular hypertrophy
2.) CO2 narcosis lead to coma
3.) Atelectasis
4.) Pneumothorax air in pleural space
9. Adherence to meds
Predisposing factors:
1.Chest trauma
2.Inflammatory lung conditions
3.Tumor
S/Sx:
1. Sudden sharp chest pain
2. Dyspnea
3. Cyanosis
4. Diminished breath sound of affected lung
5. Cool moist skin
6. Mild restlessness/ apprehension
7. Resonance to hyper resonance
Diagnosis:
1. ABG pO2 decrease
2. CXR confirms pneumothorax
Nursing Mgt:
1. Endotracheal intubation
2. Thoracenthesis
3. Meds Morphine SO4
- Anti microbial agents
4. Assist in test tube thoracotomy
Nursing Mgt if pt is on CPT attached to H2O drainage
1. Maintain strict aseptic technique
2. DBE
3. At bedside
67
a.) Petroleum gauze pad if dislodged Hemostan
b.) If with air leakage clamp
c.) Extra bottle
4. Meds Morphine SO4
Antimicrobial
5. Monitor & assess for oscillation fluctuations or bubbling
a.) If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
1. Check for loop, clots, and kink
2. Milk towards H2O seal
3. Indicates re-expansion of lungs
When will MD remove chest tube:
1. If (-) fluctuations
2. (+) Breath sounds
3. CXR full expansion of lungs
GIT
I. Upper alimentary canal - function for digestion
a. Mouth
b. Pharynx (throat)
c. Esophagus
d. Stomach
e. 1st half of duodenum
II. Middle Alimentary canal Function: for absorption
- Complete absorption large intestine
a. 2nd half of duodenum
b. Jejunum
c. Ileum
d. 1st half of ascending colon
III. Lower Alimentary Canal Function: elimination
a. 2nd half of ascending colon
b. Transverse
c. Descending colon
d. Sigmoid
e. Rectum
IV. Accessory Organ
a. Salivary gland
b. Verniform appendix
c. Liver
d. Pancreas auto digestion
e. Gallbladder storage of bile
I. Salivary Glands
1. Parotid below & front of ear
2. Sublingual
3. Submaxillary
S/Sx:
1. Fever, chills anorexia, gen body malaise
2. Swelling of parotid gland
3. Dysphagia
4. Ear ache otalgia
Nursing Mgt:
1. CBR
2. Strict isolation
3. Meds: analgesic
Antipyretic
Antibiotics to prevent 2 complications
4. Alternate warm & cold compress at affected part
5. Gen liquid to soft diet
6. Complications
Women cervicitis, vaginitis, oophoritis
Both sexes meningitis & encephalitis/ reason why antibiotics is needed
Men orchitis might lead to sterility if it occur during / after puberty.
S/Sx:
1. Pathognomonic sign: (+) rebound tenderness
2. Low grade fever, anorexia, n/v
3. Diarrhea / & or constipation
4. Pain at Rt iliac region
5. Late sign due pain tachycardia
Diagnosis:
1. CBC mild leukocytosis increase WBC
2. PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area rebound)
3. Urinalysis
Treatment: - appendectomy 24 45
Nursing Mgt:
1. Consent
2. Routinary nursing measures:
a.) Skin prep
b.) NPO
c.) Avoid enema lead to rupture of appendix
3. Meds:
Antipyretic
69
Antibiotics
*Dont give analgesic will mask pain
- Presence of pain means appendix has not ruptured.
4. Avoid heat application will rupture appendix.
5. Monitor VS, I&O bowel sound
Function:
1. Produces bile
Bile emulsifies fats
- Composed of H2O & bile salts
-Gives color to urine urobilin
Stool stircobilin
2. Detoxifies drugs
3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins
Hypevitaminosis vit D & K
Vit A retinol
Def Vit A night blindness
Vit D cholecalciferon
- Helps calcium
- Rickets, osteoarthritis
LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Early sign hepatic encephalopathy
1. Asterixis flapping hand tremors
Late signs headache, restlessness, disorientation, decrease LOC hepatic coma.
Nursing priority assist in mechanical ventilation
Predisposing factor:
70
Decrease Laennacs cirrhosis caused by alcoholism
1. Chronic alcoholism
2. Malnutrition decreaseVit B, thiamin - main cause
3. Virus
4. Toxicity- eg. Carbon tetrachloride
5. Use of hepatotoxic agents
S/Sx:
Early 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
2. Late signs
a.) Hematological changes all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- decrease
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusate, Palmar errythema
Hepatic coma
Diagnosis:
1. Liver enzymes- increase
SGPT (ALT)
SGOT (AST)
2. Serum cholesterol & ammonia increase
3. Indirect bilirubin increase
4. CBC - pancytopenia
5. PTT prolonged
6. Hepatic ultrasonogram fat necrosis of liver lobules
Nursing Mgt
1. CBR
2. Restrict Na!
3. Monitor VS, I&O
4. With pt daily & assess pitting edema
5. Measure abdominal girth daily notify MD
6. Meticulous skin care
71
7. Diet increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
8. Complications:
a.) Ascites fluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics 10 15 min effect
2. Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted
Bilirubin
Kernicterus/ hyperbilirubinia
PANCREATITIS acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto
digestion.
