MEDICAL-SURGICAL NURSINGNERVOUS SYSTEMOverview of structures and functions:Central Nervous System11 Brain12 Spinal CordPeripheral Nervous System13 Cranial Nerves14 Spinal NervesAutonomic Nervous System15 Sympathetic nervous system16 Parasympathetic nervous system

AUTONOMIC NERVOUS SYSTEM

Sympathetic Nervous System(ADRENERGIC)- Involved in fight or aggression response.- Release of Norepinephrine (cathecolamines)from adrenal glands and causesvasoconstriction.- Increase all bodily activity except GITEFFECTS OF SNS- Dilation of pupils(mydriasis) in order 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 skeletalmuscles.- SNSI. Adrenergic Agents- Give Epinephrine.Signs and Symptoms:- SNSContraindication:- Contraindicated to patients suffering from COPD(Broncholitis, Bronchoectasis, Emphysema, Asthma).II. Beta-adrenergic Blocking Agents- Also called Beta-blockers.- All ending with “lol”- Propranolol, Atenelol, Metoprolol.Effects of Beta-blockersB – roncho spasmE – licits a decrease in myocardial contraction.T – reats hypertension.A – V conduction slows down.q1Should be given to patients with Angina Pectoris,Myocardial Infarction, Hypertension.ANTI- HYPERTENSIVE AGENTS1. Beta-blockers – “lol”2. Ace Inhibitors – Angiotensin, “pril” (Captopril,Enalapril)3. Calcium Antagonist – Nifedipine (Calcibloc)q1 In chronic cases of arrhythmia giveLidocaine(Xylocaine)

Parasympathetic Nervous System(CHOLINERGIC, VAGAL, SYMPATHOLYTIC)- Involved in fight or withdrawal response.- Release of Acetylcholine.- Decreases all bodily activities except GIT.EFFECTS OF PNS- Constriction of pupils (meiosis).- Increase salivation.- Decrease BP and Heart Rate.- Bronchoconstriction, Decrease RR.- Diarrhea- Urinary frequency.I. Cholinergic Agents- Mestinon, Neostigmine.Side Effects- PNSII. Anti-cholinergic Agents- To counter cholinergic agents.- Atropine SulfateSide Effects- SNS

CENTRAL NERVOUS SYSTEM

17 Brain and Spinal Cord.I. CELLSA. NEURONS18 Basic cells for nerve impulse and conduction.PROPERTIESExcitability – ability of neuron to be affected by changes in external environment.Conductivity – ability of neuron to transmit a wave of excitation from one cell to another.Permanent Cell – once destroyed not capable of regeneration.TYPES OF CELLS BASED ON REGENERATIVE CAPACITY1. Labile19 Capable of regeneration.20 Epidermal cells, GIT cells, GUT cells, cells of lungs.2. Stable21 Capable of regeneration with limited time, survival period.22 Kidney cells, Liver cells, Salivary cells, pancreas.3. Permanent23 Not capable of regeneration.24 Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.B. NEUROGLIA25 Support and protection of neurons.TYPES1. Astrocytes – maintains blood brain barrier semi-permeable.26 Majority of brain tumors (90%) arises from called astrocytoma.2. Oligodendria3. Microglia4. Epindymal

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER1. Ammonia27 Cerebral toxin28 Hepatic Encephalopathy (Liver Cirrhosis)29 Ascites30 Esophageal VaricesEarly Signs of Hepatic Encephalopathy31 asterixis (flapping hand tremors).Late Signs of Hepatic Encephalopathy32 Headache33 Dizziness34 Confusion35 Fetor hepaticus (ammonia like breath)36 Decrease LOC

PATHOGNOMONIC SIGNS1. PTB – low-grade afternoon fever.2. PNEUMONIA – rusty sputum.3. ASTHMA – wheezing on expiration.4. EMPHYSEMA – barrel chest.5. KAWASAKI SYNDROME – strawberry tongue.6. PERNICIOUS ANEMIA – red beefy tongue.7. DOWN SYNDROME – protruding tongue.8. CHOLERA – rice watery stool.9. MALARIA – stepladder like fever with chills.10. TYPHOID – rose spots in abdomen.11. DIPTHERIA – pseudo membrane formation12. MEASLES – koplik’s spots.13. SLE – butterfly rashes.14. LIVER CIRRHOSIS – spider like varices.15. LEPROSY – lioning face.16. BULIMIA – chipmunk face.17. APPENDICITIS – rebound tenderness.18. DENGUE – petechiae or (+) Herman’s sign.19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain).20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm).21. TETANUS – risus sardonicus.22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots.23. PYLORIC STENOSIS – olive like mass.24. PDA – machine like murmur.25. ADDISON’S DISEASE – bronze like skin pigmentation.26. CUSHING’S SYNDROME – moon face appearance and buffalo hump.27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus.28. INTUSSUSCEPTION – sausage shaped mass2. Carbon Monoxide and Lead Poisoning37 Can lead to Parkinson’s Disease.38 Epilepsy39 Treat with ANTIDOTE: Calcium EDTA.3. Type 1 DM (IDDM)

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40 Causes diabetic ketoacidosis.41 And increases breakdown of fats.42 And free fatty acids43 Resulting to cholesterol and (+) to Ketones (CNS depressant).44 Resulting to acetone breath odor/fruity odor.45 KUSSMAUL’S respiration, a rapid shallow respiration.46 Which may lead to diabetic coma.4. Hepatitis47 Signs of jaundice (icteric sclerae).48 Caused by bilirubin (yellow pigment)5. Bilirubin49 Increase bilirubin in brain (Kernicterus).50 Causing irreversible brain damage.

DEMYELINATING DISORDERS1. ALZHEIMER’S DISEASE51 Atrophy of brain tissues.Sign and Symptoms4 A’s of Alzheimera. Amnesia – loss of memory.b. Agnosia – no recognition of inanimate objects.c. Apraxia – no recognition of objects function.d. Aphasia – no speech (nodding).*Expressive aphasia52 “motor speech center”53 Broca’s Aphasia*Receptive aphasia54 inability to understand spoken words.55 Wernicke’s Aphasia56 General Knowing Gnostic Area or General Interpretative Area.DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX.

2. MULTIPLE SCLEROSIS57 Chronic intermittent disorder of CNS characterized by white patches of demyelination inbrain and spinal cord.58 Characterized by remission and exacerbation.59 Women ages 15-35 are prone60 Unknown Cause61 Slow growing virus62 Autoimmune disorders63 Pernicious anemia64 Myasthenia gravis65 Lupus66 Hypothyroidism67 GBSIg G – only antibody that pass placental circulation causing passive immunity.- short term protection.- Immediate action.Ig A – present in all bodily secretions (tears, saliva, colostrums).Ig M – acute in inflammation.Ig E – for allergic reaction.Ig D – for chronic inflammation.* Give palliative or supportive care.Signs and Symptoms1. Visual disturbances68 blurring of vision (primary)69 diplopia (double vision)70 scotomas (blind spots)2. Impaired sensation71 to touch, pain, pressure, heat and cold.72 tingling sensation73 paresthesia74 numbness3. Mood swings75 euphoria (sense of well being)4. Impaired motor function76 weakness77 spasticity78 paralysis5. Impaired cerebral function79 scanning speechTRIAD SIGNS OF MSAtaxia(Unsteady gait, (+) Romberg’s test)Intentional tremors Nystagmus6. Urinary retention/incontinence7. Constipation8. Decrease sexual capacityDIAGNOSTIC PROCEDURE80 CSF analysis (increase in IgG and Protein).81 MRI (reveals site and extent of demyelination).

82 (+) Lhermitte’s sign a continuous and increase contraction of spinal column.

NURSING MANAGEMENT1. Administer medications as ordereda. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduceedema at siteof demyelination to prevent paralysis.b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants.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. Increase fluid intake and increase fiber to prevent constipation.5. Catheterization to prevent retention.a. Diureticsb. Bethanicol Chloride (Urecholine)Nursing Management83 Only given subcutaneous.84 Monitor side effects bronchospasm and wheezing.85 Monitor breath sounds 1 hour after subcutaneous administration.c. For Urinary IncontinenceAnti spasmodic agenta. Prophantheline Bromide (Promanthene)86 Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C andorange.87 To acidify urine and prevent bacterial multiplication.

COMMON CAUSE OF UTIFemale88 short urethra (3-5 cm, 1-1 . inches)89 poor perineal hygiene90 vaginal environment is moistNursing Management91 avoid bubble bath (can alter Ph of vagina).92 avoid use of tissue papers93 avoid using talcum powder and perfume.Male94 Urethra (20 cm, 8 inches)95 urinate after intercourseMICROGLIA96 stationary cells that carry on phagocytosis (engulfing of bacteria or cellulardebris, eating), pinocytosis (cell drinking).MACROPHAGE ORGANMicrogliaMonocytesKupffers cellsHistiocytesAlveolarMacrophageBrainBloodKidneySkinLungEPINDYMAL CELLS97 Secretes a glue called chemo attractants that concentrate the bacteria.COMPOSITION OF BRAIN98 80% brain mass99 10% blood10010% CSFI. Brain Mass

PARTS OF THE BRAIN1. CEREBRUM101largest part102composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphereenclosed in the Corpus Callosum.Functions of Cerebrum103integrative104sensory105motorLobes of Cerebrum1. Frontal106higher cortical thinking

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107controls personality108controls motor activity109Broca’s Area (motor speech area) when damaged results to garbled speech.2. Temporal110hearing111short term memory3. Parietal112for appreciation113discrimination of sensory impulses to pain, touch, pressure, heat, cold,numbness.4. Occipital114for visionInsula (Island of Reil)115visceral function activities of internal organ like gastric motility.Limbic System (Rhinencephalon)116controls smell and if damaged results to Anosmia (absence of smell).117controls libido118controls long term memory2. BASAL GAGLIA119areas of grey matter located deep within each cerebral hemisphere.120release dopamine (controls gross voluntary movement.NEURO TRANSMITTER DECREASE INCREASEAcethylcholine Myasthenia Gravis Bi-polar DisorderDopamine Parkinson’s Disease Schizophrenia3. MIDBRAIN/ MESENCEPHALON121acts as relay station for sight and hearing.122size of pupil is 2 – 3 mm.123equal size of pupil is isocoria.124unequal size of pupil is anisocoria.125hearing acuity is 30 – 40 dB.126positive PERRLA4. INTERBRAIN/ DIENCEPHALONParts of DiencephalonA. Thalamus127acts as relay station for sensation.B. Hypothalamus128controls temperature (thermoregulatory center).129controls blood pressure130controls thirst131appetite/satiety132sleep and wakefulness133controls some emotional responses like fear, anxiety and excitement.134controls pituitary functions135androgenic hormones promotes secondary sex characteristics.136early sign for males are testicular and penile enlargement137late sign is deepening of voice.138early sign for females telarche and late sign is menarche.5. BRAIN STEM139located at lowest part of brainParts of Brain Stem1. Pons140pneumotaxic center controls the rate, rhythm and depth of respiration.2. Medulla Oblongata141controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center(dilation and constriction of bronchioles).3. Cerebellum142smallest part of the brain.143lesser brain.144controls 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 HEMATOMA145CSF cushions brain (shock absorber)146Obstruction of flow of CSF will lead to enlargement of skull posteriorly calledhydrocephalus.

