Myelin Sheath

MEDICAL-SURGICAL NURSING  A wrapping of myelin (whitish, fatty material) that protects and insulates
nerve fibers and enhances the speed of impulse conduction.
Overview of structures and functions: o Both axons and dendrites may or may not have a myelin sheath
NERVOUS SYSTEM (myelinated/unmyelinated)
 The functional unit of the nervous system is the nerve cells or neurons o Most axons leaving the CNS are heavily myelinated by schwann
 The nervous system is composed of the ff: cells
Central Nervous System Functional Classification
 Brain 1. Afferent (sensory) neurons
 Spinal Cord – serves as a connecting link between the brain & the  Transmit impulses from peripheral receptors to the CNS
periphery. 2. Efferent (motor) neurons
Peripheral Nervous System  Conduct impulses from CNS to muscle and glands
 Cranial Nerves –12 pairs; carry impulses to & from the brain. 3. Internuncial neurons (interneurons)
 Spinal Nerves – 31 pairs; carry impulses to & from spinal cord.  Connecting links between afferent and efferent neurons
Autonomic Nervous System Properties
 subdivision of the PNS that automatically controls body function such as 1. Excitability – ability of neuron to be affected by changes in external
breathing & heart beat. environment.
 Special senses of vision and hearing are also covered in this section 2. Conductility – ability of neuron to transmit a wave of excitetation from one
cell to another.
 Sympathetic nervous system – generally accelerate some body functions in 3. Permanent Cell – once destroyed not capable of regeneration.
response to stress.
 Parasympathetic nervous system – controls normal body functioning. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY
CELLS 1. Labile
A. NEURONS  Capable of regeneration.
 Primary component of nervous system  Epidermal cells, GIT cells, GUT cells, cells of lungs.
 Composed of cell body (gray matter), axon, and dendrites 2. Stable
 Basic cells for nerve impulse and conduction.  Capable of regeneration with limited time, survival period.
Axon  Kidney cells, Liver cells, Salivary cells, pancreas.
 Elongated process or fiber extending from the cell body 3. Permanent
 Transmits impulses (messages) away from the cell body to dendrites or  Not capable of regeneration.
directly to the cell bodies of other neurons  Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
 Neurons usually has only one axon
Dendrites B. NEUROGLIA
 Short, blanching fibers that receives impulses and conducts them toward  Support and protection of neurons.
the nerve cell body.
 Neurons may have many dendrites. TYPES
Synapse 1. Astrocytes
 Junction between neurons where an impulse is transmitted  maintains blood brain barrier semi-permiable.
Neurotransmitter  majority of brain tumors (90%) arises from called astrocytoma.
 Chemical agent (ex. Acetylcholine, norepinephrine) involved in the  integrity of blood brain barrier.
transmission of impulse across synapse. 2. Oligodendria
  produces myelin sheath in CNS.  hearing, taste, smell
 act as insulator and facilitates rapid nerve impulse transmission.  short term memory
3. Microglia  Wernicke’s area: sensory speech area (understanding/formulation of
 stationary cells that carry on phagocytosis (engulfing of bacteria or language)
cellular debris, eating), pinocytosis (cell drinking). 3. Pareital Lobe
4. Epindymal  for appreciation
 secretes a glue called chemo attractants that concentrate the bacteria.  integrates sensory information
 discrimination of sensory impulses to pain, touch, pressure, heat, cold,
MACROPHAGE ORGAN numbness.
Microglia Brain  Postcentral gyrus: registered general sensation (ex. Touch, pressure)
Monocytes Blood 4. Occipital Lobe
Kupffers Kidney  for vision
Histiocytes Skin Insula (Island of Reil)
Alveolar Macrophage Lung  visceral function activities of internal organ like gastric motility.
Limbic System (Rhinencephalon)
 controls smell - if damaged results to anosmia (absence of smell).
Central Nervous System  controls libido
Composition Of Brain  controls long term memory
 80% brain mass Corpus Callosum
 10% blood  large fiber tract that connects the two cerebral hemisphere
 10% CSF Basal Ganglia
Brain Mass  island of gray matter within white matter of cerebrum
Parts Of The Brain  regulate & integrate motor activity originating in the cerebral cortex
1. Cerebrum  part of extrapyramidal system
 largest part of the brain  area of gray matter located deep within each cerebral hemisphere.
 outermost area (cerebral cortex) is gray matter  release dopamine (controls gross voluntary movement).
 deeper area is composed of white matter
 function of cerebrum: integration, sensory, motor 2. Diencephalon/interbrain
 composed of two hemisphere the Right Cerebral Hemisphere and Left  Connecting part of the brain, between the cerebrum & the brain stem
Cerebral Hemisphere enclosed in the Corpus Callosum.  Contains several small structures: the thalamus & hypothalamus are
 Each hemisphere divided into four lobes; many of the functional areas most important
of the cerebrum have been located in these lobes: Thalamus
 acts as relay station for discrimination of sensory signals (ex. Pain,
Lobes of Cerebrum temperature, touch)
1. Frontal Lobe  controls primitive emotional responses (ex. Rage, fear)
 controls personality, behavior Hypothalamus
 higher cortical thinking, intellectual functioning  found immediately beneath the thalamus
 precentral gyrus: controls motor function  plays a major role in regulation/controls of vital function: blood
 Broca’s Area: specialized motor speech area - when damaged results pressure, thirst, appetite, sleep & wakefulness, temperature
to garbled speech. (thermoregulatory center)
2. Temporal Lobe
  acts as controls center for pituitary gland and affects both divisions of  H-shaped gray matter in the center (cell bodies) surrounded by white
the autonomic nervous system. matter (nerve tract and fibers)
 controls some emotional responses like fear, anxiety and excitement.
 androgenic hormones promotes secondary sex characteristics. Gray Matter
 early sign for males are testicular and penile enlargement 1. Anterior Horns
 late sign is deepening of voice.  Contains cell bodies giving rise to efferent (motor) fibers
 early sign for females telarch and late sign is menarch. 2. Posterior Horns
 Contains cell bodies connecting with afferent (sensory) fibers
3. Mesencephalon/Midbrain from dorsal root ganglion
 acts as relay station for sight and hearing. 3. Lateral Horns
 size of pupil is 2 – 3 mm.  In thoracic region, contain cells giving rise to autonomic fibers of
 equal size of pupil is isocoria. sympathetic nervous system
 unequal size of pupil is anisocoria.
 hearing acuity is 30 – 40 dB. White Matter
 positive PERRLA 1. Ascending Tracts (sensory pathways)
a. Posterior Column
4. Brain Stem  Carry impulses concerned with touch, pressure,
 located at lowest part of brain. vibration, & position sense
b. Spinocerebellar
 contains midbrain, pons, medulla oblongata.
 extends from the cerebral hemispheres to the foramen magnum at  Carry impulses concerned with muscle tension &
the base of the skull. position sense to cerebellum
 contains nuclei of the cranial nerves and the long ascending and
c. Lateral Spinothalamic
descending tracts connecting the cerebrum and the spinal cord.
 Carry impulses resulting in pain & temperature
 contains vital center of respiratory, vasomotor, and cardiac functions.
sensations
d. Anterior Spinothlamic
Pons
 Carry impulses concerned with crude touch &
 pneumotaxic center controls the rate, rhythm and depth of
pressure
respiration.
2. Descending Tracts (motor pathways)
Medulla Oblongata
a. Corticospinal (pyramidal, upper motor neurons)
 controls respiration, heart rate, swallowing, vomiting, hiccup,
 Conduct motor impulses from motor cortex to
vasomotor center (dilation and constriction of bronchioles).
anterior horn cells (cross in the medulla)
b. Extrapyramidal
5. Cerebellum
 Help to maintain muscle tone & to control body
 smallest part of the brain, lesser brain.
movement, especially gross automatic movements
 coordinates muscle tone and movements and maintains position in
such as walking
space (equilibrium)
 controls balance, equilibrium, posture and gait.
Reflex Arc
 Reflex consists of an involuntary response to a stimulus occurring over
Spinal Cord
a neural pathway called a reflex arc.
 serves as a connecting link between the brain and periphery
 Not relayed to & from brain: take place at cord levels
 extends from foramen magnum to second lumbar vertebra
  Surrounds brain & spinal cord
Components  Offer protection by functioning as a shock absorber
a. Sensory Receptors  Allows fluid shifts from the cranial cavity to the spinal cavity
 Receives/reacts to stimulus  Carries nutrient to & waste product away from nerve cells
b. Afferent Pathways  Component of CSF: CHON, WBC, Glucose
 Transmits impulses to spinal cord 6. Vascular Supply
c. Interneurons  Two internal carotid arteries anteriorly
 Synapses with a motor neuron (anterior horn cell)  Two vertebral arteries leading to basilar artery posteriorly
d. Efferent Pathways  These arteries communicate at the base of the brain through the circle
 Transmits impulses from motor neuron to effector of willis
e. Effectors  Anterior, middle, & posterior cerebral arteries are the main arteries
 Muscle or organ that responds to stimulus for distributing blood to each hemisphere of the brain
 Brain stem & cerebellum are supplied by branches of the vertebral &
Supporting Structures basilar arteries
1. Skull  Venous blood drains into dural sinuses & then into jugular veins
 Rigid; numerous bones fused together 7. Blood-Brain-Barrier (BBB)
 Protects & support the brain  Protective barrier preventing harmful agents from entering the
2. Spinal Column capillaries of the CNS; protect brain & spinal cord
 Consists of 7 cervical, 12 thoracic, & 5 lumbar vertebrae as well as
sacrum & coccyx Substance That Can Pass Blood-Brain Barrier
 Supports the head & protect the spinal cord 1. Amonia
3. Meninges  Cerebral toxin
 Membranes between the skull & brain & the vertebral column &  Hepatic Encephalopathy (Liver Cirrhosis)
spinal cord  Ascites
 3 fold membrane that covers brain and spinal cord.  Esophageal Varices
 For support and protection; for nourishment; blood supply Early Signs of Hepatic Encephalopathy
 Area between arachnoid & pia mater is called subarachnoid space:  Asterexis (flapping hand tremors).
CSF aspiration is done Late Signs of Hepatic Encephalopathy
 Subdural space between the dura and arachnoid  Headache
 Layers:  Dizziness
Dura Mater  Confusion
 outermost layer, tough, leathery  Fetor hepaticus (amonia like breath)
Arachnoid Mater  decrease LOC
 middle layer, weblike 2. Carbon Monoxide and Lead Poisoning
Pia Mater  Can lead to Parkinson’s Disease.
 innermost layer, delicate, clings to surface of brain  Epilepsy
4. Ventricles  Treated with calcium EDTA.
 Four fluid-filled cavities connecting with one another & spinal 3. Type 1 DM (IDDM)
canal  Causes diabetic ketoacidosis.
 Produce & circulate cerebrospinal fluid  And increases breakdown of fats.
5. Cerebrospinal Fluid (CSF)  And free fatty acids
  Resulting to cholesterol and positive to ketones (CNS depressant). Controlling mastication.
 Resulting to acetone breath odor/fruity odor. Abducens : CN VI Motor: muscles for lateral deviation of
 And kusshmauls respiration a rapid shallow respiration. eye
 Which may lead to diabetic coma. Facial : CN VII Mixed: impulses for taste from anterior
4. Hepatitis tongue; muscles for facial
 Signs of jaundice (icteric sclerae). Movement.
 Caused by bilirubin (yellow pigment) Acoustic : CN VIII Sensory: impulses for hearing (cochlear
5. Bilirubin division) & balance (vestibular
 Increase bilirubin in brain (kernicterus). Division).
 Causing irreversible brain damage. Glossopharyngeal : CN IX Mixed: impulses for sensation to
posterior tongue & pharynx; muscle
Peripheral Nervous System For movement of pharynx (elevation) &
swallowing.
Spinal Nerves Vagus : CN X Mixed: impulses for sensation to lower
 31 pairs: carry impulses to & from spinal cord pharynx & larynx; muscle for
 Each segment of the spinal cord contains a pair of spinal nerves (one of Movement of soft palate, pharynx, &
each side of the body) larynx.
 Each nerve is attached to the spinal by two roots: Spinal Accessory : CN XI Motor: movement of sternomastoid
1. Dorsal (posterior) roots muscles & upper part of trapezius
 contains afferent (sensory) nerve whose cell body is in the Muscles.
dorsal roots ganglion Hypoglossal : CN XII Motor: movement of tongue.
2. Ventral (anterior) roots
Autonomic Nervous System
 Contains efferent (motor) nerve whose nerve fibers originate
 Part of the peripheral nervous system
in the anterior horn cell of the spinal cord (lower motor
 Include those peripheral nerves (both cranial & spinal) that regulates
neuron)
smooth muscles, cardiac muscles, & glands.
 Component:
Cranial Nerves
1. Sympathetic Nervous System
 12 pairs: carry impulses to & from the brain.
 Generally accelerates some body function in response to stress.
 May have sensory, motor, or mixed functions.
2. Parasympathetic Nervous System
 Controls normal body functioning
Name & Number Function
Olfactory : CN I Sensory: carries impulses for sense of
smell. Sympathetic Nervous System Parasympathetic Nervous System
Optic : CN II Sensory: carries impulses for vision. (Adrenergic) Effect (Cholinergic) Effect, Vagal, Sympatholytic
Oculomotor : CN III Motor: muscles for papillary - Involved in fight or aggression - Involved in flight or withdrawal
constriction, elevation of upper eyelid; response. response.
4 out of 6 extraocular movement. - Release of Norepinephrine - Release of Acetylcholine.
Trochlear : CN IV Motor: muscles for downward, inward, (cathecolamines) from adrenal glands - Decreases all bodily activities except
movement of the eye and causes vasoconstriction. GIT.
Trigeminal : CN V Mixed: impulses from face, surface of - Increase all bodily activity except GIT
eyes (corneal reflex); muscle
EFFECTS OF SNS EFFECTS OF PNS
- Dilation of pupils (mydriasis) in order - Constriction of pupils (miosis).
to be aware. - Increase salivation. Effectors Sympathetic (Adrenergic) Effect
- Dry mouth (thickened saliva). - Decrease BP and Heart Rate. Parasympathetic (Cholinergic) Effect
- Increase BP and Heart Rate. - Bronchoconstriction, Decrease RR.
- Bronchodilation, Increase RR - Diarrhea Eye dilate pupil (mydriasis)
- Constipation. - Urinary frequency. constrict pupil (miosis)
- Urinary Retention.
- Increase blood supply to brain, heart Gland of Head
and skeletal muscles. Lacrimal no effect
- SNS stimulate secretions
I. Cholinergic Agents Salivary scanty thick, viscous secretions
I. Adrenergic Agents - Mestinon, Neostignin. copious thin, watery secretions
- Give Epinephrine. SE: Dry mouth
SE: - PNS effect
- SNS effect Heart increase rate & force of contraction
Contraindication: decrease rate
- Contraindicated to patients suffering
from COPD (Broncholitis, Blood Vessel constrict smooth muscles of the skin, no
Bronchoectasis, Emphysema, Asthma). II. Anti-cholinergic Agents effect
- To counter cholinergic agents. Abdominal blood vessels, and
II. Beta-adrenergic Blocking Agents - Atrophine Sulfate Cutaneous blood vessels
- Also called Beta-blockers. Dilates smooth muscles of bronchioles,
- all ending with “lol” SE: Blood vessels of the heart & skeletal muscles
- Propranolol, Atenelol, Metoprolol. - SNS effect
Effect of Beta-blockers Lungs bronchodilation
B – broncho spasm bronchoconstriction
E – elicits a decrease in myocardial
contraction.
T – treats hypertension. GI Tract decrease motility increase
A – AV conduction slows down. motility
- Should be given to patients with Constrict sphincters
Angina, Myocardial Infarction, relaxed sphincters
Hypertension Possibly inhibits secretions
stimulate secretions
ANTI- HYPERTENSIVE AGENTS Inhibits activity of gallbladder & ducts stimulate
1. Beta-blockers – “lol” activity of gallbladder & ducts
2. Ace Inhibitors – Angiotensin “pril” Inhibits glycogenolysis in liver
(Captopril, Enalapril)
3. Calcium Antagonist – Nifedipine Adrenal Gland stimulates secretion of epinephrine & no effect
(Calcibloc) Norepinephrine
- In chronic cases of arrhythmia give
Lidocane, Xylocane.
Urinary Tract relaxes detrusor muscles contract GCS Grading / Scoring
detrusor muscles 1. Conscious 15 – 14
Contract trigone sphincter (prevent voiding) relaxes 2. Lethargy 13 – 11
trigone sphincter (allows voiding) 3. Stupor 10 – 8
4. Coma 7
NEURO TRANSMITTER Decrease Increase 5. Deep Coma 3
Acethylcholine Myesthenia Gravis Bi-polar Disorder
Dopamine Parkinson’s Disease Schizophrenia 3. Pupillary Reaction & Eye Movement
a. Observe size, shape, & equality of pupil (note size in millimeter)
Physical Examination b. Reaction to light: pupillary constriction
Comprehensive Neuro Exam c. Corneal reflex: blink reflex in response to light stroking of cornea
Neuro Check d. Oculocephalic reflex (doll’s eyes): present in unconscious client with
1. Level of Consciousness (LOC) intact brainstem
a. Orientation to time, place, person 4. Motor Function
b. Speech: clear, garbled, rambling a. Movement of extremities (paralysis)
c. Ability to follow command b. Muscle strength
d. If does not respond to verbal stimuli, apply a painful stimulus (ex. 5. Vital Signs: respiratory patterns (may help localize possible lesion)
Pressure on the nailbeds, squeeze trapezius muscle); note response to a. Cheyne-Stokes Respiration: regular rhythmic alternating between
pain hyperventilation & apnea; may be caused by structural cerebral
 Appropriate: withdrawal, moaning dysfunction or by metabolic problems such as diabetic coma
 Inappropriate: non-purposeful b. Central Neurogenic Hyperventilation: sustained, rapid, regular
e. Abnormal posturing (may occur spontaneously or in response to respiration (rate of 25/min) with normal O2 level; usually due to
stimulus) brainstem dysfunction
 Decorticate Posturing: extension of leg, internal rotation & c. Apneustic Breathing: prolonged inspiratory phase, followed by a 2-to-
abduction of arms with flexion of elbows, wrist, & finger: (damage 3 sec pause; usually indicates dysfunction respiratory center in pons
to corticospinal tract; cerebral hemisphere) d. Cluster Breathing: cluster of irregular breathing, irregularly followed
 Decerebrate Posturing: back arched, rigid extension of all four by periods of apnea; usually caused by a lesion in upper medulla &
extremities with hyperpronation of arms & plantar flexion of feet: lower pons
(damage to upper brain stem, midbrain, or pons) e. Ataxic Breathing: breathing pattern completely irregular; indicates
damage to respiratory center of the medulla
2. Glasgow Coma Scale
 Objective measurement of LOC sometimes called as the quick neuro Neurologic Exam
check 1. Mental status and speech (Cerebral Function)
 Objective evaluation of LOC, motor / verbal response a. General appearance & behavior
 A standardized system for assessing the degree of neurologic b. LOC
impairment in critically ill client c. Intellectual Function: memory (recent & remote), attention span,
cognitive skills
Components d. Emotional status
1. Eye opening e. Thought content
2. Verbal response f. Language / speech
3. Motor response 2. Cranial nerve assessment
3. Cerebellar Function: posture, gait, balance, coordination
 a. Romberg’s Test: 2 nurses, positive for ataxia  Consider educational background
b. Finger to Nose Test: positive result mean dimetria (inability of body to
stop movement at desired point) Level of Orientation
4. Sensory Function: light touch, superficial pain, temperature, vibration & 1. Time: first asked
position sense 2. Person: second asked
5. Motor Function: muscle size, tone, strength; abnormal or involuntary 3. Place: third asked
movements
6. Reflexes Cranial Nerves
a. Deep tendon reflex: grade from 0 (no response); to 4 (hyperactive); 2 Cranial Nerves Function
(normal) 1. Olfactory S
b. Superficial 2. Optic S
c. Pathologic: babinski reflex (dorsiflexion of the great toe with fanning 3. Oculomotor M
of toes): indicates damage to corticospinal tracts 4. Trochlear M (smallest)
5. Trigeminal B (largest)
Level Of Consciouness (LOC) 6. Abducens M
1. Conscious: awake 7. Facial B
2. Lethargy: lethargic (drowsy, sleepy, obtunded) 8. Acoustic S
3. Stupor 9. Glossopharengeal B
 Stuporous: (awakened by vigorous stimulation) 10. Vagus B (longest)
 Generalized body weakness 11. Spinal Accessory M
 Decrease body reflex 12. Hypoglossal M
4. Coma
 Comatose CRANIAL NERVE I: OLFACTORY
 light coma: positive to all forms of painful stimulus  Sensory function for smell
 deep coma: negative to all forms of painful stimulus Material Used
 Don’t use alcohol, ammonia, perfume because it is irritating and highly
Different Painful Stimulation diffusible.
1. Deep sternal stimulation / deep sternal pressure  Use coffee granules, vinegar, bar of soap, cigarette
2. Orbital pressure Procedure
3. Pressure on great toes  Test each nostril by occluding each nostril
4. Corneal or blinking reflex Abnormal Findings
 Conscious Client: use a wisp of cotton 1. Hyposnia: decrease sensitivity to smell
 Unconscious Client: place 1 drop of saline solution 2. Dysosmia: distorted sense of smell
3. Anosmia: absence of smell
Test of Memory Either of the 3 may indicate head injury damaging the cribriform plate of ethmoid
1. Short term memory bone where olfactory cells are located may indicate inflammatory conditions
 Ask most recent activity (sinusitis)
 Positive result mean anterograde amnesia and damage to temporal
lobe CRANIAL NERVE II: OPTIC
2. Long term memory  Sensory function for vision or sight
 Ask for birthday and validate on profile sheet Functions
 Positive result mean retrograde amnesia and damage to limbic system 1. Test visual acuity or central vision or distance
  Use Snellen’s Chart CRANIAL NERVE V: TRIGEMINAL
 Snellen’s Alphabet chart: for literate client  Largest cranial nerve
 Snellen’s E chart: for illiterate client  Consists of ophthalmic, maxillary, mandibular
 Snellen’s Animal chart: for pediatric client  Sensory: controls sensation of face, mucous membrane, teeth, soft palate
 Normal visual acuity 20/20 and corneal reflex
 Numerator: is constant, it is the distance of person from the chart (6-7  Motor: controls the muscle of mastication or chewing
m, 20 feet)  Damage to CN V leads to Trigeminal Neuralgia / Tic Douloureux
 Denominator: changes, indicates distance by which the person  Medication: Carbamezapine (Tegretol)
normally can see letter in the chart.
 20/200 indicates blindness CRANIAL NERVE VII: FACIAL
 20/20 visual acuity if client is able to read letters above the red line.  Sensory: controls taste, anterior 2/3 of tongue
2. Test of visual field or peripheral vision  Pinch of sugar and cotton applicator placed on tip of tongue
a. Superiorly  Motor: controls muscle of facial expression
b. Bitemporaly  Instruct client to smile, frown and if results are negative there is facial
c. Nasally paralysis or Bell’s Palsy and the primary cause is forcep delivery.
d. Inferiorly
CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR
CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS  Controls balance particularly kinesthesia or position sense, refers to
 Controls or innervates the movement of extrinsic ocular muscle (EOM) movement and orientation of the body in space.
 6 muscles:
Superior Rectus Superior Oblique CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS
 Glosopharenageal: controls taste, posterior 1/3 of tongue
 Vagus: controls gag reflex
 Uvula should be midline and if not indicative of damage to cerebral
hemisphere
 Effects of vagal stimulation is PNS
Lateral Rectus Medial Rectus CRANIAL NERVE XI: SPINAL ACCESSORY
 Innervates with sternocleidomastoid (neck) and trapezius (shoulder)

CRANIAL NERVE XII: HYPOGLOSSAL

Inferior Oblique Inferior Rectus  Controls the movement of tongue
 Trochlear: controls superior oblique  Let client protrude tongue and it should be midline and if unable to do
 Abducens: controls lateral rectus indicative of damage to cerebral hemisphere and/or has short frenulum.
 Oculomotor: controls the 4 remaining EOM
Pathognomonic Signs:
Oculomotor
 Controls the size and response of pupil 1. PTB – low grade afternoon fever
 Normal pupil size is 2 – 3 mm 2. PNEUMONIA – rusty sputum.
 Equal size of pupil: Isocoria 3. ASTHMA – wheezing on expiration.
 Unequal size of pupil: Anisocoria 4. EMPHYSEMA – barrel chest.
 Normal response: positive PERRLA 5. KAWASAKI SYNDROME – strawberry tongue
6. PERNICIOUS ANEMIA – red beefy tongue
 7. DOWN SYNDROME – protruding tongue  Wernike’s Aphasia
8. CHOLERA – rice watery stool.  General Knowing Gnostic Area or General Interpretative Area.
9. MALARIA – step ladder like fever with chills.
10. TYPHOID – rose spots in abdomen. DOC
11. DIPTHERIA – pseudo membrane.  Aricept (taken at bedtime)
12. MEASLES – koplick’s spots  Cognex
13. SLE – butterfly rashes.
14. LIVER CIRRHOSIS – spider like varices Management
15. LEPROSY – lioning face 1. Palliative & supportive
16. BOLIMIA – chipmunk face.
17. APPENDICITIS – rebound tenderness Multiple Sclerosis (MS)
18. DENGUE – petichae or positive herman’s sign.  Chronic intermittently progressive disorder of CNS characterized
19. MENINGITIS – kernig’s sign (leg pain), brudzinski sign (neck pain). by scattered white patches of demyelination in brain and spinal
20. TETANY – hypocalcemia (+) trousseu’s sign or carpopedal spasm/ (+) cord.
chvostek sign (facial spasm).  Characterized by remission and exacerbation.
21. TETANUS – risus sardonicus  S/sx are varied & multiple, reflecting the location of
22. PANCREATITIS – cullen’s sign (echymosis of umbilicus) / (+) grey turners demyelination within the CNS.
spots.  Cause unknown: maybe a slow growing virus or possibly
23. PYLORIC STENOSIS – olive like mass. autoimmune disorders.
24. PDA – machine like murmur  Incident: Affects women more than men ages 20-40 are prone &
25. ADDISON’S DISEASE – bronze like skin pigmentation. more frequent in cool or temperate climate.
26. CUSHING’S SYNDROME – moon face appearance and buffalo hump.
27. HYPERTHYROIDSM/GRAVES DISEASE – exopthalmus.  Ig G - only antibody that pass placental circulation causing passive
immunity, short term protection
DEMYELINATING DISORDERS  Ig A - present in all bodily secretions (tears, saliva, colostrums).
 Ig M - acute in inflammation.
Alzheimer’s disease  Ig E - for allergic reaction
 Atrophy of brain tissue due to deficiency of acetylcholine.  Ig D - for chronic inflammation.

