MS Notes Review

7/31/2019 MS Notes Review

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MEDICAL-SURGICAL NURSINGNERVOUS SYSTEM

Overview of structures and functions:

Central Nervous SystemBrainSpinal Cord

Peripheral Nervous SystemCranial NervesSpinal Nerves

Autonomic Nervous SystemSympathetic nervous systemParasympathetic nervous system

AUTONOMIC NERVOUS SYSTEM

Sympathetic Nervous System(ADRENERGIC)

Parasympathetic NervousSystem(CHOLINERGIC, VAGAL,SYMPATHOLYTIC)

EFFECTS OF SNS- Dilation of pupils(mydriasis) inorder to be aware.- Dry mouth (thickened saliva).- Increase BP and Heart Rate.- Bronchodilation, Increase RR

- Constipation.- Urinary Retention.- Increase blood supply to brain,heart and skeletal

muscles.- SNSI. Adrenergic Agents- Give Epinephrine.

Signs andSymptoms:

- SNS

Contraindication:- Contraindicated to patientssuffering from COPD(Broncholitis, Bronchoectasis,Emphysema, Asthma).II. Beta-adrenergic BlockingAgents- Also called Beta-blockers.-All ending with lol- Propranolol, Atenelol,Metoprolol.

Effects of Beta-blockersB roncho spasmE licits a decrease inmyocardial contraction.T reats hypertension.A V conduction slows down.

Should be given to patientswith Angina Pectoris,Myocardial Infarction,Hypertension.ANTI- HYPERTENSIVE

AGENTS1. Beta-blockerslol2. Ace Inhibitors Angiotensin,pril (Captopril,Enalapril)3. Calcium AntagonistNifedipine (Calcibloc)

In chronic cases of arrhythmiagiveLidocaine(Xylocaine)

- Involved in fight or aggressionresponse.- Release of Norepinephrine(cathecolamines)from adrenal glands and

causes

vasoconstriction.- Increase all bodily activityexcept GIT- Involved in fight or withdrawalresponse.- Release of Acetylcholine.- Decreases all bodily activitiesexcept 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- PNSII. Anti-cholinergic Agents- To counter cholinergic agents.- Atropine SulfateSide Effects- SNS

CENTRAL NERVOUS SYSTEMBrain and Spinal Cord.

I. CELLSA. NEURONS

Basic cells for nerve impulse and conduction.

PROPERTIESExcitability ability of neuron to be affected by changes in externalenvironment.Conductivity ability of neuron to transmit a wave of excitation fromone cell to another.Permanent Cell once destroyed not capable of regeneration.TYPES OF CELLS BASED ON REGENERATIVE CAPACITY1. Labile

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

2. StableCapable of regeneration with limited time, survival period.Kidney cells, Liver cells, Salivary cells, pancreas.

3. PermanentNot capable of regeneration.Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

B. NEUROGLIASupport and protection of neurons.TYPES1. Astrocytesmaintains blood brain barrier semi-permeable.

Majority of brain tumors (90%) arises from calledastrocytoma.2. Oligodendria3. Microglia4. Epindymal

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER1. Ammonia

Cerebral toxinHepatic Encephalopathy (Liver Cirrhosis)AscitesEsophageal Varices

Early Signs of Hepatic Encephalopathyasterixis (flapping hand tremors).

Late Signs of Hepatic EncephalopathyHeadacheDizzinessConfusionFetor hepaticus (ammonia like breath)Decrease LOC

2. Carbon Monoxide and Lead PoisoningCan lead to Parkinsons Disease.EpilepsyTreat with ANTIDOTE: Calcium EDTA.

3. Type 1 DM (IDDM)Causes diabetic ketoacidosis.And increases breakdown of fats.And free fatty acidsResulting 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. HepatitisSigns of jaundice (icteric sclerae). Caused by bilirubin (yellow pigment)

5. BilirubinIncrease bilirubin in brain (Kernicterus).Causing irreversible brain damage.

Astrocites

Maintains integrity of blood brain barrier.


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Oligodendria

Produces myelin sheath in CNSAct as insulator and facilitates rapid nerve impulse transmission.

1. ALZHEIMERS DISEASEAtrophy of brain tissues.

Sign and Symptoms4 As of AlzheimerDEMYELINATING DISORDERSa. 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 centerBrocas Aphasia

*Receptive aphasia

inability to understand spoken words.Wernickes Aphasia

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 whitepatches of demyelination in brain andspinal cord.

Characterized by remission and exacerbation.Women ages 15-35 are proneUnknown CauseSlow growing virusAutoimmune disordersPernicious anemiaMyasthenia gravisLupusHypothyroidismGBS

Ig Gonly antibody that pass placental circulation causing passiveimmunity.

- 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 Symptoms1. Visual disturbances

blurring of vision (primary)diplopia (double vision)scotomas (blind spots)

2. Impaired sensationto touch, pain, pressure, heat and cold. tingling sensationparesthesianumbness

3. Mood swingseuphoria (sense of well being)

4. Impaired motor functionweaknessspasticityparalysis

5. Impaired cerebral functionscanning speech

TRIAD SIGNS OF MSAtaxia (Unsteady gait, (+) Rombergs test)

CHARCOTSTRIAD

IAN

Intentional tremors Nystagmus

6. Urinary retention/incontinence7. Constipation8. Decrease sexual capacityDIAGNOSTIC 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 MANAGEMENT1. Administer medications as ordereda. ACTH (Adreno Corticotropic Hormone)/ Steroids for acuteexacerbation to reduce edema at site

of demyelination to prevent paralysis.b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) musclerelaxants.c. Interferons alter immune response.d. Immunosupresants2. Maintain side rails to prevent injury related to falls.3. Institute stress management techniques.a. Deep breathing exercisesb. Yoga4. Increas e fluid intake and increase fiber to prevent constipation.5. Catheterization to prevent retention.

a. Diureticsb. Bethanicol Chloride (Urecholine)

Nursing ManagementOnly given subcutaneous.

Monitor side effects bronchospasm and wheezing.Monitor breath sounds 1 hour after subcutaneous administration.

c. For Urinary IncontinenceAnti spasmodic agenta. Prophantheline Bromide (Promanthene)Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin

C and orange.To acidify urine and prevent bacterial multiplicat ion.

COMMON CAUSE OF UTIFemale

short urethra (3-5 cm, 1-1 inches)poor perineal hygienevaginal environment is moist

Nursing Managementavoid bubble bath (can alter Ph of vagina). avoid use of tissue papersavoid using talcum powder and perfume.MaleUrethra (20 cm, 8 inches)urinate after intercourse

MICROGLIAstationary cells that carry on phagocytosis (engulfing of bacteria or

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

MACROPHAGE ORGAN

Microglia Brain

Monocytes Blood

Kupffers cells

Kidney

Histiocytes Skin

Alveolar Lung

EPINDYMAL CELLSSecretes a glue called chemo attractants that concentrate the

bacteria.COMPOSITION OF BRAIN

80% brain mass10% blood10% CSF

I. Brain MassPARTS OF THE BRAIN1. CEREBRUM

largest part


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composed of the Right Cerebral Hemisphere and Left CerebralHemisphere enclosed in theCorpus Callosum.Functions of Cerebrum

integrativesensorymotor

Lobes of Cerebrum1. Frontal

2. Temporalhigher cortical thinking

controls personalitycontrols motor activityBrocas Area (motor speech area) when damaged results to

garbled speech.hearingshort term memory

3. Parietalfor appreciationdiscrimination of sensory impulses to pain, touch, pressure, heat,

cold, numbness.4. Occipital

for visionInsula (Island of Reil)

visceral function activities of internal organ like gastric motility.Limbic System (Rhinencephalon)

controls smell and if damaged results to Anosmia (absence ofsmell).

controls libidocontrols long term memory

2. BASAL GAGLIAareas of grey matter located deep within each cerebral hemisphere.release dopamine (controls gross voluntary movement.

NEUROTRANSMITTER

DECREASE INCREASE

Acethylcholine Myasthenia Gravis Bi-polar Disorder

Dopamine Parkinsons Disease Schizophrenia

3. MIDBRAIN/ MESENCEPHALONacts as relay station for sight and hearing.size of pupil is 2 3 mm.equal size of pupil is isocoria.unequal size of pupil is anisocoria.hearing acuity is 30 40 dB.

positive PERRLA4. INTERBRAIN/ DIENCEPHALONParts of DiencephalonA. Thalamus

acts as relay station for sensation.B. Hypothalamus

controls temperature (thermoregulatory center).controls blood pressurecontrols thirstappetite/satietysleep and wakefulnesscontrols some emotional responses like fear, anxiety and

excitement.controls pituitary functionsandrogenic hormones promotes secondary sex characteristics.early sign for males are testicular and penile enlargementlate sign is deepening of voice. early sign for females telarche and late sign is menarche.

5. BRAIN STEMlocated at lowest part of brain

Parts of Brain Stem1. Pons

pneumotaxic center controls the rate, rhythm and depth ofrespiration.2. Medulla Oblongata

3. Cerebellumcontrols respiration, heart rate, swallowing, vomiting, hiccup,

vasomotor center (dilation andconstriction of bronchioles).

smallest part of the brain.lesser brain.controls balance, equilibrium, posture and gait.

INTRA CRANIAL PRESSUREMonroe Kellie HypothesisSkull is a closed containerAny alteration or increase in one of the intracranial componentsIncrease intra-cranial pressure(normal ICP is 0 15 mmHg)Cervical 1 also known as ATLAS.Cervical 2 also known as AXIS.Foramen MagnumMedulla OblongataBrain HerniationIncrease intra cranial pressure

* Alternate hot and cold compress to prevent HEMATOMACSF 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 DISORDERSINCREASE INTRACRANIAL PRESSURE increase in intra-cranialbulk brought about by an increase in oneof the 3 major intra cranial components.Causes:

head trauma/injurylocalized abscesscerebral edemahaemorrhage inflammatory condition (stroke)hydrocephalustumor (rarely)

Signs and Symptoms (Early)decrease LOCrestlessness/agitationirritability

Signs and Symptoms (Late)changes in vital signslethargy/stuporcomablood 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 decreaserespiratory rate decreasetemperature increase directly proportional to blood pressure.projective vomitingheadachepapilledema (edema of optic disc)abnormal posturingdecorticate posturing (damage to cortex and spinal cord).decerebrate posturing (damage to upper brain stem that

includes pons, cerebellum andmidbrain).

unilateral dilation of pupils called uncal herniationbilateral dilation of pupils called tentorial herniationresulting to mild headachepossible seizure activity


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Nursing Management1. Maintain patent and adequate ventilation by: a. Prevention of hypoxia and hypercarbiaEarly signs of hypoxia

restlessnessagitationtachycardia

Late signs of hypoxiaBradycardiaExtreme restlessnessDyspneaCyanosis

HYPERCARBIA Increase CO2 (most powerful respiratory stimulant) retention.In chronic respiratory distress syndrome decrease O2 stimulates

respiration.b. Before and after suctioning hyper oxygenate client 100% anddone 10 15 seconds only.c. Assist in mechanical ventilation2. Elevate bed of client 30 35angle with neck in neutral position unless contraindicated to promotevenousdrainage.3. Limit fluid intake to 1200 1500 ml/day (in force fluids 2000 3000ml/day).