147Early closure of posterior fontanels causes posterior enlargement of skull inhydrocephalus.

NEUROLOGIC DISORDERSINCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by anincrease in one of the 3 major intra cranial components.Causes:q1 head trauma/injury148localized abscess149cerebral edema150hemorrhage151inflammatory condition (stroke)152hydrocephalus153tumor (rarely)Signs and Symptoms (Early)154decrease LOC155restlessness/agitation156irritability157lethargy/stupor158comaSigns and Symptoms (Late)159changes in vital signs160blood pressure (systolic blood pressure increases but diastolic remains thesame).161widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).162heart rate decrease163respiratory rate decrease164temperature increase directly proportional to blood pressure.165projective vomiting166headache167papilledema (edema of optic disc)168abnormal posturing169decorticate posturing (damage to cortex and spinal cord).170decerebrate posturing (damage to upper brain stem that includes pons,cerebellum and midbrain).171unilateral dilation of pupils called uncal herniation172bilateral dilation of pupils called tentorial herniation173resulting to mild headache174possible seizure activityNursing Management1. Maintain patent and adequate ventilation by:a. Prevention of hypoxia and hypercarbiaEarly signs of hypoxia175restlessness176agitation177tachycardiaLate signs of hypoxia178Bradycardia179Extreme restlessness180Dyspnea181Cyanosis

HYPERCARBIA182Increase CO2 (most powerful respiratory stimulant) retention.183In chronic respiratory distress syndrome decrease O2 stimulates respiration.b. Before and after suctioning hyper oxygenate client 100% and done 10 – 15seconds only.c. Assist in mechanical ventilation2. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated topromote venous drainage.3. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/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:184straining stool185excessive vomiting (use anti emetics)186excessive coughing (use anti tussive like dextromethorphan)187avoid stooping/bending188avoid lifting heavy objectse. avoid clustering of nursing activity together.7. Administer medications like:

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a. Osmotic diuretic (Mannitol)189for cerebral diuresisNursing Management190monitor vital signs especially BP (hypotension).191monitor strictly input and output every 1 hour notify physician ifoutput is less 30 cc/hr.192administered via side drip193regulated fast drip to prevent crystal formation.b. Loop diuretic (Lasix, Furosemide)194Drug of choice for CHF (pulmonary edema)195Loop of Henle in kidneys.Nursing Management196Monitor vital signs especially BP (hypotension).197monitor strictly input and output every 1 hour notify physician if output is less 30cc/hr.198administered IV push or oral.199given early morning200immediate effect of 10 – 15 minutes.201maximum effect of 6 hours.c. Corticosteroids202Dexamethasone (Decadron)203Hydrocortisone204Prednisone (to reduce edema that may lead to increase ICP)205Mild Analgesics (Codeine Sulfate for respiratory depression)206Anti Convulsants (Dilantin, Phenytoin)*CONGESTIVE HEART FAILURESigns and Symptoms207dyspnea208orthopnea209paroxysmal nocturnal dyspnea210productive cough211frothy salivation212cyanosis213rales/crackles214bronchial wheezing215pulsus alternans216anorexia and general body malaise217PMI (point of maximum impulse/apical pulse rate) is displaced laterally218S3 (ventricular gallop)219Predisposing Factors/Mitral Valve RHD AgingTREATMENTMorphine SulfateAminophellineDigoxinDiureticsOxygenGases, blood monitorRIGHT CONGESTIVE HEART FAILURE (Venous congestion)Signs and Symptoms220jugular vein distention (neck)221ascites222pitting edema223weight gain224hepatosplenomegaly225jaundice226pruritus227esophageal varices228anorexia and general body malaiseSigns and Symptoms of Lasix in terms of electrolyte imbalances1. Hypokalemia229decrease potassium level230normal value is 3.4 – 5.5 meq/LSign and Symptoms231weakness and fatigue232constipation233positive U wave on ECG tracingNursing Management234administer potassium supplements as ordered (Kalium Durule, Oral PotassiumChloride)235increase intake of foods rich in potassiumFRUITS VEGETABLESAppleBananaCantalopeOrangesAsparagusBrocolli

CarrotsSpinach2. Hypocalcemia/ Tetany236decrease calcium level237normal value is 8.5 – 11 mg/100 mlSigns and Symptoms238tingling sensation239paresthesia240numbness241(+) Trousseau’s sign/ Carpopedal spasm242(+) Chvostek’s signComplications Arrhythmia SeizuresNursing Managementq Calcium Gluconate per IV slowly as ordered* Calcium Gluconate toxicity – results to SEIZUREMagnesium SulfateMagnesium Sulfate toxicityS/SBPUrine output DECREASERespiratory ratePatellar relfex absent3. Hyponatremia243decrease sodium level244normal value is 135 – 145 meq/LSigns and Symptoms245hypotension246dehydration signs (Initial sign in adult is THIRST, in infant TACHYCARDIA)247agitation248dry mucous membrane249poor skin turgor250weakness and fatigueNursing Management251force fluids252administer isotonic fluid solution as ordered4. Hyperglycemia253normal FBS is 80 – 100 mg/dlSigns and Symptoms254polyuria255polydypsia256polyphagiaNursing Management257monitor FBS5. Hyperuricemia258increase uric acid (purine metabolism)259foods high in uric acid (sardines, organ meats and anchovies)260*Increase in tophi deposit leads to Gouty arthritis.Signs and Symptoms261joint pain (great toes)262swellingNursing Management263force fluids264administer medications as ordereda. Allopurinol (Zyloprim)265Drug of choice for gout.266 Mechanism of action : inhibits synthesis of uric acid.b. Colchecine267Acute gout268 Mechanism of action : promotes excretion of uric acid.* KIDNEY STONESSigns and Symptoms269renal colic270Cool moist skinNursing Management271force fluids272administer medications as ordereda. Narcotic Analgesic273Morphine Sulfate274ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors.b. Allopurinol (Zyloprim)Side Effects275Respiratory depression (check for RR)

PARKINSON’S DISEASE/ PARKINSONISM276Chronic progressive disorder of CNS characterized by degeneration ofdopamine producing cells in the SUBSTANCIA NIGRA of the midbrain andbasal ganglia.Predisposing Factors1. Poisoning (lead and carbon monoxide)

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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 suicideAlonenessLoss of spouse Loss of Job277direct approach towards the client278close surveillance is a nursing priority279time to commit suicide is on weekends early morningSigns and Symptoms for Parkinson’s280pill rolling tremors of extremities especially the hands.281bradykinesia (slowness of movement)282rigidity (cogwheel type)283stooped posture284shuffling and propulsive gait285over fatigue286mask like facial expression with decrease blinking of the eyes.287difficulty rising from sitting position.288Monotone type speech289mood lability (in state of depression)290increase salivation (drooling type)291autonomic changesa. increase sweatingb. increase lacrimationc. seborrhead. constipatione. decrease sexual capacityNursing Management1. Administer medications as orderedAnti Parkinsonian agents292Levodopa (L-dopa) short acting293Amantadine Hydrochloride (Symmetrel)294Carbidopa (Sinemet)Mechanism of Action295increase level of dopamineSide Effects296GIT irritation (should be taken with meals297orthostatic hypotension298arrhythmia299hallucinationsContraindications300clients with narrow angle closure glaucoma301clients taking MAOI’s (no foods with triptophan and thiamine)302urine and stool may be darkened303no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid HydrazideAnti Cholinergic Agents (ARTANE and COGENTIN) - to relieve tremorsMechanism of Action304inhibits action of acethylcholineSide Effects305SNSAnti Histamine (Dipenhydramine Hydrochloride)Side EffectsAdult: drowsinessChildren: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.Dopamine Agonist - relieves tremor rigidityBromocriptene Hydrochloride (Parlodel)Side Effects306Respiratory depression2. Maintain side rails to prevent injury3. Prevent complications of immobility4. Decrease protein in morning and increase protein in afternoon to induce sleep5. Encourage increase fluid intake and fiber.6. Assist/supervise in ambulation7. Assist in Stereotaxic ThalamotomyMAGIC 2’s IN DRUG MONITORINGDRUG NORMAL RANGE TOXICITYLEVELINDICATION CLASSIFICATIONDigoxin/ Lanoxin(Increase force ofcardiac output).5 – 1.5 meq/L 2 CHF Cardiac GlycosideLithium/ Lithane

(Decrease level ofAch/NE/Serotonin).6 – 1.2 meq/L 2 Bipolar Anti-Manic AgentsAminophylline(Dilates bronchial tree)10 – 19 mg/100 ml 20 COPD BronchodilatorsDilantin/ Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-ConvulsantAcetaminophen/Tylenol 10 – 30 mg/100 ml 200 OsteoArthritisNon-narcoticAnalgesic1. Digitalis ToxicitySigns and Symptoms307nausea and vomiting308diarrhea309confusion310photophobia311changes in color perception (yellowish spots)Antidote: Digibind2. Lithium ToxicitySigns and Symptoms312anorexia313nausea and vomiting314diarrhea315dehydration causing fine tremors316hypothyroidismNursing Management317force fluids318increase sodium intake to 4 – 10 g% daily3. Aminophylline ToxicitySigns and Symptoms319tachycardia320palpitations321CNS excitement (tremors, irritability, agitation and restlessness)Nursing Management322only mixed with plain NSS or 0.9 NaCl to prevent development of crystals orprecipitate.323administered sandwich method324avoid taking alcohol because it can lead to severe CNS depression325avoid caffeine4. Dilantin ToxicitySigns and Symptoms326gingival hyperplasia (swollen gums)327hairy tongue328ataxia329nystagmusNursing Management330provide oral care331massage gums5. Acetaminophen ToxicitySigns and Symptoms332hepatotoxicity (monitor for liver enzymes)333SGPT/ALT (Serum Glutamic Pyruvate Transaminace)334SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)335nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)336hypoglycemiaTremors, tachycardiaIrritabilityRestlessnessExtreme fatigueDiaphoresis, depressionAntidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.MYASTHENIA GRAVIS337neuromuscular disorder characterized by a disturbance in the transmission ofimpulses from nerve to muscle cells at the neuromuscular junction leading todescending muscle weakness.Incidence rate: women 20 – 40 years oldPredisposing factors338unknown339autoimmune: it involves release of cholinesterase an enzyme that destroys Ach.Signs and Symptoms340initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.341diplipia342mask like facial expression343dysphagia344hoarseness of voice