S/sx * Give palliative or supportive care.

4 A’s of Alzheimer
a. Amnesia – loss of memory. S/sx
b. Agnosia – unable to recognized inanimate/familiar objects. 1. Visual disturbances
c. Apraxia – unable to determine purpose/ function of objects.  blurring of vision (primary)
d. Aphasia – no speech (nodding).  diplopia (double vision)
 scotomas (blind spots)
*Expressive aphasia 2. Impaired sensation
 “motor speech center” unable to speak  touch, pain, pressure, temperature, or position sense
 Broca’s Aphasia  paresthesia such as tingling sensation, numbness
*Receptive aphasia 3. Mood swings or euphoria (sense of elation)
 inability to understand spoken words. 4. Impaired motor function
 Common to Alzheimer’s  weakness
  spasticity a. ACTH (adreno chorticotropic hormone), Corticosteroids (prednisone)
 paralysis for acute exacerbations: to reduce edema at site of demyelination to
5. Impaired cerebral function prevent paralysis.
 scanning speech b. Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam (Valium) -
 ataxic gait muscle relaxants: for spacity
 nystagmus c. Beta Interferons - Immunosuppresants: alter immune response.
 dysarthria 4. Encourage independence in self-care activities
 intentional tremor 5. Prevent complications of immobility
6. Bladder 6. Institute bowel program
 Urinary retention or incontinence 7. Maintain side rails to prevent injury related to falls.
7. Constipation 8. Institute stress management techniques.
8. Sexual impotence in male / decrease sexual capacity a. Deep breathing exercises
b. Yoga
TRIAD SIGNS OF MS 9. Increase fluid intake and increase fiber to prevent constipation.
10. Maintain urinary elimination
ATAXIA 1. Urinary Retention
(unsteady gait, positive a. perform intermittent catheterization as ordered: to prevent
romberg’s test) retention.
NYSTAGMUS b. Bethanecol Chloride (Urecholine) as ordered
Nursing Management
CHARCOTS INTENTIONAL TREMORS  only given subcutaneous.
TRIAD  monitor side effects bronchospasm and wheezing.
 monitor breath sounds 1 hour after subcutaneous administration.
2. Urinary Incontinence
a. Establish voiding schedule
Dx b. Anti spasmodic agent Prophantheline Bromide (Pro-banthine) if
1. CSF Analysis: increase in IgG and Protein. ordered
2. MRI: reveals site and extent of demyelination. 3. Force fluid to 3000 ml/day.
3. CT Scan: increase density of white matter. 4. Promote use of acid ash diet like cranberry juice, plums, prunes,
4. Visual Evoked Response (VER) determine by EEG: maybe delayed pineapple, vitamin C and orange: to acidify urine and prevent bacterial
5. Positive Lhermittes Sign: a continuous and increase contraction of spinal multiplication.
column. 11. Prevent injury related to sensory problems.
a. Test bath water with thermometer.
Nursing Intervention b. Avoid heating pads, hot water bottles.
1. Assess the client for specific deficit related to location of demyelination c. Inspect body parts frequently for injury.
2. Promote optimum mobility d. Make frequent position changes.
a. Muscles stretching & strengthening exercises 12. Prepare client for plasma exchange if indicated: to remove antibodies
b. Walking exercises to improve gait: use wide-base gait 13. Provide psychologic support to client/significant others.
c. Assistive devices: canes, walker, rails, wheelchair as necessary a. Encourage positive attitude & assist client in setting realistic goals.
3. Administer medications as ordered b. Provide compassion in helping client adapt to changes in body image
& self-concept.
c. Do not encourage false hope during remission.
 d. Refer to MS societies & community agencies. Medulla Oblongata
14. Provide client teaching & discharge planning concerning:
a. General measures to ensure optimum health. Brain Herniation
 Balance between activity & rest
 Regular exercise such as walking, swimming, biking in mild Increase intra cranial pressure
case. Nursing Intervention
 Use energy conservation techniques 1. alternate hot and cold compress to prevent hematoma
 Well-balance diet
 Fresh air & sunshine  CSF cushions brain (shock absorber)
 Avoiding fatigue, overheating or chilling, stress, infection.  Obstruction of flow of CSF will lead to enlargement of skull posteriorly
b. Use of medication & side effects. called hydrocephalus.
c. Alternative methods for sexual counseling if indicated.  Early closure of posterior fontanels causes posterior enlargement of skull
in hydrocephalus.
COMMON CAUSE OF UTI
Female DISORDERS
- short urethra (3-5 cm, 1-1 ½ inches) Increase Intracranial Pressure (IICP)
- poor perineal hygiene  Increase in intracranial bulk brought due to an increase in any of the 3
- vaginal environment is moist major intracranial components: Brain Tissue, CSF, Blood.
Nursing Management  Untreated increase ICP can lead to displacement of brain tissue
- avoid bubble bath (can alter Ph of vagina). (herniation).
- avoid use of tissue papers  Present life threatening situation because of pressure on vital structures in
- avoid using talcum powder and perfume. the brain stem, nerve tracts & cranial nerve.
Male  Increase ICP may be caused:
- urethra (20 cm, 8 inches)  head trauma/injury
- do not urinate after intercourse  localized abscess
 cerebral edema
INTRACRANIAL PRESSURE ICP  hemorrhage
 inflammatory condition (stroke)
Monroe Kelly Hypothesis  hydrocephalus
 tumor (rarely)
Skull is a closed container
S/sx
Any alteration or increase in one of the intracranial components (Early signs)
1. Decrease LOC
Increase intracranial pressure 2. Irritability / agitation
(normal ICP is 0 – 15 mmHg) 3. Progresses from restlessness to confusion & disorientation to lethargy &
coma
Cervical 1 – also known as atlas.
Cervical 2 – also known as axis. (Late signs)
1. Changes in Vital Signs (may be a late signs)
Foramen Magnum a. Systolic blood pressure increases while diastolic pressure remains
the same (widening pulse pressure)
 b. Pulse rate decrease b. Before and after suctioning hyperventilate the client with
c. Abnormal respiratory patterns (cheyne-stokes respiration) resuscitator bag connected to 100% O2 & limit suctioning to 10 –
d. temperature increase directly proportional to blood pressure. 15 seconds only.
2. Pupillary Changes c. Assist with mechanical hyperventilation as indicated: produces
a. Ipsilateral (same side) dilatation of pupil with sluggish hypocarbia (decease CO2) causing cerebral constriction &
reaction to light from compression of cranial nerve III decrease ICP.
b. unilateral dilation of pupils called uncal herniation 2. Monitor V/S, input and output & neuro check frequently to detect increase
c. bilateral dilation of pupils called tentorial herniation in ICP
d. Pupil eventually becomes fixed & dilated 3. Maintain fluid balance: fluid restriction to 1200-1500 ml/day may be
3. Motor Abnormalities ordered
o
a. Contralateral (opposite side) hemiparesis from compression 4. Position the client with head of bed elevated to 30-45 angle with neck in
of corticospinal tract neutral position unless contraindicated to improve venous drainage from
b. abnormal posturing brain.
c. decorticate posturing (damage to cortex and spinal cord). 5. Prevent further increase ICP by:
d. decerebrate posturing (damage to upper brain stem that a. Provide comfortable and quite environment.
includes pons, cerebellum and midbrain). b. Avoid use of restraints.
4. Headache c. Maintain side rails.
5. Projective Vomiting d. Instruct client to avoid forms of valsalva maneuver like:
6. Papilledema (edema of optic disc)  Straining stool: administer stool softener & mild laxatives as
7. Possible seizure activity ordered (Dulcolax, Duphalac)
 Excessive vomiting: administer anti-emetics as ordered (Plasil
Nursing Intervention - Phil only, Phenergan)
1. Maintain patent airway and adequate ventilation by:  Excessive coughing: administer anti-tussive
a. Prevention of hypoxia (decrease O2) and hypercarbia (increase (dextromethorphan)
CO2) important:  Avoid stooping/bending
 Hypoxia may cause brain swelling which increase ICP  Avoid lifting heavy objects
 Early signs of hypoxia: e. Avoid clustering of nursing care activity together.
 Restlessness 6. Prevent complications of immobility.
 Tachycardia 7. Administer medications as ordered:
 Agitation a. Hyperosmotic agent / Osmotic Diuretic [Mannitol (Osmitrol)]: to
 Late signs of hypoxia: reduce cerebral edema
 Extreme restlessness Nursing Management
 Bradycardia  Monitor V/S especially BP: SE hypotension.
 Dyspnea  Monitor strictly input and output every hour: (output should
 Cyanosis increase): notify physician if output is less 30 cc/hr.
 Hypercarbia may cause cerebral vasodilation which increase  Administered via side drip
ICP  Regulate fast drip to prevent crystal formation.
 Hypercabia b. Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral edema
 Increase CO2 (most powerful respiratory stimulant)  drug of choice for CHF (pulmonary edema)
retention.  loop of henle in kidneys.
 In chronic respiratory distress syndrome decrease O2
stimulates respiration. Nursing Management
  Monitor V/S especially BP: SE hypotension. d. Constant monitoring of the client’s ICP, arterial blood gas, serum
 Monitor strictly input and output every hour: (output should barbiturates level, & ECG is necessary.
increase): notify physician if output is less 30 cc/hr. e. EEG monitoring as necessary
 Administered IV push or oral. f. Provide appropriate nursing care for the client on a ventilator
 Given early morning 10. Observe for hyperthermia secondary to hypothalamus damage.
 Immediate effect of 10-15 minutes.
 Maximum effect of 6 hours. *CONGESTIVE HEART FAILURE
c. Corticosteroids [Dexamethasone (Decadron)]: anti-inflammatory Signs and Symptoms
effect reduces cerebral edema - dyspnea
d. Analgesics for headache as needed: - orthopnea
 Small dose of Codein SO4 - paroxysmal nocturnal dyspnea
 Strong opiates may be contraindicated since they potentiate - productive cough
respiratory depression, alter LOC, & cause papillary changes. - frothy salivation
e. Anti-convulsants [Phenytoin (Dilantin)]: to prevent seizures. - cyanosis
8. Assist with ICP monitoring when indicated: - rales/crackles
a. ICP monitoring records the pressure exerted within the cranial cavity - bronchial wheezing
by the brain, cerebral blood, & CSF - pulsus alternans
b. Types of monitoring devices: - anorexia and general body malaise
 Intraventricular Catheter: inserted in lateral ventricle to give
- PMI (point of maximum impulse/apical pulse rate) is displaced
direct measurement of ICP; also allows for drainage of CSF if
laterally
needed.
- S3 (ventricular gallop)
 Subarachnoid screw (bolt): inserted through the skull & dura
- Predisposing Factors/Mitral Valve
matter into subarachnoid space.
o RHD
 Epidural Sensor: least invasive method; placed in space between
o Aging
skull & dura matter for indirect measurement of ICP.
c. Monitor ICP pressure readings frequently & prevent complications:
Treatment
 Normal ICP reading is 0-15 mmHg; a sustained increase above 15
Morphine Sulfate
mmHg is considered abnormal.
Aminophelline
 Use strict aseptic technique when handling any part of the
Digoxin
monitoring system.
Diuretics
 Check insertion site for signs of infection; monitor temperature.
Oxygen
 Assess system for CSF leakage, loose connections, air bubbles in
Gases, blood monitor
he line, & occluded tubing.
9. Provide intensive nursing care for clients treated with barbiturates therapy
RIGHT CONGESTIVE HEART FAILURE (venous congestion)
or administration of paralyzing agents.
Signs and Symptoms
a. Intravenous administration of barbiturates may be ordered: to induce
- jugular vein distention (neck)
coma artificially in the client who has not responded to conventional
- ascites
treatment.
- pitting edema
b. Paralytic agents such as [vercuronium bromide (Norcuron)]: may be
- weight gain
administered to paralyzed the client
- hepatosplenomegaly
c. Reduces metabolic demand that may protect the brain from further
- jaundice
injury.
- pruritus S/S
- esophageal varices BP
- anorexia and general body malaise Urine output DECREASE
Respiratory rate
Signs and Symptoms of Lasix in terms of electrolyte imbalances Patellar relfex absent
1. Hypokalemia
- decrease potassium level 3. Hyponatremia
- normal value is 3.4 – 5.5 meq/L - decrease sodium level
Sign and Symptoms - normal value is 135 – 145 meq/L
- weakness and fatigue Signs and Symptoms
- constipation - hypotension
- positive U wave on ECG tracing - dehydration signs (initial sign in adult is thirst, in infant tachycardia)
Nursing Management - agitation
- administer potassium supplements as ordered (Kalium Durule, Oral Potassium - dry mucous membrane
Chloride) - poor skin turgor
- increase intake of foods rich in potassium - weakness and fatigue
Nursing Management
FRUITS VEGETABLES - force fluids
Apple Asparagus - administer isotonic fluid solution as ordered
Banana Brocolli
Cantalope Carrots 4. Hyperglycemia
Oranges Spinach - normal FBS is 80 – 100 mg/dl
Signs and Symptoms
2. Hypocalcemia/Tetany - polyuria
- decrease calcium level - polydypsia
- normal value is 8.5 – 11 mg/100 ml - polyphagia
Signs and Symptoms Nursing Management
- tingling sensation - monitor FBS
- paresthesia
- numbness 5. Hyperuricemia
- (+) Trousseus sign/Carpopedal spasm - increase uric acid (purine metabolism)
- (+) Chvostek’s sign - foods high in uric acid (sardines, organ meats and anchovies)
Complications
- arrythmia *Increase in tophi deposit leads to gouty arthritis.
- seizures Signs and Symptoms
Nursing Management - joint pain (great toes)
- Calcium Glutamate per IV slowly as ordered - swelling
* Calcium Glutamate toxicity – results to seizure
Nursing Management
Magnesium Sulfate - force fluids
- administer medications as ordered
Magnesium Sulfate toxicity a. Allopurinol (Zylopril)
 - drug of choice for gout. 4. Encephalitis
- mechanism of action: inhibits synthesis of uric acid. 5. Increase dosage of the following drugs:
b. Colchesine a. Reserpine (Serpasil)
- acute gout b. Methyldopa (Aldomet) Antihypertensive
- mechanism of action: promotes excretion of uric acid. c. Haloperidol (Haldol) _______
d. Phenothiazine ___________________ Antipsychotic
* Kidney stones
Signs and Symptoms Side Effects Reserpine: Major depression lead to suicide
- renal cholic Aloneness
- cool moist skin
Nursing Management
- force fluids
- administer medications as ordered Multiple
a. Narcotic Analgesic loss
- Morphine Sulfate causes
- antidote: Naloxone (Narcan) toxicity leads to tremors. Loss of spouse suicide Loss of Job
b. Allopurinol (Zylopril) Nursing Intervention for Suicide
Side Effects  direct approach towards the client
- respiratory depression (check for RR)  close surveillance is a nursing priority
 time to commit suicide is on weekends early morning
Parkinson’s Disease/ Parkinsonism
 Chronic progressive disorder of CNS characterized by degeneration of S/sx
dopamine producing cells in the substantia nigra of the midbrain and basal 1. Tremor: mainly of the upper limbs “pill rolling tremors” of extremities
ganglia. especially the hands; resting tremor: most common initial symptoms
 Progressive disorder with degeneration of the nerve cell in the basal 2. Bradykinesia: slowness of movement
ganglia resulting in generalized decline in muscular function 3. Rigidity: cogwheel type
 Disorder of the extrapyramidal system 4. Stooped posture: shuffling, propulsive gait
 Usually occurs in the older population 5. Fatigue
 Cause Unknown: predominantly idiopathic, but sometimes disorder is 6. Mask like facial expression with decrease blinking of the eyes.
postencephalitic, toxic, arteriosclerotic, traumatic, or drug induced 7. Difficulty rising from sitting position.
(reserpine, methyldopa (aldomet) haloperidol (haldol), phenothiazines). 8. Quite, monotone speech
9. Emotional lability: state of depression
Pathophysiology 10. Increase salivation: drooling type
 Disorder causes degeneration of dopamine producing neurons in the 11. Cramped, small handwriting
substantia nigra in the midbrain 12. Autonomic Symptoms
 Dopamine: influences purposeful movement a. excessive sweating
 Depletion of dopamine results in degeneration of the basal ganglia b. increase lacrimation
c. seborrhea
Predisposing Factors d. constipation
1. Poisoning (lead and carbon monoxide) e. decrease sexual capacity
2. Arteriosclerosis
3. Hypoxia Nursing Intervention
1. Administer medications as ordered a. Eldepryl (Selegilene)
Anti-Parkinson Drug  MOA: inhibit dopamine breakdown & slow progression of disease
a. Levodopa (L-dopa) short acting
 MOA: Increase level of dopamine in the brain; relieves tremors; Anti-Depressant Drug
rigidity; bradykinesia a. Tricyclic
 SE: GIT irritation (should be taken with meal); anorexia; N/V;  MOA: given to treat depression commonly seen in Parkinson’s
postural hypotension; mental changes: confusion, agitation, disease
hallucination; cardiac arrhythmias; dyskinesias. 2. Provide safe environment
 CI: narrow-angled glaucoma; client taking MAOI inhibitor;  Side rails on bed
reserpine; guanethidine; methyldopa; antipsychotic; acute  Rails & handlebars in the toilet, bathtub, & hallways
psychoses  No scattered rugs
 Avoid multi-vitamins preparation containing vitamin B6 & food  Hard-back or spring-loaded chair to make getting up easier
rich in vitamin B6 (Pyridoxine): reverses the therapeutic effects of 3. Provide measures to increase mobility
Levodopa  Physical Therapy: active & passive ROM exercise; stretching exercise;
 Urine and stool may be darkened warm baths
 Be aware of any worsening of symptoms with prolonged high-  Assistive devices
dose therapy: “on-off” syndrome.  If client “freezes” suggest thinking of something to walk over
b. Carbidopa-levodopa (Sinemet) 4. Encourage independence in self-care activities:
 Prevents breakdown of dopamine in the periphery & causes fewer  alter clothing for ease in dressing
side effects.  use assistive device
c. Amantadine Hydrochloride (Symmetrel)  do not rush the client
 Used in mild cases or in combination with L-dopa to reduce 5. Improve communication abilities:
rigidity, tremors, & bradykinesia  Instruct the client to practice reading a loud
 Listen to own voice & enunciate each syllable clearly
Anti-Cholinergic Drug 6. Refer for speech therapy when indicated.
a. Benztropine Mesylate (Cogentin) 7. Maintain adequate nutrition.
b. Procyclidine (Kemadrine)  Cut food into bite-size pieces
c. Trihexyphenidyl (Artane)  Provide small frequent feeding
 MOA: inhinit the action of acetylcholine; used in mild cases or in  Allow sufficient time for meals, use warming tray
combination with L-dopa; relived tremors & rigidity 8. Avoid constipation & maintain adequate bowel elimination
 SE: dry mouth; blurred vision; constipation; urinary retention; 9. Provide significant support to client/ significant others:
confusion; hallucination; tachycardia  Depression is common due to changes in body image & self-concept
Anti-Histamines Drug 10. Provide client teaching & discharge planning concerning:
a. Diphenhydramine (benadryl) a. Nature of the disease
 MOA: decrease tremors & anxiety b. Use prescribed medications & side effects
 SE: Adult: drowsiness Children: CNS excitement (hyperactivity) c. Importance of daily exercise as tolerated: balanced activity & rest
because blood brain barrier is not yet fully developed.  walking
b. Bromocriptine (Parlodel)  swimming
 MOA: stimulate release of dopamine in the substantia nigra  gardening
 Often employed when L-dopa loses effectiveness d. Activities/ methods to limit postural deformities:
 Firm mattress with small pillow
MAOI Inhibitor  Keep head & neck as erected as possible
  Use broad-based gait - force fluids
 Raise feet while walking - increase sodium intake to 4 – 10 g% daily
e. Promotion of active participation in self-care activities. 3. Aminophelline Toxicity
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide Signs and Symptoms
* Dopamine Agonist relieves tremor rigidity - tachycardia
- palpitations
MAGIC 2’s IN DRUG MONITORING - CNS excitement (tremors, irritability, agitation and restlessness)
DRUG NORMAL RANGE TOXI INDICATIO CLASSIFICATION Nursing Management
CITY N - only mixed with plain NSS or 0.9 NaCl to prevent development of crystals of
LEVE precipitate.
L - administered sandwich method
Digoxin/Lanoxin .5 – 1.5 meq/L 2 CHF Cardiac Glycoside - avoid taking alcohol because it can lead to severe CNS depression
(increase force of - avoid caffeine
cardiac output) 4. Dilantin Toxicity
Lithium/Lithane .6 – 1.2 meq/L 2 Bipolar Anti-Manic Agents Signs and Symptoms
(decrease level of - gingival hyperplasia (swollen gums)
Ach/NE/Serotonin) - hairy tongue
Aminophelline 10 – 19 mg/100 ml 20 COPD Bronchodilators - ataxia
(dilates bronchial - nystagmus
tree) Nursing Management
Dilantin/Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-Convulsant - provide oral care
Acetaminophen/Tyl 10 – 30 mg/100 ml 200 Osteo Non-narcotic Analgesic- massage gums
enol Arthritis 5. Acetaminophen Toxicity
Signs and Symptoms
1. Digitalis Toxicity - hepatotoxicity (monitor for liver enzymes)
Signs and Symptoms - SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
- nausea and vomiting - SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
- diarrhea - nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)
- confusion - hypoglycemia
- photophobia Tremors, tachycardia
- changes in color perception (yellowish spots) Irritability
Antidote: Digibind Restlessness
2. Lithium Toxicity Extreme fatigue
Signs and Symptoms Diaphoresis, depression
- anorexia Antidote: Acetylceisteine (mucomyst) prepare suction apparatus as bedside.
- nausea and vomiting
- diarrhea MYASTHENIA GRAVIS (MG)
- dehydration causing fine tremors  neuromuscular disorder characterized by a disturbance in the transmission
- hypothyroidism of impulses from nerve to muscle cells at the neuromuscular junction
leading to descending muscle weakness.
Nursing Management  Incidence rate:
 highest between 15 & 35 years old for women, over 40 for men.
  Affects women more than men  MOA: block the action of cholinesterase & increase the level of
 Cause: acetylcholine at the neuromuscular junction.
 Unknown/ idiopathic  SE: excessive salivation & sweating, abdominal cramps, N/V,
 Thought to be autoimmune disorder whereby antibodies destroy diarrhea, fasciculations (muscle twitching).
acetylcholine receptor sites on the postsynaptic membrane of the b. Corticosteroids: Prednisone
neuromuscular junction.  MOA: suppress autoimmune response
 Voluntary muscles are affected, especially those muscles innervated by the  Used if other drugs are not effective
cranial nerve. 2. Surgery (Thymectomy)
a. Surgical removal of thymus gland: thought to be involve in the
Pathophysiology production of acetylcholine receptor antibodies.
 Autoimmune = Release of Cholinesterase Enzymes = Cholinesterase b. May cause remission in some clients especially if performed early in
destroy Acetylcholine (ACH) = Decrease of Acetylcholine (ACH) the disease.
 Acetylcholine: activate muscle contraction 3. Plasma Exchange (Plasmapheresis)
 Autoimmune: it involves release of cholinesterase an enzyme that destroys a. Removes circulating acetylcholine receptor antibodies.
Ach b. Use in clients who do not respond to other types of therapy.
 Cholinesterase: an enzyme that destroys ACH
Nursing Interventions
S/sx 1. Administer anti-cholinesterase drugs as ordered:
1. Initial sign is ptosis a clinical parameter to determine ptosis is palpebral a. Give medication exactly on time.
fissure: cracked or cleft in the lining or membrane of the eyelids b. Give with milk & crackers to decrease GI upset
2. Diplopia c. Monitor effectiveness of drugs: assess muscle strength & vital capacity
3. Dysphagia before & after medication.
4. Mask like facial expression d. Avoid use of the ff drugs:
5. Hoarseness of voice, weakness of voice  Morphine SO4 & Strong Sedatives: respiratory depressant
6. Respiratory muscle weakness that may lead to respiratory arrest effects
7. Extreme muscle weakness especially during exertion and morning;  Quinine, Curare, Procainamide, Neomycin, Streptomycine,
increase activity & reduced with rest. Kanamycine & other aminoglycosides: skeletal muscle
blocking effect
Dx e. Observe for side effects
1. Tensilon Test (Edrophonium Hydrochloride): IV injection of tensilon 2. Promote optimal nutrition:
provides temporary relief of S/sx for about 5-10 minutes and a maximum a. Mealtime should coincide with the peak effect of the drugs: give
of 15 minutes. medication 30 minutes before meals.
 If there is no effect there is no damage to occipital lobe and midbrain b. Check gag reflex & swallowing ability before feeding.
and is negative for M.G. c. Provide mechanical soft diet.
2. Electromyography (EMG): amplitudes of evoked potentials decrease d. If the client has difficulty in chewing & swallowing, do not leave alone
rapidly. at mealtime; keep emergency airway & suctioning equipment nearby.
3. Presence of anti-acetlycholine receptors antibodies in the serum. 3. Monitor respiratory status frequently: Rate, Depth, Vital Capacity; ability to
Medical Management deep breathe & cough
1. Drug Therapy 4. Assess muscle strength frequently; plan activity to take advantage of
a. Anti-cholinesterase Drugs: [Ambenonium (Mytelase), Neostigmine energy peaks & provide frequent rest periods.
(Prostigmin), Pyridostigmine (Mestinon)] 5. Observe for signs of myasthenic or cholinergic crisis.
 c. Importance of checking with physician before taking any new
medication including OTC drugs
d. Importance of planning activities to take advantage of energy peaks &
MYASTHENIC CRISIS CHOLINERGIC CRISIS of scheduling frequent rest period
 Abrupt onset of severe,  Symptoms similar to myasthenic e. Need o avoid fatigue, stress, people with upper respiratory infection
generalized muscle weakness crisis & in addition the side effect f. Use of eye patch for diplopia (alternate eyes)
with inability to swallow, speak, of anti-cholinesterase drugs g. Need to wear medic-alert bracelet
or maintain respirations. (excessive salivation & sweating, h. Myasthenia Gravis foundation & other community agencies
 Symptoms will improve abdominal carmp, N/V, diarrhea,
