MUSCULOSKELETAL

1. FRACTURE
INTRODUCTION
⚫ A fracture is defined as a complete or partial break in a bone, which occurs when the
physical force applied to the bone is stronger than the bone itself.
⚫ A fracture is a complete or incomplete disruption in the continuity of bone structure and is
defined according to its type and extent. Fractures occur when the bone is subjected to
stress greater than it can absorb (Porth, 2015). Fractures may be caused by direct blows,
crushing forces, sudden twisting motions, and extreme muscle contractions. When the
bone is broken, adjacent structures are also affected, which may result in soft tissue
edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons,
severed nerves, and damaged blood vessels. Body organs may be injured by the force
that caused the fracture or by fracture fragments.
⚫ Closed (Simple) Fracture - bone breaks, but overlying skin intact
⚫ Open (Compound) Fracture 0- fractured ends pierce through overlying skin
Types of Fracture
⚫ Greenstick fractures - one side of bone breaks, other side bends
⚫ Impacted fractures - a piece of one bone gets wedged into another one
⚫ Comminuted fractures - bone breaks into multiple fragments
⚫ Spiral fractures - fracture line follows projection of a strong, twisting force
Spiral fractures are most commonly seen in non-accidental traumas such as physical abuse
CLINICAL MANIFESTATION
• Pain - is continuous and increases in severity until the bone fragments are immobilized.
• Loss of Function - the extremity cannot function properly because normal function of
the muscles depends on the integrity of the bones to which they are attached.
• Deformity - Displacement, angulation, or rotation of the fragments in a fracture of the
arm or leg causes a deformity that is detectable when the limb is compared with the
uninjured extremity.
• Shortening - actual shortening of the extremity because of the compression of the
fractured bone.
• Crepitus - It is caused by the rubbing of the bone fragments against each other.
• Localized Edema and Ecchymosis - after a fracture as a result of trauma and bleeding
into the tissues.

MODIFIABLE RISK FACTORS

⚫ Vitamin D
⚫ Smoking
⚫ Alcohol
⚫ Glucocorticoid use

NON-MODIFIABLE FACTORS
⚫ Increasing age
⚫ Congenital disorders such as Osteogenesis imperfecta
⚫ Malabsorption problems that may impair the ability to absorb important nutirents like
calcium and vitamin D

PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• x-ray – visualization of the location of any loose bony pieces or confirmation if a bone
is broken.
• Bone densitometry - is to evaluate the bone mineral density
• Bone scan - to detect metastatic and primary bone tumors, osteomyelitis, some
fractures, and aseptic necrosis, and to monitor the progression of degenerative bone
diseases.
 • Magnetic resonance imaging (MRI) - Visualizes fractures, bleeding, and soft-tissue
damage; differentiates between stress/trauma fractures and bone neoplasms.
• Complete blood count (CBC): Hematocrit (Hct) may be increased
(hemoconcentration) or decreased (signifying hemorrhage at the fracture site or at
distant organs in multiple trauma). Increased white blood cell (WBC) count is a normal
stress response after trauma.
• Urine creatinine (Cr) clearance: Muscle trauma increases the load of Cr for renal
clearance.
• Coagulation profile: Alterations may occur because of blood loss, multiple transfusions,
or liver injury.
NURSING DIAGNOSIS
• Risk for falls related to movement of bone fragments
• Risk for trauma related to loss of skeletal integrity
• Acute pain related to muscle spasms, edema, or movement of bone fragments
• Risk for Peripheral Neurovascular Dysfunction related to Reduction/interruption of blood
flow, tissue trauma, excessive edema, or hypovolemia (deficient fluid volume)
• Impaired physical mobility related to musculoskeletal impairment, pain, discomfort,
restrictive therapies
• Risk for infection related to opening in the skin in an open fracture.
• Deficient knowledge regarding healing process, therapy requirements, potential
complications, and self-care needs related to lack of exposure or recall or
misinterpretation of information
MEDICAL MANAGEMENT
• Reduction - restoration of the fracture fragments to anatomic alignment and
positioning.
• Immobilization - immobilized and maintained in proper position and alignment until
union occurs. Immobilization may be accomplished by external or internal fixation.
Methods of external fixation include bandages, casts, splints, continuous traction, and
external fixators.
• Maintaining and restoring function - Edema is controlled by elevating the injured
extremity and applying ice as prescribed. Neurovascular status (circulation, motion, and
sensation) is monitored routinely, and the primary provider is notified immediately if signs
of neurovascular compromise develop. Restlessness, anxiety, and discomfort are
controlled with a variety of approaches, such as reassurance, position changes, and
pain-relief strategies, including the use of analgesic medications. Isometric and muscle
setting exercises are encouraged to minimize atrophy and to promote circulation.
Participation in activities of daily living (ADLs) is encouraged to promote independent
functioning and self-esteem.
NURSING MANAGEMENT
• The nurse educates the patient regarding the proper methods to control edema and
pain
• It is important to educate about exercises to maintain the health of unaffected muscles
and to increase the strength of muscles needed for transferring and for using assistive
devices such as crutches, walkers, and special utensils. The patient is also educated to
use assistive devices safely.
• plans are made to help patients modify the home environment as needed and to
ensure safety, such as removing floor rugs or anything that obstructs walking paths
throughout the house.
• Patient education includes self-care, medication information, monitoring for potential
complications, and the need for continuing health care supervision.
• Intravenous (IV) antibiotics are given upon the patient’s arrival in the hospital along with
intramuscular (IM) tetanus toxoid if needed
• Wound irrigation and débridement (removal of tissues and foreign material) are initiated
in the operating room as soon as possible.
• The extremity is elevated to minimize edema.
• Neurovascular status must be assessed frequently.
• Temperature is monitored at regular intervals, and the patient is monitored for signs of
infection.
COMPLICATIONS:
⚫ Broken ends of bone may damage surrounding structures
⚫ Compartment syndrome - bleeding or edema
⚫ Fractures of long bone - fat embolism
2. CARPAL TUNNEL SYNDROME
INTRODUCTION
Carpal tunnel syndrome is a common condition that causes numbness, tingling, and
pain in the hand and forearm. The condition occurs when one of the major nerves to the hand
— the median nerve — is squeezed or compressed as it travels through the wrist.
Carpal tunnel syndrome occurs when the tunnel becomes narrowed or when the tissue
surrounding the flexor tendons (known as synovium) swells, putting pressure on the median
nerve and reducing its blood supply.
Carpal tunnel syndrome is an entrapment neuropathy that occurs when the median
nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment,
edema, or a soft tissue mass.
RISK FACTROS
• Heredity. This is likely an important factor. The carpal tunnel may be naturally smaller in
some people, or there may be anatomic differences that change the amount of space
for the nerve — and these traits can run in families.
• Repetitive hand use. Repeating the same hand and wrist motions or activities over a
prolonged period of time may aggravate the tendons in the wrist, causing swelling that
puts pressure on the nerve.
• Hand and wrist position. Doing activities that involve extreme flexion or extension of the
hand and wrist for a prolonged period of time can increase pressure on the nerve.
• Pregnancy. Hormonal changes during pregnancy can cause swelling that results in
pressure on the nerve.
• Health conditions. Diabetes, rheumatoid arthritis, and thyroid gland imbalance are
conditions that are associated with carpal tunnel syndrome.
CLINICAL MANIFESTATION
• Numbness, tingling, burning, and pain — primarily in the thumb and index, middle, and
ring fingers. This often wakes people up at night.
• Occasional shock-like sensations that radiate to the thumb and index, middle, and ring
fingers
• Pain or tingling that may travel up the forearm toward the shoulder
• Weakness and clumsiness in the hand — this may make it difficult to perform fine
movements such as buttoning your clothes
• Dropping things — due to weakness, numbness, or a loss of proprioception (awareness
of where your hand is in space)
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Tinel’s sign - The doctor will tap or press on the median nerve in your wrist with a reflex
hammer. If your fingers tingle or if you feel an electric-shock-like sensation, the test is
positive. You may have carpal tunnel syndrome.
• Phalen’s maneuver - This is also known as the wrist-flexion test. The doctor will tell you to
press the backs of your hands and fingers together with your wrists flexed and your
fingers pointed down. You’ll stay that way for a minute or two. If your fingers tingle or
get numb, you have carpal tunnel syndrome.
• Nerve conduction velocity test - In a variation of electromyography, two electrodes are
taped to the skin. A small shock is passed through the median nerve to see if electrical
impulses are slowed in the carpal tunnel. This test may be used to diagnose the
condition and rule out other conditions.
• Ultrasound - Your provider may recommend an ultrasound of your wrist to get a good
picture of the bones and nerve. This can help determine whether the nerve is being
compressed.
• Electromyography - This test measures the tiny electrical discharges produced in
muscles. During this test, your provider inserts a thin-needle electrode into specific
muscles to evaluate the electrical activity when muscles contract and rest. This test can
identify damage to the muscles controlled by the median nerve, and also may rule out
other conditions.
• X-ray - an show arthritis or a broken bone
NURSING DIAGNOSIS
• Acute pain related to inflammation and swelling secondary to pressure on median
nerve
• Acute pain related to nerve compression
• Risk for injury
MEDICAL MANAGEMENT
• Nonsteroidal anti-inflammatory drugs (NSAIDs). Anti-inflammatory medications such as
ibuprofen and naproxen can help relieve pain and inflammation.
• Steroid injections. Corticosteroid, or cortisone, is a powerful anti-inflammatory agent that
can be injected into the carpal tunnel. These injections often relieve painful symptoms
or help to calm a flare-up of symptoms or lessen swelling.
NURSING MANAGEMENT
• Monitor level of pain, numbness, paresthesia, and functioning.
• Monitor for adverse effects of NSAID therapy, especially in elderly. GI distress or
bleeding, dizziness, or increased serum creatinine.
• After surgery, monitor neurovascular status of affected extremity: pulses, color, swelling,
movement, sensation, or warmth.
• Apply wrist splint so wrist is in neutral position, with slight extension of wrist and slight
abduction of thumb; make sure that it fits correctly without constriction.
• Administer NSAIDs and assist with tendon sheath injections as required.
• Apply ice or cold compress to relieve inflammation and pain.
• Teach patient the cause of condition and ways to alter activity to prevent flexion of
wrists; refer to an occupational therapist as indicated.
• Advise patient of NSAID therapy dosage schedule and potential adverse effects;
instruct patient to report GI pain and bleeding.
• Teach patient to gentle range-of-motion exercises; refer to a physical therapist as
indicated.
• Wrist splint in slight extension (cock-up splint) to relieve pressure aggravated by wrist
flexion: worn at night, and during day if symptomatic.
3. DUPUYTREN'S DISEASE
INTRODUCTION
Dupuytren's disease is a condition that affects the fascia—the fibrous layer of tissue that
lies underneath the skin in the palm and fingers. In patients with Dupuytren's, the fascia
thickens, then tightens over time. This causes the fingers to be pulled inward, towards the palm,
resulting in what is known as a "Dupuytren's contracture."
Dupuytren disease is also associated with arthritis, diabetes, gout, cigarette smoking,
and alcoholism.
Dupuytren contracture, a flexion deformity caused by an inherited trait, is a slowly
progressive contracture of the palmar fascia, which severely impairs the function of the fourth,
fifth, and, sometimes, middle finger.
The fascia is a layer of tissue that helps to anchor and stabilize the skin on the palm side
of the hand. Without the fascia, the skin on your palm would be as loose and moveable as
the skin on the back of your hand. In patients with Dupuytren's disease, this palmar fascia
slowly begins to thicken, then tighten.
The patient may experience dull and aching discomfort, morning numbness, and
stiffness in the affected fingers. This condition starts in one hand, but eventually both are
affected. Finger-stretching exercises or intra- nodular injections of corticosteroids may prevent
contractures. With loss of movement, palmar and digital fasciotomies are performed to
improve function.
CLINICAL MANIFESTATION
• Nodules - may develop one or more small lumps, or nodules, in the palm of your hand.
These nodules are typically fixed to the overlying skin. Initially, the nodules may feel
tender but, over time, this tenderness usually goes away. In some cases, there can be
"pitting" or deep indentation of the skin near the nodules.
• Cords - The nodules may thicken and contract, contributing to the formation of dense
and tough cords of tissue under the skin. These cords can restrict or tether the fingers
and thumb from straightening or from spreading apart.
• Contractures (loss of joint mobility) - the tissue under the skin tightens, one or more of
your fingers may be pulled toward your palm and may be restricted from spreading
apart. The ring and little fingers are most commonly affected, but any or all of the fingers
can be involved, even the thumb. Most commonly, the first joint (knuckle joint) of the
finger is affected, but the other joints may also be involved.
o As the bend in your finger increases, it may be hard to straighten it fully. It may be
difficult to grasp large objects, put your hand in your pocket, or perform other
simple activities.
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• X-rays of the hand should be obtained to examine for other contributing, bony
abnormalities that may contribute to the loss of range of motion.
• Laboratory workup to rule out diabetes is recommended.
• Ultrasound may demonstrate thickened palmar fascia and the nodules.
NURSING DIAGNOSIS
• Impaired physical mobility related to stiffness of muscles
• Fatigue related to muscular stiffness
• Acute pain related to contractures
• Self-care deficit related to musculoskeletal impairment and physical limitations
MEDICAL MANAGEMENT
• Surgery. This is the most common treatment used for advanced cases. It may be done
when you have limited use of your hand. During Dupuytren's contracture surgery, the
surgeon makes a cut (incision) in your hand and takes out the thickened tissue. This can
improve the mobility of your fingers. Some people have contractures return. They may
need surgery again.
 • Steroid shot (injection). If a lump is painful, a steroid injection may help ease the pain. In
some cases, it may stop your condition from getting worse. You may need repeated
injections.
• Radiation therapy. This treatment is not as common in the U.S. Low energy X-rays are
directed at the nodules. This works best in the early stage of the disease. It can soften
the nodules and help keep contractions from happening.
• Enzyme injection. This is a newer, less invasive procedure done by specially trained
surgeons. Your doctor injects a medicine into the area to numb the hand. Then the
enzyme is injected into the lump of tissue. Over several hours, the enzyme breaks down
and dissolves the tough bands. This lets the fingers straighten when the cord is snapped
by the surgeon, usually the next day.
• Needle aponeurotomy. This is another newer, less invasive procedure. Medicine is
injected into the area to numb the hand. The surgeon uses a needle to divide the
diseased tissue. No incision is made.
NURSING MANAGEMENT
• Range of motion exercises are arguably the most important weapon in preventing
contractures.
• Splinting devices can be very useful in helping prevent painful and debilitating
contractures
• To prevent leg contractures, the resident should not be allowed to sleep with her legs in
a bent or twisted position. Rather, pillows or cushions should be placed between the
legs to help prevent contractures.
• Passive stretching to maintain or improve range of motion is an enormously important
component of the program to prevent contractures.
4. OSTEOPOROSIS
INTRODUCTION
Osteoporosis is a bone disease that develops when bone mineral density and bone
mass decreases, or when the quality or structure of bone changes. Osteoporosis causes bones
to become weak and brittle, so fragile that even minor stressors like leaning over or coughing
can result in a fracture.
When osteoporosis develops, the "holes" in the "sponge" grow larger and more
numerous, weakening the bone's interior. Bones provide structural support to the body and
protect essential organs. Calcium and other minerals are also stored in bones. When the body
requires calcium, it breaks down and rebuilds bone. This process, known as bone remodeling,
provides the body with necessary calcium while also keeping the bones strong.
Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and
diminished bone architectural strength. Normal homeostatic bone turnover is altered; the rate
of bone resorption that is maintained by osteoclasts is greater than the rate of bone formation
that is maintained by osteoblasts, resulting in a reduced total bone mass.
Age-related loss begins soon after the peak bone mass is achieved (i.e., in the fourth
decade). Calcitonin, which inhibits bone resorption and promotes bone formation, is
decreased. Estrogen, which inhibits bone breakdown, also decreases with aging. On the other
hand, parathyroid hormone (PTH) increases with aging, thus increasing bone turnover and
resorption.
The recommended vitamin D intake for adults up to 70 years of age is 600 IU daily, and
800 IU daily for those over the age of 70. The recommended adequate intake level of calcium
for men 50 to 70 years is 1000 mg daily, and for women aged 51 and older and men aged 71
and older is 1200 mg daily.
CLINICAL MANIFESTATION
• Receding gums. Your gums can recede if your jaw is losing bone. Ask your dentist to
screen for bone loss in the jaw.
• Weaker grip strength. In a study of postmenopausal women and overall bone mineral
density, researchers found that low handgrip strength was linked to low bone mineral
density. In addition, lower grip strength can increase your risk for falls.
• Weak and brittle fingernails. Nail strength can signal bone health. But you should also
take other factors into consideration that may affect your nails, such as exposure to very
hot or cold temperatures, regular use of nail polish remover or acrylic nails, or submersion
in water for long periods of time.
• Loss of height. Compression fractures in the spine can cause you to become shorter. This
is one of the most noticeable symptoms of osteoporosis.
• Fracture from a fall. A fracture is one of the most common signs of fragile bones.
Fractures can occur with a fall or from minor movement such as stepping off a curb.
Some osteoporosis fractures can even be triggered by a strong sneeze or cough.
• Back or neck pain. Osteoporosis can cause compression fractures of the spine. These
fractures can be very painful because the collapsed vertebrae may pinch the nerves
that radiate out from the spinal cord. The pain symptoms can range from minor
tenderness to debilitating pain.
• Stooped posture or fracture. The compression of the vertebrae may also cause a slight
curving of the upper back. A stooped back is known as kyphosis, which can cause back
and neck pain. It can even affect breathing due to the extra pressure on the airway
and limited expansion of your lungs.
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Bone density scan – to measure the bone loss; and to assess the risk of developing
osteoporotic fracture
• Bone x-ray – to see if there is a fracture due to brittleness
NURSING DIAGNOSIS
• Impaired Physical Mobility related to bone loss secondary to osteoporosis
• Risk for Injury related to acute problems in gait and balance
 • Imbalanced Nutrition Less than Body Requirements related to inadequate calcium and
vitamin D secondary to osteoporosis
• Deficient Knowledge related to insufficient exposure to information regarding
medications, dietary modifications
MEDICAL MANAGEMENT
• Risedronate: it prevents bone breakdown and increasing bone density (thickness)
• Alendronate: to prevent postmenopausal osteoporosis
• Raloxifene: to help prevent and treat thinning of the bones (osteoporosis) only in
postmenopausal women.
• Ibandronate: increases bone mineral density (BMD) and reduces the incidence of
vertebral (spine) fractures.
NURSING MANAGEMENT
Lifestyle changes includes:
• Quitting cigarette smoking: cigarettes smoking considered a risk factor for osteoporosis
and related to loss of bone mass and an increased risk of fractures. Kasi ang smoking
linked to increased yung FSH or follicle stimulating hormone and LH or luteinizing
hormone, na kung saan yung estrogen levels will decreased and ang result is rapid bone
loss.
o Smoking reduces the blood supply to the bones and to many other body tissues.
o Smoking decreases the body’s absorption of calcium, which is necessary for vital
cellular functions and bone health.
o Smoking affects the balance of hormones, including estrogen and testosterone,
which is needed to build and maintain a strong skeleton in women and men.
o The nicotine in cigarettes slows production of bone-producing cells, called
osteoblasts.
• Stop excessive alcohol intake: to prevent po yung fractures (Drinking heavily can lead
to bone loss. Be sure to limit alcohol consumption)
• Exercising regularly: to make the bones stronger
o Recommendations include 20 to 30 minutes of aerobic, bone-stressing exercise
daily (e.g., not swimming).
• Weight-bearing exercises are performed with either the feet or arms fixed to the ground
or another surface. Examples include:
o climbing stairs
o resistance training, such as:
▪ leg presses
▪ squats
▪ pushups
• Balance diet
o Rich in Calcium (is best absorbed through the foods we eat and the beverages
we drink; Calcium is a mineral that the body needs for good health; Calcium helps
blood vessels contract (narrow) and expand, makes muscles contract, helps send
messages through the nervous system and helps parathyroid glands secrete
parathyroid hormones – which increases levels of calcium in the blood)
▪ Dark green, leafy vegetables contain high amounts of calcium (Broccoli,
kale, spinach)
▪ Dairy products have the highest calcium content. Dairy products include
milk, yogurt and cheese.
▪ Soybeans
▪ Some fish, like sardines, salmon
• Absorb enough Vitamin D
o Helps with calcium absorption from food in the intestine
o Helps to keep muscles strong and so reduces the risk of falling
o Ensures the correct renewal and mineralization of bone
• Demonstrate on how to use any type of assistive devices such as walkers and canes.
5. OSTEOMALACIA
INTRODUCTION
Osteomalacia means "soft bones." Osteomalacia is a disease that weakens bones and
can cause them to break more easily. It is a disorder of decreased mineralization, which results
in bone breaking down faster than it can re-form. It is a condition that occurs in adults. In
children, inadequate concentrations of vitamin D may cause rickets.
Metabolic bone disease characterized by inadequate mineralization of bone softening
and weakening of the skeleton and most cammon cause is not having enough vitamin D.
CLINICAL MANIFESTATION
• Pain in bones and hips and joints
• Bone fractures
• Muscle pain and weakness
• Have difficulty of walking
PATHOPHYSIOLOGY
The primary defect in osteomalacia is a deficiency of activated vitamin D (calcitriol),
which promotes calcium absorption from the gastrointestinal tract and facilitates
mineralization of bone. Without adequate vitamin D, calcium and phosphate are not moved
to calcification sites in bones.
DIAGNOSTIC TEST
• The most important indicator is low levels of vitamin D, but low levels of calcium or a
significant drop in phosphate levels may also indicate osteomalacia.
• X-rays may be taken to see if there is any evidence of osteomalacia.
• A bone mineral density scan may be helpful in evaluating the amount of calcium and
other minerals present in a patient’s bone segment. These scans are not required to
make the diagnosis of osteomalacia. However, they may give important information
about a patient’s bone health.
NURSING DIAGNOSIS
• Acute pain related to the disease process of osteomalacia as evidenced by pain scale
• Imbalance nutrition less than body requirements related to inadequate vitamin d
• Activity intolerance related to join and bone pain
• Risk for injury related to softening of the bones
MEDICAL MANAGEMENT
• taking vitamin D, calcium, and phosphorus supplements
• High doses of vitamin D are toxic and increase the risk for hypercalcemia,
NURSING MANAGEMENT
• Vitamin D supplements - is essential for calcium absorption and for maintaining bone
health.
• Advice for exercising regularly to strengthen bones and muscles (weight-bearing
exercise)
• maintain a healthy weight
• advice the patient about intake of diet rich in calcium and phosphorus
• Teach about safety measures to prevent falls i.e. proper light in bathroom, hallways and
avoid slippery floors and use of grab rails in bathrooms for shower and bath tubs and
toilet seats
• Reduce the patient’s discomfort and pain. Assist the patient to change positions,
handles the patient gently, and pillows are used to support the body
• Encourage the patient towards use of assistive devices – walkers sticks, canes or
crutches while ambulating
• Teach the patient to observe anorexia, nausea/vomiting, frequent urination, muscle
weakness and constipation as these are the systems of vitamin D toxicity. It exists,
concern the physician.
• Instruct the patient to focus on careful positioning, ambulation, and prescribed
exercises.
• Teach client how to use ambulatory device with physical therapist’s assistance as
necessary
• Teach client about high fracture risk even with minor trauma related to fragile bone
status
6. PAGET'S DISEASE
INTRODUCTION
Paget's disease (osteitis deformans) is a disorder of localized rapid bone turnover, most
commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae
Paget's disease of bone is a chronic disease of the skeleton. In healthy bone, a process called
remodeling removes old pieces of bone and replaces them with new, fresh bone.
Bone Remodeling
In normal bone, a process called remodeling takes place every day. Bone is absorbed and
then reformed in response to the normal stresses on the skeleton. More specifically:
• Cells of the bone called osteoclasts absorb bone.
• Cells of the bone called osteoblasts make new bone.
In Paget's disease, osteoclasts are more active than osteoblasts. This means that there is more
bone absorption than normal. The osteoblasts try to keep up by making new bone, but they
overreact and make excess bone that is abnormally large, deformed, and fits together
haphazardly.
CLINICAL MANIFESTATION
• Pain due to:
o Fractures caused by brittle bones
o Deformity of bones, including bowing of the affected bone producing waddling
gait
o Advanced arthritis
o Compression on neighboring nerves from enlarge bones, leading to a loss of bone
sensation or movement.
• Joint pain, stiffness, and swelling
• Nerve problems
o Pain travelling from the spine to the legs
o Pain travelling from the neck to arms and chest
o Numbness or tingling in the affected limbs
o Partial loss of movement in the affected limbs
o Problems in limbs
o Lower of bladder or bowel control
• Enlargement of bowing of femurs and lower legs
• Enlargement of the skull around the forehead
PATHOPHYSIOLOGY
In Paget’s disease, there is primary proliferation of osteoclasts, which induce bone resorption
in population older than 50 years. As bone turnover continues, a classic mosaic (disorganized)
pattern of bone develops. Because the diseased bone is highly vascularized and structurally
weak, pathologic fractures develop
DIAGNOSTIC TEST
• Bone X-rays. Affected bones often look deformed and too thick on X-rays.
• Bone scan. This is the best test for diagnosing Paget's disease. You may have a bone
scan of your whole body to find out which bones are affected.
• Blood and urine tests. The most important one for diagnosing Paget's disease is a blood
test for alkaline phosphatase, an enzyme made by bone. If the level of this enzyme is
high, your doctor will want to do other tests. Wherein it is Elevated serum alkaline
phosphatase
• Normal blood calcium levels
• X-rays confirm the diagnosis of Paget’s disease
• local areas of demineralization and bone overgrowth produce characteristic mosaic
patterns and irregularities
NURSING DIAGNOSIS
• pain related to joint inflammation
• activity intolerance related to joint inflammation and pain
• deficient knowledge related to new diagnosis of paget disease
• risk for fracture related to
MEDICAL MANAGEMENT
• Anti-osteoclastic therapy medications reduce bone turnover
• Calcitonin retards bone resorption by decreasing the number and availability of
osteoclasts.
o Side effect includes blushing of the face and nausea
o The effect of calcitonin therapy is evident in 3 to 6 months through reduction of
bone loss and pain.
• Plicamycin (Mithracin), cytotoxic antibiotic This medication has dramatic effects on
pain reduction and on serum calcium, alkaline phosphate, level
o Administered by IV infusion diet with adequate calcium and vitamin
NURSING MANAGEMENT
• Physical therapy for the improvement of muscle strength and pain relief in some types
of pain
• Analgesia is needed for pain control and should be tailored according to the patient’s
symptoms.
7. OSTEOMYELITIS
INTRODUCTION
Infection of the bone that result in inflammation, necrosis (death of body tissue), and
formations of new bone. Infections can reach a bone by traveling through the bloodstream
or spreading from nearby tissue. Infections can also begin in the bone itself if an injury exposes
the bone to germs. . It causes painful swelling of bone marrow, the soft tissue inside your bones.
It is an acute or chronic inflammatory process involving the bone and its structures
secondary to infection with pyogenic organisms, including bacteria, fungi, and mycobacteria.
Staphylococcus aureus is the most common offending organism, although other organisms
may cause osteomyelitis.
Invasion of the bone by microorganisms may occur via indirect entry in which infection
spreads from the blood to the bone, or by direct entry through an open wound or medical
implant.
CLINICAL MANIFESTATION
• Drainage (yellow pus).
• Fever.
• Irritability or lethargy.
• Limited, painful movement.
• Loss of appetite.
• Lower back pain.
• Nausea and vomiting.
• Sweating or chills.
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• blood tests that look at white blood cells as well as markers for inflammation that are
usually elevated during an infection.
• A blood culture may also be done to look for organisms in the blood that may be
causing the infection; show if infectious organisms have escaped into the bloodstream
• X-rays may show a change in bone density indicating bone destruction by bacteria;
are taken of the affected area. However, they may be normal in early stages of the
infection.
• Magnetic resonance imaging (MRI) or bone scans may be recommended to identify
the cause of bone pain or inflammation; provides more precise images; ability to
visualize fluid in the bone and how extensively the infection has spread
• Computed tomography (CT) scans can be helpful in later stages of osteomyelitis.
• bone aspirations or biopsies are useful in the diagnosis of osteomyelitis and to determine
the most appropriate treatment.
• Bone scan – enhanced visualization of the bone through radioactive material; may
allow seeing early changes in bone structure
NURSING DIAGNOSIS
• Acute Pain r/t infectious process and swelling
• Hyperthermia r/t inflammatory response secondary to infection
• Ineffective Tissue Perfusion r/t ischemia due to disease process
• Impaired Physical Mobility r/t loss of integrity of the bone structure, stiffness of affected
body part
• Risk for infection related to open wound
MEDICAL MANAGEMENT
• IV antibiotic therapy begins, based on the assumption that infection results from a
staphylococcal organism that is sensitive to a penicillin or cephalosporin.
o The aims is to control the infection before the blood supply to the area diminishes
as a result of thrombosis

