Compilation of MS Notes

8/14/2019 Compilation of MS Notes

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MEDICAL-SURGICAL NURSING

NERVOUS SYSTEM

Overview of structures and functions:

Central Nervous System

Brain

Spinal Cord

Peripheral Nervous System

Cranial Nerves

Spinal Nerves

Autonomic Nervous System

Sympathetic nervous system

Parasympathetic nervous system

AUTONOMIC NERVOUS SYSTEM

Sympathetic Nervous System

(ADRENERGIC)

Parasympathetic Nervous

System(CHOLINERGIC, VAGAL,

SYMPATHOLYTIC)

- Involved in fight or aggressionresponse.- Release of Norepinephrine(cathecolamines)

from adrenal glands and causesvasoconstriction.

- Increase all bodily activity except GIT

EFFECTS OF SNS- Dilation of pupils(mydriasis) in orderto be aware.- Dry mouth (thickened saliva).- Increase BP and Heart Rate.- Bronchodilation, Increase RR- Constipation.- Urinary Retention.

- Increase blood supply to brain, heartand skeletal

muscles.- SNS

I. Adrenergic Agents- Give Epinephrine.Signs and Symptoms:- SNS

- Involved in fight or withdrawalresponse.- Release of Acetylcholine.

- Decreases all bodily activities

except GIT.

EFFECTS OF PNS- Constriction of pupils (meiosis).- Increase salivation.- Decrease BP and Heart Rate.- Bronchoconstriction, DecreaseRR.- Diarrhea- Urinary frequency.

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

Compilation of MS Notes | Karl Gerald C. Manalili, UASN 2010


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Contraindication:- Contraindicated to patients sufferingfrom COPD (Broncholitis,Bronchoectasis, Emphysema, Asthma).

II. Beta-adrenergic Blocking Agents- Also called Beta-blockers.- All ending with lol- Propranolol, Atenelol, Metoprolol. Effects of Beta-blockersB roncho spasmE licits a decrease in myocardialcontraction.T reats hypertension.

A V conduction slows down. Should be given to patients withAngina Pectoris, MyocardialInfarction, Hypertension.

ANTI- HYPERTENSIVE AGENTS1. Beta-blockers lol2. Ace Inhibitors Angiotensin, pril(Captopril, Enalapril)

3. Calcium Antagonist Nifedipine(Calcibloc) In chronic cases of arrhythmia give

Lidocaine(Xylocaine)

II. Anti-cholinergic Agents

- To counter cholinergic agents.- Atropine SulfateSide Effects- SNS

CENTRAL NERVOUS SYSTEM

Brain and Spinal Cord.

I. CELLS

A. NEURONS Basic cells for nerve impulse and conduction.

PROPERTIES

Excitability ability of neuron to be affected by changes in external

environment.

Conductivity ability of neuron to transmit a wave of excitation from one

cell to another.



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Permanent Cell once destroyed not capable of regeneration.

TYPES OF CELLS BASED ON REGENERATIVE CAPACITY

1. Labile

Capable of regeneration.

Epidermal cells, GIT cells, GUT cells, cells of lungs.

2. Stable

Capable of regeneration with limited time, survival period.

Kidney cells, Liver cells, Salivary cells, pancreas.

3. Permanent

Not capable of regeneration.

Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

B. NEUROGLIA

Support and protection of neurons.

TYPES

1. Astrocytes maintains blood brain barrier semi-permeable.

Majority of brain tumors (90%) arises from called

astrocytoma.

2. Oligodendria

3. Microglia

4. Epindymal

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER

1. Ammonia

Cerebral toxin

Hepatic Encephalopathy (Liver Cirrhosis)

Ascites

Esophageal VaricesEarly Signs of Hepatic Encephalopathy

asterixis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy

Headache

Dizziness

Confusion



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Fetor hepaticus (ammonia like breath)

Decrease LOC



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PATHOGNOMONIC SIGNS

1. PTB low-grade afternoon fever.

2. PNEUMONIA rusty sputum.

3. ASTHMA wheezing on expiration.

4. EMPHYSEMA barrel chest.

5. KAWASAKI SYNDROME strawberry tongue.

6. PERNICIOUS ANEMIA red beefy tongue.

7. DOWN SYNDROME protruding tongue.

8. CHOLERA rice watery stool.9. MALARIA stepladder like fever with chills.

10. TYPHOID rose spots in abdomen.

11. DIPTHERIA pseudo membrane formation

12. MEASLES kopliks spots.

13. SLE butterfly rashes.

14. LIVER CIRRHOSIS spider like varices.

15. LEPROSY lioning face.

16. BULIMIA chipmunk face.

17. APPENDICITIS rebound tenderness.

18. DENGUE petechiae or (+) Hermans sign.

19. MENINGITIS Kernigs sign (leg pain), Brudzinski sign (neck pain).

20. TETANY HYPOCALCEMIA (+) Trousseaus sign/carpopedal

spasm; Chvostek sign (facial spasm).

21. TETANUS risus sardonicus.

22. PANCREATITIS Cullens sign (ecchymosis of umbilicus); (+) Grey

turners spots.

23. PYLORIC STENOSIS olive like mass.

24. PDA machine like murmur.

25. ADDISONS DISEASE bronze like skin pigmentation.26. CUSHINGS SYNDROME moon face appearance and buffalo hump.

27. HYPERTHYROIDISM/GRAVES DISEASE exopthalmus.

28. INTUSSUSCEPTION sausage shaped mass

2. Carbon Monoxide and Lead Poisoning

Can lead to Parkinsons Disease.



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Epilepsy

Treat with ANTIDOTE: Calcium EDTA.

3. Type 1 DM (IDDM)

Causes diabetic ketoacidosis.

And increases breakdown of fats.

And free fatty acids

Resulting to cholesterol and (+) to Ketones (CNS depressant).

Resulting to acetone breath odor/fruity odor.

KUSSMAULS respiration, a rapid shallow respiration.

Which may lead to diabetic coma.

4. Hepatitis

Signs of jaundice (icteric sclerae).

Caused by bilirubin (yellow pigment)

5. Bilirubin

Increase bilirubin in brain (Kernicterus).

Causing irreversible brain damage.

DEMYELINATING DISORDERS

1. ALZHEIMERS DISEASE

Atrophy of brain tissues.

Sign and Symptoms

4 As of Alzheimer

a. Amnesia loss of memory.

b. Agnosia no recognition of inanimate objects.

c. Apraxia no recognition of objects function.

d. Aphasia no speech (nodding).*Expressive aphasia

motor speech center

Brocas Aphasia

*Receptive aphasia

inability to understand spoken words.

Wernickes Aphasia


Astrocites

Maintains integrity of blood brain barrier.

Oligodendria

Produces myelin sheath in CNS

Act as insulator and facilitates rapid nerve impulse transmission.


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General Knowing Gnostic Area or General Interpretative Area.

DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX.

2. MULTIPLE SCLEROSIS

Chronic intermittent disorder of CNS characterized by white patches of

demyelination in brain and spinal cord.

Characterized by remission and exacerbation.

Women ages 15-35 are prone

Unknown Cause

Slow growing virus

Autoimmune disorders

Pernicious anemia

Myasthenia gravis

Lupus

Hypothyroidism

GBS

Ig G only antibody that pass placental circulation causing passive

immunity.

- short term protection.

- Immediate action.

Ig A present in all bodily secretions (tears, saliva, colostrums).

Ig M acute in inflammation.

Ig E for allergic reaction.

Ig D for chronic inflammation.

* Give palliative or supportive care.

Signs and Symptoms

1. Visual disturbances

blurring of vision (primary) diplopia (double vision)

scotomas (blind spots)

2. Impaired sensation

to touch, pain, pressure, heat and cold.

tingling sensation



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paresthesia

numbness

3. Mood swings

euphoria (sense of well being)

4. Impaired motor function

weakness

spasticity

paralysis

5. Impaired cerebral function

scanning speech

TRIAD SIGNS OF MS

Ataxia

(Unsteady gait, (+) Rombergs test)

Intentional tremors Nystagmus

6. Urinary retention/incontinence

7. Constipation

8. Decrease sexual capacity

DIAGNOSTIC PROCEDURE

CSF analysis (increase in IgG and Protein).

MRI (reveals site and extent of demyelination). (+) Lhermittes sign a continuous and increase contraction of spinal

column.

NURSING MANAGEMENT

1. Administer medications as ordered


CHARCOTSTRIAD

IAN


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a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute

exacerbation to reduce edema at site

of demyelination to prevent paralysis.

b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) muscle

relaxants.

c. Interferons alter immune response.

d. Immunosupresants

2. Maintain side rails to prevent injury related to falls.

3. Institute stress management techniques.

a. Deep breathing exercises

b.Yoga

4. Increase fluid intake and increase fiber to prevent constipation.

5. Catheterization to prevent retention.

a. Diuretics

b. Bethanicol Chloride (Urecholine)

Nursing Management

Only given subcutaneous.