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345respiratory muscle weakness that may lead to respiratory arrest346extreme muscle weakness especially during exertion and morningDiagnostic Procedure347Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signsand symptoms for about 5 – 10 minutes and a maximum of 15 minutes.q if there is no effect there is damage to occipital lobe and midbrain and isnegative for M.G.Nursing Management1. airway2. aspiration maintain patent airway and adequate ventilation3. 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 Actionq increase level of AchSide Effectsq PNSq Cortocosteroids suppress immune responseq monitor for 2 types of crisis:MYASTHENIC CRISIS CHOLINERGIC CRISISCauses:- under medication- stress- infectionSigns and Symptoms- The client is unable to see, swallow, speak,breatheTreatment- administer cholinergic agents as orderedCause:- over medicationSigns and Symptoms- PNSTreatment- Administer anti cholinergic agents(Atropine Sulfate)7. Assist in surgical procedure known as thymectomy because it is believed that the thymus glandis responsible for M.G.8. Assist in plasma paresis and removing auto immune anti bodies9. Prevent complicationsINFLAMMATORY CONDITIONS OF THE BRAINMENINGITISMeningesq 3 fold membrane that covers brain and spinal cord.q for support and protectionq for nourishmentq blood supplyLAYERS OF THE MENINGES1. Dura matter – outer layer2. Arachnoid – middle layer3. Pia matter – inner layerq subdural space between the dura and arachnoidq subarachnoid space between the arachnoid and pia, CSF aspiration isdone.A. Etiology1. Meningococcus – most dangerous2. Pneumococcus3. Streptococcus - causes adult meningitis4. Hemophilus Influenzae – causes pediatric meningitisB. Mode of transmission348airborne transmission (droplet nuclei)C. Signs and Symptoms349headache350photophobia351projectile vomiting352fever, chills, anorexia, general body malaise and weight loss353Possible increase in ICP and seizure activity354Abnormal posturing (decorticate and decerebrate)355Signs of meningeal irritationa. Nuchal rigidity or stiff neck

b. Opisthotonus (arching of back)c. (+) Kernig’s sign (leg pain)d. (+) Brudzinski sign (neck pain)D. Diagnostic Procedures356Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid spacebetween the L3 – 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 Puncture1. Place flat on bed 12 – 24 o2. Force fluids3. Check punctured site for any discoloration, drainage and leakage to tissues.4. Assess for movement and sensation of extremities.CSF analysis reveals1. Increase CHON and WBC2. Decrease glucose3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)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 anti biotic therapy4. Elevate head 30-45o5. 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 small frequent feedings.b. Prevent complications357most feared is hydrocephalus358hearing loss/nerve deafness is second complication359consult audiologistc. Rehabilitation for neurological deficit360mental retardation361delayed psychomotor developmentCVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)362a partial or complete disruption in the brains blood supply.3632 most common cerebral artery affected by strokea. Mid Cerebral Arteryb. Internal Cerebral Artery – the 2 largest arteryA. Incidence Rate364men are 2-3 times high riskB. Predisposing Factors365thrombus (attached)366embolus (detached and most dangerous because it can go to the lungs andcause pulmonary embolism or the brain and cause cerebral embolism.Signs and Symptoms of Pulmonary Embolism367Sudden sharp chest pain368Unexplained dyspnea369Tachycardia370Palpitations371Diaphoresis372Mild restlessnessSigns and Symptoms of Cerebral Embolism373Headache and dizziness374Confusion375Restlessness376Decrease LOC Fat embolism is the most feared complications after femur fracture. Yellow bone marrow are produced from the medullary cavity of the long bones and producesfat cells. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in thecirculation. Compartment syndrome (compression of arteries and nerves)

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C. Risk Factors1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular HeartDisease, Post Cardiac 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 (breakdown of lipids) leading toatherosclerosis that will lead to hypertension and eventually CVA.D. Signs and Symptoms377dependent on stages of development1. TIA378Initial sign of stroke or warning signSigns and Symptoms379headache and dizziness380tinnitus381visual and speech disturbances382paresis (plegia)383possible increase ICP2. Stroke in evolution384progression of signs and symptoms of stroke3. Complete stroke385resolution phase characterized by:Signs and Symptoms386headache and dizziness387Cheyne Stokes Respiration388anorexia, nausea and vomiting389dysphagia390(+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke391focal neurological deficitsa. 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 Arteriography392reveals the site and extent of malocclusion393uses dye for visualization394most of dye are iodine based395check for shellfish allergy396after diagnostic exam force fluids to release dye because it is nephro toxic397check for distal pulse (femoral)398check for hematoma formationF. 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 – 45o4. 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 bedc. provide sand bag or food board.6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and preventcontractures7. Institute NGT feeding8. Provide alternative means of communicationa. 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 thrombus399Streptokinase Side Effect: Allergic Reaction400Urokinase401Tissue Plasminogen Activating Factor

402Side Effect: Chest Painf. Anti Coagulants403Heparin (short acting)404check for partial thromboplastin time if prolonged there is arisk for bleeding.405give Protamine Sulfate406Comadin/ Warfarin (long acting)407give simultaneously because Coumadin will take effect after3 days408check for prothrombin time if prolonged there is a risk forbleeding409give Vit. K (Aqua Mephyton)g. Anti Platelet410PASA (Aspirin)411Contraindicated for dengue, ulcer and unknown cause of headachebecause it may potentiate bleeding11. Provide client health teachings and discharge planning concerninga. avoidance of modifiable risk factors (diet, exercise, smoking)b. prevent complication (subarachnoid hemorrhage is the most feared complication)c. dietary modification (decrease salt, saturated fats and caffeine)d. importance of follow up careGUILLAIN BARRE SYNDROME412a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading toascending muscle paralysis.A. Predisposing Factors1. Autoimmune2. Antecedent viral infections such as LRT infectionsB. Signs and Symptoms1. 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 proteinD. 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 2 hours5. 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 Agents413Lidocaine, Zylocaine414Bretylium – blocks release of norepinephrine to prevent increase of BP8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies)9. Prevent complicationsa. Arrythmiab. Paralysis or respiratory muscles/Respiratory arrest* Sengstaken Blakemore Tube415for liver cirrhosis416to decompress bleeding esophageal verices (prepare scissor to cut tube incaseof difficulty in breathing to release air in the balloon417for hemodialysis prepare bulldog clips to prevent air embolism.CONVULSIVE DISORDER/ CONVULSION418disorder of CNS characterized by paroxysmal seizure with or without loss ofconsciousness abnormal motor activity alternation in sensation and perceptionand changes in behavior.419Seizure – first convulsive attack420Epilepsy – second or series of attacks

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421Febrile 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 factor for status epilepticus (drug ofchoice is Diazepam, Valium)B. Signs and Symptoms422Dependent on stages of development or types of seizureI. Generalized Seizure1. Grand mal Seizure (tonic-clonic seizure)a. Signs or aura with auditory, olfactory, visual, tactile, sensory experienceb. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutesc. Tonic contractions - direct symmetrical extension of extremitiesClonic contractions - contraction of extremitiesd. Post ictal sleep – unresponsive sleep2. Petit mal Seizure – absence of seizure common among pediatric clients 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)423Characterized by tingling and jerky movement of index finger and thumb that spreads to theshoulder and 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 Epilepticus424A continuous uninterrupted seizure activity, if left untreated can lead tohyperpyrexia and lead to coma and eventually death.425Drug of choice: Diazepam, Valium and GlucoseC. 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 railsd. avoid use of restrainse. turn clients head to side to prevent aspirationf. place mouth piece of tongue guard to prevent biting or tongue2. 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 SCALE426objective measurement of LOC sometimes called as the quick neuro checkComponents1. Motor response2. Verbal response3. Eye opening427Survey of mental status and speecha. LOCb. Test of memory428Levels of orientation

429Cranial nerve assessment430Sensory nerve assessment431Motor nerve assessment432Deep tendon reflex433Autonimics434Cerebellar testa, Romberg’s 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 dimetriaI. LEVEL OF CONSCIOUSNESS1. Conscious - awake2. Lethargy – lethargic (drowsy, sleepy, obtunded)3. Stupor435stuporous (awakened by vigorous stimulation)436generalized body weakness437decrease body reflex4. Coma438comatose439light coma (positive to all forms of painful stimulus)440deep 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 reflex441Conscious client use a wisp of cotton442Unconscious client place 1 drop of saline solutionII. TEST OF MEMORY1. Short term memory443ask most recent activity444positive result mean anterograde amnesia and damage to temporal lobe2. Long term memory445ask for birthday and validate on profile sheet446positive result mean retrograde amnesia and damage to limbic system447consider 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 MXII. HYPOGLOSSAL MCRANIAL NERVE I: OLFACTORY448sensory function for smellMaterial Used449don’t use alcohol, ammonia, perfume because it is irritating and highly diffusible.450use coffee granules, vinegar, bar of soap, cigaretteProcedure451test each nostril by occluding each nostrilAbnormal 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 where olfactory cells are located2. may indicate inflammatory conditions (sinusitis)CRANIAL NERVE II: OPTIC452sensory function for vision or sightFunctions1. Test visual acuity or central vision or distance453use Snellen’s Chart454Snellen’s Alphabet chart: for literate clients

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455Snellen’s E chart: for illiterate clients456Snellen’s Animal chart: for pediatric clients457normal visual acuity 20/20458numerator is constant, it is the distance of person from the chart (6 – 7 m, 20feet)459denominator changes, indicates distance by which the person normally can seeletter in the chart.460- 20/200 indicates blindness46120/20 visual acuity if client is able to read letters above the red line.2. Test of visual field or peripheral visiona. Superiorlyb. Bitemporalyc. Nasallyd. Inferiorly

