38078786 medical surgical nursing ii
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RESPIRATORY SYSTEM
Normal Value of AtmosphericPressure (PA)
760 mm Hg
14.7 psi (pounds per square inch)Important Concepts!!!
Principle of air flow is from areasof higher pressure to areas of lower pressureFor exchange of gases to occur,NORMALLY (N), there must be apressure gradient of PLUS ANDMINUS SIX(+/-) 6 mm Hg
Pressure must be positive (+) (or greater outside) to enter the lung
RESPIRATORYMECHANISM
INSPIRATION EXPIRATION
RespiratoryMuscles
1. Diaphragm
2.PectoralMuscle
3. IntercostalMuscles
Lowers andcontracts
Contracts
Moves inwardand contracts
Rises andrelaxes
Relaxes
Moves outwardand contracts
Lung Size Increases DecreasesThorax Size Increases DecreasesIntrapulmonicPressure
Decreases(less thanatmosphericpressure)
Increases(greater thanatmosphericpressure)
IntrathoracicPressure
Decreases (lessthanatmosphericpressure)
Increases(greater thanatmosphericpressure)
Important Concepts!!!Upper Respiratory Tract
Composed of:NosePharynxAssociated Structures
Lower Respiratory Tract:Composed of:
LarynxTracheaBronchiLungs
Important Concepts!!!Hiluso Hilar Mass
Pleurisyo Pleural Effusion
Intrapulmonic Spaceo Space inside the lung
Intrathoracic Spaceo Space between the lungs
and the bony thoraxNormal Respiratory Rate
o
Twelve (12) cycles per minuteo Also known as Eupnea
Tachypneao Respiratory Rate above
the normal rateBradypnea
o Respiratory Rate belowthe normal rate
Apneao Absence of Respiration jor
absence of breathing
Types of RespirationReference is the cell
Internal or Cellular RespirationExternal Respiration
Important Concepts!!!Hyperpnea
o Deep BreathingHypopnea
o Shallow Breathing Kussmauls Breathing
o Deep, rapid breathsFactors Affecting the Rate and Depthof RespirationNeurological
MedullaCenter of Respiration
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PonsAffects the rhythmExpansion of the lungsHerring Brewer Prevents over distension of the
lungsClinicalArterial Blood Gas
Arteryo Complete presence of
oxygen and carbon dioxideParameters:
o pH7.35 to 7.45
o pHCO 3
22 to 26 meq / Liter o PCO 2 35 to 45 mm Hg
o PO 2 80 to 100 mm Hg(for adults)40 to 60 mm Hg (for infants)If increased or greater than 60% ininfants, it leads toRETROLENTALFIBROPLASIA
Important Concepts!!!Acidosis or alkalosis is detectedby the pH
Control:Respiratory / metabolic
Bicarbonateo Buffer / neutralizer o Must be > 26 meq / L to
counteract acidosisKidney
o Base factor Determination of Lung function
o PCO 2 Hypoxic Drive
o Stimulant is CO 2 Hyperventilation
o Prone to Alkalosiso Patient gets a lot of O 2 o Decreases amount of CO 2 o Therefore, breathe inside
a bago
Do paper bag breathingo Do cupped hand breathingRespiratory Acidosis
o Do pursed lip breathingo You want to retain positive
(+) pressure on the lungo Takes effect on CO 2
utilizationo To remove CO 2
Expiration is prolonged (longer than inspiration) by pursed lip
breathingASSESSMENT TO RULE OUTRESPIRATORY DISORDER
1. Cough
Important Concept!!!Three (3) types of cough medications:
Antitussiveso Suppresses the cough
reflexExpectorant
o Clears the airway
Mucolytico Lyses, breaks down,
liquefies the phlegm
Types of Cough
1.1) Non-productive CoughWith presence of phlegmWith copious amounts of phlegmPhlegm is retained and is notexpelled from the bodyMedication is a MUCOLYTIC
o It lyses, breaks down andliquefies the phlegm
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1.2) Productive CoughWith presence of phlegmWith copious amounts of phlegmPhlegm is being expelled fromthe body
Medication is anEXPECTORANTo To clear airway
1.3) Dry CoughNo phlegmCough needs to be suppressedMedication is an ANTITUSSIVE
o With sedating effect Important Concept!
o No antitussive is given
when there is phlegmo Suppression of cough willnot allow the phlegm to beexpelled from the body
2. Sputum and Phlegm
2.1 Color Important Concepts!!!
Salivao Normal color is clear
Phlegmo Red
With bloodHemoptysis
Spitting of blood
HematamesisUpper GIbleedingVomiting of bright red
bloodo Yellow GreenSignifies infection
o GreenishDepends on type of infecting microbe
o RustyBrown
Blood is brownishdue toextravasationPneumoniaDue to blood (old
blood)Viral or bacterialWith consolidation(hardening or naninigas)
o Two Types of Consolidation
Lobar Occurs at thelobes
Bronchial
Occurs in thebronchiOccurs inbronchopneu-monia
More common
Interjected Concept!Pulmonary Tuberculosis
o Bacterialo Mode of Transmission
Droplet nucleio RouteAirborne
o It is appropriate to wear MASK
o It is inappropriate to wear GOWN
o With CAVITIES
Other Interjected Concepts!Black and tarry stool
o
Indicates dead bloodMelena indicates upper GIbleeding
2.2) Viscosity and TenacityMucin
o Makes saliva slipperyPhlegm
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o Irritated salivao Thick and tenacious saliva
Hypermucous Productiono Leads to phlegm
Important Interjected Concepts!!!Rhinitiso Nasal cavity inflammation
Coldso Viral in nature
Coryzao Viral in nature
Glossitiso Inflammation of the tongue
Glottitiso Inflammation of the glottis
Tracheitiso Inflammation of thetrachea
Bronchiolitiso Inflammation of the
bronchiolesPneumonitis
o Inflammation of the alveoliGastritis
o Inflammation of thestomach
Stomatitiso Inflammation of the oral
cavity
Important Interjected Concepts!Signs of Inflammation
Rubor o Redness
Calor o Heat
Tumor o Swelling
Dolor o Pain
Functiolaesao Loss of Function
Viscosity and Tenacity of Sputum (continued. . .)
2.2.1) Frothy SputumAir is present but is due toPULMONARY EDEMAPneumothorax
o
Air at intrapleural space2.2.2) Stringy and Thready (thinner)Sputum
Due to BRONCHIAL ASTHMA Masyadong malagkit
Caused by allergeno Dusto Polleno All dust particles
Interjected ConceptClear and stretchy vaginal mucusor discharge indicates fertility
3. Assess for CyanosisBluish color due to lack of oxygen
3.1) Central CyanosisBluish coloration of the:FaceChest
3.2) Peripheral CyanosisBluish coloration of theextremities
3.3) Differential CyanosisAcrocyanosisUse Apgar scoring
o Within one (1) minuteo After five (5) minutes
APGAR also stands for:o A for Appearanceo P for Pulse
Heart Ratedetermines if thebaby is alive
o G for GrimaceTo rule outneurological
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problems or problems with thenervous systemImportant Concept!!
In newborns,
eyeblinking beforecrying is Normal
If there is NOBLINKING, thisindicates A SIGNOF MYASTHENIAGRAVIS of thenewbornThis indicates thatthere is NO
INNERVA-TIONo A for Activity
Muscle Tonicityo R for Respiration
Changes inrespiration requiresimmediateintervention andactionFirst thing to do tonewborn:
Suction
4. Abnormal Breath SoundsAlso called Adventitious BreathSounds
4.1) RalesTwo (2) types:
Fine RalesCoarse Rales
4.1.1) Fine RalesSound similar to when you rubyour hair Also called Friction Rub
4.1.2) Coarse RalesSound similar to crumpling of paper
4.2) RonchiSound similar to bubbling water
4.3) Wheezing
Musical soundWhistling soundOccurs more on or duringexpiratory phase
Important Concept!Abnormal breath sounds are dueto:
o Obstructiono Phlegm
5. Abnormal RespirationPattern of breathing or sequenceof breathing
5.1) Biots Respiration Initially NORMALFollowed by APNEAThen NORMALThen APNEAPattern is NANA normal,apnea, normal, apnea, etc.