NURSING MANAGEMENT
• Wound care
• Affected part may be immobilized with a splint to decrease pain and muscle spasm
• Elevate the affected area to reduce swelling and discomfort.
• Do pain management techniques such as massage, distraction, relaxation, hypnosis to
reduce pain perception and collaboration with medical for providing analgesic.
8. RHEUMATOID ARTHRITIS
INTRODUCTION
Rheumatoid arthritis, or RA, is an autoimmune and inflammatory disease, which means
that your immune system attacks healthy cells in your body by mistake, causing inflammation
(painful swelling) in the affected parts of the body.
Is a systemic (involve at least two organ systems) inflammatory disease which manifests
itself in multiple joints of the body.
The inflammatory process primarily affects the lining of the joints (synovial membrane),
but can also affect other
organs.
The inflamed synovium leads to erosions of the cartilage and bone and sometimes joint
deformity.
CLINICAL MANIFESTATION
• Tender, warm, swollen joints
• Joint stiffness that is usually worse in the mornings and after inactivity
• Fatigue, fever and loss of appetite
• Pain
• Weakness
PATHOPHYSIOLOGY
• Autoimmune reaction. In RA, the autoimmune reaction primarily occurs in the synovial
tissue.
• Phagocytosis. Phagocytosis produces enzymes within the joint.
• Collagen breakdown. The enzymes break down collagen, causing edema, proliferation
of the synovial membrane, and ultimately pannus formation.
• Damage. Pannus destroys cartilage and erodes the bone.
• Consequences. The consequences are loss of articular surfaces and joint motion.
• Degenerative changes. Muscle fibers undergo degenerative changes, and tendon and
ligament elasticity and contractile power are lost.
DIAGNOSTIC TEST
• Arthrocentesis (also called joint aspiration). This is an exam of joint fluid. A thin needle is
inserted into the joint. Synovial fluid is removed with a syringe and examined for cell
counts, crystal analysis, culture, and other tests.
• physical exam, your doctor will check your joints for swelling, redness and warmth. He or
she may also check your reflexes and muscle strength.
• Blood tests - People with rheumatoid arthritis often have an elevated erythrocyte
sedimentation rate (ESR, also known as sed rate) or C-reactive protein (CRP) level, which
may indicate the presence of an inflammatory process in the body.
• X-rays to help track the progression of rheumatoid arthritis in your joints
• MRI and ultrasound tests can help your doctor judge the severity of the disease in your
body.
NURSING DIAGNOSIS
• Pain related to joint inflammation
• Activity intolerance related to joint inflammation and pain
• Impaired physical mobility related to pain, discomfort, decrease muscle strength
• Self-care deficit related to decrease strength
• Disturbed body image related to physical and psychological changes and
dependency imposed by chronic illness.
• Fatigue related to increased disease activity, pain, inadequate sleep/rest,
deconditioning, inadequate nutrition, and emotional stress/depression
MEDICAL MANAGEMENT
• NSAIDs are given to decrease inflammation and alleviate pain
• Steroids (prednisone) is frequently given to decrease inflammation and slow joint
damage
• DMARDs (methotrexate, hydroxychloroquine) are disease-modifying antirheumatic
medications which are given to impede the development of RA and rescue the tissues
and joints from permanent damage
 • Biologic representatives (rituximab, adalimumab) are biologic response modifiers and
operate by targeting portions of the immune system that trigger inflammation.
• Reconstructive surgery. Reconstructive surgery is indicated when pain cannot be
relieved by conservative measures and the threat of loss of independence is eminent.
• Synovectomy. Synovectomy is the excision of the synovial membrane.
• Tenorrhaphy. Tenorrhaphy is the suturing of a tendon.
• Arthrodesis. Arthrodesis is the surgical fusion of the joint.
• Arthroplasty. Arthroplasty is the surgical repair and replacement of the joint.
NURSING MANAGEMENT
• Nutrition and lifestyle instruction: wholesome diet, Prevent alcohol, Stop smoking – When
individuals are in pain, they frequently wish to switch to comfort foods. Assist patients to
make wholesome diet choices, avoiding smoking and alcohol.
• Provide a variety of comfort measures (eg, application of heat or cold; massage,
position changes, rest; foam mattress, supportive pillow, splints; relaxation techniques,
diversional activities).
9. OSTEOARTHRITIS
INTRODUCTION
• degenerative joint disease or “wear and tear” arthritis. It occurs most frequently in the
hands, hips, and knees.
• Degeneration of cartilage and its underlying bone within a joint as well as bony
overgrowth.
• The breakdown of these tissues eventually leads to pain and joint stiffness
• “Wear and tear” related to aging
- The joint most commonly affected are the knees, hips, and those in the hands
and spine.
- The specific causes of are believed to be a result of both mechanical and
molecular events in the affected joint.
• Inflammation and injury to the joint cause bony changes, deterioration of tendons and
ligaments and a breakdown of cartilage, resulting in pain, swelling, and deformity of the
joint.
CLINICAL MANIFESTATION
• Pain. Affected joints might hurt during or after movement.
• Stiffness. Joint stiffness might be most noticeable upon awakening or after being
inactive.
• Tenderness. Your joint might feel tender when you apply light pressure to or near it.
• Loss of flexibility. You might not be able to move your joint through its full range of
motion.
• Grating sensation. You might feel a grating sensation when you use the joint, and you
might hear popping or crackling.
• Bone spurs. These extra bits of bone, which feel like hard lumps, can form around the
affected joint.
• Swelling. This might be caused by soft tissue inflammation around the joint.
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Joint aspiration. After numbing the area, a needle is inserted into the joint to pull out
fluid. This test will look for infection or crystals in the fluid to help rule out other medical
conditions or other forms of arthritis.
• X-ray. X-rays can show joint or bone damage or changes related to osteoarthritis.
• MRI. Magnetic resonance imaging (MRI) gives a better view of cartilage and other parts
of the joint.
NURSING DIAGNOSIS
• Acute pain related to inflammation of the synovium and irritation of the nerve endings.
• Activity intolerance related to joint pain.
• Impaired physical mobility related to joint stiffness.
MEDICAL MANAGEMENT
• Acetaminophen. Acetaminophen (Tylenol, others) has been shown to help some
people with osteoarthritis who have mild to moderate pain. Taking more than the
recommended dose of acetaminophen can cause liver damage.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). Over-the-counter NSAIDs, such as
ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), taken at the
recommended doses, typically relieve osteoarthritis pain. Stronger NSAIDs are available
by prescription.
• NSAIDs can cause stomach upset, cardiovascular problems, bleeding problems, and
liver and kidney damage. NSAIDs as gels, applied to the skin over the affected joint,
have fewer side effects and may relieve pain just as well.
• Duloxetine (Cymbalta). Normally used as an antidepressant, this medication is also
approved to treat chronic pain, including osteoarthritis pain.
NURSING MANAGEMENT
• Weight loss. Weight loss is an important approach to pain and disability improvement.
• Assistive devices. Canes and other ambulatory devices are very helpful for ambulation.
• Exercise. Exercises such as walking should begin moderately and increase gradually to
strengthen the muscles that surround the joints and reduce pain.
• Analgesic. Adequate pain management is essential to the success of an exercise
program.
• Physical therapy. A referral for physical therapy for people with similar problems can be
very helpful.
• Ensure their safety
10. GOUT
INTRODUCTION
• Gout is a common and complex form of arthritis that can affect anyone. It's
characterized by sudden, severe attacks of pain, swelling, redness and tenderness in
one or more joints, most often in the big toe.
• An attack of gout can occur suddenly, often waking you up in the middle of the night
with the sensation that your big toe is on fire. The affected joint is hot, swollen and so
tender that even the weight of the bedsheet on it may seem intolerable.
• Genetic defect of purine metabolism that result in hyperuricemia
• Is a rheumatic disease resulting from deposition of uric acid crystals (monosodium urate)
in tissue and fluids within the body
• This process is caused by an overproduction or under excretion of uric acid.
Gout is a kind of arthritis caused by a buildup of uric acid crystals in the joints. Uric acid is a
breakdown product of purines that are part of many foods we eat. An abnormality in handling
uric acid and crystallization of these compounds in joints can cause attacks of painful arthritis,
kidney stones, and blockage of the kidney filtering tubules with uric acid crystals, leading to
kidney failure. Gout has the unique distinction of being one of the most frequently recorded
medical illnesses throughout history.
CLINICAL MANIFESTATION
• Intense joint pain. Gout usually affects the big toe, but it can occur in any joint. Other
commonly affected joints include the ankles, knees, elbows, wrists and fingers. The pain
is likely to be most severe within the first four to 12 hours after it begins.
• Lingering discomfort. After the most severe pain subsides, some joint discomfort may last
from a few days to a few weeks. Later attacks are likely to last longer and affect more
joints.
• Inflammation and redness. The affected joint or joints become swollen, tender, warm
and red.
• Limited range of motion. As gout progresses, you may not be able to move your joints
normally.
PATHOPHYSIOLOGY
Gout is a common and painful form of arthritis that causes swollen, hot, and stiff joints. When
uric acid crystallizes, it settles into the joints and body tissues, most frequently affecting the big
toe and, if not treated, progresses to the ankles, heels, wrists, and hands. This results in severe
pain, stiffness, and redness at the joint. Gout attacks often occur in the middle of the night
when the joint is immobile. Once the initial pain has subsided, the general discomfort of the
area can last for several weeks.
DIAGNOSTIC TEST
• Joint fluid test. Your doctor may use a needle to draw fluid from your affected joint.
Urate crystals may be visible when the fluid is examined under a microscope.
• Blood test. Elevated uric acid and creatinine levels in the blood may indicate gout, but
these are not confirmatory for diagnosis
• X-ray imaging. Joint X-rays can be helpful to rule out other causes of joint inflammation.
• Ultrasound. This test uses sound waves to detect urate crystals in joints or in tophi.
• Dual-energy computerized tomography (DECT). This test combines X-ray images taken
from many different angles to visualize urate crystals in joints.
NURSING DIAGNOSIS
• Pain related to joint inflammation
• Activity intolerance related to joint inflammation and pain
• Imbalanced nutrition: less than body requirements related to decrease food intake
• Risk for fall related to
MEDICAL MANAGEMENT
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include over-the-counter options
such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), as well as
more-powerful prescription NSAIDs such as indomethacin (Indocin, Tivorbex) or
celecoxib (Celebrex). NSAIDs carry risks of stomach pain, bleeding and ulcers.
• Colchicine. Your doctor may recommend colchicine (Colcrys, Gloperba, Mitigare), an
anti-inflammatory drug that effectively reduces gout pain. The drug's effectiveness may
be offset, however, by side effects such as nausea, vomiting and diarrhea.
 • Corticosteroids. Corticosteroid medications, such as prednisone, may control gout
inflammation and pain. Corticosteroids may be in pill form, or they can be injected into
your joint. Side effects of corticosteroids may include mood changes, increased blood
sugar levels and elevated blood pressure.
• Allopurinol (Aloprim, Zyloprim)reduces uric acid production.
• Colchicine(Colcrys, Mitigare) reduces inflammation.
• Febuxostat(Uloric) reduces uric acid production.
• Indomethacin(Indocin, Tivorbex) is a stronger NSAID pain reliever.
• Lesinurad (Zurampic) helps your body get rid of uric acid when you pee.
• Pegloticase (Krystexxa) breaks down uric acid.
• Probenecidhelps the kidneys excrete uric acid from your body.
• Steroids (also called corticosteroids) fight inflammation.
NURSING MANAGEMENT
• Have the patient drink 3 liters of fluid per day to avoid crystallization of uric in the
kidneys. Increased fluids help flush the uric acid through the kidney
• Assist with positioning for comfort
• Avoid touching inflamed joint unnecessarily
• Explain to patient which foods are high-purine proteins to prevent the gout attacks
o Turkey
o Organ meals
o sardines
o smelts
o mackerel
o anchovies
o herring
o bacon
• Avoid alcohol, which inhibits renal excretion of uric acid.
11. SCOLIOSIS
INTRODUCTION
• Scoliosis is an abnormal lateral curvature of the spine
• Scoliosis is a progressive condition causing the spine to curve or twist into a "C" or "S"
shape.
o Dextroscoliosis is a scoliosis with the convexity on the right side.
o Levoscoliosis is a scoliosis with the convexity on the left side.
o Rotoscoliosis: Pronounced rotation of the vertebrae
• Cause is unknown or idiopathic. Contrary to common belief, scoliosis does not come
from slouching, sitting in awkward
positions, or sleeping on an old mattress
CLINICAL MANIFESTATION
• Uneven shoulders
• One shoulder blade that appears more prominent than the other
• Uneven waist
• One hip higher than the other
• One side of the rib cage jutting forward
• A prominence on one side of the back when bending forward
DIAGNOSTIC TEST
• X-ray : Application of radiation to produce a film or picture of a part of the body can
show the structure of the vertebrae and the outline of the joints. X-rays of the spine are
obtained to search for other potential causes of pain, i.e. infections, fractures,
deformities, etc.
• Computed tomography scan (CT or CAT scan): A diagnostic image created after a
computer reads X-rays; can show the shape and size of the spinal canal, its contents
and the structures around it. Very good at visualizing bony structures.
• Magnetic resonance imaging (MRI) : A diagnostic test that produces three-dimensional
images of body structures using powerful magnets and computer technology; can show
the spinal cord, nerve roots and surrounding areas, as well as enlargement,
degeneration and deformities.
NURSING DIAGNOSIS
• ineffective breathing pattern related to musculoskeletal impairment or decreased lung
expansion
• Impaired physical mobility related to musculoskeletal impairment, pain and discomfort,
restricted movement.
• Disturbed body image related to biophysical and psychosocial factors of spinal
deformity.
• Risk for injury related to decreased mobility.
• Risk for impaired skin integrity related to irritation of brace.
• Risk for disturbed body image related to wearing a brace continuously.
• Risk for noncompliance related to long-term treatment.
MEDICAL MANAGEMENT
• Braces to prevent the curve from getting worse.
• Advise the client that brace can weak 23 hours a day and the 1 hour is for the period
for hygiene and skincare
NURSING MANAGEMENT
• Promote mobility. Prescribed exercises must be practiced and performed as directed;
this can help to minimize the risks of immobility and promote self-esteem.
• Prevent injury. Evaluate the child’s environment after the brace has been applied and
take precautions to prevent injury; help the child practice moving about safely; advise
the family caregiver to contact school personnel to ensure that the child has
comfortable, supportive seating at school.
• Prevent skin irritation. Check the child regularly to confirm proper fit of brace; observe
for any areas of rubbing, discomfort, or skin irritation and adjust the brace as necessary;
skin under the pads should be massaged daily; and daily bathing is essential.
• Promote positive body image. The child should be involved in all aspects of care
planning; it is important for the child to have an opportunity to talk about his or her
feelings; help the child select clothing that blends with current styles but is loose enough
to hide the brace.
• Promote compliance with therapy. The child must wear the brace for years until spinal
growth is completed; during this period, the caregivers and the child need emotional
support from healthcare personnel; to encourage compliance, teach them about
possible complications of spinal instability and possible further deformity if correction is
unsuccessful.
• Advise the client that brace can weak 23 hours a day and the 1 hour is for the period
for hygiene and skincare
12. LEGG-CALVE-PERTHES DISEASE
INTRODUCTION
• This disease is characterized by necrosis of the femoral head that occurs in children
between 2 and 12 years of age caused by a decreased blood supply to the femoral
head
• This disease is self-limiting, and the child will fully recover after the disease has run its
course
• The femoral head then “necroses,” or loses blood supply, which weakens the bone and
can lead to multiple fractures. Next, the bone is taken up by the body, or resorbed,
which can lead to a complete collapse of the femoral head.
3 STAGES
1. Avascular: Blood supply to the head of the femur is interrupted within 1 year.
2. Revascularization: Creeping substitution occurs where connective and vascular tissue
enter the necrotic bone causing live noncalcified bone to replace the necrotic tissue.
3. Healing: The bone ossifies over 3 years.
CLINICAL MANIFESTATION
• Pain in the hip or groin, or in other parts of the leg, such as the thigh or knee (called
"referred pain.").
• Pain that worsens with activity and is relieved with rest.
• Painful muscle spasms that may be caused by irritation around the hip.
• Irritation and inflammation in the hip area that may result in muscle spasms.
• Stiffness or decreased motion in the hip joint
• Limping – action of difficulty in walking
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Radiograph: Shows decreased bone mass, ossification centers, and possibly
subchondral fracture
NURSING DIAGNOSIS
• Impaired physical mobility related to musculoskeletal impairment
• Impaired social interaction related to physical mobility restrictions
MEDICAL MANAGEMENT
• Anti-inflammatory medications. Your doctor might recommend ibuprofen (Advil, Motrin,
IV others) or naproxen sodium (Aleve) to help relieve your child's pain.
NURSING MANAGEMENT
• Perform range-of-motion activities to maintain normal motion of the joint.
• Teach the patient how to use crutches to protect the joint.
• Explain to the parents and the patient that the disease is self-limiting and that the patient
will fully recover once the disease has run its course.
• Physical therapy. As the hip stiffens, the muscles and ligaments around it may shorten.
Stretching exercises can help keep the hip more flexible.
13. BONE TUMORS
INTRODUCTION
Bone tumors develop when cells within a bone divide uncontrollably, forming a lump or
mass of abnormal tissue. Most bone tumors are benign (not cancerous). Benign tumors are
usually not life-threatening and, in most cases, will not spread to other parts of the body.
(Neoplasm of the musculoskeletal system)
TYPES
BENIGN BONE TUMORS
• Benign tumors of the bone and soft tissue are more common than malignant primary
bone tumor
• Slow growing
• Well circumscribed
• Encapsulated
• Osteochondroma is the most common benign bone tumor.
• It usually occurs as a large projection of bone at the end of long bones (at the knee or
shoulder
MALIGNANT BONE TUMORS
• Rare and arise from connective and supportive tissue cells (sarcomas) or bone marrow
elements
• Osteosarcoma (i.e., osteogenic sarcoma) is the most common and most often fatal
primary malignant bone tumor.
• Prognosis depends on whether the tumor has metastasized to the lungs
• Appears most frequently in children, adolescents and young adults (in bones that grow
rapidly)
• Most common sites are the distal femur, the proximal tibia, and the proximal humerus.
METASTATIC BONE DISEASE
• Metastatic bone disease (secondary bone tumor) is more common than primary bone
tumors
• Tumors arising from tissues elsewhere in the body that may invade the bone
• The most common primary sites of tumors that metastasize to bone are the kidney,
prostate. lung, breast, ovary, and thyroid
• Most frequently attack the skull, spine, pelvis. femur, and humerus
CLINICAL MANIFESTATION
• Pain
• May be disability
• Visible/palpable bony growth
• Have pain that ranges from mild an: occasional to constant and severe
• Varying degrees of disability Weight loss malaise, and fever may be present
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Serum alkaline phosphatase levels are frequently elevated in osteogenic sarcoma
• Serum acid phosphatase in metastatic carcinoma of the prostate
• Hypercalcemia is present with bone metastases from breast, lung, or kidney cancer.
• A surgical biopsy is performed for histologic identification
Imaging tests use x-rays, magnetic fields, or radioactive substances to create pictures of the
inside of the body. Imaging tests might be done for a number of reasons, including:
• To help find out if a suspicious area might be cancer
• To help determine if a cancer might have started in another part of the body
• To learn how far cancer has spread
• To help determine if treatment is working
• To look for signs that the cancer might have come back
An x-ray of the bone is often the first test done if some type of bone tumor is suspected. Tumors
might look “ragged” instead of solid on an x-ray, or they might look like a hole in the bone.
Sometimes doctors can see a tumor that might extend into nearby tissues (such as muscle or
fat).
A bone scan can show if a cancer has spread to other bones, and is often part of the workup
for people with bone cancer. This test is useful because it can show the entire skeleton at once.
A positron emission tomography (PET) scan, described below, can often provide similar
information, so a bone scan might not be needed if a PET scan is done.
A core needle biopsy uses a large needle to remove a cylinder of tissue. This is the most
common type of needle biopsy used for bone tumors.
A fine needle aspiration (FNA) biopsy uses a very thin needle on the end of a syringe to suck
out a small amount of fluid and some cells from the tumor.
NURSING DIAGNOSIS
• Situational low self-esteem related to biophysical: surgery, chemotherapy
• Altered nutrition: less than body requirements related to emotional distress, poorly
controlled pain
• Fear/anxiety related to situational crisis, threat of death
• Risk for impaired skin integrity related to effects of radiation and chemotherapy
• Risk for Fluid Volume Excess related to damage to fluid intake.
• Risk for Infection related to the inadequate immunosuppression, malnutrition and
invasive procedures.
MEDICAL MANAGEMENT
• Prescribe IV or epidural analgesic medications are used during the early postoperative
period
• Affected extremities should be support and handled gently.
• Prophylactic antibiotics and strict aspect dressing techniques are used to diminish the
occurrence of osteomyelitis and wound infections
MANAGEMENT FOR PRIMARY BONE TUMOR
• The goal of primary bone tumor treatment is to destroy or remove the tumor through:
✓ Surgical excision
✓ Radiation therapy
✓ Chemotherapy
• Chemotherapy is started before and continued after surgery in an effort to eradicate
micro metastatic lesions
• Chemotherapy may be delivered intra-arterially for patients with osteosarcoma.
MANAGEMENT FOR SECONDARY BONE TUMORS
• The treatment of metastatic bone cancer es palliative
• Goal is to relieve the patient's pain and discomfort while promoting life.
• Patients with metastatic disease are at higher risk than other patients for postoperative
pulmonary congestion
• Hypercalcemia results from breakdown of bone
• Treatment includes hydration with IV administration of normal saline solution; dieresis;
mobilization; and medication such as bisphosphonates, (e.g., pamidronate [Aredia])
and calcitonin.