Monitor side effects bronchospasm and wheezing.

Monitor breath sounds 1 hour after subcutaneous administration.

c. For Urinary Incontinence

Anti spasmodic agent

a. Prophantheline Bromide (Promanthene)

Acid ash diet like cranberry juice, plums, prunes, pineapple,

vitamin C and orange.

To acidify urine and prevent bacterial multiplication.

COMMON CAUSE OF UTI

Female

short urethra (3-5 cm, 1-1 inches) poor perineal hygiene

vaginal environment is moist

Nursing Management

avoid bubble bath (can alter Ph of vagina).

avoid use of tissue papers

avoid using talcum powder and perfume.



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Male

Urethra (20 cm, 8 inches)

urinate after intercourse

MICROGLIA

stationary cells that carry on phagocytosis (engulfing of bacteria

or cellular debris, eating), pinocytosis (cell drinking).

MACROPHAGE ORGAN

Microglia

Monocytes

Kupffers cells

Histiocytes

Alveolar

Macrophage

Brain

Blood

Kidney

Skin

Lung

EPINDYMAL CELLS

Secretes a glue called chemo attractants that concentrate the

bacteria.

COMPOSITION OF BRAIN

80% brain mass

10% blood

10% CSF

I. Brain Mass

PARTS OF THE BRAIN

1. CEREBRUM

largest part

composed of the Right Cerebral Hemisphere and Left Cerebral

Hemisphere enclosed in the Corpus Callosum.

Functions of Cerebrum

integrative sensory

motor

Lobes of Cerebrum

1. Frontal

higher cortical thinking

controls personality



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controls motor activity

Brocas Area (motor speech area) when damaged results to

garbled speech.

2. Temporal

hearing

short term memory

3. Parietal

for appreciation

discrimination of sensory impulses to pain, touch, pressure, heat,

cold, numbness.

4. Occipital

for vision

Insula (Island of Reil)

visceral function activities of internal organ like gastric motility.

Limbic System (Rhinencephalon)

controls smell and if damaged results to Anosmia (absence of

smell).

controls libido

controls long term memory

2. BASAL GAGLIA

areas of grey matter located deep within each cerebral

hemisphere.

release dopamine (controls gross voluntary movement.

NEURO

TRANSMITTER

DECREASE INCREASE

Acethylcholine Myasthenia Gravis Bi-polar Disorder

Dopamine Parkinsons Disease Schizophrenia

3. MIDBRAIN/ MESENCEPHALON

acts as relay station for sight and hearing.

size of pupil is 2 3 mm.

equal size of pupil is isocoria.

unequal size of pupil is anisocoria.



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hearing acuity is 30 40 dB.

positive PERRLA

4. INTERBRAIN/ DIENCEPHALON

Parts of Diencephalon

A. Thalamus

acts as relay station for sensation.

B. Hypothalamus

controls temperature (thermoregulatory center).

controls blood pressure

controls thirst

appetite/satiety

sleep and wakefulness

controls some emotional responses like fear, anxiety and

excitement.

controls pituitary functions

androgenic hormones promotes secondary sex characteristics.

early sign for males are testicular and penile enlargement

late sign is deepening of voice.

early sign for females telarche and late sign is menarche.

5. BRAIN STEM

located at lowest part of brain

Parts of Brain Stem

1. Pons

pneumotaxic center controls the rate, rhythm and depth of

respiration.

2. Medulla Oblongata

controls respiration, heart rate, swallowing, vomiting, hiccup,vasomotor center (dilation and constriction of bronchioles).

3. Cerebellum

smallest part of the brain.

lesser brain.



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controls balance, equilibrium, posture and gait.

INTRA CRANIAL PRESSURE

Monroe Kellie Hypothesis

Skull is a closed container

Any alteration or increase in one of the intracranial components

Increase intra-cranial pressure

(normal ICP is 0 15 mmHg)

Cervical 1 also known as ATLAS.

Cervical 2 also known as AXIS.

Foramen Magnum

Medulla Oblongata

Brain Herniation

Increase intra cranial pressure

* Alternate hot and cold compress to prevent HEMATOMA

CSF cushions brain (shock absorber)

Obstruction of flow of CSF will lead to enlargement of skull posteriorly called

hydrocephalus.

Early closure of posterior fontanels causes posterior enlargement of skull in

hydrocephalus.

NEUROLOGIC DISORDERS

INCREASE INTRACRANIAL PRESSURE increase in intra-cranial bulk

brought about by an increase in one of the 3 major intra cranial components.

Causes:

head trauma/injury localized abscess



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cerebral edema

hemorrhage

inflammatory condition (stroke)

hydrocephalus

tumor (rarely)

Signs and Symptoms (Early)

decrease LOC

restlessness/agitation

irritability

lethargy/stupor

coma

Signs and Symptoms (Late)

changes in vital signs

blood pressure (systolic blood pressure increases but diastolic

remains the same).

widening of pulse pressure is neurologic in nature (if narrow

cardiac in nature).

heart rate decrease

respiratory rate decrease

temperature increase directly proportional to blood pressure.

projective vomiting

headache

papilledema (edema of optic disc)

abnormal posturing

decorticate posturing (damage to cortex and spinal cord).

decerebrate posturing (damage to upper brain stem that includes

pons, cerebellum and midbrain).

unilateral dilation of pupils called uncal herniation

bilateral dilation of pupils called tentorial herniation

resulting to mild headache

possible seizure activity

Nursing Management1. Maintain patent and adequate ventilation by:

a. Prevention of hypoxia and hypercarbia

Early signs of hypoxia

restlessness

agitation

tachycardia



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monitor strictly input and output every 1 hour notify physician if output is less

30 cc/hr.

administered via side drip

regulated fast drip to prevent crystal formation.

b. Loop diuretic (Lasix, Furosemide)

Drug of choice for CHF (pulmonary edema)

Loop of Henle in kidneys.

Nursing Management

Monitor vital signs especially BP (hypotension).

monitor strictly input and output every 1 hour notify physician if

output is less 30 cc/hr.

administered IV push or oral.

given early morning

immediate effect of 10 15 minutes.

maximum effect of 6 hours.

c. Corticosteroids

Dexamethasone (Decadron)

Hydrocortisone

Prednisone (to reduce edema that may lead to increase ICP)

Mild Analgesics (Codeine Sulfate for respiratory depression)

Anti Convulsants (Dilantin, Phenytoin)

*CONGESTIVE HEART FAILURE

Signs and Symptoms

dyspnea

orthopnea

paroxysmal nocturnal dyspnea

productive cough

frothy salivation cyanosis

rales/crackles

bronchial wheezing

pulsus alternans

anorexia and general body malaise



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PMI (point of maximum impulse/apical pulse rate) is displaced

laterally

S3 (ventricular gallop)

Predisposing Factors/Mitral Valve

RHD

Aging

TREATMENT

Morphine Sulfate

Aminophelline

DigoxinDiuretics

Oxygen

Gases, blood monitor

RIGHT CONGESTIVE HEART FAILURE (Venous congestion)

Signs and Symptoms

jugular vein distention (neck)

ascites

pitting edema

weight gain

hepatosplenomegaly

jaundice

pruritus

esophageal varices

anorexia and general body malaise

Signs and Symptoms of Lasix in terms of electrolyte imbalances1. Hypokalemia

decrease potassium level

normal value is 3.4 5.5 meq/L

Sign and Symptoms

weakness and fatigue

constipation



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positive U wave on ECG tracing

Nursing Management

administer potassium supplements as ordered (Kalium Durule, Oral

Potassium Chloride)

increase intake of foods rich in potassium

FRUITS VEGETABLES

Apple

Banana

Cantalope

Oranges

Asparagus

Brocolli

Carrots

Spinach

2. Hypocalcemia/ Tetany

decrease calcium level

normal value is 8.5 11 mg/100 ml

Signs and Symptoms

tingling sensation

paresthesia

numbness

(+) Trousseaus sign/ Carpopedal spasm

(+) Chvosteks sign

Complications

Arrhythmia

Seizures

Nursing Management

Calcium Gluconate per IV slowly as ordered

* Calcium Gluconate toxicity results to SEIZURE

Magnesium Sulfate

Magnesium Sulfate toxicity

S/S

BP

Urine output DECREASE

Respiratory rate

Patellar relfex absent



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a. Allopurinol (Zyloprim)

Drug of choice for gout.

Mechanism of action : inhibits synthesis of uric acid.

b. Colchecine

Acute gout

Mechanism of action: promotes excretion of uric acid.