temporarily with tensilon test. fasciculation) Guillain-Barre Syndrome
 Symptoms worsen with tensilon  a disorder of the CNS characterized by bilateral, symmetrical, peripheral
test: keep Atropine Sulfate & polyneuritis characterized by ascending muscle paralysis.
Causes: emergency equipment on hand.  Can occur at any age; affects women and men equally
 under medication Cause:  Progression of disease is highly individual; 90% of clients stop progression
 physical or emotional stress  over medication with the in 4 weeks; recovery is usually from 3-6 months; may have residual deficits.
 infection cholinergic drugs (anti- Causes:
Signs and Symptoms cholinesterase) 1. Unknown / idiopathic
 the client is unable to see, 2. May be autoimmune process
swallow, speak, breathe Signs and Symptoms
Treatment  PNS Predisposing Factors
 administer cholinergic agents as 1. Immunization
ordered Treatment 2. Antecedent viral infections such as LRT infections
 administer anti-cholinergic agents
(Atrophine Sulfate) S/sx
1. Mild Sensory Changes: in some clients severe misinterpretation of sensory
Nursing Care in Crisis: stimuli resulting to extreme discomfort
a. Maintain tracheostomy set or endotracheal tube with mechanical 2. Clumsiness (initial sign)
ventilation as indicated. 3. Progressive motor weakness in more than one limb (classically is ascending
b. Monitor ABG & Vital Capacity & symmetrical)
c. Administer medication as ordered: 4. Dysphagia: cranial nerve involvement
 Myasthenic Crisis: increase doses of anti-cholinesterase drug 5. Ascending muscle weakness leading to paralysis
as ordered. 6. Ventilatory insufficiency if paralysis ascends to respiratory muscles
 Cholinergic Crisis: discontinue anti-cholinesterase drugs as 7. Absence or decreased deep tendon reflex
ordered until the client recovers. 8. Alternate hypotension to hypertension
d. Established method of communication 9. Arrythmia (most feared complication)
e. Provide support & reassurance. 10. Autonomic disfunction: symptoms that includes
6. Provide nursing care for the client with thymectomy. a. increase salivation
7. Provide client teaching & discharge planning concerning: b. increase sweating
a. Nature of the disease c. constipation
b. Use of prescribe medications their side effects & sign of toxicity
Dx
1. CSF analysis: reveals increased in IgG and protein
2. EMG: slowed nerve conduction b. Start with pureed food
c. Assess need for NGT feeding: if unable to swallow; to prevent
Medical Management aspiration
1. Mechanical Ventilation: if respiratory problems present 10. Administer medications as ordered
2. Plasmapheresis: to reduce circulating antibodies a. Corticosteroids: suppress immune response
3. Continuous ECG monitoring to detect alteration in heart rate & rhythm b. Anti Cholinergic Agents:
4. Propranolol: to prevent tachycardia  Atrophine Sulfate
5. Atropine SO4: may be given to prevent episodes of bradycardia during c. Anti Arrythmic Agents:
endotracheal suctioning & physical therapy  Lidocaine (Xylocaine)
 Bretylium: blocks release of norepinephrine; to prevent increase
Nursing Intervention of BP
1. Maintain patent airway & adequate ventilation: 11. Assist in plasmapheresis (filtering of blood to remove autoimmune anti-
a. Monitor rate & depth of respiration; serial vital capacity bodies)
b. Observe for ventilatory insufficiency 12. Prevent complications:
c. Maintain mechanical ventilation as needed a. Arrythmia
d. Keep airway free of secretions & prevent pneumonia b. Paralysis of respiratory muscles / respiratory arrest
2. Check individual muscle groups every 2 hrs in acute phase to check 13. Provide psychologic support & encouragement to client / significant others
progression of muscle weakness 14. Refer for rehabilitation to regain strength & treat any residual deficits.
3. Assess cranial nerve function:
a. Check gag reflex INFLAMMATORY CONDITIONS OF THE BRAIN
b. Swallowing ability
c. Ability to handle secretion Meningitis
d. Voice  Inflammation of the meninges of the brain & spinal cord.
4. Monitor strictly the following:  Cause by bacteria, viruses, & other M.O.
a. Vital signs
b. Input and output Etiology / Most Common M.O.
c. Neuro check 1. Meningococcus: most dangerous
d. ECG: due to arrhythmia 2. Pneumococcus
e. Observe signs of autonomic dysfunction: acute period of hypertension 3. Streptococcus: cause of adult meningitis
fluctuating with hypotension 4. Hemophilus Influenzae: cause of pediatric meningitis
f. Tachycardia
g. Arrhythmias Mode of transmission
5. Maintain side rails to prevent injury related to fall 1. Airborne transmission (droplet nuclei)
6. Prevent complications of immobility: turning the client every 2 hrs 2. Via blood, CSF, lymph
7. Assist in passive ROM exercise 3. By direct extension from adjacent cranial structures (nasal, sinuses,
8. Promote comfort (especially in clients with sensory changes): mastoid bone, ear, skull fracture)
a. Foot cradle 4. By oral or nasopharyngeal route
b. Sheepskin
c. Guided imagery Signs and Symptoms
d. Relaxation techniques 2. Headache, photophobia, general body malaise, irritability,
9. Promote optimum nutrition: 3. Projectile vomiting: due to increase ICP
a. Check gag reflex before feeding 4. Fever & chills
5. Anorexia & weight loss a. Broad spectrum antibiotics (Penicillin, Tetracycline)
6. Possible seizure activity & decrease LOC b. Mild analgesics: for headaches
7. Abnormal posturing: (decorticate and decerebrate) c. Antipyretics: for fever
8. Signs of Meningeal Irritation: 2. Enforced strict respiratory isolation 24 hours after initiation of anti biotic
a. Nuchal rigidity or stiff neck: initial sign therapy (for some type of meningitis)
b. Opisthotonos (arching of back): head & heels bent backward & body 3. Provide nursing care for increase ICP, seizure & hyperthermia if they occur
arched forward 4. Provide nursing care for delirious or unconscious client as needed
c. PS: Kernig’s sign (leg pain): contraction or pain in the hamstring 5. Enforce complete bed rest
muscles when attempting to extend the leg when the hip is flexed 6. Keep room quiet & dark: if the client has headache & photophobia
d. PS: Brudzinski sign (neck pain): flexion at the hip & knee in response to 7. Monitor strictly V/S, I & O & neuro check
forward flexion of the neck 8. Maintain fluid & electrolyte balance
9. Prevent complication of immobility
Dx 10. Provide client teaching & discharge planning concerning:
1. Lumbar Puncture: a. Importance of good diet: high CHON, high calories with small frequent
 Measurement & analysis of CSF shows increased pressure, elevated feedings.
WBC & CHON, decrease glucose & culture positive for specific M.O. b. Rehabilitation program for residual deficit
 A hollow spinal needle is inserted in the subarachnoid space between  mental retardation
the L3-L4 or L4-L5.  delayed psychomotor development
c. Prevent complications
Nursing Management Before Lumbar Puncture  most feared is hydrocephalus
1. Secure informed consent and explain procedure.  hearing loss/nerve deafness is second complication
2. Empty bladder and bowel to promote comfort.  consult audiologist
3. Encourage to arch back to clearly visualize L3-L4.
Cerebrovascular Accident (CVA) (Stroke/Brain Attack/Apoplexy/Cerebral
Nursing Management Post Lumbar Puncture Thrombosis)
1. Place flat on bed 12 – 24 o  Destruction (infarction) of brain cells caused by a reduction in cerebral
2. Force fluids blood flow and oxygen
3. Check punctured site for any discoloration, drainage and leakage to  A partial or complete disruption in the brains blood supply.
tissues.  2 largest & most common cerebral artery affected by stroke:
4. Assess for movement and sensation of extremities. a. Mid Cerebral Artery
b. Internal Cerebral Artery
CSF analysis reveals  Incidence Rate:
1. Increase CHON and WBC a. Affects men more than women; Men are 2-3 times high risk; Incidence
2. Decrease glucose increase with age
3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)  Causes:
4. (+) cultured microorganism (confirms meningitis) a. Thrombosis (attached)
b. Embolism (detached): most dangerous because it can go to the lungs
CBC reveals & cause pulmonary embolism or the brain & cause cerebral embolism.
1. Increase WBC c. Hemorrhage
d. Compartment Syndrome: compression of nerves & arteries
Nursing Management
1. Administer large doses of antibiotic IV as ordered: S/sx Pulmonary Embolism
 1. Sudden sharp chest pain 6. Related to diet: increase intake of saturated fats like whole milk
2. Unexplained dyspnea 7. Related stress physical and emotional
3. SOB 8. Prolong use of oral contraceptives: promotes lypolysis (breakdown of
4. Tachycardia lipids) leading to atherosclerosis that will lead to hypertension &
5. Palpitations eventually CVA.
6. Diaphoresis
7. Mild restlessness
Pathophysiology
S/sx of Cerebral Embolism 1. Interruption of cerebral blood flow for 5 min or more causes death of
1. Headache neurons in affected area with irreversible loss of function.
2. disorientation 2. Modifying Factors:
3. Confusion a. Cerebral Edema:
4. Decrease LOC  Develops around affected area causing further impairment
b. Vasospasm:
S/sx Compartment syndrome  Constriction of cerebral blood vessel may occur, causing further
1. Fat embolism is the most feared complications w/in 24 hrs after a decrease in blood flow
femur fracture. c. Collateral Circulation:
 Yellow bone marrow are produced from the medullary cavity  May help to maintain cerebral blood flow when there is
of the long bones and produces fat cells. compromise of main blood supply
 If there is bone fracture there is hemorrhage and there would
be escape of the fat cells in the circulation. Stages of Development
1. Transient Ischemic Attack (TIA)
Risk Factors a. Initial / warning signs of impending CVA / stroke
Disease: b. Brief period of neurologic deficit:
1. Hypertension  Visual loss / Visual disturbance
2. Diabetes Mellitus  Hemiparesis
3. Atherosclerosis / Arteriosclerosis  Slurred Speech / Speech disturbance
4. Myocardial Infarction  Vertigo
5. Mitral valve replacement  Aphasia
6. Valvular Disease / replacement  Headache: initial sign
7. Chronic atrial Fibrillation  Dizziness
8. Post Cardiac Surgery  Tinnitus
 Possible Increase ICP
Lifestyle: c. May last less than 30 sec, but no more than 24 hrs with complete
1. Smoking resolution of symptoms
2. Sedentary lifestyle 2. Stroke in Evolution
3. Obesity (increase 20% ideal body weight)  Progressive development of stroke symptoms over a period of hours
4. Hyperlipidemia more on genetics/genes that binds to cholesterol to days
5. Type A personality 3. Complete Stroke
a. Deadline driven  Neurologic deficit remains unchanged for 2-3-days period
b. Can do multiple tasks
c. Usually fells guilty when not doing anything S/sx
1. Headache 3. Provide CBR as ordered
2. Generalized Signs: 4. Maintain fluid & electrolyte balance & ensure adequate nutrition:
 Vomiting a. IV therapy for the first few days
 Seizure b. NGT for feeding the client who is unable to swallow
 Confusion c. Fluid restriction as ordered: to decrease cerebral edema & might also
 Disorientation increase ICP
 Decrease LOC 5. Maintain proper positioning & body alignment:
 Nuchal Rigidity a. Elevate head 30-45 degree to decrease ICP
 Fever b. Turn & reposition every 2 hrs (20 min only on the affected side)
 Hypertension c. Passive ROM exercise every 4 hrs: prevent contractures; promote
 Slow Bounding Pulse body alignment
 Cheyne-Strokes Respiration 6. Promote optimum skin integrity: turn client & apply lotion every 2 hrs
 (+) Kernig’s & Brudzinski sign: may lead to hemorrhagic stroke 7. Prevent complications of immobility by:
3. Focal Signs (related to site of infarction): a. Turn client to side
 Hemiplegia b. Provide egg crate mattresses or water bed
 Homonymous hemianopsia: loss of half of visual field c. Provide sand bag or food board.
 Sensory loss 8. Maintain adequate elimination:
 Aphasia a. Offer bed pan or urinal every 2 hrs; catheterized only if necessary
 Dysarthia: inability to articulate words b. Administer stool softener & suppositories as ordered: to prevent
 Alexia: difficulty reading constipation & fecal impaction
 Agraphia: difficulty writing 9. Provide quiet, restful environment
10. Provide alternative means of communication to the client:
Dx a. Non verbal cues
1. CT & Brain Scan: reveals brain lesions b. Magic slate: not paper & pen tiring for client
2. EEG: abnormal changes c. If positive to hemianopsia: approach client on unaffected side
3. Cerebral Arteriography: invasive procedure due to injection of dye (iodine 11. Administer medications as ordered:
based); Uses dye for visualization a. Hyperosmotic agent: to decrease cerebral edema
 May show occlusion or malformation of blood vessels  Osmotic Diuretics (Mannitol)
 Reveals the site and extent of malocclusion  Loop Diuretics Furosemide (Lasix)
 Corticosteroids (Dexamethazone)
Nursing Management Post Cerebral Arteriography b. Anti-convulsants: to prevent or treat seizures
 Allergy Test (shellfish) c. Thrombolytic / Fibrinolytic Agents: given to dissolve clot (hemorrhage
 Force fluids to release dye because it is nephro toxic must be ruled out)
 Check for peripheral pulse: distal (femoral)  Tissue Plasminogen Activating Factor (tPA, Alteplase): SE: allergic
 Check for hematoma formation Reaction
 Streptokinase, Urokinase: SE: chest pain
Nursing Intervention: Acute Stage d. Anticoagulants: for stroke in evolution or embolic stroke (hemorrhage
1. Maintain patent airway and adequate ventilation by: must be ruled out)
a. Assist in mechanical ventilation  Heparin: short acting
b. Administer O2 inhalation  Check for Partial Thromboplastin Time (PTT): if prolonged
2. Monitor strictly V/S, I & O, neuro check & observe signs of increase ICP, there is a risk for bleeding
shock, hyperthermia, & seizure  Antidote: Protamine SO4
  Warfarin (Comadin): long acting / long term therapy 4. Homonymous Hemianopsia: loss of right or left half of each visual field
 Give simultaneously with Heparin cause Warfarin (Coumadin) a. Approach the client on unaffected side
will take effect after 3 days b. Place personal belongings, food etc., on unaffected side
 Check for Prothrombin Time (PT): if prolonged there is a risk c. Gradually teach the client to compensate by scanning (ex. Turning the
for bleeding head to see things on affected side)
 Antidote: Vitamin K (Aqua Mephyton) 5. Emotional Lability: mood swings, frustrations
 Anti Platelet: to inhibit platelet aggregation in treating TIA’s a. Create a quiet, restful environment with a reduction in excessive
 PASA (Aspirin) sensory stimuli
 Contraindicated for dengue, ulcer and unknown cause of b. Maintain a calm, non-threatening manner
headache because it may potentiate bleeding c. Explain to family that client’s behavior is not purposeful
e. Antihypertensive: if indicated for elevated BP 6. Aphasia: most common in right hemiplegics; may be receptive / expressive
f. Mild Analgesics: for pain a. Receptive Aphasia
12. Provide client health teachings and discharge planning concerning  Give simple, slow directions
a. Avoid modifiable risk factors (diet, exercise, smoking)  Give one command at a time; gradually shift topics
b. Prevent complication (subarachnoid hemorrhage is the most  Use non-verbal techniques of communication (ex. Pantomime,
feared complication) demonstration)
c. Dietary modification (decrease salt, saturated fats and caffeine) b. Expressive Aphasia
d. Importance of follow up care  Listen & watch very carefully when the client attempts to speak
 Anticipate client’s needs to decrease frustrations & feeling of
Nursing Intervention: Rehabiltation helplessness
1. Hemiplegia: results from injury to cell in the cerebral motor cortex or to  Allow sufficient time for client to answer
corticospinal tract (causes contralateral hemiplegia since tracts crosses 7. Sensory / Perceptual Deficit: more common in left hemiplegics;
medulla) characterized by impulsiveness unawareness of disabilities, visual neglect
a. Turn every 2 hrs (20 min only on affected side) (neglect of affected side & visual space on affected side)
b. Use proper positioning & repositioning to prevent deformities (foot a. Assist with self-care
drop, external rotation of hips, flexion of fingers, wrist drop, abduction b. Provide safety measures
of shoulder & arms) c. Initially arrange objects in environment on unaffected side
c. Support paralyzed arm on pillow or use sling while out of bed to d. Gradually teach client to take care of the affected & turn frequently &
prevent subluxation of shoulders look at affected side
d. Elevate extremities to prevent dependent edema 8. Apraxia: loss of ability to perform purposeful, skilled acts
e. Provide active & passive ROM exercises every 4 hrs a. Guide client through intended movement (ex. Take object such as
2. Susceptibility to hazard wash cloth & guide client through movement of washing)
a. Keep side rails up at all times b. Keep repeating the movement
b. Institute safety measures 9. Generalizations about the clients with left hemiplegia vs. right hemiplegia
c. Inspect body parts frequently for signs of injury & nursing care
3. Dysphagia: difficulty of swallowing a. Left Hemiplegia
a. Check for gag reflex before feeding client  Perceptual, sensory deficits: quick & impulsive behavior
b. Maintain a calm, unhurried approach  Use safety measures, verbal cues, simplicity in all area of care
c. Place client in upright position b. Right Hemiplegia
d. Place food in unaffected side of the mouth  Speech-language deficits: slow & cautious behavior
e. Offer soft foods  Use pantomime & demonstration
f. Give mouth care before & after meals
  Clonic contractions: contraction of extremities
CONVULSIVE DISORDER/CONVULSION  Postictal sleep: unresponsive sleep
 disorder of CNS characterized by paroxysmal seizure with or without loss  Seizure ends with postictal period of confusion, drowsiness
of consciousness abnormal motor activity alternation in sensation and b. Absence Seizure (Petit mal Seizure):
perception and changes in behavior.  Usually non-organic brain damage present
 Seizure: first convulsive attack  Must be differentiated from daydreaming
 Epilepsy: second or series of attacks  Sudden onset with twitching & rolling of eyes that last 20-40 sec
 Febrile seizure: normal in children age below 5 years  Common among pediatric clients characterized by:
 Blank stare
Predisposing Factors  Decrease blinking of eyes
1. Head injury due to birth trauma  Twitching of mouth
2. Genetics  Loss of consciousness (5 – 10 seconds)
3. Presence of brain tumor
4. Toxicity from the ff: 2. Partial or Localized Seizure
a. Lead  Begins in focal area of brain & symptoms are related to a dysfunction
b. Carbon monoxide of that area
5. Nutritional and Metabolic deficiencies  May progress into a generalized seizure
6. Physical and emotional stress a. Jacksonian Seizure (focal seizure)
7. Sudden withdrawal to anti-convulsant drug: is predisposing factor for  characterized by tingling and jerky movement of index finger and
status epilepticus: DOC: Diazepam (Valium) & Glucose thumb that spreads to the shoulder and other side of the body.
b. Psychomotor Seizure (focal motor seizure)
S/sx  May follow trauma, hypoxia, drug use
 Dependent on stages of development or types of seizure  Purposeful but inappropriate repetitive motor acts
1. Generalized Seizure  Aura is present: daydreaming like
 Initial onset in both hemisphere, usually involves loss of consciousness  Automatism: stereotype repetitive and non propulsive behavior
& bilateral motor activity.  Clouding of consciousness: not in contact with environment
a. Major Motor Seizure (Grand mal Seizure): tonic-clonic seizure  Mild hallucinatory sensory experience
 Signs or aura with auditory, olfactory, visual, tactile, sensory
experience 3. Status Epilepticus
 Epileptic cry: is characterized by fall and loss of consciousness for  Usually refers to generalized grand mal seizure
3-5 minutes  Seizure is prolong (or there are repeated seizures without regaining
 Tonic Phase: consciousness) & unresponsive to treatment
 Limbs contract or stiffens  Can result in decrease in O2 supply & possible cardiac arrest
 Pupils dilated & eye roll up to one side  A continuous uninterrupted seizure activity
 Glottis closes: causing noise on exhalation  If left untreated can lead to hyperpyrexia and lead to coma and
 May be incontinent eventually death.
 Occurs at same time as loss of consciousness last 20-40 sec  DOC: Diazepam (Valium) & Glucose
 Tonic contractions: direct symmetrical extension of extremities
 Clonic Phase: C. Diagnostic Procedures
 repetitive movement 1. CT Scan – reveals brain lesions
 increase mucus production 2. EEG – reveals hyper activity of electrical brain waves
 slowly tapers
D. Nursing Management b. Cornea: transparent tissue through which light enters the eye;
1. Maintain patent airway and promote safety before seizure activity located anteriorly
a. clear the site of blunt or sharp objects 2. Middle Layer
b. loosen clothing of client a. Choroid: highly vascular layer, nourishes retina; located
c. maintain side rails posteriorly
d. avoid use of restrains b. Ciliary Body: anterior to choroid, secrets aqueous humor; muscle
e. turn clients head to side to prevent aspiration change shape of lens
f. place mouth piece of tongue guard to prevent biting or tongue c. Iris: pigmented membrane behind cornea, gives color to eye;
2. Avoid precipitating stimulus such as bright/glaring lights and noise located anteriorly
3. Administer medications as ordered d. Pupil: is circular opening in the middle of the iris that constrict or
a. Anti convulsants (Dilantin, Phenytoin) dilates to regulate amount of light entering the eye
b. Diazepam, Valium 3. Inner Layer
c. Carbamazepine (Tegnetol) – trigeminal neuralgia a. Light-sensitive layer composed of rods & cones (visual cell)
d. Phenobarbital, Luminal  Cones: specialized for fine discrimination & color vision;
4. Institute seizure and safety precaution post seizure attack (daylight / colored vision)
a. administer O2 inhalation  Rods: more sensitive to light than cones, aid in peripheral
b. provide suction apparatus vision; (night twilight vision)
5. Document and monitor the following b. Optic Disk: area in retina for entrance of optic nerve, has no
a. onset and duration photoreceptors
b. types of seizures
c. duration of post ictal sleep may lead to status epilepticus B. Lens: transparent body that focuses image on retina
d. assist in surgical procedure cortical resection C. Fluid of the eye
1. Aqueous Humor: clear, watery fluid in anterior & posterior chambers
Overview Anatomy & Physiology of the Eye in anterior part of eye; serves as refracting medium & provides
nutrients to lens & cornea; contribute to maintenance of intraocular
External Structure of Eye pressure
a. Eyelids (Palpebrae) & Eyelashes: protect the eye from foreign particles 2. Vitreous Humor: clear, gelatinous material that fills posterior cavity of
b. Conjunctiva: eye; maintains transparency & form of eye
 Palpebral Conjunctiva: pink; lines inner surface of eyelids Visual Pathways
 Bulbar Conjunctiva: white with small blood vessels, covers a. Retina (rods & cones) translates light waves into neural impulses that
anterior sclera travel over the optic nerves
c. Lacrimal Apparatus (lacrimal gland & its ducts & passage): produces tears b. Optic nerves for each eye meet at the optic chiasm
to lubricate the eye & moisten the cornea; tears drain into the  Fibers from median halves of the retinas cross here & travel to the
nasolacrimal duct, which empties into nasal cavity opposite side of the brain
d. The movement of the eye is controlled by 6 extraocular muscles (EOM)  Fibers from lateral halves of retinas remain uncrossed
c. Optic nerves continue from optic chiasm as optic tracts & travels to the
Internal Structure of Eye cerebrum (occipital lobe) where visual impulses are perceived &
A. 3 layers of the eyeball interpreted
1. Outer Layer
a. Sclera: tough, white connective tissue (“white of the eye”); Canal of schlemm: site of aqueous humor drainage
located anteriorly & posteriorly Meibomian gland: secrets a lubricating fluid inside the eyelid
Maculla lutea: yellow spot center of retina
 Fovea centralis: area with highest visual acuity or acute vision  Characterized by increase intraocular pressure resulting in progressive loss
of vision
2 muscles of iris:  May cause blindness if not recognized & treated
Circular smooth muscle fiber: Constricts the pupil  Early detection is very important
Radial smooth muscle fiber: Dilates the pupil  preventable but not curable
 Regular eye exam including tonometry for person over age 40 is
Physiology of vision recommended
4 Physiological processes for vision to occur:
1. Refraction of light rays: bending of light rays Predisposing Factors
2. Accommodation of lens 1. Common among 40 years old and above
3. Constriction & dilation of pupils 2. Hereditary
4. Convergence of eyes 3. Hypertension
4. Obesity
Unit of measurements of refraction: diopters 5. History of previous eye surgery, trauma, inflammation
Normal eye refraction: emmetropia
Normal IOP: 12-21 mmHg Types of Glaucoma:
1. Chronic (open-angle) Glaucoma:
Error of Refraction  Most common form
1. Myopia: nearsightedness: Treatment: biconcave lens  Due to obstruction of the outflow of aqueous humor, in trabecular
2. Hyperopia: farsightedness: Treatment: biconvex lens meshwork or canal of schlemm
3. Astigmatisim: distorted vision: Treatment: cylindrical 2. Acute (close-angle) Glaucoma:
4. Presbyopia: “old sight” inelasticity of lens due to aging: Treatment: bifocal  Due to forward displacement of the iris against the cornea,
lens or double vista obstructing the outflow of the aqueous humor
 Occurs suddenly & is an emergency situation
Accommodation of lenses: based on thelmholtz theory of accommodation  If untreated it will result to blindness
Near Vision: Ciliary muscle contracts: Lens bulges 3. Chronic (close-angle) Glaucoma:
 similar to acute (close-angle) glaucoma, with the potential for an acute
Far Vision: ciliary muscle dilates / relaxes: lens is flat attack