5.2) Cheyne StokesInitially NORMALFollowed by HYPERPNEA (deepbreathing)Then APNEAPattern is NHA normal,hyperpnea, apnea
5.3) Kussmauls Respiration Hyperpnic with tachypnea
Malalim na, mabilis pa Asthmatic and labored breathing
Common Signs and Symptoms of Respiratory Diseases
1. DyspneaAlso called Difficulty of Breathing
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o ManagementPositioning
High-Fowlers
Interjected Concept!!In reverse trendelenberg, only thehead part is elevatedThis is indicated for arterialocclusion
2. Cough3. Anorexia
o Loss of appetiteo Management
Provide small
frequent feedingsPatient chooses hisown foodNurse assists in theselection of the foodGood oral hygienetriggers appetite
4. Weight Loss5. Malaise
o Weakness6. Easy Fatigability
o
Managemento Provide bed rest7. General Debilitation
o Loss of functiono Patient wants to move but
is unable to do soo Debilitation
Apathetic(schizophrenic)
8. Irritability
Interjected Concept!!!Correct technique in cleaning thepatient is from A CLEANER
AREA to a DIRTIER AREA toavoid conveying infection
Chronic Signs and Symptoms of Respiratory Diseases
Overdeveloped strap musclesElevated sternum and shoulder Barrel chest or Pigeon Breast
o No elastic recoilo
Common in emphysemaStridor o Noisy Respiration
Clubbing of Fingerso Caused by hypoxia of the
jointsChest Retraction
Interjected Concept!The urinary bladder is consideredfull when it contains a volume of
about 450 to 500 mlYou cannot stop the urge to voidat this level of fullness of theurinary bladder
General Management Techniques:To minimize weakness
o Provide bed restFor dyspnea
o Proper positioningProvide good nutrition
o Proper and balancednutrition
Environmental SanitationOxygenation
o If patient is dyspneic andnot relieved by positioning
o Nasal Cannula or nasalprongs
o Nasal flowLow flowOne (1) to three (3)liters per minuteAverage of two (2)liters per minuteHigh flow is at six(6) liters per minute
Coupetteo A plastic bubble
Isolette
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o An incubator Nasal Catheter Tip should be placed posterior tothe uvula
Important Concepts!!!If the respiratory disease in an infectiousdisorder, management would includethe following:
Isolationo Reverse Isolation
Patient is beingisolated because hecould easily beinfected bydiseases
The patient himself is being protectedExample:Burn patients aresubjected toreverse isolationbecause they areprone to infectionAIDS patients areon reverse isolationbecause they areimmunocompro-mised
o Strict IsolationPatient is beingisolated because hecan readily spreadthe diseaseThe people aroundthe patient arebeing protectedExample:PTB patients aresubjected to strictisolationMycobacteriumtuberculosis is
transmitted throughdroplet and isairborne
Medicationo A dependent functiono
Antibiotics areadministeredo For allergens
Antihistamines aregiven
o BronchospasmBronchodilators
o CoughCough medication
RESPIRATORY DISORDERS
PULMONARY TUBERCULOSIS Causative agent isMycobacterium tuberculosisAcid-fast bacillusTemperature
o Coated with waxo Melt this with temperature
(an additional factor)Mode of transmission is droplet /airborne
Stages of Pulmonary Tuberculosis
Stage No. 1 MINIMALINFILTRATION
No cavitaries but with lesionPrimary complex in childrenWith chemotherapy or multi-drugtherapyUrine becomes BRICK ORANGE
o Due to Rifampicino A normal and expected
side effect of Rifampicinuse
Interjected Concepts!!!In cancer, chemotherapy causesthe following:
o Alopecia
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Loss of hair o Keratin
Protein in the hair o Collagen
Protein in the
internal organso DNA and RNA proliferationis blocked
Stage No. 2 MODERATELYADVANCED
With cavitaryOne-half of lung is affectedLobectomy or removal of onelobe is performedInitially, position the patient at the
UNAFFECTED SIDEThen, turn patient on an hourlybasis
Stage No. 3 FAR ADVANCEDWith cavitaryWhole or entire lungs areaffectedPneumonectomy or removal of the entire lungs is performedPosition patient at the
AFFECTED SIDEMediastinal Shift is a commoncomplicationTurning on an hourly basis is alsoperformed
Diagnostic Tests for PulmonaryTuberculosis
Chest X-rayTo show where the lesion islocated
Sputum ExaminationCulture and SensitivityTo identify the bacteriaTo know what antibiotic will beused to combat the invadingmicroorganism
The doctor and the medicaltechnician would perform this
White Blood Cell (WBC) andErythrocyte Sedimentation Rate
(ESR) TestIncreased WBC levels indicate:o Bacterial infectiono Kochs infection
Mantoux Test or Tubercullin TestUtilizes PPD (Purified ProteinDerivative)Route is IntradermalResult is read after forty-eight(48) to seventy-two (72) hours
Positive Reading if:o 10 mm induration or diameter of the wheal(hardness or pantal butnot the erythema)
o 5 mm induration for HIVpositive patients
Important Concepts!A positive result or a positiveMantoux Test does not mean thata person has PTBIt only means that the person hadbeen exposed to the invadingbacteriaThen, it is advised that the other tests would be performedThe most credible test is theSPUTUM TEST (also for pneumonia)You will know the microorganismYou will know the drug to be used
Signs and Symptoms of PTB
Fever o Low grade fever (onset) in
the afternoono Patients resistance is low
at this time
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o Virulence also increaseso If PTB is advanced, fever
does not manifest as lowgrade
Excessive Sweatingo
HyperhidrosisDehydrationo Management is to
increase oral fluid intakeAnorexiaWeight LossEasy Fatigability
Management of PTB patientsBed RestPositioning
For patients with dyspnea, placein high- Fowlers position Provide good and proper nutritionIncrease Fluid IntakeMedication
o Triple Chemotherapyo Rifampicin
Brick orange urineo Isoniazid (INH)
Peripheral neuritisProvide Vitamin B 6 or pyridoxine
o Pyrazinamide (PZA)Gout formationUric acid crystals
Important Concepts!!!In PTB, there is an onset of low-grade fever In Pneumonia, there is an onsetof high-grade fever
Short-Course ChemotherapySix (6) monthsProlonged
o More than one year Use Ethambutol
o Side effect is OPTICALNEURITIS
Use Streptomycin
o Side effect is on the 8 th cranial nerve
o Therefore, this isOTOTOXIC
CHRONIC OBSTRUCTIVEPULMONARY DISEASESMnemonic is ABBE
AsthmaBronchitisBronchiectasis
o With scarring or nodulescalled SARCOID
o With numerous sarcoidscalled SARCOIDOSIS
May lead to:o
Lung cancer o Emphysema
Important Concept on COPDs!!! All COPDs are characterized by:
Presence of phlegmObstruction by phlegm
Signs and Symptoms of COPDProductive CoughExertional Dyspnea
o In asthmaticPink Cyanosis
o Due to compensatorymechanism
Blue bloaterso Cyanosiso Hyperventilateo Reddish during attack -
hyperemiao Increases altitude and
decreased PO 2 results intohyperemia
Wheezingo Expiratory
Barrel Chesto Common in emphysema
AnorexiaFollowed by weight loss, bodymalaise, etc.
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Respiratory infectionFatigueCor Pulmonale
o Right Ventricular Hypertrophy due to
increased vascular resistance or vasoconstriction
Results into a BOOT-SHAPEDHEART
Nursing Interventions for COPDpatients:
Assess the following:o Breathing patterno Breath soundso
SecretionsPromote mobilization of secretions through:
o Mucolytic agentso For productive cough, use
expectorantso Increased humidification of
moisteningo Fluid intake of 1.5 to 2.0
liters per daySaliva is not part of daily fluid loss
o Suctioningo Chest Physiotherapyo Positioning to allow
maximum breathingo Teach the patient to use
pursed lip breathingAdminister low flow oxygenMonitor therapeutic and sideeffects of the medications usedBed restEncourage Range of MotionexercisesAssist with activities of daily living(ADL) as neededAssess for signs of infectionProvide proper caloricrequirement: Increase proteinintake
Provide health teachings:o Avoidance of smoking,
irritants, infectiono Avoidance of extreme
temperatureso
Proper nutrition andhydrationo Use measures to conserve
energy
Important Concepts!!!For Orthopnea
o Do the Orthopnic positiono Fowlers Position and lean
forwardo Lung is most expanded in
this positiono Lung is most open in thisposition
o Lungs expand but they donot thicken
Atelectasiso Lung collapseo Overdistended lung
collapseEmphysema
o Bursting of alveolio Bleeding occurso If there is pus, it is called
EMPYEMAPyothorax
o Presence of pus in thepleural space
Important Concepts!!!The heart is located at the center of the chestThe apex of the heart ispositioned to the left of the chestRight Atrium is larger than theother chambersThe Left Ventricle has the highestpressure among the four chambers of the heartThis serves as the main pump of the heart
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Cardiac Outputo Five (5) to seven (7) literso Average is six (6) liters
Stroke Volumeo Amount or volume of blood
released through the heartin one beato Equivalent to about fifty
(50) to seventy (70) mlTidal Volume is about 500 to 700ml per respirationCardiac Output
o 5 7 liters per minuteStroke Volume
o 50 70 ml per beatTidal Volume
o
500 700 ml per respiration
Important Concepts!!!Approximate Distribution of Oxygenin the BodyBrain 15% of oxygen in
the circulatingblood
Heart 5% of oxygen inthe circulating
bloodGI and Liver 25% of oxygen inthe circulatingblood
Renal System 25% of oxygen inthe circulatingblood
Extremities(upper andlower)
30% of oxygen inthe circulatingblood
Important Concepts!!!Decreased level of consciousnessCaused by peripheral hypoxiaSyncope
o FaintingTachycardia
o Early sign of decreasedlevel of consciousness
Bradycardiao Late sign of decreased
level of consciousness
Interjected Concepts!!!
Angina Pectoriso Stabbing paino Unifocal pain
Myocardial Infarctiono Crushing paino Excruciating paino Radiating to the left
Due to the fact thatthe output is at theleftCoarctation of the
aortaOther Important Concepts!!!
Pulse Deficito The difference between
the APICAL and theBRACHIAL PULSE
o Normally, the differencebetween these values isZERO
o Difference signifies thepresence of anOCCLUSION
Pulse Rate resembles the HeartRatePulse Pressure
o Systolic-Diastolico Normal is 40 mm Hgo Artery is 40 mm Hgo Vein is 10 mm Hgo Artery has pulse
Tricuspid Valve is locatedbetween the Right Atrium and theRight Ventricle
Important Concept!!!Cor Pulmonale
Also called Right Ventricular Hypertropy
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Pulmonary artery constrictionleads to decreased blood flow tothe lungs for oxygenationBlood is, therefore, retained atthe Right Ventricle
A sphincter can be opened byincreased pressureA valve cannot be opened byincreased pressureTherefore, there is an INCREASEIN THE SIZE OF THE RIGHTVENTRICLECor Pulmonale results into aBOOT-SHAPED HEART
Suctioning
OB-gyneo The first thing to do to thenewborn in the Philippinesetting is to SUCTIONTHE BABY
CGFNSo The first thing to do to the
newborn is to WRAP THEBABY to preventhypothermia
Situation:Newborn has mucus on mouthand nose.
Question:Which do you suction first?
Answer The mouth!