COMMON VISUAL DISORDERS1. Glaucoma462increase IOP463normal IOP is 12 – 21 mmHg464preventable but not curableA. Predisposing Factors465Common among 40 years old and above466Hereditary467Hypertension468ObesityB. Signs and Symptoms1. Loss of peripheral vision469pathognomonic sign is tunnel vision2. Headache, nausea, vomiting, eye pain (halos around light)470steamy cornea471may lead to blindnessC. 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 aqueous humor or drainage4. Timoptics (Timolol Maleate)E. Surgical Procedures1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor2. Cataract472Decrease opacity of lensA. Predisposing Factor1. Aging 65 years and above2. 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 colors473Complication is blindnessD. Diagnostic Procedure1. Opthalmoscopic examE. Treatment1. Mydriatics (Mydriacyl) – constricts pupils2. Cyclopegics (Cyclogyl) – paralyses cilliary muscleF. Surgical ProcedureExtra IntraCapsular CapsularCataract CataractLens LensExtraction Extraction- Partial removal - Total removal of cataract with its surrounding capsules474Most feared complication post op is RETINAL DETACHMENT3. Retinal Detachment475Separation 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 Degeneration476Degeneration of the macula lutea (yellowish spot at the center of retina)A. Signs and Symptoms1. Black SpotsCRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS477Controls or innervates the movement of extrinsic ocular muscle (EOM)4786 musclesSuperior Rectus Superior ObliqueLateral Rectus Medial RectusInferior Oblique Inferior Rectus479trochlear controls superior oblique480abducens controls lateral rectus481oculomotor controls the 4 remaining EOMOculomotor482controls the size and response of pupil483normal pupil size is 2 – 3 mm484equal size of pupil: Isocoria485Unequal size of pupil: Anisocoria486Normal response: positive PERRLACRANIAL NERVE V: TRIGEMINAL487largest cranial nerve488consists of ophthalmic, maxillary, mandibular489sensory: controls sensation of face, mucous membrane, teeth, soft palate andcorneal reflex)490motor: controls the muscle of mastication or chewing491damage to CN V leads to trigeminal neuralgia/thickdolorum492medication: Carbamezapine(Tegretol)CRANIAL NERVE VII: FACIAL493Sensory: controls taste, anterior 2/3 of tongue494pinch of sugar and cotton applicator placed on tip of tongue495Motor: controls muscle of facial expression496instruct client to smile, frown and if results are negative there is facial paralysis orBell’s Palsy and the primary cause is forcep delivery.CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR497Controls balance particularly kinesthesia or position sense, refers to movementand orientation of the body in space.Parts of the Ear1. Outer Ear498Pinna499Eardrum2. Middle Ear500Hammer Malleus501Anvil Incus502Stirrup Stapes3. Inner Ear503Vestibule: Meinere’s Disease504Cochlea505Mastoid Cells506Endolymph and Perilymph507COCHLEA: controls hearing, contains the Organ of Corti(the true organ of hearing)508Let client repeat words utteredCRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE509Glosopharyngeal: controls taste, posterior 1/3 of tongue510Vagus: controls gag reflex511Uvula should be midline and if not indicative of damage to cerebral hemisphere512Effects of vagal stimulation is PNSCRANIAL NERVE XI: SPINAL ACCESSORY513Innervates with sternocleidomastoid (neck) and trapezius (shoulder)CRANIAL NERVE XII: HYPOGLOSSAL514Controls the movement of tongue515Let client protrude tongue and it should be midline and if unable to do indicativeof damage to cerebral 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 clocko Controls all metabolic function of body

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PARTS OF THE PITUITARY GLAND1. Anterior Pituitary Glando called as adenohypophysis2. Posterior Pituitary Glando called as neurohypophysiso secretes hormones oxytocin -promotes uterine contractions preventingbleeding/ hemorrhageo administrate oxytocin immediately after delivery to prevent uterine atony.o initiates milk let down reflex with help of hormone prolactin2. Antidiuretic Hormoneo Pitressin (Vasopressin)o Function: prevents urination thereby conserving watero Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic HormoneDIABETES INSIPIDUSo Decrease production of anti diuretic hormoneA. Predisposing Factoro Related to pituitary surgeryo Traumao Inflammationo Presence of tumorB. Signs and Symptoms1. Polyuria2. Signs of dehydrationa. Adult: thirstb. Agitationc. Poor Skin turgord. 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 – 1.030o 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 most feared complicationSIADHo hypersecretion of anti diuretic hormoneA. Predisposing Factors1. Head injury2. Related to presence of bronchogenic cancero initial sign of lung cancer is non productive cougho non invasive procedure is chest x-ray3. Related to hyperplasia (increase size of organ brought about by increase of number of cells) ofpituitary gland.B. Signs and Symptoms1. Fluid retentiona. Hypertensionb. Edemac. Weight gain2. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizureactivityC. 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 pitting edema5. Provide meticulous skin care6. Prevent complications

ANTERIOR PITUITARY GLAND516also called ADENOHYPOPHYSIS secretes1. Growth hormones (somatotropic hormone)517Promotes elongation of long bones518Hyposecretion of GH among children results to Dwarfism519Hypersecretion of GH results to Gigantism

520Hypersecretion of GH among adults results to Acromegaly (square face)521Drug 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 secretiono 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 hormoneo promotes cerebration (thinking)3. Thyrocalcitonin – antagonizes the effects of parathormone to promote calciumresorption.HYPOTHYROIDISMo all are decrease except weight and menstruationo memory impairmentSigns and Symptomso there is loss of appetite but there is weight gaino menorrhagiao cold intoleranceo constipationHYPERTHYROIDISMo all are increase except weight and menstruationSigns and Symptomso increase appetite but there is weight losso amenorrheao exophthalmosTHYROID DISORDERSSIMPLE GOITERo enlargement of thyroid gland due to iodine deficiencyA. Predisposing Factors1. Goiter belt areaa. 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 iodineo goitrogenic drugsa. Anti Thyroid Agent – Prophylthiuracil (PTU)b. Lithium Carbonatec. PASA (Aspirin)d. Cobalte. Phenylbutazones (NSAIDs)- if goiter is caused byB. Signs and Symptoms1. Enlarged thyroid gland2. Mild dysphagia3. Mild restlessnessC. 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. Lugol’s 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: Lugol’s, Iron, Tetracycline, Nitrofurantoin(drug of choice for pyelonephritis)

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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 causes tachycardia andpalpitations3. Monitor side effectso insomniao tachycardia and palpitationso hypertensiono heat intolerance4. Increase dietary intake of foods rich in iodineo seaweedso seafood’s like oyster, crabs, clams and lobster but not shrimps because itcontains lesser amount of iodine.o iodized salt, best taken raw because it it is easily destroyed by heat5. Assist in surgical procedure of subtotal thyroidectomyHYPOTHYROIDISMo hyposecretion of thyroid hormoneo adults: MYXEDEMA non pitting edemao children: CRETINISM the only endocrine disorder that can lead to mentalretardationA. Predisposing Factors1. Iatrogenic Cause – disease caused by medical intervention such as surgery2. Related to atrophy of thyroid gland due to trauma, presence of tumor, inflammation3. Iodine deficiency4. Autoimmune (Hashimotos Disease)B. Signs and Symptoms(Early Signs)1. Weakness and fatigue2. Loss of appetite but with weight gain which promotes lipolysis leading toatherosclerosis and MI3. Dry skin4. Cold intolerance5. Constipation(Late Signs)1. Brittleness of hair and nails2. Non pitting edema (Myxedema)3. Hoarseness of voice4. Decrease libido5. Decrease in all vital signs – hypotension, bradycardia, bradypnea, hypothermia6. CNS changeso lethargyo memory impairmento psychosiso menorrhagiaC. Diagnostic Procedures1. Serum T3 and T4 is decreased2. Serum Cholesterol is increased3. RAIU (Radio Active Iodine Uptake) is decreasedD. Nursing Management1. Monitor strictly vital signs and intake and output to determine presence ofo Myxedema coma is a complication of hypothyroidism and an emergency caseo a severe form of hypothyroidism is characterized by severe hypotension,bradycardia, bradypnea, hypoventilation, hyponatremia, hypoglycemia,hypothermia leading to pregressive stupor and coma.Nursing Management for Myxedema Coma Assist in mechanical ventilation Administer thyroid hormones as ordered Force 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 care

8. Provide client health teaching and discharge planning concerninga. Avoid precipitating factors leading to myxedema comao stresso infectiono cold intoleranceo use of anesthetics, narcotics, and sedativeso prevent complications (myxedema coma, hypovolemic shocko hormonal replacement therapy for lifetimeo importance of follow up careHYPERTHYROIDISMo increase in T3 and T4o Grave’s Disease or Thyrotoxicosiso developed by Robert GraveA. Predisposing Factors1. Autoimmune – it involves release of long acting thyroid stimulator causingexopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration amonginfants)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. Tremorsd. 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 Agenta. Prophythioracill (PTU)b. Methymazole (Tapazole)Side Effects of Agranulocytosis522increase lymphocytes and monocytes523fever and chills524sore throat (throat swab/culture)525leukocytosis (CBC)3. Provide dietary intake that is increased in calories.4. Provide meticulous skin care5. 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 thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity ofthe thyroidgland to prevent bleeding and hemorrhage.POST OPERATIVELY,1. Watch out for signs of thyroid storm/ thyrotoxicosisAgitationHyperthermia Tachycardia526administer medications as ordereda. Anti Pyreticsb. Beta-blockers527monitor strictly vital signs, input and output and neuro check.528maintain side rails529offer TSB2. Watch out for accidental removal of parathyroid gland that may lead toHypocalcemia (tetany)Signs and Symptoms530(+) trousseau’s sign531(+) chvostek sign532Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered3. Watch out for accidental Laryngeal damage which may lead to hoarseness ofvoiceNursing Management