S/sx
Convergence of the eye: 1. Chronic (open-angle) Glaucoma: symptoms develops slowly
Error:  Impaired peripheral vision (PS: tunnel vision)
1. Exotropia:1 eye normal  Halos around light
2. Esophoria: corrected by  Mild discomfort in the eye
corrective eye surgery  Loss of central vision if unarrested
3. Strabismus: squint eye 2. Acute (close-angle) Glaucoma
4. Amblyopia: prolong squinting  Severe eye pain
 Blurred cloudy vision
 Halos around light
Common Visual Disorder  N/V
Glaucoma  Steamy cornea
 Moderate pupillary dilation
3. Chronic (close-angle) Glaucoma  Argon Laser Beam Surgery: non-invasive procedure using laser
 Transient blurred vision produces same effect as iridectomy; done in out-client basis
 Slight eye pain  Iridectomy: usually performed on second eye later since a large
 Halos around lights number of client have an acute acute attack in the other eye
3. Chronic (close-angle) Glaucoma
Dx a. Drug Therapy:
1. Visual Acuity: reduced  miotics (pilocarpine)
2. Tonometry: reading of 24-32 mmHg suggest glaucoma; may be 50 mmHg b. Surgery:
of more in acute (close-angle) glaucoma  bilateral peripheral iridectomy: to prevent acute attacks
3. Ophthalmoscopic exam: reveals narrowing of small vessels of optic disk,
cupping of optic disk Nursing Intervention
4. Perimetry: reveals defects in visual field 1. Administer medication as ordered
5. Gonioscopy: examine angle of anterior chamber 2. Provide quite, dark environment
3. Maintain accurate I & O with the use of osmotic agent
Medical Management 4. Prepare client for surgery if indicated
1. Chronic (open-angle) Glaucoma 5. Provide post-op care
a. Drug Therapy: one or a combination of the following 6. Provide client teaching & discharge planning
 Miotics eye drops (Pilocarpine): to increase outflow of aqueous a. Self-administration of eye drops
humor b. Need to avoid stooping, heavy lifting or pushing, emotional upsets,
 Epinephrine eye drops: to decrease aqueous humor production & excessive fluid intake, constrictive clothing around the neck
increase outflow c. Need to avoid the use antihistamines or sympathomimetic drugs
 Carbonic Anhydrase Inhibitor: Acetazolamide (Diamox): to (found in cold preparation) in close-angle glaucoma since they may
decrease aqueous humor production cause mydriasis
 Timolol Maleate (Timoptic): topical beta-adrenergic blocker: to d. Importance of follow-up care
decrease intraocular pressure (IOP) e. Need to wear medic-alert tag
b. Surgery (if no improvement with drug)
 Filtering procedure (Trabeculectomy / Trephining): to create Cataract
artificial openings for the outflow of aqueous humor  Decrease opacity of ocular lens
 Laser Trabeculoplasty: non-invasive procedure performed with  Incidence increases with age
argon laser that can be done on an out-client basis; procedure
similar result as trabeculectomy Predisposing Factor
2. Acute (close-angle) Glaucoma 1. Aging 65 years and above
a. Drug Therapy: before surgery 2. May caused by changes associated with aging (“senile” cataract)
 Miotics eye drops (Pilocarpine): to cause pupil to contract & draw 3. Related to congenital
iris away from cornea 4. May develop secondary to trauma, radiation, infection, certain drugs
 Osmotic Agent (Glycerin oral, Mannitol IV): to decrease (corticosteroids)
intraocular pressure (IOP) 5. Diabetes Mellitus
 Narcotic Analgesic: for pain 6. Prolonged exposure to UV rays
b. Surgery
 Peripheral Iridectomy: portion of the iris is excised to facilitate S/sx
outflow of aqueous humor 1. Loss of central vision
2. Blurring or hazy vision
3. Progressive decrease of vision a. Reorient the client to surroundings
4. Glare in bright lights b. Provide safety measures:
5. Milky white appearance at center of pupils  Elevate side rails
6. Decrease perception to colors  Provide call bells
 Assist with ambulation when fully recovered from anesthesia
Diagnostic Procedure c. Prevent intraocular pressure & stress on the suture line:
1. Ophthalmoscopic exam: confirms presence of cataract  Elevate head of the bed 30-40 degree
 Have the client lie on back or unaffected side
Nursing Intervention  Avoid having the client cough, sneeze, bend over, or move head
1. Prepare client for cataract surgery: too rapidly
a. Performed when client can no longer remain independent because of  Treat nausea with anti-emetics as ordered: to prevent vomiting
reduced vision  Give stool softener as ordered: to prevent straining
b. Surgery performed on one eye at a time; usually in a same day surgery  Observe for & report signs of intraocular pressure (IOP):
unit  Severe eye pain
c. Local anesthesia & intravenous sedation usually used  Restlessness
d. Types of cataract surgery:  Increased pulse
 Extracapsular Extraction: lens capsule is excised & the lens is 4. Protect eye from injury:
expressed; posterior capsule is left in place (may be used to a. Dressing usually removed the day after the surgery
support new artificial lens implant); partial removal of lens b. Eyeglasses or eye shield used during the day
 Phacoemulsification: type of extracapsular extraction; a hollow c. Always use eye shield during the night
needle capable of ultrasonic vibration is inserted into lens, 5. Administer medication as ordered:
vibrations emulsify the lens, which is aspirated a. Topical mydriatics & cycloplegic: to decrease spasm of ciliary body &
 Intracapsular Extraction: lens is totally removed within its relieve pain
capsules, may be delivered from eye by cryoextraction (lens is b. Topical antibiotics & corticosteroids
frozen with metal probe & removed); total removal of lens & c. Mild analgesic as needed
surrounding capsules 6. Provide client teaching & discharge planning concerning:
e. Peripheral Iridectomy: may be performed at the time of surgery; small a. Technique of eyedrop administration
hole cut in iris to prevent development of secondary glaucoma b. Use of eye shield at night
f. Intraocular Lens Implant: often performed at the time of surgery c. No bending, stooping, or lifting
2. Nursing Intervention Pre-op d. Report signs & symptoms of complication immediately to physician:
a. Assess vision in the unaffected eye since the affected eye will be  Severe eye pain
patched post-op  Decrease vision
b. Provide pre-op teaching regarding measures to prevent intraocular  Excessive drainage
pressure (IOP) post-op  Swelling of eyelid
c. Administer medication as ordered: e. Cataract glasses / contact lenses
 Topical Mydriatics (Mydriacyl) & Cyclopegics (Cyclogyl): to dilate  If a lens implant has not been performed the client will need
the pupil glasses or contact lenses
 Topical antibiotics: to prevent infection  Temporary glasses are worn for 1-4 weeks then permanent
 Acetazolamide (Diamox) & osmotic agent (Oral Glycerin or glasses fitted
Mannitol IV): to decrease intraocular pressure to provide soft  Cataract glasses magnify object by 1/3 & distortion peripheral
eyeball for surgery vision
3. Nursing Intervention Post-op
  Have the client practice manual coordination with assistance c. Scleral buckling: shortening of sclera to force pigment epithelium close
until new spatial relationship becomes familiar to retina
 Have client practice walking, using stairs, reaching for articles
 Contact lenses cause less distortion of vision; prescribe at one Nursing Intervention Pre-op
month 1. Maintain bed rest as ordered with head of bed flat & detached area in a
dependent position
Retinal Detachment 2. Use bilateral eye patches as ordered; elevate side rails to prevent injury
 Separation of epithelial surface of retina 3. Identify yourself when entering the room
 Detachment or the sensory retina from the pigment epithelium of the 4. Orient the client frequently to time of date & surroundings; explain
retina procedures
5. Provide diversional activities to provide sensory stimulation
Predisposing Factors Nursing Intervention Post-op
1. Trauma 1. Check orders for positioning & activity level:
2. Aging process a. May be on bed rest for 1-2 days
3. Severe diabetic retinopathy b. May need to position client so that detached area is in dependent
4. Post-cataract extraction position
5. Severe myopia (near sightedness) 2. Administer medication as ordered:
a. Topical mydriatics
Pathophysiology b. Analgesic as needed
 Tear in the retina allows vitreous humor to seep behind the sensory retina 3. Provide client teaching & discharge planning concerning:
& separate it from the pigment epithelium a. Techniques of eyedrop administration
b. Use eye shield at night
S/sx c. No bending from waist; no heavy work or lifting for 6 weeks
1. Curtain veil like vision coming across field of vision d. Restriction of reading for 3 weeks or more
2. Flashes of light e. May watch TV
3. Visual field loss f. Need to check to physician regarding combing & shampooing hair &
4. Floaters shaving
5. Gradual decrease of central vision g. Need to report complications such as recurrence of detachment

Dx Overview of Anatomy & Physiology Of Ear (Hearing)

1. Ophthalmoscopic exam: confirms diagnosis External Ear
1. Auricle (Pinna): outer projection of ear composed of cartilage & covered by
Medical Management skin; collects sound waves
1. Bed rest with eye patched & detached areas dependent to prevent further 2. External Auditory Canal: lined with skin; glands secretes cerumen (wax),
detachment providing protection; transmits sound waves to tympanic membrane
2. Surgery: necessary to repair detachment 3. Tympanic Membrane (Eardrum): at end of external canal; vibrates in
a. Photocoagulation: light beam (argon laser) through dilated pupil response to sound & transmits vibrations to middle ear
creates an inflammatory reaction & scarring to heal the area
b. Cryosurgery or diathermy: application of extreme cold or heat to Middle Ear
external globe; inflammatory reaction causes scarring & healing of 1. Ossicles
area a. 3 small bones: malleus (Hammer) attached to tympanic membrane,
incus (anvil), stapes (stirrup)
 b. Ossicles are set in motion by sound waves from tympanic membrane 1. Audiometry: reveals conductive hearing loss
c. Sound waves are conducted by vibration to the footplate of the 2. Weber’s & Rinne’s Test: show bone conduction is greater than air
stapes in the oval widow (an opening between the middle ear & the conduction
inner ear)
2. Eustachian Tube: connects nasopharynx & middle ear; bring air into Medical Management
middle ear, thus equalizing pressure on both sides of eardrum 1. Stapedectomy: procedure of choice
 Removal of diseased portion of stapes & replacement with
Inner Ear prosthesis to conduct vibrations from the middle ear to inner ear
1. Cochlea  Usually performed under local anesthesia
 Controls hearing  Used to treat otoscrlerosis
 Contains Organ of Corti (the true organ of hearing): the receptor
end-organ for hearing Nursing Intervention Pre-op
 Transmit sound waves from the oval window & initiates nerve 1. Provide general pre-op nursing care, including an explanation of post-
impulses carried by cranial nerve VIII (acoustic branch) to the op expectation
brain (temporal lobe of cerebrum) 2. Explain to the client that hearing may improve during surgery & then
2. Vestibular Apparatus decrease due to edema & packing
 Organ of balance
 Composed of three semicircular canals & the utricle Nursing Intervention Post-op
3. Endolymph & Perilymph 1. Position the client according to the surgeon’s orders (possibly with
 For static equilibrium operative ear uppermost to prevent displacement of the graft)
4. Mastoid air cells 2. Have the client deep breathe every 2 hours while in bed, but no
 Air filled spaces in temporal bone in skull coughing
3. Elevate side rails; assist the client with ambulation & move slowly:
Disorder of the Ear may have some vertigo
Otosclerosis 4. Administer medication as ordered:
 Formation of new spongy bone in the labyrinth of the ear causing  Analgesic
fixation of the stapes in the oval window  Antibiotics
 This prevent transmission of auditory vibration to the inner ear  Anti-emetics
 Anti-motion sickness drug: Meclesine Hcl (Bonamine)
Predisposing Factor 5. Check for dressing frequently for excessive drainage or bleeding
1. Found more often in women 6. Assess facial nerve function: Ask the client to do the ff:
 Wrinkle forehead
Cause  Close eyelids
1. Unknown / idiopathic  Puff out checks for any asymmetry
2. There is familial tendency 7. Question the client about the ff: report existence to physicians
3. Ear trauma & surgery  Pain
 Headaches
S/sx  Vertigo
1. Progressive hearing loss  Unusual sensations in the ear
2. Tinnitus 8. Provide client teaching & discharge planning concerning:
a. Warning against blowing nose or coughing; sneeze with mouth
Dx open
 b. Need to keep ear dry in the shower; no shampooing until allowed 2. Chronic:
c. No flying for 6 mos. Especially if upper respiratory tract infection a. Drug Therapy:
is present  Vasodilators (nicotinic Acid)
d. Placement of cotton balls in auditory meatus after packing is  Diuretics
removed; change twice daily  Mild sedative or tranquilizers: Diazepam (Valium)
 Antihistamines: Diphenhydramine (Benadryl)
Meniere’s Disease  Meclizine (antivert)
 Disease of the inner ear resulting from dilatation of the endolymphatic b. Diet:
system & increase volume of endolymph  Low sodium diet
 Characterized by recurrent & usually progressive triad of symptoms:  Restricted fluid intake
vertigo, tinnitus, hearing loss  Restrict caffeine & nicotine
3. Surgery:
Predisposing Factor a. Surgical destruction of labyrinth causing loss of vestibular &
1. Incidence highest between ages 30 & 60 cochlear function (if disease is unilateral)
b. Intracranial division of vestibular portion of cranial nerve VIII
Cause c. Endolymphatic sac decompression or shunt to equalize pressure
2. Unknown / idiopathic in endolymphatic space
3. Theories include the ff:
a. Allergy Nursing Intervention
b. Toxicity 1. Maintain bed rest in a quiet, darkened room in position of choice;
c. Localized ischemia elevate side rails as needed
d. Hemorrhage 2. Only move the client for essential care (bath may not be essential)
e. Viral infection 3. Provide emesis basin for vomiting
f. Edema 4. Monitor IV Therapy; maintain accurate I&O
5. Assist in ambulation when the attack is over
S/sx 6. Administer medication as ordered
1. Sudden attacks of vertigo lasting hours or days; attacks occurs several 7. Prepare client for surgery as indicated (pot-op care includes using
times a year above measures)
2. N/V 8. Provide client care & discharge planning concerning:
3. Tinnitus a. Use of medication & side effects
4. Progressive hearing loss b. Low sodium diet & decrease fluid intake
5. Nystagmus c. Importance of eliminating smoking

Dx Overview of Anatomy & Physiology of Endocrine System

1. Audiometry: reveals sensorineural hearing loss
2. Vestibular Test: reveals decrease function Endocrine System
 Is composed of an interrelated complex of glands (Pituitary G, Adrenal G,
Medical Management Thyroid G, Parathyroid G, Islets of langerhans of the pancreas, Ovaries &
1. Acute: Testes) that secretes a variety of hormones directly into the bloodstream.
 Atropine (decreases autonomic nervous system activity)  Its major function, together with the nervous system: is to regulate body
 Diazepam (Valium) function
 Fentanyl & Droperidol (Innovar)
Hormones Regulation Or in response to an increase
1. Hormones: chemical substance that acts s messenger to specific cells & in plasma osmolality
organs (target organs), stimulating & inhibiting various processes To stimulate reabsorption of
Two Major Categories H2O & decrease urine
a. Local: hormones with specific effect in the area of secretion (ex. Output
Secretin, cholecystokinin, panceozymin [CCK-PZ]) : Oxytocin : stimulate uterine
b. General: hormones transported in the blood to distant sites where contractions during delivery & the
they exert their effects (ex. Cortisol) Release of milk in lactation
2. Negative Feedback Mechanisms: major means of regulating hormone  Intermediate lobe : MSH : affects skin pigmentation
levels
a. Decreased concentration of a circulating hormones triggers Adrenal G
production of a stimulating hormones from pituitary gland; this  Adrenal Cortex : Mineralocorticoid : regulate fluid & electrolyte
hormones in turn stimulates its target organ to produce hormones balance; stimulate
b. Increased concentration of a hormones inhibits production of the (ex. Aldosterone) reabsoption of sodium, chloride, &
stimulating hormone, resulting in decreased secretion of the target H2O; stimulate
organ hormone potassium excretion
3. Some hormones are controlled by changing blood levels of specific : Glucocorticoids : increase blood glucose level by
substances (ex. Calcium, glucose) increasing rate of
4. Certain hormones (ex. Cortisol or female reproductive hormones) follow (ex. Cortisol, glyconeogenesis; increase
rhythmic patterns of secretion CHON catabolism; increase
5. Autonomic & CNS control (pituitary-hypothalamic axis): hypothalamus corticosterone) mobilization of fatty acid;
controls release of the hormones of the anterior pituitary gland through promote sodium & H2O
releasing & inhibiting factors that stimulate or inhibits hormone secretions retention; anti-inflammatory effect; aid body in
coping
Hormone Function with stress
Endocrine G Hormone Functions : Sex Hormones : influence development of secondary
Pituitary G sex
 Anterior lobe: TSH : stimulate thyroid G to release (androgens, estrogens characeristics
thyroid hormones progesterones)
: ACTH : stimulate adrenal cortex to  Adrenal Medulla : Epinephrine, : function in acute stress;
produce & release increase HR, BP; dilates
adrenocoticoids Norepinephrine bronchioles; convert glycogen to
: FSH, LH : stimulate growth, glucose when
maturation, & function of primary Needed by the muscles for
& secondary sex organ energy
: GH, Somatotropin : stimulate growth of body
tissues & bones Thyroid G : T3, T4 : regulate metabolic rate; CHO,
: Prolactin or LTH : stimulate development of fats, & CHON
mammary gland & Metabolism; aid in regulating
Lactation physical & mental
 Posterior lobe : ADH : regulates H2O metabolism; Growth & development
release during stress
 : Thyrocalcitonin : lowers serum calcium &  Somatotropic / GH: promotes elongation of long bones
phosphate levels  Hyposecretion of GH: among children results to dwarfism
 Hypersecretion of GH: among children results to gigantism
Parathyroid G : PTH : regulates serum calcium &  Hypersecretion of GH: among adults results to acromegaly
phosphate levels (square face)
 DOC: Ocreotide (Sandostatin)
Pancreas (islets of  Prolactin: promotes development of mammary gland; with
Langerhans) help of oxytocin it initiates milk let down reflex
 Beta Cells : Insulin : allows glucose to diffuse c. Regulated by hypothalamic releasing & inhibiting factors & by negative
across cell membrane; feedback system
Converts glucose to glycogen 2. Posterior Lobe PG (Neurohypophysis)
 Alpha Cells : Glucagon : increase blood glucose by  Does not produce hormones
causing glyconeogenisis  Store & release anti-diuretic hormones (ADH) & oxytocin produced by
& glycogenolysis in the liver; hypothalamus
secreted in response to  Secretes hormones oxytocin (promotes uterine contractions
low blood sugar preventing bleeding or hemorrhage)
 Administer oxytocin immediately after delivery to prevent uterine
Ovaries : Estrogen, Progesterone : development of secondary sex characteristics atony.
in the  Initiates milk let down reflex with help of hormone prolactin
Female, maturation of sex 3. Intermediate Lobe PG
organ, sexual functioning  Secretes melanocytes stimulating H (MSH)
Maintenance of pregnancy  MSH: for skin pigmentation
Testes : Testosterone : development of secondary  Hyposecretion of MSH: results to albinism
sex characteristics in the  Hypersecretion of MSH: results to vitiligo
Male maturation of the sex  2 feared complications of albinism:
organs, sexual functioning 1. Lead to blindness due to severe photophobia
2. Prone to skin cancer

Pituitary Gland (Hypophysis) Adrenal Glands

 Located in sella turcica at the base of brain  Two small glands, one above each kidney; Located at top of each
 “Master Gland” or master clock kidney
 Controls all metabolic function of body
3 Lobes of Pituitary Gland 2 Sections of Adrenal Glands
1. Anterior Lobe PG (Adenohypophysis) 1. Adrenal Cortex (outer portion): produces mineralocorticoids,
a. Secretes tropic hormones (hormones that stimulate target glands to glucocorticoids, sex hormones
produce their hormones): adrenocorticotropic H (ACTH), thyroid-  3 Zones/Layers
stimulating H (TSH), follicle-stimulating H (FSH), luteinizing H (LH)  Zona Fasciculata: secretes glucocortocoids (cortisol): controls
 ACTH: promotes development of adrenal cortex glucose metabolism: Sugar
 LH: secretes estrogen  Zona Reticularis: secretes traces of glucocorticoids & androgenic
 FSH: secretes progesterone hormones: promotes secondary sex characteristics: Sex
b. Also secretes hormones that have direct effects on tissues:
somatotropic or growth H, prolactin
  Zona Glumerulosa: secretes mineralocorticoids (aldosterone):  Testes: located in scrotum; produces testosterone
promotes sodium and water reabsorption and excretion of
potassium: Salt Pineal Gland
2. Adrenal Medulla (inner portion): produces epinephrine, norepinephrine  Secretes melatonin
(secretes catecholamines a power hormone): vasoconstrictor  Inhibits LH secretion
 2 Types of Catecholamines:  It controls & regulates circadian rhythm (body clock)
 Epinephrine (vasoconstrictor) Diabetes Incipidus (DI)
 Norepinephrine (vasoconstrictor)  DI: dalas-ihi
o Pheochromocytoma (adrenal medulla): Increase secretion of  Decrease of anti-diuretic hormone (ADH)
norepinephrine: Leading to hypertension which is resistant to  Hyposecretion of ADH
pharmacological agents leading to CVA: Use beta-blockers  Hypofunction of the posterior pituitary gland (PPG) resulting in deficiency
of ADH
Thyroid Gland  Characterized by excessive thirst & urination
 Located in anterior portion of the neck
 Consist of 2 lobes connected by a narrow isthmus Anti-diuretic Hormone: Pitressin (Vasopressin)
 Produces thyroxine (T4), triiodothyronine (T3), thyrocalcitonin Function: prevents urination thereby conserving water
 3 Hormones Secreted:  Note: Alcohol inhibits release of ADH
 T3: 3 molecules of iodine (more potent)
 T4: 4 molecule of iodine Predisposing Factor
 T3 and T4 are metabolic hormone: increase brain activity; 1. Related to pituitary surgery
promotes cerebration (thinking); increase V/S 2. Trauma
 Thyrocalcitonin: antagonizes the effects of parathormone to 3. Inflammation
promote calcium reabsorption. 4. Presence of tumor