4. Monitor strictly input and output and neuro check5. Prevent complications of6. Prevent further increase ICP by: a. provide an comfortable and quite environment.b. avoid use of restraints.c. maintain side rails.d. instruct client to avoid forms of valsalva maneuver like:

straining stoolexcessive vomiting (use anti emetics)excessive coughing (use anti tussive like dextromethorphan)avoid stooping/bendingavoid lifting heavy objects

e. avoid clustering of nursing activity together.7. Administer medications like:a. Osmotic diuretic (Mannitol)

for cerebral diuresisNursing Management

monitor vital signs especially BP (hypotension). monitor strictly input and output every 1 hour notify physician if

output is less 30 cc/hr.administered via side dripregulated fast drip to prevent crystal formation.

b. Loop diuretic (Lasix, Furosemide)Drug of choice for CHF (pulmonary edema)Loop of Henle in kidneys.

Nursing ManagementMonitor 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 morningimmediate effect of 10 15 minutes.maximum effect of 6 hours.

c. CorticosteroidsDexamethasone (Decadron)HydrocortisonePrednisone (to reduce edema that may lead to increase ICP)Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin, Phenytoin)

*CONGESTIVE HEART FAILURESigns and Symptoms

dyspneaorthopneaparoxysmal nocturnal dyspneaproductive coughfrothy salivationcyanosis

rales/cracklesbronchial wheezingpulsus alternansanorexia and general body malaisePMI (point of maximum impulse/apical pulse rate) is displaced

laterallyS3 (ventricular gallop)Predisposing Factors/Mitral Valve

RHD

Aging

TREATMENTMorphine SulfateAminophellineDigoxinDiureticsOxygenGases, blood monitorRIGHT CONGESTIVE HEART FAILURE (Venous congestion)Signs and Symptoms

jugular vein distention (neck)ascitespitting edemaweight gainhepatosplenomegalyjaundicepruritusesophageal varicesanorexia and general body malaise

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

decrease potassium levelnormal value is 3.4 5.5 meq/L

Sign and Symptomsweakness and fatigueconstipationpositive U wave on ECG tracing

Nursing Managementadminister potassium supplements as ordered (Kalium Durule,

Oral Potassium Chloride)increase intake of foods rich in potassium

FRUITS VEGETABLESApple

BananaCantalopeOranges

AsparagusBrocolliCarrotsSpinach

2. Hypocalcemia/ Tetanydecrease calcium levelnormal value is 8.5 11 mg/100 ml

Signs and Symptomstingling sensationparesthesianumbness(+) Trousseaus sign/ Carpopedal spasm(+) Chvosteks sign

ComplicationsArrhythmia

SeizuresNursing Management

Calcium Gluconate per IV slowly as ordered* Calcium Gluconate toxicity results to SEIZUREMagnesium Sulfate

Magnesium Sulfate toxicityS/SBPUrine output DECREASERespiratory ratePatellar relfex absent


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3. Hyponatremia

decrease sodium levelnormal value is 135 145 meq/L

Signs and Symptomshypotensiondehydration signs (Initial sign in adult is THIRST, in infant

TACHYCARDIA)agitationdry mucous membranepoor skin turgorweakness and fatigue

Nursing Managementforce fluidsadminister isotonic fluid solution as ordered

4. Hyperglycemianormal FBS is 80 100 mg/dl

Signs and Symptomspolyuriapolydypsiapolyphagia

Nursing Managementmonitor FBS

5. Hyperuricemiaincrease uric acid (purine metabolism)foods high in uric acid (sardines, organ meats and anchovies)*Increase in tophi deposit leads to Gouty arthritis.

Signs and Symptomsjoint pain (great toes)swelling

Nursing Managementforce fluidsadminister medications as ordered

a. Allopurinol (Zyloprim)Drug of choice for gout.Mechanism of action : inhibits synthesis of uric acid.

b. ColchecineAcute goutMechanism of action : promotes excretion of uric acid.

* KIDNEY STONESSigns and Symptoms

renal colicCool moist skinNursing Management

force fluidsadminister medications as ordered

a. Narcotic AnalgesicMorphine SulfateANTIDOTE: 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 bydegeneration of dopamine producingcells in the SUBSTANCIA NIGRA of the midbrain and basalganglia.Predisposing Factors

1. Poisoning (lead and carbon monoxide)2. Arteriosclerosis3. Hypoxia4. Encephalitis5. Increase dosage of the following drugs: a. Reserpine(Serpasil)b. Methyldopa(Aldomet) AntihypertensiveSc. Haloperidol(Haldol)d. Phenothiazine AntipsychoticSSIDE EFFECTS RESERPINE Major depression leading to suicide

Multiple loss Causes suicideAloneness

Loss of spouse Loss of Jobdirect approach towards the clientclose surveillance is a nursing prioritytime to commit suicide is on weekends early morning

Signs and Symptoms for Parkinsonspill rolling tremors of extremities especially the hands.bradykinesia (slowness of movement)rigidity (cogwheel type)stooped postureshuffling and propulsive gaitover fatiguemask like facial expression with decrease blinking of the eyes.difficulty rising from sitting position.Monotone type speechmood lability (in state of depression)increase salivation (drooling type)autonomic changes

a. increase sweatingb. increase lacrimation

c. seborrhead. constipatione. decrease sexual capacityNursing Management1. Administer medications as orderedAnti Parkinsonian agents

Levodopa (L-dopa) short actingAmantadine Hydrochloride (Symmetrel)Carbidopa (Sinemet)

Mechanism of Actionincrease level of dopamine

Side EffectsGIT irritation (should be taken with mealsorthostatic hypotensionarrhythmiahallucinations

Contraindicationsclients with narrow angle closure glaucoma clients taking MAOIs (no foods with t riptophan and thiamine)urine and stool may be darkenedno Vitamin B6 (Pyridoxine) reverses the therapeutic effects of

Levodopa* Increase Vitamin B when taking INH (Isoniazid), IsonicotinicAcid Hydrazide

Anti Cholinergic Agents (ARTANE and COGENTIN) - to relievetremorsMechanism of Actioninhibits action of acethylcholine

Side EffectsSNS

Anti Histamine (Dipenhydramine Hydrochloride)Side EffectsAdult: drowsinessChildren: CNS excitement (hyperactivity) because blood brain barrieris not yet fully developed.

Dopamine Agonist - relieves tremor rigidityBromocriptene Hydrochloride (Parlodel)Side Effects

Respiratory depression2. Maintain side rails to prevent injury3. Prevent complications of immobility4. Decrease protein in morning and increase protein in afternoonto induce sleep5. Encourage increase fluid intake and fiber.6. Assist/supervise in ambulation7. Assist in Stereotaxic Thalamotomy


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MAGIC 2s IN DRUG MONITORINGDRUG NORM

ALRANGE

TOXICITYLEVEL

INDICATION

CLASSIFICATION

Digoxin/ Lanoxin(Increase force ofcardiac output)

.5 1.5meq/L

2 CHF CardiacGlycoside

Lithium/ Lithane(Decrease level ofAch/NE/Serotonin)

.6 1.2meq/L

2 Bipolar Anti-ManicAgents

Aminophylline(Dilates bronchialtree

10 19mg/100ml

20 COPD Bronchodilators

Dilantin/ Phenytoin 10 19mg/100ml

20 Seizures Anti-Convulsant

Acetaminophen/Tylenol

10 30mg/100ml

200 OsteoArthritis

Non-narcoticAnalgesic

1. Digitalis ToxicitySigns and Symptoms

nausea and vomitingdiarrheaconfusionphotophobiachanges in color perception (yellowish spots)

Antidote: Digibind

2. Lithium ToxicitySigns and Symptoms

anorexianausea and vomitingdiarrheadehydration causing fine tremorshypothyroidism

Nursing Managementforce fluidsincrease sodium intake to 4 10 g% daily

3. Aminophylline ToxicitySigns and SymptomstachycardiapalpitationsCNS excitement (tremors, irritability, agitation and restlessness)

Nursing Managementonly 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 depressionavoid caffeine

4. Dilantin ToxicitySigns and Symptoms

gingival hyperplasia (swollen gums)hairy tongueataxianystagmus

Nursing Managementprovide oral caremassage gums

5. Acetaminophen ToxicitySigns 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, tachycardiaIrritabilityRestlessnessExtreme fatigueDiaphoresis, depressionAntidote: Acetylcisteine (mucomyst) prepare suction apparatus asbedside.MYASTHENIA GRAVIS

neuromuscular disorder characterized by a disturbance in thetransmission of impulses fromnerve to muscle cells at the neuromuscular junction leading todescending muscle weakness.Incidence rate: women 20 40 years oldPredisposing factors

unknownautoimmune: it involves release of cholinesterase an enzyme that

destroys Ach.Signs and Symptoms

initial sign is ptosis a clinical parameter to determine ptosis ispalpebral fissure.

diplipiamask like facial expressiondysphagiahoarseness of voicerespiratory muscle weakness that may lead to respiratory arrestextreme muscle weakness especially during exertion and morning

Diagnostic ProcedureTensilon test (Edrophonium Hydrochloride) provides temporary

relief of signs and symptomsfor about 5 10 minutes and a maximum of 15 minutes.

if there is no effect there is damage to occipital lobe and midbrainand is negative for M.G.Nursing Management1. airway2. aspiration maintain patent airway and adequate ventilation3.i 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 scale4. maintain side rails to prevent injury related to falls5. institute NGT feeding6. administer medications as ordereda. Cholinergic (Mestinon)b. Anti Cholenisterase (Neostegmin)Mechanism of Action

increase level of AchSide Effects

PNSCortocosteroids suppress immune responsemonitor for 2 types of crisis:

MYASTHENIC CRISIS CHOLINERGIC CRISIS

Causes:- under medication- stress- infectionSigns and Symptoms- The client is unable to see,swallow, speak,breatheTreatment- administer cholinergic agents

as ordered

Cause:- over medicationSigns and Symptoms- PNSTreatment- Administer anti cholinergicagents