Rationale:There is more mucus in themouth from the GI tract.This gives rise to greater risk for aspirationThen place the patient on lateraltrendelenberg
Important Concept!!Infants are obligate nose breathers
Important Concepts!!!After a month, if the infant has arespiratory disorder
o Suction the NOSE FIRSTIn adults, the nose is cleaner
Therefore, the proper sequenceof suctioning is from cleaner todirtier (nose then mouth)
Interjected Concepts!!!Wash the breast of a woman withlukewarm water
Important Concepts!!!For patient with increasedIntracranial pressure and mucus
at both the nose and the mouth o Do suctioning only at themouth
o Do not suction at the noseo This would cause the
patient to sneezeSneezing further increasesintracranial pressure
Chest Physiotherapy (CPT)Done on the chest in a gentlemanner If the patient is female, do it atthe upper part of the chestComposed of:
o TappingUsing one handWith greater force
o ClappingUsing both hands
o CuppingUsing one hand
Positiono Semi- Fowlers Position
Important Concepts!Back tapping, back clapping andback cupping is not part of CPTLow-flow oxygenation is used inCOPDs to maintain hypoxic drive
o CO 2 stimulates breathing
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Use pursed lip breathing for acidosis to maintain positive (+)pressure as expiration is longer
Signs and Symptoms of Infection
Mnemonic is SHIRP S is for:o Swelling
H is for:o Heat
I is for:o Impaired Motor Function
R is for:o Redness
P is for:o Pain
Important Concepts!!!If infection is present, there is
ALWAYS INFLAMMATIONBut not all inflammation isaccompanied by infectionIncrease protein in diet for tissuerepair Increase protein in diet for repair of lung tissueExtreme temperature is atriggering factor for asthma but isnot an allergen
PNEUMONIAViral and bacterialWith consolidationWith fever High-grade at onsetDuring an attack of pain, positionthe patient ON THE AFFECTEDSIDEManagement
o Turn patientTurning promotescirculationWithout circulation,one cannot removethe consolidation of phlegm
o Cough-upPriority interventionFirst thing to doIncreasescirculation to
removeconsolidatedphlegm
o Deep Breathing
LUNG CANCERBiopsy is needed to confirm thisdiseaseReal cause is unknown,idiopathicSmoking only decreases cellular
resistancePredisposing Factors in Lung Cancer
Familialo Genetic / hereditary
Cigarette smokingo Second hand smokeo Filtered cigarettes lessens
contaminationExposure to occupationalcarcinogens
o AsbestosAsbestos in lungs inincreasingquantities causeslung cancer
o SilicosisSilicon oxide inlungs
o TalcosisCement in the lungs
o BronchiectasisNodules are sarcoidBenign or malignant
Diagnostic Tests for Lung Cancer
Chest X-rayTo know where the tumor is
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CT ScanCAT Scan
For axial skeleton
Sputum ExaminationCytologic examination of thesputum
BronchoscopyDirect visualization of the tracheaand the bronchusIf with biopsy, it is calledFIBEROPTIC BRONCHOSCOPYPre-procedure
o Anesthesia is giveno
Xylocaine appliedPost-procedureo NPO until gag reflex
returnsWithout the presence of the gagreflex, there is a risk for aspiration
Signs and Symptoms of Lung Cancer Persistent Coughing andExpectoration
o Phlegmo Irritation due to the
presence of tumor o This is the CLASSIC SIGN
and SYMPTOM of lungcancer
DyspneaDysphagiaHoarseness of voice
o Vocal cords arecompressed by the tumor
Anorexia
Important Interjected Concepts!!!Pediculosis
o Presence of licePTB is characterized by:
o Bacterial causationo Cavitaries in the lungs
o Low-grade fever (onset)with chills
Lighteningo Fetus if floating above
pelvis
Descento Also considered asSTATION
o Fetus is no longer floatingabove pelvis but is at thelevel of the ischial spine
Crowningo Fetus is at about +3 or +4
relative to level of theischial spine
Chest TubeThoracostomy TubePurposes:
o Primary PurposeFor re-expansion of the lung
o Secondary PurposeTo maintainnegative pressurein the lung throughdrainage
Important Concepts!All chest surgeries require chesttubesIn pneumonectomy, no lungs areleftAll bottles should be placedbelow the chest levelBubbling must be intermittentIf bubbling is continuous, there IS
A LEAKAGEFluctuations in water level isnormalUpon INSPIRATION
o The water at the tubeDESCENDS
o The water level at thebottle ASCENDS
Upon EXPIRATION
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o The water at the tube ASCENDS
o The water level at thebottle DESCENDS
Avoid milking and kinking the
tubeo These are not routinelydone
Negative pressure is suctionpressureClamping of the tube is NOTDONE
Indicators for Chest Tube RemovalAbsence of distressAbsence of fluctuation
o
This means that the lung isalready re-expandedNormal breath sounds in the areaFully expanded lung on X-ray isthe most determinant indicator
o This means that theprimary purpose has beenserved
Important Concepts!!!When pulling out the Chest Tube
o Ask the patient to EXPIREo Thorax should be airtighto Petroleum gauze is
needed before pulling outthe tube
If Valsalva is included in thechoices in the board examination,CHOOSE VALSALVA
Interjected Concept!!!In the removal of the FoleyCatheter,
o Ask the patient toINSPIRE
This allows the patient to relax
GENITOURINARY TRACT
Important Concepts!
The female labia majora ishomologous to the male scrotumThe female clitoris is homologousto the male glans penisBoth these structures have a
special type of blood vesselcontaining erectilesThe meatus is the area where theurine is passed outThe female urethra is the avenuefor passage of urine while themale urethra is the avenue for thepassage of both urine and spermThe females have a vaginalopening a canal serving as thereceptacle for the penis
Both sexes have a rectum and ananus
CatheterizationDone to prevent urinary retentionand bladder distention
Important Concepts!!!The urinary bladder is paralyzedby anesthesiaVaginal Opening
o SpeculumFor pap smear For dilatation andcurettage
Vaginal Doucheo For Vaginitiso This is an acidic solutiono Contains lactic acid or
acetic acido Normal pH of the vagina is
4.5 to 5.5o Acidic environment aids to
prevent possible infectionEnema
o Applied to the rectumo For diagnostic purposes:
Barium EnemaWhite andmilky
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o For cleansing purposesBase enemaSoap enema
Important Concepts!!!
Upper GI Serieso Barium SwallowLower GI Series
o Barium Enema Skenes Gland in F emales
o Found at the sides of theurinary meatus
o For lubrication purposeso Homologous to the
Cowpers gland in males Bartholins Gland
o
Found at the sides of thevaginal openingo Also for lubrication
purposesSmegma
o This is the cheesy whitesubstance found aroundthe clitoris
Radical Perineal Prostatectomyo This is a procedure done
to maleso Therefore, males also
have a perineumFourchette
o Site of episiotomyo Site of episiorraphy
On the mons pubiso APOCRINE GLANDS are
presentSweat glandsPresent at puberty
o When young, these areECCRINE GLANDS
KIDNEYSPaired, comes in the same sizePosition
o Right kidney is lower dueto the anatomical positionof the liver
o Fat anchors the kidney tomaintain it at theretroperitoneal area
Important Concepts!!!
Glomerular Filtration Rate (GFR)Normal Valueo 125 ml per minute
Normal Urine Productiono 0.5 to 1.0 ml per minuteo 24 ml reabsorbed by the
kidneyMicturition Reflex
o 250 450 mlo 125 ml can still be
contained
Hydronephrosiso Drowning of the kidney inurine
Nephrotosiso Falling of the kidneyso When fat is losto Kidney fallso Ureter kinks
Nephrosclerosiso Hardening of the Kidney
Arteriosclerosiso Hardening of the arteries
Important Terminologies!!!Nephrolithiasis
o Stones in the kidneyUreterolithiasis
o Stones in the ureter Cystolithiasis
o Stones in the bladder Urolithiasis
o Stones in the urinary tractStones in the Biliary Tract
o CholelithiasisStones in the gallbladder
o CholedocholitihasisStones in the bile duct
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BREAST CANCERIdiopathicLeft breast
o Commonly first to developtumor
o
Less active tissue is tumor proneHeart is an involuntary organ
o Heart is activeo Thus, there is no cancer of
the heart
Predisposing Factors in BreastCancer
Familialo Genetic
Hormoneso Estrogeno Extremes of estrogen
Positive estrogenreceptor tumor Negative estrogenreceptor tumor In menopause,there is higher negative estrogenreceptor tumor Early Menarche(first menstruation)
Positiveestrogenreceptor tumor
o NulliparityUnable to give birthdue to inability tobecome pregnantReproductive age isfrom 15 to 45
o Also due to failure tobreast feed
o Andropause is malemenopause
o RadiationBreast tumor Breast gland tumor
Adenocarcinomao Obesity
20% and aboveideal weight
o Multiple Pregnancy
Presence of morethan one (1) fetusUniovular
One (1) zygoteMonozygotictwinsSame sex
Biovular Two (2) eggcellsTwo (2)
zygotesDizygotictwins or fraternaltwinsMay be of differentsexes
o IsograftGraft from identicaltwin
Signs and Symptoms of BreastCancer
Cysto Movable
Breast Tumor o Fixedo Non-encapsulatedo Therefore, it can
metastasizeo Commonly located at:
Upper outer
quadrant near theaxial (tail of Spence)Below the nipple
o This results toELEVATION when thetumor is SHALLOWLYLOCATED
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o This may also result toRETRACTION when thetumor is DEEPLYLOCATED
Usually painless INITIALLYo
Pain is present at VERYLATE STAGEWith discharge that may be clear or bloodySkin DimplingSkin ElevationLymphadenopathy on affectedarm
Important Concept!For non-lactating women with
breast discharge:o No cancer yeto Have check-up
Diagnostic Test for Breast Cancer Biopsy
o Excisional BiopsyTumor is removed
o Incisional BiopsyOnly a portion isremoved
o Needle BiopsyDone throughaspiration
Management of Breast Cancer Medical managementSurgical management
o LumpectomySurgical removal of non-cancerousmassWedge resection
o MastectomyRemoval of thebreast
o Radical Mastectomy
Removal of thebreast and other tissues
o Simple MastectomyBreast alone is
removedFat alone
Important Concepts!!!Post-mastectomy
o Elevate affected armabove chest or heart level
o Use pillows to elevate armHemovac
o SuctionCheck the back for bleeding
Protect affected armo Prevent overuse for firsttwo months
o Overuse of affected arm iscontraindicated
No exercise that is strenuousNo exposure to sunlightBreast Self Examination (BSE)