NURSING MANAGEMENT
• Provide quiet environment and calm activities to prevent or lessen pain.
• Provide comfort measure such as back rub, change position and use of heat or cold
application.
• Encourage diversional activities
• Administer analgesics as indicated to maximal dose as needed.
• Encourage the patient to increase fluid intake.
• Encourage rest periods to prevent fatigue.
• Provide accurate information about the situation, medication and treatment.
• Assess muscle strength, gross and fine motor coordination.
• Provide pillows for cushion and support.
• Keep side rails up all the time.
 NEUROLOGIC

1. HEADACHES
INTRODUCTION
• Other term: Cephalgia
• It is a symptom rather than a disease entity
Headaches are a very common condition that most people will experience many times
during their lives. The main symptom of a headache is a pain in your head or face. This can
be throbbing, constant, sharp or dull. Headaches can be treated with medication, stress
management and biofeedback.
Classification
1. Primary Headache
• No organic cause can be identified
Migraine
• It is a complex of symptoms characterized by periodic and recurrent attacks of severe
headache lasting from 4 to 72 hours in adults.
• Throbbing, boring, viselike and pounding pain
Types of Migraine:
1) Classic Migraine
• Gas a pre-headache in which the patient may experience visual disturbance, difficulty
with speaking, and/or numbness or tingling
2) Common Migraine
• Does not have a pre-headache, but the patient experience an immediate onset of a
throbbing headaches
Four Phase of Migraine
1. Prodromal Phase
• Symptoms that occur hour to days before a migraine headaches
• Depression
• Irritation
• Feeling cold
• Anorexia
• Changes in activity level
• Increased urination
• Diarrhea/constipation
2. Aura Phase
• Last less than 1 hour
• Characterized by focal neurologic symptoms.
• Visual disturbance (light flashes & bright spots)
• Numbness & tingling of the lips, face or hands
• Mild confusion
• Slight weakness of an extremity
• Drowsiness & dizziness
3. Headaches Phase
• Several hours of throbbing headaches
• Photophobia
• N/V
• Duration of manifestation: 4 to 72 hours
4. Recovery Phase
• Also termed as Termination/Postdrome
• Pain gradually subside
• Muscles contraction in the neck
• Localized tenderness
• Exhaustion
Tension-Type
• Most common type of headaches
• Chronic & less severe
Cluster headaches
• Severe form of vascular headaches
• Most frequent in men
Secondary Headaches
• Symptom associated with an organic cause (brain tumor aneurysm)
CLINICAL MANIFESTATION
• Pressure pain & tight feeling in the temporal area
• Nausea
• Weakness
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
⚫ Blood chemistry and urinalysis. These tests may determine many medical conditions,
including diabetes, thyroid problems, and infections, which can cause headaches.
⚫ CT scan. This is a test in which X-rays and computers are used to produce an image of a
cross-section of the body. A CT scan of the head may be recommended to rule out other
conditions if you are getting daily or almost daily headaches.
⚫ MRI. This test produces very clear pictures, or images, of the brain without the use of X-rays.
It uses a large magnet, radio waves, and a computer to produce these images. An MRI
may be recommended if you are getting daily or almost daily headaches. It may also be
recommended if a CT scan does not show definitive results. In addition, an MRI scan is used
to evaluate certain parts of the brain that are not as easily viewed with CT scans, such as
the spine at the level of the neck and the back portion of the brain.
⚫ Sinus X-ray. Although the CT scan and MRI provide more details, your doctor may use this
test if your symptoms seem to indicate sinus problems.
⚫ EEG. Electroencephalogram is not a standard part of a headache evaluation, but may be
performed if your doctor suspects you are having seizures.
⚫ Eye exam. An eye pressure test performed by an eye doctor will rule out glaucoma or
pressure on the optic nerve as a cause of headaches.
⚫ Spinal tap. This is the removal of fluid from your spine. It looks for conditions such as
infections of the brain or spinal cord.
NURSING DIAGNOSIS
• Acute pain related to headache
• Activity intolerance related to headache
• Impaired comfort related to headache as evidenced by pain
• Disturbed sleep pattern related to headache
MEDICAL MANAGEMENT
• Abortive approach
✓ Best use in patient who have less frequent attacks
✓ Aimed at relieving or limiting a headache at the onset or while it is in progress
• Preventive approach
✓ Used in patient who experience more frequent attacks at regular or predictable
intervals
✓ May have medical condition that precludes the use of abortive therapies
• Anti-migraine Agents
✓ Cause vasoconstriction, reduce inflammation and may reduce pain transmission

Triptans – for both migraines and episodic tension typr of headaches

1. Sumatriptan
• Most widely used
• Effective for the treatment of acute migraine & cluster headaches
• Contraindicated: Ischemic heart diseases (causes chest pain)
2. Naratriptan
3. Rizatriptan
 4. Zolmitriptan
5. Almotriptan

Serotonin Receptor Agonists

1. Ondansetron
2. Granisetron
3. Dolasetron

NURSING MANAGEMENT
• Goals:
✓ Enhance pain relief
✓ Treat acute event of headache
✓ Prevent recurrent episodes
• Provide comfort measures
✓ Quiet, dark environment
✓ Elevation of the head of the bed to 30 degrees
✓ Application of local heat / massage
✓ Administration of analgesic agents
• Biofeedback / Stress reduction
✓ This helps the patient participate in the treatment of the headache and provides in
the treatment of the headache and provides a sense of control over his or her illness
• Exercise Programs
• Meditation
2. INCREASED INTRACRANIAL PRESSURE
INTRODUCTION
• Increase in intracranial bulk due to increase in any of the major intracranial
components: brain, CSF, or blood.
• Increased intracranial pressure is a medical term that refers to growing pressure inside a
person’s skull
• Normal: 0 to 10 mm Hp: 15 mm Hg (upper limit of normal
CLINICAL MANIFESTATION
• Early Manifestations
✓ Changes in LOC (earliest)
✓ Pupillary changes (fixed, slowed response)
✓ Slowing of speech Restlessness
✓ Confusion
✓ Increasing drowsiness
• Late Manifestations
✓ Decorticate – arms are adducted and flexed against the chest = arms are liked “C”
✓ Decerebrate – arms are straight, extended and hands are curled = arms like “E”
• Cushing’s Triad
✓ Bradycardia – decrease heart (pulse) rate
✓ Hypertension – increase blood pressure
✓ Bradypnea – decrease respiratory rate
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• CT Scan & MRI (most common) can usually determine the cause of increased
intracranial pressure and confirm the diagnosis
• Cerebral Angiography
• Positron Emission Tomography (PET) Scan
• Spinal tap (lumbar puncture). This test measures the pressure of cerebrospinal fluid.
NURSING DIAGNOSIS
• Ineffective airway clearance related to diminished protective reflexes
• Ineffective breathing pattern related to neurologic dysfunction
• Ineffective cerebral tissue perfusion related to the effect of increased intracranial
pressure
• Deficient fluid volume related to fluid restriction
• Acute pain related to ICP
MEDICAL MANAGEMENT
Administer prescribed medications:
• Mannitol
• Corticosteroid
• Anticonvulsant
NURSING MANAGEMENT
• Maintain patent airway
• Elevate the head of the bed 30 to 45 degrees unless contraindicated to facilitate
venous drainage
• Assist in administering 100% oxygen
• Prevent Valsalva Maneuver and the activities that may increase ICP
3. CEREBROVASCULAR ACCIDENT
INTRODUCTION
Cerebrovascular accident: The sudden death of some brain cells due to lack of oxygen
when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain.
A CVA is also referred to as a stroke.
Refers to a functional abnormality of the central nervous system (CNS) that that occurs
when the normal blood supply to the brat is disrupted.
Types:
• Ischemic Stroke
✓ Caused by thrombus (common) and embolus
Types based on cause:
✓ Large artery thrombotic strokes
✓ Due to atherosclerotic plaques in the large blood vessels of the brain.
✓ Small penetrating artery
➢ Thrombotic strokes affect one or more vessels
➢ Most common type of ischemic stroke
✓ Cardiogenic embolic strokes
➢ Associated with dysrhythmias usually atrial fibrillation
✓ Cryptogenic Stroke
• Hemorrhagic Stroke
✓ Caused commonly by hypertension
Types based on cause:
✓ Intracerebral Hemorrhage
➢ Most common in patients with hypertension & cerebral atherosclerosis
✓ Intracranial Aneurysm
➢ Dilation of the walls of a cerebral artery that develops as a result of weakness in
the arterial wall
✓ Arteriovenous Malformation
➢ This is due to an abnormality in embryonal development that leads to a tangle of
arteries and veins in the brain without capillary bed.
• Subarachnoid Hemorrhage
✓ Most common cause is a leaking aneurysm in the area of the Circle of Willis or a
congenital AVM of the brain
❖ Diagnostic Tests
• CT Scan
• MRI
• Angiography
❖ Risk Factors
• Hypertension (major risk factor)
• Atrial fibrillation
• Hyperlipidemia
• DM
• Advanced Age (>55 y/o)
• Race (African-American)
• Smoking
• Asymptomatic Carotid Stenosis
• Obesity
• Excessive alcohol consumption
CLINICAL MANIFESTATION
• Sudden numbness or weakness in the face, arm or leg (especially on one side of the
body).
• Sudden confusion or trouble speaking or understanding speech.
• Sudden vision problems in one or both eyes.
• Sudden difficulty walking or dizziness, loss of balance or problems with coordination.
• Severe headache with no known cause.Cognitive Disturbance
• Confusion / Altered LOC
Visual-Perceptual Disturbance
 • Homonymous Hemianopsia (loss of half of the visual field)
• Loss of peripheral vision
• Double vision
Motor Loss
• Hemiplegia (most common)
• Hemiparesis
• Loss/Decrease in deep tendon reflexes
• Ataxia
Communication Loss
• Dysarthria (difficulty in speaking)
• Dysphasia (impaired speech)
• Apraxia (inability to perform a previously learned actions)
Expressive Aphasia
✓ Unable to form words that are understandable
✓ May be able to speak in single-word responses
Receptive Aphasia
✓ Unable to comprehend the spoken word
✓ Can speak but may not make sense
Global (Mixed) Aphasia
✓ Combination of both receptive and expressive aphasia
Sensory Loss
• Paresthesia
Emotional Deficits
• Loss of self-control
• Emotional lability
• Decreased tolerance to stressful situations
• Depression
• Withdrawal
• Fear, hostility & anger
• Feelings of isolation
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Complete blood count. This includes a check for your level of platelets, which are cells
that help clot blood.
• PET scan. Provides data on cerebral metabolism and blood flow changes.
• MRI. Shows areas of infarction, hemorrhage, AV malformations, and areas of ischemia.
• Cerebral angiography. Helps determine specific cause of stroke, e.g., hemorrhage or
obstructed artery, pinpoints site of occlusion or rupture. Digital subtraction angiography
evaluates patency of cerebral vessels, identifies their position in head and neck, and
detects/evaluates lesions and vascular abnormalities.
• EEG. Identifies problems based on reduced electrical activity in specific areas of
infarction; and can differentiate seizure activity from CVA damage.
• ECG and echocardiography. To rule out cardiac origin as source of embolus (20% of
strokes are the result of blood or vegetative emboli associated with valvular disease,
dysrhythmias, or endocarditis).
NURSING DIAGNOSIS
• Impaired physical mobility related to hemiparesis, loss of balance and coordination,
spasticity, and brain injury.
• Acute pain related to hemiplegia and disuse.
• Deficient self-care related to stroke sequelae.
• Disturbed sensory perception related to altered sensory reception, transmission, and/or
integration.
• Impaired urinary elimination related to flaccid bladder, detrusor instability, confusion, or
difficulty in communicating.
 • Disturbed thought processes related to brain damage.
• Impaired verbal communication related to brain damage.
• Risk for impaired skin integrity related to hemiparesis or hemiplegia and decreased
mobility.
• Interrupted family processes related to catastrophic illness and caregiving burdens.
• Sexual dysfunction related to neurologic deficits or fear of failure.
MEDICAL MANAGEMENT
• Platelet-inhibiting medications: aspirin, dipyridamole (persantine), clopidogrel (plavix),
and ticlopidine (ticlid) to make the platelets less sticky and thereby help prevent blood
clots from forming in the arteries.
• Thrombolytic therapy to help dissolve the clot quicly.
• Carotid endarterectomy. This is the removal of atherosclerotic plaque or thrombus from
the carotid artery to prevent stroke in patients with occlusive disease of the extracranial
cerebral arteries.
• Hemicraniectomy. Hemicraniectomy may be performed for increased ICP from brain
edema in severe cases of stroke.
NURSING MANAGEMENT
• Prevent shoulder adduction with a pillow placed in the axilla.
• Ensure patent airway
• Give 100% 02 (decreases /CP)
• Maintain a quiet, restful environment
• Position: Lateral (initially): Low fowlers with neck aligned (stable)
• Monitor VS & GCS, pupil size
• Provide safety measures (Hemianopsia)
✓ Approach client on unaffected side
✓ Place personal belongings. Foods on unaffected side
✓ Instruct/remind the patient to turn head in the direction of visual loss to compensate
for loss of visual field
• Manage dysphagia
✓ Check gag reflex before feeding client
✓ Maintain calm, unhurried approach
✓ Upright position
✓ Place food in unaffected side of the mouth ü Offer soft foods Give mouth care before
and after meals
• Manage motor deficits
✓ Place objects within the patient reach on the non-affected side
✓ Instruct the client to exercise and increase the strength on the unaffected side
✓ Encourage the client to provide range-of-motion exercises to the affected side
✓ Maintain body alignment in functional position as needed.
• Manage verbal deficits
✓ Encourage patient to repeat sounds of the alphabet
✓ Explore the patient's ability to write as an alternative means of communication
✓ Speak slowly and clearly
✓ Explore the patient's ability to read as an alternative means of communication
✓ Speak clearly in simple sentences
✓ Use gestures or pictures when able
• Manage cognitive deficits
✓ Reorient patient to time, place and situation frequently.
✓ Provide familiar objects
4. MENINGITIS
INTRODUCTION
Meningitis is an inflammation (swelling) of the protective membranes covering the brain and
spinal cord. A bacterial or viral infection of the fluid surrounding the brain and spinal cord
usually causes the swelling. However, injuries, cancer, certain drugs, and other types of
infections also can cause meningitis. It is important to know the specific cause of meningitis
because the treatment differs depending on the cause.
CLINICAL MANIFESTATION
• Headache and fever (initial symptoms)
• Positive Kernig's sign
• Positive Brudzinski's sign
• Photophobia
• Nuchal rigidity
• Opisthotonus

PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Bacterial culture & Gram Staining of CSF & blood through lumbar puncture

NURSING DIAGNOSIS
• Acute pain related to Inflammation or irritation of the meninges as evidenced by
Narrowed focus.
• Ineffective cerebral tissue perfusion related to hypoxemia as evidence by
restlessness.
• Disturbed sensory perception related to decreased loss of consciousness as
evidence by disorientation to time, place and person.

MEDICAL MANAGEMENT
• Vancomycin
• Cephalosporins
• Dexamethasone
• Fluid volume expanders

NURSING MANAGEMENT
• Administer large doses of antibiotics IV as ordered
• Enforce respiratory isolation for 24 hours after initiation of antibiotic medication"
• Provide bed rest; keep room dark and 1 quiet
• Administer analgesics for headache ordered
• Maintain fluid and electrolyte balance
• Monitor vital signs and neurol assessment frequently
• Diet: High calorie, high protein, small frequent feeding
• Monitoring daily body weight
• Prevent development of pressure & pneumonia
5. ENCEPHALITIS
INTRODUCTION
Encephalitis is inflammation of the brain. There are several causes, including viral infection,
autoimmune inflammation, bacterial infection, insect bites and others. Sometimes there is no
known cause. Encephalitis may cause only mild flu-like signs and symptoms such as a fever or
headache or no symptoms at all. Sometimes the flu-like symptoms are more severe.
Encephalitis can also cause severe symptoms including confusion, seizures, or problems with
movement or with senses such as sight or hearing. In some cases, encephalitis can be life-
threatening. Prompt diagnosis and treatment are important because it's difficult to predict
how encephalitis will affect each individual.
CLINICAL MANIFESTATION
• Headache & fever (most presenting symptoms)
• Nuchal rigidity
• Confusion
• Decreased level of consciousness
• Seizures
• Sensitivity to light
• Ataxia
• Abnormal sleep patterns
• Tremors
• Hemiparesis

PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• CT Scan
• MRI
• Lumbar puncture
• EEG

NURSING DIAGNOSIS
• Ineffective Cerebral Tissue Perfusion related to inflammatory processes, increased ICP
(increased intracranial pressure)
• Risk for injury related to disorientation, seizures, and the unfamiliar environment.
• Altered thought processes related to changes in the level of consciousness.
• Imbalanced Nutrition: Less Than Body Requirements related to anorexia, fatigue,
nausea, and vomiting.
MEDICAL MANAGEMENT
• Anticonvulsants
• Antipyretics
• Analgesics
• Sedatives Antiviral (Acyclovir)

NURSING MANAGEMENT
• Monitor vital signs
• Perform neurological assessment frequently
• Provide nursing care for confused / unconscious client
• Comfort measures to reduce stress:
✓ Dimming the lights
✓ Limiting the noise
✓ Administering analgesics
• Injury prevention is key because of the potential for falls and seizures
6. SEIZURES
INTRODUCTION
A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause
changes in your behavior, movements or feelings, and in levels of consciousness. Having two
or more seizures at least 24 hours apart that aren't brought on by an identifiable cause is
generally considered to be epilepsy. There are many types of seizures, which range in
symptoms and severity. Seizure types vary by where in the brain they begin and how far they
spread. Most seizures last from 30 seconds to two minutes. A seizure that lasts longer than five
minutes is a medical emergency. Seizures are more common than you might think. Seizures
can happen after a stroke, a closed head injury, an infection such as meningitis or another
illness. Many times, though, the cause of a seizure is unknown. Most seizure disorders can be
controlled with medication, but management of seizures can still have a significant impact on
your daily life. The good news is that you can work with your doctor to balance seizure control
and medication side effects.
Classifications of Seizures
1. Partial Seizures
• Seizures beginning locally
• Repetitive purposeless behaviors (classic symptoms)
• Patient appears to be in a dream-like state while picking at his / her clothing,
chewing or smacking his or her lips
❖ Simple Partial
• Does not lose consciousness
• Symptoms confined to one hemisphere
• Affectation of the motor change in posture), sensory (hallucinations), or autonomic
(flushing / tachycardia)
• Lasts for less than 1 minute
❖ Complex Partial
• Also termed as psychomotor seizure
• Consciousness is lost
• May last from 2 to 15 minutes
2. Generalized Seizures
• Entire cerebral cortex is involved
Absence Seizures
• Also referred to as petit mal seizure
• Most often seen in children
• Manifested by a period of staring for several seconds
• Precipitated by stress, hypoglycemia, fatigue, hyperventilation.
Tonic-clonic
• Also termed as grand mal seizures
• Lasts for 30 to 60 seconds
• Characterized by rigidity, fixed & dilated pupils, hands and jaws are clenched
• Patient's breathing may temporarily stop
• Urinary incontinence
Cyclonic
• Repeated shock like, often violent contractions in one or more muscle.

CLINICAL MANIFESTATION
• Temporary confusion
• A staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness
• Cognitive or emotional symptoms, such as fear, anxiety or deja vu

PATHOPHYSIOLOGY

DIAGNOSTIC TEST
 • ECG- abnormal wave patterns, focus of seizure activity
• CT scan- a space occupying lesion
• MRI- pathologic changes
• BRAIN MAPPING- identification of seizure areas
NURSING DIAGNOSIS
• Fluid volume deficit or excess related to seizure activity.
• Activity intolerance related to seizure activity.
MEDICAL MANAGEMENT
• Diet: Ketogenic (a diet high in fats and proteins, and low in carbohydrates)
• Activity: bed rest
• Monitoring: Vital signs, I/O, and neurovital signs
• Laboratory studies: glucose, potassium, and anticonvulsant drug levels if applicable
• Anticonvulsants: phenytoin (Dilantin), ethosuximide (Zarontin), Phenobarbital (Luminal),
Carbamazepine (Tegretol), valporic acid (Depakote), gabapentin (Neurontin),
lamotrigine (Lamictal), topiramote (Topamax)
NURSING MANAGEMENT
During Seizure
• Remove harmful objects from the patient's surrounding
• Ease the client to the floor
• Protect the head of the patient
• Observe and note for the duration, parts of the body affected, behaviors before and
after the seizure
• Loosen constrictive clothing
• Do not restrain, or attempt to place tongue blade or insert oral airway
After Seizure
• Document the events during and after the seizure
• Side-lying position (prevent aspiration)
• Suction equipment should be available Place bed in low position
7. MYASTHENIA GRAVIS
INTRODUCTION
Myasthenia gravis (MG) is an autoimmune disease a disease that occurs when the
immune system attacks the body’s own tissues. In MG, that attack interrupts the connection
between nerve and muscle the neuromuscular junction. Myasthenia gravis is characterized
by autoantibodies against the acetylcholine receptor, or against a receptor-associated
protein called muscle-specific tyrosine kinase. There are two clinical forms of myasthenia
gravis: ocular and generalized. In ocular myasthenia gravis, muscle weakness often first
appears in the muscles of the eyelids and other muscles that control movement of the eye
(extraocular muscle). In generalized MG, the weakness involves the ocular muscles and a
variable combination of the arm, legs, and respiratory muscles.
CLINICAL MANIFESTATION
• Diplopia & Ptosis (earliest)
• Dysphonia (voice impairment)
• Dysarthria
• Generalized weakness
• Respiratory paralysis (cause of death)

PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Tensilon Test (Edrophonium chloride)
✓ Fast-acting acetylcholinesterase inhibitor
✓ Positive (+) = resolved facial muscle weakness & ptosis (5 minutes)
✓ Atropine sulfate = for edrophonium toxicity
• EMG
✓ Detects delay or failure of neuromuscular transmission.
NURSING DIAGNOSIS
• Ineffective breathing pattern related to intercostal muscle weakness.
• Ineffective airway clearance related to muscle weakness.
• Impaired verbal communication related to weakening of larynx.
MEDICAL MANAGEMENT
• The aim of medical management is to improve function and reduce and remove
circulating antibodies.
• This could be achieved through: Anticholinesterase agents such as pyridostigmine
bromide and neostigmine bromide provide symptomatic relief by increasing the
concentration of available acetylcholine at the neuromuscular junction.
• Immunosuppressive therapy (corticosteroids, cyclophosphamide, azathioprine) aims to
reduce the production of the antibody.
• Prednisone appears to be successful in suppressing the disease.
• Pyridostigmine (first line of therapy)
• Neostigmine
• Plasmapheresis (plasma exchange; centrifugation of plasma in order to separate
packed cells and plasma)
• Thymectomy
Medications to be AVOIDED
• Muscle relaxant
• Barbiturates
• Morphine sulfate
• Tranquilizers
• Neomycin
NURSING MANAGEMENT
• Nursing care focuses on patient and family teaching.
• Educational topics include:
• Medication management where emphasis is placed on understanding their action,
taking them on time, consequences of delaying administration, and the signs and
symptoms of myasthenic and cholinergic crisis.
• Energy conservation through identifying the best times for rest periods throughout the
day. The nurse is in position to teach the patient various ways of conserving energy.
How? And to schedule activities to coincide with peak energy and strength levels.
8. MULTIPLE SCLEROSIS
INTRODUCTION
Multiple Sclerosis is a condition of the central nervous system and is chronic in nature.
This is described as the demyelination of the brain, spinal cord, and optic nerve’s white matter
and usually occurs as small patches. The multiple sclerosis (MS) is an autoimmune disease of
the central nervous system (CNS) characterized by chronic inflammation, demyelination,
gliosis, and neuronal loss. Multiple sclerosis is an immune-mediated inflammatory disease that
attacks myelinated axons in the central nervous system, destroying the myelin and the axon
in variable degrees and producing significant physical disability within 20-25 years in more than
30% of clients.
CLINICAL MANIFESTATION
• CHARCOT'S TRIAD
- Scanning speech
- Intentional tremors
- Nystagmus
• Visual Disturbances
- Blurring of vision
- Diplopia
- Patchy blindness
- Total blindness
• Sensory Nerve Disturbances
- Paresthesia
- Proprioception loss
- Pain
• Cognitive Disturbance
- Memory loss
- Decreased concentration
- Dementia
- Poor abstract reasoning
• Cerebellum / Basal Ganglia Involvement
- Ataxia
- Tremors
- Weakness of muscle in throat and face
• Others:
- Bowel & Bladder dysfunction
- Importance
- Muscle hypertonicity
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• MRI
• Electrophoresis (CSF)
• EEG
NURSING DIAGNOSIS
• Impaired physical mobility related to Pain and discomfort as evidence by muscle
cramps.
• Self-care deficit related to activity intolerance as evidence by Inability to perform tasks
of self-care.
• Impaired urinary elimination related to neurogenic bladder as evidence by urinary
frequency.
MEDICAL MANAGEMENT
Pharmacologic Therapy
• Interferon beta
• Methylprednisolone
• Baclofen (medication of choice for spasticity)
• Steroids
NURSING MANAGEMENT
Promoting physical mobility
• Walking
• Use of assistive devices
Others:
• Warm packs (minimizes spasticity of contractures)
• Avoid hot baths (increases risk for burn injury)
• Swimming & stationary bicycling are useful in treating muscle spasticity
• Strenuous exercises are to be avoided (this may exacerbate symptoms)
• Instruct client to prevent cuts and burns
• Eye patch for diplopia
• Respiratory distress precautions
• Bowel and bladder program
9. GUILLAIN — BARRE SYNDROME
INTRODUCTION
Guillain-Barre syndrome is a rare disorder in which your body's immune system attacks
your nerves. Weakness and tingling in your hands and feet are usually the first symptoms. These
sensations can quickly spread, eventually paralyzing your whole body. In its most severe form
Guillain-Barre syndrome is a medical emergency. Most people with the condition must be
hospitalized to receive treatment. There's no known cure for Guillain-Barre syndrome, but
several treatments can ease symptoms and reduce the duration of the illness. Although most
people recover completely from Guillain-Barre syndrome, some severe cases can be fatal.
While recovery may take up to several years, most people are able to walk again six months
after symptoms first started. Some people may have lasting effects from it, such as weakness,
numbness or fatigue.
CLINICAL MANIFESTATION
• Diminished reflexes and muscle weakness that goes upward
• Clumsiness (initial symptom)
• Paralysis of the diaphragm
• Dysphagia
• Respiratory depression
• Paresthesia
• Paralysis of the ocular muscles
• Ataxia
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• EMG
• CSF
• ECG
NURSING DIAGNOSIS
• Ineffective breathing pattern related to progressive weakness and impending
respiratory failure.
• Acute pain related to inflammation of nerves.
• Impaired physical mobility related to progressive loss of motor function and muscle
weakness as a result of disease process.
• Self-care deficit related to decreased motor function and strength.
• Anxiety related to loss of control and paralysis.