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533encourage client to talk/speak immediately after operation and notify physician4. Signs of bleeding (feeling of fullness at incisional site)Nursing Management534Check the soiled dressings at the back or nape area.5. Hormonal replacement therapy for lifetime6. Importance of follow up carePARATHYROID GLAND535A pair of small nodules behind the thyroid gland536Secretes parathormone537Promotes calcium reabsorption538Hypoparathyroidism539HyperparathyroidismHYPOPARATHYROIDISM540Decrease secretion of parathormone leading to hypocalcemia541Resulting to hyperphospatemiaA. Predisposing Factors1. Following subtotal thyroidectomy2. Atrophy of parathyroid gland due to:a. inflammationb. tumorc. traumaB. Signs and Symptoms1. Acute tetanya. tingling sensationb. paresthesiac. numbnessd. dysphagiae. positive trousseu’s sign/carpopedal spasmf. positive chvostek signg. laryngospasm/broncospasmh. seizure feared complicationsi. arrhythmia2. Chronic tetanya. 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/100 ml)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 supplements Calcium Gluconate Calcium Lactate Calcium Carbonatec. Vitamin D (Cholecalciferol) for absorption of calciumCHOLECALCIFEROL ARE DERIVED FROMDrug Diet (Calcidiol) Sunlight(Calcitriol)d. Phosphate binder542Aluminum Hydroxide Gel (Ampogel)543Side effect: constipationANTACIDA.A.C MAD▼ ▼Aluminum Containing Magnesium ContainingAntacids Antacids▼ ▼AluminumHydroxideGel▼Side Effect: Constipation Side Effect: Diarrhea2. Avoid precipitating stimulus such as glaring lights and noise3. Encourage increase intake of foods rich in calciuma. anchoviesb. salmonc. green turnips4. Institute seizure and safety precaution5. Encourage client to breathe using paper bag to produce mild respiratory 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.HYPERTHYROIDISM

544Decrease parathormone545Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% inbone and 1% blood)546Kidney 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 demineralizationD. 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 decrease in calcium6. Provide acid ash in the diet to acidify urine and prevent bacterial growth7. 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 GLAND547Located atop of each kidney5482 layers of adrenal glanda. Adrenal Cortex – outermostb. Adrenal Medulla – innermost (secretes catecholamines a power hormone)2 Types of Catecholamines549Epinephrine and Norepinephrine (vasoconstrictor)550Pheochromocytoma (adrenal medulla)551Increase secretion of norepinephrine552Leading to hypertension which is resistant to pharmacological agents leading to CVA553Use 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 of potassium- Salt

ADDISON’S DISEASE554Hyposecretion of adreno cortical hormone leading toa. 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

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- diarrhea- arrhythmia5. Decrease libido6. Loss of pubic and axillary hair7. 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 presence of Addisonian crisis(complication of addison’s disease)555Addisonian crisis results from acute exacerbation of addison’s disease characterizedbya. severe hypotensionb. hypovolemic shockc. hyponatremia leading to progressive stupor and comaNursing 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 the afternoon to mimic thenormal diurnal rhythm2. 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, protein but decrease in potassium6. Provide meticulous skin care7. Provide client health teaching and discharge planninga. avoid precipitating factor leading to addisonian crisis leading to- stress- infection- sudden withdrawal to steroidsb. prevent complications- addisonian crisis- hypovolemic shockc. hormonal replacement for lifetimed. importance of follow up careCUSHING SYNDROME556Hypersecretion of adenocortical hormonesA. Predisposing Factors1 Related to hyperplasia of adrenal gland2. Increase susceptibility to infections3. Hypernatremiaa. hypertensionb. 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 output

2. Weigh patient daily and assess for pitting 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 carePANCREAS- Located behind the stomach- Mixed gland (exocrine and endocrine)- Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is anexocrine 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 effects of 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 metabolismCLASSIFICATION OF DMType 1 (IDDM)- Juvenile onset type- Brittle diseaseType 2 (NIDDM)- Adult onset- Maturity onset type- Obese over 40 years oldA. Incidence Rate- 10% general population has type 1 DMB. Predisposing Factors1. Hereditary (total destruction of pancreatic cells)2. Related to viruses3. Drugsa. Lasixb. Steroids4. Related to carbon tetrachloride toxicityC. Signs and Symptoms1. Polyuria2. Polydypsia3. Polyphagia4. Glucosuria5. Weight loss6. Anorexia, nausea and vomiting7. Blurring of vision8. Increase susceptibility to infection9. Delayed/poor wound healingD. Treatment1. Insulin therapy2. Diet3. ExerciseE. Complication1. Diabetic KetoacidosisA. Incidence Rate- 90% of general population has type 2 DMB. Predisposing Factors1. Obesity – because obese persons lack insulinreceptor binding sitesC. Signs and Symptoms1. Usually asymptomatic2. Polyuria3. Polydypsia4. Polyphagia5. Glucosuria6. Weight gainD. Treatment1. Oral Hypoglycemic agents2. Diet3. ExerciseE. Complications1. Hyper2. Osmolar3. Non4. Ketotic5. ComaMAIN

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FOODSTUFFANABOLISM CATABOLISM1. Carbohydrates2. Protein3. FatsGlucoseAmino AcidsFatty AcidsGlycogenNitrogenFree Fatty Acids- Cholesterol- KetonesHYPERGLYCEMIAIncrease osmotic diuresisGlycosuria PolyuriaCellular starvation – weight loss Cellular dehydrationStimulates the appetite/satiety center Stimulates the thirst center(Hypothalamus) (Hypothalamus)Polyphagia Polydypsia* Liver has glycogen that undergo glycogenesis/ glycogenolysisGLUCONEOGENESISFormation of glucose from non-CHO sourcesIncrease protein formation▼Negative Nitrogen balance▼Tissue wasting (Cachexia)▼INCREASE FAT CATABOLISM▼Free fatty acidsCholesterol Ketones▼ ▼Atherosclerosis Diabetic Keto Acidosis▼HypertensionAcetone Breath Kussmaul’sRespirationodorMI CVADeath Diabetic ComaDIABETIC KETOACIDOSIS- Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNSdepressionA. Predisposing Factors1. Hyperglycemia2. Stress – number one precipitating factor3. InfectionB. Signs and Symptoms1. Polyuria2. Polydypsia3. Polyphagia4. Glucosuria5. Weight loss6. Anorexia, nausea and vomiting7. Blurring of vision8. Acetone breath odor9. Kussmaul’s 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 severe dehydrationD. Nursing Management1. Assist in mechanical ventilation2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration andshock3. Monitor strictly vital signs, intake and output and blood sugar levels4. Administer medications as ordereda. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours)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. Restlessness

3. Seizure activity4. Decrease LOC – diabetic comaB. Nursing Management1. Assist in mechanical ventilation2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration andshock3. 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 thus less 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 of lipodystrophy (atrophy, hypertrophyof subcutaneous tissues)2. Place in refrigerator once opened3. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formationof bubbles4. Use gauge 25 – 26 needle5. Administer insulin either 45o – 90o depending on amount of clients tissue deposit6. No need to aspirate upon injection7. Rotate insulin injection sites to prevent development of lipodystrophy8. Most accessible route is abdomen9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to preventcontaminating the clear insulin and promote proper calibration.10. Monitor for signs of local complications such asa. Allergic reactionsb. Lipodystrophyc. Somogyis Phenomenon – rebound effect of insulin characterized 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 and prevent hypoglycemia2. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reactionor Disulfiram (Antabuse) toxicity symptomsB. Diagnostic Procedures1. FBS is increased (3 consecutive times with signs or polyuria, polydypsia, polyphagia andglucosuria confirmatory for DM)2. Random Blood Sugar is increased3. Oral glucose tolerance test is increased – most sensitive test4. Alpha Glycosylated Hemoglobin is increasedC. 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 levels

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4. Monitor for signs of hypoglycemia and hyperglycemia- administer simple sugars- for hypoglycemia (cold and clammy skin) give simple sugars- for hyperglycemia (dry and warm skin)5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% andfats 20% or offer alternative food substitutes6. Instruct client to exercise best after meals when blood glucose is rising7. Monitor signs for complicationsa. Atherosclerosis (HPN, MI, CVA)b. Microangiopathy (affects small minute blood vessels of eyes and kidneys)EYES KIDNEY-PREMATURE CATARACT- Blindness-RECURRENT PYELONEPHRITIS- Renal failurec. 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 mins prior)9. Instruct client to have an annual eye and kidney exam10. Monitor for signs of DKA and HONKC11. Assist in surgical procedureHEMATOLOGICAL SYSTEMI. Blood II. Blood Vessels III. Blood FormingOrgans1. Arteries 1. Liver55% Plasma 45% Formed 2. Veins 3. Spleen4. Lymphoid OrganSerum Plasma CHON 5. Lymph Nodes(formed in liver) 6. Bone Marrow1. Albumin2. Globulins3. Prothrombin and FibrinogenALBUMIN- 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 factorsFORMED 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 – 16 gms%- 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 red pulp of spleen2. 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. LymphocytesB-cell T-cell Natural killer cell- bone marrow - thymus - anti viral and anti tumor propertyfor immunityHIV- 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. Kaposi’s 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 is the target of dengue virus- Normal life span of platelet is 9 – 12 daysSigns of Platelet Dysfunction1. Petechiae2. Echhymosis3. Oozing of blood from venipunctured siteBLOOD DISORDERSIron Deficiency Anemia- A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemictissue 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 traumaa. Heavy menstruationb. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GITbleeding)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 VINSON’S SYNDROME- Dysphagia9. PICA (abnormal appetite or craving for non edible foodsD. 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, stool and 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 potatoes

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e. Dried fruitsf. Legumesg. Nuts4. Instruct the client to avoid taking tea and coffee because it contains tannates which impairsiron 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 to prevent staining ofteethMedications administered via straw- Lugol’s 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 iron preparationa. Iron Dextran (IM, IV)b. Sorbitex (IM)Nursing Management when giving parenteral iron preparations1. Administer Z tract technique to prevent discomfort, discoloration and leakage to tissues2. Avoid massaging the injection site instead encourage to ambulate to facilitateabsorption3. 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 factor leading to hypochlorhydria(decrease hydrochloric acid secretion)A. Predisposing Factors1. Subtotal gastrectomy2. Hereditary factors3. Inflammatory disorders of the ileum4. Autoimmune5. Strictly vegetarian dietSTOMACH▼Pareital cells/ Argentaffin or Oxyntic cellsProduces intrinsic factors Secretes hydrochloricacid▼ ▼Promotes reabsorption of Vit B12 Aids in digestion▼Promotes maturation of RBCB. 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 Romberg’s test – damage to cerebellum resulting to ataxiae. result to psychosis