(Atropine Sulfate)

7. Assist in surgical procedure known as thymectomy because itis believed that the thymus gland isresponsible for M.G.8. Assist in plasma paresis and removing auto immune anti bodies9. Prevent complicationsINFLAMMATORY CONDITIONS OF THE BRAIN


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MENINGITISMeninges

3 fold membrane that covers brain and spinal cord.for support and protectionfor nourishmentblood supply

LAYERS OF THE MENINGES

1. Dura matter outer layer2. Arachnoid middle layer3. Pia matter inner layer

subdural space between the dura and arachnoidsubarachnoid space between the arachnoid and pia, CSF

aspiration is done.A. Etiology1. Meningococcus most dangerous2. Pneumococcus3. Streptococcus - causes adult meningitis4. Hemophilus Influenzae causes pediatric meningitisB. Mode of transmission

airborne transmission (droplet nuclei)C. Signs and Symptoms

headachephotophobiaprojectile vomitingfever, chills, anorexia, general body malaise and weight lossPossible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate)Signs of meningeal irritation

a. Nuchal rigidity or stiff neckb. 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 thesubarachnoid space between theL3 L4 to L5.Nursing Management for LPBefore 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 Puncture

1. Place flat on bed 12 24o2. Force fluids3. Check punctured site for any discoloration, drainage and leakageto tissues.4. Assess for movement and sensation of extremities.CSF analysis reveals1. Increase CHON and WBC2. Decrease glucose3. Increase CSF opening pressure (normal pressure is 50 100mmHg)4. (+) cultured microorganism (confirms meningitis)CBC reveals1. Increase wbcE. Nursing Management1. Enforce complete bed rest2. Administer medications as ordereda. Broad spectrum antibiotics (Penicillin, Tetracycline)b. Mild analgesicsc. Anti pyretics3. Institute strict respiratory isolation 24 hours after initiation of antibiotic therapy4. Elevate head 30-455. Monitor strictly V/S, input and output and neuro check6. 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 smallfrequent feedings.b. Prevent complications

most feared is hydrocephalushearing loss/nerve deafness is second complication

consult audiologistc. Rehabilitation for neurological deficit

mental retardationdelayed psychomotor development

CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRALTHROMBOSIS)

a partial or complete disruption in the brains blood supply.2 most common cerebral artery affected by stroke

a. Mid Cerebral Arteryb. Internal Cerebral Artery the 2 largest arteryA. Incidence Rate

men are 2-3 times high risk B. Predisposing Factors

thrombus (attached)embolus (detached and most dangerous because it can go to

the lungs and causepulmonary embolism or the brain and cause cerebral embolism.Signs and Symptoms of Pulmonary Embolism

Sudden sharp chest painUnexplained dyspneaTachycardiaPalpitationsDiaphoresisMild restlessness

Signs and Symptoms of Cerebral Embolism Headache and dizzinessConfusionRestlessnessDecrease LOCFat embolism is the most feared complications after femur fracture.

Yellow bone marrow are produced from the medullary cavity of thelong bones and produces fat cells.

If there is bone fracture there is hemorrhage and there would beescape of the fat cells in the circulation.

Compartment syndrome (compression of arteries and nerves)C. Risk Factors1. Hypertension, Diabetes Mellitus, Myocardial Infarction,Atherosclerosis, Valvular Heart Disease, PostCardiac Surgery (mitral valve replacement)2. Lifestyle (smoking), sedentary lifestyle3. Obesity (increase 20% ideal body weight)4. Hyperlipidemia more on genetics/genes that binds to cholesterol5. Type A personalitya. deadline drivenb. can do multiple tasksc. usually fells guilty when not doing anything6. Related to diet: increase intake of saturated fats like whole milk7. Related stress physical and emotional8. Prolong use of oral contraceptives promotes lypolysis (breakdownof lipids) leading to atherosclerosis thatwill lead to hypertension and eventually CVA. D. Signs and Symptoms

dependent on stages of development1. TIA

Initial sign of stroke or warning signSigns and Symptoms

headache and dizzinesstinnitus

visual and speech disturbancesparesis (plegia)possible increase ICP

2. Stroke in evolutionprogression of signs and symptoms of stroke

3. Complete strokeresolution phase characterized by:

Signs and Symptomsheadache and dizzinessCheyne Stokes Respirationanorexia, nausea and vomitingdysphagia(+) Kernigs sign and Brudzinski sign which may lead to

hemorrhagic strokefocal neurological deficits


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a. phlegiab. 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 Procedure1. CT Scan reveals brain lesions2. Cerebral Arteriography

reveals the site and extent of malocclusion

uses dye for visualizationmost of dye are iodine based check for shellfish allergyafter diagnostic exam force fluids to release dye because it is

nephro toxiccheck for distal pulse (femoral)check for hematoma formation

F. Nursing Management1. Maintain patent airway and adequate ventilation by:a. assist in mechanical ventilationb. administrate O2 inhalation2. Restrict fluids to prevent cerebral edema that might increase ICP3. Elevate head 30 454. Monitor strictly vitals signs, I & O and neuro check5. Prevent complications of immobility by:a. turn client to sideb. provide egg crate mattresses or water bed

c. provide sand bag or food board.

6. Assist in passive ROM exercise every 4 hours to promote properbodily alignment and prevent contractures7. Institute NGT feeding8. Provide alternative means of communication a. non verbal cuesb. magic slate9. If positive to hemianopsia approach client on unaffected side10. Administer medications as ordereda. Osmotic Diuretics (Mannitol)b. Loop Diuretics (Lasix, Furosemide)c. Cortecosteroidsd. Mild Analgesicse. Thrombolytic/Fibrinolytic Agents dissolves thrombus

Streptokinase

Side Effect: Allergic ReactionUrokinaseTissue Plasminogen Activating Factor

Side Effect: Chest Painf. Anti Coagulantsg. Anti Platelet

Heparin (short acting)

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

give Protamine SulfateComadin/ 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)PASA (Aspirin)Contraindicated for dengue, ulcer and unknown cause of

headache because it maypotentiate bleeding11. Provide client health teachings and discharge planningconcerninga. avoidance of modifiable risk factors (diet, exercise, smoking)

b. prevent complication (subarachnoid hemorrhage is the most fearedcomplication)c. dietary modification (decrease salt, saturated fats and caffeine)d. importance of follow up care

GUILLAIN BARRE SYNDROMEa disorder of the CNS characterized by bilateral symmetrical

polyneuritis leading to ascending muscleparalysis.A. Predisposing Factors1. Autoimmune2. Antecedent viral infections such as LRT infectionsB. Signs and Symptoms

1. Clumsiness (initial sign)2. Dysphagia3. Ascending muscle weakness leading to paralysis4. Decreased of diminished deep tendon reflex5. Alternate hypotension to hypertension** ARRYTHMIA (most feared complication)6. Autonomic symptoms that includesa. increase salivationb. increase sweatingc. constipationC. Diagnostic Procedures1. CSF analysis reveals increase in IgG and protein D. Nursing Management1. Maintain patent airway and adequate ventilation by:a. assist in mechanical ventilationb. monitor pulmonary function test2. Monitor strictly the followinga. vital signsb. intake and outputc. neuro checkd. ECG3. Maintain side rails to prevent injury related to fall4. Prevent complications of immobility by turning the client every 2hours5. Institute NGT feeding to prevent aspiration6. Assist in passive ROM exercise7. Administer medications as ordereda. Corticosteroids suppress immune responseb. Anti Cholinergic Agents Atrophine Sulfatec. Anti Arrythmic Agents

Lidocaine, ZylocaineBretylium blocks release of norepinephrine to prevent increase of

BP8. Assist in plasma pharesis (filtering of blood to removeautoimmune anti-bodies)9. Prevent complicationsa. Arrythmiab. Paralysis or respiratory muscles/Respiratory arrest* Sengstaken Blakemore Tube

for liver cirrhosis

to decompress bleeding esophageal verices (prepare scissor to cuttube incase of difficulty inbreathing to release air in the balloon

for hemodialysis prepare bulldog clips to prevent air embolism.

CONVULSIVE DISORDER/ CONVULSIONdisorder of CNS characterized by paroxysmal seizure with or

without loss of consciousnessabnormal motor activity alternation in sensation and perception andchanges in behavior.

Seizure first convulsive attackEpilepsy second or series of attacks

Febrile seizure normal in children age below 5 yearsA. Predisposing Factors1. Head injury due to birth trauma2. Genetics3. Presence of brain tumor4. Toxicity froma. leadb carbon monoxide5. Nutritional and Metabolic deficiencies6. Physical and emotional stress7. Sudden withdrawal to anti convulsant drug is predisposing factorfor status epilepticus (drug of choice is

Diazepam, Valium)B. Signs and SymptomsDependent on stages of development or types of seizure

I. Generalized Seizure1. Grand mal Seizure (tonic-clonic seizure)a. Signs or aura with auditory, olfactory, visual, tactile, sensoryexperienceb. Epileptic cry is characterized by fall and loss of consciousnessfor 3 5 minutesc. Tonic contractions - direct symmetrical extension of extremities

Clonic contractions - contraction of extremitiesd. Post ictal sleep unresponsive sleep


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2. Petit mal Seizure absence of seizure common among pediatricclients characterized bya. blank stareb. decrease blinking of eyesc. twitching of mouthd. loss of consciousness (5 10 seconds)II. Partial or Localized Seizure1. Jacksonian Seizure (focal seizure)

Characterized by tingling and jerky movement of index finger and

thumb that spreads to the shoulderand other side of the body.2. Psychomotor Seizure (focal motor seizure)a. automatism stereotype repetitive and non propulsive behaviorb. clouding of consciousness not in contact with environmentc. mild hallucinatory sensory experienceIII. Status Epilepticus

A continuous uninterrupted seizure activity, if left untreated canlead to hyperpyrexia and leadto coma and eventually death.