Parathyroid Gland S/sx

 4 small glands located in pairs behind the thyroid gland 1. Severe polyuria with low specific gravity
 Produce parathormone (PTH) 2. Polydipsia (excessive thirst)
 Promotes calcium reabsorption 3. Fatigue
4. Muscle weakness
Pancreas 5. Irritability
 Located behind the stomach 6. Weight loss
 Has both endocrine & exocrine function (mixed gland) 7. Hypotension
 Consist of Acinar Cells (exocrine gland): which secretes pancreatic juices: 8. Signs of dehydration
that aids in digestion a. Adult: thirst; Children: tachycardia
 Islets of langerhans (alpha & beta cells) involved in endocrine function: b. Agitation
 Alpha Cell: produce glucagons: (function: hyperglycemia) c. Poor Skin turgor
 Beta Cell: produce insulin: (function: hypoglycemia) d. Dry mucous membrane
 Delta Cells: produce somatostatin: (function: antagonizes the effects 9. Tachycardia, eventually shock if fluids is not replaced
of growth hormones) 10. If left untreated results to hypovolemic shock (late sign anuria)

Gonads Dx
 Ovaries: located in pelvic cavity; produce estrogen & progesterone 1. Urine Specific Gravity (NV: 1.015 – 1.030): less than 1.004
 2. Serum Na: increase resulting to hypernatremia Dx
3. H2O deprivation test: reveals inability to concentrate urine 1. Urine specific gravity: is increase
2. Serum Sodium: is decreased
Nursing Intervention
1. Maintain F&E balance / Force fluids 2000-3000 ml/day Medical Management
a. Keep accurate I&O 1. Treat underlying cause if possible
b. Weigh daily 2. Diuretics & fluid restriction
c. Administer IV/oral fluids as ordered to replace fluid loss
2. Monitor strictly V/S & observe for signs of dehydration & hypovolemia Nursing Intervention
3. Administer hormone replacement as ordered: 1. Restrict fluid: to promote fluid loss & gradual increase in serum Na
a. Vasopressin (Pitressin) & Vasopressin Tannate (Pitressin Tannate Oil): 2. Administer medications as ordered:
administered by IM injection a. Loop diuretics (Lasix)
 Warm to body temperature before giving b. Osmotic diuretics (Mannitol)
 Shake tannate suspension to ensure uniform dispersion 3. Monitor strictly V/S, I&O & neuro check
b. Lypressin (Diapid): nasal spray 4. Weigh patient daily and assess for pitting edema
4. Prevent complications: hypovolemic shock is the most feared complication 5. Monitor serum electrolytes & blood chemistries carefully
5. Provide client teaching & discharge planning concerning: 6. Provide meticulous skin care
a. Lifelong hormone replacement: Lypressin (Diapid) as needed to 7. Prevent complications
control polyuria & polydipsia
b. Need to wear medic-alert bracelet HYPOTHYROIDISM
- all are decrease except weight and menstruation
Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH) - memory impairment
 Hypersecretion of anti-diuretic hormone (ADH) from the PPG even when Signs and Symptoms
the client has abnormal serum osmolality - there is loss of appetite but there is weight gain
- menorrhagia
Predisposing Factors - cold intolerance
1. Head injury - constipation
2. Related to presence of bronchogenic cancer
 Initial sign of lung cancer is non productive cough HYPERTHYROIDISM
 Non invasive procedure is chest x-ray - all are increase except weight and menstruation
3. Related to hyperplasia of pituitary gland (increase size of organ brought Signs and Symptoms
about by increase of number of cells) - increase appetite but there is weight loss
- amenorrhea
S/sx - exophthalmos
1. Person with SIADH cannot excrete a dilute urine
2. Fluid retention & Na deficiency Thyroid Disorder
a. Hypertension
b. Edema Simple Goiter
c. Weight gain  Enlargement of thyroid gland due to iodine deficiency
3. Water intoxication: may lead to cerebral edema: lead to increase ICP; may  Enlargement of the thyroid gland not caused by inflammation of neoplasm
lead to seizure activity
 Low level of thyroid hormones stimulate increased secretion of TSH by 1. Drug Therapy:
pituitary; under TSH stimulation the thyroid increases in size to  Hormone replacement with levothyroxine (Synthroid) (T4), dessicated
compensate & produce more thyroid hormone thyroid, or liothyronine (Cytomel) (T3)
 Small dose of iodine (Lugol’s or potassium iodide solution): for goiter
Predisposing Factors resulting from iodine deficiency
1. Endemic: caused by nutritional iodine deficiency, most common in the 2. Avoidance of goitrogenic food or drugs in sporadic goiter
“goiter belt” area, areas where soil & H2O are deficient in iodine; occurs 3. Surgery:
most frequently during adolescence & pregnancy  Subtotal thyroidectomy: (if goiter is large) to relieve pressure
 Goiter belt area: symptoms & for cosmetic reasons
a. Midwest, northwest & great lakes region
b. Places far from sea Nursing Intervention
c. Mountainous regions 1. Administer Replacement therapy as ordered:
2. Sporadic: caused by a. Lugol’s Solution / SSKI (Saturated Solution of Potassium Iodine)
 Increase intake of goitrogenic foods (contains agent that decrease the  Color purple or violet and administered via straw to prevent
thyroxine production: pro-goitrin an anti-thyroid agent that has no staining of teeth.
iodine). Ex. cabbage, turnips, radish, strawberry, carrots, sweet  4 Medications to be taken via straw: Lugol’s, Iron, Tetracycline,
potato, rutabagas, peaches, peas, spinach, broccoli, all nuts Nitrofurantoin (DOC: for pyelonephritis)
 Soil erosion washes away iodine b. Thyroid Hormones:
 Goitrogenic drugs:  Levothyroxine (Synthroid)
a. Anti-Thyroid Agent: Propylthiouracil (PTU)  Liothyronine (Cytomel)
b. Large doses of iodine  Thyroid Extracts
c. Phenylbutazone
d. Para-amino salicylic acid Nursing Intervention when giving Thyroid Hormones:
e. Lithium Carbonate 1. Instruct client to take in the morning to prevent insomnia
f. PASA (Aspirin) 2. Monitor vital signs especially heart rate because drug causes
g. Cobalt tachycardia and palpitations
3. Genetic defects that prevents synthesis of thyroid hormones 3. Monitor side effects:
 Insomnia
S/sx  Tachycardia and palpitations
1. Enlarged thyroid gland  Hypertension
2. Dysphagia  Heat intolerance
3. Respiratory distress 2. Increase dietary intake of foods rich in iodine:
4. Mild restlessness  Seaweeds
 Seafood’s like oyster, crabs, clams and lobster but not shrimps
Dx because it contains lesser amount of iodine.
1. Serum T4: reveals normal or below normal  Iodized salt: best taken raw because it is easily destroyed by heat
2. Thyroid Scan: reveals enlarged thyroid gland. 3. Assist in surgical procedure of subtotal thyroidectomy
3. Serum Thyroid Stimulating Hormone (TSH): is increased (confirmatory 4. Provide client teaching & discharge planning concerning:
diagnostic test)  Used of iodized salt in preventing & treating endemic goiter
4. RAIU (Radio Active Iodine Uptake): normal or increased  Thyroid hormone replacement

Medical Management Hypothyroidism (Myxedema)

 Slowing of metabolic processes caused by hypofunction of the thyroid c. Bradypnea
gland with decreased thyroid hormone secretion d. Hypothermia
 Hyposecretion of thyroid hormone 10. Weakness and fatigue
 Decrease in all V/S except wt & menses 11. Slowed mental processes
 Adults: myxedema non pitting edema 12. Dull look
 Children: cretinism the only endocrine disorder that can lead to mental 13. Slow clumsy movement
retardation 14. Lethargy
 In severe or untreated cases myxedema coma may occur: 15. Generalized interstitial non-pitting edema (Myxedema)
 Characterized by intensification of S/sx of hypothyroidism & 16. Hoarseness of voice
neurologic impairment leading to coma 17. Decrease libido
 Mortality rate high; prompt recognition & treatment essential 18. Memory impairment
 Precipitating factors: failure to take prescribed medications; infection; 19. Psychosis
trauma; exposure to cold; use of sedatives, narcotics or anesthetics 20. Menorrhagia

Predisposing Factors Dx
1. Primary hypothyroidism: atrophy of the gland possibly caused by an 1. Serum T3 and T4: is decreased
autoimmune process 2. Serum Cholesterol: is increased
2. Secondary hypothyroidism: caused by decreased stimulation from 3. RAIU (Radio Active Iodine Uptake): is decreased
pituitary TSH Medical Management
3. Iatrogenic: surgical removal of the gland or over treatment of 1. Drug Therapy:
hyperthyroidism with drugs or radioactive iodine; disease caused by  Levothyroxine (Synthroid)
medical intervention such as surgery  Thyroglobulin (Proloid)
4. Related to atrophy of thyroid gland due to trauma, presence of tumor,  Dessicated thyroid
inflammation  Liothyronine (Cytomel)
5. Iodine deficiency 2. Myxedema coma is a medical emergency:
6. Autoimmune (Hashimotos Disease)  IV thyroid hormones
7. Occurs more often to women ages 30 & 60  Correction of hypothermina
 Maintenance of vital function
 Treatment of precipitating cause
S/sx
1. Loss of appetite: but there is wt gain Nursing Intervention
2. Anorexia 1. Monitor strictly V/S & I&O, daily weights; observe for edema & signs
3. Weight gain: which promotes lipolysis leading to atherosclerosis and of cardiovascular complication & to determine presence of myxedema
MI coma
4. Constipation 2. Administer thyroid hormone replacement therapy as ordered &
5. Cold intolerance monitor effects:
6. Dry scaly skin a. Observe signs of thyrotoxicosis:
7. Spares hair  Tachycardia & palpitation
8. Brittleness of nails  N/V
9. Decrease in all V/S: except wt gain & menses  Diarrhea
a. Hypotension  Sweating
b. Bradycardia  Tremors
  Agitation
 Dyspnea Hyperthyroidism
b. Increase dosage gradually, especially in clients with cardiac  Secretion of excessive amounts of thyroid hormone in the blood causes an
complication increase in metabolic process
3. Provide comfortable and warm environment: due to cold intolerance  Increase in T3 and T4
4. Provide a low calorie diet  Grave’s Disease or Thyrotoxicosis
5. Avoid the use of sedatives; reduce the dose of any sedatives,  Increase in all V/S except wt & menses
narcotics, or anesthetic agent by half as ordered
6. Provide meticulous skin care: to prevent skin breakdown Predisposing Factors
7. Increase fluid & food high in fiber: to prevent constipation; administer 1. More often seen in women between ages 30 & 50
stool softener as ordered 2. Autoimmune: involves release of long acting thyroid stimulator
8. Observe for signs of myxedema coma; provide appropriate nursing causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of
care dehydration among infants)
a. Administer medication as ordered 3. Excessive iodine intake
b. Maintain vital functions: 4. Related to hyperplasia (increase size of TG)
 Correct hypothermia
 Maintain adequate ventilation S/sx
9. Myxedema coma: 1. Increase appetite (hyperphagia): but there is weight loss
 A complication of hypothyroidism & an emergency case 2. Heat intolerance
 A severe form of hypothyroidism is characterized by: 3. Weight loss
 Severe hypotension 4. Diarrhea: increase motility
 Bradycardia 5. Increased in all V/S: except wt & menses
 Bradypnea a. Tachycardia
 Hypoventilation b. Increase systolic BP
 Hyponatremia c. Palpitation
 Hypoglycemia 6. Warm smooth skin
 Hypothermia 7. Fine soft hair
 Leading to progressive stupor and coma 8. Pliable nails
Nursing Management for Myxedema Coma 9. CNS involvement
1. Assist in mechanical ventilation a. Irritability & agitation
2. Administer thyroid hormones as ordered b. Restlessness
3. Administer IVF replacement isotonic fluid solution as ordered / c. Tremors
Force fluids d. Insomnia
10. Provide client health teaching and discharge planning concerning: e. Hallucinations
a. Thyroid hormone replacement f. Sweating
b. Importance of regular follow-up care g. Hyperactive movement
c. Need in additional protection in cold weather 10. Goiter
d. Measures to prevent constipation 11. PS: Exopthalmus (protrusion of eyeballs)
e. Avoid precipitating factors leading to myxedema coma & 12. Amenorrhea
hypovolemic shock
f. Stress & infection Dx
g. Use of anesthetics, narcotics, and sedatives 1. Serum T3 and T4: is increased
2. RAIU (Radio Active Iodine Uptake): is increased 13. Provide client teaching & discharge planning concerning:
3. Thyroid Scan: reveals an enlarged thyroid gland a. Need to recognized & report S/sx of agranulocytosis (fever, sore
throat, skin rash): if taking anti-thyroid drugs
Medical Management b. S/sx of hyperthyroidism & hypothyroidism
1. Drug Therap:
a. Anti-thyroid drugs: Propylthiouracil (PTU) & methimazole Thyroid Storm
(Tapazole): blocke synthesis of thyroid hormone; toxic effect  Uncontrolled & potentially life-threatening hyperthyroidism caused by
include agranulocytosis sudden & excessive release of thyroid hormone into the bloodstream
b. Adrenergic Blocking Agent: Propranolol (Inderal): used to
decrease sympathetic activity & alleviate symptoms such as Precipitating Factors
tachycardia 1. Stress
2. Radioactive Iodine Therapy 2. Infection
a. Radioactive isotope of iodine (ex. 131I): given to destroy the 3. unprepared thyroid surgery
thyroid gland, thereby decreasing production of thyroid hormone
b. Used in middle-aged or older clients who are resistant to, or S/sx
develop toxicity from drug therapy 1. Apprehension
c. Hypothyroidism is a potential complication 2. Restlessness
3. Surgery: Thyroidectomy performed in younger client for whom drug 3. Extremely high temp (up to 106 F / 40.7 C)
therapy has not been effective 4. Tahchycardia
5. HF
Nursing Intervention 6. Respiratory Distress
1. Monitor strictly V/s & I&O, daily weight 7. Delirium
2. Administer anti-thyroid medications as ordered: 8. Coma
a. Propylthiouracil (PTU)
b. Methimazole (Tapazole) Nursing Intervention
3. Provide for period of uninterrupted rest: 1. Maintain patent airway & adequate ventilation; administer O2 as
a. Assign a private room away from excessive activity ordered
b. Administer medication to promote sleep as ordered 2. Administer IV therapy as ordered
4. Provide comfortable and cold environment 3. Administer medication as ordered:
5. Minimized stress in the environment a. Anti-thyroid drugs
6. Encourage quiet, relaxing diversional activities b. Corticosteroids
7. Provide dietary intake that is high in CHO, CHON, calories, vitamin & c. Sedatives
minerals with supplemental feeding between meals & at bedtime; d. Cardiac Drugs
omit stimulant
8. Observe for & prevent complication
a. Exophthalmos: protects eyes with dark glasses & artificial tears as Thyroidectomy
ordered  Partial or total removal of thyroid gland
b. Thyroid Storm  Indication:
9. Provide meticulous skin care  Subtotal Thyroidectomy: hyperthyroidism
10. Maintain side rails  Total Thyroidectomy: thyroid cancer
11. Provide bilateral eye patch to prevent drying of the eyes
12. Assist in surgical procedures subtotal Thyroidectomy: Nursing Intervention Pre-op
1. Ensure that the client is adequately prepared for surgery Hyperthermia
a. Cardiac status is normal Tachycardia
b. Weight & nutritional status is normal  Administer medications as ordered:
2. Administer anti-thyroid drugs as ordered: to suppressed the  Anti Pyretics
production of thyroid hormone & to prevent thyroid storm  Beta-blockers
3. Administer iodine preparation Lugol’s Solution (SSKI) or Potassium  Monitor strictly vital signs, input and output and neuro check.
Iodide Solution: to decrease vascularity of the thyroid gland & to  Maintain side rails
prevent hemorrhage.  Offer TSB
8. Administer IV fluids as ordered: until the client is tolerating fluids by
Nursing Intervention Post-Op mouth
1. Monitor V/S & I&O 9. Administer analgesics as ordered: for incisional pain
2. Check dressing for signs of hemorrhage: check for wetness behind the 10. Relieve discomfort from sore throat:
neck a. Cool mist humidifier to thin secretions
3. Place client in semi-fowlers position & support head with pillow b. Administer analgesic throat lozenges before meals prn as ordered
4. Observe for respiratory distress secondary to hemorrhage, edema of 11. Encourage coughing & deep breathing every hour
glottis, laryngeal nerve damage, or tetany: keep tracheostomy set, O2 12. Assist the client with ambulation: instruct the client to place the hands
& suction nearby behind the neck: to decrease stress on suture line if added support is
5. Assess for signs of tetany: due to hypocalcemia: due to secondary necessary
accidental removal of parathyroid glands: keep Calcium Gluconate 13. Hormonal replacement therapy for lifetime
available: 14. Watch out for accidental laryngeal damage which may lead to
 Watch out for accidental removal of parathyroid which may lead hoarseness of voice: encourage client to talk/speak immediately after
to hypocalcemia (tetany) operation and notify physician
Classic S/sx of Tetany 15. Provide client teaching& discharge planning concerning:
 Positive trousseu’s sign a. S/sx of hyperthyroidism & hypothyroidism
 Positive chvostek sign b. Self administration of thyroid hormone: if total thyroidectomy is
 Observe for arrhythmia, seizure: give Calcium Gluconate IV slowly performed
as ordered c. Application of lubricant to the incision once suture is removed
6. Ecourage clients voice to rest: d. Perform ROM neck exercise 3-4 times a day
a. Some hoarseness is common e. Importance of follow up care with periodic serum calcium level
b. Check every 30-60 min for extreme hoarseness or any
accompanying respiratory distress Hypoparathyroidism
7. Observe for signs of thyroid storm / thyrotoxicosis: due to release of  Disorder characterized by hypocalcemia resulting from a deficiency of
excessive amount of thyroid hormone during surgery parathormone (PTH) production
 Decrease secretion of parathormone: leading to hypocalcemia: resulting to
Agitation hyperphospatemia
 If calcium decreases phosphate increases

Predisposing Factors
1. May be hereditary
TRIAD SIGNS
2. Idiopathic
3. Caused by accidental damage to or removal of parathyroid gland
during thyroidectomy surgery
4. Atrophy of parathyroid gland due to: inflammation, tumor, trauma  Oral calcium preparation: Calcium Gluconate, Calcium
Lactate, Calcium Carbonate (Os-Cal)
S/sx  Large dose of vitamin D (Calciferol): to help absorption of
1. Acute hypocalcemia (tetany) calcium
a. Paresthesia: tingling sensation of finger & around lip
b. Muscle spasm
c. laryngospasm/broncospasm CHOLECALCIFEROL ARE DERIVED FROM
d. Dysphagia
e. Seizure: feared complications Drug Diet (Calcidiol)
f. Cardiac arrhythmia: feared complications Sunlight (Calcitriol)
g. Numbness
h. Positive trousseu’s sign: carpopedal spasm  Phosphate Binder: Aluminum Hydroxide Gel (Amphogel) or
i. Positive chvostek sign aluminum carbonate gel, basic (basaljel): to decrease
2. Chronic hypocalcemia (tetany) phosphate levels
a. Fatigue
b. Weakness ANTACID
c. Muscle cramps
d. Personality changes A.A.C MAD
e. Irritability
f. Memory impairment Aluminum
g. Agitation Magnesium Containing
h. Dry scaly skin Containing
i. Hair loss Antacids Antacids
j. Loss of tooth enamel
k. Tremors
l. Cardiac arrhythmias Aluminum
m. Cataract formation Hydroxide
n. Photophobia Gel
o. Anorexia
p. N/V Side Effect: Constipation Side Effect:
Diarrhea
Diagnostic Procedures 2. Institute seizure & safety precaution
1. Serum Calcium level: decreased (normal value: 8.5 – 11 mg/100 ml) 3. Provide quite environment free from excessive stimuli
2. Serum Phosphate level: increased (normal value: 2.5 – 4.5 mg/100 ml) 4. Avoid precipitating stimulus such as glaring lights and noise
3. Skeletal X-ray of long bones: reveals a increased in bone density 5. Monitor signs of hoarseness or stridor; check for signs for Chvostek’s
4. CT Scan: reveals degeneration of basal ganglia & Trousseau’s sign
6. Keep emergency equipment (tracheostomy set, injectable Calcium
Nursing Management Gluconate) at bedside: for presence of laryngospasm
1. Administer medications as ordered such as: 7. For tetany or generalized muscle cramp: may use rebreathing bag or
a. Acute Tetany: Calcium Gluconate slow IV drip as ordered paper bag to produce mild respiratory acidosis: to promote increase
b. Chronic Tetany: ionized Ca levels
8. Monitor serum calcium & phosphate level
 9. Provide high-calcium & low-phosphorus diet
10. Provide client teaching & discharge planning concerning: Nursing Intervention
a. Medication regimen: oral calcium preparation & vit D to be taken 1. Administer IV infusions of normal saline solution & give diuretics as
with meal to increase absorption ordered:
b. Need to recognized & report S/sx of hypo/hypercalcemia 2. Monitor I&O & observe fluid overload & electrolytes imbalance
c. Importance of follow-up care with periodic serum calcium level 3. Assist client with self care: Provide careful handling, Moving,
d. Prevent complications Ambulation: to prevent pathologic fracture
e. Hormonal replacement therapy for lifetime 4. Monitor V/S: report irregularities
5. Force fluids 2000-3000 L/day: to prevent kidney stones
Hyperparathyroidism 6. Provide acid-ash juices (ex. Cranberry, orange juice): to acidify urine &
 Increase secretion of PTH that results in an altered state of calcium, prevent bacterial growth
phosphate & bone metabolism 7. Strain urine: using gauze pad: for stone analysis
 Decrease parathormone 8. Provide low-calcium & high-phosphorus diet
 Hypercalcemia: bone demineralization leading to bone fracture (calcium is 9. Provide warm sitz bath: for comfort
stored 99% in bone and 1% blood) 10. Administer medications as ordered: Morphine Sulfate (Demerol)
 Kidney stones 11. Maintain side rails
12. Assist in surgical procedure: Parathyroidectomy
Predisposing Factors 13. Provide client teaching & discharge planning concerning:
1. Most commonly affects women between ages 35 & 65 a. Need to engage in progressive ambulatory activities
2. Primary Hyperparathyroidism: caused by tumor & hyperplasia of b. Increase fluid intake
parathyroid gland c. Use of calcium preparation & importance of high-calcium diet
3. Secondary Hyperparathyroidism: cause by compensatory over following a parathyroidectomy
secretion of PTH in response to hypocalcemia from: d. Prevent complications: renal failure
a. Children: Ricketts e. Hormonal replacement therapy for lifetime
b. Adults: Osteomalacia f. Importance of follow up care
c. Chronic renal disease
d. Malabsorption syndrome Addison’s Disease
 Primary adrenocortical insufficiency; hypofunction of the adrenal cortex
S/sx causes decrease secretion of the mineralcorticoids, glucocorticoids, & sex
1. Bone pain (especially at back); Bone demineralization; Pathologic hormones
fracture  Hyposecretion of adrenocortical hormone leading to:
2. Kidney stones; Renal colic; Polyuria; Polydipsia; Cool moist skin  Metabolic disturbance: Sugar
3. Anorexia; N/V; Gastric Ulcer; Constipation  Fluid and electrolyte imbalance: Na, H2O, K
4. Muscle weakness; Fatigue  Deficiency of neuromascular function: Salt, Sex
5. Irritability / Agitation; Personality changes; Depression; Memory
impairment Predisposing Factors
6. Cardiac arrhythmias; HPN 1. Relatively rare disease caused by:
 Idiopathic atrophy of the adrenal cortex: due to an autoimmune
Dx process
1. Serum Calcium: is increased  Destruction of the gland secondary to TB or fungal infections
2. Serum Phosphate: is decreased
3. Skeletal X-ray of long bones: reveals bone demineralization S/sx
1. Fatigue, Muscle weakness 6. Weight daily
2. Anorexia, N/V, abdominal pain, weight loss 7. Provide small frequent feeding of diet: decrease in K, increase cal,
3. History of hypoglycemic reaction / Hypoglycemia: tremors, CHO, CHON, Na: to prevent hypoglycemia, & hyponatremia & provide
tachycardia, irritability, restlessness, extreme fatigue, diaphoresis, proper nutrition
depression 8. Monitor I&O: to determine presence of addisonian crisis (complication
4. Hyponatremia: hypotension, signs of dehydration, weight loss, weak of addison’s disease)
pulse 9. Provide meticulous skin care
5. Decrease tolerance to stress 10. Provide client teaching & discharge planning concerning:
6. Hyperkalemia: agitation, diarrhea, arrhythmia a. Disease process: signs of adrenal insufficiency
7. Decrease libido b. Use of prescribe medication for lifelong replacement therapy:
8. Loss of pubic and axillary hair never omit medication
9. Bronze like skin pigmentation c. Need to avoid stress, trauma & infection: notify the physician if
these occurs as medication dosage may need to be adjusted
Dx d. Stress management technique
1. FBS: is decreased (normal value: 80 – 100 mg/dl) e. Diet modification
2. Plasma Cortisol: is decreased f. Use of salt tablet (if prescribe) or ingestion of salty foods (potato
3. Serum Sodium: is decrease (normal value: 135 – 145 meq/L) chips): if experiencing increase sweating
4. Serum Potassium: is increased (normal value: 3.5 – 4.5 meq/L) g. Importance of alternating regular exercise with rest periods
h. Avoidance of strenuous exercise especially in hot weather
Nursing Intervention i. Avoid precipitating factor: leading to addisonian crisis: stress,
1. Administer hormone replacement therapy as ordered: infection, sudden withdrawal to steroids
a. Glucocorticoids: stimulate diurnal rhythm of cortisol release, give j. Prevent complications: addisonian crisis, hypovolemic shock
2/3 of dose in early morning & 1/3 of dose in afternoon k. Importance of follow up care
 Corticosteroids: Dexamethasone (Decadrone)
 Hydrocortisone: Cortisone (Prednisone) Addisonian Crisis
b. Mineralocorticoids:  Severe exacerbation of addison’s diseasecaused by acute adrenal
 Fludrocortisone Acetate (Florinef) insufficiency