o Done one (1) week after menstruation
o Because estrogen iselevated
o Use one hando Three fingerso Outer to inner o Anytime of the dayo Lift up affected armo If lying down, put a pillow
at the backo If patient is already
menopause, BSE could bedone anytime
Interjected Concepts!!!In thyroidectomy, check the napeIn obtaining urine specimen:
o Get this early in themorning
o First void is discarded
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o Midstream void iscollected as specimen
Parasympathetic NervousSystem
o Increases smooth muscle
activity of glandso Salivation during sleepAtropine Sulfate
o Used to decreasesecretions
With anti-cholinergic effect
URINARY TRACTKidneys
Most aggressive
Functions of the Kidney:Homeostatic Functionso Fluid and Electrolyte
Balanceo Acid-Base Balanceo Hemoconcentration
Through filtrationSecretory Functions
o Urineo Renino Erythropoietin
Excretory Functionso Water o Electrolyteso Metabolic Wasteso Ureao Purines converted into uric
acido Creatinine
Metabolic wastefrom musclesReaction to tissuedamageVery crediblemeasure of kidneyfunction
o Presence of damagedtissues and cells results toincrease in Creatininelevels
o In Brain DamageCreatinine releasedis creatinine kinaseor BB
o In Heart Damage
Creatinine releasedis MBo In damage of other
musclesCreatinine releasedis MM
o Blood Urea NitrogenAffected by proteindiet
Vitamin D Synthesiso Vitamin D comes from
foodo Raw vitamin Do Goes to the kidney and the
skino Must be exposed to
ultraviolet radiation to beconverted to its active form
o Deficiency of Vitamin Dresults into weak bones
Ricketts in childrenOsteomalacia inadults
Abnormal Constituents of UrineNormal urine has hormonesGlucosuria
o Presence of glucose inDiabetes mellitus patients
Diabetes insipidus patients havedecreased levels of Anti-diureticHormone or ADH
o This leads to the two (2)Ps
PolyuriaPolydipsia
Diabetes mellitus patients haveproblems with insulin
o This leads to the three (3)Ps
Polyuria
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PolydipsiaPolyphagia
Types of Diabetes Mellitus
Type 1 Diabetes mellitusInsulin Dependent DiabetesMellitusJuvenile onsetMore controlled diet is necessaryMore severe type of diabetesPancreas could not produceinsulinInsulin is administered to thepatientFats and proteins are utilized by
the body in a process calledgluconeogenesisUtilization of fats results in theformation of ketonesThis leads to DIABETICKETOACIDOSISBlood becomes more viscousThere is less plasma due todehydration secondary topolyuria
Type 2 Diabetes mellitusAdult onsetNon-ketotic diabetesManagement:
o Dieto Exerciseo Oral hypoglycemics
Type 3 Diabetes mellitusGestational Diabetes
Type 4 Diabetes mellitusSecondary DMCaused by disease
Important Interjected Concepts!!!In polycythemia vera
o There is also increaseblood viscosity
o However, there is nodecrease in blood volume(this occurs in DM)
Hematuriao Blood in the urineo
This is ABNORMALPyuriao Pus in the urineo This is ABNORMAL
Proteinuriao Presence of protein in the
urineo This is ABNORMAL
Blood contains the following:o Albumino Globulino
FibrinogenAlbuminuriao Presence of albumin in the
urineo Results into decreased
albumin in the bloodo This brings about
DECREASED OSMOTICCOLLOID PRESSURE
o This leads to EDEMAo To compensate for
Albumin loss, lipid levelsincrease in the blood
o This results toHYPERLIPIDEMIA
o Hyperlipidemia contributesto both:
AtherosclerosisDeposition of fat at the bloodvessel
Arteriosclerosis
Hardening of the bloodvessels
Hypertensiono Increased pressureo Decreased perfusion
Thirty percent (30%) of oxygengoes to the extremities
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SEIZURE DISORDERSEpilepsyConvulsions
Types of SeizuresPetit mal seizureso Short-term seizures
Grand mal seizureso Involves the whole bodyo With aurao Lasts for one (1) to two (2)
minutesMyoclonic Seizures
o Involves the upper extremities
Akinetic Seizureso Patient collapseso Drop attack
Jacksonian Seizureso Partial seizureso Patient can still walk
Psychomotor Seizureso Decorticatedo Decerebrated
Types of ConvulsionsTonic
o Sustainedo Prolonged
Clonico kabilaan
Tonic-Clonico kabilaan at matagalan
Epiliptiformo Can recover quickly
Important Concepts!!!Epilepsy is more serious thanconvulsionsFainting always occurs withepilepsyIn epilepsy, EEG is needed
URINARY TRACT INFECTION (UTI)Urethra is affected
Females are commonly affectedo Due to the proximity of the
anus to the urinary meatusE. coli
o Normally present in the
colono Normal flora in the colono Comes out even during
flatus
Management of UTIIncrease fluid intakeCollect sterile urine specimen
o First void is discardedo Midstream void is
collectedo
For urine culture andsensitivity testProvide warm SITZ BATH
o In the hospital, warm water is used to submergepatient up to below thelevel of the umbilicus
o Also called HIP BATH Suob
o Warm compress
Medications for UTIAntibiotics are given
Important Concepts!!!Nystatin is givenIn cases of fungal infectionrelated to antibiotic therapyOral ThrushManagement
o Padded tongue depressor Swab
ACUTE GLOMERULONEPHRITIS(AGN)
Causative organismGroup A Beta-hemolyticStreptococcus (GABHS)
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Assess to rule outUpper Respiratory TractInfectionsTonsillitis6x or chronic type
Suggestive of tonsillectomyBoth are indication or complication of AcuteGlomerulonephritis andRheumatic Heart DiseaseAnasarca
o More prominent in lower extremities
o Prevent complicationsManagement of Lower ExtremityEdema
Modified trendelenbergElevate
Types of EdemaBipedal Edema
o Feet EdemaSacral EdemaAscitesCarpal EdemaFacial EdemaPeriorbital Edema
Important Concepts!!!Right-sided Congestive HeartFailure
o Systemic effectso Compromises the kidney
Important Concepts in AcuteGlomerulonephritis
This would bring aboutperforations in the glomeruli anddamage the permeability of theglomerular wallAssess for AlbuminuriaHypoalbuminemia or Albuminuria
o Gives rise to decreasedCOLLOID OSMOTICPRESSURE
o Decreased colloid osmoticpressure gives rise toEDEMA
Hearto Left-Sided Congestive
Heart FailureAffects thePulmonaryCirculation
o Right-Sided CongestiveHeart Failure
Affects theSystemicCirculation
Kidneyo Anasarca or full-body
edemaIncrease in Lipidso Hyperlipidemiao Gives rise to Hypertensiono Hypertension gives rise to
seizureso Seizures gives rise to
convulsionsEdema
o Results into decreasedblood volume
o Decreased blood volumetranslates to hypovolemia
Oliguriao Scanty urine
Hematuriao Blood in the urineo Brought about by
perforations in the kidneycaused by GABHS
Blood Urea Nitrogen Clearanceo The manner in which the
kidney can clear BloodUrea Nitrogen
o This decreases in AGNBlood Urea Nitrogen (BUN)
o Increases due to thepresence of oliguria
o Normal Value10 20 mg / dl
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o Other sources say it is:5 25 mg / dl8 25 mg / dl
o Lowest BUN value inFemales is 4 8 mg / dl
o
Therefore, always assessfor BUNAGN onset with Hypertension
NEPHROTIC SYNDROMEA cluster of diseasesEnd point of a variety of diseasesdamaging the permeability of theglomerular wallTherefore, there is POLYURIADuring the onset, there is. . .
o
HYPOTENSIONDuring the latter stage, there is. ..
o HYPERTENSIONWhen theglomerular wallbecomes perforatedand thepermeability isdamaged
Proteinuria Edema Hyperlipidemia Hypertension
Management of Edema
Use diuretics
1. Chlorothiazide GroupExample:
o Diuril
2. Loop DiureticsStops reabsorption of water atthe loop of HenleExample:
o Lasix
3. Potassium-sparing DiureticsFor patients with heart conditionAllows sodium out and letspotassium get inExample:
o Spironolactone
4. Osmotic DiureticsFor the brainI.V. route for quick effect
Example:o Mannitol
Important Concepts!!!To decrease lipid levels inhyperlipidimia
o Use LIPOSTATPrevents lipidproliferation
Hyperlipidemiao Increased lipid levels in
bloodo Results into scarring of
blood vesselso Blood accumulates in
scarred areaso Thrombus formation or
blood clots occur in thescarred areas of the bloodvessel walls
o Thrombus detaches fromthe blood vessel wall andis carried by the blood.Thrombus is now called anembolus
Important Terminologies!!!Thrombosis
o Presence of plenty of thrombi
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Venous Thrombosiso Presence of plenty of
thrombi in the veinsThrombophlebitis
o Inflammation of the veins
Arteritiso Inflammation of thearteries
Interjected Concepts!!!Angio signifies arteriesThromboangitiis obliterans
o Buergers Disease o Brought about by smokingo Nicotine causes
vasoconstrictiono
Lower extremities usuallyaffected Raynauds Disease
o Affects mostly femaleso Upper extremity affectation
Avascularityo Peripheral Vascular
Diseases Raynauds Disease Buergers Disease
Gangrene
Massiveblood vesseldeathAmputationis needed ingangrene
All thrombi are blood clotso Therefore, all thrombi are
bloodBut not all emboli are blood
o Other types of emboli are:
Air emboliFat emboliAnticoagulants
o HeparinProvides quicker anti-coagulanteffect
Effect manifested inhours or in one (1)hour
o WarfarinProvides slower
anti-coagulanteffectEffect manifested intwo (2) to three (3)days
Heparino Protamine Sulfate
Antidote of heparinPartial Thromboplastin Time(PTT)
o Related to heparino
Normal is 26 to 32secondsThis is withoutheparin
o In the presence of heparinPTT increases toone and one-half totwo times its normalvalue (1.5x to 2.0xnormal value)Approximately sixty-four seconds (64secs.)PTT Range of 60 70 secondsindicates thatpatient is properlyheparinized
o Thromboplastin is clottingfactor number three
Warfarino Antidote is Vitamin K
Prothrombin Time (PT)o Related to warfarino Normal is 11 to 12
secondso Other sources say that
normal PT is 9.5 to 11.3seconds
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o This is in the absence of warfarin
o In the presence of warfarin, PT is lengthenedor increased to 1.5x to
2.0x its normal valueEffect of warfarin is manifested intwo (2) to three (3) days
NEPHROLITHIASISRenal CalculiTwo Types
o Acid Stoneo Alkali Stone
Acid Stone
Uric Acid StoneVitamin C
Alkali StoneCalcium oxalate
o Magnesiumo Phosphateo Ammonium
Vitamin D
Predisposing Factors inNephrolithiasis
Diet rich in the following:o Vitamin Co Vitamin Do Calcium
Immobilityo Blood stasis