Drug of choice: Diazepam, Valium and Glucose C. Diagnostic Procedures1. CT Scan reveals brain lesions2. EEG reveals hyper activity of electrical brain wavesD. Nursing Management1. Maintain patent airway and promote safety before seizure activitya. clear the site of blunt or sharp objectsb. loosen clothing of clientc. maintain side rails

d. avoid use of restrainse. turn clients head to side to prevent aspirationf. place mouth piece of tongue guard to prevent biting or tongue 2. Avoid precipitating stimulus such as bright/glaring lights and noise3. Administer medications as ordereda. Anti convulsants (Dilantin, Phenytoin)b. Diazepam, Valiumc. Carbamazepine (Tegretol) Trigeminal neuralgiad. Phenobarbital, Luminal4. Institute seizure and safety precaution post seizure attacka. administer O2 inhalationb. provide suction apparatus5. Document and monitor the followinga. onset and durationb. types of seizuresc. duration of post ictal sleep may lead to status epilepticusd. assist in surgical procedure cortical resectionCOMPREHENSIVE NEURO EXAM

GLASGOW COMA SCALEobjective measurement of LOC sometimes called as the quick

neuro checkComponents1. Motor response2. Verbal response3. Eye opening

Conscious 15 14Lethargy 13 11Stupor 10 8Coma 7

Deep Coma 3Survey of mental status and speech

a. LOC

b. Test of memory

Levels of orientationCranial nerve assessmentSensory nerve assessmentMotor nerve assessmentDeep tendon reflexAutonimicsCerebellar test

a, Rombergs test 2 nurses, positive for ataxiab. Finger to nose test positive result mean dimetria

(inability of body to stop movement at desiredpoint)c. Alternate supination and pronation positive result mean dimetria

I. LEVEL OF CONSCIOUSNESS1. Conscious - awake2. Lethargy lethargic (drowsy, sleepy, obtunded)3. Stupor

stuporous (awakened by vigorous stimulation)generalized body weaknessdecrease body reflex

4. Comacomatoselight coma (positive to all forms of painful stimulus)deep coma (negative to all forms of painful stimulus)

DIFFERENT PAINFUL STIMULATION1. Deep sternal stimulation/ deep sternal pressure2. Orbital pressure3. Pressure on great toes4. Corneal or blinking reflex

Conscious client use a wisp of cotton

Unconscious client place 1 drop of saline solutionII. TEST OF MEMORY1. Short term memory

ask most recent activitypositive result mean anterograde amnesia and damage to temporal

lobe2. Long term memory

ask for birthday and validate on profile sheetpositive result mean retrograde amnesia and damage to limbic

system

consider educational backgroundIII. LEVELS OF ORIENTATION1. Time first asked2. Person second asked3. Place third asked

CRANIAL NERVESCRANIAL NERVES FUNCTIONI. OLFACTORY SII. OPTIC SIII OCCULOMOTOR MIV. TROCHLEAR M (Smallest)V. TRIGEMINAL B (Largest)VI. ABDUCENSE MVII. FACIAL BVIII. ACOUSTIC SIX. GLOSSOPHARYNGEAL BX. VAGUS B (Longest)XI. SPINAL ACCESSORY M

XII. HYPOGLOSSAL M

CRANIAL NERVE I: OLFACTORYsensory 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

Proceduretest each nostril by occluding each nostril

Abnormal Findings1. Hyposnia decrease sensitivity to smell2. Dysosmia distorted sense of smell3. Anosmia absence of smellIndicative of1. head injury damaging the cribriform plate of ethmoid bone whereolfactory cells are located

2. may indicate inflammatory conditions (sinusitis)

CRANIAL NERVE II: OPTICsensory function for vision or sight

Functions1. Test visual acuity or central vision or distance

use Snellens Chart

Snellens Alphabet chart: for literate clientsSnellens E chart: for illiterate clientsSnellens Animal chart: for pediatric clientsnormal 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 personnormally can see letter in thechart.

- 20/200 indicates blindness20/20 visual acuity if client is able to read letters above the red line.

2. Test of visual field or peripheral visiona. Superiorlyb. Bitemporalyc. Nasally

d. InferiorlyCOMMON VISUAL DISORDERS1. Glaucoma

increase IOPnormal IOP is 12 21 mmHgpreventable but not curable

A. Predisposing FactorsCommon among 40 years old and aboveHereditaryHypertensionObesity

B. Signs and Symptoms1. Loss of peripheral vision

pathognomonic sign is tunnel vision2. Headache, nausea, vomiting, eye pain (halos around light)

steamy corneamay lead to blindness

C. Diagnostic Procedures1. Tonometry2. Perimetry3. GonioscopyD. Treatment1. Miotics constricts pupila. Pilocarpine Sodium, Carbachol2. Epinephrine eyedrops decrease formation of aqueous humor3. Carbonic Anhydrase Inhibitorsa. Acetazolamide (Diamox) promotes increase outflow of aqueoushumor or drainage4. Timoptics (Timolol Maleate)E. Surgical Procedures1. TRABECULECTOMY (Peripheral Indectomy) drain aqueoushumor2. Cataract

Decrease opacity of lensA. Predisposing Factor1. Aging 65 years and above

2. Related to congenital3. Diabetes Mellitus4. Prolonged exposure to UV raysB. Signs and Symptoms1. Loss of central visionC. Pathognomonic Signs1. Blurring or hazy vision2. Milky white appearance at center of pupils3. Decrease perception to colors

Complication is blindnessD. Diagnostic Procedure1. Opthalmoscopic examE. Treatment1. Mydriatics (Mydriacyl) constricts pupils2. Cyclopegics (Cyclogyl) paralyses cilliary muscleF. Surgical ProcedureExtra IntraCapsular CapsularCataract Cataract

Lens LensExtraction Extraction- Partial removal - Total removal of cataract with itssurrounding capsules

Most feared complication post op is RETINAL DETACHMENT3. Retinal Detachment

Separation of epithelial surface of retinaA. Predisposing Factors1. Post Lens Extraction2. Myopia (near sightedness)B. Signs and Symptoms1. Curtain veil like vision

2. FloatersC. Surgical Procedures1. Scleral Buckling2. Cryosurgery cold application3. Diathermy heat application4. Macular Degeneration

Degeneration of the macula lutea (yellowish spot at the center ofretina)A. Signs and Symptoms

1. Black Spots

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

Controls or innervates the movement of extrinsic ocular muscle(EOM)

6 muscles

Superior Rectus Superior ObliqueLateral Rectus Medial RectusInferior Oblique Inferior Rectus

trochlear controls superior obliqueabducens controls lateral rectusoculomotor controls the 4 remaining EOM

Oculomotorcontrols the size and response of pupil normal pupil size is 2 3 mmequal size of pupil: Isocoria Unequal size of pupil: Anisocoria Normal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINALlargest cranial nerveconsists of ophthalmic, maxillary, mandibularsensory: controls sensation of face, mucous membrane, teeth, soft

palate and corneal reflex)motor: controls the muscle of mastication or chewingdamage to CN V leads to trigeminal neuralgia/thickdolorummedication: Carbamezapine(Tegretol)

CRANIAL NERVE VII: FACIALSensory: controls taste, anterior 2/3 of tongue pinch of sugar and cotton applicator placed on tip of tongue

Motor: controls muscle of facial expressioninstruct client to smile, frown and if results are negative there is

facial paralysis or Bells Palsyand the primary cause is forcep delivery. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR

Controls balance particularly kinesthesia or position sense,refers to movement andorientation of the body in space.Parts of the Ear1. Outer Ear

PinnaEardrum

2. Middle EarHammer MalleusAnvil IncusStirrup Stapes

3. Inner EarVestibule: Meineres DiseaseCochleaMastoid CellsEndolymph and Perilymph

COCHLEA: controls hearing, contains the Organ of Corti (the trueorgan of hearing)

Let client repeat words uttered CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE

Glosopharyngeal: controls taste, posterior 1/3 of tongue Vagus: controls gag reflexUvula should be midline and if not indicative of damage to cerebral

hemisphereEffects of vagal stimulation is PNS


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CRANIAL NERVE XI: SPINAL ACCESSORYInnervates with sternocleidomastoid (neck) and trapezius

(shoulder)CRANIAL NERVE XII: HYPOGLOSSAL

Controls the movement of tongueLet client protrude tongue and it should be midline and if unable to

do indicative of damage tocerebral hemisphere and/or has short frenulum.

ENDOCRINE SYSTEMOverview of the structures and functions1. Pituitary Gland (Hypophysis Cerebri)o Located at base of brain particularly at sella turcicao Master gland or master clock

o Controls all metabolic function of bodyPARTS OF THE PITUITARY GLAND1. Anterior Pituitary Glando called as adenohypophysis2. Posterior Pituitary Glando called as neurohypophysis

o secretes hormones oxytocin -promotes uterine contractionspreventing bleeding/ hemorrhageo administrate oxytocin immediately after delivery to prevent uterineatony.o initiates milk let down reflex with help of hormone prolactin2. Antidiuretic Hormoneo

Pitressin (Vasopressin)

o Function: prevents urination thereby conserving water

o Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic

Hormone

DIABETES INSIPIDUSo Decrease production of anti diuretic hormone A. Predisposing Factoro Related to pituitary surgeryo Trauma

o Inflammation

o Presence of tumorB. Signs and Symptoms1. Polyuria2. Signs of dehydrationa. Adult: thirstb. Agitationc. Poor Skin turgor

d. Dry mucous membrane3. Weakness and fatigue4. Hypotension5. Weight loss6. If left untreated results to hypovolemic shock (sign is anuria)C. Diagnostic Procedures1. Urine Specific Gravityo Normal value: 1.015 1.030

o Ph 4 82. Serum Sodiumo Increase resulting to hypernatremiaD. Nursing Management1. Force fluids2. Monitor strictly vital signs and intake and output3. Administer medications as ordereda. Pitressin (Vasopresin Tannate) administered IM Z-tract4. Prevent complilcations HYPOVOLEMIC SHOCK is the mostfeared complication