Bleeding of pancreas - Cullens sign at umbilicus
Predisposing factors:
1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam)
7. Diet increase saturated fats
S/Sx:
1. Severe Lt epigastric pain radiates from back &flank area
- Aggravated by eating, with DOB
2. N/V
3. Tachycardia
4. Palpitation due to pain
5. Dyspepsia indigestion
6. Decrease bowel sounds
72
7. (+) Cullens sign - ecchymosis of umbilicus hemorrhage
8. (+) Grey Turners 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 Hcl (Demerol)
Dont give Morphine SO4 will cause spasm of sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- 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
Diagnosis:
1. Oral cholecystogram (or gallbladder series)- confirms presence of stones
Nursing Mgt:
1. Meds a.) Narcotic analgesic - Meperdipine Hcl Demerol
b.) Anti cholinergic - Atropine SO4
c.) Anti emetic
Phenergan Phenothiazide with anti emetic properties
73
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
Cells
1. Chief/ Zymogenic cells secrets
a.) Gastric amylase - digest CHO
b.) Gastric lipase digest fats
c.) Pepsin CHON
d.) Rennin digests milk products
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 - Secrets gastrin increase Hcl acid secretion
PEPTIC ULCER DISEASE (PUD) excoriation / erosion of submucosa & mucosal lining due to:
a.) Hypercecretion of acid pepsin
b.) Decrease resistance to mucosal barrier
Incidence Rate:
1. Men 40 55 yrs old
2. Aggressive persons
Predisposing factors:
1. Hereditary
2. Emotional
3. Smoking vasoconstriction GIT ischemia
4. Alcoholism stimulates release of histamine = Parietal cell release Hcl acid = ulceration
5. Caffeine tea, soda, chocolate
6. Irregular diet
7. Rapid eating
8. Ulcerogenic drugs NSAIDS, aspirin, steroids, indomethacin, ibuprofen
Indomethacin - S/E corneal cloudiness. Needs annual eye check up.
74
According to location
1. Stress ulcer
2. Gastric ulcer
3. Duodenal ulcer most common
2 types
1.Curings ulcer cause: trauma & birth
hypovolemia
GIT schemia
Ulcerations
Hyperacidity
Ulcerations
Nursing Mgt:
1. Diet bland, non irritating, non spicy
2. Avoid caffeine & milk/ milk products
75
a.) Antacids
AAC
Aluminum containing antacids Magnesium containing antacids
Ex. aluminum OH gel ex. milk of magnesia
(Ampho-gel) S/E diarrhea
S/E constipation
Nursing Mgt:
1. Administer antacid & H2 receptor antagonist 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. Cytotec
d.) Sedatives/ Tranquilizers - Valium, lithium
e.)Anticholinergics
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.
Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.
Nursing Mgt:
1. Monitor NGT output
a.) Immediately post op should be bright red
b.) Within 36- 42h output is yellow green
c.) After 42h output is dark red
2. Administer meds:
a.) Analgesic
b.) Antibiotic
c.) Antiemetics
3. Maintain patent IV line
4. VS, I&O & bowel sounds
5. Complications:
a.) Hemorrhage hypovolemic shock
Late signs anuria
b.) Peritonitis
c.) Paralytic ileus most feared
d.) Hypokalemia
e.) Thromobphlebitis
f.) Pernicious anemia
76
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
2. Small frequent feeding s-6 equally divided feedings
3. Diet decrease CHO, moderate fats & CHON
4. Flat on bed 15 -30 minutes after q feeding
BURNS direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority infection (all kinds of burns)
Head burn-priority- a/w
2nd priority for 1st & 2nd - pain
2nd priority for 3rd - F&E
Stages:
1. Emergent phase Removal of pt from cause of burn. Determine source or loc or burn
2. Shock phase 48 - 72. Characterized by shifting of fluids from intravascular to interstitial space
=Hypovolemia
S/Sx:
- BP decrease
- Urine output
- HR increase
- Hct increase
- Serum Na decrease
- Serum K increase
- Met acidosis
3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
4. Recovery/ convalescent phase complete diuresis. Wound healing starts immediately after tissue injury.
Class:
I. Partial Burn
1. 1st degree superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure with no fluid filled vesicles
2. 2nd degree deep burns
- Affects epidermis & dermis
- Cause chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
1. Third & 4th 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.
77
Assessment findings
Rule of nines
Head & neck = 9%
Ant chest = 18%
Post chest = 18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum= 1%
Total 100%
Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth Claustridium tetany
Tetany
Tetanolysin tetanospasmin
Parts:
1. Renal pelvis pyenophritis infl
2. Cortex
3. Medulla
78
Function of kidneys:
1. Urine formation
2. Regulation of BP
Regulation of BP:
Predisposing factor:
Ex CS hypovolemia decrease BP going to kidneys
Activation of RAAS
Angiotensin II vasoconstrictor
Aldosterone
Increase BP
Increase Na &
H2O reabsorption
Hypervolemia
Color amber
Odor aromatic
Consistency clear or slightly turbid
pH 4.5 8
Specific gravity 1.015 1.030
WBC/ RBC (-)
Albumin (-)
E coli (-)
Mucus thread few
Amorphous urate (-)
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
Predisposing factors:
1. Microbial invasion E. coli
79
2. High risk women
3. Obstruction
4. Urinary retention
5. Increase 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
Diagnosis:
1. Urine culture & sensitivity - (+) to E. coli
Nursing Mgt:
1. Force fluid 2000 ml
2. Warm sitz bath to promote comfort
3. Monitor & assess for gross hematuria
4. Acid ash diet cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
5. Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides cotrimaxazole (Bactrim)
- Gantrism (ganthanol)
Urinary antiseptics Mitropurantoin (Macrodantin)
Urinary analgesic- Pyridum
6. Ht
a.) Importance of Hydration
b.) Void after sex
c.) Female avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications:
Pyelonephritis
PYELONEPHRITIS acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, interstitial abscess
formation.
- Lead to Renal Failure
Predisposing factor:
1. Microbial invasion
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary frequency, urgency
d.) Nocturia, dsyuria, hematuria
e.) Burning on urination
Chronic Pyelonephritis
a.) Fatigue, wt loss
b.) Polyuuria, polydypsia
c.) HPN
80
Diagnosis:
1. Urine culture & sensitivity (+) E. coli & streptococcus
2. Urinalysis
Increase WBC, CHON & pus cells
3. Cystoscopic exam urinary obstruction
Nursing Mgt:
1. Provide CBR acute phase
2. Force fluid
3. Acid ash diet
4. Meds:
a.) Urinary antiseptic nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
b.) Urinary analgesic Peridium
2. Complication- Renal Failure
Predisposing factors:
1. Diet increase Ca & oxalate
2. Hereditary gout
3. Obesity
4. Sedentary lifestyle
5. Hyperparathyroidism
S/Sx:
1. Renal colic
2. Cool moist skin (shock)
3. Burning upon urination
4. Hematuria
5. Anorexia, n/v
Diagnosis:
1. IVP 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
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 IV line
d.) Diet if + Ca stones acid ash diet
If + oxalate stone alkaline ash diet - (Ex milk/ milk products)
If + uric acid stones decrease organ meat / anchovies sardines
6. Surgery
a.) Nephectomy removal of affected kidney
Litholapoxy removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones
b.) Extracorporeal shock wave lithotripsy
81
- Non - invasive
- Dissolve stones by shock wave
7. Complications: Renal Failure
Predisposing factor:
1. High risk 50 years old & above
60 70 (3 to 4 x at risk)
2. Influence of male hormone
S/Sx:
1.Decrease force of urinary stream
2.Dysuria
3.Hematuria
4.Burning upon urination
5.Terminal bubbling
6.Backache
7.Sciatica
Diagnosis:
1. Digital rectal exam enlarged prostate gland
2. KUB urinary obstruction
3. Cystoscopic exam obstruction
4. Urinalysis increase WBC, CHON
Nursing Mgt:
1. Prostatic message promotes evacuation of prostatic fluid
2. Limit fluid intake
3. Provide catheterization
4. Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter
b. Fenasteride (Proscar) - Atrophy of Prostate Gland
5. Surgery: Prostatectomy TURP- Transurethral resection of Prostate- No incision
-Assist in cystoclysis or continuous bladder irrigation.