* KIDNEY STONES

Signs and Symptoms

renal colic

Cool moist skin

Nursing Management

force fluids

administer medications as ordered

a. Narcotic Analgesic

Morphine Sulfate

ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors.

b. Allopurinol (Zyloprim)

Side Effects

Respiratory depression (check for RR)

PARKINSONS DISEASE/ PARKINSONISM

Chronic progressive disorder of CNS characterized by

degeneration ofdopamine producing cells in the SUBSTANCIA

NIGRA of the midbrain and basal ganglia.



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Multiple losscausessuicide

Predisposing Factors

1. Poisoning (lead and carbon monoxide)

2. Arteriosclerosis

3. Hypoxia

4. Encephalitis

5. Increase dosage of the following drugs:

a. Reserpine(Serpasil)

b. Methyldopa(Aldomet) AntihypertensiveS

c. Haloperidol(Haldol)

d. Phenothiazine AntipsychoticS

SIDE EFFECTS RESERPINE Major depression leading to suicide

Aloneness

Loss of spouse Loss of Job

direct approach towards the client

close surveillance is a nursing priority

time to commit suicide is on weekends early morning

Signs and Symptoms for Parkinsons

pill rolling tremors of extremities especially the hands.

bradykinesia (slowness of movement) rigidity (cogwheel type)

stooped posture

shuffling and propulsive gait

over fatigue

mask like facial expression with decrease blinking of the eyes.

difficulty rising from sitting position.



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Monotone type speech

mood lability (in state of depression)

increase salivation (drooling type)

autonomic changes

a. increase sweating

b. increase lacrimation

c. seborrhea

d. constipation

e. decrease sexual capacity

Nursing Management


Anti Parkinsonian agents

Levodopa (L-dopa) short acting

Amantadine Hydrochloride (Symmetrel)

Carbidopa (Sinemet)

Mechanism of Action

increase level of dopamine

Side Effects

GIT irritation (should be taken with meals

orthostatic hypotension

arrhythmia

hallucinations

Contraindications

clients with narrow angle closure glaucoma

clients taking MAOIs (no foods with triptophan and thiamine)

urine and stool may be darkened

no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of

Levodopa

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

Hydrazide

Anti Cholinergic Agents (ARTANE and COGENTIN) - to relieve tremors

Mechanism of Action

inhibits action of acethylcholine



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Side Effects

SNS

Anti Histamine (Dipenhydramine Hydrochloride)

Side Effects

Adult: drowsiness

Children: CNS excitement (hyperactivity) because blood brain barrier is not yet

fully developed.

Dopamine Agonist - relieves tremor rigidity

Bromocriptene Hydrochloride (Parlodel)

Side Effects

Respiratory depression

2. Maintain side rails to prevent injury

3. Prevent complications of immobility

4. Decrease protein in morning and increase protein in afternoon to

induce sleep

5. Encourage increase fluid intake and fiber.

6. Assist/supervise in ambulation

7. Assist in Stereotaxic Thalamotomy

MAGIC 2s IN DRUG MONITORING

DRUG NORMAL

RANGE

TOXICI

TYLEVEL

INDICATI

ON

CLASSIFICATI

ON

Digoxin/ Lanoxin(Increase force of

cardiac output)

.5 1.5 meq/L 2 CHF CardiacGlycoside

Lithium/ Lithane (Decrease levelof

Ach/NE/Serotonin)

.6 1.2 meq/L 2 Bipolar Anti-ManicAgents

Aminophylline(Dilates bronchialtree)

10 19mg/100 ml

20 COPD Bronchodilators

Dilantin/Phenytoin

10 19mg/100 ml

20 Seizures Anti-Convulsant

Acetaminophen/Tylenol

10 30mg/100 ml

200 OsteoArthritis

Non-narcoticAnalgesic



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1. Digitalis Toxicity

Signs and Symptoms

nausea and vomiting

diarrhea

confusion

photophobia

changes in color perception (yellowish spots)

Antidote: Digibind

2. Lithium Toxicity

Signs and Symptoms

anorexia

nausea and vomiting

diarrhea

dehydration causing fine tremors

hypothyroidism

Nursing Management

force fluids

increase sodium intake to 4 10 g% daily

3. Aminophylline Toxicity

Signs and Symptoms

tachycardia

palpitations

CNS excitement (tremors, irritability, agitation and restlessness)Nursing Management

only mixed with plain NSS or 0.9 NaCl to prevent development of

crystals or precipitate.

administered sandwich method

avoid taking alcohol because it can lead to severe CNS depression

avoid caffeine



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4. Dilantin Toxicity

Signs and Symptoms

gingival hyperplasia (swollen gums)

hairy tongue

ataxia

nystagmus

Nursing Management

provide oral care

massage gums

5. Acetaminophen Toxicity

Signs and Symptoms

hepatotoxicity (monitor for liver enzymes)

SGPT/ALT (Serum Glutamic Pyruvate Transaminace)

SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)

nephrotoxicity monitor BUN (10 20) and Creatinine (.8 1)

hypoglycemia

Tremors, tachycardia

Irritability

Restlessness

Extreme fatigue

Diaphoresis, depression

Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.

MYASTHENIA GRAVIS

neuromuscular disorder characterized by a disturbance in the

transmission of impulses from nerve to muscle cells at the

neuromuscular junction leading to descending muscle weakness.

Incidence rate: women 20 40 years oldPredisposing factors

unknown

autoimmune: it involves release of cholinesterase an enzyme that

destroys Ach.

Signs and Symptoms



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initial sign is ptosis a clinical parameter to determine ptosis is

palpebral fissure.

diplipia

mask like facial expression

dysphagia

hoarseness of voice

respiratory muscle weakness that may lead to respiratory arrest

extreme muscle weakness especially during exertion and morning

Diagnostic Procedure

Tensilon test (Edrophonium Hydrochloride) provides temporary

relief of signs and symptoms for about 5 10 minutes and a

maximum of15 minutes.

if there is no effect there is damage to occipital lobe and

midbrain and is negative for M.G.

Nursing Management

1. airway

2. aspiration maintain patent airway and adequate ventilation

3. mmobility

* assist in mechanical ventilation and monitor pulmonary function test

* monitor strictly vital signs, input and output and neuro check

* monitor strength or motor grading scale

4. maintain side rails to prevent injury related to falls

5. institute NGT feeding

6. administer medications as ordered

a. Cholinergic (Mestinon)

b. Anti Cholenisterase (Neostegmin)

Mechanism of Action

increase level of Ach

Side Effects PNS

Cortocosteroids suppress immune response

monitor for 2 types of crisis:

MYASTHENIC CRISIS CHOLINERGIC CRISIS

Causes:- under medication- stress

Cause:- over medication



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- infectionSigns and Symptoms- The client is unable to see,swallow, speak, breathe

Treatment- administer cholinergic agents asordered

Signs and Symptoms- PNS

Treatment- Administer anti cholinergic agents(Atropine Sulfate)

7. Assist in surgical procedure known as thymectomy because it is believed

that the thymus gland is responsible for M.G.

8. Assist in plasma paresis and removing auto immune anti bodies

9. Prevent complications

INFLAMMATORY CONDITIONS OF THE BRAIN

MENINGITIS

Meninges

3 fold membrane that covers brain and spinal cord.

for support and protection

for nourishment

blood supply

LAYERS OF THE MENINGES

1. Dura matter outer layer2. Arachnoid middle layer

3. Pia matter inner layer

subdural space between the dura and arachnoid

subarachnoid space between the arachnoid and pia, CSF

aspiration is done.

A. Etiology

1. Meningococcus most dangerous

2. Pneumococcus

3. Streptococcus - causes adult meningitis

4. Hemophilus Influenzae causes pediatric meningitis



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B. Mode of transmission

airborne transmission (droplet nuclei)

C. Signs and Symptoms

headache

photophobia

projectile vomiting

fever, chills, anorexia, general body malaise and weight loss

Possible increase in ICP and seizure activity

Abnormal posturing (decorticate and decerebrate)

Signs of meningeal irritation

a. Nuchal rigidity or stiff neck

b. Opisthotonus (arching of back)

c. (+) Kernigs sign (leg pain)

d. (+) Brudzinski sign (neck pain)

D. Diagnostic Procedures

Lumbar puncture: a hollow spinal needle is inserted in the

subarachnoid space between the L3 L4 to L5.

Nursing Management for LP

Before Lumbar Puncture1. Secure informed consent and explain procedure.2. Empty bladder and bowel to promote comfort.