Frequent Urinary Tract Infectionso Scanty urine that does not
irritate
Signs and Symptoms of Nephrolithiasis
Paino Flank paino In person with Cystitis
There is a dripOliguriaHydronephrosis
HematuriaHigh-grade fever with chills
Management of NephrolithiasisIncrease oral fluid intake
LithotripsyIntraurethral Lithotripsy
o No incisionPercutaneous Lithotripsy
o With small incisiono With suctiono Basket type
Extracorporeal Shock WaveLithotripsy (ESWL)
o Externalo
No incisiono Increase fluid intake toremove stones which havebeen rendered smaller insize by the procedure
LithotomyRemoval of stones
o NephrolithotomyRemoval of stonesin the kidney
o CystolithotomyRemoval of stonesin the urinarybladder
o UreterolithotomyRemoval of stonesin the ureter
Urolithotomyo Removal of stones in the
urinary tract
RENAL FAILURETwo (2) Types
Acute Renal FailureChronic Renal Failure
Acute Renal FailureCharacterized by:
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Onset of sudden loss of glomerular functionPotassium intoxicationMetabolic acidosis
Chronic Renal FailureCharacterized by:
Onset of gradual loss of glomerular functionPotassium intoxicationMetabolic acidosis
Important Concepts in Renal FailurePotassium goes out
This gives rise to potassiumintoxicationSodium gets inH+ goes out when sodium comesin
o This makes the bloodacidic
o This produces a decreasein bicarbonate (HCO 3-)levels, giving rise toMetabolic Acidosis
Signs and Symptoms of Renal FailureLethargy
o Due to cerebral hypoxiaEdema
o In the form of anasarcaDecreased blood volume
o Hypovolemiao Hypotensiono Dizzinesso No pain
Hypertensiono Occipital Headacheo Problems with blood
passagewayo They become more
constrictedo Dizziness then sets in
Pale
o Decreased blood supplyAscitesAbdominal PainAnorexiaWeight Loss
Body malaiseManagement of Renal Failure
Dietaryo Decreased protein or low
protein dietProtein contributesto nitrogenouswastes
Decreased sodiumo Presence of sodium
promotes edemaBed restPrevent infectionSkin Care
o Dry skinDue to edema andhypovolemia
o Cracked skino Injured skino Uremic frost occurs
Urea on skin Parang amag
Use dilute vinegar solution
Weigh the patiento There is increase in weight
due to edema
Pharmacological Management of Renal Failure
Diuretics
Medical Management of Renal Failure Dialysis
o Peritoneal DialysisInfection or peritonitis is acommoncomplication
Hemodialysis
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o Hemorrhage is a commoncomplication
Renal Transplanto Alternative surgical
management
Interjected Concepts!!!Levels of Consciousness
Alerto Awake, aware
Obtunded persono Awake but not awareo tulala
LethargyStupor
o Asleepo
Response to painful stimuliat sternum and sole of feetComa
o Deep Comao Cannot be revivedo Respirator sustains life
Euthanasia or mercy killing
GASTROINTESTINAL SYSTEM
Oxygen distribution to the differentbody organs:Brain 15% of oxygen in
the circulatingblood
Heart 5% of oxygen inthe circulatingblood
GI and Liver 25% of oxygen inthe circulatingblood
Renal System 25% of oxygen in
the circulatingbloodExtremities(upper andlower)
30% of oxygen inthe circulatingblood
Important Concepts!!!Small Intestine
o Final digestion occurs inthis organ
o Digested products areabsorbed by the villi
Moutho
Preliminary digestionoccurs hereo Initial digestiono Digestive juice is the
saliva, which containsenzyme for carbohydratedigestion:
AmylasePtyalin
Stomacho Partial digestion occurs
hereo Digestive juice in thestomach:
o Gastric JuiceHydrochloric AcidPepsin
o Food remains in thestomach for about two (2)to four (4) hours
o If food is fatty or has muchprotein content, foodremains in the stomach for about three (3) to four (4)hours
o Stomach is curved to theleft
Cardiac Sphincter Upper
sphincter Prevents
backflow of food to the
esophagusPyloric Sphincter Lower sphincter Preventsbackflow of food from the
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smallintestine
Small Intestineo Digestive Juice:
Bile
Pancreatic JuicePancreatic AmylasePancreaticLipasePancreaticTrypsinInduces sleepTryptophan inmilkWarm milk for
vaso-dilationIncreasestrypsin levelsInduces sleep
ProteasesLiver
o Produces bileo Bile passes through the
hepatic ducto Bile is stored in the gall
bladder Gall bladder
o Storage of bileo Bile passes through the
common bile ducto Bile passes through the
Sphincter of Oddi going tothe duodenum
After food is absorbed in theSmall Intestine, the absorbedproducts are carried by the blood
into the liver for storage
Organs Filtering the BloodKidney
o Filters out metabolicwastes
Liver o Filters out toxins
Spleeno Filters out resistant
microorganismso Red Blood Cells (old
RBCs are phagocytosedo
Main source of anti-bodiesLymph nodeso Also filters bloodo Destroys microorganisms
Important Concepts!!!Large Intestine
o No digestion occurs hereo Water absorptiono Electrolyte absorption
Diarrhea or Dehydrationo
Causes electrolyteimbalanceVomiting
o Sodium (Na +) is theelectrolyte that is mostabundantly lost in vomiting
Diarrheao Sodium (Na +) is the
electrolyte that is mostabundantly lost in diarrhea
Gastrointestinal Tracto Extracellular o Sodium is more abundant
Bloodo Extracellular o Sodium is more abundant
Important Concept!!!Question:
o Which electrolyte loss is of greater concern?
Answer:o Potassium (K +)
Rationaleo Heart suffers from
arrhythmia or absence of rhythm during increased or decreased levels of potassium
o Hypokalemia
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Decreased levels of potassiumDecreasedcontractionFlaccid
o
HyperkalemiaIncreased levels of potassiumIncreasedcontractionSpastic
Dysrhythmiao Irregular heart rhythms
Arrhythmiaso Lub-lub-dubo Lub-dub-dub
Initially, vomiting results intometabolic alkalosiso Hydrochloric acid is being
expelled through themouth
Initially, diarrhea results intometabolic acidosis
o Base (in the form of bitter,biting bile) is beingeliminated through theanus
Bileo Emulsifies fato Gives color to the stoolo Normal color of the stool
Yellowish browno Transitional color of the
stoolGolden Yellow
o Stool of infantsFrom greenish toyellow
o Adult StoolGolden Brown
o Abnormal color of theStool
Gray colored StoolAcholic Stool
Anuso End of the colon
Appendixo Living cello Composed of fecalith
matter o Immunologic
Contains anti-bodiesBut this is still under study
Interjected Concept!Nail beds and hair roots are alive,
just like the appendix, which iscomposed of living cells
Common Gastrointestinal Disorders
(these are manifestations only andare not considered as diseases)AnorexiaNausea
o Urge to vomitVomitingDiarrheaConstipation
Interjected Concept!The epiglottis, a flap-like structureand the glottis, an opening, areboth part of the respiratorysystem
Oral Cavity Disorder Gingivitis
PEPTIC ULCER Also called Gastric Ulcer Two (2) major causes:
Extrinsic Factor Intrinsic Factor
Extrinsic Factor Microbial invasion
o Viruso Bacteria
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Intrinsic Factor Integrity of Gastric MucosaMucosa
o Secretes gastric mucouso If gastric mucosa is
destroyed, acidity causesulcerationo Therefore, decreased
integrity of gastric mucosacauses ulceration
Frank hyperacidity
PREDISPOSING FACTORS in PEPTICULCER
1. Emotional Stress
Constriction of blood vesselsReaction is to produce more acidResults to hyperacidity
Interjected Concept!Ulcer due to severe burns iscalled CURLING ULCERAlso due to stress brought aboutby burns
2. Excessive SmokingNicotine causes constrictionDecreased blood flow bringsabout ischemia
3. Ingestion of Steroids (anti-inflammatory drugs)
Steroid releases HistamineHydrogen (H +)
o This reacts with chloride(Cl-) ion
Chloride ion is the most abundantanion outside the cell
o H+ + Cl - ----- HCl o Therefore, STEROIDS are
GASTRIC IRRITANTSNursing Responsibility
o Give with meals or after meals
Example is PREDNISONE
4. Irregular Eating Pattern
Interjected Concept!Number of times to chew before
swallowing solid food is:o Five (5) to ten (10) or o Six (6) to nine (9)
Assessment (to Rule Out GastricUlcer)
1. PainMid-upper abdomen
o Epigastric regionMay start a couple of hours when
stomach is empty and after eatingRelieved by eating and by anantacid Antacid relieveshyperacidity onlyOccurs at night
o Due to parasympatheticactivity
o This occurs whether patient had taken meals or not
2. Dietary Pattern
2.1) Types of FoodsEnsure nutritious meals
o To promote healing
2.2) Avoid the following foods:
Spicy Foodso Have vasodilating effect
but are irritatingGreasy and Fatty Foods
o These are hard to digestGas-forming Foods
o Most common in foods richin carbohydrates
o Sweet potato, yam, ube,hard-boiled eggs
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o Can increase pressureinside
2.3) Avoid prolonged use of milk andcream
Patients with ulcer can consumesome milk but PROLONGEDUSE IS DISCOURAGEDLactic acid is produced as a by-product of milk digestion
o This results into LACTIC ACIDOSIS
Also contraindicated in UlcerativeColitis patients
o There is lactoseintolerance due to the
absence of lactulase2.4) Avoid Alcohol
Alcohol promotes release of GastrinAlcohol triggers pancreatitis(similar to drugs)
2.5) Avoid beverages causingvasoconstriction
Teao Green Tea contains the
least amount of caffeineamong the different typesof tea
Colao With caffeineo Contains citric acido Also avoid all other types
of soda with the samecolor as soda (i.e. rootbeer, sarsa parilla)
CoffeeCaffeine
2.6) Avoid Snacks at BedtimeCommon in cold weather countriesIncreases acid levels
Increases pain, which attacks atnight
2.7) Provide Iron for HealingHeme is iron
Heme + globulin --- HemoglobinHemoglobin carries oxygenIncreased oxygenation coupledwith increased blood flow andvenous return enhances healingIron is present in the followingfoods:
o Green leafy vegetableso Liver o Egg yolk
3. Observe for Complications
3.1) HemorrhageCoffee ground emesis
o Old bloodMelena
o Black tarry stoolo Sign of Upper GI bleeding
Hematamesiso Vomiting of blood
Hematocheziao Fresh blood in the stoolo Sign of Lower GI bleeding
Interjected Concepts!!!Spicy foods do not causehemorrhoids
o Rather, it makeshemorrhoids more severe
o Spicy foods trigger moredilation
Pregnancy and increasedpressure causes hemorrhoids
3.2) Perforation
3.3) Pyloric Obstruction
Implementation:
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What to do during Ulcer?