Nursing mgt:
c. Monitor symptoms of infection
d. Monitor symptoms gross/ flank 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 ml/min)
Predisposing factor:
Pre renal cause- decrease blood flow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension decrease flow to kidneys
4. CHF
5. Hemorrhage
6. Dehydration
82
2. Pyelonephritis
3. HPN
4. Acute GN
Stages of CRF
1. Diminished Reserve Volume asymptomatic
Normal BUN & Crea, GFR < 10 30%
2. Renal Insufficiency
3. End Stage Renal disease
S/Sx:
1.) Urinary System 2.) Metabolic disturbances
a.) polyuria a.) azotemia (increase BUN & Crea)
b.) nocturia b.) hyperglycemia
c.) hematuria c.) hyperinulinemia
d.) Dysuria
e.) oliguria
3.) CNS 4.) GIT
a.) headache a.) n/v
b.) lethargy b.) stomatitis
c.) disorientation c.) uremic breath
d.) restlessness d.) diarrhea/ constipation
e.) memory impairment
5.) Respiratory 6.) hematological
a.) Kassmauls resp a.) Normocytic anemia
b.) decrease cough bleeding tendencies
reflex
7.) Fluid & Electrolytes 8.) Integumentary
a.) hyperkalemia a.) itchiness/ pruritus
b.) hypernatermia b.) uremic frost
c.) hypermagnesemia
d.) hyperposphatemia
e.) hypocalcemia
f.) met acidosis
Nursing Mgt:
1. Enforce CBR
2. Monitor VS, I&O
3. Meticulous skin care. Uremic frost assist in bathing pt
4. Meds:
a.) Na HCO3 due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
83
2.) Obtain baseline data & monitor VS, I&O, wt, blood exam
3.) Strict aseptic technique
4.) Monitor for signs of complications:
B bleeding
E embolism
D disequilibrium syndrome
S septicemia
S shock decrease in tissue perfusion
Disequilibrium syndrome from rapid removal of urea & nitrogenous waste prod leading to:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) Paresthesia
2. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
3. Maintain patency of shunt by:
i. Palpate for thrills & auscultate for bruits if (+) patent shunt!
ii. Bedside- bulldog clip
- If with accidental removal of fistula to prevent embolism.
- Infersole (diastole) common dialisate used
7. Complication
- Peritonitis
- Shock
8. Assist in surgery:
Renal transplantation : Complication rejection. Reverse isolation
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 palpebral fissure opening upper & lower lid. Protects eye from direct sunlight
Meibomean gland 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
2. Intrinsic coat
I. 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
No auto receptors
Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes
ERROR of refraction
1. Myopia near sightedness Treatment: biconcave lens
2. Hyperopia/ or farsightedness Treatment: biconvex lens
3. Astigmatisim distorted vision Treatment: cylindrical
4. Prebyopia old slight inelasticity of lens due to aging Treatment: bifocal lens or double vista
Accommodation of lenses based on thelmholtz theory of accommodation
85
4. Hereditary
5. Obesity
6. Recent eye trauma, infl, surgery
Type:
1. Chronic (open angle G.) most common type
Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema
2. Acute (close angle G.) Most dangerous type
Forward displacement of iris to cornea leading to blindness.
3. Chronic (closed angle) - Precipitated by acute attack
S/Sx:
1. Loss of peripheral vision tunnel vision
2. Halos around lights
3. Headache
4. n/v
5. Steamy cornea
6. Eye discomfort
7. If untreated gradual loss of central vision blindness
Diagnosis:
1. Tonometry increase IOP >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 lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)
b.) Epinephrine eye drops decrease secretion of aqueous humor
c.) Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
2. Surgery:
Invasive:
a.) Trabeculectomy eyetrephining removal of trabelar meshwork of canal or schlera to drain aqueous humor
b.) Peripheral Iridectomy portion of iris is excised to drain aqueous humor
Non-invasive:
Trabeculoctomy (eye laser surgery)
S/Sx:
1. Loss of central vision - Hazy or blurring of vision
2. Painless
3. Milky white appearance at center of pupil
4. Decrease perception of colors
E extra
C - capsular
C cataract partial removal of lens
L - lens
E extraction
I - intra
C - capsular
C cataract total removal of lens & surrounding capsules
L - lens
E extraction
Nursing Mgt:
S/Sx:
1. Curtain veil like vision
2. Flashes of lights
3. Floaters
4. Gradual decrease in central vision
5. Headache
87
Diagnosis- opthaloscopic exam
Nursing Mgt:
1. Siderails (all visual disease)
2. Surgery:
a.) Cryosurgery
b.) Scleral buckling
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
1. Hammer -malleus
2. Anvil -Incus for bone conduction disorder conductive hearing loss
3. Stirrups -stapes
c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth for balance, vestibule
88
Surgery
Stapedectomy removal of stapes, spongy bone & implantation of graft/ ear prosthesis
Predisposing factor:
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. Webers 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
S/Sx:
1. TRIAD symptoms of Menieres disease
a.) Tinnitus
b.) Vertigo
c.) Sensory neural hearing loss
89
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
90