3. Encourage to arch back to clearly visualize L3-L4.Post Lumbar Puncture1. Place flat on bed 12 24 o

2. Force fluids3. Check punctured site for any discoloration, drainage and leakage to tissues.4. Assess for movement and sensation of extremities.CSF analysis reveals1. Increase CHON and WBC2. Decrease glucose

3. Increase CSF opening pressure (normal pressure is 50 100 mmHg)4. (+) cultured microorganism (confirms meningitis)

CBC reveals

1. Increase wbc

E. Nursing Management



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1. Enforce complete bed rest


a. Broad spectrum antibiotics (Penicillin, Tetracycline)

b. Mild analgesics

c. Anti pyretics

3. Institute strict respiratory isolation 24 hours after initiation of anti biotic

therapy

4. Elevate head 30-45o

5. Monitor strictly V/S, input and output and neuro check

6. Institute measures to prevent increase ICP and seizure.

7. Provide a comfortable and darkened environment.

8. Maintain fluid and electrolyte balance.

9. Provide client health care and discharge planning concerning:

a. Maintain good diet of increase CHO, CHON, calories with small

frequent feedings.

b. Prevent complications

most feared is hydrocephalus

hearing loss/nerve deafness is second complication

consult audiologist

c. Rehabilitation for neurological deficit

mental retardation

delayed psychomotor development

CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)

a partial or complete disruption in the brains blood supply.

2 most common cerebral artery affected by stroke

a. Mid Cerebral Artery

b. Internal Cerebral Artery the 2 largest artery

A. Incidence Rate men are 2-3 times high risk

B. Predisposing Factors

thrombus (attached)



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embolus (detached and most dangerous because it can go to the

lungs and cause pulmonary embolism or the brain and cause

cerebral embolism.

Signs and Symptoms of Pulmonary Embolism

Sudden sharp chest pain

Unexplained dyspnea

Tachycardia

Palpitations

Diaphoresis

Mild restlessness

Signs and Symptoms of Cerebral Embolism

Headache and dizziness

Confusion

Restlessness

Decrease LOC

Fat embolism is the most feared complications after femur fracture.

Yellow bone marrow are produced from the medullary cavity of the long bones

and produces fat cells.

If there is bone fracture there is hemorrhage and there would be escape of the

fat cells in the circulation.

Compartment syndrome (compression of arteries and nerves)

C. Risk Factors

1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis,

Valvular Heart Disease, Post Cardiac Surgery (mitral valve replacement)

2. Lifestyle (smoking), sedentary lifestyle

3. Obesity (increase 20% ideal body weight)

4. Hyperlipidemia more on genetics/genes that binds to cholesterol

5. Type A personality

a. deadline driven

b. can do multiple tasks

c. usually fells guilty when not doing anything



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6. Related to diet: increase intake of saturated fats like whole milk

7. Related stress physical and emotional

8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids)

leading to atherosclerosis that will lead to hypertension and eventually CVA.

D. Signs and Symptoms

dependent on stages of development

1. TIA

Initial sign of stroke or warning sign

Signs and Symptoms

headache and dizziness

tinnitus

visual and speech disturbances

paresis (plegia)

possible increase ICP

2. Stroke in evolution

progression of signs and symptoms of stroke

3. Complete stroke

resolution phase characterized by:

Signs and Symptoms

headache and dizziness

Cheyne Stokes Respiration

anorexia, nausea and vomiting

dysphagia

(+) Kernigs sign and Brudzinski sign which may lead to

hemorrhagic stroke

focal neurological deficits

a. phlegia

b. aphasiac. dysarthria (inability to articulate words)

d. alexia (difficulty reading)

e. agraphia (difficulty writing)

f. homonymous hemianopsia (loss of half of visual field)

E. Diagnostic Procedure

1. CT Scan reveals brain lesions



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Side Effect: Allergic Reaction

Urokinase

Tissue Plasminogen Activating Factor

Side Effect: Chest Pain

f. Anti Coagulants

Heparin (short acting)

check for partial thromboplastin time if prolonged there is a risk for bleeding.

give Protamine Sulfate

Comadin/ Warfarin (long acting)

give simultaneously because Coumadin will take effect after 3 days

check for prothrombin time if prolonged there is a risk for bleeding

give Vit. K (Aqua Mephyton)

g. Anti Platelet

PASA (Aspirin)

Contraindicated for dengue, ulcer and unknown cause of

headache because it may potentiate bleeding11. Provide client health teachings and discharge planning concerning

a. avoidance of modifiable risk factors (diet, exercise, smoking)

b. prevent complication (subarachnoid hemorrhage is the most feared

complication)

c. dietary modification (decrease salt, saturated fats and caffeine)

d. importance of follow up care

GUILLAIN BARRE SYNDROME

a disorder of the CNS characterized by bilateral symmetrical polyneuritis

leading to ascending muscle paralysis.



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A. Predisposing Factors

1. Autoimmune

2. Antecedent viral infections such as LRT infections

B. Signs and Symptoms

1. Clumsiness (initial sign)

2. Dysphagia

3. Ascending muscle weakness leading to paralysis

4. Decreased of diminished deep tendon reflex

5. Alternate hypotension to hypertension

** ARRYTHMIA (most feared complication)

6. Autonomic symptoms that includes

a. increase salivation

b. increase sweating

c. constipation

C. Diagnostic Procedures

1. CSF analysis reveals increase in IgG and protein

D. Nursing Management

1. Maintain patent airway and adequate ventilation by:

a. assist in mechanical ventilation

b. monitor pulmonary function test

2. Monitor strictly the following

a. vital signs

b. intake and output

c. neuro check

d. ECG

3. Maintain side rails to prevent injury related to fall

4. Prevent complications of immobility by turning the client every 2 hours5. Institute NGT feeding to prevent aspiration

6. Assist in passive ROM exercise


a. Corticosteroids suppress immune response

b. Anti Cholinergic Agents Atrophine Sulfate

c. Anti Arrythmic Agents



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Lidocaine, Zylocaine

Bretylium blocks release of norepinephrine to prevent increase

of BP

8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-

bodies)


a. Arrythmia

b. Paralysis or respiratory muscles/Respiratory arrest

* Sengstaken Blakemore Tube

for liver cirrhosis

to decompress bleeding esophageal verices (prepare scissor to cut

tube incase of difficulty in breathing to release air in the balloon

for hemodialysis prepare bulldog clips to prevent air embolism.

CONVULSIVE DISORDER/ CONVULSION

disorder of CNS characterized by paroxysmal seizure with or

without loss of consciousness abnormal motor activity alternation in

sensation and perception and changes in behavior.

Seizure first convulsive attack

Epilepsy second or series of attacks

Febrile seizure normal in children age below 5 years


1. Head injury due to birth trauma

2. Genetics

3. Presence of brain tumor

4. Toxicity froma. lead

b carbon monoxide

5. Nutritional and Metabolic deficiencies

6. Physical and emotional stress

7. Sudden withdrawal to anti convulsant drug is predisposing factor for status

epilepticus (drug of choice is Diazepam, Valium)



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Dependent on stages of development or types of seizure

I. Generalized Seizure

1. Grand mal Seizure (tonic-clonic seizure)

a. Signs or aura with auditory, olfactory, visual, tactile, sensory

experience

b. Epileptic cry is characterized by fall and loss of consciousness for 3

5 minutes

c. Tonic contractions - direct symmetrical extension of extremities

Clonic contractions - contraction of extremities

d. Post ictal sleep unresponsive sleep

2. Petit mal Seizure absence of seizure common among pediatric clients

characterized by

a. blank stare

b. decrease blinking of eyes

c. twitching of mouth

d. loss of consciousness (5 10 seconds)

II. Partial or Localized Seizure

1. Jacksonian Seizure (focal seizure)

Characterized by tingling and jerky movement of index finger and

thumb that spreads to the shoulder and other side of the body.

2. Psychomotor Seizure (focal motor seizure)

a. automatism stereotype repetitive and non propulsive behavior

b. clouding of consciousness not in contact with environment

c. mild hallucinatory sensory experience

III. Status Epilepticus A continuous uninterrupted seizure activity, if left untreated can

lead to hyperpyrexia and lead to coma and eventually death.

Drug of choice: Diazepam, Valium and Glucose


1. CT Scan reveals brain lesions



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Survey of mental status and speech

a. LOC

b. Test of memory

Levels of orientation

Cranial nerve assessment

Sensory nerve assessment

Motor nerve assessment

Deep tendon reflex

Autonimics

Cerebellar test

a, Rombergs test 2 nurses, positive for ataxia

b. Finger to nose test positive result mean dimetria

(inability of body to stop movement at

desired point)

c. Alternate supination and pronation positive result mean

dimetria

I. LEVEL OF CONSCIOUSNESS

1. Conscious - awake

2. Lethargy lethargic (drowsy, sleepy, obtunded)

3. Stupor

stuporous (awakened by vigorous stimulation) generalized body weakness

decrease body reflex

4. Coma

comatose

light coma (positive to all forms of painful stimulus)

deep coma (negative to all forms of painful stimulus)



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DIFFERENT PAINFUL STIMULATION

1. Deep sternal stimulation/ deep sternal pressure

2. Orbital pressure

3. Pressure on great toes

4. Corneal or blinking reflex

Conscious client use a wisp of cotton

Unconscious client place 1 drop of saline solution

II. TEST OF MEMORY1. Short term memory

ask most recent activity

positive result mean anterograde amnesia and damage to temporal

lobe

2. Long term memory

ask for birthday and validate on profile sheet

positive result mean retrograde amnesia and damage to limbic

system

consider educational background

III. LEVELS OF ORIENTATION

1. Time first asked

2. Person second asked

3. Place third asked

CRANIAL NERVES

CRANIAL NERVES FUNCTION

I. OLFACTORY SII. OPTIC SIII OCCULOMOTOR MIV. TROCHLEAR M

(Smallest)V. TRIGEMINAL B

(Largest)VI. ABDUCENSE M



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VII. FACIAL BVIII. ACOUSTIC SIX.