Nursing Management when giving steroids Predisposing Factors

1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the 1. Strenuous activity
afternoon to mimic the normal diurnal rhythm 2. Stress
2. Taper dose (withdraw gradually from drug) 3. Trauma
3. Monitor side effects: 4. Infection
 Hypertension 5. Failure to take prescribe medicine
 Edema 6. Iatrogenic:
 Hirsutism  Surgery of pituitary gland or adrenal gland
 Increase susceptibility to infection  Rapid withdrawal of exogenous steroids in a client on long-
 Moon face appearance term steroid therapy
2. Monitor V/S
3. Decrease stress in the environment S/sx
4. Prevent exposure to infection 1. Generalized muscle weakness
5. Provide rest period: prevent fatigue 2. Severe hypotension
 3. Hypovolemic shock: vascular collapse Cushing Syndrome
4. Hyponatremia: leading to progressive stupor and coma  Condition resulting from excessive secretion of corticosteroids, particularly
glucocorticoid cortisol
Nursing Intervention  Hypersecretion of adrenocortical hormones
1. Assist in mechanical ventilation
2. Administer IV fluids (5% dextrose in saline, plasma) as ordered: to Predisposing Factors
treat vascular collapse 1. Primary Cushing’s Syndrome: caused by adrenocortical tumors or
3. Administer IV glucocorticoids: Hydrocortisone (Solu-Cortef) & hyperplasia
vasopressors as ordered 2. Secondary Cushing’s Syndrome (also called Cushing’s disease): caused
4. Force fluids by functioning pituitary or nonpituitary neoplasm secreting ACTH,
5. If crisis precipitate by infection: administer antibiotics as ordered causing increase secretion of glucocorticoids
6. Maintain strict bed rest & eliminate all forms of stressful stimuli 3. Iatrogenic: cause by prolonged use of corticosteroids
7. Monitor V/S, I&O & daily weight 4. Related to hyperplasia of adrenal gland
8. Protect client from infection 5. Increase susceptibility to infections
9. Provide client teaching & discharge planning concerning: same as
addison’s disease S/sx
1. Muscle weakness 14. Signs of masculinization in women: menstrual dysfunction, decrease libido
2. Fatigue 15. Osteoporosis
3. Obese trunk with thin arms & legs 16. Decrease resistance to infection
4. Muscle wasting 17. Hypertension
5. Irritability 18. Edema
6. Depression 19. Hypernatremia
7. Frequent mood swings 20. Weight gain
8. Moon face 21. Hypokalemia
9. Buffalo hump 22. Constipation
10. Pendulous abdomen 23. U wave upon ECG (T wave hyperkalemia)
11. Purple striae on trunk 24. Hirsutis
12. Acne 25. Easy bruising
13. Thin skin
4. Maintain skin integrity
Dx a. Provide meticulous skin care
1. FBS: is increased b. Prevent tearing of the skin: use paper tape if necessary
2. Plasma Cortisol: is increased 5. Minimize stress in the environment
3. Serum Sodium: is increased 6. Monitor V/S: observe for hypertension & edema
4. Serum Potassium: is decreased 7. Monitor I&O & daily weight: assess for pitting edema: Measure abdominal
girth: notify physician
Nursing Intervention 8. Provide diet low in Calorie & Na & high in CHON, K, Ca, Vitamin D
1. Maintain muscle tone 9. Monitor urine: for glucose & acetone; administer insulin as ordered
a. Provide ROM exercise 10. Provide psychological support & acceptance
b. Assist in ambulation 11. Prepare client for hypophysectomy or radiation: if condition is caused by a
2. Prevent accidents fall & provide adequate rest pituitary tumor
3. Protect client from exposure to infection
 12. Prepare client for Adrenalectomy: if condition is caused by an adrenal leads to hypovolemia, hypotension, renal failure & decease blood flow to the brain
tumor or hyperplasia resulting in coma & death unless treated.
13. Restrict sodium intake
14. Administer medications as ordered: Spironolactone (Aldactone): potassium MAIN FOODSTUFF ANABOLISM CATABOLISM
sparring diuretics 1. CHO Glucose Glycogen
15. Provide client teaching & discharge planning concerning: 2. CHON Amino Acids Nitrogen
a. Diet modification 3. Fats Fatty Acids Free Fatty Acids
b. Importance of adequate rest : cholesterol
c. Need to avoid stress & infection : ketones
d. Change in medication regimen (alternate day therapy or reduce
dosage): if caused of condition is prolonged corticosteroid therapy
e. Prevent complications (DM)
f. Hormonal replacement for lifetime: lifetime due to adrenal gland
removal: no more corticosteroid! HYPERGLYCEMIA
g. Importance of follow up care Increase osmotic diuresis

Diabetes Mellitus (DM) Glycosuria Polyuria

 Represent a heterogenous group of chronic disorders characterized by
hyperglycemia Cellular starvation: weight loss Cellular dehydration
 Hyperglycemia: due to total or partial insulin deficiency or insensitivity of the
cells to insulin Stimulates the appetite / satiety center Stimulates the thirst
center
 Characterized by disorder in the metabolism of CHO, fats, CHON, as well as
(Hypothalamus) (Hypothalamus)
changes in the structure & function of blood vessels
 Metabolic disorder characterized by non utilization of carbohydrates, protein
Polyphagia Polydypsia
and fat metabolism
* liver has glycogen that undergo glycogenesis/glycogenolysis
Pathophysiology
Lack of insulin causes hyperglycemia (insulin is necessary for the transport of glucose GLUCONEOGENESIS
across the cell membrane) = Hyperglycemia leads to osmitic diuresis as large amounts of Formation of glucose from non-CHO sources
glucose pass through the kidney result polyuria & glycosuria = Diuresis leads to cellular
Increase protein formation
dehydration & F & E depletion causing polydipsia (excessive thirst) = Polyphagia (hunger
& increase appetite) result from cellular starvation = The body turns to fat & CHON for
Negative Nitrogen balance
energy but in the absence of glucose in the cell fat cannot be completely metabolized &
ketones (intermediate products of fat metabolism) are produced = This leads to
ketonemia, ketonuria (contributes to osmotic diuresis) & metabolic acidosis (ketones are Tissue wasting (Cachexia)
acid bodies) = Ketone sacts as CNS depressants & can cause coma = Excess loss of F & E
INCREASE FAT CATABOLISM
  Secondary to destruction of beta cells in the islets of langerhans in the
Free fatty acids pancreas resulting in little of no insulin production
 Non-obese adults
Cholesterol Ketones  Requires insulin injection
Atherosclerosis Diabetic Keto Acidosis  Juvenile onset type (Brittle disease)
Hypertension
Acetone Breath Kussmaul’s Incidence Rate
Respiration 1. 10% general population has Type I DM
odor
MI CVA Predisposing Factors
1. Autoimmune response
2. Genetics / Hereditary (total destruction of pancreatic cells)
3. Related to viruses
Death Diabetic Coma 4. Drugs: diuretics (Lasix), Steroids, oral contraceptives
5. Related to carbon tetrachloride toxicity

Classification Of DM S/sx
1. Type I Insulin-dependent Diabetes Mellitus (IDDM)
1. Polyuria 7. Anorexia
2. Polydipsia 8. N/V
3. Polyphagia 9. Blurring of vision
4. Glucosuria 10. Increase susceptibility to infection
5. Weight loss 11. Delayed / poor wound healing
6. Fatigue
a. Consistency is imperative to avoid hypoglycemia
Dx b. High-fiber, low-fat diet also recommended
1. FBS: 4. Drug therapy:
a. A level of 140 mg/dl of greater on at two occasions confirms DM a. Insulin:
b. May be normal in Type II DM  Short Acting: used in treating ketoacidosis; during surgery,
2. Postprandial Blood Sugar: elevated infection, trauma; management of poorly controlled diabetes; to
3. Oral Glucose Tolerance Test (most sensitve test): elevated supplement long-acting insulins
4. Glycosolated Hemoglobin (hemoglobin A1c): elevated  Intermediate: used for maintenance therapy
 Long Acting: used for maintenance therapy in clients who
Medical Management experience hyperglycemia during the night with intermediate-
1. Insulin therapy acting insulin
2. Exercise
3. Diet:
 b. Insulin preparation can consist of mixture of pure pork, pure beef, or Insulin Zinc Ultralente Ins Cloudy 4-8 16-20 30-36
human insulin. Human insulin is the purest insulin & has the lowest Regular Ins &
antigenic effect suspension,
c. Human Insulin: is recommended for all newly diagnosed Type I & Type semilente prep
II DM who need short-term insulin therapy; the pregnant client & extended
diabetic client with insulin allergy or severe insulin resistance
d. Insulin Pumps: externally worn device that closely mimic normal Complication
pancreatic functioning 1. Diabetic Ketoacidosis (DKA)
5. Exercise: helpful adjunct to therapy as exercise decrease the body’s need
for insulin 2. Type II Non-insulin-dependent Diabetes Mellitus (NIDDM)
 May result to partial deficiency of insulin production &/or an insensitivity of
Characteristics of Insulin Preparation the cells to insulin
Drug Synonym Appearance Onset Peak Duration  Obese adult over 40 years old
Compatible Mixed  Maturity onset type
Rapid Acting
Insulin Injection Regular Ins Clear ½-1 2-4 6-8 Incidence Rate
All insulin prep 1. 90% of general population has Type II DM

except lente Predisposing Factors

1. Genetics
Insulin, Zinc Semilente Ins Cloudy ½-1 4-6 12-16 2. Obesity: because obese persons lack insulin receptor binding sites
Lente prep
suspension, S/sx
prompt 1. Usually asymptomatic
2. Polyuria
Intermediate Acting 3. Polydypsia
Isophane Ins NPH Ins Cloudy 1-1 ½ 8-12 18-24 4. Polyphagia
Regular Ins 5. Glycosuria
injection 6. Weight gain / Obesity
injection 7. Fatigue
8. Blurred Vision
Insulin Zinc Lente Ins Cloudy 1-1 ½ 8-12 18-24 9. Increase susceptibility to infection
Regular Ins & 10. Delayed / poor wound healing
Suspension
semilente prep Dx
5. FBS:
Long Acting c. A level of 140 mg/dl of greater on at two occasions confirms DM
 d. May be normal in Type II DM
6. Postprandial Blood Sugar: elevated :Decrease intestinal
7. Oral Glucose Tolerance Test (most sensitve test): elevated
8. Glycosolated Hemoglobin (hemoglobin A1c): elevated absorption of glucose &
improves
Medical Management insulin sensitivity
1. Ideally manage by diet & exercise
2. Oral Hypoglycemic agents or occasionally insulin: if diet & exercise are not Oral Alpha-glucosidose Inhibitor
effective in controlling hyperglycemia Acarbose (Precose) Unknown 1 Unknown :Delay
3. Insulin is needed in acute stress: ex. Surgery, infection glucose absorption
4. Diet: CHO 50%, CHON 30% & Fats 20% &
a. Weight loss is important since it decreases insulin resistance digestion of CHO,
b. High-fiber, low-fat diet also recommended lowering
5. Drug therapy: blood sugar
a. Occasional use of insulin Miglitol (Glyset) 2-3
b. Oral hypoglycemic agent: Troglitazone (Rezulin) Rapid 2-3 Unknown :Reduce
 Used by client who are not controlled by diet & exercise plasma glucose &
 Increase the ability of islet cells of the pancreas to secret insulin; insulin
may have some effect on cell receptors to decrease resistance to
insulin :Potetiates action of insulin
6. Exercise: helpful adjunct to therapy as exercise decrease the body’s need in
for insulin skeletal muscle &
decrease
Oral Hypoglycemic Agent glucose
Drug Onset Peak Duration
Comments production in liver
Oral Sulfonylureas
Acetohexamide (Dymelor) 1 4-6 12-24 Complications
Chlorpropamide (Diabinase) 1 4-6 40-60 1. Hyper Osmolar Non-Ketotic Coma (HONKC)
Glyburide (Micronase, Diabeta) 15 min- 1 hr 2-8 10-24
Nursing Intervention
Oral Biguanides 1. Administer insulin or oral hypoglycemic agent as ordered: monitor
Metformin (Glucophage) 2-2.5 10-16 hypoglycemia especially during period of drug peak action
:Decrease glucose 2. Provide special diet as ordered:
a. Ensure that the client is eating all meals
production in liver
 b. If all food is not ingested: provide appropriate substitute according to  Systematically rotate the site: to prevent lipodystrophy:
the exchange list or give measured amount of orange juice to (hypertrophy or atrophy of tissue)
substitute for leftover food; provide snack later in the day  Insert needle at a 45 (skinny clients) or 90 (fat or obese clients)
3. Monitor urine sugar & acetone (freshly voided specimen) degree angle depending on amount of adipose tissue
4. Perform finger sticks to monitor blood glucose level as ordered (more  May store current vial of insulin at room temperature; refrigerate
accurate than urine test) extra supplies
5. Observe signs of hypo/hyperglycemia  Somogyi’s phenomenon: hypoglycemia followed by periods of
6. Provide meticulous skin care & prevent injury hyperglycemia or rebound effect of insulin.
7. Maintain I&O; weight daily  Provide many opportunities for return demonstration
8. Provide emotional support: assist client in adapting change in lifestyle & d. Oral hypoglycemic agent
body image  Stress importance of taking the drug regularly
9. Observe for chronic complications & plan of care accordingly:  Avoid alcohol intake while on medication: it can lead to severe
a. Atherosclerosis: leads to CAD, MI, CVA & Peripheral Vascular Disease hypoglycemia reaction
b. Microangiopathy: most commonly affects eyes & kidneys  Instruct the client to take it with meals: to lessen GIT irritation &
c. Kidney Disease prevent hypoglycemia
 Recurrent Pyelonephritis e. Urine testing (not very accurate reflection of blood glucose level)
 Diabetic Nephropathy  May be satisfactory for Type II diabetics since they are more stable
d. Ocular Disorder  Use clinitest, tes-tape, diastix, for glucose testing
 Premature Cataracts  Perform test before meals & at bedtime
 Diabetic Retinopathy  Use freshly voided specimen
e. Peripheral Neuropathy  Be consistent in brand of urine test used
 Affects PNS & ANS  Report results in percentage
 Cause diarrhea, constipation, neurogenic bladder, impotence,  Report result to physician if results are greater that 1%, especially
decrease sweating if experiencing symptoms of hyperglycemia
10. Provide client teaching & discharge planning concerning:  Urine testing for ketones should be done by Type I diabetic clients
a. Disease process when there is persistent glycosuria, increase blood glucose level or
b. Diet if the client is not feeling well (acetest, ketostix)
 Client should be able to plan a meal using exchange lists before f. Blood glucose monitoring
discharge  Use for Type I diabetic client: since it gives exact blood glucose
 Emphasize importance of regularity of meals; never skip meals level & also detects hypoglycemia
c. Insulin  Instruct client in finger stick technique: use of monitor device (if
 How to draw up into syringe used), & recording & utilization of test results
 Use insulin at room temp g. General care
 Gently roll the vial between palms  Perform good oral hygiene & have regular dental exam
 Draw up insulin using sterile technique  Have regular eye exam
 If mixing insulin, draw up clear insulin, before cloudy insulin  Care for “sick days” (ex. Cold or flu)
 Injection technique
  Do not omit insulin or oral hypoglycemic agent: since infection  Learn to recognized S/sx of hypo/hyperglycemia: for hypoglycemia
causes increase blood sugar (cold and clammy skin), for hyperglycemia (dry and warm skin):
 Notify physician administer simple sugars
 Monitor urine or blood glucose level & urine ketones  Eat candy or drink orange juice with sugar added for insulin
frequently reaction (hypoglycemia)
 If N/V occurs: sip on clear liquid with simple sugar  Monitor signs of DKA & HONKC
h. Foot care k. Need to wear a Medic-Alert bracelet
 Wash foot with mild soap & water & pat dry
 Apply lanolin lotion to feet: to prevent drying & cracking Diabetic Ketoacidosis (DKA)
 Cut toenail straight across  Acute complication of DM characterized by hyperglycemia & accumulation of
 Avoid constrictive garments such as garters ketones in the body: cause metabolic acidosis
 Wear clean, absorbent socks (cotton or wool)  Acute complication of Type I DM: due to severe hyperglycemia leading to severe
 Purchase properly fitting shoes & break new shoes in gradually CNS depression
 Never go barefoot  Occurs in insulin-dependent diabetic clients
 Inspect foot daily & notify physician: if cut, blister, or break in skin  Onset slow: maybe hours to days
occurs
i. Exercise Predisposing Factors
 Undertake regular exercise; avoid sporadic, vigorous exercise 1. Undiagnosed DM
 Food intake may need to be increased before exercising 2. Neglect to treatment
 Exercise is best performed after meals when the blood sugar is 3. Infection
rising 4. cardiovascular disorder
5. Hyperglycemia
j. Complication 6. Physical & Emotional Stress: number one precipitating factor

S/sx
1. Polyuria 10. Dry mucous membrane; soft eyeballs
2. Polydipsia 11. Blurring of vision
3. Polyphagia 12. PS: Acetone breath odor
4. Glucosuria 13. PS: Kussmaul’s Respiration (rapid shallow breathing) or tachypnea
5. Weight loss 14. Alteration in LOC
6. Anorexia 15. Hypotension
7. N/V 16. Tachycardia
8. Abdominal pain 17. CNS depression leading to coma
9. Skin warm, dry & flushed
2. Serum glucose & ketones level: elevated
Dx 3. BUN (normal value: 10 – 20): elevated: due to dehydration
1. FBS: is increased 4. Creatinine (normal value: .8 – 1): elevated: due to dehydration
5. Hct (normal value: female 36 – 42, male 42 – 48): elevated: due to 6. Check urine output every hour
dehydration 7. Monitor V/S, I&O & blood sugar levels
6. Serum Na: decrease 8. Assist client with self-care
7. Serum K: maybe normal or elevated at first 9. Provide care for unconscious client if in a coma
8. ABG: metabolic acidosis with compensatory respiratory alkalosis 10. Discuss with client the reasons ketosis developed & provide additional
diabetic teaching if indicated
Nursing Intervention
1. Maintain patent airway Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC)
2. Assist in mechanical ventilation  Characterized by hyperglycemia & a hyperosmolar state without ketosis
3. Maintain F&E balance:  Occurs in non-insulin-dependent diabetic or non-diabetic persons (typically
a. Administer IV therapy as ordered: elderly clients)
 Normal saline (0.9% NaCl), followed by hypotonic solutions (.45%  Hyperosmolar: increase osmolarity (severe dehydration)
NaCl) sodium chloride: to counteract dehydration & shock  Non-ketotic: absence of lypolysis (no ketones)
 When blood sugar drops to 250 mg/dl: may add 5% dextrose to IV
 Potassium will be added: when the urine output is adequate Predisposing Factors
b. Observe for F&E imbalance, especially fluid overload, hyperkalemia & 1. Undiagnosed diabetes
hypokalemia 2. Infection or other stress
4. Administer insulin as ordered: regular acting insulin/rapid acting insulin 3. Certain medications (ex. dilantin, thiazide, diuretics)
a. Regular insulin IV (drip or push) & / or subcutaneously (SC) 4. Dialysis
b. If given IV drip: give small amount of albumin since insulin adheres to 5. Hyperalimentation
IV tubing 6. Major burns
c. Monitor blood glucose level frequently 7. Pancreatic disease
5. Administer medications as ordered:
a. Sodium Bicarbonate: to counteract acidosis S/sx
b. Antibiotics: to prevent infection
1. Polyuria 10. Dry mucous membrane; soft eyeballs
2. Polydipsia 11. Blurring of vision
3. Polyphagia 12. Hypotension
4. Glucosuria 13. Tachycardia
5. Weight loss 14. Headache and dizziness
6. Anorexia 15. Restlessness
7. N/V 16. Seizure activity
8. Abdominal pain 17. Alteration / Decrease LOC: diabetic coma
9. Skin warm, dry & flushed
2. BUN: elevated: due to dehydration
Dx 3. Creatinine: elevted: due to dehydration
1. Blood glucose level: extremely elevated 4. Hct: elevated: due to dehydration
 5. Urine: (+) for glucose