C. Diagnostic ProcedureSchilling’s Test – reveals inadequate/decrease absorption of Vitamin B12D. Nursing Management1. Enforce CBR2. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered- Never given orally because there is possibility of developing tolerance- Site of injection for Vitamin B12 is 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 soft bristled toothbrush5. Avoid heat application to prevent burnsAPLASTIC ANEMIA- Stem cell disorder leading to bone marrow depression leading to pancytopeniaPANCYTOPENIADecrease RBC Decrease WBC DecreasePlatelet(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 dizzinessc. 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 bonemarrowD. Nursing Management1. Removal of underlying cause2. 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 drugDISSEMINATED INTRAVASCULAR COAGULATIONAcute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to adeficiency of prothrombin and fibrinogenA. Predisposing Factors1. Related to rapid blood transfusion2. Massive burns3. Massive trauma4. Anaphylaxis5. Septecemia

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6. Neoplasia (new growth of tissue)7. PregnancyB. Signs and Symptoms1. Petechiae (widespread and systemic) eye, lungs and lower extremities2. 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 and GIT2. 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 by using ice or cold saline solutionof 500 – 1000 ml8. Monitor NGT output9. Prevent complicationa. Hypovolemic shockb. Anuria – late signBLOOD TRANSFUSIONGoals/Objectives1. 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 setb. 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 and darkness in color becauseit indicates bacterial contamination- Never warm blood as it may destroy vital factors in blood.- Warming is only done during emergency situation and if you have the warming device- Emergency rapid BT is given after 30 minutes and let natural room temperature warmthe blood.6. BT should be completed less than 4 hours because blood that is exposed at roomtemperature morethan 2 hours causes blood deterioration that can lead to BACTERIAL CONTAMINATION7. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS8. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to preventcirculatory overload9. Monitor strictly vital signs before, during and after BT especially every 15 minutes forfirst hourbecause majority of transfusion reaction occurs during this perioda. Hemolytic reactionb. Allergic reactionc. Pyrogenic reactiond. Circulatory overloade. Air embolismf. Thrombocytopenia

g. Cytrate intoxicationh. Hyperkalemia (caused by expired blood)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 NSS4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis5. Send the blood unit to blood bank for re examination6. Obtain urine and blood sample and send to laboratory for re examination7. 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) - if positive to hypotension, anaphylactic shock treat withEpinephrine5. Send the blood unit to blood bank for re examination6. Obtain urine and blood sample and send to laboratory for re examination7. Monitor vital signs and intake and outputSIGNS AND SYMPTOMS PYROGENIC REACTIONS1. Fever and chills2. Headache3. Tachycardia4. Palpitations5. Diaphoresis6. DyspneaNursing Management1. Stop BT2. 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 re examination7. 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 SYSTEMOVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEARTHEART- 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 pericardium2 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 layer

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2. Myocardium – middle layer3. Endocardium – inner layer- Myocarditis can lead to cardiogenic shock and rheumatic heart diseaseB. 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 backflow1. 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 (S2 “dub”)Extra Heart Sounds1. S3 – ventricular gallop usually seen in Left Congestive Heart Failure2. S4 – atrial gallop usually seen in Myocardial Infarction and HypertensionD. Coronary Arteries- Arises from base of the aortaTypes 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 allow ventricular filling3. Bundle of His- Right Main Bundle of His- Left Main Bundle of His- Located at the interventricular septum4. Purkinje Fibers- Located at the walls of the ventricles for ventricular contractionPURKINJE FIBERS- P WAVE (atrial depolarization) contraction- QRS WAVE (ventricular depolarization)- T WAVE (ventricular repolarization) Insert pacemaker if there is complete heart block Most 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 InfarctionATHEROSCLEROSISATHEROSCLEROSIS ARTERIOSCLEROSIS- narrowing of artery- lipid or fat deposits- tunica intima- hardening of artery- calcium and protein deposits- tunica mediaA. Predisposing Factors1. Sex – male2. Race – black3. Smoking4. Obesity5. Hyperlipidemia6. sedentary lifestyle7. Diabetes Mellitus

8. Hypothyroidism9. Diet – increased saturated fats10. Type A personalityB. Signs and Symptoms1. Chest pain2. 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 doneCoronary Arterial Bypass And Graft Surgery3 Complications of CABG1. Pneumonia – encourage to perform deep breathing, coughing exercise and use of incentivespirometer2. Shock3. Thrombophlebitis

ANGINA PECTORIS (SYNDROME)Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest ornitroglycerine due to temporary myocardial ischemiaA. Predisposing Factors1. Sex – male2. Race – black3. Smoking4. Obesity5. Hyperlipidemia6. sedentary lifestyle7. Diabetes Mellitus8. Hypothyroidism9. Diet – increased saturated fats10. Type A personalityB. Precipitating Factors4 E’s 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. Levine’s Sign – initial sign that shows the hand clutching the chest2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates fromback, shoulder, arms, axilla and jaw muscles, usually relieved by rest or taking nitroglycerine3. 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 as venodilator, but inlarge doses will act as vasodilator- Give first dose of NTG (sublingual) 3 – 5 minutes- Give second dose of NTG if pain persist after giving first dose with interval of 3- 5 minutes- Give third and last dose of NTG if pain still persist at 3 – 5 minutes intervalNursing Management when giving NTG557Keep the drug in a dry place, avoid moisture and exposure to sunlight as it mayinactivate the drug558Monitor side effectso Orthostatic hypotensiono Transient headache and dizziness559Instruct the client to rise slowly from sitting position560Assist or supervise in ambulation561When giving nitrol or transdermal patch

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o Avoid placing near hairy areas as it may decrease drug absorptiono Avoid rotating transdermal patches as it may decrease drug absorptiono Avoid placing near microwave ovens or duting defibrillation as it may lead toburns (most important thing to remember)b. Beta-blockers- Propanolol - side effects PNS- Not given to COPD cases because it causes bronchospasmc. ACE Inhibitors- Enalaprild. Calcium Antagonist- NIfedipine3. Administer oxygen inhalation4. Place client on semi fowlers position5. Monitor strictly vital signs, intake and output and ECG tracing6. Provide decrease saturated fats sodium and caffeine7. Provide client health teachings and discharge planninga. Avoidance of 4 E’sb. Prevent complication (myocardial infarction)c. Instruct client to take medication before indulging into physical exertion to achieve themaximum therapeutic effect of drugd. The importance of follow up care

MYOCARDIAL INFARCTIONHeart attackTerminal stage of coronary artery disease characterized by malocclusion, necrosis and scarring.A. Types1. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of bothright and left coronary artery2. Subendocardial Myocardial Infarction – characterized by occlusion of either right or leftcoronary arteryB. The Most Critical Period Following Diagnosis of Myocardial Infarction** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’sC. Predisposing Factors1. Sex – male2. Race – black3. Smoking4. Obesity5. Hyperlipidemia6. sedentary lifestyle7. Diabetes Mellitus8. Hypothyroidism9. Diet – increased saturated fats10. Type A personalityD. Signs and Symptoms1. Chest pain- Excruciating visceral, viselike pain located at substernal and rarely in precordial- Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles(abdominal ischemia)- Not usually relieved by rest or by nitroglycerine2. Dyspnea3. Increase in blood pressure (initial sign)4. Hyperthermia5. Ashen skin6. Mild restlessness and apprehension7. Occasional findingsa. Pericardial friction rubb. Split S1 and S2c. Rales/Crackles upon auscultationd. S4 or atrial gallopE. Diagnostic Procedure1. Cardiac Enzymesa. CPK – MB- Creatinine phosphokinase is increased- Heart only, 12 – 24 hoursb. LDH – Lactic acid dehydroginase is increasedc. SGPT – Serum glutamic pyruvate transaminase is increasedd. SGOT – Serum glutamic oxal-acetic transaminase is increased2. Troponin Test – is increased3. ECG tracing revealsa. ST segment elevationb. T wave inversionc. Widening of QRS complexes indicates that there is arrhythmia in MI4. Serum Cholesterol and uric acid are both increased

5. CBC – increased WBCF. Nursing ManagementGoal: Decrease myocardial oxygen demand1. Decrease myocardial workload (rest heart)- Administer narcotic analgesic/morphine sulfate- Side Effects: respiratory depression- Antidote: Narcan/Naloxone- Side Effects of Naloxone Toxicity is tremors2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min3. Enforce CBR without bathroom privilegesa. Using bedside commode4. Instruct client to avoid forms of valsalva maneuver5. Place client on semi fowlers position6. Monitor strictly vital signs, intake and output and ECG tracing7. Provide a general liquid to soft diet that is low in saturated fats, sodium and caffeine8. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy to induce vasodilation9. Administer medication as ordereda. Vasodilators- Nitroglycerine- ISD (Isosorbide Dinitrate, Isodil) sublingualb. Anti Arrythmic Agents- Lidocaine (Xylocane- Side Effects: confusion and dizziness- Brutyliumc. Beta-blockersd. ACE Inhibitorse. Calcium Antagonistf. Thrombolytics/ Fibrinolytic Agents- Streptokinase- Side Effects: allergic reaction, pruritus- Urokinase- TIPAF (tissue plasminogen activating factor)- Side Effects: chest pain- Monitor for bleeding timeg. Anti Coagulant- Heparin (check for partial thrombin time)- Antidote: protamine sulfate- Coumadin/ Warfarin Sodium (check for prothrombin time)- Antidote: Vitamin Kh. Anti Platelet- PASA (Aspirin)- Anti thrombotic effect- Side Effects of Aspirin562Tinnitus563Heartburn564Indigestion/Dyspepsia- Contraindication565Dengue566Peptic Ulcer Disease567Unknown cause of headache10. Provide client health teaching and discharge planning concerninga. Avoidance of modifiable risk factors- arrhythmia (caused by premature ventricular contraction)b. Cardiogenic shock- late sign is oliguriac. Left Congestive Heart Failured. Thrombophlebitis- homan’s signe. Stroke/CVAf. Post MI Syndrome/Dressler’s Syndrome- client is resistant to pharmacological agents, administer 150,000 – 450,000units of streptokinase as orderedg. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab,post CABG and instruct to- make sex as an appetizer rather than dessert- instruct client to assume a non weight bearing position- client can resume sexual intercourse if can climb staircase- dietary modificationh. Strict compliance to mediation and importance of follow up careCONGESTIVE HEART FAILUREInability of the heart to pump blood towards systemic circulation

Types of Heart Failure1. LEFT SIDED HEART FAILUREA. Predisposing Factors1. 90% is mitral valve stenosis due toa. RHD – inflammation of mitral valve due to invasion of Grp. A beta-hemolytic