GLOSSOPHARYNGEAL

B

X. VAGUS B

(Longest)XI. SPINAL

ACCESSORY

M

XII. HYPOGLOSSAL M

CRANIAL NERVE I: OLFACTORY

sensory function for smell

Material Used dont use alcohol, ammonia, perfume because it is irritating and

highly diffusible.

use coffee granules, vinegar, bar of soap, cigarette

Procedure

test each nostril by occluding each nostril

Abnormal Findings

1. Hyposnia decrease sensitivity to smell

2. Dysosmia distorted sense of smell

3. Anosmia absence of smell

Indicative of

1. head injury damaging the cribriform plate of ethmoid bone where olfactory

cells are located

2. may indicate inflammatory conditions (sinusitis)

CRANIAL NERVE II: OPTIC

sensory function for vision or sight

Functions

1. Test visual acuity or central vision or distance

use Snellens Chart Snellens Alphabet chart: for literate clients

Snellens E chart: for illiterate clients

Snellens Animal chart: for pediatric clients

normal visual acuity 20/20

numerator is constant, it is the distance of person from the chart (6

7 m, 20 feet)



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denominator changes, indicates distance by which the person

normally can see letter in the chart.

- 20/200 indicates blindness

20/20 visual acuity if client is able to read letters above the red line.

2. Test of visual field or peripheral vision

a. Superiorly

b. Bitemporaly

c. Nasally

d. Inferiorly

COMMON VISUAL DISORDERS

1. Glaucoma

increase IOP

normal IOP is 12 21 mmHg

preventable but not curable


Common among 40 years old and above

Hereditary

Hypertension

Obesity


1. Loss of peripheral vision

pathognomonic sign is tunnel vision

2. Headache, nausea, vomiting, eye pain (halos around light)

steamy cornea

may lead to blindness

C. Diagnostic Procedures1. Tonometry

2. Perimetry

3. Gonioscopy

D. Treatment

1. Miotics constricts pupil



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a. Pilocarpine Sodium, Carbachol

2. Epinephrine eyedrops decrease formation of aqueous humor

3. Carbonic Anhydrase Inhibitors

a. Acetazolamide (Diamox) promotes increase outflow of aqueous

humor or drainage

4. Timoptics (Timolol Maleate)

E. Surgical Procedures

1. TRABECULECTOMY (Peripheral Indectomy) drain aqueous humor

2. Cataract

Decrease opacity of lens

A. Predisposing Factor

1. Aging 65 years and above

2. Related to congenital

3. Diabetes Mellitus

4. Prolonged exposure to UV rays


1. Loss of central vision

C. Pathognomonic Signs

1. Blurring or hazy vision

2. Milky white appearance at center of pupils

3. Decrease perception to colors

Complication is blindness

D. Diagnostic Procedure1. Opthalmoscopic exam

E. Treatment

1. Mydriatics (Mydriacyl) constricts pupils

2. Cyclopegics (Cyclogyl) paralyses cilliary muscle



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F. Surgical Procedure

Extra Intra

Capsular Capsular

Cataract Cataract

Lens Lens

Extraction Extraction

- Partial removal - Total removal of cataract with its surrounding

capsules

Most feared complication post op is RETINAL DETACHMENT

3. Retinal Detachment

Separation of epithelial surface of retina


1. Post Lens Extraction

2. Myopia (near sightedness)


1. Curtain veil like vision

2. Floaters

C. Surgical Procedures

1. Scleral Buckling

2. Cryosurgery cold application

3. Diathermy heat application

4. Macular Degeneration

Degeneration of the macula lutea (yellowish spot at the center of

retina)

A. Signs and Symptoms

1. Black Spots



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CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

Controls or innervates the movement of extrinsic ocular muscle

(EOM)

6 muscles

Superior Rectus Superior Oblique

Lateral Rectus Medial Rectus

Inferior Oblique Inferior Rectus

trochlear controls superior oblique

abducens controls lateral rectus

oculomotor controls the 4 remaining EOM

Oculomotor

controls the size and response of pupil

normal pupil size is 2 3 mm

equal size of pupil: Isocoria

Unequal size of pupil: Anisocoria Normal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINAL

largest cranial nerve



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consists of ophthalmic, maxillary, mandibular

sensory: controls sensation of face, mucous membrane, teeth, soft

palate and corneal reflex)

motor: controls the muscle of mastication or chewing

damage to CN V leads to trigeminal neuralgia/thickdolorum

medication: Carbamezapine(Tegretol)

CRANIAL NERVE VII: FACIAL

Sensory: controls taste, anterior 2/3 of tongue

pinch of sugar and cotton applicator placed on tip of tongue

Motor: controls muscle of facial expression

instruct client to smile, frown and if results are negative there is

facial paralysis or Bells Palsy and the primary cause is forcep

delivery.

CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR

Controls balance particularly kinesthesia or position sense, refers

to movement and orientation of the body in space.

Parts of the Ear

1. Outer Ear

Pinna

Eardrum

2. Middle Ear

Hammer Malleus

Anvil Incus

Stirrup Stapes

3. Inner Ear

Vestibule: Meineres Disease

Cochlea Mastoid Cells

Endolymph and Perilymph

COCHLEA: controls hearing, contains the Organ of Corti (the true organ of

hearing)

Let client repeat words uttered



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CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE

Glosopharyngeal: controls taste, posterior 1/3 of tongue

Vagus: controls gag reflex

Uvula should be midline and if not indicative of damage to cerebral

hemisphere

Effects of vagal stimulation is PNS

CRANIAL NERVE XI: SPINAL ACCESSORY

Innervates with sternocleidomastoid (neck) and trapezius

(shoulder)

CRANIAL NERVE XII: HYPOGLOSSAL

Controls the movement of tongue

Let client protrude tongue and it should be midline and if unable to

do indicative of damage to cerebral hemisphere and/or has short

frenulum.

ENDOCRINE SYSTEM

Overview of the structures and functions

1. Pituitary Gland (Hypophysis Cerebri)

o Located at base of brain particularly at sella turcica

o Master gland or master clock

o Controls all metabolic function of body

PARTS OF THE PITUITARY GLAND1. Anterior Pituitary Gland

o called as adenohypophysis

2. Posterior Pituitary Gland

o called as neurohypophysis



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o secretes hormones oxytocin -promotes uterine contractions

preventing bleeding/ hemorrhage

o administrate oxytocin immediately after delivery to prevent

uterine atony.

o initiates milk let down reflex with help of hormone prolactin

2. Antidiuretic Hormone

o Pitressin (Vasopressin)

o Function: prevents urination thereby conserving water

o Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic

Hormone

DIABETES INSIPIDUS

o Decrease production of anti diuretic hormone

A. Predisposing Factoro Related to pituitary surgery

o Trauma

o Inflammation

o Presence of tumor


1. Polyuria2. Signs of dehydration

a. Adult: thirst

b. Agitation

c. Poor Skin turgor

d. Dry mucous membrane

3. Weakness and fatigue

4. Hypotension

5. Weight loss

6. If left untreated results to hypovolemic shock (sign is anuria)


1. Urine Specific Gravity

o Normal value: 1.015 1.030



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1. Restrict fluid


a. Loop diuretics (Lasix)

b. Osmotic diuretics (Mannitol)

3. Monitor strictly vital signs, intake and output and neuro check

4. Weigh patient daily and assess for pitting edema

5. Provide meticulous skin care


ANTERIOR PITUITARY GLAND

o also called ADENOHYPOPHYSIS secretes

1. Growth hormones (somatotropic hormone)

o Promotes elongation of long bones

o Hyposecretion of GH among children results to Dwarfism

o Hypersecretion of GH results to Gigantism

o Hypersecretion of GH among adults results to Acromegaly

(square face)

o Drug of choice: Ocreotide (Sandostatin)

2. Melanocyte Stimulating hormone

o for skin pigmentation

o Hyposecretion of MSH results to Albinism

o Most feared complications of albinism

a. Lead to blindness due to severe photophobia

b. Prone to skin cancer

o Hypersecretion of MSH results to Vitiligo

3. Adrenochorticotropic hormone (ACTH)

o promotes development of adrenal cortex

4. Lactogenic homone (Prolactin)



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o promotes development of mammary gland

o with help of oxytocin it initiates milk let down reflex

5. Leutinizing hormone

o secretes estrogen

6. Follicle stimulating hormone

o secretes progesterone

PINEAL GLAND

o secretes melatonin

o inhibits LH secretion

o it controls/regulates circadian rhythm (body clock)

THYROID GLAND

o located anterior to the neck

3 Hormones secreted

1. T3 (Tri iodothyronine)- 3 molecules of iodine (more potent)2. T4 (tetra iodothyronine, Thyroxine)

o T3 and T4 are metabolic or calorigenic hormone

o promotes cerebration (thinking)

3. Thyrocalcitonin antagonizes the effects of parathormone to

promote calcium resorption.