MEDICAL MANAGEMENT
• Plasmapheresis
• Corticosteroids
NURSING MANAGEMENT
• Mostly supportive
• Maintain adequate ventilation
• Incentive spirometry
• Chest physiotherapy
• Perform range-of-motion
• Assess gag reflex before starting the feeding
• Monitor vital signs
• Check cranial nerve function
• Administer corticosteroids to suppress immune function
10. PARKINSON’S DISEASE
Introduction
Parkinson’s disease is a condition where a part of your brain deteriorates, causing more severe
symptoms over time. While this condition is best known for how it affects muscle control,
balance and movement, it can also cause a wide range of other effects on your senses,
thinking ability, mental health and more.
Cause
- When nerve cells in the basal ganglia, an area of the brain that controls movement,
become impaired and/or die. Normally, these nerve cells, or neurons, produce an important
brain chemical known as dopamine. When the neurons die or become impaired, they
produce less dopamine, which causes the movement problems associated with the disease.
When dopamine levels decrease, it causes abnormal brain activity, leading to impaired
movement and other symptoms of Parkinson's disease.
Risk Factors
- Age. Young adults rarely experience Parkinson's disease. It ordinarily begins in middle or
late life, and the risk increases with age. People usually develop the disease around age 60 or
older.
- Heredity. Having a close relative with Parkinson's disease increases the chances that
you'll develop the disease. However, your risks are still small unless you have many relatives in
your family with Parkinson's disease.
- Exposure to toxins. Ongoing exposure to herbicides and pesticides may slightly increase
your risk of Parkinson's disease.
Signs and Symptoms
- Tremor in hands, arms, legs, jaw, or head
- Muscle stiffness, where muscle remains contracted for a long time
- Slowness of movement
- Impaired balance and coordination, sometimes leading to falls
Diagnostic Test
No specific test exists to diagnose Parkinson's disease. Your doctor trained in nervous system
conditions (neurologist) will diagnose Parkinson's disease based on your medical history, a
review of your signs and symptoms, and a neurological and physical examination.
Nursing diagnosis
• Impaired Physical Mobility related to stiffness and muscle weakness
• Self-care deficits related to neuromuscular weakness, decreased strength, loss of
muscle control / coordination
• Impaired Bowel Elimination: Constipation related to medication and decreased activity
• Imbalanced Nutrition: Less than Body Requirements related to tremor, slowing the
process of eating, difficulty chewing and swallowing
• Impaired verbal communication related to the decrease in the volume of speech,
delayed speech, inability to move facial muscles
• Ineffective individual coping related to depression and dysfunction due to disease
progression
• Knowledge Deficit related to information resources inadequate maintenance
procedures.
Treatment
⚫ Carbidopa-levodopa. Levodopa, the most effective Parkinson's disease medication, is a
natural chemical that passes into your brain and is converted to dopamine.
⚫ Dopamine agonists. Unlike levodopa, dopamine agonists don't change into dopamine.
Instead, they mimic dopamine effects in your brain.
⚫ Anticholinergics. These medications were used for many years to help control the tremor
associated with Parkinson's disease.
⚫ eating foods high in fiber and drinking an adequate amount of fluids can help prevent
constipation that is common in Parkinson's disease.
⚫ Exercising may increase your muscle strength, flexibility and balance. Exercise can also
improve your well-being and reduce depression or anxiety.
11. AMYOTROPHIC LATERAL SCERIOSIS
Introduction
Amyotrophic lateral sclerosis (ALS) refers to a group of progressive, neurological diseases that
cause dysfunction in the nerve cells in the brain and spinal cord that control muscle
movement.
Cause
It’s a disease that affects your motor neurons. These nerve cells send messages from your brain
to your spinal cord and then to your muscles. These motor neurons control all your voluntary
movements -- the muscles in your arms, legs, and face. They tell your muscles to contract so
you can walk, run, pick up your smartphone, chew and swallow food, and even breathe.
With ALS, motor neurons in your brain and spinal cord break down and die. When this happens,
your brain can't send messages to your muscles anymore. Because the muscles don't get any
signals, they become very weak. This is called atrophy. In time, the muscles no longer work
and you lose control over their movement.
Risk Factors
- Genetics
- Smoking. Smoking is the only likely environmental risk factor for ALS. The risk seems to be
greatest for women, particularly after menopause.
- Environmental toxin exposure. Some evidence suggests that exposure to lead or other
substances in the workplace or at home might be linked to ALS. Much study has been done,
but no single agent or chemical has been consistently associated with ALS.

Signs and Symptoms

• Difficulty walking or doing normal daily activities
• Tripping and falling
• Weakness in your legs, feet or ankles
• Hand weakness or clumsiness
• Slurred speech or trouble swallowing
• Muscle cramps and twitching in your arms, shoulders and tongue
• Inappropriate crying, laughing or yawning
• Cognitive and behavioral changes
Diagnose
- Electromyogram (EMG). Your doctor inserts a needle electrode through your skin into
various muscles. The test evaluates the electrical activity of your muscles when they contract
and when they're at rest.
- Abnormalities in muscles seen in an EMG can help doctors diagnose or rule out ALS. An
EMG can also help guide your exercise therapy.
- Nerve conduction study. This study measures your nerves' ability to send impulses to
muscles in different areas of your body. This test can determine if you have nerve damage or
certain muscle or nerve diseases.
- MRI. detailed images of your brain and spinal cord. An MRI can reveal spinal cord
tumors, herniated disks in your neck or other conditions that might be causing your symptoms.
- Blood and urine tests. Analyzing samples of your blood and urine in the laboratory might
help your doctor eliminate other possible causes of your signs and symptoms.
- Spinal tap (lumbar puncture). This involves removing a sample of your spinal fluid for
laboratory testing using a small needle inserted between two vertebrae in your lower back.
- Muscle biopsy. If your doctor believes you may have a muscle disease rather than ALS,
you might undergo a muscle biopsy. While you're under local anesthesia, a small portion of
your muscle is removed and sent to a lab for analysis.
Nursing diagnosis
• Ineffective breathing pattern related to respiratory muscle weakness.
• Risk for imbalance nutrition: less than body requirements related to dysphagia /
swallowing difficulties, secondary to cranial nerve disorders.
 • Impaired verbal communication related to dysarthria.
• Impaired physical mobility related to weakness and muscular damage secondary to
neuromuscular damage.
Treatment
There is no cure for ALS. But treatment can slow the progression of the disease. The right
treatment plan can help you stay comfortable and independent for as long as possible.
Treatments include:
- Medications to relieve muscle cramps, extra saliva and other symptoms
- Physical therapy to help you stay mobile. It can ease discomfort from stiff muscles,
cramps and fluid retention
- Nutritional counseling ensures you eat a healthy, balanced diet. A nutritionist can also
recommend other food options when swallowing becomes difficult
- Speech therapy provides strategies for safer swallowing and communication training
help you maintain verbal communication for as long as possible. You may also learn nonverbal
communication techniques
- Assistive devices, including splints, braces, grab bars and reach devices, help you stay
independent. You use these devices to get dressed, eat, use the toilet and bathe
- Special equipment such as wheelchairs and electric beds to help you function
independently.
12. SPINAL CORD INJURY
Introduction
- A spinal cord injury damages the spinal cord itself or nearby tissues and bones.
Depending on the severity of the injury, you may lose function or mobility in different parts of
your body.
- The spinal cord relays messages between the brain and the rest of the body. The body
loses many essential functions if an injury means nerves can’t communicate with the brain. A
damaged spinal cord can affect:
• Bladder and bowel (intestinal) function.
• Breathing.
• Heart rate.
• Metabolism, or the body’s process of converting food into energy.
• Muscle movement.
• Reflexes.
• Sensations
Causes
- Spinal cord injuries can result from damage to the vertebrae, ligaments or disks of the
spinal column or to the spinal cord itself.
- A traumatic spinal cord injury can stem from a sudden, traumatic blow to your spine
that fractures, dislocates, crushes or compresses one or more of your vertebrae. It can also
result from a gunshot or knife wound that penetrates and cuts your spinal cord.
Risk Factors
- Engaging in risky behavior. Diving into too-shallow water or playing sports without
wearing the proper safety gear or taking proper precautions can lead to spinal cord injuries.
Motor vehicle crashes are the leading cause of spinal cord injuries for people under 65.
- Having certain diseases. A relatively minor injury can cause a spinal cord injury if you
have another disorder that affects your joints or bones, such as osteoporosis.
Signs and Symptoms
- Extreme back pain or pressure in your neck, head or back
- Weakness, incoordination or paralysis in any part of your body
- Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
- Loss of bladder or bowel control
- Difficulty with balance and walking
- Impaired breathing after injury
- An oddly positioned or twisted neck or back
Diagnostic test
- CT scan, to see broken bones, blood clots or blood vessel damage.
- MRI, to see the spinal cord or soft tissues.
- X-ray, to show broken bones or dislocations (bones knocked out of place).
- Electromyogram (EMG) to check electrical activity in muscles and nerve cells if there
are co-exist peripheral nerve injury.
Nursing diagnosis
• Ineffective breathing patter related to impairment of diaphragm
• Disturbed sensory perception related to Destruction of sensory tracts with altered
sensory reception
• Acute pain related to physical injury
• Ineffective breathing patterns related to weakness or paralysis of abdomen and
intercostal muscles and inability to clear secretions
• Impaired physical mobility related to neuromuscular impairment
• Risk for Autonomic Dysreflexia related to altered nerve function
• Risk for impaired skin integrity related to immobility and sensory loss.
Treatment
- corticosteroid injection may help spinal cord injuries.
 • Improve blood flow.
• Preserve nerve function.
• Reduce inflammation.
- Immobilization. You might need traction to stabilize or align your spine. Options include
soft neck collars and various braces.
- Surgery. Often surgery is necessary to remove fragments of bones, foreign objects,
herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery might
also be needed to stabilize the spine to prevent future pain or deformity.
13. AUTONOMIC DYSREFLEXIA
Introduction
- autonomic dysreflexia is a serious medical problem that can happen if you’ve injured
your spinal cord in your upper back. It makes your blood pressure dangerously high and,
coupled with very low heartbeats, can lead to a stroke, seizure, or cardiac arrest.
- This happens when your autonomic nervous system -- which controls things like
breathing and digestion that you do without thinking -- overreacts to something below the
damaged spinal cord.

Cause
Autonomic nervous system s the part of the nervous system responsible for maintaining
involuntary bodily functions, such as:
• blood pressure
• heart and breathing rates
• body temperature
Two branches
- Sympathetic – Over reacts
- Para Sympathetic – Compensate
⚫ AD interrupts both the sympathetic and parasympathetic nervous systems. This means that
the body’s SANS overreacts to stimuli, such as a full bladder. What’s more, the PANS can’t
effectively stop that reaction.
⚫ Pain causes an automatic increase in blood pressure. Normally, the brain receives
messages about the rise in blood pressure and takes steps to lower it. With AD, the message
cannot reach the brain because of the spinal cord injury. This causes the blood pressure
to rise to dangerous levels.
⚫ However, the messages still go to the parts of the sympathetic and parasympathetic
autonomic nervous systems that operate below the spinal cord injury.

⚫ Signals can trigger the SANS and PANS, but the brain can’t appropriately respond to them,
so they no longer work effectively as a team. The result is that the SANS and PANS can get
out of control.
Risk Factors
- All patients with spinal cord injury at or above T6
- Osteoporosis
Signs and Symptoms
- Heavy sweating
- Anxiety
- Slow heart rate
- Blurry vision
- Dilated pupils
- Goosebumps on the lower body
- Trouble breathing
Diagnostic Test
- Physical Exam: Physical examination will reveal increased blood pressure, an abnormally
fast or slow heart rate, and dilated pupils. Physicians will also exam patients to identify the
underlying causes of this response.ECG or an echocardiogram to check the heart function
- Blood and urine tests
Nursing diagnosis
• Risk for seizure related to loss of muscular control
• Risk for fall related to loss of sensory coordination and muscular control
Treatment
- sitting upright, or receiving assistance to sit upright, to help lower blood pressure
- checking for bladder or bowel triggers and treating them as needed
- removing tight clothes and socks
- removing any other potential triggers, such as drafts of air blowing on you or objects
touching your skin
- administering medication to bring your blood pressure under control

14. ALZHEIMER’S DISEASE

Introduction
- Alzheimer’s disease is a progressive form of dementia. Dementia is a broader term for
conditions that negatively affect memory, thinking, and behavior. The changes interfere with
daily living.
- Alzheimer’s disease is a chronic (long-term), ongoing condition. It is not a typical sign of
aging.
- Alzheimer’s and dementia aren’t the same thing. Alzheimer’s disease is a type of
dementia.
- Its symptoms come on gradually, and the effects on the brain are degenerative,
meaning they cause slow decline
Causes
- Alzheimer’s disease is caused by the abnormal build-up of proteins in the brain. The
build-up of these proteins — called amyloid protein and tau protein — leads to cell death.

- The human brain contains over 100 billion nerve cells as well as other cells. The nerve
cells work together to fulfill all the communications needed to perform such functions as
thinking, learning, remembering, and planning. Scientists believe that amyloid protein builds
up in the brain cells, forming larger masses called plaques. Twisted fibers of another protein
called tau form into tangles. These plaques and tangles block the communication between
nerve cells, which prevents them from carrying out their processes. The slow and ongoing
death of the nerve cells, starting in one area of the brain (usually in the area of the brain that
controls memory) then spreading to other areas, results in the symptoms seen in patients with
Alzheimer’s disease
o Plaques. Beta-amyloid is a fragment of a larger protein. When these fragments cluster
together, they appear to have a toxic effect on neurons and to disrupt cell-to-cell
communication. These clusters form larger deposits called amyloid plaques, which also
include other cellular debris.
o Neurofibrillary tangles are abnormal accumulations of a protein called tau that collect
inside neurons. Healthy neurons, in part, are supported internally by structures called
microtubules, which help guide nutrients and molecules from the cell body to the axon and
dendrites. In healthy neurons, tau normally binds to and stabilizes microtubules. In Alzheimer’s
disease, however, abnormal chemical changes cause tau to detach from microtubules and
stick to other tau molecules, forming threads that eventually join to form tangles inside neurons.
These tangles block the neuron’s transport system, which harms the synaptic communication
between neurons.
Risk Factors
- Age is the greatest known risk factor for Alzheimer's disease. Alzheimer's is not a part of
normal aging, but as you grow older the likelihood of developing Alzheimer's disease
increases.
- a family history of the condition
- untreated depression, although depression can also be one of the symptoms of
Alzheimer's disease
- lifestyle factors and conditions associated with cardiovascular disease.
Signs and Symptoms
- confusion, disorientation and getting lost in familiar places
- difficulty planning or making decisions
- problems with speech and language
 - problems moving around without assistance or performing self-care tasks
- personality changes, such as becoming aggressive, demanding and suspicious of
others
- hallucinations (seeing or hearing things that are not there) and delusions (believing
things that are untrue)
- low mood or anxiety
Diagnostic Test
- Magnetic resonance imaging (MRI). produce detailed images of the brain. While they
may show brain shrinkage of brain regions associated with Alzheimer's disease, MRI scans also
rule out other conditions.
- Computerized tomography (CT). cross-sectional images (slices) of your brain. It's usually
used to rule out tumors, strokes and head injuries.
Nursing diagnosis
• Self-care deficit related to impaired cognitive and motor function
• Risk for injury related to unable to recognize/identify hazards in the environment
• impaired thought processes related to changes in cognitive abilities
• Ineffective family coping related to the presence of a chronic disease on a family
member that exhausts the family
Management
- Memantine (Namenda). This drug works in another brain cell communication network
and slows the progression of symptoms with moderate to severe Alzheimer's disease.
- Cholinesterase inhibitors. These drugs work by boosting levels of cell-to-cell
communication by preserving a chemical messenger that is depleted in the brain by
Alzheimer's disease.
- Regular exercise is an important part of a treatment plan. Activities such as a daily walk
can help improve mood and maintain the health of joints, muscles and the heart.
- Nutrition
- Daily social activities
15. BELL’S PALSY
Introduction
- Bell’s palsy is a condition that causes a temporary weakness or paralysis of the muscles
in the face. It can occur when the nerve that controls your facial muscles becomes inflamed,
swollen, or compressed. The condition causes one side of your face to droop or become stiff.
You may have difficulty smiling or closing your eye on the affected side. In most cases, Bell’s
palsy is temporary, and symptoms usually go away within a few weeks or months.
Causes
The nerve that controls facial muscles passes through a narrow corridor of bone on its way to
the face. In Bell's palsy, that nerve becomes inflamed and swollen — usually related to a viral
infection. Besides facial muscles, the nerve affects tears, saliva, taste and a small bone in the
middle of the ear.
o German measles (rubella)
o Mumps (mumps virus)
o Flu (influenza B)
Risk Factors
- Family History
- Have an upper respiratory infection, such as the flu or a cold
- Have diabetes
- Have high blood pressure
- Have obesity
Signs and Symptoms
- Rapid onset of mild weakness to total paralysis on one side of your face — occurring
within hours to days
- Facial droop and difficulty making facial expressions, such as closing your eye or smiling
- Drooling
- Pain around the jaw or in or behind your ear on the affected side
- Increased sensitivity to sound on the affected side
- Headache
Diagnostic Test
- blood tests to check for the presence of a bacterial or viral infection
- blood tests to check for diabetes or other conditions
- imaging tests such as an MRI or CT scan to check the nerves in your face and rule out
the possibility of a stroke or brain tumor
- an electromyography (EMG) test, in which a doctor inserts very thin wire electrodes into
a muscle to confirm whether there’s any damage to the nerves that control the facial muscles
— this test can also determine how much damage there is
Nursing diagnosis
• Body image disturbance related to alteration in structure and function for vision
Treatment/ Management
- corticosteroid drugs, which reduce inflammation
- antiviral or antibacterial medication, which may be prescribed if a virus or bacteria
causes your Bell’s palsy
- over-the-counter pain medications, such as ibuprofen or acetaminophen, which can
help relieve mild pain
- eye drops to keep your affected eye well lubricated
- an eye patch (for your dry eye)
- a warm, moist towel over your face to relieve pain
- facial massage
- physical therapy exercises to stimulate your facial muscles
16. HUNTINGTON’S DISEASE
Introduction
- Huntington's disease (HD) is a hereditary and deadly disorder that causes nerve cells in
the brain to break down. This causes physical and mental abilities to weaken, and they get
worse over time. There is no cure. If it starts early in life, it’s called juvenile Huntington’s disease.
Cause
- Huntington's disease is caused by an altered gene. This gene is passed on from parent
to child. Huntington's disease is an autosomal dominant disorder, which means that a person
needs only one copy of the nontypical gene to develop the disorder.
- Huntington’s disease (HD) is a brain disease that is passed down in families from
generation to generation. It is caused by a mistake in the DNA instructions that build our bodies
and keep them running. DNA is made up of thousands of genes, and people with HD have a
small error in one gene, called huntingtin. Over time this error causes damage to the brain and
leads to HD symptoms.
Signs and symptoms
Physical symptoms include:
- Mild twitching of the fingers and toes
- Lack of coordination and a tendency to knock things over
- Walking difficulties
- Dance-like or jerky movements of the arms or legs (chorea)
- Speech and swallowing difficulties.
Cognitive symptoms include:
- Short-term memory loss
- Difficulties in concentrating, learning new things and making plans.
- Rigidity in thought patterns
Diagnosis
- Brain-imaging tests for assessing the structure or function of the brain. The imaging
technologies may include MRI or CT scans that show detailed images of the brain.
- Genetic test for the nontypical gene.- This test can confirm the diagnosis. It may also be
valuable if there's no known family history of Huntington's disease or if no other family member's
diagnosis was confirmed with a genetic test.

Nursing diagnosis

Treatment
- Drugs to control movement include tetrabenazine (Xenazine) and deutetrabenazine
(Austedo).
- Antipsychotic drugs, such as haloperidol and fluphenazine, have a side effect of
suppressing movements
- Psychotherapy - A psychotherapist — a psychiatrist, psychologist or clinical social worker
— can provide talk therapy to help with behavioral problems, develop coping strategies,
manage expectations during progression of the disease.
- Speech therapy- Huntington's disease can significantly impair control of muscles of the
mouth and throat that are essential for speech, eating and swallowing. A speech therapist
can help improve your ability to speak clearly or teach you to use communication devices
- A physical therapist can teach you appropriate and safe exercises that enhance
strength, flexibility, balance and coordination. These exercises can help maintain mobility as
long as possible and may reduce the risk of falls.
17. TRIGEMINAL NEURALGIA
Introduction
Trigeminal neuralgia is a condition that causes painful sensations similar to an electric shock
on one side of the face. This chronic pain condition affects the trigeminal nerve, which carries
sensation from your face to your brain. If you have trigeminal neuralgia, even mild stimulation
of your face — such as from brushing your teeth or putting on makeup — may trigger a jolt of
excruciating pain.
You may initially experience short, mild attacks. But trigeminal neuralgia can progress and
cause longer, more-frequent bouts of searing pain. Trigeminal neuralgia affects women more
often than men, and it's more likely to occur in people who are older than 50.
Cause
In trigeminal neuralgia, also called tic douloureux, the trigeminal nerve's function is disrupted.
Usually, the problem is contact between a normal blood vessel — in this case, an artery or a
vein — and the trigeminal nerve at the base of your brain. This contact puts pressure on the
nerve and causes it to malfunction.
While compression by a blood vessel is one of the more common causes of trigeminal
neuralgia, there are many other potential causes as well. Some may be related to multiple
sclerosis or a similar disorder that damages the myelin sheath protecting certain nerves.
Trigeminal neuralgia can also be caused by a tumor compressing the trigeminal nerve.
Some people may experience trigeminal neuralgia due to a brain lesion or other
abnormalities. In other cases, surgical injuries, stroke or facial trauma may be responsible for
trigeminal neuralgia.

Risk Factors
- Age and gender are primary risk factors, as women over the age of 50 are most likely to
develop this condition. Hypertension (high blood pressure) is also a risk factor, as is the
occurrence of a stroke.
- Excessive or improper dental work can cause neuropathic facial pain, as can surgery
on the sinuses.
- blow or injury to the face (i.e., as a result of a contact sport injury) is a risk factor for
trigeminal neuralgia.
Signs and Symptoms
- Episodes of severe, shooting or jabbing pain that may feel like an electric shock
- Spontaneous attacks of pain or attacks triggered by things such as touching the face,
chewing, speaking or brushing teeth
- Pain that occurs with facial spasms
- Pain in areas supplied by the trigeminal nerve, including the cheek, jaw, teeth, gums,
lips, or less often the eye and forehead
- Pain affecting one side of the face at a time
Diagnostic Test
- Be ready to tell your doctor about how your pain first appeared, how often you feel it,
and what seems to trigger it.
- neurological examination. Touching and examining parts of your face can help your
doctor determine exactly where the pain is occurring and — if you appear to have trigeminal
neuralgia — which branches of the trigeminal nerve may be affected. Reflex tests also can
help your doctor determine if your symptoms are caused by a compressed nerve or another
condition.
- Magnetic resonance imaging (MRI). Your doctor may order an MRI scan of your head
to determine if multiple sclerosis or a tumor is causing trigeminal neuralgia
Nursing diagnosis
• Chronic Pain related to trigeminal nerve compression and inflammation of the temporal
artery.
 • Imbalanced nutrition: less than body requirements related to pain when chewing
• Ineffective individual coping related to severe pain, excessive threats to self.
• Knowledge deficit; regarding the condition and need for treatment related to cognitive
limitations.
• Anxiety related to disease prognosis and changes in health
• Ineffective self-health management related to lack of knowledge about preventing
pain-triggering stimuli.
• Risk for injury ; in the eye related to risk factors: possible decreased corneal sensation
Treatment
- To keep the nerves from reacting to irritation, you may take anticonvulsant medications.
- You also may take muscle relaxants -- alone or along with anticonvulsants.
- Your doctor may suggest a tricyclic antidepressant to manage your symptoms
- Microvascular decompression, which moves or takes out blood vessels that are
affecting the nerve.
- Neurectomy, in which the trigeminal nerve is partly cut to relieve pain.
 SENSES