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streptococcus- Formation of aschoff bodies in the mitral valve- Common among children- ASO Titer (Anti streptolysin O titer)- Penicillin- Aspirinb. Aging2. Myocardial Infarction3. Ischemic heart disease4. Hypertension5. Aortic valve stenosisB. Signs and Symptoms1. Dyspnea2. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing3. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers4. Productive cough with blood tinged sputum5. Frothy salivation6. Cyanosis7. Rales/Crackles8. Bronchial wheezing9. Pulsus Alternans – weak pulse followed by strong bounding pulse10. PMI is displaced laterally due to cardiomegaly11. There is anorexia and generalized body malaise12. S3 – ventricular gallopC. Diagnostic Procedure1. Chest x-ray – reveals cardiomegaly2. PAP (pulmonary arterial pressure) – measures pressure in right ventricle or cardiac statusPCWP (pulmonary capillary wedge pressure) – measures end systolic and dyastolic pressure568both are increased569done by cardiac catheterization (insertion of swan ganz catheter)3. Ecocardiography – enlarged heart chamber (cardiomyopathy), dependent on extent of heartfailure4. ABG – reveals PO2 is decreased (hypoxemia), PCO2 is increased (respiratory acidosis)

2. RIGHT SIDED HEART FAILUREA. Predisposing Factors1. Tricuspid valve stenosis2. Pulmonary embolism3. Related to COPD4. Pulmonic valve stenosis5. Left sided heart failureB. Signs and Symptoms (venous congestion)1. Neck/jugular vein distension2. Pitting edema3. Ascites4. Weight gain5. Hepatosplenomegaly6. Jaundice7. Pruritus8. Anorexia9. Esophageal varicesC. Diagnostic Procedures1. Chest x-ray – reveals cardiomegaly2. Central venous pressure (CVP)- Measure pressure in right atrium (4 – 10 cm of water)- CVP fluid status measure- If CVP is less than 4 cm of water hypovolemic shock- Do the fluid challenge (increase IV flow rate)- If CVP is more than 10 cm of water hypervolemic shock- Administer loop diuretics as ordered- When reading CVP patient should be flat on bed- Upon insertion place client in trendelendberg position to promote ventricular filling andprevent pulmonary embolism3. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy4. Liver enzymes – SGPT and SGOT is increasedD. Nursing ManagementGoal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min)1. Enforce CBR2. Administer medications as ordereda. Cardiac glycosides- Digoxin (Lanoxin)- Increase force of cardiac contraction- If heart rate is decreased do not give

b. Loop Diuretics- Lasix (Furosemide)c. Bronchodilatorsd. Narcotic analgesics- Morphine Sulfatee. Vasodilators- Nitroglycerinef. Anti Arrhythmic- Lidocaine (Xylocane)3. Administer oxygen inhalation with high inflow, 3 – 4 L/min, delivered via nasal cannula4. High fowlers position5. Monitor strictly vital signs, intake and output and ECG tracing6. Measure abdominal girth daily and notify physician7. Provide a dietary intake of low sodium, cholesterol and caffeine8. Provide meticulous skin care9. Assist in bloodless phlebotomy – rotating tourniquet, rotated clockwise every 15 minutes topromote decrease venous return10. Provide client health teaching and discharge planninga. Prevent complications- Arrythmia- Shock- Right ventricular hypertrophy- MI- Thrombophlebitisb. Dietary modificationc. Strict compliance to medications

PERIPHERAL VASCULAR DISORDERArterial UlcerI. Thrombo Angitis Obliterans570Burger’s Disease571Reynaud’s DiseaseVenous Ulcer1. Varicose Veins2. Thrombophlebitis (deep vein thrombosis)THROMBOANGITIS OBLITERANSAcute inflammatory disorder usually affecting the small medium sized arteries and veins of thelower extremitiesA. Predisposing Factors1. High risk groups – men 30 years old and above2. SmokingB. Signs and Symptoms1. Intermittent claudication – leg pain upon walking2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)3. Decreased peripheral pulses4. Trophic changes5. Ulceration6. Gangrene formationC. Diagnostic Procedures1. Oscillometry – decrease in peripheral pulses2. Doppler UTZ – decrease blood flow to the affected extremity3. Angiography – reveals site and extent of malocclusionD. Nursing Management1. Encourage a slow progressive physical activitya. walking 3 – 4 times a dayb. out of bed 3 – 4 times a day2. Administer medications as ordereda. Analgesicsb. Vasodilatorsc. Anti coagulants3. Institute foot care management4. Instruct client to avoid smoking and exposure to cold environment5. Assist in surgical procedure – bellow knee amputationREYNAUD’S DISEASEDisorder characterized by acute episodes of arterial spasm involving the fingers or digits of thehandsA. Predisposing Factors1. High risk group – female 40 years old and above2. Smoking3. Collagen diseasesa. SLE (butterfly rash)b. Rheumatoid Arthritis4. Direct hand traumaa. Piano playingb. Excessive typingc. Operating chainsawB. Signs and Symptoms1. Intermittent claudication – leg pain upon walking

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2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)3. Trophic changes4. Ulceration5. Gangrene formationC. Diagnostic Procedures1. Doppler UTZ – decrease blood flow to the affected extremity2. Angiography – reveals site and extent of malocclusionD. Nursing Management1. Administer medications as ordereda. Analgesicsb. Vasodilators2. Encourage to wear gloves3. Instruct client on importance of cessation of smoking and exposure to cold environment

VARICOSITIESAbnormal dilation of veins of lower extremities and trunks due toIncompetent valve resulting toIncreased venous pooling resulting toVenous stasis causingDecrease venous returnA. Predisposing Factors1. Hereditary2. Congenital weakness of veins3. Thrombophlebitis4. Cardiac disorder5. Pregnancy6. Obesity7. Prolonged standing or sittingB. Signs and Symptoms1. Pain after prolonged standing2. Dilated tortuous skin veins3. Warm to touch4. Heaviness in legsC. Diagnostic Procedure1. Venography2. Trendelenburg’s Test - veins distends quickly in less than 35 secondsD. Nursing Management1. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillowsunder the legs2. Measure the circumference of leg muscle to determine if swollen3. Wear anti embolic stockings4. Administer medications as ordereda. Analgesics5. Assist in surgical procedurea. Vein stripping and ligation (most effective)b. Sclerotherapy – can recur and only done in spider web varicosities and danger ofthrombosis (2 – 3 years for embolism)

THROMBOPHLEBITISDeep vein thrombosisInflammation of the veins with thrombus formationA. Predisposing Factors1. Obesity2. Smoking3. Related to pregnancy4. Chronic anemia5. Prolong use of oral contraceptives – promotes lipolysis6. Diabetes mellitus7. Congestive heart failure8. Myocardial infarction9. Post op complication10. Post cannulation – insertion of various cardiac catheter11. Increase in saturated fats in the diet.B. Signs and Symptoms1. Pain at affected extremity2. Warm to touch3. Dilated tortuous skin veins4. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the footC. Diagnostic Procedure1. Venography2. AngiographyD. Nursing Management1. Elevate legs above heart level to promote increase venous return2. Apply warm moist pack – to reduce lymphatic congestion3. Measure circumference of leg muscle to determine if swollen4. Encourage to wear anti embolic stockings or knee elastic stockings5. Administer medications as ordered

a. Analgesicsb. Anti Coagulant- Heparin6. Monitor for signs of complicationsEmbolisma. Pulmonary- Sudden sharp chest pain- Unexplained dyspnea- Tachycardia- Palpitations- Diaphoresis- Restlessnessb. Cerebral- Headache- Dizziness- Decrease LOC572MURPHY’S SIGN is seen in clients with cholelithiasis, cholecystitis characterizedby pain at the right upper quadrant with tenderness

RESPIRATORY SYSTEMOVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEMI. Upper Respiratory System1. Filtering of air2. Warming and moistening of air3. HumidificationA. Nose- Cartillage- Right nostril- Left nostril- Separated by septum- Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding)B. Pharynx/Throat- Serves as a muscular passageway for both food and airC. Larynx- For phonation (voice production)- For cough reflexGlottis- Opening of larynx- Opens to allow passage of air- Closes to allow passage of food going to the esophagus- The initial sign of complete airway obstruction is the inability to coughII. Lower Respiratory System- For gas exchangeA. Trachea/Windpipe- Consist of cartilaginous rings- Serves as passageway of air going to the lungs- Site of tracheostomyB. Bronchus- Right main bronchus- Left main bronchusC. Lungs- Right lung (consist of 3 lobes, 10 segments)- Left lung (consist of 2 lobes, 8 segments)- Serous membranesPleural Cavity573Pareital574Pleural fluid575VisceralWith Pleuritic Friction Ruba. Pneumoniab. Pleural effusionc. Hydrothorax (air and blood in pleural spaceAlveoli- Site of gas exchange (CO2 and O2)- Diffusion (Dalton’s law of partial pressure of gases)Respiratory Distress Syndrome- Decrease oxygen stimulates breathing- Increase carbon dioxide is a powerful stimulant for breathingType II Cells of Alveoli- Secretes surfactant- Decrease surface tension- Prevent collapse of alveoli- Composed of lecithin and spingomyelin- L/S ratio to determine lung maturity- Normal L/S ratio is 2:1- In premature infants 1:2- Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias- retinopathy/blindness in prematurityDisorders of Respiratory System