SIADHo hypersecretion of anti diuretic hormone A. Predisposing Factors1. Head injury2. Related to presence of bronchogenic cancero initial sign of lung cancer is non productive cough

o non invasive procedure is chest x-ray3. Related to hyperplasia (increase size of organ brought about byincrease of number of cells) of pituitarygland.B. Signs and Symptoms1. Fluid retention

a. Hypertensionb. Edemac. Weight gain2. Water intoxication may lead to cerebral edema and lead toincrease ICP may lead to seizure activityC. Diagnostic Procedure1. Urine specific gravity is increased2. Serum Sodium is decreasedD. Nursing Management1. Restrict fluid2. Administer medications as ordereda. Loop diuretics (Lasix)b. Osmotic diuretics (Mannitol)3. Monitor strictly vital signs, intake and output and neuro check4. Weigh patient daily and assess for pi tting edema5. Provide meticulous skin care6. Prevent complicationsANTERIOR PITUITARY GLANDo also called ADENOHYPOPHYSIS secretes1. Growth hormones (somatotropic hormone)o Promotes elongation of long boneso 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 hormoneo for skin pigmentationo Hyposecretion of MSH results to Albinismo Most feared complications of albinisma. Lead to blindness due to severe photophobiab. Prone to skin cancero Hypersecretion of MSH results to Vitiligo3. Adrenochorticotropic hormone (ACTH)o promotes development of adrenal cortex4. Lactogenic homone (Prolactin)

o promotes development of mammary glando with help of oxytocin it initiates milk let down reflex5. Leutinizing hormoneo secretes estrogen6. Follicle stimulating hormoneo secretes progesteronePINEAL GLANDo secretes melatonino inhibits LH secretion

o it controls/regulates circadian rhythm (body clock) THYROID GLANDo located anterior to the neck3 Hormones secreted1. 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 topromote calcium resorption.HYPOTHYROIDISMo all are decrease except weight and menstruationo memory impairmentSigns and Symptomso there is loss of appetite but there is weight gain

o menorrhagia

o cold intolerance

o constipationHYPERTHYROIDISMo all are increase except weight and menstruationSigns and Symptomso increase appetite but there is weight losso amenorrhea

o exophthalmosTHYROID DISORDERS

SIMPLE GOITERo enlargement of thyroid gland due to iodine deficiency A. Predisposing Factors1. Goiter belt area


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a. places far from seab. Mountainous regions2. Increase intake of goitrogenic foodso 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 drugsa. Anti Thyroid Agent Prophylthiuracil (PTU)

b. Lithium CarbonateB. Signs and Symptoms1. Enlarged thyroid gland2. Mild dysphagia3. Mild restlessnessc. PASA (Aspirin)d. Cobalte. Phenylbutazones (NSAIDs)- if goiter is caused byC. Diagnostic Procedures1. Serum T3 and T4 reveals normal or below normal2. Thyroid Scan reveals enlarged thyroid gland.3. Serum Thyroid Stimulating Hormone (TSH) is increased(confirmatory diagnostic test)D. Nursing Management1. Enforce complete bed rest2. Administer medications as ordereda. 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 choicefor pyelonephritis)b. Thyroid Hormoneso Levothyroxine (Synthroid)o Liothyronine (Cytomel)

o Thyroid ExtractsNursing Management when giving Thyroid Hormones1. Instruct client to take in the morning to prevent insomnia2. Monitor vital signs especially heart rate because drug causestachycardia and palpitations3. Monitor side effectso insomnia

o tachycardia and palpitations

o hypertension

o heat intolerance4. Increase dietary intake of foods rich in iodineo

seaweeds

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

because it contains lesseramount of iodine.o iodized salt, best taken raw because it it is easily destroyed byheat5. Assist in surgical procedure of subtotal thyroidectomyHYPOTHYROIDISMo hyposecretion of thyroid hormoneo adults : MYXEDEMA non pitting edema

o children : CRETINISMthe only endocrine disorder that canlead to mental retardationA. Predisposing Factors1. Iatrogenic Cause disease caused by medical intervention suchas surgery2. Related to atrophy of thyroid gland due to trauma, presence oftumor, inflammation3. Iodine deficiency

4. Autoimmune (Hashimotos Disease)B. Signs and Symptoms(Early Signs)1. Weakness and fatigue2. Loss of appetite but with weight gain which promotes lipolysisleading to atherosclerosis and MI3. Dry skin4. Cold intolerance5. Constipation(Late Signs)1. Brittleness of hair and nails2. Non pitting edema (Myxedema)3. Hoarseness of voice4. Decrease libido

5. Decrease in all vital signs hypotension, bradycardia, bradypnea,hypothermia6. CNS changeso lethargy

o memory impairment

o psychosis

o menorrhagiaC. Diagnostic Procedures1. Serum T3 and T4 is decreased

2. Serum Cholesterol is increased3. RAIU (Radio Active Iodine Uptake) is decreasedD. Nursing Management1. Monitor strictly vital signs and intake and output to determinepresence ofo Myxedema coma is a complication of hypothyroidism and anemergency caseo a severe form of hypothyroidism is characterized by severehypotension, bradycardia,bradypnea, hypoventilation, hyponatremia, hypoglycemia,hypothermia leading to pregressivestupor and coma.Nursing Management for Myxedema Coma

Assist in mechanical ventilation

Administer thyroid hormones as ordered

Force fluids2. Force fluids3. Administer isotonic fluid solution as ordered4. Administer medications as orderedThyroid Hormonesa. Levothyroxineb. Leothyroninec. Thyroid Extracts5. Provide dietary intake that is low in calories6. Provide comfortable and warm environment7. Provide meticulous skin care8. Provide client health teaching and discharge planning concerninga. Avoid precipitating factors leading to myxedema comao stresso infection

o cold intolerance

o use of anesthetics, narcotics, and sedatives

o prevent complications (myxedema coma, hypovolemic shocko hormonal replacement therapy for lifetime

o importance of follow up careHYPERTHYROIDISM

o increase in T3 and T4o Graves Disease or Thyrotoxicosis

o developed by Robert GraveA. Predisposing Factors1. Autoimmune it involves release of long acting thyroid stimulatorcausing exopthalmus (protrusionof eyeballs) enopthalmus (late sign of dehydration among infants)2. Excessive iodine intake3. Related to hyperplasia (increase size)B. Signs and Symptoms1. Increase appetite (hyperphagia) but there is weight loss2. Moist skin3. Heat intolerance4. Diarrhea5. All vital signs are increased6. CNS involvementa. Irritability and agitationb. Restlessnessc. Tremors

d. Insomniae. Hallucinations7. Goiter8. Exopthalmus9. AmenorrheaC. Diagnostic Procedures1. Serum T3 and T4 is increased2. RAIU (Radio Active Iodine Uptake) is increased3. Thyroid Scan- reveals an enlarged thyroid glandD. Nursing Management1. Monitor strictly vital signs and intake and output2. Administer medications as orderedAnti Thyroid Agent


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a. Prophythioracill (PTU)b. Methymazole (Tapazole)Side Effects of Agranulocytosiso increase lymphocytes and monocytes

o fever and chills

o sore throat (throat swab/culture)

o leukocytosis (CBC)3. Provide dietary intake that is increased in calories.4. Provide meticulous skin care

5. Comfortable and cold environment6. Maintain side rails7. Provide bilateral eye patch to prevent drying of the eyes.8. Assist in surgical procedures known as subtotal thyroidectomy** Before thyroidectomyadminister Lugols Solution (SSKI) todecrease vascularity of the thyroid

gland to prevent bleeding and hemorrhage.POST OPERATIVELY,1. Watch out for signs of thyroid storm/ thyrotoxicosis

Agitation

TRIAD SIGNS

Hyperthermia Tachycardia

o administer medications as ordereda. Anti Pyreticsb. Beta-blockerso monitor strictly vital signs, input and output and neuro check.

o maintain side rails

o offer TSB2. Watch out for accidental removal of parathyroid gland thatmay lead to

Hypocalcemia (tetany)Signs and Symptomso (+) trousseaus signo (+) chvostek sign

o Watch out for arrhythmia, seizure give Calcium Gluconate IVslowly as ordered3. Watch out for accidental Laryngeal damage which may lead tohoarseness of voiceNursing Managemento encourage client to talk/speak immediately after operation andnotify physician4. Signs of bleeding (feeling of fullness at incisional site)

Nursing Managemento Check the soiled dressings at the back or nape area.5. Hormonal replacement therapy for lifetime6. Importance of follow up carePARATHYROID GLANDo A pair of small nodules behind the thyroid glando Secretes parathormone

o Promotes calcium reabsorption

o Hypoparathyroidism

o HyperparathyroidismHYPOPARATHYROIDISMo Decrease secretion of parathormone leading to hypocalcemiao Resulting to hyperphospatemiaA. Predisposing Factors1. Following subtotal thyroidectomy2. Atrophy of parathyroid gland due to:a. inflammation

b. tumorc. traumaB. Signs and Symptoms1. Acute tetanya. tingling sensationb. paresthesiac. numbnessd. dysphagiae. positive trousseus sign/carpopedal spasmf. positive chvostek signg. laryngospasm/broncospasmh. seizure feared complicationsi. arrhythmia2. Chronic tetany

a. photophobia and cataract formationb. loss of tooth enamelc. anorexia, nausea and vomitingd. agitation and memory impairmentC. Diagnostic Procedures1. Serum Calcium is decreased (normal value: 8.5 11 mg/100 ml)2. Serum Phosphate is decreased (normal value: 2.5 4.5 mg/100ml)3. X-ray of long bones reveals a decrease in bone density4. CT Scan reveals degeneration of basal gangliaD. Nursing Management1. Administer medications as ordered such as:a. Acute Tetany

Calcium Gluconate IV slowlyb. Chronic Tetany

Oral Calcium supplementsCalcium Gluconate

Calcium Lactate

Calcium Carbonatec. Vitamin D (Cholecalciferol) for absorption of calciumCHOLECALCIFEROL ARE DERIVED FROM

Drug Diet (Calcidiol) Sunlight (Calcitriol)d. Phosphate binder

Aluminum Hydroxide Gel (Ampogel)

Side effect: constipationANTACID

A.A.C MAD

Aluminum Containing Magnesium ContainingAntacids Antacids

AluminumHydroxide

Gel

Side Effect: Constipation Side Effect: Diarrhea2. Avoid precipitating stimulus such as glaring lights and noise3. Encourage increase intake of foods rich in calciuma. anchovies

b. salmonc. green turnips4. Institute seizure and safety precaution5. Encourage client to breathe using paper bag to produce mildrespiratory acidosis result.6. Prepare trache set at bedside for presence of laryngo spasm7. Prevent complications8. Hormonal replacement therapy for lifetime9. Importance of follow up care.HYPERTHYROIDISMo Decrease parathormoneo Hypercalcemia: bone demineralization leading to bone fracture(calcium is stored 99% in bone and 1%blood)o Kidney stonesA. Predisposing Factors1. Hyperplasia of parathyroid gland2. Over compensation of parathyroid gland due to vitamin D

deficiencya. Children: Rickettsb. Adults: OsteomalaciaB. Signs and Symptoms1. Bone pain especially at back (bone fracture)2. Kidney stonesa. renal cholicb. cool moist skin3. Anorexia, nausea and vomiting4. Agitation and memory impairmentC. Diagnostic Procedures1. Serum Calcium is increased2. Serum Phosphate is decreased3. X-ray of long bones reveals bone demineralization