1. BLEPHARITIS
INTRODUCTION
Blepharitis it is the inflammation of the eyelids that is marked by red, scaly, crusting eyelids and
a burning, itching, grainy feeling in the eye. The eye itself often has some redness. There are
two forms of blepharitis: anterior, which affects the exterior edge of the eyelid, and posterior,
which affects the inner part of the eyelid (the surface that touches the eye). Anterior
blepharitis can result from either an infectious or a noninfectious process, while posterior
blepharitis is caused by dysfunction of the meibomian glands, which are oil-secreting glands
located along the lid margin behind the eyelashes.
CLINICAL MANIFESTATION
• Flaking
• Redness
• Irritation
• Recurrent styes
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Culture from eyelid margins: Culture from eyelid margins may be done for patients with
recurrent anterior blepharitis having severe inflammation or who are not responding to
treatment.
• Microscopic evaluation: Microscopic evaluation of eyelashes may reveal Demodex
mites.
• Biopsy: Biopsy from eyelid may be indicated to exclude the possibility of carcinoma in
cases showing marked asymmetry or one with unifocal recurrent chalazion not
responding to therapy.
• Histological findings:
• Seborrhoeic blepharitis: Seborrhoeic blepharitis shows spongiosis, mild perivascular
lymphohistiocytic, mononuclear cellular infiltrates in superficial dermis.
• Staphylococcal blepharitis: Staphylococcal blepharitis is a chronic non-granulomatous
inflammation, usually with neutrophils and often shows acanthosis or parakeratosis.
NURSING DIAGNOSIS
• Acute pain r / t inflammation due to bacterial infection.
• Anxiety r / t visual impairment, damage to the eyelids.
• Risk for injury r / t the deficit of knowledge, blurred vision or decrease the sharpness of
the eyes
MEDICAL MANAGEMENT
Medical therapy:
• Antibiotics: Topical antibiotics are useful to provide symptomatic relief and in
eradicating bacteria from eyelid margin.
• Oral antibiotics: Oral antibiotics are recommended for patients with MGD not controlled
with eyelid hygiene or patients with associated rosacea.
• Steroids: Short courses of topical steroids provide symptomatic relief in cases with
significant ocular inflammation.
• Combined antibiotic and steroid: Topical combination of antibiotic and steroid is useful
in cases with coexistent bacterial infection and inflammation.
• Artificial tears: Many blepharitis patients have tear film abnormalities. Topical lubrication
with artificial tears may improve symptoms when used as an adjunct to eyelid hygiene
and medications.
• Cyclosporine: In patients with severe blepharitis, topical cyclosporine improve
symptoms superior to combined antibiotic and steroid regimen.
NURSING MANAGEMENT
General measures:
• Eyelid hygiene: Eyelid hygiene includes warm compresses, eyelid massage and eyelid
scrubs with wet washcloth and no tears baby shampoo, help to clear scales and debris.
2. CONJUNCTIVITIS
INTRODUCTION
Pink eye (conjunctivitis) is the inflammation or infection of the transparent membrane that lines
your eyelid and eyeball. It's characterized by redness and a gritty sensation in your eye, along
with itching. Often a discharge forms a crust on your eyelashes during the night.
CLINICAL MANIFESTATION
• Foreign body sensation in the eyes
• Scratching or burning sensation
• Itching and photophobia
DIAGNOSTIC TEST
• Patient history to determine the symptoms, when the symptoms began, and
whether any general health or environmental conditions are contributing to
the problem.
• Visual acuity measurements to determine whether vision has been affected.
• Evaluation of the conjunctiva and external eye tissue using bright light and
magnification.
• Evaluation of the inner structures of the eye to ensure that no other tissues are
affected by the condition.
• Supplemental testing, which may include taking cultures or smears of
conjunctival tissue. This is particularly important in cases of chronic
conjunctivitis or when the condition is not responding to treatment.
NURSING DIAGNOSIS
• Acute pain related to inflammation of conjunctiva and edema.
• Anxiety related to lack of knowledge about the diseases process.
• Risk for injury related to limited vision.
MEDICAL MANAGEMENT
• Bacterial Conjunctivitis are caused by Streptococcus pneumoniae, Haemophilus
influenzae, and Staphylococcus aureus
• Viral Conjunctivitis are caused by adenovirus and herpes simplex virus
• Allergic conjunctivitis is a hypersensitivity reaction that occurs as part of allergic rhinitis
(hay fever) or allergic reaction due to pollens or other environmental pollutants
NURSING MANAGEMENT
• Warm soaks (10 minutes four times per day) is used when crusting and drainage are
present for bacterial conjunctivitis
• Cold compress for viral conjunctivitis
• If topical antibiotic (broad spectrum) is ordered, teach patient instillation technique
• Urge good hand washing to prevent spread of infection
• Allergic conjunctivitis treated with topical or oral antihistamines.
vasoconstrictors, and mast cell stabilizers.
3. CORNEAL ABRASION AND ULCERATION (KERATITIS)
INTRODUCTION
It is an inflammation or irritation of the cornea. Although treatable, this condition is the most
common cause of corneal blindness through an infection in the United States. Loss of epithelial
layers of cornea due to some type of trauma, contact with fingernail, tree branch, spark or
other projectile, or over wearing contact lens.
CLINICAL MANIFESTATION
• Pain and redness
• Foreign body sensation
• Photophobia
• Increased tearing
• Difficulty opening the eye
DIAGNOSTIC TEST
• Eye exam. Although it may be uncomfortable to open your eyes for the exam, it's
important that your doctor examines your eyes. The exam will include how well you can
see (visual acuity).
• Penlight exam. Your doctor may examine your eye using a penlight, to check your
pupil's reaction, size and other factors. Your doctor may apply a stain to the surface of
your eye, to help identify the extent and character of surface irregularities and ulcers of
the cornea.
• Slit-lamp exam. Your doctor will examine your eyes with a special instrument called a
slit lamp. It provides a bright source of light and magnification to detect the character
and extent of keratitis, as well as the effect it may have on other structures of the eye.
• Laboratory analysis. Your doctor may take a sample of tears or some cells from your
cornea for laboratory analysis to determine the cause of keratitis and to help develop
a treatment plan for your condition.
NURSING DIAGNOSIS
• Acute pain related to trauma, increased IOP, surgical intervention or administration
inflammatory eye drops.
• Fear or anxiety related to sensory impairment and lack of understanding of post-
operative care, drug delivery.
• Risk for Self-Care Deficit related to impaired vision.
MEDICAL MANAGEMENT
• Always wash and dry your hands before handling lenses. Never use saliva to wet your
lenses, because your mouth has bacteria that can hurt your cornea.
• Take out your lenses every evening. Carefully clean them with solution, not tap water.
• Never sleep with your contacts in.
• Store the lenses overnight in disinfecting solution.
• Take out your lenses whenever your eyes are irritated. Don’t put them back in until your
eyes feel better.
• Regularly clean your lens case.
• Follow your doctor’s instructions on when to throw out and replace your contacts.
NURSING MANAGEMENT
• Treatment is urgent
• Fortified (high concentration) antibiotic eyedrops may be instilled and eye patched for
24 hours _
• Cycloplegics are administered to reduce pain caused by ciliary spasm
• Abrasion heals in 24 to 48 hours.
• Ulceration should be followed by an ophthalmologist
• Make sure that patch is secure enough so patient cannot open eyelid
• Teach patient to use topical antibiotic (or antiviral in cases of herpes simplex dendritic
keratitis) after patch is removed, and follow up as directed
• Review safety practices such as wearing protective eye shields and washing hands
frequently.
4. IRITIS/UVEITIS
INTRODUCTION
Iritis is inflammation of your iris, the colored part of your eye. It’s also called anterior uveitis.
Anterior uveitis iris (iritis) or iris and ciliary body (iridocyclitis). Your iris is made up of muscular
fibers that control how much light enters your pupil, the opening in the center, so you can see
clearly. It makes your pupil smaller in bright light and larger in dim light.
CLINICAL MANIFESTATION
• Onset is acute with deep eye pain
• Photophobia
• Conjunctival redness
• Small pupil that does not react briskly
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• A visual acuity test. You might read an eye chart to check your vision.
• Pressure readings. Your doctor will measure the pressure inside your eye with a special
device.
• Penlight and slit lamp exams. A small beam of light can give your doctor a good look
at your eye. A slit lamp uses a magnifying lens to show more detail. You might get
drops to dilate (widen) your pupil first.
NURSING DIAGNOSIS
• Disturbed Sensory Perception related to Altered sensory reception altered status of
sense organ as evidence by progressive loss of visual field.
• Anxiety related to Physiological factors change in health status presence of pain
possibility/reality of loss of vision as evidence by how to expressed concern regarding
changes in life events.
• Deficient Knowledge related to Lack of exposure or unfamiliarity with resources as
evidence by inaccurate follow-through of instruction.
MEDICAL MANAGEMENT
• Cycloplegic agents are often prescribed in any case of AAU and in exacerbations of
chronic anterior uveitis (CAU); they are usually given according to the severity of
inflammation. In the acute stage, phenylephrine 2.5% or 10% can be used as an
adjunctive drug.
• Corticosteroids (CS) penetrate the posterior segment phakic eyes poorly, and their
use is thus primarily in the setting of anterior uveitis and for the management of the
anterior component of panuveitis. Posology of eye drop instillation must take into
account disease severity and chronicity.
NURSING MANAGEMENT
• Urgent ophthalmology evaluation is Needed
• Inflammation is treated with a topical corticosteroid and a cycloplegic agent
• Teach patient how to instill medications and adhere to dosing schedule to prevent
permanent eye damage
• Suggest sunglasses to decrease pain from photophobia
• Encourage follow-up for intraocular pressure (I0P) measurements because
corticosteroids can increase I0P.
 5. CATARACT
INTRODUCTION
Cataract is a clouding of the lens in the eye that normally affects vision. Cataract, the most
common cause of blindness and visual impairment, is often related to ageing. Occasionally
children are born with the condition, or a cataract may develop following an eye injury, or as
a result of inflammation or other diseases, such glaucoma and diabetes. Sometimes, the
development of cataract is linked to steroid use or it may develop after exposure to some
types of radiation. Cataract is responsible for over 51% of blindness in the Eastern
Mediterranean Region. Although cataract can be easily surgically operated , in many
countries access to eye care is limited. As people in the world live longer, the number of
people with cataract is anticipated to grow. Cataract is also an important cause of low vision.
There is no known prevention for the cataract. Reduction of cigarette smoking, ultraviolet light
exposure may delay the development of cataract.
CLINICAL MANIFESTATION
• Blurred or distorted central vision
• Glare from bright lights
• Gradual and painless loss of vision
• Previously dark pupil may appear milky or white
DIAGNOSTIC TEST
• Slit-lamp examination to provide magnification and visualize opacity of lens
• Direct and indirect ophthalmoscopy to rule out retinal disease
• Perimetry to determine the scope of the visual field (normal with cataract)
• Snellen visual acuity test
NURSING DIAGNOSIS
• Anxiety related to lack of knowledge.
• Risk for injury related to blurred vision
• Acute pain related to trauma to the incision and increased IOP.
• Risk for infection related to trauma to the incision
MEDICAL MANAGEMENT
• No medical treatment.
• Surgery if severe visual problems.
• Most common surgery is extra-capsular cataract extraction with intraocular lens
implant.
• Portion of anterior capsule removed to allow extraction of lens nucleus and cortex.
NURSING MANAGEMENT
• Surgical removal of the lens is indicated.
• Cataract surgery is usually done under local anesthesia
• Preoperative eyed drops produce decreased response to pain and lessened motor
activity (neuroleptanalgesia).
• Oral medications may be given to reduce IOP.
• IOL implants are usually implanted at the time of cataract extraction, replacing thick
glasses that may provide suboptimal refraction.
• If intraocular lens implant is not used, the patient will be fitted with appropriate
eyeglasses or a contact lens to correct refraction after the healing process
6. ACUTE (CLOSE ANGLE) GLAUCOMA
INTRODUCTION
A condition in which an obstruction occurs at the access to the trabecular meshwork and the
canal of Schlemm. IOP is normal when the anterior chamber angle is open, and glaucoma
occurs when a significant portion of that angle is closed. Glaucoma is associated with
progressive visual field loss and eventual blindness if allowed to progress. Rapidly progressive
visual impairment
CLINICAL MANIFESTATION
• Periocular pain
• Conjunctival hyperemia and congestion.
• Pain may be associated with nausea and vomiting, bradycardia, and profuse
sweating.
• Peripheral visual loss
• Severely elevated IOP, corneal edema
• Pupil is vertically oval, fixed in a semi-dilated position and unreactive to light and
accommodation

PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Tonometry
• Ophthalmoscopy
• Gonioscopy
• Perimetry

NURSING DIAGNOSIS
• Anxiety related to possible vision loss
• Disturbed sensory perception related to visual impairment
• Ineffective health maintenance related to knowledge deficit
• Risk for injury related to impaired vision
• Self-care deficit related to impaired vision
MEDICAL MANAGEMENT
• Beta-blockers (Timolol: use cautiously in asthmatic clients or clients with bradycardia)
• Epinephrine (contraindicated in angle closure glaucoma.)
• Miotic eye drops (cause pupillary constriction.)
NURSING MANAGEMENT
• An ocular emergency
• Administration of:
- Hyperosmotic agents such as acetazolamide (Diamox) to reduce 10P by
promoting diuresis
- Topical ocular hypotensive agents, such as pilocarpine and beta-blockers
(Betaxolol)
• Possible laser incision in the iris (Iridotomy) to release blocked aqueous and reduce 10P
• Other eye is also treated with pilocarpine eye drops and/or surgical management to
avoid a similar spontaneous attack.
7. CHRONIC (OPEN-ANGLE) GLAUCOMA
INTRODUCTION
Disorder of increased IOP, degeneration of the optic nerve, and visual field loss. Open-angle
glaucoma makes up 90% of primary glaucoma cases and its incidence increases with age.
Usually bilateral, but one eye may be more severely affected than the other. The anterior
chamber angle is open and appears normal
CLINICAL MANIFESTATION
• Mild, bilateral discomfort (tired feeling in eyes, foggy vision).
• Slowly developing impairment of peripheral vision but central vision is unimpaired.
• Progressive loss of visual field.
• Halos may be present around lights with increased ocular pressure.
• Optic nerve may be damage
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Tonometry
• Ocular examination to check for clipping and atrophy of the optic disk
• Visual fields testing
NURSING DIAGNOSIS
• Sensory Perception, disturbed visual related to Altered sensory reception altered status
of sense organ as evidenced by progressive loss of visual field.
• Acute pain related to increased IOP.
• Self-care deficit related to loss of vision.
MEDICAL MANAGEMENT
• Beta-blockers (Timolol: use cautiously in asthmatic clients or clients with bradycardia)
• Epinephrine (contraindicated in angle closure glaucoma.)
• Miotic eye drops (cause pupillary constriction.)
NURSING MANAGEMENT
• Commonly treated with a combination of topical miotic agents (increase the outflow
of aqueous humor by enlarging the area around trabecular meshwork) and oral
carbonic anhydrase inhibitors and beta-adrenergic blockers (decrease aqueous
production).
• If medical treatment is not successful, surgery may be required, such as Laser
trabeculoplasty but is delayed as long as possible.
8. RETINAL DETACHMENT
INTRODUCTION
Detachment of the sensory area of the retina (rods and cones) from the pigmented epithelium
of the retina. A break in the continuity of the retina may first occur from small degenerative
holes and tears, which may lead to detachment. Spontaneous detachment may occur due
to degenerative changes in the retina or vitreous body
CLINICAL MANIFESTATION
• The patient notes sensation of particles moving in line of vision (person can see floating
across field of vision when looking at a light background).
• Delineated areas of vision may be blank.
• A sensation of a veil-like coating may be present if detachment develops rapidly.
• Unless the retinal holes are sealed, the retina will progressively detach; ultimately there
will be a loss of central vision as well as peripheral vision, leading to legal blindness
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Indirect ophthalmoscopy - shows gray or opaque retina.
• Slit-lamp examination and three-mirror gonioscopy
• Optical coherence tomography and ultrasound are used for the complete retinal
assessment, especially if the view is obscured by a dense cataract or vitreal
hemorrhage.
NURSING DIAGNOSIS
• Disturbed sensory receptors.
• Self-care deficit.
• Risk for injury.
• Risk for impaired home maintenance.
MEDICAL MANAGEMENT
• Scleral Buckling
- The retinal surgeon compresses the sclera (often with a scleral buckle or a silicone band)
to indent the scleral wall from the outside of the eye and bring the two retinal layers in
contact with each other.
• Pneumatic Retinopexy
- A gas bubble, silicone oil, or perfluorocarbon and liquids may be injected into the
vitreous cavity to help push the sensory retina up against the RPE (Retinal Pigment
Epithelium)
• Cryosurgery or retinal cryopexy
- Super cooled probe is touched to the sclera, causing minimal damage; as a result
of scarring, the pigment epithelium adheres to the retina.
NURSING MANAGEMENT
• Encourage self-care at discharge (Avoid falls, jerks, bumps, or accidental injury.)
• Instruct patient about the following:
- Rapid eye movements should be avoided for several weeks.
- Driving is restricted.
- Within 3 weeks, light activities may be pursued.
- Within 6 weeks, heavier activities and athletics are possible. Define such activities
for the patient.
- Avoid straining and bending head below the waist.
- Use meticulous cleanliness when instilling eye medications.
- Apply a clean, warm, moist washcloth to eyes and eyelids several times a day for
10 minutes to provide soothing and relaxing comfort.
- Symptoms that indicate a recurrence of the detachment: Floating spots, flashing
light, progressive shadows. Recommend that the patient contact health care
provider if they occur.
- Advise patient to follow up. The first follow-up visit to the ophthalmologist should
occur in 2 weeks
9. MACULAR DEGENERATION
INTRODUCTION
Macular Degeneration is an eye disease affecting the macula (the center of the light-
sensitive retina at the back of the eye), causing loss of central vision. Most common cause of
visual loss in people older than 60 years of age
• Two types:
• Dry (non-neovascular, nonexudative) type of the condition, in which the outer layers of
the retina slowly break down
- When the drusen occur outside of the macular area, patients generally have no
symptoms
- When the drusen occur within the macula, however, there is a gradual blurring of
vision that patients may notice when they try to read
• Wet (neovascular, exudative) type, may have an abrupt onset
- Patients report that straight lines appear crooked and distorted or that letters in
words appear broken
- Results from proliferation of abnormal blood vessels growing under the retina,
within the choroid layer of the eye
- Affected vessels can leak fluid and blood, elevating the retina
CLINICAL MANIFESTATION
• Blurred vision
• Blind spot in the middle of the visual field
• Central vision can also be lost as small blind spot may also begin to develop
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Fluorescein angiography and indocyanine green angiography may be used to identify
signs of macular degeneration.
NURSING DIAGNOSIS
• Disturbed sensory perception related to visual impairment
• Ineffective health maintenance related to knowledge deficit
• Risk for injury related to impaired vision
• Self-care deficit related to impaired vision
MEDICAL MANAGEMENT
• There is no known cure for the dry (nonexudative, non-neovascular)
• Study revealed that use of antioxidants (vitamin C, vitamin E, and betacarotene) and
minerals (zinc oxide) in megadoses can slow the progression of AMD and vision loss for
people at high risk for developing advanced Macular Degeneration
• For Wet type Macular Degeneration following drugs are given:
- Ranibizumab (Lucentis)
- Monoclonal antibody bevacizumab (Avastin)
NURSING MANAGEMENT
• Amsler grids are given to patients to use in their homes to monitor for a sudden onset or
distortion of vision
• Patients should be encouraged to look at these grids, one eye at a time, several times
each week with glasses on. If there is a change in the grid, the patient should notify the
ophthalmologist immediately
10. OTITIS EXTERNA
INTRODUCTION
Otitis externa is a condition that causes inflammation (redness and swelling) of the external
ear canal, which is the tube between the outer ear and eardrum. Otitis externa is often
referred to as "swimmer's ear" because repeated exposure to water can make the ear canal
more vulnerable to inflammation.
CLINICAL MANIFESTATION
• Pain and discharge from the external auditory canal
• Aural tenderness
• Fever, cellulitis, and lymphadenopathy.
• Hearing loss or feeling of fullness
• Ear canal is erythematous and edematous
• Discharge may be yellow or green and foul-smelling
• In fungal infections, hair-like black spores may even be visible
PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• History
• Physical Examination
• Otoscopic examination
• Culture
• Auditory and tympanometry
NURSING DIAGNOSIS
• Pain related to infection
• Risk for infection related to Eustachian tube dysfunction.
• Altered auditory sensory perceptions related to fluid in the middle year.
MEDICAL MANAGEMENT
• Careful suctioning the ear under microscopic guidance.
• Installation of antibiotic drops
NURSING MANAGEMENT
• If canal is swollen and tender, an antibiotic solution containing a corticosteroid is chosen
to reduce inflammation and swelling. If acute inflammation and closure of the ear canal
prevent drops from saturating canal, a wick may need to be inserted so drops will gain
access to walls of entire ear canal.
• Burow's solution (aluminum acetate solution) or topical corticosteroid cream or lotion is
used in otitis externa caused by dermatitis.
• Fungal infection may be treated with a topical antifungal such as nystatin.
• In chronic otitis externa, debris from ear canal may need to be removed through
irrigation or suction, after pain and swelling have subsided.
• Tympanic membrane perforation or a current Warm compresses and analgesics may
be needed.
11. MENIERE'S DISEASE
INTRODUCTION
Meniere's disease is a disorder of the inner ear that can lead to dizzy spells (vertigo) and
hearing loss. In most cases, Meniere's disease affects only one ear. Meniere's disease can
occur at any age, but it usually starts between young and middle-aged adulthood. It's
considered a chronic condition, but various treatments can help relieve symptoms and
minimize the long-term impact on your life.
CLINICAL MANIFESTATION
• Fluctuating, progressive sensorineural hearing loss
• Feeling of pressure or fullness in the ear
• Meniere’s Triad
- Tinnitus or a roaring sound
- Vertigo, often accompanied by nausea and vomiting
- Sensorineural hearing loss
DIAGNOSTIC TEST
• Caloric testing to differentiate Meniere's disease from intracranial lesion
- Fluid, above or below body temperature, is instilled into the auditory canal
- Will precipitate an attack in patients with Meniere's disease
- Normal patient complains of dizziness; patient with acoustic neuroma has no
reaction
NURSING DIAGNOSIS
• Risk for injury related to altered mobility because of gait disturbed and vertigo.
• Impaired adjustment related to disability requiring change in lifestyle because of
unpredictability of vertigo.
• Risk for fluid volume imbalance and deficit related to increased fluid output, altered
intake, and medications.
• Anxiety related to threat of, or change in, health status and disabling effects of vertigo.
• Ineffective coping related to personal vulnerability and unmet expectations stemming
from vertigo.
MEDICAL MANAGEMENT
• Patient can be asked to keep a diary noting presence of aural symptoms (eg,
tinnitus, distorted hearing) when episodes of vertigo occur. This may help diagnose
which ear is involved and whether surgery will be needed
• Administration of osmotic diuretics (Diamox)
• Administration of the vestibular suppressant to control symptoms
- Meclizine (Antivert, Bonine) up to 25 mg qid
- Diphenhydramine (Benadryl) 25 to 50 mg tid to qid
• Streptomycin (I.M.) or gentamicin (transtympanic injection) may be given to
selectively destroy vestibular apparatus if vertigo is uncontrollable
• Additional antiemetic, such as Promethazine (Phenergan), may be needed to
reduce nausea, vomiting, and resistant vertigo

NURSING MANAGEMENT
• Help patient recognize aura so patient has time to prepare for an attack
• Encourage patient to lie down during attack, in safe place, and lie still
• Limit foods high in salt or sugar. Be aware of foods with hidden salts and sugars.
• Limit alcohol intake. Alcohol may change the volume and concentration of the inner
ear fluid and may worsen symptoms.
• Avoid aspirin and aspirin-containing medications
• Teach about medication therapy, including side effects
• Advise patient to keep a log of attacks, triggers, and severity of symptoms
• Encourage follow-up hearing evaluations and provide information about surgical
care
• Hearing aids
12. IMPACTED CERUMEN AND FOREIGN BODIES
INTRODUCTION
Accumulated cerumen (earwax) may become impacted due to use of cotton swabs
to clean ears and may be a problem for some people. Cerumen becomes drier in elderly
people, making impaction more likely. Foreign bodies may be lodged in the ear canal
intentionally or accidentally by the patient or other person (usually in children), or the patient
may be completely unaware, as in insect obstruction
CLINICAL MANIFESTATION
• Decreased hearing acuity
• Feeling that ears is plugged
• Pain and fever
• Drainage may occur

PATHOPHYSIOLOGY

DIAGNOSTIC TEST
• Caloric testing to differentiate Meniere's disease from intracranial lesion
- Fluid, above or below body temperature, is instilled into the auditory canal
- Will precipitate an attack in patients with Meniere's disease
- Normal patient complains of dizziness; patient with acoustic neuroma has no
reaction

NURSING DIAGNOSIS
• Potential infection related to deficit knowledge regarding ear care.
• Fear and anxiety related to procedure.
•
MEDICAL MANAGEMENT
• Cerumen can be removed by irrigation.
• Suction, or instrumentation unless the patient has a perforated eardrum or an
inflamed external ear
• For successful removal, the water stream must flow behind the obstructing cerumen
to move it first laterally and then out of the canal
• If irrigation is unsuccessful, direct visual, mechanical removal can be performed.
• Instilling a few drops of warmed glycerin, mineral oil, or half-strength hydrogen
peroxide into the ear canal for 30 minutes can soften cerumen before its removal
• Use of cerumen curette, aural suction, and a binocular microscope for magnification
NURSING MANAGEMENT
• Irrigation for dislodged bodies and insects are contraindicated
• Insect can be dislodged by instilling mineral oil
• Mechanical removal and aural suction can be performed
• Foreign body may have to be extracted in the operating room with the patient under
general anesthesia
 ENDOCRINE

1. DIABETES MELLITUS
Introduction
- Diabetes mellitus is a disorder in which the body does not produce enough or respond
normally to insulin, causing blood sugar (glucose) levels to be abnormally high.
- Type 1 diabetes can develop at any age, though it often appears during childhood or
adolescence. Type 2 diabetes, the more common type, can develop at any age, though it's
more common in people older than 40

Causes
How insulin works
o Insulin is a hormone that comes from a gland situated behind and below the stomach
(pancreas).
o The pancreas secretes insulin into the bloodstream.
o The insulin circulates, enabling sugar to enter your cells.
o Insulin lowers the amount of sugar in your bloodstream.
o As your blood sugar level drops, so does the secretion of insulin from your pancreas.
the role of glucose
o Glucose — a sugar — is a source of energy for the cells that make up muscles and other
tissues.
o Glucose comes from two major sources: food and your liver.
o Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.
o Your liver stores and makes glucose.
o When your glucose levels are low, such as when you haven't eaten in a while, the liver
breaks down stored glycogen into glucose to keep your glucose level within a normal
range.

Causes of type 1 diabetes

The exact cause of type 1 diabetes is unknown. What is known is that your immune system —
which normally fights harmful bacteria or viruses — attacks and destroys your insulin-producing
cells in the pancreas. This leaves you with little or no insulin. Instead of being transported into
your cells, sugar builds up in your bloodstream.