Nursing Intervention HEMATOLOGICAL SYSTEM

1. Maintain patent airway
2. Assist in mechanical ventilation
3. Maintain F&E balance: I. Blood II. Blood Vessels III. Blood Forming
a. Administer IV therapy as ordered: Organs
 Normal saline (0.9% NaCl), followed by hypotonic solutions (.45%
NaCl) sodium chloride: to counteract dehydration & shock 1. Arteries 1. Liver
 When blood sugar drops to 250 mg/dl: may add 5% dextrose to IV 55% Plasma 45% Formed 2. Veins 2. Thymus
 Potassium will be added: when the urine output is adequate (Fluid) cellular elements 3. Capillaries 3. Spleen
b. Observe for F&E imbalance, especially fluid overload, hyperkalemia & 4. Lymphoid
hypokalemia Organ
4. Administer insulin as ordered: Serum Plasma CHON 5. Lymph Nodes
a. Regular insulin IV (drip or push) & / or subcutaneously (SC) (formed in liver) 6. Bone Marrow
b. If given IV drip: give small amount of albumin since insulin adheres to 1. Albumin
IV tubing 2. Globulins
c. Monitor blood glucose level frequently 3. Prothrombin and Fibrinogen
5. Administer medications as ordered:
a. Antibiotics: to prevent infection
6. Check urine output every hour Bone Marrow
7. Monitor V/S, I&O & blood sugar levels  Contained inside all bones, occupies interior of spongy bones & center of long
8. Assist client with self-care bones; collectively one of the largest organs in the body (4-5% of total body
9. Provide care for unconscious client if in a coma weight)
10. Discuss with client the reasons ketosis developed & provide additional  Primary function is Hematopoiesis: the formation of blood cells
diabetic teaching if indicated  All blood cells start as stem cells in the bone marrow; these mature into
different, specific types of cells, collectively referred to as Formed Elements of
Overview of Anatomy & Physiology of Hematologic System Blood or Blood Components:
1. Erythrocytes
 The structure of the hematological of hematopoietic system includes the blood, 2. Leukocytes
blood vessels, & blood forming organs (bone marrow, spleen, liver, lymph 3. Thrombocytes
nodes, & thymus gland).  Two kinds of Bone Marrow:
 The major function of blood: is to carry necessary materials (O2, nutrients) to 1. Red Marrow
cells & remove CO2 & metabolic waste products.  Carries out hematopoiesis; production site of erythroid, myeloid, &
 The hematologic system also plays an important role in hormone transport, the thrombocytic component of blood; one source of lymphocytes &
inflammatory & immune responses, temperature regulation, F&E balance & macrophages
acid-base balance.  Found in the ribs, vertebral column, other flat bones
 2. Yellow Marrow
 Red marrow that has changed to fats; found in long bone; does not Cellular Components or Formed Elements
contribute to hematopoiesis 1. Erythrocytes (RBC)
a. Normal value: 4 – 6 million/mm3
Blood b. No nucleus, Biconcave shape discs, Chiefly sac of hemoglobin
 Composed of plasma (55%) & cellular components (45%) c. Call membrane is highly diffusible to O2 & CO2
 Hematocrit d. Responsible for O2 transport via hemoglobin (Hgb)
1. Reflects portion of blood composed of red blood cells  Two portion: iron carried on heme portion; second portion is CHON
2. Centrifugation of blood results in separation into top layer of plasma,  Normal blood contains 12-18 g Hgb/100 ml blood; higher (14-18 g) in
middle layer of leukocytes & platelets, & bottom layer of erythrocytes men than in women (12-14 g)
3. Majority of formed elements is erythrocytes; volume of leukocytes & e. Production
platelets is negligible  Start in bone marrow as stem cells, release as reticulocytes (immature
 Distribution cells), mature into erythrocytes
1. 1300 ml in pulmonary circulation  Erythropoietin stimulates differentiation; produced by kidneys &
a. 400 ml arterial stimulated by hypoxia
b. 60 ml capillary  Iron, vitamin B12, folic acid, pyridoxine vitamin B6, & other factors
c. 840 ml venous required for erythropoiesis
2. 3000 ml in systemic circulation f. Hemolysis (Destruction)
a. 550 ml arterial  Normal life span of RBC is 80 – 120 days and is killed in red pulp of
b. 300 ml capillary spleen
c. 2150 ml venous  Immature RBCs destroyed in either bone marrow or other
reticuloendothelial organs (blood, connective tissue, spleen, liver, lungs
Plasma and lymph nodes)
 Liquid part of the blood; yellow in color because of pigments  Mature cells remove chiefly by liver and spleen
 Consists of serum (liquid portion of plasma) & fibrinogen  Bilirubin (yellow pigment): by product of Hgb (red pigment) released
 Contains plasma CHON such as albumin, serum, globulins, fibrinogen, when RBCs destroyed, excreted in bile
prothrombin, plasminogen  Biliverdin (green pigment)
1. Albumin  Hemosiderin (golden brown pigment)
 Largest & numerous plasma CHON  Iron: feed from Hgb during bilirubin formation; transported to bone
 Involved in regulation of intravascular plasma volume marrow via transferring and and reclaimed for new Hgb production
 Maintains osmotic pressure: preventing edema  Premature destruction: may be caused by RBC membrane
2. Serum Globulins abnormalities, Hgb abnormalities, extrinsic physical factors (such as the
a. Alpha: role in transport steroids, lipids, bilirubin & hormones enzyme defects found in G6PD)
b. Beta: role in transport of iron & copper  Normal age RBCs may be destroyed by gross damage as in trauma or
c. Gamma: role in immune response, function of antibodies extravascular hemolysis (in spleen, liver, bone marrow)
3. Fibrinogens, Prothrombin, Plasminogens: clotting factors to prevent g. Hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms%
bleeding
 h. Hematocrit red cell percentage in wholeblood (normal value: female 36 –  Macrophage in blood
42% male 42 – 48%)  Largest WBC
i. Substances needed for maturation of RBC:  Produced by bone marrow: give rise to histiocytes (kupffer
a. Folic acid cells of liver), macrophages & other components of
b. Iron reticuloendothelial system
c. Vitamin c b. Lymphocytes: immune cells; produce substances against foreign
d. Vitamin b12 (Cyanocobalamin) cells; produced primarily in lymph tissue (B cells) & thymus (T cells)
e. Vitamin b6 (Pyridoxine) Lymphocytes
f. Intrinsic factor

2. Leukocytes (WBC) B-cell T-cell Natural killer cell

a. Normal value: 5000 – 10000/mm3 - bone marrow - thymus - anti-viral and anti-tumor property
b. Granulocytes and mononuclear cells: involved in the protection from for immunity
bacteria and other foreign substances
c. Granulocytes:
 Polymorphonuclear Neutrophils HIV
- 60 – 70% of WBC c. Thrombocytes (Platelets)
- Involved in short term phagocytosis for acute inflammation  Normal value: 150,000 – 450,000/mm3
- Mature neutrophils: polymorphonuclear leukocytes  Normal life span of platelet is 9 – 12 days
- Immature neutrophils: band cells (bacterial infection usually  Fragments of megakaryocytes formed in bone marrow
produces increased numbers of band cells)  Production regulated by thrombopoietin
 Polymorphonuclear Basophils  Essential factors in coagulation via adhesion, aggregation &
- For parasite infections plug formation
- Responsible for the release of chemical mediation for  Release substances involved in coagulation
inflammation  Promotes hemostasis (prevention of blood loss)
- Involved in prevention of clotting in microcirculation and allergic  Consist of immature or baby platelets or megakaryocytes
reactions which is the target of dengue virus
 Polymorphonuclear Eosinophils
- Involved in phagocytosis and allergic reaction Signs of Platelet Dysfunction
 Eosinophils & Basophils: are reservoirs of histamine, serotonin & 1. Petechiae
heparin 2. Echhymosis
d. Non Granulocytes 3. Oozing of blood from venipunctured site
 Mononuclear cells: large nucleated cells
a. Monocytes: Blood Groups
 Involved in long-term phagocytosis for chronic inflammation  Erythrocytes carry antigens, which determine the different blood group
 Play a role in immune response
  Blood-typing system are based on the many possible antigens, but the most Wide temp blood flow to days to 2 restlessness,
important are the antigens of the ABO & Rh blood groups because they are hemoglobinuria.
most likely to be involved in transfusion reactions fluctuation organs. weeks after anemia, jaundice,
Treat or prevent
1. ABO Typing Hemolysis (Hgb dyspnea, signs
a. Antigens of systems are labeled A & B shock, DIC, &
b. Absence of both antigens results in type O blood into plasma & of shock, renal
c. Presence of both antigen is type AB renal shutdown
d. Presence of either type A or B results in type A & type B, respectively urine) shutdown, DIC
e. Type O: universal donor
f. Antibodies are automatically formed against ABO antigens not on persons Complication of Blood Transfusion
own RBC Type Causes Mechanism Occurrence S/sx
2. Rh Typing Intervention
a. Identifies presence or absence of Rh antigens (Rh + or Rh -)
b. Anti-Rh antibodies not automatically formed in Rh (-) persons, but if Rh (+) Allergic Transfer of an Immune Within 30 min Uticaria, larygeal
blood is given, antibody formation starts & second exposure to Rh antigen Stop transfusion.
will trigger a transfusion reaction antigen & sensitivity to start of edema, wheezing
c. Important for Rh (-) woman carrying Rh (+) baby; 1st pregnancy not Administer
affected, but subsequent pregnancy with an Rh (+) baby, mother’s antibody from foreign serum transfusion dyspnea,
antibodies attack baby’s RBC antihistamine &
donor to CHON bronchospasm,
Complication of Blood Transfusion or epinephrine.
Type Causes Mechanism Occurrence S/sx recipient; headache,
Intervention Treat
Allergic donor anaphylaxis
Hemolytic ABO Antibodies in Acute: Headache, life-threatening
Stop transfusion.
Incompatibility; recipient plasma first 5 min lumbar or reaction
continue saline IV _________________________________________________________________________
Rh react w/ antigen after completion sternal pain, ______________
send blood unit & Pyrogenic Recipient Leukocytes Within 15-90 Fever, chills,
Incompatibility; in donor cells. of transfusion diarrhea, fever, Stop transfusion.
client blood possesses agglutination min after flushing,
Use of dextrose Agglutinated cell chills, flushing, Treat temp.
sample to lab. antibodies bacterial initiation of palpitation,
solutions; block capillary Delayed: heat along vein, Transfuse with
Watch for
 directed against organism transfusion tachycardia, blood loss apprehension
leukocytes-poor Thrombo- Used of large Platelets When large Abnormal
WBC; bacterial occasional Assess for signs
blood of washed cytopenia amount of deteriorate amount of blood bleeding
contamination; lumbar pain of bleeding.
RBC. banked blood rapidly in stored given over 24 hr
Multitransfused Initiate bleeding
Administer blood
client; precautions.
antibiotics prn
multiparous Use fresh blood.
client _________________________________________________________________________
_________________________________________________________________________ ______________
______________ Citrate Large amount Citrate binds After large Neuromascular
Circulatory Too rapid Fluid volume During & after Dyspnea, Monitor/treat
Slow infusion rate Intoxication of citrated blood ionic calcium amount of irritability
Overload infusion in overload transfusion increase BP, hypocalcemia.
Used packed cells in client with banked blood Bleeding due to
Susceptible tachycardia, Avoid large
instead of whole decrease liver decrease calcium
Client orthopnea, amounts of
blood. function
cyanosis, anxiety citrated blood.
Monitor CVP
t Monitor liver fxn
hrough a _________________________________________________________________________
______________
separate line. Hyperkalemia Potassium level Release of In client with Nausea, colic,
_________________________________________________________________________ Administer blood
______________ increase in potassium into renal diarrhea, muscle
Air Embolism Blood given Bolus of air Anytime Dyspnea, less than 5-7
Clamp tubing. stored blood plasma with insufficiency spasm, ECG
under air blocks pulmonary increase pulse, days old in client
Turn client on red cell lysis changes (tall
pressure artery outflow wheezing, chest with impaired
left side peaked T-waves,
following severe pain, decrease BP, potassium
 short Q-T  1%-2% of red cell mass or 200 ml blood/minute stored in the spleen; blood
excretion comes via splenic artery to the pulp for cleansing, then passes into splenic
segments) venules that are lined with phagocytic cells & finally to the splenic vein to the
liver.
Blood Coagulation  Important hematopoietic site in fetus; postnatally procedures lymphocytes &
 Conversion of fluid blood into a solid clot to reduce blood loss when blood monocytes
vessels are ruptured  Important in phagocytosis; removes misshapen erythrocytes, unwanted parts of
erythrocytes
System that Initiating Clotting  Also involved in antibody production by plasma cells & iron metabolism (iron
1. Intrinsic System: initiated by contact activation following endothelial injury released from Hgb portion of destroyed erythrocytes returned to bone marrow)
(“intrinsic” to vessel itself)  In the adult functions of the spleen can be taken over by the reticuloendothelial
a. Factor XII: initiate as contact made between damaged vessel & plasma system.
CHON
b. Factors VIII, IX & XI activated Liver
2. Extrinsic System:  Involved in bile production (via erythrocyte destruction & bilirubin production)
a. Initiated by tissue thromboplastins released from injured vessels & erythropoeisis (during fetal life & when bone marrow production is
(“extrinsic” to vessel) insufficient).
b. Factor VII activated  Kupffer cells of liver have reticuloendothelial function as histiocytes; phagocytic
activity & iron storage.
Common Pathways: activated by either intrinsic or extrinsic pathways  Liver also involved in synthesis of clotting factors, synthesis of antithrombins.
1. Platelet factor 3 (PF3) & calcium react with factor X & V
2. Prothrombin converted to thrombin via thromboplastin Blood Tranfusion
3. Thrombin acts on fibrinogens, forming soluble fibrin Purpose
4. Soluble fibrin polymerized by factor XIII to produce a stable, insoluble fibrin clot 1. RBC: Improve O2 transport
2. Whole Blood, Plasma, Albumin: volume expansion
Clot Resolution: takes place via fibrinolytic system by plasmin & proteolytic enzymes; 3. Fresh Frozen Plasma, Albumin, Plasma Protein Fraction: provision of
clots dissolves as tissue repairs. proteins
4. Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole Blood: provision of
Spleen coagulation factors
 Largest Lymphatic Organ: functions as blood filtration system & reservoir 5. Platelet Concentration, Fresh Whole Blood: provision of platelets
 Vascular bean shape; lies beneath the diaphragm, behind & to the left of the
stomach; composed of fibrous tissue capsule surrounding a network of fiber Blood & Blood Products
 Contains two types of pulp: 1. Whole Blood: provides all components
a. Red Pulp: located between the fibrous strands, composed of RBC, WBC & a. Large volume can cause difficulty: 12-24 hr for Hgb & Hct to rise
macrophages b. Complications: volume overload, transmission of hepatitis or AIDS,
b. White Pulp: scattered throughout the red pulp, produces lymphocytes & transfusion reacion, infusion of excess potassium & sodium, infusion of
sequesters lymphocytes, macrophages, & antigens
 anticoagulant (citrate) used to keep stored blood from clotting, calcium Principles of blood transfusion
binding & depletion (citrate) in massive transfusion therapy 1. Proper refrigeration
2. Red Blood Cell (RBC) a. Expiration of packed RBC is 3-6 days
a. Provide twice amount of Hgb as an equivalent amount of whole blood b. Expiration of platelet is 3-5 days
b. Indicate in cases of blood loss, pre-op & post-op client & those with 2. Proper typing and cross matching
incipient congestive failure a. Type O: universal donor
c. Complication: transfusion reaction (less common than with whole b. Type AB: universal recipient
blood: due to removal of plasma protein) c. 85% of population is RH positive
3. Fresh Frozen Plasma 3. Aseptically assemble all materials needed for BT
a. Contains all coagulation factors including V & VIII a. Filter set
b. Can be stored frozen for 12 months; takes 20 minutes to thaw b. Gauge 18-19 needle
c. Hang immediately upon arrival to unit (loses its coagulation factor c. Isotonic solution (0.9 NaCl / plain NSS): to prevent hemolysis
rapidly) 4. Instruct another RN to re check the following
4. Platelets a. Client name
a. Will raise recipient’s platelet count by 10,000/mm 3 b. Blood typing & cross matching
b. Pooled from 4-8 units of whole blood c. Expiration date
c. Single-donor platelet transfusion may be necessary for clients who d. Serial number
have developed antibodies; compatibilities testing may be necessary 5. Check the blood unit for bubbles cloudiness, sediments and darkness in
5. Factor VIII Fractions (Cryoprecipitate): contains factor VIII, fibrinogens & XIII color because it indicates bacterial contamination
6. Granulocytes a. Never warm blood: it may destroy vital factors in blood.
a. Do not increase WBC: increase marginal pool (at tissue level) rather b. Warming is only done: during emergency situation & if you have the
than circulating pool warming device
b. Premedication with steroids, antihistamine & acetaminophen c. Emergency rapid BT is given after 30 minutes & let natural room
c. Respiratory distress with shortness of breath, cyanosis & chest pain temperature warm the blood.
may occur; requires cessation of transfusion & immediate attention 6. BT should be completed less than 4 hours because blood that is exposed at
d. Shaking chills or rigors common, require brief cessation of therapy, room temperature more than 2 hours: causes blood deterioration that can
administration of meperdine IV until rigors are diminished & lead to bacterial contamination
resumption of transfusion when symptoms relieved 7. Avoid mixing or administering drugs at BT line: to prevent hemolysis
7. Volume Expander: albumin; percentage concentration varies (50-100 8. Regulate BT 10-15 gtts/min or KVO rate or equivalent to 100 cc/hr: to
ml/unit); hyperosmolar solution should not be used in dehydrated clients prevent circulatory overload
9. Monitor strictly vital signs before, during & after BT especially every 15
Goals / Objectives minutes for first hour because majority of transfusion reaction occurs
1. Replace circulating blood volume during this period
2. Increase the O2 carrying capacity of blood a. Hemolytic reaction
3. Prevent infection: if there is a decrease in WBC b. Allergic reaction
4. Prevent bleeding: if there is platelet deficiency c. Pyrogenic reaction
d. Circulatory overload
 e. Air embolism a. Anti Histamine (Benadryl): if positive to hypotension, anaphylactic
f. Thrombocytopenia shock: treat with Epinephrine
g. Cytrate intoxication 5. Send the blood unit to blood bank for re examination
h. Hyperkalemia (caused by expired blood) 6. Obtain urine & blood sample & send to laboratory for re-examination
7. Monitor vital signs and intake and output
S/sx of Hemolytic reaction
1. Headache and dizziness S/sx Pyrogenic reactions
2. Dyspnea 1. Fever and chills
3. Diarrhea / Constipation 2. Headache
4. Hypotension 3. Tachycardia
5. Flushed skin 4. Palpitations
6. Lumbasternal / Flank pain 5. Diaphoresis
7. Urine is color red / portwine urine 6. Dyspnea

Nursing Management Nursing Management

1. Stop BT 1. Stop BT
2. Notify physician 2. Notify physician
3. Flush with plain NSS 3. Flush with plain NSS
4. Administer isotonic fluid solution: to prevent shock and acute tubular 4. Administer medications as ordered
necrosis a. Antipyretic
5. Send the blood unit to blood bank for re-examination b. Antibiotic
6. Obtain urine & blood sample & send to laboratory for re-examination 5. Send the blood unit to blood bank for re examination
7. Monitor vital signs & I&O 6. Obtain urine & blood sample & send to laboratory for re-examination
7. Monitor vital signs & I&O
S/sx of Allergic reaction 8. Render TSB
1. Fever
2. Dyspnea S/sx of Circulatory reaction
3. Broncial wheezing 1. Orthopnea
4. Skin rashes 2. Dyspnea
5. Urticaria 3. Rales / Crackles upon auscultation
6. Laryngospasm & Broncospasm 4. Exertional discomfort

Nursing Management Nursing Management

1. Stop BT 1. Stop BT
2. Notify physician 2. Notify physician
3. Flush with plain NSS 3. Administer medications as ordered
4. Administer medications as ordered a. Loop diuretic (Lasix)
 2. Pneumocystic Carini Pneumonia
Nursing Care
1. Assess client for history of previous blood transfusions & any adverse Blood Disorder
reaction
2. Ensure that the adult client has an 18-19 gauge IV catheter in place Iron Deficiency Anemia (Anemias)
3. Use 0.9% sodium chloride  A chronic microcytic anemia resulting from inadequate absorption of iron
4. At least two nurse should verify the ABO group, RH type, client & blood leading to hypoxemic tissue injury
numbers & expiration date  Chronic microcytic, hypochromic anemia caused by either inadequate
5. Take baseline V/S before initiating transfusion absorption or excessive loss of iron
6. Start transfusion slowly (2 ml/min)  Acute or chronic bleeding principal cause in adults (chiefly from trauma,
7. Stay with the client during the first 15 min of the transfusion & take V/S dysfunctional uterine bleeding & GI bleeding)
frequently  May also be caused by inadequate intake of iron-rich foods or by inadequate
8. Maintain the prescribed transfusion rate: absorption of iron
a. Whole Blood: approximately 3-4 hr  In iron-deficiency states, iron stores are depleted first, followed by a reduction
b. RBC: approximately 2-4 hr in Hgb formation
c. Fresh Frozen Plasma: as quickly as possible
d. Platelet: as quickly as possible Incidence Rate
e. Cryoprecipitate: rapid infusion 1. Common among developed countries & tropical zones (blood-sucking
f. Granulocytes: usually over 2 hr parasites)
g. Volume Expander: volume-dependent rate 2. Common among women 15 & 45 years old & children affected more
9. Monitor for adverse reaction frequently, as are the poor
10. Document the following: 3. Related to poor nutrition
a. Blood component unit number (apply sticker if available)
b. Date of infusion starts & end Predisposing Factors
c. Type of component & amount transfused 1. Chronic blood loss due to:
d. Client reaction & vital signs a. Trauma
e. Signature of transfusionist b. Heavy menstruation
c. Related to GIT bleeding resulting to hematemasis and melena (sign for
HIV upper GIT bleeding)
- 6 months – 5 years incubation period d. Fresh blood per rectum is called hematochezia
- 6 months window period 2. Inadequate intake or absorption of iron due to:
- western blot opportunistic a. Chronic diarrhea
- ELISA b. Related to malabsorption syndrome
- drug of choice AZT (Zidon Retrovir) c. High cereal intake with low animal CHON digestion
d. Partial or complete gastrectomy
2 Common fungal opportunistic infection in AIDS e. Pica
1. Kaposis Sarcoma 3. Related to improper cooking of foods
 e. Dried fruits
S/sx f. Legumes
1. Usually asymptomatic (mild cases) g. Nuts
2. Weakness & fatigue (initial signs) 5. Instruct the client to avoid taking tea and coffee: because it contains
3. Headache & dizziness tannates which impairs iron absorption
4. Pallor & cold sensitivity 6. Administer iron preparation as ordered:
5. Dyspnea a. Oral Iron Preparations: route of choice
6. Palpitations  Ferrous Sulfate
7. Brittleness of hair & nails, spoon shape nails (koilonychias)  Ferrous Fumarate
8. Atrophic Glossitis (inflammation of tongue)  Ferrous Gluconate
a. Stomatitis PLUMBER VINSON’S
SYNDROME Nursing Management when taking oral iron preparations
b. Dysphagia  Instruct client to take with meals: to lessen GIT irritation
9. PICA: abnormal appetite or craving for non edible foods  Dilute in liquid preparations well & administer using a straw: to
prevent staining of teeth
Dx  When possible administer with orange juice as vitamin C (ascorbic
1. RBC: small (microcytic) & pale (hypochromic) acid): to enhance iron absorption
2. RBC: is decreased  Warn clients that iron preparations will change stool color &
3. Hgb: decreased consistency (dark & tarry) & may cause constipation
4. Hct: moderately decreased  Antacid ingestion will decrease oral iron effectiveness
5. Serum iron: decreased
6. Reticulocyte count: is decreased b. Parenteral: used in clients intolerant to oral preparations, who are
7. Serum ferritin: is decreased noncompliant with therapy or who have continuing blood losses
8. Hemosiderin: absent from bone marrow
Nursing Management when giving parenteral iron preparation
Nursing Intervention  Use one needle to withdraw & another to administer iron
1. Monitor for s/sx of bleeding through hematest of all elimination including preparation as tissue staining & irritation are a problem
urine, stool & gastrict content  Use Z-track injection technique: to prevent leakage into tissue
2. Enforce CBR / Provide adequate rest: plan activities so as not to over tire  Do not massage injection site but encourage ambulation as this
the client will enhance absorption; advice against vigourous exercise &
3. Provide thorough explanation of all diagnostic exam used to determine constricting garments
sources of possible bleeding: help allay anxiety & ensure cooperation  Observe for local signs of complication:
4. Instruct client to take foods rich in iron  Pain at the injection site
a. Organ meat  Development of sterile abscesses
b. Egg yolk  Lymphadenitis
c. Raisin  Fever & chills
d. Sweet potatoes  Headache
  Urticaria Pathophysiology
 Pruritus 1. Intrinsic factor is necessary for the absorbtion of vitamin B12 into small
 Hypotension intestines
 Skin rashes 2. B12 deficiency diminished DNA synthesis, which results in defective
 Anaphylactic shock maturation of cell (particularly rapidly dividing cells such as blood cells & GI
tract cells)
Medications administered via straw 3. B12 deficiency can alter structure & function of peripheral nerves, spinal
 Lugol’s Solution cord, & the brain
 Iron
 Tetracycline STOMACH
 Nitrofurantoin (Macrodentin)
7. Administer with Vitamin C or orange juice for absorption Pareital cells/Argentaffin or Oxyntic cells
8. Monitor & inform client of side effects
a. Anorexia
b. N/V Produces intrinsic factors Secretes hydrochloric acid
c. Abdominal pain
d. Diarrhea / constipation Promotes reabsorption of Vit B12 Aids in digestion
e. Melena
9. If client can’t tolerate / no compliance administer parenteral iron Promotes maturation of RBC
preparation
a. Iron Dextran (IM, IV) Predisposing Factors
b. Sorbitex (IM) 1. Usually occurs in men & women over age of 50 with an increase in blue-
10. Provide dietary teaching regarding food high in iron eyed person of Scandinavian decent
11. Encourage ingestion of roughage & increase fluid intake: to prevent 2. Subtotal gastrectomy
constipation if oral iron preparation are being taken 3. Hereditary factors
4. Inflammatory disorders of the ileum
Pernicious Anemia 5. Autoimmune
 Chronic progressive, macrocytic anemia caused by a deficiency of intrinsic 6. Strictly vegetarian diet
factor; the result is abnormally large erythrocytes & hypochlorhydria (a S/sx
deficiency of hydrochloric acid in gastric secretion) 1. Anemia
 Chronic anemia characterized by a deficiency of intrinsic factor leading to 2. Weakness & fatigue
hypochlorhydria (decrease hydrochloric acid secretion) 3. Headache and dizziness
 Characterized by neurologic & GI symptoms; death usually resuls if untreated 4. Pallor & cold sensitivity
 Lack of intrinsic factor is caused by gastric mucosal atrophy (possibly due to 5. Dyspnea & palpitations: as part of compensation
heredity, prolonged iron deficiency, or an autoimmune disorder); can also 6. GIT S/sx:
results in clients who have had a total gastrctomy if vitamin B 12 is not administer a. Mouth sore
b. PS: Red beefy tongue
 c. Indigestion / dyspepsia 7. Gastric Analysis: decrease free hydrochloric acid
d. Weight loss 8. Large number of reticulocytes in the blood following parenteral vitamin B 12
e. Constipation / diarrhea administration
f. Jaundice
7. CNS S/sx: Medical Management
a. Tingling sensation 1. Drug Therapy:
b. Numbness a. Vitamin B12 injection: monthly maintenance
c. Paresthesias of hands & feet b. Iron preparation: (if Hgb level inadequate to meet increase numbers of
d. Paralysis erythrocytes)
e. Depression c. Folic Acid
f. Psychosis  Controversial
g. Positive to Romberg’s test: damage to cerebellum resulting to ataxia  Reverses anemia & GI symptoms but may intensify neurologic
symptoms
Dx  May be safe if given in small amounts in addition to vitamin B 12
1. Erythrocytes count: decrease 2. Transfusion Therapy
2. Blood Smear: oval, macrocytic erythrocytes with a proportionate amount of Nursing Intervention
Hgb 1. Enforce CBR: necessary if anemia is severe
3. Bilirubin (indirect): elevated unconjugated fraction 2. Adminster Vitamin B12 injections at monthly intervals for lifetime as ordered
4. Serum LDH: elevated  Never given orally because there is possibility of developing tolerance
5. Bone Marrow:  Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal
a. Increased megaloblasts (abnormal erythrocytes)  No side effects
b. Few normoblasts or maturing erythrocytes 3. Provide a dietary intake that is high in CHON, vitamin c and iron (fish, meat,
c. Defective leukocytes maturation milk / milk product & eggs)
6. Positive Schilling’s Test: reveals inadequate / decrease absorption of 4. Avoid highly seasoned, coursed, or very hot foods: if client has mouth sore
Vitamin B12 5. Provide safety when ambulating (especially when carrying hot item)
a. Measures absorption of radioactive vitamin B12 bothe before & after 6. Instruct client to avoid irritating mouth washes instead use soft bristled
parenteral administration of intrinsic factor toothbrush
b. Definitive test for pernicious anemia 7. Avoid heat application to prevent burns
c. Used to detect lack of intrinsic factor 8. Provide client teaching & discharge planning concerning:
d. Fasting client is given radioactive vitamin B12 by mouth & non- a. Dietery instruction
radioactive vitamin B12 IM to permit some excretion of radioactive b. Importance of lifelong vitamin B12 therapy
vitamin B12 in the urine if it os absorbed c. Rehabilitation & physical therapy for neurologic deficit, as well as
e. 24-48 hour urine collection is obtained: client is encourage to drink instruction regarding safety
fluids
f. If indicated, second stage schilling test performed 1 week after first Aplastic Anemia
stage. Fasting client is given radioactive vitamin B12 combined with  Stem cell disorder leading to bone marrow depression leading to pancytopenia
human intrinsic factor & test is repeated
  Pancytopenia or depression of granulocytes, platelets & erythrocytes 1. CBC: reveals pancytopenia
production: due to fatty replacement of the bone marrow 2. Normocytic anemia, granulocytopenia, thrombocytopenia
 Bone marrow destruction may be idiopathic or secondary 3. Bone marrow biopsy: aspiration (site is the posterior iliac crest): marrow is
fatty & contain very few developing cells; reveals fat necrosis in bone
PANCYTOPENIA marrow