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D. Nursing Management1. Force fluids to prevent kidney stones2. Strain all the urine using gauze pad for stone analysis3. Provide warm sitz bath4. Administer medications as ordereda. Morphine Sulfate (Demerol)5. Encourage increase intake of foods rich in phosphate but decreasein calcium6. Provide acid ash in the diet to acidify urine and prevent bacterialgrowth7. Assist/supervise in ambulation8. Maintain side rails9. Prevent complications (seizure and arrhythmia)10. Assist in surgical procedure known as parathyroidectomy11. Hormonal replacement therapy for lifetime12. Importance of follow up careADRENAL GLANDo Located atop of each kidneyo 2 layers of adrenal glanda. Adrenal Cortex outermostb. Adrenal Medulla innermost (secretes catecholamines a powerhormone)2 Types of Catecholamineso Epinephrine and Norepinephrine (vasoconstrictor)o Pheochromocytoma (adrenal medulla)

o Increase secretion of norepinephrine

o Leading to hypertension which is resistant to pharmacologicalagents leading to CVA

o Use beta-blockersADRENAL CORTEX3 Zones/Layers1. Zona Fasciculata- secretes glucocortocoids (cortisol)- function: controls glucose metabolism- Sugar2. Zona Reticularis- secretes traces of glucocorticoids and androgenic hormones- function: promotes secondary sex characteristics- Sex3. Zona Glumerulosa- secretes mineralocorticoids (aldosterone)- function: promotes sodium and water reabsorption and excretion ofpotassium- SaltADDISONS DISEASEo Hyposecretion of adreno cortical hormone leading to

a. metabolic disturbance Sugarb. fluid and electrolyte imbalance Saltc. deficiency of neuromuscular function Salt/SexA. Predisposing Factors1. Related to atrophy of adrenal glands2. Fungal infectionsB. Signs and Symptoms1. Hypoglycemia TIRED2. Decrease tolerance to stress3. Hyponatremia- hypotension- signs of dehydration- weight loss4. Hyperkalemia- agitation- diarrhea- arrhythmia5. Decrease libido6. Loss of pubic and axillary hair

7. Bronze like skin pigmentationC. Diagnostic Procedures1. FBS is decreased (normal value: 80 100 mg/dl)2. Plasma Cortisol is decreased3. Serum Sodium is decrease (normal value: 135 145 meq/L)4. Serum Potassium is increased (normal value: 3.5 4.5 meq/L)D. Nursing Management1. Monitor strictly vital signs, input and output to determine presenceof Addisonian crisis (complication ofaddisons disease)o Addisonian crisis results from acute exacerbation of addisons

disease characterized bya. severe hypotension

b. hypovolemic shockc. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis1. Assist in mechanical ventilation,- administer steroids as ordered- force fluids2. Administer isotonic fluid solution as ordered3. Force fluids4. Administer medications as orderedCorticosteroidsa. Dexamethasone (Decadrone)b. Prednisonec. Hydrocortisone (Cortison)Nursing Management when giving steroids1. Instruct client to take 2/3 dose in the morning and 1/3 dose in theafternoon to mimic the normal diurnalrhythm2. Taper dose (withdraw gradually from drug)3. Monitor side effectsa. hypertensionb. edemac. hirsutismd. increase susceptibility to infectione. moon face appearance4. Mineralocorticoids (Flourocortisone)5. Provide dietary intake, increase calories, carbohydrates, proteinbut decrease in potassium6. Provide meticulous skin care7. Provide client health teaching and discharge planning a. avoid precipitating factor leading to addisonian crisis leadingto- stress- infection- sudden withdrawal to steroidsb. prevent complications- addisonian crisis- hypovolemic shockc. hormonal replacement for lifetimed. importance of follow up careCUSHING SYNDROMEo Hypersecretion of adenocortical hormonesA. Predisposing Factors1 Related to hyperplasia of adrenal gland2. Increase susceptibility to infections3. Hypernatremiaa. hypertension

b. edemac. weight gaind. moon face appearance and buffalo humpe. obese trunkf. pendulous abdomeng. thin extremities4. Hypokalemiaa. weakness and fatigueb. constipationc. U wave upon ECG (T wave hyperkalemia)5. Hirsutism6. Acne and striae7. Easy bruising8. Increase masculinity among femalesB. Diagnostic Procedures1. FBS is increased2. Plasma Cortisol is increased3. Serum Sodium is increased4. Serum Potassium is decreasedC. Nursing Management1. Monitor strictly vital signs and intake and output2. Weigh patient daily and assess for pi tting edema3. Measure abdominal girth daily and notify physician4. Restrict sodium intake5. Provide meticulous skin care6. Administer medications as ordereda. Spinarolactone potassium sparring diuretics7. Prevent complications (DM)8. Assist in surgical procedure (bilateral adrenoraphy)9. Hormonal replacement for lifetime10. Importance of follow up care PANCREAS- Located behind the stomach


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- Mixed gland (exocrine and endocrine)- Consist of acinar cells which secretes pancreatic juices that aids indigestion thus it is an exocrine gland- Consist of islets of langerhans- Has alpha cells that secretes glucagons (function: hyperglycemia)- Beta cells secretes insulin (function: hypoglycemia)- Delta cells secretes somatostatin (function: antagonizes the effectsof growth hormones)3 Main Disorders of Pancreas1. Pancreatic Tumor/Cancer2. Diabetes Mellitus3. PancreatitisDIABETES MELLITUS- metabolic disorder characterized by non utilization of carbohydrates,protein and fat metabolism

CLASSIFICATION OF DM

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

A. Incidence Rate- 10% general population hastype 1 DM

B. Predisposing Factors1. Hereditary (total destruction ofpancreatic cells)2. Related to viruses3. Drugsa. Lasixb. Steroids4. Related to carbontetrachloride toxicityC. Signs and Symptoms1. Polyuria2. Polydypsia3. Polyphagia4. Glucosuria5. Weight loss6. Anorexia, nausea andvomiting

7. Blurring of vision8. Increase susceptibility toinfection9. Delayed/poor wound healing

D. Treatment1. Insulin therapy2. Diet3. ExerciseE. Complication1. Diabetic Ketoacidosis

- Adult onset- Maturity onset type- Obese over 40 years old

A. Incidence Rate- 90% of general population hastype 2 DM

B. Predisposing Factors1. Obesity because obesepersons lack insulinreceptor binding sites

C. Signs and Symptoms1. Usually asymptomatic2. Polyuria3. Polydypsia4. Polyphagia5. Glucosuria6. Weight gain

D. Treatment1. Oral Hypoglycemic agents2. Diet3. ExerciseE. Complications1. Hyper2. Osmolar3. Non4. Ketotic5. Coma

MAINFOODSTUFF ANABOLISM CATABOLISM

1.Carbohydrates2. Protein3. Fats

GlucoseAmino AcidsFatty Acids

GlycogenNitrogenFree FattyAcids- Cholesterol- Ketones

HYPERGLYCEMIA

Increase osmotic diuresis

Glycosuria Polyuria

Cellular starvation weight loss Cellular dehydration

Stimulates the appetite/satiety center Stimulates the thirstcenter

(Hypothalamus) (Hypothalamus)

Polyphagia Polydypsia* Liver has glycogen that undergo glycogenesis/ glycogenolysis

GLUCONEOGENESISFormation of glucose from non-CHO sources Increase protein formation

Negative Nitrogen balance

Tissue wasting (Cachexia)

INCREASE FAT CATABOLISM

Free fatty acids

Cholesterol Ketones

Atherosclerosis Diabetic Keto Acidosis

HypertensionAcetone Breath odor

KussmaulsRespiration

MI CVA

Death Diabetic Coma

DIABETIC KETOACIDOSIS- Acute complication of type 1 DM due to severe hyperglycemialeading to severe CNS depressionA. Predisposing Factors1. Hyperglycemia2. Stressnumber one precipitating factor3. InfectionB. Signs and Symptoms1. Polyuria2. Polydypsia3. Polyphagia4. Glucosuria5. Weight loss6. Anorexia, nausea and vomiting7. Blurring of vision8. Acetone breath odor9. Kussmauls Respiration (rapid shallow breathing)10 CNS depression leading to comaC. Diagnostic Procedures1. FBS is increased2. BUN (normal value: 10 20)3. Creatinine (normal value: .8 1)4. Hct (normal value: female 36 42, male 42 48) due to severedehydrationD. Nursing Management1. Assist in mechanical ventilation2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) tocounteract dehydration and shock3. Monitor strictly vital signs, intake and output and blood sugar levels4. Administer medications as ordereda. Insulin therapy (regular acting insulin/rapid acting insulin peakaction of 2 4 hours)


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b. Sodium Bicarbonate to counteract acidosisc. Antibiotics to prevent infectionHYPER OSMOLAR NON KETOTIC COMA- Hyperosmolar: increase osmolarity (severe dehydration)- Non ketotic: absence of lypolysis (no ketones)A. Signs and Symptoms1. Headache and dizziness2. Restlessness3. Seizure activity4. Decrease LOC diabetic comaB. Nursing Management1. Assist in mechanical ventilation2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) tocounteract dehydration and shock3. Monitor strictly vital signs, intake and output and blood sugar levels4. Administer medications as ordereda. Insulin therapy (regular acting insulin peak action of 2 4 hours)- for DKA use rapid acting insulinb. Antibiotics to prevent infectionINSULIN THERAPYA. Sources of Insulin1. Animal sources- Rarely used because it can cause severe allergic reaction- Derived from beef and pork2. Human Sources- Frequently used type because it has less antigenicity property thusless allergic reaction3. Artificially Compound InsulinB. Types of Insulin1. Rapid Acting Insulin (clear)- Regular acting insulin (IV only)- Peak action is 2 4 hours2. Intermediate Acting Insulin (cloudy)- Non Protamine Hagedorn Insulin (NPH)- Peak action is 8 16 hours3. Long Acting Insulin (cloudy)- Ultra Lente- Peak action is 16 24 hoursC. Nursing Management for Insulin Injections1. Administer at room temperature to prevent development oflipodystrophy (atrophy, hypertrophy ofsubcutaneous tissues)2. Place in refrigerator once opened3. Avoid shaking insulin vial vigorously instead gently roll vialbetween palm to prevent formation of bubbles4. Use gauge 25 26 needle5. Administer insulin either 45 90 depending on amount of clientstissue deposit6. No need to aspirate upon injection7. Rotate insulin injection sites to prevent development oflipodystrophy8. Most accessible route is abdomen9. When mixing 2 types of insulin aspirate first the clear insulinbefore cloudy to prevent contaminating theclear insulin and promote proper calibration.10. Monitor for signs of local complications such asa. Allergic reactionsb. Lipodystrophyc. Somogyis Phenomenon rebound effect of insulincharacterized by hypoglycemia tohyperglycemiaORAL HYPOGLYCEMIC AGENTS- Stimulates the pancreas to secrete insulinA. Classsification1. First Generation Sulfonylureasa. Chlorpropamide (Diabenase)b. Tolbutamide (Orinase)c. Tolamazide (Tolinase)2. Second Generation Sulfonylureasa. Glipzide (Glucotrol)b. Diabeta (Micronase)Nursing Management when giving OHA1. Instruct the client to take it with meals to lessen GIT irritation andprevent hypoglycemia2. Instruct the client to avoid taking alcohol because it can lead tosevere hypoglycemia reaction or Disulfiram(Antabuse) toxicity symptomsB. Diagnostic Procedures