HYPOTHYROIDISM

o all are decrease except weight and menstruation

o memory impairment

Signs and Symptoms

o there is loss of appetite but there is weight gain

o menorrhagia

o cold intolerance

o constipation

HYPERTHYROIDISM

o all are increase except weight and menstruation

Signs and Symptoms



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o increase appetite but there is weight loss

o amenorrhea

o exophthalmos

THYROID DISORDERS

SIMPLE GOITER

o enlargement of thyroid gland due to iodine deficiency


1. Goiter belt area

a. places far from sea

b. Mountainous regions

2. Increase intake of goitrogenic foods

o contains pro-goitrin an anti thyroid agent that has no iodine.

o cabbage, turnips, radish, strawberry, carrots, sweet potato,

broccoli, all nutso soil erosion washes away iodine

o goitrogenic drugs

a. Anti Thyroid Agent Prophylthiuracil (PTU)

b. Lithium Carbonate

c. PASA (Aspirin)

d. Cobalt

e. Phenylbutazones (NSAIDs)

- if goiter is caused by


1. Enlarged thyroid gland

2. Mild dysphagia

3. Mild restlessness


1. Serum T3 and T4 reveals normal or below normal

2. Thyroid Scan reveals enlarged thyroid gland.



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3. Serum Thyroid Stimulating Hormone (TSH) is increased (confirmatory

diagnostic test)


1. Enforce complete bed rest


a. Lugols Solution/SSKI ( Saturated Solution of Potassium Iodine)

o color purple or violet and administered via straw to prevent staining

of teeth.

o

4 Medications to be taken via straw: Lugols, Iron, Tetracycline,Nitrofurantoin (drug of choice for pyelonephritis)

b. Thyroid Hormones

o Levothyroxine (Synthroid)

o Liothyronine (Cytomel)

o Thyroid Extracts

Nursing Management when giving Thyroid Hormones

1. Instruct client to take in the morning to prevent insomnia

2. Monitor vital signs especially heart rate because drug causes

tachycardia and palpitations

3. Monitor side effects

o insomnia

o tachycardia and palpitations

o hypertension

o heat intolerance

4. Increase dietary intake of foods rich in iodine

o seaweeds

o seafoods like oyster, crabs, clams and lobster but not shrimps

because it contains lesser amount of iodine.

o iodized salt, best taken raw because it it is easily destroyed by heat

5. Assist in surgical procedure ofsubtotal thyroidectomy

HYPOTHYROIDISM

o hyposecretion of thyroid hormone

o adults: MYXEDEMA non pitting edema



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o children: CRETINISMthe only endocrine disorder that can lead

to mental retardation


1. Iatrogenic Cause disease caused by medical intervention such as

surgery

2. Related to atrophy of thyroid gland due to trauma, presence of

tumor, inflammation

3. Iodine deficiency

4. Autoimmune (Hashimotos Disease)


(Early Signs)

1. Weakness and fatigue

2. Loss of appetite but with weight gain which promotes lipolysis leading

to atherosclerosis and MI

3. Dry skin

4. Cold intolerance

5. Constipation

(Late Signs)

1. Brittleness of hair and nails

2. Non pitting edema (Myxedema)

3. Hoarseness of voice

4. Decrease libido

5. Decrease in all vital signs hypotension, bradycardia, bradypnea,

hypothermia

6. CNS changes

o

lethargyo memory impairment

o psychosis

o menorrhagia




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1. Serum T3 and T4 is decreased

2. Serum Cholesterol is increased

3. RAIU (Radio Active Iodine Uptake) is decreased


1. Monitor strictly vital signs and intake and output to determine presence

of

o Myxedema coma is a complication of hypothyroidism and an

emergency case

o

a severe form of hypothyroidism is characterized by severehypotension, bradycardia, bradypnea, hypoventilation,

hyponatremia, hypoglycemia, hypothermia leading to pregressive

stupor and coma.

Nursing Management for Myxedema Coma

Assist in mechanical ventilation

Administer thyroid hormones as ordered

Force fluids

2. Force fluids

3. Administer isotonic fluid solution as ordered


Thyroid Hormones

a. Levothyroxine

b. Leothyronine

c. Thyroid Extracts

5. Provide dietary intake that is low in calories

6. Provide comfortable and warm environment


8. Provide client health teaching and discharge planning concerning

a. Avoid precipitating factors leading to myxedema coma

o stress

o infection

o cold intolerance

o use of anesthetics, narcotics, and sedatives

o prevent complications (myxedema coma, hypovolemic shock



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o hormonal replacement therapy for lifetime

o importance of follow up care

HYPERTHYROIDISM

o increase in T3 and T4

o Graves Disease orThyrotoxicosis

o developed by Robert Grave


1. Autoimmune it involves release of long acting thyroid stimulator

causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign ofdehydration among infants)

2. Excessive iodine intake

3. Related to hyperplasia (increase size)


1. Increase appetite (hyperphagia) but there is weight loss

2. Moist skin

3. Heat intolerance

4. Diarrhea

5. All vital signs are increased

6. CNS involvement

a. Irritability and agitation

b. Restlessness

c. Tremors

d. Insomnia

e. Hallucinations

7. Goiter

8. Exopthalmus

9. Amenorrhea


1. Serum T3 and T4 is increased

2. RAIU (Radio Active Iodine Uptake) is increased

3. Thyroid Scan- reveals an enlarged thyroid gland



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TRIAD SIGNS


1. Monitor strictly vital signs and intake and output


Anti Thyroid Agent

a. Prophythioracill (PTU)

b. Methymazole (Tapazole)

Side Effects of Agranulocytosis

o increase lymphocytes and monocytes

o

fever and chillso sore throat (throat swab/culture)

o leukocytosis (CBC)

3. Provide dietary intake that is increased in calories.


5. Comfortable and cold environment

6. Maintain side rails

7. Provide bilateral eye patch to prevent drying of the eyes.

8. Assist in surgical procedures known as subtotal thyroidectomy

** Before thyroidectomy administer Lugols Solution (SSKI) to

decrease vascularity of the thyroid

gland to prevent bleeding and hemorrhage.

POST OPERATIVELY,

1. Watch out for signs of thyroid storm/ thyrotoxicosis

Agitation



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Hyperthermia Tachycardia

o administer medications as ordered

a. Anti Pyretics

b. Beta-blockers

o monitor strictly vital signs, input and output and neuro check.

o maintain side rails

o offer TSB

2. Watch out for accidental removal of parathyroid gland that may

lead to

Hypocalcemia (tetany)

Signs and Symptoms

o (+) trousseaus sign

o (+) chvostek sign

o Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as

ordered

3. Watch out for accidental Laryngeal damage which may lead to

hoarseness of voice

Nursing Management

o encourage client to talk/speak immediately after operation and notify

physician

4. Signs of bleeding (feeling of fullness at incisional site)

Nursing Management

o Check the soiled dressings at the back or nape area.