Type 1 is thought to be caused by a combination of genetic susceptibility and environmental

factors, though exactly what those factors are is still unclear. Weight is not believed to be a
factor in type 1 diabetes.
Causes of prediabetes and type 2 diabetes
- type 2 diabetes, your cells become resistant to the action of insulin, and your pancreas
is unable to make enough insulin to overcome this resistance. Instead of moving into your cells
where it's needed for energy, sugar builds up in your bloodstream.
Causes of gestational diabetes
During pregnancy, the placenta produces hormones to sustain your pregnancy. These
hormones make your cells more resistant to insulin.
Normally, your pancreas responds by producing enough extra insulin to overcome this
resistance. But sometimes your pancreas can't keep up. When this happens, too little glucose
gets into your cells and too much stays in your blood, resulting in gestational diabetes.
Risk Factors
- Family history.
- Inactivity. The less active you are, the greater your risk. Physical activity helps you control
your weight, uses up glucose as energy and makes your cells more sensitive to insulin.
- Age. Your risk increases as you get older. This may be because you tend to exercise less,
lose muscle mass and gain weight as you age. But type 2 diabetes is also increasing among
children, adolescents and younger adults.
Signs and symptoms
- Increased thirst - High blood sugar levels force your kidneys to go into overdrive to get
rid of the extra sugar.
The kidneys need to make more urine to help pass the extra sugar from your body. You will
likely have to urinate more and have a higher volume of urine
o Frequent urination
o Extreme hunger
o Unexplained weight loss
o Fatigue – cells do not get enough glucose
o Irritability
o Blurred vision
o Slow-healing sores - also affect circulation, causing blood to move more slowly, which
makes it more difficult for the body to deliver nutrients to wounds
o Frequent infections, such as gums or skin infections and vaginal infections

Diagnostic
- Blood test to check glucose level
o Oral glucose tolerance test: In this test, blood glucose level is first measured after an
overnight fast. Then you drink a sugary drink. Your blood glucose level is then checked at hours
one, two and three.
o Fasting plasma glucose test: This test is best done in the morning after an eight hour fast
(nothing to eat or drink except sips of water).
o The A1C test is one of the most common because its results estimate blood sugar levels
over time, and you don’t have to fast before the test.
o Random Blood sugar
Treatment
- Healthy eating- foods that are high in nutrition and fiber and low in fat and calories —
and cut down on saturated fats, refined carbohydrates and sweets.
- Exercise lowers your blood sugar level by moving sugar into your cells, where it's used for
energy. Exercise also increases your sensitivity to insulin, which means your body needs less
insulin to transport sugar to your cells.
- Monitoring your blood sugar. Depending on your treatment plan, you may check and
record your blood sugar as many as four times a day or more often if you're taking insulin.
Careful monitoring is the only way to make sure that your blood sugar level remains within your
target range.
- Insulin can't be taken orally to lower blood sugar because stomach enzymes interfere
with insulin's action. Often insulin is injected using a fine needle and syringe or an insulin pen
NURSING DX.
- Risk for Unstable Blood Glucose Level
- Deficient Knowledge
- Risk for Infection
- Risk for Disturbed Sensory Perception
- Powerlessness
- Risk for Ineffective Therapeutic Regimen Management
2. CUSHINGS DISEASE
Introduction
Cushing syndrome occurs when your body has too much of the hormone cortisol over time.
This can result from taking oral corticosteroid medication. Or your body might produce too
much cortisol.

Too much cortisol can cause some of the hallmark signs of Cushing syndrome — a fatty hump
between your shoulders, a rounded face, and pink or purple stretch marks on your skin.
Cushing syndrome can also result in high blood pressure, bone loss and, on occasion, type 2
diabetes.

Cause
Too much of the hormone cortisol in your body causes Cushing syndrome. Cortisol, which is
produced in the adrenal glands, plays a variety of roles in your body.
For example, cortisol helps regulate your blood pressure, reduces inflammation, and keeps
your heart and blood vessels functioning normally. Cortisol helps your body respond to stress.
It also regulates the way your body converts proteins, carbohydrates and fats in your diet into
energy.
- Pituitary tumors that make too much ACTH (the hormone that tells the adrenal glands
to make cortisol)
- Adrenal cortical tumors. A tumor on the adrenal gland itself can make too much cortisol.
These are usually benign.
- Some steroid medications have the same effect as the hormone cortisol does when
produced in your body. But as with an excessive production of cortisol in your body, taking
too much corticosteroid medications can, over time, lead to Cushing's syndrome.

Risk Factors
- High dose of corticosteroid
- living with pituitary or adrenal tumors

Signs and Symptoms

• A rounded, rosy face
• Weight gain, especially in the upper body
• A fat pad in the upper back or base of the neck (You may hear this called a "buffalo
hump.")
• Thinning skin that is easy to bruise
• Acne
• Being very tired
• Weak muscles, especially when using your shoulders and hip muscles
• High blood pressure
• High blood sugar levels
• Depression and anxiety

Diagnostic Test
- 24-hour urinary free cortisol test. This common test collects your urine for 24 hours to
measure how much cortisol is in it.
- Dexamethasone suppression test. You’ll take a low-dose steroid pill at 11:00 p.m. and then
take a blood test in the morning to see how much cortisol your body still makes.
- Late-night salivary cortisol level. This test measures cortisol in your saliva. As the name
suggests, these tests happen at night.
- Urine and blood tests. These tests measure hormone levels and show whether your body
is producing excessive cortisol. For the urine test, you may be asked to collect your urine
over a 24-hour period. Urine and blood samples will be sent to a laboratory to be
analyzed.
 - Saliva test. Cortisol levels normally rise and fall throughout the day. In people without
Cushing syndrome, levels of cortisol drop significantly in the evening. By analyzing cortisol
levels from a small sample of saliva collected late at night, doctors can see if cortisol
levels are too high.

Treatment
- Reducing corticosteroid use
- If the cause of Cushing syndrome is a tumor, your doctor may recommend complete
surgical removal
- Medications to control excessive production of cortisol at the adrenal gland include
ketoconazole, mitotane (Lysodren) and metyrapone (Metopirone).
- surgical removal of your adrenal glands (bilateral adrenalectomy). This procedure will
cure excess production of cortisol but will require lifelong replacement medications.

NURSING DX.
o Risk For Excess Fluid Volume
o Risk For Injury
o Risk For Infection
o Deficient Knowledge
o Disturbed Body Image
3. ADDISONS DISEASE
Introduction
Your adrenal glands are located on top of your kidneys. These glands produce many of the
hormones that your body needs for normal functions.
Addison’s disease occurs when the adrenal cortex is damaged, and the adrenal glands don’t
produce enough of the steroid hormones cortisol and aldosterone.
Cortisol regulates the body’s reaction to stressful situations. Aldosterone helps with sodium and
potassium regulation. The adrenal cortex also produces sex hormones (androgens).

Cause
Addison's disease is caused by damage to your adrenal glands, resulting in not enough of the
hormone cortisol and, often, not enough aldosterone as well. Your adrenal glands are part of
your endocrine system. They produce hormones that give instructions to virtually every organ
and tissue in your body.
Your adrenal glands are composed of two sections. The interior (medulla) produces
adrenaline-like hormones. The outer layer (cortex) produces a group of hormones called
corticosteroids.

Primary adrenal insufficiency

- When the cortex is damaged and doesn't produce enough adrenocortical hormones,
the condition is called primary adrenal insufficiency. This is most commonly the result of the
body attacking itself (autoimmune disease). For unknown reasons, your immune system views
the adrenal cortex as foreign, something to attack and destroy.

Secondary adrenal insufficiency

- Occurs when the pituitary, a small gland at the base of the brain, does not secrete
enough adrenocorticotropic hormone (ACTH), which activates the adrenal glands to
produce cortisol.

Risk Factors
o have cancer
o take anticoagulants (blood thinners)
o have chronic infections like tuberculosis
o had surgery to remove any part of your adrenal gland
o have an autoimmune disease, like type 1 diabetes or Graves’ disease

Signs and Symptoms

• Abdominal pain
• Abnormal menstrual periods
• Craving for salty food
• Dehydration
• Depression
• Diarrhea
• Irritability
• Lightheadedness or dizziness when standing up
• Loss of appetite

Diagnostic Test
- Blood test. Tests can measure your blood levels of sodium, potassium, cortisol and
adrenocorticotropic hormone (ACTH), which stimulates the adrenal cortex to produce its
hormones. A blood test can also measure antibodies associated with autoimmune Addison's
disease.
- ACTH stimulation test. ACTH signals your adrenal glands to produce cortisol. This test
measures the level of cortisol in your blood before and after an injection of synthetic ACTH.
- Imaging tests. You may undergo a computerized tomography (CT) scan of your
abdomen to check the size of your adrenal glands and look for other abnormalities. You may
also undergo an MRI scan of your pituitary gland if testing indicates you might have secondary
adrenal insufficiency.

Treatment
- Hormone replacement therapy
• Hydrocortisone (Cortef), prednisone or methylprednisolone to replace cortisol. These
hormones are given on a schedule to mimic the normal 24-hour fluctuation of cortisol
levels.
• Fludrocortisone acetate to replace aldosterone
- You may need to take a combination of glucocorticoids medications (drugs that stop
inflammation) to improve your health.
- Alternative ways to relieve stress, such as yoga and meditation.

NURSING DX.
- Risk for deficient volume
- Risk for Imbalanced Nutrition: Less Than Body Requirements
4. HYPERPITUITARISM
Introduction
- The condition hyperpituitarism occurs when this gland begins overproducing hormones.
The pituitary gland produces hormones that regulate some of your body’s major functions.
These major body functions include growth, blood pressure, metabolism, and sexual function.

Cause
- When your pituitary gland is overactive, it releases excessive amounts of certain types
of pituitary hormones into your bloodstream. A noncancerous (benign) tumor in the gland,
called a pituitary adenoma, is usually the cause of this condition. An overactive pituitary gland
can cause a variety of disorders that affect growth, metabolism, reproduction and other vital
body functions.
- A malfunction in the pituitary gland like hyperpituitarism is most likely caused by a tumor.
The most common type of tumor is called an adenoma and is noncancerous. The tumor can
cause the pituitary gland to overproduce hormones. The tumor, or fluid that fills in around, it
may also press on the pituitary gland. This pressure can result in too much hormone being
produced or too little being produced, which causes hypopituitarism.
- pituitary is called the “master gland” because it controls the activity of other endocrine
glands. Most importantly, it controls the activity of your thyroid gland, adrenal gland and
gonadal glands (ovaries or testes).

Result and Signs and Symptoms

- Cushing’s syndrome (hypercortisolism): If your pituitary gland secretes too much
adrenocorticotropic hormone (ACTH), your adrenal glands may release too much cortisol.
Besides being a “stress hormone,” cortisol manages the metabolism of proteins, fats and
carbohydrates. It's also involved in your body’s inflammatory and immune responses.
• Accumulation of fat in your upper body.
• Excessive facial hair in people assigned female at birth.
• Pink or purplish stretch marks on your belly (abdomen).
• Tendency to bruise easily.
• Bones may become fragile and tend to break more easily.
- Acromegaly: This disorder is a rare but serious condition that happens when your body
releases high levels of growth hormone (GH) into your bloodstream, leading your bones and
tissues to grow in abnormal ways.
• Skin that's thick, coarse and oily.
• Irregular periods in people assigned female at birth.
• Erectile dysfunction in people assigned male at birth.
• Increased risk for high blood pressure, diabetes, heart attacks and certain types of
cancer.

- Hyperthyroidism: If a pituitary tumor (adenoma) causes overproduction of thyroid

stimulating hormone (TSH) (which is very rare), your thyroid gland will become hyperactive.
This condition is also called overactive thyroid and can increase your metabolism, heartbeat
rhythm and anxiety.
• Nervousness.
• Rapid or irregular heartbeat (arrhythmia).
• Weight loss.
• Fatigue.
• Muscle weakness.
Risk Factors
- Genetics
o Multiple endocrine neoplasia type 1 (MEN 1): A small number of pituitary tumors are
caused by this rare genetic disorder in the RET gene. MEN 1 can lead to over-activity or
enlargement of the pituitary gland.
Diagnostic
- For prolactinoma: Blood tests measure your prolactin levels.
- For acromegaly: Elevated blood levels of growth hormone (GH) cause acromegaly.
Two blood tests are usually used to diagnose the condition. These include a test to check the
level of the insulin-like growth factor-1 (which is a more stable marker for GH) and an oral
glucose tolerance test.
- For Cushing’s syndrome: Several samples of your blood, cortisol level in saliva and urine
may be needed to check for cortisol levels. Tests can determine other causes than Cushing’s
disease, such as a tumor on your adrenal gland, or if cortisol levels are affected by use of anti-
inflammatory drugs. Other tests include specialized invasive blood sampling, where blood is
taken from the veins of your sinuses that drain blood from your pituitary gland.
- For tumors: imaging tests can determine if this is the case, and if so, where the tumor is
located and how big it is. Usually magnetic resonance imaging (MRI) is used. CT (computed
tomography) scan may be used if you can’t have an MRI, such as if you have a pacemaker
or other implant.

Management
- Transsphenoidal adenomectomy. To remove the tumor, your surgeon will make a small
cut in your upper lip or nose. This incision will allow the surgeon to get to the pituitary gland
and remove the tumor.
- Radiation may be used for people who can’t have surgery or who have some tumor
tissue left after surgery which doesn’t respond to medication. There are two approaches to
radiation:
o Conventional radiation therapy: Conventional radiation therapy is given in small doses
over a period of four to six weeks. However, radiation treatments can damage normal tissue
surrounding the tumor.
o Stereotactic therapy: Stereotactic therapy provides a high-dose beam of radiation
targeted at the tumor. It can be done in one session, causing less damage to surrounding
tissue.
5. SIADH
Introduction
- Syndrome of inappropriate antidiuretic hormone secretion occurs when excessive levels
of antidiuretic hormones (hormones that help the kidneys, and body, conserve the correct
amount of water) are produced. The syndrome causes the body to retain water and certain
levels of electrolytes in the blood to fall (such as sodium).
- Antidiuretic hormone (ADH) is a chemical produced in the brain that causes the kidneys
to release less water, decreasing the amount of urine produced. A high ADH level causes the
body to produce less urine.

Causes/ Risk Factors

• brain infections
• bleeding in or around the brain
• head trauma
• medications
• anesthesia
• hereditary factors

Signs and Symptoms

• irritability and restlessness
• loss of appetite
• cramps
• nausea and vomiting
• muscle weakness
• confusion - When sodium levels in the blood are too low, extra water goes into body cells
causing them to swell. This swelling can be especially dangerous for brain cells, resulting in
neurological symptoms
• hallucinations
• decrease urine output

Diagnostics
- Blood tests, specifically one called an ADH test, can measure circulating ADH levels in
the blood, but it’s very difficult to obtain an accurate level.
- Blood tests to measure sodium, potassium chloride levels, and osmolality (concentration
of solution in the blood).
- urine tests will need to be performed to measure sodium, potassium, and osmolality
(concentration of solution in the blood and urine).

Treatment
- The first line of treatment is to limit fluid intake to avoid further buildup.
- Medications may include those that can reduce fluid retention, such as furosemide
(Lasix), and those that can inhibit ADH, like demeclocycline.
- Monitor fluid intake, weight
- Regular assess mental status

NURSING DX.
- Excess fluid volume related to excessive amount of antidiuretic hormone
secretion
- decreased urine output
6. DIABETES INSIPIDUS
Introduction
- an uncommon disorder that causes an imbalance of fluids in the body. This imbalance
leads you to produce large amounts of urine. It also makes you very thirsty even if you have
something to drink.

Cause
- Your body makes a hormone called vasopressin in a part of your brain called the
hypothalamus. It’s stored in your pituitary gland. Vasopressin tells your kidneys to hold on to
water, which makes your urine more concentrated. (Vasopressin is also called antidiuretic
hormone or ADH.)
- When you’re thirsty or a little dehydrated, your vasopressin levels go up. Your kidneys
absorb more water and put out concentrated urine. If you’ve had enough to drink,
vasopressin levels fall, and what comes out is clear and diluted.
o When your body doesn’t make enough vasopressin, the condition is called central
diabetes insipidus.
o If you make enough but your kidneys don’t respond to it the way they should, you have
nephrogenic diabetes insipidus.

Risk Factors
- Nephrogenic diabetes insipidus that's present at or shortly after birth usually has an
inherited (genetic) cause that permanently changes the kidneys' ability to concentrate urine.

Signs and symptoms

o Pale, colorless urine
o Low measured concentration of urine
o Preference for cold drinks
o Dehydration
o Weakness
o Muscle pains
o Severe thirst
o Excessive urination

Diagnostic test
- Magnetic resonance imaging (MRI). An MRI can look for abnormalities in or near the
pituitary gland.
- Urinalysis - They can also check for glucose, which can help them decide if you have
diabetes insipidus or diabetes mellitus.
- Blood test. This will measure the electrolytes and glucose in your blood. This lets your
doctor know if you have diabetes mellitus or diabetes insipidus. It may help them figure out
which type.
- Fluid deprivation test. This measures the changes in your body weight, blood sodium,
and urine concentration after you don’t drink anything for a while.
o Short-form fluid deprivation test. You stop drinking for a short time. You collect a sample
and take it back to your doctor, who sends it to a lab.

Treatment
Central
o Desmopressin (DDAVP, Nocturna) is an artificial hormone that’s often used to treat central
diabetes insipidus.
Nephro
 o high doses of desmopressin
o diuretics, which can be taken along with either aspirin or ibuprofen (Advil, Motrin)
o other nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin
o When taking these medications, it’s important to drink water only when you’re thirsty.
Lifestyle
o The most important action is avoiding dehydration. You can do this by bringing water
with you
o Carry a medical alert card in your wallet or wear a medical bracelet so that others know
about your diabetes insipidus in case of an emergency. Dehydration can happen
quickly, so those around you should know of your condition.

NURSING DX.
1. Deficient Fluid Volume
2. Risk for Impaired Skin Integrity
3. Deficient Knowledge
7. HYPERTHYRODISM
Introduction
- Hyperthyroidism, also called overactive thyroid, is a condition where your thyroid makes
and releases high levels of thyroid hormone. This condition can make your metabolism speed
up.
- Thyroid hormone helps the body use energy, stay warm and keep the brain, heart,
muscles, and other organs working properly.

Cause
- Every aspect of your metabolism is regulated by thyroid hormones.
Your thyroid gland produces two main hormones, thyroxine (T4) and triiodothyronine (T3), that
influence every cell in your body. They maintain the rate at which your body uses fats and
carbohydrates, help control your body temperature, influence your heart rate, and help
regulate the production of protein. Your thyroid also produces a hormone that helps regulate
the amount of calcium in your blood (calcitonin
o Graves’ disease: In this disorder, your immune system attacks your thyroid. This makes
your thyroid create too much thyroid hormone. Graves’ disease is a hereditary condition
(passed down through a family).
o Thyroid nodules: A thyroid nodule is a lump or growth of cells in your thyroid gland. They
can produce more hormones than your body needs. Thyroid nodules are rarely cancerous.

Risk Factors
• A family history, particularly of Graves' disease
• Having an autoimmune disease (such as type 1 diabetes)
• Family history of thyroid disease or autoimmune disease
• Personal history of thyroid problems, like goiter (an abnormally large thyroid gland) or
having had thyroid surgery

Signs and symptoms

• Rapid heartbeat (palpitations).
• Feeling shaky and/or nervous.
• Weight loss.
• Increased appetite.
• Diarrhea and more frequent bowel movements.
• Increased sensitivity to heat
• Fatigue, muscle weakness

Diagnostic test
• Blood tests to look for high levels of thyroid hormone in your body.
• Imaging tests to look at your thyroid.
• Thyroid panel. This blood test measures levels of thyroid hormones and thyroid-stimulating
hormone (TSH).
• Thyroid scan. A technician injects a small amount of radioactive iodine into your
bloodstream. Your thyroid absorbs it, and a special camera takes pictures of the gland
to look for nodules or other signs of problems.
• Ultrasound. A technician runs a device called a transducer over your neck. It uses sound
waves to create images of your thyroid.

Treatment
- Antithyroid drugs methimazole (Tapazole) or propylthiouracil (PTU): These drugs block
the ability of your thyroid to make hormones. They offer rapid control of your thyroid.
- Radioactive iodine is an oral medication that your overactive thyroid cells absorb. The
radioactive iodine damages these cells and causes your thyroid to shrink and thyroid hormone
levels to go down over a few weeks.
- Beta blockers: These drugs block the action of thyroid hormones on the body. They do
not change the level of hormones in your blood, but they can help control symptoms like rapid
heartbeat, nervousness

NURSING DX
- Risk for Decreased Cardiac Output
- Fatigue
- Risk for Disturbed Thought Processes
- Risk for Imbalanced Nutrition: Less Than Body Requirements
8. HYPOTHYROIDISM
Introduction
- Hypothyroidism happens when your thyroid doesn’t create and release enough thyroid
hormone into your body. This makes your metabolism slow down, affecting you entire body
- Thyroid hormone helps the body use energy, stay warm and keep the brain, heart,
muscles, and other organs working properly.
Cause
- When your thyroid doesn't produce enough hormones, the balance of chemical
reactions in your body can be upset. There can be a number of causes, including autoimmune
disease, hyperthyroidism treatments, radiation therapy, thyroid surgery and certain
medications.
o Autoimmune disease. The most common cause of hypothyroidism is an autoimmune
disorder known as Hashimoto's thyroiditis. Autoimmune disorders occur when your immune
system produces antibodies that attack your own tissues. Sometimes this process involves your
thyroid gland.
o Over-response to hyperthyroidism treatment. People who produce too much thyroid
hormone (hyperthyroidism) are often treated with radioactive iodine or anti-thyroid
medications. The goal of these treatments is to get thyroid function back to normal. But
sometimes, correcting hyperthyroidism can end up lowering thyroid hormone production too
much, resulting in permanent hypothyroidism.
o Thyroid surgery. Removing all or a large portion of your thyroid gland can diminish or halt
hormone production. In that case, you'll need to take thyroid hormone for life

Risk factors
• Have a family history of thyroid disease
• Have an autoimmune disease, such as type 1 diabetes or celiac disease
• Have been treated with radioactive iodine or anti-thyroid medications
• Received radiation to your neck or upper chest
• Have had thyroid surgery (partial thyroidectomy)

Signs and symptoms

• Feeling tired (fatigue).
• Experiencing numbness and tingling in your hands.
• Having constipation.
• Gaining weight.
• Experiencing soreness throughout your body (can include muscle weakness).
• Having higher than normal blood cholesterol levels.
• Feeling depressed.
• Being unable to tolerate cold temperatures.

Diagnostic Test
- blood tests that measure the level of TSH and sometimes the level of the thyroid
hormone thyroxine. A low level of thyroxine and high level of TSH indicate an underactive
thyroid. That's because your pituitary produces more TSH in an effort to stimulate your thyroid
gland into producing more thyroid hormone.

Management
- hormone levothyroxine (Levo-T, Synthroid, others). This oral medication restores
adequate hormone levels, reversing the signs and symptoms of hypothyroidism. You'll likely
start to feel better soon after you start treatment. The medication gradually lowers cholesterol
levels elevated by the disease and may reverse any weight gain.
- Promote rest
- Provide extra layer of clothing to avoid cold
NURSING DX.
- Activity intolerance related to fatigue and depressed cognitive process.
- Risk for imbalanced body temperature related to cold intolerance.
- Constipation related to depressed gastrointestinal function.
- Ineffective breathing pattern related to depressed ventilation.
- Disturbed thought processes related to depressed metabolism and altered
cardiovascular and respiratory status.
- Planning & Goals
9. HYPERPARATHYROIDISM
Introduction
Hyperparathyroidism is when your parathyroid glands create high amounts of parathyroid
hormone in the bloodstream. These glands, located behind the thyroid at the bottom of your
neck, are about the size of a grain of rice.

The parathyroid hormone produced by the thyroid glands helps maintain the right balance of
calcium in the bloodstream and in tissues that depend on calcium for proper functioning. This
is especially important for nerve and muscle function, as well as bone health.

Cause
The parathyroid glands keep proper levels of both calcium and phosphorus in your body by
turning the release of parathyroid hormone off or on.
Normally, this balancing act works well.
When calcium levels in your blood fall too low, your parathyroid glands release enough
parathyroid hormone to restore the balance. This hormone raises calcium levels by releasing
calcium from your bones, increasing the amount of calcium absorbed from your small intestine
and decreasing the amount of calcium lost in urine.
When blood-calcium levels are too high, the parathyroid glands produce less parathyroid
hormone.
- Primary hyperparathyroidism occurs because of a problem with one or more of the four
parathyroid glands:
o A noncancerous growth (adenoma) on a gland is the most common cause.
o Enlargement (hyperplasia) of two or more parathyroid glands accounts for most other
cases.
o A cancerous tumor is a very rare cause of primary hyperparathyroidism.
One or more of the parathyroid glands produces high amounts of parathyroid hormone. This
leads to high calcium levels and low phosphorus levels in your blood. Primary
hyperparathyroidism usually occurs randomly. But some people inherit a gene that causes the
disorder.
- Secondary hyperparathyroidism is the result of another condition that lowers the blood
calcium, which then affects the gland's function. This causes your parathyroid glands to
overwork and produce high amounts of parathyroid hormone to maintain or restore the
calcium level to the standard range. Factors that may result in secondary hyperparathyroidism
include:
o Severe calcium deficiency. Your body may not get enough calcium from your diet,
often because your digestive system doesn't absorb the calcium from food. This is common
after intestinal surgery, including weight loss surgery.
o Severe vitamin D deficiency. Vitamin D helps maintain appropriate calcium levels in the
blood. It also helps your digestive system absorb calcium from your food.
o Chronic kidney failure. Your kidneys convert vitamin D into a form that your body can
use. If your kidneys work poorly, usable vitamin D may decrease and calcium levels drop. This
causes parathyroid hormone levels to go up. Chronic kidney failure is the most common cause
of secondary hyperparathyroidism.

Risk Factors
- Have had prolonged, severe calcium or vitamin D deficiency
- Have a rare, inherited disorder, such as multiple endocrine neoplasia, type 1, which
usually affects multiple glands

Signs and Symptoms

 • Weak bones that break easily (osteoporosis)
• Kidney stones
• Excessive urination
• Stomach (abdominal) pain
• Tiring easily or weakness
• Depression or forgetfulness
• Bone and joint pain
• Frequent complaints of illness with no clear cause
• Nausea, vomiting or loss of appetite

Diagnostic Test
• Blood tests - results show that you have high calcium levels in your blood, your health
• Urine test. A 24-hour collection of urine can provide information on how well your kidneys
work and how much calcium is passed in your urine.
• X-ray or other imaging tests of your abdomen to determine if you have kidney stones or
other kidney problems.
• Ultrasound. Ultrasound uses sound waves to create images of your parathyroid glands
and surrounding tissue.

Treatment
- calcimimetic is a drug that mimics calcium circulating in the blood. The drug may trick
the parathyroid glands into releasing less parathyroid hormone. This drug is sold as cinacalcet
(Sensipar).
- Hormone replacement therapy. For women who have gone through menopause and
have signs of osteoporosis, hormone replacement therapy may help bones keep calcium.
- Bisphosphonates also prevent the loss of calcium from bones and may lessen
osteoporosis caused by hyperparathyroidism.
- care provider will also recommend watching how much calcium and vitamin D you get
in your diet. You’ll also need to drink plenty of water to reduce your risk of kidney stones. You
should get regular exercise to strengthen your bones.
- Surgical procedures involve removing enlarged parathyroid glands or tumors on the
glands

NURSING DX.
- Acute pain related to GI and CNS effects
- Imbalanced nutrition: less than body requirements related to GI effects
10. HYPOPARATHYRODISM
Introduction
Hypoparathyroidism is an uncommon condition in which the body produces abnormally low
levels of parathyroid hormone (PTH). PTH is key to regulating and maintaining a balance of
two minerals in the body — calcium and phosphorus.