1. FBS is increased (3 consecutive times with signs or polyuria,polydypsia, polyphagia and glucosuriaconfirmatory for DM)2. Random Blood Sugar is increased3. Oral glucose tolerance test is i ncreased most sensitive test4. Alpha Glycosylated Hemoglobin is increased C. Nursing Management1. Monitor for peak action of insulin and OHA and notify physician2. Administer insulin and OHA therapy as ordered3. Monitor strictly vital signs, intake and output and blood sugar levels4. 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% oroffer alternative food substitutes6. Instruct client to exercise best after meals when blood glucose isrising7. Monitor signs for complicationsa. Atherosclerosis (HPN, MI, CVA)b. Microangiopathy (affects small minute blood vessels of eyes andkidneys)

EYES KIDNEY-PREMATURECATARACT- Blindness

-RECURRENTPYELONEPHRITIS- Renal failure

c. HPN and DM major cause of renal failured. Gangrene formatione. Shock due to dehydration- peripheral neuropathy- diarrhea/constipation- sexual impotence8. Institute foot care managementa. instruct client to avoid walking barefootedb. instruct client to cut toenails straightc. instruct client to avoid wearing constrictive garmentsd. encourage client to apply lanolin lotion to prevent skin breakdowne. assist in surgical wound debriment (give analgesics 15 30 minsprior)9. Instruct client to have an annual eye and kidney exam10. Monitor for signs of DKA and HONKC11. Assist in surgical procedureHEMATOLOGICAL SYSTEM

ALBUMIN- Largest and numerous plasma CHON- Maintains osmotic pressure preventing edemaGLOBULINS- Alpha globulins - transport steroids, bilirubin and hormones- Beta globulins iron and copper- Gamma globulinsa. anti-bodies and immunoglobulinsb. prothrombin and fibrinogen clotting factors FORMED ELEMENTS1. RBC (ERYTHROCYTES)- normal value: 4 6 million/mm3- only unnucleated cell- biconcave discs- 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 16gms%- hematocrit red cell percentage in wholeblood- normal value: female 36 42% male 42 48%- substances needed for maturation of RBCa. folic acidb. ironc. vitamin cd. vitamin b12 (cyanocobalamin)e. vitamin b6 (pyridoxine)f. intrinsic factor- Normal life span of RBC is 80 120 days and is killed in redpulp of spleen


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2. WBC (LEUKOCYTES)- normal value: 5000 10000/mm3A. Granulocytes1. Polymorpho Neutrophils- 60 70% of WBC- involved in short term phagocytosis for acute inflammation2. Polymorphonuclear Basophils- for parasite infections- responsible for the release of chemical mediation for inflammation3. Polymorphonuclear Eosinophils- for allergic reactionB. Non Granulocytes1. Monocytes- macrophage in blood- largest WBC- involved in long term phagocytosis for chronic inflammation2. Lymphocytes

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 AIDS1. Kaposis Sarcoma2. Pneumocystis Carinii Pneumonia3. Platelets (THROMBOCYTES)- Normal value: 150,000 450,000/mm3- Promotes hemostasis (prevention of blood loss)- Consist of immature or baby platelets or megakaryocytes which isthe target of dengue virus- Normal life span of platelet is 9 12 daysSigns of Platelet Dysfunction1. Petechiae2. Echhymosis3. Oozing of blood from venipunctured site

BLOOD DISORDERSIron Deficiency Anemia- A chronic microcytic anemia resulting from inadequate absorption ofiron leading to hypoxemic tissue injuryA. Incidence Rate1. Common among developed countries2. Common among tropical zones3. Common among women 15 35 years old4. Related to poor nutritionB. Predisposing Factors1. Chronic blood loss due to t raumaa. Heavy menstruationb. Related to GIT bleeding resulting to hematemesis and melena(sign for upper GIT bleeding)c. fresh blood per rectum is called hematochezia2. Inadequate intake of iron due toa. Chronic diarrheab. Related to malabsorption syndromec. High cereal intake with low animal protein digestiond. Subtotal gastrectomy4. Related to improper cooking of foodsC. Signs and Symptoms1. Usually asymptomatic2. Weakness and fatigue (initial signs)3. Headache and dizziness4. Pallor and cold sensitivity5. Dyspnea6. Palpitations7. Brittleness of hair and spoon shape nails (koilonychias)8. Atropic Glossitis(inflammation of tongue)- Stomatitis PLUMBER VINSONS SYNDROME- Dysphagia9. PICA (abnormal appetite or craving for non edible foods

D. Diagnostic Procedures1. RBC is decreased2. Hgb is decreased3. Hct is deceased4. Iron is decreased5. Reticulocyte is decreased6. Ferritin is decreasedE. Nursing Management1. Monitor for signs of bleeding of all hema test including urinw, stooland GIT2. Enforce CBR so as not to over tire client3. Instruct client to take foods rich in irona. Organ meatb. Egg (yolk)c. Raisind. Sweet potatoese. Dried fruitsf. Legumesg. Nuts4. Instruct the client to avoid taking tea and coffee because it containstannates which impairs iron absorption5. Administer medications as orderedOral Iron Preparationsa. Ferrous Sulfateb. Ferrous Fumaratec. Ferrous Gluconate- 300 mg/dayNursing Management when taking oral iron preparations1. Instruct client to take with meals to lessen GIT irritation2. When diluting it in liquid iron preparations administer with straw toprevent staining of teeth

Medications administered via straw- Lugols solution- Iron- Tetracycline- Nitrofurantoin (Macrodentin)3. Administer with Vitamin C or orange juice for absorption4. Monitor and inform client of side effectsa. Anorexiab. Nausea and vomitingc. Abdominal paind. Diarrhea/constipatione. Melena5. If client cant tolerate/no compliance administer parenteral ironpreparationa. Iron Dextran (IM, IV)b. Sorbitex (IM)Nursing Management when giving parenteral iron preparations1. Administer Z tract technique to prevent discomfort, discolorationand leakage to tissues2. Avoid massaging the injection site instead encourage to ambulateto facilitate absorption3. Monitor side effectsa. Pain at injection siteb. Localized abscessc. Lymphadenopathyd. Fever and chillse. Skin rashesf. Pruritus/orticariag. Hypotension (anaphylactic shock)PERNICIOUS ANEMIA- Chronic anemia characterized by a deficiency of intrinsic factorleading to hypochlorhydria (decreasehydrochloric acid secretion)A. Predisposing Factors1. Subtotal gastrectomy

2. Hereditary factors3. Inflammatory disorders of the ileum4. Autoimmune5. Strictly vegetarian diet

STOMACH

Pareital cells/ Argentaffin or Oxyntic cells

Produces intrinsic factors Secretes hydrochloric acid

Promotes reabsorption of Vit B12 Aids in digestion

Promotes maturation of RBC


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B. Signs and Symptoms1. Weakness and fatigue2. Headache and dizziness3. Pallor and cold sensitivity4. Dyspnea and palpitations as part of compensation5. GIT changes that includesa. mouth soreb. red beefy tonguec. indigestion/dyspepsiad. weight losse. jaundice6. CNS changesa. tingling sensationb. numbnessc. paresthesiad. positive to Rombergs test damage to cerebellum resulting toataxiae. result to psychosisC. Diagnostic ProcedureSchillings Test reveals inadequate/decrease absorption ofVitamin B12D. Nursing Management1. Enforce CBR2. Administer Vitamin B12injections at monthly intervals for lifetime as ordered- Never given orally because there is possibility of developingtolerance- Site of injection for Vitamin B12is dorsogluteal and ventrogluteal- No side effects3. Provide a dietary intake that is high in carbohydrates, protein,vitamin c and iron4. Instruct client to avoid irritating mouth washes instead use softbristled toothbrush5. Avoid heat application to prevent burns APLASTIC ANEMIA- Stem cell disorder leading to bone marrow depression leading topancytopenia

PANCYTOPENIA

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

A. Predisposing Factors1. Chemicals (Benzine and its derivatives)2. Related to irradiation/exposure to x-ray3. Immunologic injury4. DrugsBroad Spectrum Antibioticsa. Chloramphenicol (Sulfonamides)Chemotherapeutic Agentsa. Methotrexate (Alkylating Agent)b. Vincristine (Plant Alkaloid)c. Nitrogen Mustard (Antimetabolite)Phenylbutazones (NSAIDS)B. Signs and Symptoms1. Anemiaa. Weakness and fatigueb. Headache and dizziness

c. Pallor and cold sensitivityd. Dyspnea and palpitations2. Leukopeniaa. Increase susceptibility to infection3. Thrombocytopeniaa. Petechiae (multiple petechiae is called purpura)b. Ecchymosisc. Oozing of blood from venipunctured sitesC. Diagnostic Procedures1. CBC reveals pancytopenia2. Bone marrow biopsy/aspiration (site is the posterior iliac crest)reveals fat necrosis in bone marrow D. Nursing Management1. Removal of underlying cause

2. Institute BT as ordered3. Administer oxygen inhalation4. Enforce CBR5. Institute reverse isolation6. Monitor for signs of infectiona. feverb. cough7. Avoid IM, subcutaneous, venipunctured sites8 Instead provide heparin lock9. Instruct client to use electric razor when shaving10. Administer medications as ordereda. Corticosteroids caused by immunologic injuryb. ImmunosuppressantsAnti Lymphocyte Globulin