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1. PTB/Pulmonary Tuberculosis (Koch’s Disease)- Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli- An acid fast, gram negative, aerobic and easily destroyed by heat or sunlightA. Precipitating Factors1. Malnutrition2. Overcrowded places3. Alcoholism4. Over fatigue5. Ingestion of an infected cattle with mycobacterium bovis6. Virulence (degree of pathogenecity) of microorganismB. Mode of Transmission1. Airborne transmission via droplet nucleiC. Signs and Symptoms1. Low grade afternoon fever, night sweats2. Productive cough (yellowish sputum)3. Anorexia, generalized body malaise4. Weight loss5. Dyspnea6. Chest pain7. Hemoptysis (chronic)D. Diagnostic Procedure1. Mantoux Test (skin test)- Purified protein derivative- DOH 8 – 10 mm induration, 48 – 72 hours- WHO 10 – 14 mm induration, 48 – 72 hours- Positive Mantoux test (previous exposure to tubercle bacilli but without active TB)2. Sputum Acid Fast Bacillus- Positive to cultured microorganism3. Chest X-ray- Reveals pulmonary infiltrates4. CBC- Reveals increase WBCE. Nursing Management1. Enforce CBR2. Institute strict respiratory isolation3. Administer oxygen inhalation4. Force fluids to liquefy secretions5. Place client on semi fowlers position to promote expansion of lungs6. Encourage deep breathing and coughing exercise7. Nebulize and suction when needed8. Comfortable and humid environment9. Institute short course chemotherapya. Intensive phase- INH (Isonicotinic Acid Hydrazide)- Rifampicin (Rifampin)- PZA (Pyrazinamide)- Given everyday simultaneously to prevent resistance- INH and Rifampicin is given for 4 months, taken before meals to facilitate absorption- PZA is given for 2 months, taken after meals to facilitate absorption- Side Effect INH: peripheral neuritis/neuropathy (increase intake of VitaminB6/Pyridoxine)- Side Effect Rifampicin: all bodily secretions turn to red orange color- Side Effect PZA: allergic reaction, hepatotoxicity, nephrotoxicity- PZA can be replaced by Ethambutol- Side Effect Ethambutol: optic neuritisb. Standard phase- Injection of streptomycin (aminoglycoside)- Kanamycin- Amikacin- Neomycin- Gentamycin- Side Effect:- Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss- Nephrotoxicity check for BUN and Creatinine- Give aspirin if there is fever- Side Effect: tinnitus, dyspepsia, heartburn10. Provide increase carbohydrates, protein, vitamin C and calories11. Provide client health teaching and discharge planninga. Avoidance of precipitating factorsb. Prevent complications (atelectasis, military tuberculosis)PTB- Bones (potts)- Meninges- Eyes- Skin

- Adrenal glandc. Strict compliance to medicationsd. Importance of follow up care

PNEUMONIAInflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filledwith exudatesA. Etiologic Agents1. Streptococcus Pneumonae – causing pneumococal pneumonia2. Hemophylus Influenzae – causing broncho pneumonia3. Diplococcus Pneumoniae4. Klebsella Pneumoniae5. Escherichia Pneumoniae6. PseudomonasB. High Risk Groups1. Children below 5 years old2. ElderlyC. Predisposing Factors1. Smoking2. Air pollution3. Immuno compromiseda. AIDS- Pneumocystic carini pneumonia- Drug of choice is Retrovirb. Bronchogenic Cancer- Initial sign is non productive cough- Chest x-ray confirms lung cancer4. Related to prolonged immobility (CVA clients), causing hypostatic pneumonia5. Aspiration of food causing aspiration pneumoniaD. Signs and Symptoms1. Productive cough with greenish to rusty sputum2. Dyspnea with prolong expiratory grunt3. Fever, chills, anorexia and general body malaise4. Weight loss5. Rales/crackles6. Bronchial wheezing7. Cyanosis8. Pleuritic friction rub9. Chest pain10. Abdominal distention leading to paralytic ileus (absence of peristalsis)E. Diagnostic Procedure1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms2. Chest x-ray – reveals pulmonary consolidation3. ABG analysis – reveals decrease PO24. CBC – reveals increase WBC, erythrocyte sedimentation rate is increasedF. Nursing Management1. Enforce CBR2. Administer oxygen inhalation low inflow3. Administer medications as orderedBroad Spectrum Antibiotic576Penicillin577Tetracycline578Microlides (Zethromax)579Azethromycin (Side Effect: Ototoxicity)580Antipyretics581Mucolytics/Expectorants582Analgesics4. Force fluid5. Place on semi fowlers position6. Institute pulmonary toilet (tends to promote expectoration)- Deep breathing exercises- Coughing exercises- Chest physiotherapy- Turning and reposition7. Nebulize and suction as needed8. Assist in postural drainage- Drain uppermost area of lungs- Placed on various positionNursing Management for Postural Drainagea. Best done before meals or 2 – 3 hours to prevent gastro esophageal refluxb. Monitor vital signsc. Encourage client deep breathing exercisesd. Administer bronchodilators 15 – 30 minutes before proceduree. Stop if client cannot tolerate proceduref. Provide oral care after procedureg. Contraindicated with- Unstable vital signs- Hemoptysis

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- Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg)- Increase ICP9. Provide increase carbohydrates, calories, protein and vitamin C10. Health teaching and discharge planninga. Avoid smokingb. Prevent complications- Atelectasis- Meningitis (nerve deafness, hydrocephalus)c. Regular adherence to medicationsd. Importance of follow up care

HISTOPLASMOSISAcute fungal infection caused by inhalation of contaminated dust or particles with histoplasmacapsulatum derived from birds manureA. Signs and SymptomsPTB or Pneumonia like1. Productive cough2. Dyspnea3. Fever, chills, anorexia, general body malaise4. Cyanosis5. Hemoptysis6. Chest and joint painsB. Diagnostic Procedures1. Histoplasmin Skin Test – positive2. ABG analysis PO2 decreaseC. Nursing Management1. Enforce CBR2. Administer oxygen inhalation3. Administer medications as ordereda. Antifungal- Amphotericin B- Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia)b. Steroidsc. Mucolyticsd. Antipyretics4. Force fluids to liquefy secretions5. Nebulize and suction as needed6. Prevent complications – bronchiectasis7. Prevent the spread of infection by spraying of breeding placesCOPD (Chronic Obstructive Pulmonary/Lung Disease)Chronic BronchitisInflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producingcells leading to narrowing of smaller airwaysA. Predisposing Factors1. Smoking2. Air pollutionB. Signs and Symptoms1. Productive cough (consistent to all COPD)2. Dyspnea on exertion3. Prolonged expiratory grunt4. Anorexia and generalized body malaise5. Scattered rales/ronchi6. Cyanosis7. Pulmonary hypertensiona. Peripheral edemab. Cor Pulmonale (right ventricular hypertrophy)C. Diagnostic ProcedureABG analysis – reveals PO2 decrease (hypoxemia), PCO2 increase, pH decreaseBronchial AsthmaReversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing ofsmaller airwaysA. Predisposing Factors (Depending on Types)1. Extrinsic Asthma ( Atopic/ Allergic )Causesa. Pollenb. Dustc. Fumesd. Smokee. Gasesf. Dandersg. Fursh. Lints2. Intrinsic Asthma (Non atopic/Non allergic)Causesa. Hereditaryb. Drugs (aspirin, penicillin, beta blocker)c. Foods (seafoods, eggs, milk, chocolates, chickend. Food additives (nitrates)

e. Sudden change in temperature, air pressure and humidityf. Physical and emotional stress3. Mixed Type 90 – 95%B. Signs and Symptoms1. Cough that is non productive2. Dyspnea3. Wheezing on expiration4. Cyanosis5. Mild Stress/apprehension6. Tachycardia, palpitations7. DiaphoresisC. Diagnostic Procedure1. Pulmonary Function Test- Incentive spirometer reveals decrease vital lung capacity2. ABG analysis – PO2 decrease- Before ABG test for positive Allens Test, apply direct pressure to ulnar and radial artery todetermine presence of collateral circulationD. Nursing Management1. Enforce CBR2. Oxygen inhalation, with low inflow of 2 – 3 L/min3. Administer medications as ordereda. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutesb. Steroids – decrease inflammationc. Mucomysts (acetylceisteine)d. Mucolytics/expectorantse. Anti histamine4. Force fluids5. Semi fowlers position6. Nebulize and suction when needed7. Provide client health teachings and discharge planning concerninga. Avoidance of precipitating factorb. Prevent complications- Emphysema- Status Asthmaticus (give drug of choice)- Epinephrine- Steroids- Bronchodilatorsc. Regular adherence to medications to prevent development of status asthmaticusd. Importance of follow up care

BRONCHIECTASISAbnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues ofalveoliA. Predisposing Factors1. Recurrent lower respiratory tract infections2. Chest trauma3. Congenital defects4. Related to presence of tumorB. Signs and Symptoms1. Productive cough2. Dyspnea3. Cyanosis4. Anorexia and generalized body malaise5. Hemoptysis (only COPD with sign)C. Diagnostic Procedure1. ABG – PO2 decrease2. Bronchoscopy – direct visualization of bronchus using fiberscopeNursing Management PRE Bronchoscopy1. Secure inform consent and explain procedure to client2. Maintain NPO 6 – 8 hours prior to procedure3. Monitor vital signs and breath soundPOST Bronchoscopy1. Feeding initiated upon return of gag reflex2. Avoid talking, coughing and smoking, may cause irritation3. Monitor for signs of gross4. Monitor for signs of laryngeal spasm – prepare tracheostomy setD. Treatment1. Surgery (pneumonectomy , 1 lung is removed and position on affected side)2. Segmental Wedge Lobectomy (promote re expansion of lungs)- Unaffected lobectomy facilitate drainageEMPHYSEMAIrreversible terminal stage of COPD characterized bya. Inelasticity of alveolib. Air trappingc. Maldistribution of gasesd. Over distention of thoracic cavity (barrel chest)A. Predisposing Factors1. Smoking

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2. Air pollution3. Allergy4. High risk: elderly5. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase, forrecoil of alveoli)B. Signs and Symptoms1. Productive cough2. Dyspnea at rest3. Prolong expiratory grunt4. Anorexia and generalized body malaise5. Resonance to hyperresonance6. Decrease tactile fremitus7. Decrease or diminished breath sounds8. Rales or ronchi9. Bronchial wheezing10. Barrel chest11. Flaring of alai nares12. Purse lip breathing to eliminates excess CO2 (compensatory mechanism)C. Diagnostic Procedure1. Pulmonary Function Test – reveals decrease vital lung capacity2. ABG analysis revealsa. Panlobular/ centrilobular- Decrease PO2 (hypoxemia leading to chronic bronchitis, “Blue Bloaters”)- Decrease ph- Increase PCO2- Respiratory acidosisb. Panacinar/ centriacinar- Increase PO2 (hyperaxemia, “Pink Puffers”)- Decrease PCO2- Increase ph- Respiratory alkalosisD. Nursing Management1. Enforce CBR2. Administer oxygen inhalation via low inflow3. Administer medications as ordereda. Bronchodilatorsb. Steroidsc. Antibioticsd. Mucolytics/expectorants4. High fowlers position5. Force fluids6. Institute pulmonary toilet7. Nebulize and suction when needed8. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximumalveolar lung expansion9. Provide comfortable and humid environment10. Provide high carbohydrates, protein, calories, vitamins and minerals11. Health teachings and discharge planning concerninga. Avoid smokingb. Prevent complications- Atelectasis- Cor Pulmonale- CO2 narcosis may lead to coma- Pneumothoraxc. Strict compliance to medicationd. Importance of follow up care

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