Causes
- Neck surgery. This is the most common cause of hypoparathyroidism. It develops after
accidental damage to or removal of the parathyroid glands during surgery. Neck surgery may
be done to treat conditions of the thyroid gland, or to treat throat or neck cancer.
- Autoimmune disease. In some cases, the immune system attacks parathyroid tissues as
if they were foreign bodies. In the process, the parathyroid glands stop producing their
hormone.
- Hereditary hypoparathyroidism. This form can result from either being born without
parathyroid glands or with glands that don't work properly. Some types of hereditary
hypoparathyroidism are associated with deficiencies of other hormone-producing glands.

Signs and Symptoms

o muscle aches or cramps
o tingling, burning, or numbness in the fingertips, toes, and lips
o muscle spasms, especially around the mouth
o patchy hair loss
o dry skin
o brittle nails
o fatigue
Diagnostic Test
- Test your urine for calcium to determine if excess levels of calcium are being secreted
in the urine.
- An electrocardiogram (EKG) measures the electrical activity in your heart. The
information from this test can tell your doctor if you have an abnormal heart rhythm, which
can be caused by calcium deficiency.
- X-rays and bone density tests can help your doctor determine if low calcium levels have
affected your bones.

Treatment
- Oral calcium supplements — as tablets, chews or liquid — can increase calcium levels
in your blood. However, at high doses, calcium supplements can cause digestive side effects,
such as constipation, in some people
- Vitamin D. High doses of vitamin D, generally in the form of calcitriol, can help your body
absorb calcium and eliminate phosphorus.
- Rich in calcium. This includes dairy products, green leafy vegetables, broccoli and foods
with added calcium, such as some orange juices and breakfast cereals.

NURSING DX.
- Acute pain related to GI and CNS effects
- Imbalanced nutrition: less than body requirements related to GI effects
 GASTROINTESTINAL

1. GASTROESOPHAGEAL REFLUX DISEASE (GERD)

INTRODUCTION
Gastroesophageal reflux disease (GERD) is a condition in which the stomach contents leak
backward from the stomach into the esophagus (food pipe). Food travels from your mouth to
the stomach through your esophagus. GERD can irritate the food pipe and cause heartburn
and other symptoms.
Causes
When you eat, food passes from the throat to the stomach through the esophagus. A ring of
muscle fibers in the lower esophagus prevents swallowed food from moving back up. These
muscle fibers are called the lower esophageal sphincter (LES).
When this ring of muscle does not close all the way, stomach contents can leak back into the
esophagus. This is called reflux or gastroesophageal reflux. Reflux may cause symptoms. Harsh
stomach acids can also damage the lining of the esophagus.
CLINICAL MANIFESTATION
• A burning sensation in your chest (heartburn), usually after eating, which might be worse
at night
• Chest pain
• Difficulty swallowing
• Regurgitation of food or sour liquid
• Sensation of a lump in your throat

PATHOPHYSIOLOGY
A weak or incompetent LES allows backward movement of gastric contents into the
esophagus; decreased esophageal peristalsis and salivary function impair clearance of
the refluxed acid, resulting in mucosal injury to the esophagus.
DIAGNOSTIC TEST

Upper gastrointestinal (GI) endoscopy

Upper GI endoscopy is a procedure in which a doctor uses an endoscope—a flexible tube
with a camera—to see the lining of your upper GI tract, including your esophagus, stomach,
and duodenum. During upper GI endoscopy, a doctor may obtain biopsies by passing an
instrument through the endoscope to take small pieces of tissue from the lining of your
esophagus. A pathologist will examine the tissue under a microscope. Doctors may order an
upper GI endoscopy to check for complications of GERD or problems other than GERD that
may be causing your symptoms.
Esophageal pH monitoring
Esophageal pH monitoring is the most accurate way to detect stomach acid in the
esophagus. Two types of esophageal pH monitoring are
• Catheter monitoring, in which a health care professional passes one end of a catheter—
a thin, flexible tube—through your nose and into your esophagus to measure acid and
nonacid reflux
• Capsule monitoring, in which a health care professional uses an endoscope to place a
small, wireless capsule on the lining of your esophagus to measure acid reflux
NURSING DIAGNOSIS
• Imbalanced nutrition: less than body requirements related to inability to intake enough
food because of reflux.
• Acute pain related to irritated esophageal mucosa
• Imbalanced nutrition: more than body requirements related to eating to try to assuage
pain
MEDICAL MANAGEMENT
• Antacids: These drugs can help neutralize acid in the esophagus and stomach and stop
heartburn. Many people find that nonprescription antacids provide temporary or partial
 relief. An antacid combined with a foaming agent helps some people. Researchers
think these compounds form a foam barrier on top of the stomach that stops acid reflux
• H2blockers: For chronic reflux and heartburn, the doctor may recommend medications to
reduce acid in the stomach. These medicines include H2 blockers, which help block acid
secretion in the stomach. H2 blockers include: cimetidine (Tagamet), famotidine (Pepcid),
and nizatidine.
• Proton pump inhibitors (PPIs): Also known as acid pumps, these drugs block a protein
needed to make stomach acid. PPIs include
dexlansoprazole(Dexilant), esomeprazole (Nexium), lansoprazole (Prevacid), omepraz
ole (Prilosec).
• Prokinetics: In rare cases, these drugs help your stomach empty faster so you don’t have
as much acid left behind. They may also help with symptoms like bloating, nausea, and
vomiting
NURSING MANAGEMENT
Teach the client to avoid factors that increase lower esophageal irritation.
• Eat a low-fat, high-fiber diet
• Avoid foods and beverages triggers: Stay away from foods that can relax the LES,
including chocolate, peppermint, fatty foods, caffeine, and alcoholic beverages. You
should also avoid foods and beverages that can irritate a damaged esophageal lining if
they cause symptoms, such as citrus fruits and juices, tomato products, and pepper.
• Eat smaller servings: Eating smaller portions at mealtime may also help control symptoms.
Also, eating meals at least 2 to 3 hours before bedtime lets the acid in your stomach go
down and your stomach partially empty.
• Chew your food thoroughly: It may help you remember to do this if you set your fork down
after you take a bite. Pick it up again only when you’ve completely chewed and
swallowed that bite.
• Stop smoking: Cigarette smoking weakens the LES. Stopping smoking is important to
reduce GERD symptoms.
• Elevate the head: Raising the head of your bed on 6-inch blocks or sleeping on a specially
designed wedge lets gravity lessen the reflux of stomach contents into your esophagus.
Don’t use pillows to prop yourself up. That only puts more pressure on the stomach.
2. HIATAL HERNIA
INTRODUCTION
A hiatal hernia occurs when the upper part of your stomach bulges through the large muscle
separating your abdomen and chest (diaphragm).
Your diaphragm has a small opening (hiatus) through which your food tube (esophagus)
passes before connecting to your stomach. In a hiatal hernia, the stomach pushes up through
that opening and into your chest.
A small hiatal hernia usually doesn't cause problems. You may never know you have one unless
your doctor discovers it when checking for another condition.
But a large hiatal hernia can allow food and acid to back up into your esophagus, leading to
heartburn. Self-care measures or medications can usually relieve these symptoms. A very large
hiatal hernia might require surgery
Causes
A hiatal hernia occurs when weakened muscle tissue allows your stomach to bulge up through
your diaphragm. It's not always clear why this happens. But a hiatal hernia might be caused
by:

• Age-related changes in your diaphragm

• Injury to the area, for example, after trauma or certain types of surgery
• Being born with an unusually large hiatus
• Persistent and intense pressure on the surrounding muscles, such as while coughing,
vomiting, straining during a bowel movement, exercising or lifting heavy objects
CLINICAL MANIFESTATION

• Heartburn
• Regurgitation of food or liquids into the mouth
• Backflow of stomach acid into the esophagus (acid reflux)
• Difficulty swallowing
• Chest or abdominal pain
• Feeling full soon after you eat
• Shortness of breath
• Vomiting of blood or passing of black stools, which may indicate gastrointestinal bleeding
DIAGNOSTIC TEST
• Barium swallow. You drink a liquid that shows up on an X-ray so your doctor can get a
better look at your esophagus and stomach.
• Endoscopy. Your doctor puts a long, thin tube called an endoscope down your throat.
A camera on the end shows inside your esophagus and stomach.
• Esophageal manometry (pressure study). A different kind of tube goes down your throat
to check the pressure in your esophagus when you swallow.
• pH test. This measures the acid levels in your esophagus.
NURSING DIAGNOSIS
• Risk for aspiration related to reflux of gastric content
• Impaired swallowing related to function change as evidenced by dyspnea or
inflammation process.
• Acute pain related to swelling and pressure

MEDICAL MANAGEMENT
• Antacids to weaken your stomach acid ( Mylanta, Rolaids and Tums)
• Proton pump inhibitors or H-2 receptor blockers to keep your stomach from making as
much acid
 • Prokinetics to make your esophageal sphincter -- the muscle that keeps stomach acid
from backing up into your esophagus -- stronger. They also help muscles in your
esophagus work and help your stomach empty.
NURSING MANAGEMENT
Advise the patient about preventing reflux of gastric contents into esophagus by:
• Eating smaller meals to reduce stomach bulk.
• Avoiding stimulation of gastric secretions by omitting caffeine and alcohol, which may
intensify symptoms.
• Refraining from smoking, which stimulates gastric acid secretions.
• Avoiding fatty foods, which promote reflux and delay gastric emptying.
• Refraining from lying down for at least 1 hour after meals.
• Losing weight, if obese.
• Avoiding bending from the waist or wearing tight-fitting clothes.Advise the patient to
report health care facility immediately at onset of acute chest pain – may indicate
incarceration of paraesophageal hernia.
• Reassure patient that he or she is not having a heart attack, but all instances of chest
pain should be taken seriously and reported to the patient’s health care provider.
3. GASTRITIS
INTRODUCTION
Gastritis is a general term for a group of conditions with one thing in common: Inflammation
of the lining of the stomach. The inflammation of gastritis is most often the result of infection
with the same bacterium that causes most stomach ulcers or the regular use of certain pain
relievers. Drinking too much alcohol also can contribute to gastritis.
Gastritis may occur suddenly (acute gastritis) or appear slowly over time (chronic gastritis). In
some cases, gastritis can lead to ulcers and an increased risk of stomach cancer. For most
people, however, gastritis isn't serious and improves quickly with treatment.
CLINICAL MANIFESTATION

• Gnawing or burning ache or pain (indigestion) in your upper abdomen that may become
either worse or better with eating
• Nausea
• Vomiting
• A feeling of fullness in your upper abdomen after eating

DIAGNOSTIC TEST

Upper GI endoscopy
• Upper GI endoscopy is a procedure in which a doctor uses an endoscope—a flexible
tube with a camera—to see the lining of your upper GI tract, including
your esophagus, stomach, and duodenum. During upper GI endoscopy, a doctor
obtains biopsies by passing an instrument through the endoscope to take small pieces
of tissue from your stomach lining. A pathologist will examine the tissue with a
microscope. Doctors may use upper GI endoscopy to diagnose gastritis or gastropathy,
determine the cause, and manage complications.
• Blood tests Doctors may use blood tests to check for other causes of gastritis or signs of
complications. For a blood test, a health care professional will take a blood sample from
you and send the sample to a lab.
• Stool tests Doctors may use stool tests to check for H. pylori infection and for blood in
your stool, a sign of bleeding in your stomach.
• Urea breath test Doctors may use a urea breath test to check for H. pylori infection. For
the test, you will swallow a capsule, liquid, or pudding that contains urea that is
“labeled” with a special carbon atom. If H. pylori is present, the bacteria will convert the
urea into carbon dioxide. After a few minutes, you will breathe into a container, exhaling
carbon dioxide. A health care professional will test your exhaled breath. If the test
detects the labeled carbon atoms, the health care professional will confirm an H.
pylori infection in your digestive tract.

NURSING DIAGNOSIS
• Imbalanced Nutrition: less than body requirements r/t insufficient absorption of nutrients
• Acute Pain r/t inflammation of the gastric lining
• Risk for Fluid Volume Deficit: Risk factors: Vomiting; Decreased intake
MEDICAL MANAGEMENT
• Antibiotics: Antibiotics can treat the bacterial infection. You may need to take more
than one type of antibiotic for couple of weeks.
• Antacids: Calcium carbonate medications reduce stomach acid exposure. They can
help relieve inflammation. Antacids, such as Tums® and Rolaids®, also treat heartburn.
• Histamine (H2) blockers: Cimetidine (Tagamet®), ranitidine (Zantac®) and similar
medications decrease the production of stomach acid.
• Proton pump inhibitors: These medications, such as omeprazole (Prilosec®) and
esomeprazole (Nexium®), reduce the amount of acid your stomach produces. Proton
pump inhibitors also treat stomach ulcers and gastroesophageal reflux disease (GERD).
NURSING MANAGEMENT
• Instruct patient to avoid alcohol.
• If the patient is able to eat by mouth nutritious diet is recommended.
• If symptoms persist, fluids should be given parenterally.
• If bleeding occurs, do gastromfestinal channel management to hemorrhage.
• To neutralize the acids commonly used antacids.
• To neutralize the alkali used diluted lemon juice or vinegar diluted.
• Emergency surgery may be needed to remove gangrene or perforation.
• The reaction needed to overcome obstruction gastric pylorus
• Can be overcome by modifying the patient's diet, eating soft diet was given little but
more often.
• reduce stress
• H. Pylori treated with antibiotics.
4. PEPTIC ULCER DISEASE
INTRODUCTION
Peptic ulcers are open sores that develop on the inside lining of your stomach and the upper
portion of your small intestine. The most common symptom of a peptic ulcer is stomach pain.
Peptic ulcers include:

• Gastric ulcers that occur on the inside of the stomach

• Duodenal ulcers that occur on the inside of the upper portion of your small intestine
(duodenum)
The most common causes of peptic ulcers are infection with the bacterium Helicobacter pylori
(H. pylori) and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as
ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Stress and spicy foods do not
cause peptic ulcers. However, they can make your symptoms worse.

CLINICAL MANIFESTATION

• Burning stomach pain

• Feeling of fullness, bloating or belching
• Intolerance to fatty foods
• Heartburn
• Nausea
PATHOPHYSIOLOGY
Defects (open sores) in the protective lining of the stomach and upper small intestine. Gastric
ulcers occur on the inside of the stomach and duodenal ulcers occur on the inside of the
upper portion of the small intestine (duodenum). Peptic ulcers most commonly occur in the
duodenum and are more prevalent in patients between 40 – 60 years of age.

DIAGNOSTIC TEST
• Esophagogastroduodenoscopy. Confirms the presence of an ulcer and allows
cytologic studies and biopsy to rule out H. pylori or cancer.
• Physical examination. A physical examination may reveal pain, epigastric tenderness,
or abdominal distention.
• Barium study. A barium study of the upper GI tract may show an ulcer.
• Endoscopy. Endoscopy is the preferred diagnostic procedure because it allows direct
visualization of inflammatory changes, ulcers, and lesions.
• Occult blood. Stools may be tested periodically until they are negative for occult blood.
• Carbon 13 (13C) urea breath test. Reflects activity of H. pylori.

NURSING DIAGNOSIS
• Acute pain related to the effect of gastric acid secretion on damaged tissue.
• Anxiety related to an acute illness.
• Imbalanced nutrition related to changes in the diet

MEDICAL MANAGEMENT
• Proton pump inhibitor (Omeprazole) – to reduce stomach acid
• H2 Histamine blockers (Famotidine) – to reduce stomach acid
• Antacids – may be given for symptom relief, but do not heal the ulcer
• Cytoprotective agents (Sucralfate) – to protect the lining of the stomach and intestine
• Antibiotics – commonly given to treat H. pylori infection
• AVOID NSAIDS (aspirin, ibuprofen, naproxen)

NURSING MANAGEMENT
Educate the client about the following:
• eat many small meals rather than 3 large ones
• lie down for 30 minutes after eating
• eat without drinking fluids….wait 30 minutes after meals and then consume liquids
• avoid sugary food and drinks
• eat food high in protein, fiber, and low-carbs
• Avoid spicy, acidic foods(tomato/citric juices/fruits), foods with caffeine, chocolate, soft
drinks , fried foods, alcohol
• Consume a low-fiber diet that is bland and eat to digest, eat white rice, bananas etc.
 5. DUMPING SYNDROME
INTRODUCTION
Dumping syndrome is a condition in which food, especially food high in sugar, moves from
your stomach into your small bowel too quickly after you eat. Sometimes called rapid gastric
emptying, dumping syndrome most often occurs as a result of surgery on your stomach or
esophagus.
Most people with dumping syndrome develop signs and symptoms, such as abdominal
cramps and diarrhea, 10 to 30 minutes after eating. Other people have symptoms 1 to 3 hours
after eating. And still others have both early and late symptoms.
Generally, you can help prevent dumping syndrome by changing your diet after surgery.
Changes might include eating smaller meals and limiting high-sugar foods. In more-serious
cases of dumping syndrome, you may need medications or surgery.

CLINICAL MANIFESTATION

• Feeling bloated or too full after eating

• Nausea
• Vomiting
• Abdominal cramps
• Diarrhea
• Flushing
• Dizziness, lightheadedness
• Rapid heart rate
• Palpitation

DIAGNOSTIC TEST
• Oral glucose tolerance test. This test measures your blood sugar before and after you
drink a glucose solution. It also measures your hematocrit (red blood cell count). A rise
in hematocrit after you drink the glucose indicates large volumes of fluids moving from
your bloodstream into your intestines. A drop in blood sugar one to three hours afterward
indicates late dumping syndrome.
• Hydrogen breath test. This test measures hydrogen levels in your breath after you drink
a glucose solution. A positive breath test for hydrogen shows that the glucose wasn’t
well-absorbed in your small intestine. This suggests that your small intestine was too
overloaded.
• Upper endoscopy. This test examines the inside of your esophagus, stomach and
duodenum with an endoscope, a thin, flexible tube with a lighted camera attached. It
can help find structural problems and other possible causes of your symptoms.
• Upper GI series. This imaging test allows healthcare providers to watch a fluid contrast
solution travel through your esophagus, stomach and upper small intestine (duodenum).
After you drink the solution, a technician takes a series of video X-rays
(called fluoroscopy). The series will show how fast the solution travels.
• Gastric emptying test. This test measures how fast food moves through your stomach
by adding a trace amount of radioactive material to your meal. Your healthcare
provider will be able to watch your meal progress through your stomach on a special
type of scanner.

NURSING DIAGNOSIS
• Imbalanced Nutrition: Less Than Body Requirements

MEDICAL MANAGEMENT
Certain medications can help modify the symptoms of early and late dumping syndrome,
including:
• Octreotide acetate. Octreotide inhibits certain hormones in your digestive system, which
slows down gastric emptying and small intestinal transit time. It also suppresses insulin.
 This medicine is given as an injection, either daily (short-acting form) or monthly (long-
acting form).
• Acarbose. This medicine controls blood sugar by slowing the rate at which your body
absorbs carbohydrates. This has been shown to reduce hypoglycemia in late dumping
syndrome.

NURSING MANAGEMENT

Providers recommend following these general guidelines to reduce symptoms:

• Eat smaller meals more frequently. Aim for six small meals instead of three. Eat slowly
and chew thoroughly.
• Avoid simple sugars, carbohydrates and milk products. This will prevent rapid blood
sugar shifts. Complex carbs, such as whole grains, are better (see below).
• Eat more protein and healthy fats to replace carbohydrates in your diet. Fats slow down
digestion and provide a steadier form of energy.
• Eat more dietary fiber to add bulk to your meal and slow down its transit time. Fiber slows
down sugar absorption in your digestive system.
• Lie down on your back for 30 minutes after eating. This may slow down gastric emptying
and help maintain blood pressure during digestion.
• Don’t drink fluids within 30 minutes before or after eating. Fluids encourage motility.
 6. DIVERTICULAR DISEASE
INTRODUCTION
Diverticulosis is a condition that occurs when small pouches, or sacs, form and push
outward through weak spots in the wall of your colon. When diverticulosis causes
symptoms, bleeding, inflammation, or complications, doctors call this condition
diverticular disease.
CLINICAL MANIFESTATION
• Pain, which may be constant and persist for several days. The lower left side of the
abdomen is the usual site of the pain. ...
• Nausea and vomiting.
• Fever.
• Abdominal tenderness.
• Constipation or, less commonly, diarrhea.

PATHOPHYSIOLOGY
Diverticulosis: A benign condition where pouches form along the intestine wall. These pouches
may form anywhere along the intestine, but are most commonly found at the end of the
descending and sigmoid colons on the left side of the abdomen. They are also commonly
found in the first section of the small intestine, but diverticula in this area rarely cause
problems. Diverticulitis: involves small abscesses or infection in one or more of the diverticula,
or perforation of the bowel.

DIAGNOSTIC TEST
Blood tests
A health care professional will take a blood sample from you and send the sample to a lab.
Doctors may use blood tests to check for signs of diverticulitis or its complications.
Stool test
Doctors may order a stool test to help find out if you have diverticular disease or another health
problem, such as irritable bowel syndrome. Your doctor will give you a container for catching
and holding a stool sample. You will receive instructions on where to send or take the kit for
testing.
Imaging tests
computed tomography (CT) NIH external link, which uses a combination of x-rays and
computer technology to create images
Ultrasound NIH external link, which uses sound waves to create an image of your organs
Magnetic resonance imaging (MRI) NIH external link, which takes pictures of your body’s
internal organs and soft tissues without using x-rays
Colonoscopy
Doctors may recommend a colonoscopy to confirm a diagnosis of diverticular disease and
rule out other conditions, such as cancer NIH external link. Doctors may also order a
colonoscopy to see and treat diverticular bleeding.

NURSING DIAGNOSIS
• Deficient Knowledge r/t diet regimen and medication regimen
• Imbalanced Nutrition: Less than body requirements r/t loss of appetite, nausea, vomiting
• Ineffective Tissue Perfusion r/t fecal blockage of diverticula
• Risk for Deficient Fluid Volume
MEDICAL MANAGEMENT
• If your diverticulitis is mild, your healthcare provider will prescribe an oral antibiotic, such
as metronidazole (Flagyl®), trimethoprim-sulfamethoxazole (Bactrim®), ciprofloxacin
(Cipro®) or amoxicillin and clavulanic acid (Augmentin®)
NURSING MANAGEMENT
1. Administer antibiotics, stool softeners, and antispasmodics, as ordered. For severe pain,
administer analgesics as ordered.
2. Maintain bed rest for patient with acute diverticulitis.
3. Maintain liquid diet during the acute attack.
4. If diverticular bleeding occurs, the patient may require angiography and catheter
placement for vasopressin infusion.
5. When administering medications, monitor the patient for desired effects and possible
adverse reaction.
6. Inspect all stools carefully for color and consistency. Note frequency of bowel
movements.
7. Monitor the patient for signs and symptoms of complications. Watch for temperature
elevation, increasing abdominal pain, blood in stools, and leukocytosis.
 7. CROHN'S DISEASE (REGIONAL ENTERITIS)
INTRODUCTION
Crohn’s disease, also called regional enteritis or ileitis, is a lifelong form of inflammatory bowel
disease (IBD). The condition inflames and irritates the digestive tract — specifically the small
and large intestines. Crohn’s disease can cause diarrhea and stomach cramps. It’s common
to experience periodic disease flare-ups.

CLINICAL MANIFESTATION
• Diarrhea
• Cramping and pain in your abdomen
• Weight loss
• Bleeding and abscess

DIAGNOSTIC TEST
• Blood test: A blood test checks for high numbers of white blood cells that may indicate
inflammation or infection. The test also checks for low red blood cell count, or anemia.
Approximately one in three people with Crohn’s disease have anemia.
• Stool test: This test looks at a sample of your stool to check for bacteria or parasites. It
can rule out infections that cause chronic diarrhea.
• Colonoscopy: During a colonoscopy, your doctor uses an endoscope (thin tube with an
attached light and camera) to examine the inside of your colon. Your doctor may take
a tissue sample (biopsy) from the colon to test for signs of inflammation.
• Computed tomography (CT) scan: A CT scan creates images of the digestive tract. It
tells your healthcare provider how severe the intestinal inflammation is.
• Upper gastrointestinal (GI) endoscopy: Your doctor threads a long, thin tube called an
endoscope through your mouth and into your throat. An attached camera allows your
doctor to see inside. During an upper endoscopy, your doctor may also take tissue
samples.
• Upper gastrointestinal (GI) exam: X-ray images used during an upper GI exam allow
your doctor to watch as a swallowed barium liquid moves through your digestive tract.

NURSING DIAGNOSIS
• Pain related to irritable initestinal, abdominal cramps and surgical response.
• Fluid and Electrolyte imbalances related to discharge of excessive vomiting.
• Imbalanced Nutrition Less Than Body Requirements related to the inadequate
nutritional intake secondary to pain, stomach and intestinal inconveniences.
• Risk for infection related to post- surgical wound.
• Anxiety related to the prognosis of the disease and surgical plan.

MEDICAL MANAGEMENT
• Antibiotics: Antibiotics can prevent or treat infections. Severe infections can lead to
abscesses (pockets of pus). Or they can cause fistulas (openings or tunnels that connect
two organs that don’t normally connect).
• Antidiarrheal medication: Prescription medications like loperamide (Imodium A-D®)
can stop severe diarrhea.
• Biologics: These medications include monoclonal antibodies to suppress the immune
response.
• Bowel rest: To give your intestines a chance to heal, your provider may recommend
going without food or drink for several days or longer. To get the nutrition you need, you
may receive intravenous (parenteral) nutrition. Only drink a prescribed liquid or have
a feeding tube during this time.
• Corticosteroids: Cortisone, prednisone and other corticosteroids ease inflammation
brought on by autoimmune disease.
• Immunomodulators: These drugs calm inflammation by suppressing an overactive
immune system. They include azathioprine and cyclosporine.
 • Surgery: Surgery won’t cure Crohn’s disease, but it can treat complications. You may
need surgery to correct intestinal perforations (holes), blockages or bleeding.