5. Hormonal replacement therapy for lifetime

6. Importance of follow up care

PARATHYROID GLAND

o A pair of small nodules behind the thyroid gland

o Secretes parathormone

o Promotes calcium reabsorption

o Hypoparathyroidism



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o Hyperparathyroidism

HYPOPARATHYROIDISM

o Decrease secretion of parathormone leading to hypocalcemia

o Resulting to hyperphospatemia


1. Following subtotal thyroidectomy

2. Atrophy of parathyroid gland due to:

a. inflammationb. tumor

c. trauma


1. Acute tetany

a. tingling sensation

b. paresthesia

c. numbness

d. dysphagia

e. positive trousseus sign/carpopedal spasm

f. positive chvostek sign

g. laryngospasm/broncospasm

h. seizure feared complications

i. arrhythmia

2. Chronic tetany

a. photophobia and cataract formation

b. loss of tooth enamel

c. anorexia, nausea and vomiting

d. agitation and memory impairment


1. Serum Calcium is decreased (normal value: 8.5 11 mg/100 ml)

2. Serum Phosphate is decreased (normal value: 2.5 4.5 mg/100 ml)

3. X-ray of long bones reveals a decrease in bone density

4. CT Scan reveals degeneration of basal ganglia



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1. Administer medications as ordered such as:

a. Acute Tetany

Calcium Gluconate IV slowly

b. Chronic Tetany

Oral Calcium supplements

Calcium Gluconate

Calcium Lactate

Calcium Carbonate

c. Vitamin D (Cholecalciferol) for absorption of calcium

CHOLECALCIFEROL ARE DERIVED FROM

Drug Diet (Calcidiol) Sunlight

(Calcitriol)

d. Phosphate binder

Aluminum Hydroxide Gel (Ampogel)

Side effect: constipation

ANTACID

A.A.C MAD

Aluminum Containing Magnesium ContainingAntacids Antacids

AluminumHydroxide

Gel Side Effect: Constipation Side Effect:

Diarrhea

2. Avoid precipitating stimulus such as glaring lights and noise

3. Encourage increase intake of foods rich in calcium



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a. anchovies

b. salmon

c. green turnips

4. Institute seizure and safety precaution

5. Encourage client to breathe using paper bag to produce mild

respiratory acidosis result.

6. Prepare trache set at bedside for presence of laryngo spasm



9. Importance of follow up care.

HYPERTHYROIDISM

o Decrease parathormone

o Hypercalcemia: bone demineralization leading to bone fracture (calcium

is stored 99% in bone and 1% blood)

o Kidney stones


1. Hyperplasia of parathyroid gland

2. Over compensation of parathyroid gland due to vitamin D deficiency

a. Children: Ricketts

b. Adults: Osteomalacia


1. Bone pain especially at back (bone fracture)

2. Kidney stones

a. renal cholic

b. cool moist skin

3. Anorexia, nausea and vomiting

4. Agitation and memory impairment


1. Serum Calcium is increased

2. Serum Phosphate is decreased

3. X-ray of long bones reveals bone demineralization




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1. Force fluids to prevent kidney stones

2. Strain all the urine using gauze pad for stone analysis

3. Provide warm sitz bath


a. Morphine Sulfate (Demerol)

5. Encourage increase intake of foods rich in phosphate but decrease in

calcium

6. Provide acid ash in the diet to acidify urine and prevent bacterial growth

7. Assist/supervise in ambulation

8. Maintain side rails

9. Prevent complications (seizure and arrhythmia)

10. Assist in surgical procedure known as parathyroidectomy



ADRENAL GLAND

o Located atop of each kidney

o 2 layers of adrenal gland

a. Adrenal Cortex outermost

b. Adrenal Medulla innermost (secretes catecholamines a power

hormone)

2 Types of Catecholamines

o Epinephrine and Norepinephrine (vasoconstrictor)

o Pheochromocytoma (adrenal medulla)

o Increase secretion of norepinephrine

o Leading to hypertension which is resistant to pharmacological agents

leading to CVA

o Use beta-blockers

ADRENAL CORTEX



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3 Zones/Layers

1. Zona Fasciculata

- secretes glucocortocoids (cortisol)

- function: controls glucose metabolism

- Sugar

2. Zona Reticularis

- secretes traces of glucocorticoids and androgenic hormones

- function: promotes secondary sex characteristics

- Sex

3. Zona Glumerulosa

- secretes mineralocorticoids (aldosterone)

- function: promotes sodium and water reabsorption and excretion of

potassium

- Salt

ADDISONS DISEASE

o Hyposecretion of adreno cortical hormone leading to

a. metabolic disturbance Sugar

b. fluid and electrolyte imbalance Salt

c. deficiency of neuromuscular function Salt/Sex


1. Related to atrophy of adrenal glands

2. Fungal infections


1. Hypoglycemia TIRED

2. Decrease tolerance to stress

3. Hyponatremia- hypotension

- signs of dehydration

- weight loss

4. Hyperkalemia

- agitation

- diarrhea



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- arrhythmia

5. Decrease libido

6. Loss of pubic and axillary hair

7. Bronze like skin pigmentation


1. FBS is decreased (normal value: 80 100 mg/dl)

2. Plasma Cortisol is decreased

3. Serum Sodium is decrease (normal value: 135 145 meq/L)

4. Serum Potassium is increased (normal value: 3.5 4.5 meq/L)


1. Monitor strictly vital signs, input and output to determine presence of

Addisonian crisis (complication of addisons disease)

o Addisonian crisis results from acute exacerbation of addisons disease

characterized by

a. severe hypotension

b. hypovolemic shock

c. hyponatremia leading to progressive stupor and coma

Nursing Management for Addisonian Crisis

1. Assist in mechanical ventilation,

- administer steroids as ordered

- force fluids

2. Administerisotonic fluid solution as ordered

3. Force fluids


Corticosteroids

a. Dexamethasone (Decadrone)

b. Prednisonec. Hydrocortisone (Cortison)

Nursing Management when giving steroids

1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon

to mimic the normal diurnal rhythm

2. Taper dose (withdraw gradually from drug)

3. Monitor side effects



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a. hypertension

b. edema

c. hirsutism

d. increase susceptibility to infection

e. moon face appearance

4. Mineralocorticoids (Flourocortisone)

5. Provide dietary intake, increase calories, carbohydrates, protein but

decrease in potassium


7. Provide client health teaching and discharge planning

a. avoid precipitating factor leading to addisonian crisis leading to

- stress

- infection

- sudden withdrawal to steroids

b. prevent complications

- addisonian crisis

- hypovolemic shock

c. hormonal replacement for lifetime

d. importance of follow up care

CUSHING SYNDROME

o Hypersecretion of adenocortical hormones

A. Predisposing Factors1 Related to hyperplasia of adrenal gland

2. Increase susceptibility to infections

3. Hypernatremia

a. hypertension

b. edema

c. weight gain



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d. moon face appearance and buffalo hump

e. obese trunk

f. pendulous abdomen

g. thin extremities

4. Hypokalemia

a. weakness and fatigue

b. constipation

c. U wave upon ECG (T wave hyperkalemia)

5. Hirsutism

6. Acne and striae

7. Easy bruising

8. Increase masculinity among females

B. Diagnostic Procedures

1. FBS is increased

2. Plasma Cortisol is increased

3. Serum Sodium is increased

4. Serum Potassium is decreased

C. Nursing Management

1. Monitor strictly vital signs and intake and output

2. Weigh patient daily and assess for pitting edema

3. Measure abdominal girth daily and notify physician

4. Restrict sodium intake



a. Spinarolactone potassium sparring diuretics

7. Prevent complications (DM)

8. Assist in surgical procedure (bilateral adrenoraphy)9. Hormonal replacement for lifetime


PANCREAS

- Located behind the stomach

- Mixed gland (exocrine and endocrine)



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- Consist ofacinar cells which secretes pancreatic juices that aids in digestion

thus it is an exocrine gland

- Consist ofislets of langerhans

- Has alpha cells that secretes glucagons (function: hyperglycemia)

- Beta cells secretes insulin (function: hypoglycemia)

- Delta cells secretes somatostatin (function: antagonizes the effects of growth

hormones)

3 Main Disorders of Pancreas

1. Pancreatic Tumor/Cancer

2. Diabetes Mellitus

3. Pancreatitis

DIABETES MELLITUS

- metabolic disorder characterized by non utilization of carbohydrates, protein

and fat metabolism

CLASSIFICATION OF DM

Type 1 (IDDM)

- Juvenile onset type

- Brittle disease

A. Incidence Rate

- 10% general population has type 1

DM


1. Hereditary (total destruction ofpancreatic cells)

2. Related to viruses

3. Drugs

a. Lasix

b. Steroids

4. Related to carbon tetrachloride

Type 2 (NIDDM)

- Adult onset

- Maturity onset type

- Obese over 40 years old

A. Incidence Rate

- 90% of general population has type 2

DM


1. Obesity because obese personslack insulin receptor binding sites



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toxicity


1. Polyuria

2. Polydypsia

3. Polyphagia

4. Glucosuria

5. Weight loss


7. Blurring of vision8. Increase susceptibility to infection

9. Delayed/poor wound healing

D. Treatment

1. Insulin therapy

2. Diet

3. Exercise

E. Complication

1. Diabetic Ketoacidosis


1. Usually asymptomatic

2. Polyuria

3. Polydypsia

4. Polyphagia

5. Glucosuria

6. Weight gain

D. Treatment

1. Oral Hypoglycemic agents

2. Diet

3. Exercise

E. Complications

1. Hyper

2. Osmolar

3. Non

4. Ketotic

5. Coma

MAIN

FOODSTUFF

ANABOLISM CATABOLISM



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1.