1. Medications
1.1) Antacids
BasicGiven one (1) hour after mealMg(OH) 2
o Milk of magnesiao Side effect is diarrhea
Al(OH) 2o Amphojelo Side effect is constipationo Absorbs water and
phosphateNaHCO 3
CaCO 3 MgAl(OH)o Maaloxo Simecoo Mylantao No diarrheao No constipation
1.2) Sucralfate and CarafateGiven one (1) hour antecebumProtective agent
o Coats the lining of thestomach
Again, give before eating
1.3) Anti-cholinergicAnti-parasympathetic drugsAtropine Sulfate
o Anti-diarrhealTo decrease themotility of the bowel(diarrhea)
o Anti-emeticTo decrease GImotility
o Increased heart rateo Indicated for Bradycardiao A chronotropic drug
1.4) Histamine
H2-receptor Antagonisto Taken per orem
Cimetidineo Tagamet
Ranitidineo
Zantac Coats chloride toprevent theformation of hydrochloric acid
2. Reduce Stressful SituationsNon-specific
3. Promote Rest
4. Provide Health TeachingsDietary therapy
5. Provide Dietary Control
6. Observe for Complications
7. Provide Moral Support
Interjected Concepts!!! Inotropic Drugs
o Increases cardiaccontractility
o Examples are:DopamineDobutamineDigoxin
Beta-Adrenergic Blockerso Decreases heart rate in
tachycardic patients
Surgery for Ulcer
VagotomyCutting of the vagus nerve(pneumogastric nerve)Innervates the upper region of the respiratory tract (increasedintracranial pressure during GIsuctioning
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Indicated for hypersecretion of acid
o Do vagotomyo Complication is diarrheao No more acids are present
for digestion2. Gastroenterostomy or Pyloroplasty
Decreases stimulation of GastrinFormation in the antral regionStomach and Small intestine areanastomosedShortening of the pylorusReinforcement of the pylorusBariatic surgery
o Indicated for obese
patients3. Partial Gastrectomy
Complication is hemorrhageIncreased pressure leads tohematamesisTwo types:
o Billroth Io Billroth II
3.1) Billroth I or Gastroduodenostomy
Removal of the pylorusHigh abdominal incision results topulmonary complicationsAnastomosis is done
3.2) Billroth II or GastrojejunostomyTwo structures are removed:
o Pyloruso Duodenum
Anastomosis is done
Important Concept!-plasty means repair or reinforcement
Post-operative Complications
1. Hypovolemic ShockDecrease in blood volume
2. Hematamesis
3. Pulmonary ComplicationsAtelectasiso First complicationo Lung collapseo Loss of function of the
lungso Anesthesia may cause
atelectasisBronchitis
o Infectiono This may occur around
three (3) days post-operativelyPneumonia
4. Fluid and Electrolyte Imbalance
5. Dumping Syndrome Recline patient or place patient inrecumbent position after meals
6. Hemorrhage
7. DiarrheaDue to vagotomy
8. Vitamin B 12 deficiencyDue to malabsorption syndromeVitamin B 12 is cyanocobalaminThis is for RBC maturationThere is no absorption of VitaminB12
o A GIT problemo An intrinsic problem
9. AnemiaAbsence of Vitamin B 12 results topernicious anemiaDecreased levels of RBC if thereis a GIT problem with intrinsicfactor
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Interjected Concepts!If GIT is functional and VitaminB12 is lacking
o Extrinsic Problemo
Megaloblastic Anemiao Vitamin B 12 and Vitamin B 9needed for maturation
Decrease in Irono Iron deficiency anemia
Decrease in foodo Nutritional anemiao An Extrinsic problem
Yellow Bone Marrowo Indirect Red Blood Cell
formation
Red Bone Marrowo Direct Red Blood Cellformation
Bone Marrow Extractiono Pelvic Bone
This has lesscomplications
o Sternum and ScapulaHas pulmonarycomplications
In Bone Marrow Extractiono Consider the following
bones in the followingorder:
PelvisPosterior
Iliac CrestPosition
patient ataffected sidefor preventionof bleeding
ApplypressureSternumScapula
Flat bones contain Red BoneMarrowIschial Tuberosity
o inuupuan
o nangingitim Ischial Spine
o Reference for fetaldescent
If Bone Marrow does not produce
RBCo The resulting RBCdeficiency is called
APLASTIC ANEMIAIn SICKLE CELL ANEMIA
o RBCs have decreasedoxygen-carrying capacity
In whatever type of anemia, ablood loss of five-hundredmilliliters (500 ml) and aboveREQUIRES BLOOD
TRANSFUSIONBLOOD TYPING AND CROSSMATCHING
Blood Type Oo The universal DONOR
Blood Type ABo The universal RECIPIENT
Consider the following figure:In cross matching, arrowindicates which blood type couldbe a donor to which blood typeNo counter flow is observed
o Meaning blood type,where arrow points,cannot be a donor to theblood type where thearrow begins
No crossing of vertical or horizontal lines is allowed (exceptwhen there is an arrow indicatingsource can donate blood towhere arrow is pointing)
o Meaning, that blood typesconnected by lines withoutarrows cannot donate toeach other.
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Type O
Type A Type B
Type AB
Therefore, from the figure aboveType O individuals could
o Donate blood to type Aindividuals
o Donate blood to type Bindividuals
o
Donate blood to type ABindividualsType A individuals could
o Donate blood to type ABindividuals
Type B individuals couldo Donate blood to type AB
individualsType O individuals could notreceive blood from any of theother blood groupsType A individuals cannot receiveblood from type B individualsType B individuals cannot receiveblood from type A individualsAll blood types can receive bloodfrom other individuals with thesame blood type
ERYTHROBLASTOSIS FETALIS
Important Concepts!!!Blood type is in the Red BloodCellThe liver and the spleen of thechild is responsible for the RBCof the childTypes of Placental Separation
o Duncan sideDull sideSide is tearing off Bloody separationRevealed placental
expulsionDurkyo Schultz side
Center is tearing off Shiny sideConcealedplacental expulsion
When placenta separates either:o At birtho During birtho Abortiono
Still BirthBlood from theinfant may flow tothe mother
Direction of flow upon placentalbreakage is from the newborn tothe mother
o If the mother is type AB(universal acceptor) therein no incompatibility
o If the mother is type O(universal donor) there ishigh-risk for incompatibility
Therefore, always check if theplacenta is intact
o The placental breakageduring separation causesincompatibility
If the mother is Rh- and thenewborn is Rh+, upon placentalseparation there is flow of fetalblood to the mother.
o The mother will thendevelop antibodies for Rh+
o This situation would giverise to problems with thesubsequent fetuses whichare also Rh+
Second child or fetus with Rh+
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blood will haveincreased risk for fatality due tohemolysis asmother has
antibodies for Rh+Third child or fetuswith Rh+ blood willhave even greater risk for fatality, alsodue to hemolysis,again, as mother has antibodies for Rh+
Preventive measure would be theadministration of RHOGAM within
seventy-two (72) hours after delivery or abortion or still birth.If antibody is inactive, thisindicates that RHOGAM ISEFFECTIVEIf antibody is active, and it causeshemolysis and fatality to thesecond or third child, thenRHOGAM IS INEFFECTIVE
CHRONS DISEASE Regional Enteritis
VolvolusIntertwining of the bowelsCommon in pediatric patients
IntussusceptionTelescoping of the bowelPart or segment of the intestinegoes into another segment
ColitisInflammation of the LargeIntestine
Ulcerative ColitisOccurs at right side or at
ASCENDING COLONClassical sign is DIARRHEA
Reabsorption of water is a normalfunction of the large intestine
o If the large intestine isinflammed, it cannotreabsorb water
o
This gives rise to diarrheaMilk cannot be administered toUlcerative Colitis patient
o There is lactoseintolerance
o LACTAMASE cannot beproduced (lactobacilli)
o If the large intestine isimpaired, lactamasecannot be synthesized
DiverticulumOut-pouching of the membrane inthe sigmoid area
DiverticulosisExists when multiple diverticulaare present without inflammationor symptoms
DiverticulitisOccurs when food and bacteriaare retained in a diverticulumThis produces infection andinflammation that can impededrainage and lead to perforationor abscess formationWith left side painAt side of sigmoid
HemorrhoidsProtrusion of rectal vein at therectum
VaricosityA ballooning of the vein
AneurysmA ballooning of the artery
INTESTINAL HERNIA
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1. Inguinal Hernia (bituka) Part of intestine goes to the malescrotum
2. Femoral HerniaHerniation along the femoral
head3. Umbilical Hernia
4. Incisional HerniaAfter appendectomyEvisceration is an example of incisional hernia
APPENDICITISCharacterized by the presence of pain at the right lower region
Rebound Tenderness is presentPalpate at the left side McBurneys Point McBurneys Sign
o To rule out appendicitiso Do Rovsings Test o Pinch at the left side of the
abdomeno There will be pain at the
right side of the abdomeno Presence of pain indicates
positive for McBurneyssign.