Given via central venous catheter

Given 6 days to 3 weeks to achieveMaximum therapeutic effect of drug

DISSEMINATED INTRAVASCULAR COAGULATIONAcute hemorrhagic syndrome characterized by wide spread bleedingand thrombosis due to a deficiency ofprothrombin and fibrinogenA. Predisposing Factors1. Related to rapid blood transfusion2. Massive burns3. Massive trauma4. Anaphylaxis5. Septecemia6. Neoplasia (new growth of tissue)7. PregnancyB. Signs and Symptoms1. Petechiae (widespread and systemic) eye, lungs and lowerextremities2. Ecchymosis3. Oozing of blood from punctured sites4. Hemoptysis6. Oliguria (late sign)C. Diagnostic Procedures1. CBC reveals decreased platelets2. Stool occult blood positive3. ABG analysis reveals metabolic acidosis4. Opthamoscopic exam reveals sub retinal hemorrhagesD. Nursing Management1. Monitor for signs of bleeding of all hema test including stool andGIT2. Administer isotonic fluid solution as ordered3. Administer oxygen inhalation4. Force fluids5. Administer medications as ordereda. Vitamin Kb. Pitressin/ Vasopresin to conserve fluidsc. Heparin/Coumadin is ineffective6. Provide heparin lock7. Institute NGT decompression by performing gastric lavage byusing ice or cold saline solution of 500 1000 ml8. Monitor NGT output9. Prevent complicationa. Hypovolemic shockb. Anuria late signBLOOD TRANSFUSIONGoals/Objectives

1. Replace circulating blood volume2. Increase the oxygen carrying capacity of blood3. Prevent infection in there is a decrease in WBC4. Prevent bleeding if there is platelet deficiencyPrinciples of blood transfusion1. Proper refrigeration- Expiration of packed RBC is 3 6 days- Expiration of platelet is 3 5 days2. Proper typing and cross matchinga. Type O universal donorb. Type AB universal recipientc. 85% of population is RH positive3. Aseptically assemble all materials needed for BTa. Filter set


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b. Gauge 18 19 needlec. Isotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis4. Instruct another RN to re check the followinga. Client nameb. Blood typing and cross matchingc. Expiration dated. Serial number5. Check the blood unit for bubbles cloudiness, sediments anddarkness in color because it indicatesbacterial contamination- Never warm blood as it may destroy vital factors in blood.- Warming is only done during emergency situation and if you havethe warming device- Emergency rapid BT is given after 30 minutes and let natural roomtemperature warm the blood.6. BT should be completed less than 4 hours because blood thatis exposed at room temperature more

than 2 hours causes blood deterioration that can lead toBACTERIAL CONTAMINATION7. Avoid mixing or administering drugs at BT line to preventHEMOLYSIS8. Regulate BT 10 15 gtts/min or KVO rate or equivalent to 100cc/hr to prevent circulatory overload9. Monitor strictly vital signs before, during and after BTespecially every 15 minutes for first hour

because majority of transfusion reaction occurs during thisperioda. Hemolytic reactionb. Allergic reactionc. Pyrogenic reactiond. Circulatory overloade. Air embolismf. Thrombocytopeniag. Cytrate intoxicationh.Hyperkalemia(causedbyexpiredblood)Signs and Symptoms of Hemolytic reaction1. Headache and dizziness2. Dyspnea3. Diarrhea/Constipation4. Hypotension5. Flushed skin6. Lumbasternal/ Flank pain7. Urine is color red/portwine urineNursing Management1. Stop BT2. Notify physician3. Flush with plain NSS

4. Administer isotonic fluid solution to prevent shock and acutetubular necrosis5. Send the blood unit to blood bank for re examination6. Obtain urine and blood sample and send to laboratory for reexamination7. Monitor vital signs and intake and outputSIGNS AND SYMPTOMS OF ALLERGIC REACTION1. Fever2. Dyspnea3. Broncial wheezing4. Skin rashes5. Urticaria6. Laryngospasm and BroncospasmNursing Management1. Stop BT2. Notify physician3. Flush with plain NSS4. Administer medications as ordereda. Anti Histamine (Benadryl) - i f positive to hypotension, anaphylactic

shock treat with Epinephrine5. Send the blood unit to blood bank for re examination6. Obtain urine and blood sample and send to laboratory for reexamination7. Monitor vital signs and intake and outputSIGNS AND SYMPTOMS PYROGENIC REACTIONS1. Fever and chills2. Headache3. Tachycardia4. Palpitations5. Diaphoresis6. DyspneaNursing Management1. Stop BT

2. Notify physician3. Flush with plain NSS4. Administer medications as ordereda. Antipyreticb. Antibiotic5. Send the blood unit to blood bank for re examination6. Obtain urine and blood sample and send to laboratory for reexamination7. Monitor vital signs and intake and output8. Render TSBSIGNS AND SYMPTOMS OF CIRCULATORY REACTION1. Orthopnea2. Dyspnea3. Rales/Crackles upon auscultation4. Exertional discomfortNursing Management1. Stop BT2. Notify physician3. Administer medications as ordereda. Loop diuretic (Lasix)

CARDIOVASCULAR SYSTEMHEART- Muscular pumping organ of the body.- Located on the left mediastinum- Resemble like a close fist- Weighs approximately 300 400 grams- Covered by a serous membrane called the pericardium 2 layers of pericardiuma. Parietal outer layerb. Visceral inner layer- In between is the pericardial fluid which is 10 20 cc- Prevent pericardial friction rub- Common among MI, pericarditis, Cardiac tamponadeA. Layers of Heart1. Epicardium outer layer2. Myocardium middle layer3. Endocardium inner layer- Myocarditis can lead to cardiogenic shock and rheumatic heartdiseaseB. Chambers of the Heart1. Upper Chamber (connecting or receiving)a. Atria2. Lower Chamber (contracting or pumping)a. Ventricles- Left ventricle has increased pressure which is 120 180 mmHg- In order to propel blood to the systemic circulation- Right atrium has decreased pressure which is 60 80 mmHgC. Valves- To promote unidimensional flow or prevent backflow 1. Atrioventricular Valves guards opening betweena. tricuspid valveb. mitral valve- Closure of AV valves give rise to first heart sound (S1 lub)2. Semi lunar Valvesa. pulmonicb. aortic- Closure of SV valve give rise to second heart sound (S2dub)Extra Heart Sounds1. S3 ventricular gallop usually seen in Left Congestive HeartFailure2. S4 atrial gallop usually seen in Myocardial Infarction andHypertensionD. Coronary Arteries- Arises from base of the aorta Types of Coronary Arteries1. Right Main Coronary Artery2. Left Main Coronary Artery- Supplies the myocardiumE. Cardiac Conduction System1. Sino Atrial Node (SA or Keith Flack Node)- Located at the junction of superior vena cava and right atrium- Acts as primary pacemaker of the heart- Initiates electrical impulse of 60 100 bpm2. Atrio Ventricular Node (AV or Tawara Node)- Located at the inter atrial septum- Delay of electrical impulse for about .08 milliseconds to allowventricular filling


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3. Bundle of His- Right Main Bundle of His- Left Main Bundle of His- Located at the interventricular septum 4. Purkinje Fibers- Located at the walls of the ventricles for ventricular contraction- P WAVE (atrial depolarization) contraction- QRS WAVE (ventricular depolarization)- T WAVE (ventricular repolarization)

Insert pacemaker if there is complete heart blockMost common pacemaker is the metal pacemaker and lasts up to 2 5 yearsABNORMAL ECG TRACING1. Positive U wave - Hypokalemia2. Peak T wave Hyperkalemia3. ST segment depression Angina Pectoris4. ST segment elevation Myocardial Infarction5. T wave inversion Myocardial Infarction6. Widening of QRS complexes ArrythmiaCARDIAC DISORDERSCoronary Arterial Disease/ Ischemic Heart DiseaseStages of Development of Coronary Artery Disease1. Myocardial Injury - Atherosclerosis2. Myocardial Ischemia Angina Pectoris3. Myocardial Necrosis Myocardial InfarctionATHEROSCLEROSIS

ATHEROSCLEROSIS ARTERIOSCLEROSIS- narrowing of artery- lipid or fat deposits- tunica intima

- hardening of artery- calcium and proteindeposits- tunica media

A. Predisposing Factors1. Sex male2. Race black3. Smoking4. Obesity5. Hyperlipidemia6. sedentary lifestyle7. Diabetes Mellitus8. Hypothyroidism9. Diet increased saturated fats10. Type A personalityB. Signs and Symptoms1. Chest pain

2. Dyspnea3. Tachycardia4. Palpitations5. DuaphoresisC. TreatmentPercutaneous Transluminal Coronary AngioplastyObjectives of PTCA1. Revascularize myocardium2. To prevent angina3. Increase survival rate- Done to single occluded vessels- If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery3 Complications of CABG1. Pneumonia encourage to perform deep breathing, coughingexercise and use of incentive spirometer2. Shock3. ThrombophlebitisANGINA PECTORIS (SYNDROME)Clinical syndrome characterized by paroxysmal chest pain that isusually relieved by rest or nitroglycerine dueto temporary myocardial ischemiaA. Predisposing Factors1. Sex male2. Race black3. Smoking4. Obesity5. Hyperlipidemia6. sedentary lifestyle7. Diabetes Mellitus8. Hypothyroidism

9. Diet increased saturated fats10. Type A personalityB. Precipitating Factors4 Es of Angina Pectoris1. Excessive physical exertion heavy exercises2. Exposure to cold environment3. Extreme emotional response fear, anxiety, excitement4. Excessive intake of foods rich in saturated fats skimmed milkC. Signs and Symptoms1. Levines Sign initial sign that shows the hand clutching the chest2. Chest pain characterized by sharp stabbing pain located at substerna usually radiates from back, shoulder,arms, axilla and jaw muscles, usually relieved by rest or takingnitroglycerine3. Dyspnea4. Tachycardia5. Palpitations6. DiaphoresisD. Diagnostic Procedure1. History taking and physical exam2. ECG tracing reveals ST segment depression3. Stress test treadmill test, reveal abnormal ECG4. Serum cholesterol and uric acid is increasedE. Nursing Management1. Enforce complete bed rest2. Administer medications as ordereda. Nitroglycerine (NTG) when given in small doses will act asvenodilator, but in large doses willact as vasodilator- Give first dose of NTG (sublingual) 3 5 minutes- Give second dose of NTG if pain persist after giving first dose withinterval of 3 - 5 minutes- Give third and last dose of NTG if pain still persist at 3 5 minutesintervalNursing Management when giving NTG-Keep the drug in a dry place, avoid moisture and exposure tosunlight as it may inactivate the drug-Monitor side effectso Orthostatic hypotensiono Transient headache and dizziness-Instruct the client to rise slowly from sitting position -Assist or supervise in ambulation-When giving nitrol or transdermal patcho Avoid placing near hairy areas as it may decrease drug absorption

o Avoid rotating transdermal patches as it may decrease drugabsorptiono Avoid placing near microwave ovens or duting defibrillation as it

may lea

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