Carbohydrates

2. Protein

3. Fats

Glucose

Amino

Acids

Fatty Acids

Glycogen

Nitrogen

Free Fatty

Acids

- Cholesterol

- Ketones

HYPERGLYCEMIA

Increase osmotic diuresis

Glycosuria Polyuria

Cellular starvation weight loss Cellular dehydration

Stimulates the appetite/satiety center Stimulates the thirst

center

(Hypothalamus) (Hypothalamus)

Polyphagia Polydypsia

* Liver has glycogen that undergo glycogenesis/ glycogenolysis

GLUCONEOGENESIS

Formation of glucose from non-CHO sourcesIncrease protein formation

Negative Nitrogen balance

Tissue wasting (Cachexia)

INCREASE FAT CATABOLISM

Free fatty acids

Cholesterol Ketones



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Atherosclerosis Diabetic Keto Acidosis Hypertension

Acetone Breath KussmaulsRespiration

odorMI CVA

Death Diabetic Coma

DIABETIC KETOACIDOSIS

- Acute complication of type 1 DM due to severe hyperglycemia leading to

severe CNS depression


1. Hyperglycemia

2. Stress number one precipitating factor

3. Infection


1. Polyuria

2. Polydypsia

3. Polyphagia

4. Glucosuria

5. Weight loss



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7. Blurring of vision

8. Acetone breath odor

9. Kussmauls Respiration (rapid shallow breathing)

10 CNS depression leading to coma


1. FBS is increased

2. BUN (normal value: 10 20)

3. Creatinine (normal value: .8 1)

4. Hct (normal value: female 36 42, male 42 48) due to severe dehydration


1. Assist in mechanical ventilation

2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract

dehydration and shock

3. Monitor strictly vital signs, intake and output and blood sugar levels


a. Insulin therapy (regular acting insulin/rapid acting insulin peak action

of 2 4 hours)

b. Sodium Bicarbonate to counteract acidosis

c. Antibiotics to prevent infection

HYPER OSMOLAR NON KETOTIC COMA

- Hyperosmolar: increase osmolarity (severe dehydration)

- Non ketotic: absence of lypolysis (no ketones)

A. Signs and Symptoms

1. Headache and dizziness2. Restlessness

3. Seizure activity

4. Decrease LOC diabetic coma

B. Nursing Management

1. Assist in mechanical ventilation



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2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract

dehydration and shock



a. Insulin therapy (regular acting insulin peak action of 2 4 hours)

- for DKA use rapid acting insulin

b. Antibiotics to prevent infection

INSULIN THERAPY

A. Sources of Insulin

1. Animal sources

- Rarely used because it can cause severe allergic reaction

- Derived from beef and pork

2. Human Sources

- Frequently used type because it has less antigenicity property thus less

allergic reaction

3. Artificially Compound Insulin

B. Types of Insulin

1. Rapid Acting Insulin (clear)

- Regular acting insulin (IV only)

- Peak action is 2 4 hours

2. Intermediate Acting Insulin (cloudy)

- Non Protamine Hagedorn Insulin (NPH)


3. Long Acting Insulin (cloudy)

- Ultra Lente


C. Nursing Management for Insulin Injections

1. Administer at room temperature to prevent development of lipodystrophy

(atrophy, hypertrophy of subcutaneous tissues)

2. Place in refrigerator once opened

3. Avoid shaking insulin vial vigorously instead gently roll vial between palm to

prevent formation of bubbles



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4. Use gauge 25 26 needle

5. Administer insulin either 45o 90o depending on amount of clients tissue

deposit

6. No need to aspirate upon injection

7. Rotate insulin injection sites to prevent development of lipodystrophy

8. Most accessible route is abdomen

9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to

prevent contaminating the clear insulin and promote proper calibration.

10. Monitor for signs of local complications such as

a. Allergic reactions

b. Lipodystrophy

c. Somogyis Phenomenon rebound effect of insulin characterized by

hypoglycemia to hyperglycemia

ORAL HYPOGLYCEMIC AGENTS

- Stimulates the pancreas to secrete insulin

A. Classsification

1. First Generation Sulfonylureas

a. Chlorpropamide (Diabenase)

b. Tolbutamide (Orinase)

c. Tolamazide (Tolinase)

2. Second Generation Sulfonylureas

a. Glipzide (Glucotrol)

b. Diabeta (Micronase)

Nursing Management when giving OHA

1. Instruct the client to take it with meals to lessen GIT irritation and prevent

hypoglycemia

2. Instruct the client to avoid taking alcohol because it can lead to severe

hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms

B. Diagnostic Procedures

1. FBS is increased (3 consecutive times with signs or polyuria, polydypsia,

polyphagia and glucosuria confirmatory for DM)

2. Random Blood Sugar is increased

3. Oral glucose tolerance test is increased most sensitive test



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4. Alpha Glycosylated Hemoglobin is increased

C. Nursing Management

1. Monitor for peak action of insulin and OHA and notify physician

2. Administer insulin and OHA therapy as ordered


4. Monitor for signs of hypoglycemia and hyperglycemia

- administer simple sugars

- for hypoglycemia (cold and clammy skin) give simple sugars

- for hyperglycemia (dry and warm skin)

5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%,

protein 30% and fats 20% or offer alternative food substitutes

6. Instruct client to exercise best after meals when blood glucose is rising

7. Monitor signs for complications

a. Atherosclerosis (HPN, MI, CVA)

b. Microangiopathy (affects small minute blood vessels of eyes and

kidneys)

EYES KIDNEY

-PREMATURE

CATARACT

- Blindness

-RECURRENT

PYELONEPHRITIS

- Renal failure

c. HPN and DM major cause of renal failure

d. Gangrene formation

e. Shock due to dehydration

- peripheral neuropathy

- diarrhea/constipation

- sexual impotence

8. Institute foot care management

a. instruct client to avoid walking barefooted

b. instruct client to cut toenails straight

c. instruct client to avoid wearing constrictive garments

d. encourage client to apply lanolin lotion to prevent skin breakdown



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e. assist in surgical wound debriment (give analgesics 15 30 mins

prior)

9. Instruct client to have an annual eye and kidney exam

10. Monitor for signs of DKA and HONKC

11. Assist in surgical procedure

HEMATOLOGICAL SYSTEM

I. Blood II. Blood Vessels III. Blood FormingOrgans

1. Arteries 1. Liver 55% Plasma 45% Formed 2. Veins 3. Spleen

4. Lymphoid OrganSerum Plasma CHON 5. Lymph

Nodes(formed in liver) 6. Bone Marrow

1. Albumin2. Globulins

3. Prothrombin and Fibrinogen

ALBUMIN

- Largest and numerous plasma CHON

- Maintains osmotic pressure preventing edema

GLOBULINS- Alpha globulins - transport steroids, bilirubin and hormones

- Beta globulins iron and copper

- Gamma globulins

a. anti-bodies and immunoglobulins

b. prothrombin and fibrinogen clotting factors

FORMED ELEMENTS

1. RBC (ERYTHROCYTES)

- normal value: 4 6 million/mm3

- only unnucleated cell

- biconcave discs



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- consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin

(green pigment) hemosiderin (golden brown pigment)

- transports and carries oxygen to tissues

- hemoglobin: normal value female 12 14 gms% male 14 16 gms%

- hematocrit red cell percentage in wholeblood

- normal value: female 36 42% male 42 48%

- substances needed for maturation of RBC

a. folic acid

b. iron

c. vitamin c

d. vitamin b12 (cyanocobalamin)

e. vitamin b6 (pyridoxine)

f. intrinsic factor

- Normal life span of RBC is 80 120 days and is killed in red pulp of

spleen

2. WBC (LEUKOCYTES)

- normal value: 5000 10000/mm3

A. Granulocytes

1. Polymorpho Neutrophils

- 60 70% of WBC

- involved in short term phagocytosis for acute inflammation

2. Polymorphonuclear Basophils

- for parasite infections

- responsible for the release of chemical mediation for inflammation

3. Polymorphonuclear Eosinophils

- for allergic reaction

B. Non Granulocytes

1. Monocytes- macrophage in blood

- largest WBC

- involved in long term phagocytosis for chronic inflammation

2. Lymphocytes



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B-cell T-cell Natural killer cell- bone marrow - thymus - anti viral and anti tumor property

for immunity

HIV

- 6 months 5 years incubation period

- 6 months window period

- western blot opportunistic

- ELISA

- drug of choice AZT (Zidon Retrovir)

2 Common fungal opportunistic infection in AIDS

1. Kaposis Sarcoma

2. Pneumocystis Carinii Pneumonia

3. Platelets (THROMBOCYTES)

- Normal value: 150,000 450,000/mm3

- Promotes hemostasis (prevention of blood loss)

- Consist of immature or baby platelets or megakaryocytes which is the target

of dengue virus

- Normal life span of platelet is 9 12 days

Signs of Platelet Dysfunction

1. Petechiae

2. Echhymosis

3. Oozing of blood from venipunctured

Documents

Compilation of MS Notes