Analgesics are not giveno They mask the symptoms
of pain
ACCESSORY ORGANS OF THEGASTROINTESTINAL TRACT
LIVER CIRRHOSIS DegenerativeNecroticHepatocytes are no longer functional
Important Interjected ConceptsViral infections are self-limitingThere are five (5) types of hepatitis:
o Hepatitis AInfectious hepatitisOral Fecal route
o Hepatitis BSerum hepatitis
BloodDeath throughhepatitis B isquicker than deaththrough AIDSDeath throughhepatitis B may onlybe months away
o Hepatitis Co Hepatitis Do Hepatitis E
Liver Cirrhosis (continued)A chronic progressivedegenerative disease of he liver with structural changesScarring is the biological or structural change
Types of Liver Cirrhosis
1. Laennecs Cirrhosis This is the original liver cirrhosisPortal, nutritional or alcoholiccirrhosis
2. Post-necrotic CirrhosisPost-hepatitis or toxin inducedhepatitisViruses excrete toxins; after thedeath of liver cells
3. Biliary CirrhosisRelated to prolonged biliaryobstructive jaundice due toinfectionJaundice is yellowishdiscoloration due to bilirubinMay involve any of the following:
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o Bile ducto Biliary duct and biliary
stoneso Cholelithiasiso Choledocholithiasis
4. Cardiac CirrhosisRelated to long-standingCongestive Heart FailureRight-Sided CHFWith Primary and SecondaryHypertension due to arterialsystem constraint
Scar Structural change
Decreased blood flow to the liver Most blood stays in the portalveinPortal hypertension occursPortal veins are dilatedThis is localizedVasopressin or Pitressin
o Used to constrict bloodvessels
o If vessels are notreinforced, portal vein willexplode
Backflow of pressure is towardthe Gastrointestinal Tract / GIsyndrome composed of:
o Esophageal Variceso Hemorrhoids
Caput Medusae
Pathophysiology of Liver Cirrhosis
Toxic Effect on Liver
Common causes are alcohol, drugs
or nutrition; with incidence in men
Liver Cells are Damaged
Tissue Scarring and Fibrosis Distortion of Normal Liver Structure
Interferes with blood flow through theliver Portal Hypertension(Enlargement of umbilical, esophageal,and rectal veins resulting to liver dysfunction) Insufficient removal of metabolic wastes Fluid retention in peritoneal cavity
Hepatic encephalopathy Coma
Types of JaundicePhysiologic TypePathologic Type
Physiologic JaundiceImmature body part or organOccurs in infants onlyImmature liver of the infant
o Lacks enzymeso Glucoronyl Transferase is
lackingo Conjugation of bilirubin is
not facilitatedJaundice occurs after twenty-four hoursYellowish skin is exhibited withinseven (7) to ten (10) daysPatient is most yellowish ataround third (3 rd) to fourth (4 th)dayAlways get the middle!!!
Pathologic JaundiceJaundice within twenty-four (24)hours
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Erythroblastosis fetalis
Interjected Concepts!!!Liver
o The biochemist of the
bodyo The biochemist of all thebody functions
o Filters toxinsIf this is notfacilitated, thetoxins will stay inthe bloodToxins will get tothe brain and wouldlead to
encephalopathy,hepatic coma andbrain comaAlters proteinsynthesisDecreased levels of protein in bloodresults todecreased colloidosmotic pressureThis would lead toEdema or ascites
o Cirrhosis is a term used for the liver only
Infarction is a term used for theheart and the brainCerebral Infarction
o Brain infarctionMyocardial Infarction
o Heart infarction
Adult JaundiceIt is always PATHOLOGIC
Types of Adult Jaundice
1. Hepatocellular JaundiceHepatocytes die
2. Hemolytic Jaundice
RBCs are hemolyzedIncreased bilirubin escapes
3. Obstructive JaundiceBiliary problemsGall stones
Important Concepts!!!Increased bilirubin in blood
o UnconjugatedIndirect bilirubinAlso known as b 1 Normal value istwice that of b 2 Normal value is 0.8mg / dl
o Conjugated
Direct bilirubinAlso known as b 2 Normal value isabout half of b 1 Normal value is 0.4mg / dl
o Total BilirubinRepresents thecumulative value of Unconjugated (b 1)and Conjugated (b 2)bilirubinNormal value is 1.2mg / dlThis is a gaugeused to determine if there is jaundiceAt birth, if TotalBilirubin level is 2.0,then there isphysiologic jaundice
Signs and Symptoms of Liver Cirrhosis
1. Anorexia, dyspepsia, indigestion,change in bowel habits, flatulence,constipation, fatigue
Anorexia
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o Gives rise to weight lossand body weakness
Dyspepsiao Inability of the stomach to
produce pepsin for
digestiono The absence of pepsingives rise to indigestion
Flatulenceo Kabag leads to flatus
formationo Due to increased pressure
(blood flows back to theGIT)
2. Hepatomegaly, Splenomegaly and
JaundiceIncreased PT or prothrombin timeNewborn
o Prone to bleed at umbilicalcord
o Immature liver cannotproduce prothrombin
o Therefore, give Vitamin Ko Administer via I.M. routeo Site is at vastus lateralis
Never inject at thebuttocksSciatic nerve maybe damaged andthis will causeirreversibleparalysis
o Allow the child to walk firstbefore administeringinjections at the buttocks
3. Edema of the Extremities, Ascites,Hematamesis
4. Caput medusaeProminent abdominal wall veinsBig ones
5. Anemia, Esophageal varices,Emaciation
Anemiao Pernicious anemiao GI is affected
Esophageal Variceso Use Sengstaken-
Blakemore tubeEmaciationo Excessive or severe
weight loss or cachexia
6. Altered Hair Distribution, Spider nevi, Angiomas
Altered Hair Distributiono Decreased keratin
synthesis by the liver o This affects the skin, the
hair and the nailso Deceased collagensynthesis by the liver affects the structure of theinternal organs
Deficiency incollagen leads toSystemic LupusErythematosus
Important Interjected Concepts!!!In order for adults to fart, placethem in NICHES POSITION
o If not, use a rectal tubeand a basin of water
In infants, COLIC is equivalent toflatulenceProne position is best
Hagod sa likod nagburp pataas ThoracentesisIf air is to be removed, inserttrocar at the level of the second(2 nd ) or third (3 rd) intercostalspaceIf fluid (i.e. water) is to beremoved, insert trocar at the levelof the sixth (6 th) to eighth (8 th)intercostal space
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Implementation in Liver Cirrhosis
1. Provide adequate nutritional intakeHigh Calorie diet
o 3,000 calories per day
Carbohydrateso 300 400 grams per dayProteins
o If pre-coma70 100 grams per day
o If comatoseTotally eliminateproteins from thediet
Fatso
100 150 grams per dayLow sodium dieto 0.5 to 1.0 gram per day
2. Bed rest
3. Maintain clean and dry skin
4. Assess level of pain and preventbleeding
5. Maintain Fluid Balance1.0 to 1.5 liters per day
6. Monitor for signs of mentaldeterioration
Allow the client to demonstratesignature dailyAvoid tranquilizers and sedatives
o These drugs mask thesigns of mentaldeterioration
o Cardiovascular andneuromuscular drugs areall hepatotoxic
o Liver cannot detoxify thesedrugs
Administer lactulose if orderedo Duphalac is an ammonia
detoxicant
o Also a laxative for easypassage of stools
Stool softeners soften the stool
Important Interjected Concepts!!!
Mesenteryo Membrane that suspendsan organ
Omentumo Organ to organ
suspensionCollagen
o Internal protein or proteinof internal organs
Desquamationo tuklap ang balat
Infant with Desquamationo Due to environmentaladaptation to externalenvironment
Important Concepts!!!Liver Flap
o Flapping Tremorso Asterixis
Sign of impendinghepatic comaDue toaccumulation of ammonia in thebloodstream
Hyperthyroid Person has FINETREMORSProtein is metabolized toammoniaAmmonia is converted by theliver to ureaUrea is removed by the kidneysTherefore, the liver and thekidney are both blood filtersRenal Failure
o Characterized by:o Increased levels of Blood
Urea Nitrogeno Decreased levels of Blood
Urea Nitrogen Clearance
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o Decreased protein or controlled protein diet
o Decreased intake of sodium due to thepresence of edema
Liver Cirrhosiso Characterized by:o Controlled protein intakeo Controlled fat intake (as
bile is not produced)o Decreased intake of
sodium due to thepresence of edema
Important Concepts in theManagement of Renal Failure and
Liver CirrhosisIn Renal Failureo Bed rest is neededo Skin is Dryo Skin is whitish due to the
presence of UREMICFROST
o Therefore, apply vinegar In Liver Cirrhosis
o Bed rest is neededo Skin is dry due to edema
and dehydrationo Urticaria is presento Rashes are present
Implementation in Liver Cirrhosis(continued. . .)
7. Assist client to comply withprescribed bed therapy
8. Maintain normal respiratoryfunction
9. Encourage patient to expressfeelings
Sengstaken-Blakemore TubeThis tube is inserted at the nose
It has three (3) lumenso First lumen
For nasogastric suctionSuction to preventvomiting
o
Second lumenFor inflation of esophageal balloon
o Third lumenTo inflate thegastric balloon
Complicationo Congestion in the lungo Keep scissors readyo If respiratory depression or
arrest occurs:
Cut the tubeDeflate the balloonRemove theSengstaken-Blakemore Tube
Interjected Concepts!!!Striae Gravidarum
o In primigravidaThis is pinkish
o In multigravidaThis is silvery white
Increased pigmentation is due toestrogen
o This intensifies the activityof Melanin
For neurologic problem and heartproblem patients, give stoolsofteners and not laxatives
Medications used in the Managementof Liver CirrhosisNeomycin
Anti-biotic that reduces colonicbacteriaIt decreases the number of microorganisms thriving inammonia
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If normal flora in the colonbecomes violent, there isinfection
Pitressin or VasopressinDecreases portal blood pressure
This constricts the dilated veinsLactulose
Cephulaco For ammonia
detoxificationo As a laxative
FurosemideLasix
o A diuretic
SpironolactoneAldactoneDiureticAldosterone antagonistPotassium sparingRetains potassium but notsodium
Vitamin B 9 Folic AcidFor maturation of RBCs topromote healingIncreased RBC levels leads toincreased oxygenationIncreased oxygenation facilitateshealingVitamin B 12 is also for maturationof RBCs
CHOLELITHIASISStones in the gall bladder
CHOLECYSTITISInflammation of the gall bladder Not always due to the presenceof stones
Renal CalculiTwo (2) Types:
Acidic CalculiBasic Calculi
Important Concepts!!!Gall Stones
o
Are alkali onlyThe following are all basic:o Bileo Bile pigmento Cholesterolo Calcium
In Cholelithiasis and cholecystitis,there is pain at the UPPERRIGHT QUADRANTIn Appendicitis, there is pain atthe RIGHT ILIAC or the RIGHT
LOWER QUADRANT Murphys Signo For Cholelithiasis with
cholecystitis McBurneys Sign
o For Appendicitis
Important Concepts in Cholelithiasisand Cholecystitis
Fatty foods are not givenSteatorrhea
o Foul-smelling stoolo Fatty stoolo Frothy stool
Frequent Stool (diarrhea)
Important Interjected Concepts!!!In asthma
o Avoid antitussiveso Avoid anti-biotics
Important Concepts!!!Acholic Stool
o Clay-colored stoolLiver Cirrhosis patients are withnasogastric tube (NGT)For Gall Bladder with stones,medical management mayinvolve LITHOTRIPSY
o Percutaneous Lithotripsy
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o Extracorporeal ShockwaveLithotripsy
Cholelithotomyo Removal of stones in the
gall bladder
Cholecystectomyo Removal of the gallbladder
o T-tube is used withJackson-Pratt (JP) Drain
o Initially, there will becopious drainage from theJP drain
This is because thebile duct isinflammed
Failure to drainwould result tocongestion
o Later, if there is lessdrainage,
Bile duct is nolonger inflammedBile goes to theduodenum
PANCREATITISThe head of the pancreas islocated posterior to the liver The body and tail of the pancreasis locate near the stomach at theleft upper quadrantTherefore, pain in pancreatitis issituated at the left upper quadrant
Inflammation of the Pancreas is dueto the following:
1. Fat necrosisIncrease in pancreatic amylaseand pancreatic lipase gives riseto lipolysisThis can trigger autodigestion of the pancreas
Pancreatic Lipase levels is amuch better determinant of thepresence of pancreatitis
2. Pancreatic Edema
3. Acute Hemorrhagic PancreatitisDeadly
Important Concepts in PancreatitisDemerol
o Drug of choice in thetreatment of pancreatitis
Non-narcotico Does not cause
drowsinesso
Blocks prostaglandinsynthesisMorphine
o Can constrict the sphincter of Oddi
Interjected Concepts!!!In checking for the proper placement of the Nasogastric Tube or NGT, thefollowing could be done:
X-rayo Most effective
Aspirateo Second most effective way
is to check the pHAuscultate
o This is the most commonmethod of checking
o Gurgling sound at theabdominal region indicatesproper placement
Dipping the end of the tube inwater and noting for bubbles
o This indicates that theNGT is displaced and is inthe lungs
o Not an advisable thing todo
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Damage to heart muscle isindicated by increased levels of CK-MB and CK-MM
o Troponin T and Troponin Iare more reliable
indicators of cardiac tissuedamage
Peculiarity of PancreatitisHematomaEcchymosis around the navel
o Also known as CullensSign
Petechiae
Interjected Concept!