NURSING MANAGEMENT
• Provide emotional support to the patient and his family.
• Schedule patient care to include rest periods throughout the day.
• If the patient is receiving parenteral nutrition, provide meticulous site care.
• Give iron supplements and blood transfusion as ordered.
• Administer medications as ordered.
• Provide good patient hygiene and meticulous oral care if the patient is restricted to
nothing by mouth.
• Record fluid intake and output, weigh the patient daily.
• If the patient is receiving TPN, monitor his condition closely.
• Evaluate the effectiveness of medication administration.
• Emphasize the importance of adequate rest.
• Give the patient a list of foods to avoid, including lactose-containing milk products,
spicy or fried high-residue foods.
• Teach the patient about the prescrib d medications, their desires effects and possible
adverse reactions.
 8. ULCERATIVE COLITIS
INTRODUCTION
Ulcerative colitis (UL-sur-uh-tiv koe-LIE-tis) is an inflammatory bowel disease (IBD) that causes
inflammation and ulcers (sores) in your digestive tract. Ulcerative colitis affects the innermost
lining of your large intestine (colon) and rectum. Symptoms usually develop over time, rather
than suddenly.
Ulcerative colitis can be debilitating and can sometimes lead to life-threatening
complications. While it has no known cure, treatment can greatly reduce signs and symptoms
of the disease and bring about long-term remission.

CLINICAL MANIFESTATION

• Diarrhea, often with blood or pus

• Abdominal pain and cramping
• Rectal pain
• Rectal bleeding — passing small amount of blood with stool
• Urgency to defecate
• Inability to defecate despite urgency
• Weight loss
• Fatigue
• Fever
• In children, failure to grow

DIAGNOSTIC TEST
• Blood test: Using a sample of your blood, we may run a number of blood tests, including:
Complete blood count to look for signs of anemia and infections
• Colonoscopy or sigmoidoscopy: Examining the entire length of your colon
(colonoscopy) or just the lower part of your colon (sigmoidoscopy) with the help of a
small flexible tube and tiny camera we insert into your rectum (endoscope).
• Magnetic resonance imaging: A magnetic resonance imaging test produces detailed
images of your small and large intestine without radiation and shows tissue inflammation
in exquisite detail.
• Stool culture: Also known as a fecal occult blood test (FOBT), this test examines a sample
of your stool under a microscope to look for microscopic amounts of blood.
• Upper endoscopy: With the help of an endoscope that we pass through your mouth
and esophagus, we carefully examine the lining of your intestines. During an upper
endoscopy, we may also take a tissue sample (biopsy) and examine it under a
microscope.
NURSING DIAGNOSIS
• Diarrhea related to inflammation of bowel as evidenced by loose watery stools
• Deficient fluid volume related to diarrhea and loss of fluids and electrolytes
• Innefective coping related to fatigue

MEDICAL MANAGEMENT
Anti-inflammatory drugs Anti-inflammatory drugs are often the first step in the treatment of
ulcerative colitis and are appropriate for the majority of people with this condition. These drugs
include:
• 5-aminosalicylates. Examples of this type of medication include sulfasalazine
(Azulfidine), mesalamine (Asacol HD, Delzicol, others), balsalazide (Colazal) and
olsalazine (Dipentum). Which one you take, and whether it is taken by mouth or as an
enema or suppository, depends on the area of your colon that's affected.
• Corticosteroids. These drugs, which include prednisone and budesonide, are generally
reserved for moderate to severe ulcerative colitis that doesn't respond to other
treatments. Due to the side effects, they are not usually given long term.
Immune system suppressors:
Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixan). These are the most
widely used immunosuppressants for the treatment of inflammatory bowel disease. Taking
them requires that you follow up closely with your doctor and have your blood checked
regularly to look for side effects, including effects on the liver and pancreas.
Cyclosporine (Gengraf, Neoral, Sandimmune). This drug is normally reserved for people who
haven't responded well to other medications. Cyclosporine has the potential for serious side
effects and is not for long-term use.
Tofacitinib (Xeljanz). This is called a "small molecule" and works by stopping the process of
inflammation. Tofacitinib is effective when other therapies don't work. Main side effects
include the increased risk of shingles infection and blood clots.

NURSING MANAGEMENT
• Watch foods that can cause a “flare-up” or should be avoided during a “flare-up”:
• High-fiber foods (they require a lot of digestion and the gut needs to rest)
• Food hard to digest like: nuts, raw vegetables or fruits (cooked are better)
• Allergen type foods: dairy or certain foods that the person may be intolerant too like
wheat, fish
• Avoid spicy, high-fat foods, gluten, gas causing foods like onions, beans etc.
 9. APPENDICITIS
INTRODUCTION
Appendicitis is an inflammation of the appendix, a finger-shaped pouch that projects from
your colon on the lower right side of your abdomen.
Appendicitis causes pain in your lower right abdomen. However, in most people, pain begins
around the navel and then moves. As inflammation worsens, appendicitis pain typically
increases and eventually becomes severe.
CLINICAL MANIFESTATION
• Pain. Vague epigastric or periumbilical pain progresses to right lower quadrant pain
usually accompanied by low-grade fever, nausea,and sometimes vomiting.
• Tenderness. In 50% of presenting cases, local tenderness is elicited at McBurney’s
point when pressure is applied.
• Rebound tenderness. Rebound tenderness or the production or intensification of pain
when pressure is released.
• Rovsing’s sign. Rovsing’s sign may be elicited by palpating the left lower quadrant; this
paradoxically causes pain to be felt at the right lower quadrant.

DIAGNOSTIC TEST
• Physical exam to assess your pain. Your doctor may apply gentle pressure on the painful
area. When the pressure is suddenly released, appendicitis pain will often feel worse,
signaling that the adjacent peritoneum is inflamed.
Your doctor may also look for abdominal rigidity and a tendency for you to stiffen your
abdominal muscles in response to pressure over the inflamed appendix (guarding).
Your doctor may use a lubricated, gloved finger to examine your lower rectum (digital
rectal exam). Women of childbearing age may be given a pelvic exam to check for
possible gynecological problems that could be causing the pain.

• Blood test. This allows your doctor to check for a high white blood cell count, which may
indicate an infection.
• Urine test. Your doctor may want you to have a urinalysis to make sure that a urinary tract
infection or a kidney stone isn't causing your pain.
• Imaging tests. Your doctor may also recommend an abdominal X-ray, an abdominal
ultrasound, computerized tomography (CT) scan or magnetic resonance imaging (MRI)
to help confirm appendicitis or find other causes for your pain.

NURSING DIAGNOSIS
• Acute pain related to obstructed appendix.
• Risk for deficient fluid volume related to preoperative vomiting, postoperative
restrictions.
• Risk for infection related to ruptured appendix.
MEDICAL MANAGEMENT
Most people with appendicitis need a surgery called an appendectomy. It removes a
diseased appendix. If the appendix hasn’t yet ruptured, surgery prevents that rupture and
keeps infection from spreading.
Before surgery, you receive intravenous (IV) antibiotics to treat infection. Some cases of mild
appendicitis get better with antibiotics alone. Your doctor will watch you closely to determine
if you need surgery. Surgery is the only way to treat abdominal infection when the appendix
ruptures.
If you need surgery, most appendectomies are done laparoscopically. Laparoscopic
procedures take place with a scope through small incisions. This minimally invasive approach
helps you heal faster, with less pain. You may need major abdominal surgery (laparotomy) if
the appendix ruptures.
NURSING MANAGEMENT
Nursing interventions related to the appendicitis patient include:
• Assessing and relieving pain through medication administration as well as
nonpharmacologic interventions.
• IMPORTANT: DO NOT APPLY HEAT TO THE APPENDICITIS PATIENT'S ABDOMEN AS THIS
COULD LEAD TO RUPTURE.
• Prevent fluid volume deficit. If tolerated and the patient is not NPO, oral fluid intake
should be encouraged, and intake and output recorded.
• Prevent infection. Maintain a clean environment, provide wound care to the
postoperative patient, and assess incision frequently for signs of infection. Monitor
patient temperature and heart rate for signs of potential infection. Administer antibiotics
as prescribed by the provider.
• Reduce patient anxiety by keeping the patient informed of the plan of care and ensure
the patient is aware of diagnosis and treatment options.
• Encourage patients to walk as able/ permitted to maintain circulation. If the patient is
immobile, the use of serial compression devices (SCD) and TED hose should be
implemented to avoid DVT/clots.
• Monitor for adequate bowel movements. Opioids can be necessary for pain control,
but they often lead to constipation. Encourage adequate water intake and use of a
stool softener.
 10. HEMORRHOIDS
INTRODUCTION
Hemorrhoids (HEM-uh-roids), also called piles, are swollen veins in your anus and lower rectum,
similar to varicose veins. Hemorrhoids can develop inside the rectum (internal hemorrhoids) or
under the skin around the anus (external hemorrhoids).
Nearly three out of four adults will have hemorrhoids from time to time. Hemorrhoids have a
number of causes, but often the cause is unknown.
Fortunately, effective options are available to treat hemorrhoids. Many people get relief with
home treatments and lifestyle changes

CLINICAL MANIFESTATION
External hemorrhoids

• Itching or irritation in your anal region

• Pain or discomfort
• Swelling around your anus
• Bleeding
• Internal hemorrhoids
• Painless bleeding during bowel movements. You might notice small amounts of bright
red blood on your toilet tissue or in the toilet.
• A hemorrhoid to push through the anal opening (prolapsed or protruding hemorrhoid),
resulting in pain and irritation.
DIAGNOSTIC TEST

• Digital examination. Your doctor inserts a gloved, lubricated finger into your rectum. He
or she feels for anything unusual, such as growths.
• Visual inspection. Because internal hemorrhoids are often too soft to be felt during a
rectal exam, your doctor might examine the lower portion of your colon and rectum with
an anoscope, proctoscope or sigmoidoscope.
NURSING DIAGNOSIS
• Acute pain related to inflammation and edema of prolapsed varices.
• Ineffective breathing pattern related to decreased pressure inspiration - expiration
for anesthetic agent administration.
• Fluid volume and electrolyte deficit related to lack of or loss of fluid volume during
surgery.
• Risk for injury related to the effects of anesthesia and weakness.
• Risk for Hypothermia related to multiple factors of age, body weight, factors trauma,
neuromuscular and environment.
MEDICAL MANAGEMENT
• Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository
containing hydrocortisone, or use pads containing witch hazel or a numbing agent.
• Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water for
10 to 15 minutes two to three times a day. A sitz bath fits over the toilet.
• Take oral pain relievers. You can use acetaminophen (Tylenol, others), aspirin or
ibuprofen (Advil, Motrin IB, others) temporarily to help relieve your discomfort.

NURSING MANAGEMENT
Instruct the client to the following:
• Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the
stool and increases its bulk, which will help you avoid the straining that can worsen
symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with
gas.
• Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water for
10 to 15 minutes two to three times a day. A sitz bath fits over the toilet.
 11. HEPATITIS
INTRODUCTION
Hepatitis means inflammation of the liver. The liver is a vital organ that processes nutrients, filters
the blood, and fights infections. When the liver is inflamed or damaged, its function can be
affected. Heavy alcohol use, toxins, some medications, and certain medical conditions can
cause hepatitis.
CLINICAL MANIFESTATION
• fever
• fatigue
• loss of appetite
• nausea
• vomiting
• abdominal pain
• dark urine
• light-colored stools
• joint pain
• jaundice.
PATHOPHYSIOLOGY

DIAGNOSTIC TEST

Blood Tests
Your doctor draws a small amount of blood from a vein in your arm and sends it to a laboratory
for testing. The results of a blood test can confirm the type of viral hepatitis, the severity of the
infection, whether an infection is active or dormant, and whether a person is currently
contagious.
NURSING DIAGNOSIS
• Imbalanced nutrition less than the body requirements related to compromised
absorption and metabolism secondary to hepatitis
• Risk for deficient volume related to excessive losses through vomiting and diarrhea
secondary to hepatitis .

MEDICAL MANAGEMENT
• Antiviral medications. Several antiviral medications — including entecavir (Baraclude),
tenofovir (Viread), lamivudine (Epivir), adefovir (Hepsera) and telbivudine (Tyzeka) —
can help fight the virus and slow its ability to damage your liver. These drugs are taken
by mouth. Talk to your doctor about which medication might be right for you.
• Interferon injections. Interferon alfa-2b (Intron A) is a man-made version of a substance
produced by the body to fight infection. It's used mainly for young people with hepatitis
B who wish to avoid long-term treatment or women who might want to get pregnant
within a few years, after completing a finite course of therapy. Interferon should not be
used during pregnancy.

• Liver transplant. If your liver has been severely damaged, a liver transplant may be an
option. During a liver transplant, the surgeon removes your damaged liver and replaces
it with a healthy liver. Most transplanted livers come from deceased donors, though a
small number come from living donors who donate a portion of their livers.

NURSING MANAGEMENT
Monitor dietary intake and caloric count. Suggest several small feedings and offer “largest”
meal at breakfast.
Encourage mouth care before meals.
Recommend eating in upright position.
Encourage intake of fruit juices, carbonated beverages, and hard candy throughout the day.
 12. LIVER CIRRHOSIS
INTRODUCTION
Cirrhosis is a late-stage liver disease in which healthy liver tissue is replaced with scar tissue and
the liver is permanently damaged. Scar tissue keeps your liver from working properly.
Many types of liver diseases and conditions injure healthy liver cells, causing cell death and
inflammation. This is followed by cell repair and finally tissue scarring as a result of the repair
process.

CLINICAL MANIFESTATION
• Loss of appetite.
• Feeling weak or tired.
• Nausea.
• Fever
• Unexpected weight loss.
DIAGNOSTIC TEST
Abdominal computed tomography (CT) scan: This procedure combines special x-ray
equipment with sophisticated computers to produce multiple, digital images or pictures of the
liver. It can help determine the severity of cirrhosis as well as other liver diseases. See "Radiation
Dose in X-Ray and CT Exams"for more information.
Abdominal ultrasound: Ultrasound is a type of imaging exam that uses sound waves to create
pictures of the inside of the abdomen and/or pelvis, including images of the liver. Doppler
ultrasound allows for evaluation of blood flow to and from the liver.
Elastography: This exam assesses the stiffness of your liver and can help diagnose how severe
the scarring is in your liver (known as liver fibrosis). Left untreated, liver fibrosis can eventually
lead to cirrhosis of the liver which is not reversible. Elastography can detect stiffness of the liver
caused by liver fibrosis earlier than other imaging tests. The test can be performed by
ultrasound or MRI.
Body magnetic resonance imaging (MRI): This imaging exam uses a powerful magnetic field,
radio frequency pulses and a computer to produce detailed pictures of the liver allowing for
assessment of damage caused by various liver diseases. See the MRI Safety page for more
information.
Magnetic resonance cholangiopancreatography (MRCP): MRCP is special type of MRI
protocol that is designed to evaluate a part of the liver and gallbladder, known as the biliary
system that is part of your liver.

NURSING DIAGNOSIS
• Activity intolerance related to fatigue, lethargy, and malaise.
• Imbalanced nutrition: less than body requirements related to abdominal distention and
discomfort and anorexia

MEDICAL MANAGEMENT
Alcohol-related liver disease: If you’ve developed cirrhosis from alcohol abuse, stop drinking
alcohol. If you need help, ask your healthcare provider for recommendations for alcohol
addiction treatment programs.
Hepatitis B or C: Several approved antiviral medications are available to treat hepatitis types
B and C.
Nonalcoholic fatty liver disease: Management of nonalcoholic fatty liver disease includes
losing weight, following a healthy diet, getting physical exercise and following your provider’s
instructions for managing your diabetes.
Inherited liver diseases: Treatment depends on the specific inherited disease. Treatments are
aimed at treating symptoms and managing complications. Treatment of alpha-1 antitrypsin
deficiency may include medicine to reduce swelling in your abdomen and legs, antibiotics to
treat infections and other medicines for complications. For hemochromatosis, treatment is to
remove blood to reduce the level of iron in your blood. For Wilson disease, treatment is
medicines to remove copper from your body and zinc to prevent absorption of cooper. For
cystic fibrosis, medications are prescribed to improve lung function, methods to clear mucous
and treatment of complications. Treatment for glycogen storage diseases that involve the liver
is to keep glucose at the right level.
Autoimmune hepatitis: Treatment includes medications to suppress your immune system

NURSING MANAGEMENT
• Instruct the patient of the following:
• Don't abuse alcohol. If you do drink alcohol, limit how much you drink and how often.
• Eat a well-balanced, low-fat diet, such as the Mediterranean diet. A well-balanced
healthy diet consists of fruits, vegetables, lean proteins and whole grains.
• Don’t eat raw seafood, especially oysters and clams. These foods can contain a
bacteria that can cause serious illness.
• Cut back on the amount of salt in your diet. Use other seasonings to flavor your foods.
 13. Cholelithiasis/ Cholecystitis
INTRODUCTION
Cholecystitis (ko-luh-sis-TIE-tis) is inflammation of the gallbladder. Your gallbladder is a small,
pear-shaped organ on the right side of your abdomen, beneath your liver. The gallbladder
holds a digestive fluid that's released into your small intestine (bile).
In most cases, gallstones blocking the tube leading out of your gallbladder cause cholecystitis.
This results in a bile buildup that can cause inflammation. Other causes of cholecystitis include
bile duct problems, tumors, serious illness and certain infections

CLINICAL MANIFESTATION

• Severe pain in your upper right or center abdomen

• Pain that spreads to your right shoulder or back
• Tenderness over your abdomen when it's touched
• Nausea
• Vomiting
• Fever
DIAGNOSTIC TEST
• Blood tests. Your doctor may order blood tests to look for signs of an infection or signs of
gallbladder problems.
• Imaging tests that show your gallbladder. Abdominal ultrasound, endoscopic
ultrasound, or a computerized tomography (CT) scan can be used to create pictures of
your gallbladder that may reveal signs of cholecystitis or stones in the bile ducts and
gallbladder.
• A scan that shows the movement of bile through your body. A hepatobiliary
iminodiacetic acid (HIDA) scan tracks the production and flow of bile from your liver to
your small intestine and shows blockage. A HIDA scan involves injecting a radioactive
dye into your body, which attaches to bile-producing cells so that it can be seen as it
travels with the bile through the bile ducts.

NURSING DIAGNOSIS
• Acute Pain related to biological trauma obstruction / spasm tract inflammatory
processes, iskhemia / tissue necrosis
• Risk for Deficient Fluid Volume related to increase in gastric fluid loss: vomiting, gastric
distention and hipermolity
• Imbalanced Nutrition Less Than Body Requirements related to loss of nutrients, affect
digestion due to disturbance / narrowing of the bile duct.

MEDICAL MANAGEMENT
• Surgery: If surgery is warranted, it can be performed using laparoscopic or open
technique. Laparoscopic cholecystectomy is considered the treatment of
choice.2,14 Open surgery may be suggested when concomitant gallbladder cancer is
present.1,22 Supportive care for those undergoing surgery may include IV fluids, pain
control, and IV antibiotics.
• Oral Bile Agents: For patients who decline surgery or for those who may be at higher
surgical risk because of other comorbidities or advanced age, clinicians may elect to
use oral bile acids.1
NURSING MANAGEMENT
Educate the client to the following:
• Eating a healthy diet: Choose to eat a healthy diet – one high in fruits, vegetables whole
grains and healthy fats – such as the Mediterranean diet. Stay away from foods high in
fat and cholesterol.
• Exercising: Exercise reduces cholesterol, and the lower the cholesterol level the lower
the chance of getting gallstones.
• Losing weight slowly: If you are making efforts to lose weight, don’t lose more than one
to two pounds a week. Rapid weight loss increases your risk for developing gallstones.
 14. ACUTE PANCREATITIS
INTRODUCTION
Pancreatitis is inflammation of the pancreas. The pancreas is a long, flat gland that sits tucked
behind the stomach in the upper abdomen. The pancreas produces enzymes that help
digestion and hormones that help regulate the way your body processes sugar (glucose).
Pancreatitis can occur as acute pancreatitis — meaning it appears suddenly and lasts for
days. Some people develop chronic pancreatitis, which is pancreatitis that occurs over many
years.

CLINICAL MANIFESTATION

• Upper abdominal pain

• Abdominal pain that radiates to your back
• Tenderness when touching the abdomen
• Fever
• Rapid pulse
• Nausea
• Vomiting

DIAGNOSTIC TEST

• Blood tests to look for elevated levels of pancreatic enzymes, along with white blood cells,
kidney function and liver enzymes
• Abdominal ultrasound to look for gallstones and pancreas inflammation
• Computerized tomography (CT) scan to look for gallstones and assess the extent of
pancreas inflammation
• Magnetic resonance imaging (MRI) to look for abnormalities in the gallbladder, pancreas
and ducts
• Endoscopic ultrasound to look for inflammation and blockages in the pancreatic duct or
bile duct
• Stool tests in chronic pancreatitis to measure levels of fat that could suggest your digestive
system isn't absorbing nutrients adequately

NURSING DIAGNOSIS
• Acute pain related to edema, distention of the pancreas, and peritoneal irritation.
MEDICAL MANAGEMENT
▪ Oral intake is withheld to inhibit pancreatic stimulation and secretion of pancreatic
enzymes.
▪ Parenteral nutrition is administered to the debilitated patient.
▪ Nasogastric suction is used to relieve nausea and vomiting, decrease painful abdominal
distention and paralytic ileus and remove hydrochloric acid so that it does not stimulate
the pancreas.
▪ Cimetidine (Tagamet) is given to decrease hydrochloric acid secretion.
▪ Adequate pain medication is administered; morphine and morphine derivatives are
avoided because they cause spasm of the sphincter of Oddi.
▪ Correction of fluid, blood loss, and low albumin levels is necessary.
▪ Antibiotics are administered if infection is present.
▪ Insulin is necessary if significant hyperglycemia occurs.
▪ Aggressive respiratory care is provided for pulmonary infiltrates, effusion and atelactasis.
▪ Biliary drainage (drains and stents) results in decreased pain and increased weight gain.
▪ Surgical intervention may be performed for diagnosis, drainage, resection or
debridement.
Nursing Diagnosis
▪ Pain and discomfort related to edema, distention of the pancreas, and peritoneal irritation
▪ Imbalanced nutrition: less than body requirements related to inadequacy dietary intake,
impaired absorption, reduced food intake, and increased metabolic demands.
▪ Activity intolerance related to fatigue
▪ Ineffective breathing pattern related to severe pain, pulmonary infiltrates, pleural effusion
and atelactasis
▪ Impaired skin integrity resulting from poor nutritional status, bed rest, surgical wound
▪ Fear in response to the diagnosis of pancreatitis
▪ Ineffective coping related to the diagnosis of pancreatitis
Nursing Management
• The client should avoid oral intake to inhibit pancreatic stimulation and secretion of
pancreatic enzymes.
• Total parenteral nutrition is administered to assist with metabolic stress.
• Maintain fluid and electrolyte balance.
• Assess fluid and electrolyte status (e.g. skin turgor, mucous membranes, intake and
output); and provide replacement therapy as indicated.
• Promote adequate nutrition.
• Assess nutritional status; monitor glucose levels; monitor IV therapy, provide a high-
carbohydrate, low-protein, low-fat diet when tolerate; and instruct the client to avoid
spicy foods.
• Maintain optimal respiratory status.
• Place the client in semi-Fowler’s position to decrease pressure on the diaphragm.
• Teach the client coughing and deep-breathing techniques.
 15. CHRONIC PANCREATITIS
INTRODUCTION
Chronic pancreatitis causes severe damage to your pancreas. This means that your body
won't be able to make needed enzymes and hormones. This can result in malnutrition,
because you won't be able to digest foods. Chronic pancreatitis can also cause diabetes. This
happens because your pancreas can't make insulin.

CLINICAL MANIFESTATION

• Upper abdominal pain

• Abdominal pain that feels worse after eating
• Losing weight without trying
• Oily, smelly stools (steatorrhea)

PATHOPHYSIOLOGY

DIAGNOSTIC TEST

• Laboratory Testing
• Imaging Scans
• Upper Endoscopy
• Endoscopic Retrograde Cholangiopancreatography (ERCP)
• Endoscopic Ultrasound (EUS)

NURSING DIAGNOSIS
• Chronic pain related to chronic pancreatitis
• Nutrition imbalance: less than body requirements, related to chronic pancreatitis
• Knowledge deficit related to chronic pancreatitis
MEDICAL MANAGEMENT
• Pain and discomfort are relieved with analgesics.
• Patient should avoid alcohol and foods that produce abdominal pain and discomfort.
No other treatment will relieve pain if patient continues to consume alcohol.
• Diabetes mellitus resulting from dysfunction of pancreatic islet of cells is treated with
diet, insulin or oral hypoglycemic agents. Patient and family are taught the hazard of
severe hypoglycemia related to alcohol use.
• Pancreatic enzyme replacement therapy is instituted for malabsorption and
steatorrhea.
• Surgery is done to relive abdominal pain and discomfort, restore drainage of
pancreatic secretions, and reduce frequency of attacks (pancreaticojejunostomy)
NURSING MANAGEMENT
• The patient will be NPO to give the pancreas a rest since eating stimulates the pancreas
to release enzymes
• Pancreatitis often comes with pretty significant nausea/vomiting. The NGT will decrease
gastric distention and remove gastric juices. Though patients typically HATE the insertion
aspect of the NGT, it typically often relieves their unrelenting nausea pretty effectively
and quickly.
• ETOH cessation if needed (ETOH is medical abbreviation for “alcohol”)
• Patient will need to be careful with their diet, typically starting with low-fat and low-
protein foods, then progressing slowly
• If DM is present, the patient will need a lot of education surrounding the management
of this disease and the necessary dietary modifications
• The patient will need to avoid caffeine as it can exacerbate the condition
• Teach the patient which foods trigger attacks, so they can avoid them (typically this
includes fatty red meats, fried foods, butter or margarine, sugary foods and full-fat dairy)
• If the patient is discharged with pancreatic enzymes, they need to understand to take
them WITH meals
• The patient should be instructed to report abdominal distention, abdominal cramping
or pain, and foul-smelling or frothy stools (which can indicate an ongoing problem