Cullens Sign is also present inECTOPIC PREGNANCY
Important Additional Concepts inPancreatitis
Gray Turners Spot o Ecchymosis at the flanko Indicative of Hemorrhagic
PancreatitisIncrease in Trypsin levels
o Pancreatic enzyme thatpromotes sleep
o Patient is not awakened bythe pain he feels butmoaning is present
o Defecation and urination ispresent in the late stagesof pancreatitis
MUSCULOSKELETAL SYSTEMMuscle is composed of three (3) types:
Skeletal MuscleCardiac MuscleSmooth Muscle
Types of Skeleton:Axial Skeleton
o Skullo Ribso Spinal Cord
Appendicular Skeletono Clavicleo Scapulao Limbs
Joints Also called arthrosesArticulating joints
Three (3) Types of Joints based onMotion
1. SynarthrosisFibrous jointCreates no motionNo movement
2. AmphiarthrosisCartilaginous jointCreates small amount of motion
3. DiarthrosisSynovial jointMaximum amount of motionCreates large amount of motion
Muscle has two (2) types of proteinActinMyosin
Important Concepts!!!Calcium is needed in muscular contractionAcetylcholine is aneurotransmitter needed inmuscle contractionMyasthenia Gravis is anautoimmune disorder wherein thebody destroys acetylcholinereceptor sites
Skeletal Muscle
1. Synergist MusclesGroup of muscles
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When they contract, they stabilizethe areaExamples are:
o Pectoraliso Intercostals
Antagonist MusclesWhen one muscle contracts, theother relaxesFor reciprocity of motion
Prime Mover When they contract, maximumamount of motion is created
Range of Motion
360 degreeso Shoulder Joint180 degrees
o Cervical Joint
FRACTURESBreak in the continuity of thebone
o Traumao Accidento Crashingo Twistingo Compression
Pathologico Potts Disease
Tuberculosis of thespineGibbus formation isthe pathognomonicsign of PottsDisease
o Spina BifidaNeural Tube Defect
o CysticaPresence of a bulge
o MeningocoelMeninges protrudeCerebrospinal Fluid
o MyelomeningocoelSpinal cord lesions
Herniated NucleusPolposus
o OccultaPresence of adepression or a
dimplingo Lumbar SpineBears most of thebody weight
o Lumbar Comao Slipped disko Lordosis
Waddling walko Not a flirting walk
Types of Fractures
Closed Fractureo Did not penetrate the skino Immediate care
Do not moveOpen Fracture
o Broken portion of the boneprotrudes through the skin
Fracture PatternsTransverseLongitudinalObliqueSpiralDepressedComminutedImpactedStellate
o Fracture radiates from apoint
Important Concepts!!In comminuted or crushedfractures, bone debridement isdoneMandibular Wiring
o Use wire cutter o Suction
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Anticipate vomitingto preventaspiration
Interjected Concept!
Types of Fetal LieLongitudinalTransverseOblique
Important Concepts regardingFractures!!!
First Aido At the site of the incident,
IMMOBILIZETreatment at the Hospital
o
Bone Reductiono Re-alignment of the bone
Treatment of Fractures
1. Reduction or Re-alignmentFor Closed Reduction
o Castingo Splintingo Sling
For Open Reductiono Surgical plates, pins, rods,
wireso Uses plates (metal or
stainless steel)o Uses screws and nailso Uses pins intramedullary
pins
2. Immobilization
3. Restoration of Function
Important Concepts!!!Casting
o Utilizes plaster of ParisScoliosis
o Utilizes Harrington RodWires
o Used for flat bones (i.e.mandible)
TRACTIONTwo forces are applied in
opposite directionPurposes of Traction
To immobilize the affected partBone re-alignmentRegain normal strengthReduce muscle sprain
Types of TractionMechanical Traction
o With screw and pino
With invasiono SteinmanUsing pins
o Kirchner Using wires
o Crutch-FieldTongs for cervicalaffectations
Balanced Suspension Tractiono Thomas Splint with
Pearsons Attachment Skin Traction
o No invasiono Pad areas which are
pressuredo Russell
For fractured femur Pulls the knees andthe foot
o CervicalCervical spasm
o PelvicRelieves low backpain
Important Concepts!!!Bryant Traction
For children
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Signs and Symptoms of FractureSwellingHeatImpaired functionRedness
PainCrepituso Grating sound
Deformityo Contracture
Shortening of boneDiscoloration
o Bluish and reddishindicative of hematoma
BleedingTenderness
o
Pain aggravated by touchSTAGES OF WOUND HEALINGImportant Concepts!!!
In pediatric patientso Wound healing is faster o Occurs in about three (3)
to four (4) weekso Due to quicker Basal
Metabolic RateIn adults
o Wound healing occurs inabout eight (8) to twelve(12) weeks
1. Hematoma FormationOccurs after twenty-four (24)hours
2. Cellular ProliferationProduction of OSTEOIDSBridging of blood vessels
3. Callous FormationBridging large mass of differentiated tissues
3. OssificationFractured ends meet together Three lipids in cell membrane:
o Glycolipids
o Phospholipidso Cholesterol
4. RemodellingCompact-bone formation
Complications of FracturesPulmonary EmbolismFat Embolism
o Common emboluso From the marrowo Pure cholesterol
Gangreneo Blood vessel problemo Massive avascularity
Tetanuso
Burnso Fractureso Causative agent is
Clostridium tetanio Signs and Symptoms
include:Risus sardonicusLockjawOphistotonus
Seizure witharching of
the backVertigoEnvironment ismoving, swirling
Dizzinesso Preventive measure
Tetanus Toxoidvaccine
MUSCULOSKELETAL DISORDERS
1. OsteomyelitisInflammation or infection of thebone marrowAffects weight-bearing bonesCausative agent isStaphylococcus aureus
2. Supracondylar Fracture
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Elbow affectation
3. Congenital Club FootTalipes EquinovarusUse Dennis Browne shoe
Cast4. Hip Dislocation
Unilateral or BilateralIf unrelieved, TOTAL HIPREPLACEMENT usingprosthesis is doneKept abducted
o Use abductor splint or pillow between the legs
o Reinforce with
TROCHANTER ROLL or blanket
5. Coxa PlanaAseptic necrosis of the femoralheadLegg-Calves PerthesNo infectionsTen times more common in whitechildren than in blacks
6. ScoliosisGait is changedSpinal Column deformityLateral CurvatureBased on Origin:
o StructuralLigaments holdingthe spine haveproblemsCan be relieved byexercise
o FunctionalWork
Managemento Bottleblowing for scoliosiso Swimming is best for
scoliosiso Milwaukee brace
Pelvis to chin cup
Worn for twenty-three (23) hours ina day and one (1)free hour for inspections
Scoliotic to the lefto Right hip is upo Left shoulder is up
7. Potts Disease Tuberculosis of the Spine
8. ArthritisRheumatoid Arthritis
o Systemic, bilateral,
symmetricalOsteoarthritiso Weight-bearing jointso Unilateral
Gouty Arthritiso Affects great toeo Uric acido Monosodium urate crystalso Tophi
9. Slipped DiscLaminectomy is the surgery of choiceHerniated Nucleus Polposus
10. Intertrochanteric FractureGreater to lesser or letter togreater trochanteric break
Interjected Concepts!!!Combination disorders:
o Scoliokyphosiso Kyphoscoliosiso Lordokyphosiso Kypholordosis
Sickle Cell Anemiao Blacks are mostly the ones
affected
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CARE OF CASTS1. If not yet dry, use the palm in movingto avoid deforming its contour 2. If dry, also use the palm in moving for safety
Cast should not be too tightThis may impede circulationFingers and toes should be ableto wiggleCast should not be too loose
3. Observe for cyanosis4. Open fractures
Use window type of cast
5. Observe odor
Foul odor may indicate infectionImportant Concept!!!
When there is itchiness, blow air under the cast to eliminatemoisture
ASSISTIVE DEVICES
1. CanePrinciple in use:
o Use on the HAND ONTHE UNAFFECTED SIDE
2. Walker If patient is a child
o Rota Walker o andador o No sense of direction
If patient is an adulto Four-legged walker
3. Crutch (saklay) Principle in use:
o Weight of body borne bythe ARM not by the axilla
o Therefore, it should beb t t (2) i h f
to the axilla there shouldbe about two (2) inches)
o Tip of crutch from foot isabout six (6) to eight (8)inches (to side)
Four-Point Gaito Two (2) crutches usedo Two (2) legs usedo First to move:
Crutch before