Medical Management
Decrease RBC Decrease WBC 1. Blood transfusion: key to therapy until client’s own marrow begins to
Decrease Platelet produce blood cells
(anemia) (leukopenia) 2. Aggressive treatment of infection
(thrombocytopenia) 3. Bone marrow transplantation
4. Drug Therapy:
Predisposing Factors a. Corticosteroids & / or androgens: to stimulate bone marrow function &
1. Chemicals (Benzene and its derivatives) to increase capillary resistance (effective in children but usually not in
2. Related to radiation / exposure to x-ray adults)
3. Immunologic injury b. Estrogen & / or progesterone: to prevent amenorrhea in female clients
4. Drugs: 5. Identification & withdrawal of offending agent or drug
a. Broad Spectrum Antibiotics: Chloramphenicol (Sulfonamides)
b. Cytotoxic agent / Chemotherapeutic Agents: Nursing Intervention
 Methotrexate (Alkylating Agent) 1. Removal of underlying cause
 Vincristine (Plant Alkaloid) 2. Administer Blood Transfusion as ordered
 Nitrogen Mustard (Antimetabolite) 3. Administer O2 inhalation
 Phenylbutazones (NSAIDS) 4. Enforce CBR
5. Institute reverse isolation
S/sx 6. Provide nursing care for client with bone marrow transplant
1. Anemia 7. Administer medications as ordered:
a. Weakness & fatigue a. Corticosteroids: caused by immunologic injury
b. Headache & dizziness b. Immunosuppressants: Anti Lymphocyte Globulin
c. Pallor & cold sensitivity
d. Dyspnea & palpitations Given via central venous catheter
2. Leukopenia Given 6 days to 3 weeks to achieve maximum therapeutic effect of drug
a. Increase susceptibility to infection 8. Monitor for signs of infection & provide care to minimize risk:
3. Thrombocytopenia a. Monitor neuropenic precautions
a. Petechiae (multiple petechiae is called purpura) b. Encourage high CHON, vitamin diet: to help reduce incidence of
b. Ecchymosis infection
c. Oozing of blood from venipunctured sites c. Provide mouth care before & after meals
Dx d. Fever
 e. Cough 4. Anaphylaxis
9. Monitor signs of bleeding & provide measures to minimize risk: 5. Septecemia
a. Use soft toothbrush when brushing teeth & electric razor when 6. Neoplasia (new growth of tissue)
shaving: prevent bleeding 7. Pregnancy
b. Avoid IM, subcutaneous, venipunctured sites: Instead provide heparin
lock S/sx
c. Hematest urine & stool 1. Petechiae & Ecchymosis on the skin, mucous membrane, heart, eyes, lungs
d. Observe for oozing from gums, petechiae or ecchymoses & other organs (widespread and systemic)
10. Provide client teaching & discharge planning concerning: 2. Prolonged bleeding from breaks in the skin: oozing of blood from punctured
a. Self-care regimen sites
b. Identification of offending agent & importance of avoiding it (if 3. Severe & uncontrollable hemorrhage during childbirth or surgical procedure
possible) in future 4. Hemoptysis
5. Oliguria & acute renal failure (late sign)
Disseminated Intravascular Coagulation (DIC) 6. Convulsion, coma, death
 Diffuse fibrin deposition within arterioles & capillaries with widespread
coagulation all over the body & subsequent depletion of clotting factors Dx
 Acute hemorrhagic syndrome characterized by wide spread bleeding and 1. PT: prolonged
thrombosis due to a deficiency of prothrombin and fibrinogen 2. PTT: usually prolonged
 Hemorrhage from kidneys, brain, adrenals, heart & other organs 3. Thrombin Time: usually prolonged
 May be linked with entry of thromboplasic substance into the blood 4. Fibrinogen level: usually depressed
 Mortality rate is high usually because underlying disease cannot be corrected 5. Fibrin splits products: elevated
6. Protamine Sulfate Test: strongly positive
Pathophysiology 7. Factor assay (II, V, VII): depressed
1. Underlying disease (ex. toxemia of pregnancy, cancer) cause release of 8. CBC: reveals decreased platelets
thromboplastic substance that promote the deposition of fibrin throughout 9. Stool occult blood: positive
the microcirculation 10. ABG analysis: reveals metabolic acidosis
2. Microthrombi form in many organs, causing microinfarcts & tissue necrosis 11. Opthamoscopic exam: reveals sub retinal hemorrhages
3. RBC are trapped in fibrin strands & are hemolysed
4. Platelets, prothrombin & other clotting factors are destroyed, leading to Medical Management
bleeding 1. Identification & control the underlying disease is key
5. Excessive clotting activates the fibrinolytic system, which inhibits platelet 2. Blood Tranfusions: include whole blood, packed RBC, platelets, plasma,
function, causing futher bleeding. cryoprecipitites & volume expanders
3. Heparin administration
Predisposing Factors a. Somewhat controversial
1. Related to rapid blood transfusion b. Inhibits thrombin thus preventing further clot formation, allowing
2. Massive burns coagulation factors to accumulate
3. Massive trauma
 Nursing Intervention  Weighs approximately 300 – 400 grams
1. Monitor blood loss & attemp to quantify  Covered by a serous membrane called the pericardium
2. Monitor for signs of additional bleeding or thrombus formation
3. Monitor all hema test / laboratory data including stool and GIT Heart Wall / Layers of the Heart
4. Prevent further injury Pericardium
a. Avoid IM injection  Composed of fibrous (outermost layer) & serous pericardium (parietal &
b. Apply pressure to bleeding site visceral); a sac that function to protect the heart from friction
c. Turn & position the client frequently & gently  In between is the pericardial fluid which is 10 – 20 cc: Prevent pericardial friction
d. Provide frequent nontraumatic mouth care (ex. soft toothbrush or rub
gauze sponge)  2 layers of pericardium
5. Administer isotonic fluid solution as ordered: to prevent shock  Parietal: outer layer
6. Administer oxygen inhalation  Visceral: inner layer
7. Force fluids Epicardium
8. Administer medications as ordered:  Covers surface of the heart, becomes continuous with visceral layer of serous
a. Vitamin K pericardium
b. Pitressin / Vasopresin: to conserve fluids  Outer layer
c. Heparin / Comadin is ineffective Myocardium
9. Provide heparin lock
 Middle muscular layer
10. Institute NGT decompression by performing gastric lavage: by using ice or
 Myocarditis can lead to cardiogenic shock and rheumatic heart disease
cold saline solution of 500-1000 ml
Endocardium
11. Monitor NGT output
 Thin, inner membrabous layer lining the chamber of the heart
12. Prevent complication
 Inner layer
a. Hypovolemic shock: Anuria (late sign of hypovolemic shock)
Papillary Muscle
13. Provide emotional support to client & significant other
14. Teach client the importance of avoiding aspirin or aspirin-containing  Arise from the endocardial & myocardial surface of the ventricles & attach to
compounds the chordae tendinae
Chordae Tendinae
Overview of the Structure & Functions of the Heart  Attach to the tricuspid & mitral valves & prevent eversion during systole

 Cardiovascular system consists of the heart, arteries, veins & capillaries. The Chambers of the Heart
major function are circulation of blood, delivery of O2 & other nutrients to the Atria
tissues of the body & removal of CO2 & other cellular products metabolism  2 chambers, function as receiving chambers, lies above the ventricles
Heart  Upper Chamber (connecting or receiving)
 Muscular pumping organ that propel blood into the arerial system & receive  Right Atrium: receives systemic venous blood through the superior vena
blood from the venous system of the body. cava, inferior vena cava & coronary sinus
 Located on the left mediastinum  Left Atrium: receives oxygenated blood returning to the heart from the
 Resemble like a close fist lungs trough the pulmonary veins
Ventricles  Valve open when ventricle contract & close during ventricular diastole; Closure
 2 thick-walled chambers; major responsibility for forcing blood out of the heart; of SV valve produces second heart sound (S2 “dub”)
lie below the atria
 Lower Chamber (contracting or pumping) Extra Heart Sounds
 Right Ventricle: contracts & propels deoxygenated blood into pulmonary  S3: ventricular gallop usually seen in Left Congestive Heart Failure
circulation via the aorta during ventricular systole; Right atrium has  S4: atrial gallop usually seen in Myocardial Infarction and Hypertension
decreased pressure which is 60 – 80 mmHg
 Left Ventricle: propels blood into the systemic circulation via aortaduring Coronary Circulation
ventricular systole; Left ventricle has increased pressure which is 120 – 180 Coronary Arteries
mmHg in order to propel blood to the systemic circulation  Branch off at the base of the aorta & supply blood to the myocardium & the
conduction system
Valves  Arises from base of the aorta
 To promote unidimensional flow or prevent backflow  Types of Coronary Arteries
Atrioventricular Valve  Right Main Coronary Artery
 Guards opening between  Left Main Coronary Artery
 Mitral Valve: located between the left atrium & left ventricle; contains 2 Coronary Veins
leaflets attached to the chordae tandinae  Return blood from the myocardium back to the right atrium via the coronary
 Tricuspid Valve: located between the right atrium & right ventricle; contains sinus
3 leaflets attached to the chordae tandinae
Conduction System
Functions Sinoatrial Node (SA node or Keith Flack Node)
 Permit unidirectional flow of blood from specific atrium to specific ventricle  Located at the junction of superior vena cava and right atrium
during ventricular diastole  Acts as primary pacemaker of the heart
 Prevent reflux flow during ventricular systole  Initiates the cardiac impulse which spreads across the atria & into AV node
 Valve leaflets open during ventricular diastole; Closure of AV valves give rise to  Initiates electrical impulse of 60-100 bpm
first heart sound (S1 “lub”)
Semi-lunar Valve Atrioventricular Node (AV node or Tawara Node)
 Pulmonary Valve  Located at the inter atrial septum
 Located between the left ventricle & pulmonary artery  Delays the impulse from the atria while the ventricles fill
 Aortic Valve  Delay of electrical impulse for about .08 milliseconds to allow ventricular filling
 Located between left ventricle & aorta
Function Bundle of His
 Pemit unidirectional flow of the blood from specific ventricle to arterial vessel  Arises from the AV node & conduct impulse to the bundle branch system
during ventricular diastole  Located at the interventricular septum
 Prevent reflux blood flow during ventricular diastole  Right Bundle Branch: divided into anterior lateral & posterior; transmits
impulses down the right side of the interventricular myocardium
  Left Bundle Branch: divided into anterior & posterior  Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years
 Anterior Portion: transmits impulses to the anterior endocardial
surface of the left ventricle Abnormal ECG Tracing
 Posterior Portion: transmits impulse over the posterior & inferior  Positive U wave: Hypokalemia
endocardial surface of the left ventricle  Peak T wave: Hyperkalemia
 ST segment depression: Angina Pectoris
Purkinje Fibers  ST segment elevation: Myocardial Infarction
 Transmit impulses to the ventricle & provide for depolarization after ventricular  T wave inversion: Myocardial Infarction
contraction  Widening of QRS complexes: Arrythmia
 Located at the walls of the ventricles for ventricular contraction
Vascular System
 Major function of the blood vessels isto supply the tissue with blood, remove
wastes, & carry unoxygenated blood back to the heart

Types of Blood Vessels

Arteries
 Elastic-walled vessels that can stretch during systole & recoil during diastole;
SA NODE
they carry blood away from the heart & distribute oxygenated blood throughout
the body
AV NODE Arterioles
 Small arteries that distribute blood to the capillaries & function in controlling
systemic vascular resistance & therefore arterial pressure
Capilliaries
BUNDLE OF HIS  The following exchanges occurs in the capilliaries
 O2 & CO2
 Solutes between the blood & tissue
 Fluid volume transfer between the plasma & interstitial space
PURKINJE FIBERS Venules
JLJLJLJJLJLJL  Small veins that receive blood from capillaries & function as collecting channels
Electrical activity of heart can be visualize by attaching electrodes to the skin & recording
between the capillaries & veins
activity by ECG
Veins
Electrocadiography (ECG) Tracing
 Low-pressure vessels with thin small & less muscles than arteries; most contains
 P wave (atrail depolarization) contraction valves that prevent retrograde blood flow; they carry deoxygenated blood back
 QRS wave (ventricular depolarization) to the heart. When the skeletal surrounding veins contract, the veins are
 T wave (ventricular repolarization) compressed, promoting movement of blood back to the heart.
 Insert pacemaker if there is complete heart block
Cardiac Disorders A – Angioplasty
Coronary Arterial Disease / Ischemic Heart Disease
C - Coronary
Stages of Development of Coronary Artery Disease A - Arterial
1. Myocardial Injury: Atherosclerosis B - Bypass
2. Myocardial Ischemia: Angina Pectoris A - And
3. Myocardial Necrosis: Myocardial Infarction G - Graft
S - Surgery
ATHEROSCLEROSIS
ATHEROSCLEROSIS ARTERIOSCLEROSIS Objectives
 Narrowing of artery  Hardening of artery 1. Revascularize myocardium
 Lipid or fat deposits  Calcium and protein deposits 2. To prevent angina
 Tunica intima  Tunica media 3. Increase survival rate
4. Done to single occluded vessels
Predisposing Factors 5. If there is 2 or more occluded blood vessels CABG is done
1. Sex: male
2. Race: black 3 Complications of CABG
3. Smoking 1. Pneumonia: encourage to perform deep breathing, coughing exercise and use of
4. Obesity incentive spirometer
5. Hyperlipidemia 2. Shock
6. Sedentary lifestyle 3. Thrombophlebitis
7. Diabetes Mellitus
8. Hypothyroidism Angina Pectoris
9. Diet: increased saturated fats  Transient paroxysmal chest pain produced by insufficient blood flow to the
10. Type A personality myocardium resulting to myocardial ischemia
 Clinical syndrome characterized by paroxysmal chest pain that is usually relieved
S/sx by rest or nitroglycerine due to temporary myocardial ischemia
1. Chest pain
2. Dyspnea Predisposing Factors
3. Tachycardia 1. Sex: male
4. Palpitations 2. Race: black
5. Diaphoresis 3. Smoking
4. Obesity
Treatment 5. Hyperlipidemia
P - Percutaneous 6. Sedentary lifestyle
T - Transluminal 7. Diabetes Mellitus
C - Coronary 8. Hypertension
9. CAD: Atherosclerosis  Ace Inhibitor: Enapril
10. Thromboangiitis Obliterans 2. Modification of diet & other risk factors
11. Severe Anemia 3. Surgery: Coronary artery bypass surgery
12. Aortic Insufficiency: heart valve that fails to open & close efficiently 4. Percutaneuos Transluminal Coronary Angioplasty (PTCA)
13. Hypothyroidism
14. Diet: increased saturated fats Nursing Intervention
15. Type A personality 1. Enforce complete bed rest
2. Give prompt pain relievers with nitrates or narcotic analgesic as ordered
Precipitating Factors 3. Administer medications as ordered:
4 E’s of Angina Pectoris a. Nitroglycerine (NTG): when given in small doses will act as venodilator, but
1. Excessive physical exertion: heavy exercises, sexual activity in large doses will act as vasodilator
2. Exposure to cold environment: vasoconstriction  Give 1st dose of NTG: sublingual 3-5 minutes
3. Extreme emotional response: fear, anxiety, excitement, strong emotions  Give 2nd dose of NTG: if pain persist after giving 1st dose with interval of
4. Excessive intake of foods or heavy meal 3-5 minutes
 Give 3rd & last dose of NTG: if pain still persist at 3-5 minutes interval
S/sx
1. Levine’s Sign: initial sign that shows the hand clutching the chest Nursing Management when giving NTG
2. Chest pain: characterized by sharp stabbing pain located at sub sterna usually 1. NTG Tablets (sublingual)
radiates from neck, back, arms, shoulder and jaw muscles usually relieved by  Keep the drug in a dry place, avoid moisture and exposure to sunlight
rest or taking nitroglycerine (NTG) as it may inactivate the drug
3. Dyspnea  Relax for 15 minutes after taking a tablet: to prevent dizziness
4. Tachycardia  Monitor side effects:
5. Palpitations  Orthostatic hypotension
6. Diaphoresis  Transient headache & dizziness: frequent side effect
 Instruct the client to rise slowly from sitting position
Dx
 Assist or supervise in ambulation
1. History taking and physical exam
2. NTG Nitrol or Transdermal patch
2. ECG: may reveals ST segment depression & T wave inversion during chest pain
 Avoid placing near hairy areas as it may decrease drug absorption
3. Stress test / treadmill test: reveal abnormal ECG during exercise
4. Increase serum lipid levels  Avoid rotating transdermal patches as it may decrease drug absorption
5. Serum cholesterol & uric acid is increased  Avoid placing near microwave ovens or during defibrillation as it may
lead to burns (most important thing to remember)
Medical Management b. Beta-blockers
1. Drug Therapy: if cholesterol is elevated  Propanolol: side effects PNS
 Nitrates: Nitroglycerine (NTG)  Not given to COPD cases: it causes bronchospasm
 Beta-adrenergic blocking agent: Propanolol c. ACE Inhibitors
 Calcium-blocking agent: nefedipine  Enalapril
 d. Calcium Antagonist  6-8 hours because majority of death occurs due to arrhythmia leading to
 Nefedipine premature ventricular contractions (PVC)
4. Administer oxygen inhalation
5. Place client on semi-to high fowlers position Predisposing Factors
6. Monitor strictly V/S, I&O, status of cardiopulmonary fuction & ECG tracing 1. Sex: male
7. Provide decrease saturated fats sodium and caffeine 2. Race: black
8. Provide client health teachings and discharge planning 3. Smoking
 Avoidance of 4 E’s 4. Obesity
 Prevent complication (myocardial infarction) 5. CAD: Atherosclerotic
 Instruct client to take medication before indulging into physical exertion to 6. Thrombus Formation
achieve the maximum therapeutic effect of drug 7. Genetic Predisposition
 Reduce stress & anxiety: relaxation techniques & guided imagery 8. Hyperlipidemia
 Avoid overexertion & smoking 9. Sedentary lifestyle
 Avoid extremes of temperature 10. Diabetes Mellitus
 Dress warmly in cold weather 11. Hypothyroidism
 Participate in regular exercise program 12. Diet: increased saturated fats
 Space exercise periods & allow for rest periods 13. Type A personality
 The importance of follow up care
9. Instruct the client to notify the physician immediately if pain occurs & persists S/sx
despite rest & medication administration 1. Chest pain
 Excruciating visceral, viselike pain with sudden onset located at substernal
Myocardial Infarction & rarely in precordial
 Death of myocardial cells from inadequate oxygenation, often caused by sudden  Usually radiates from neck, back, shoulder, arms, jaw & abdominal muscles
complete blockage of a coronary artery (abdominal ischemia): severe crushing
 Characterized by localized formation of necrosis (tissue destruction) with  Not usually relieved by rest or by nitroglycerine
subsequent healing by scar formation & fibrosis 2. N/V
 Heart attack 3. Dyspnea
 Terminal stage of coronary artery disease characterized by malocclusion, 4. Increase in blood pressure & pulse, with gradual drop in blood pressure (initial
necrosis & scarring. sign)
5. Hyperthermia: elevated temp
Types 6. Skin: cool, clammy, ashen
1. Transmural Myocardial Infarction: most dangerous type characterized by 7. Mild restlessness & apprehension
occlusion of both right and left coronary artery 8. Occasional findings:
2. Subendocardial Myocardial Infarction: characterized by occlusion of either right  Pericardial friction rub
or left coronary artery  Split S1 & S2
 Rales or Crackles upon auscultation
The Most Critical Period Following Diagnosis of Myocardial Infarction  S4 or atrial gallop
 7. Perform complete lung / cardiovascular assessment
Dx 8. Monitor urinary output & report output of less than 30 ml / hr: indicates
1. Cardiac Enzymes decrease cardiac output
 CPK-MB: elevated 9. Provide a full liquid diet with gradual increase to soft diet: low in saturated fats,
 Creatinine phosphokinase (CPK): elevated Na & caffeine
 Heart only, 12 – 24 hours 10. Maintain quiet environment
 Lactic acid dehydrogenase (LDH): is increased 11. Administer stool softeners as ordered: to facilitate bowel evacuation & prevent
 Serum glutamic pyruvate transaminase (SGPT): is increased straining
 Serum glutamic oxal-acetic transaminase (SGOT): is increased 12. Relieve anxiety associated with coronary care unit (CCU) environment
2. Troponin Test: is increased 13. Administer medication as ordered:
3. ECG tracing reveals a. Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate, Isodil (ISD):
 ST segment elevation sublingual
 T wave inversion b. Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium
 Widening of QRS complexes: indicates that there is arrhythmia in MI  Side Effects: confusion and dizziness
4. Serum Cholesterol & uric acid: are both increased c. Beta-blockers: Propanolol (Inderal)
5. CBC: increased WBC d. ACE Inhibitors: Captopril (Enalapril)
e. Calcium Antagonist: Nefedipine
Nursing Intervention f. Thrombolytics / Fibrinolytic Agents: Streptokinase, Urokinase, Tissue
 Goal: Decrease myocardial oxygen demand Plasminogen Activating Factor (TIPAF)
 Side Effects: allergic reaction, urticaria, pruritus
1. Decrease myocardial workload (rest heart)  Nursing Intervention: Monitor for bleeding time
 Establish a patent IV line g. Anti Coagulant
 Administer narcotic analgesic as ordered: Morphine Sulfate IV: provide pain  Heparin
relief (given IV because after an infarction there is poor peripheral  Antidote: Protamine Sulfate
perfusion & because serum enzyme would be affected by IM injection as  Nursing Intervention: Check for Partial Thrombin Time (PTT)
ordered)  Caumadin (Warfarin)
 Side Effects: Respiratory Depression  Antidote: Vitamin K
 Antidote: Naloxone (Narcan)  Nursing Intervention: Check for Prothrombin Time (PT)
 Side Effects of Naloxone Toxicity: is tremors h. Anti Platelet: PASA (Aspirin): Anti thrombotic effect
2. Administer oxygen low flow 2-3 L / min: to prevent respiratory arrest or dyspnea  Side Effects: Tinnitus, Heartburn, Indigestion / Dyspepsia
& prevent arrhythmias  Contraindication: Dengue, Peptic Ulcer Disease, Unknown cause of
3. Enforce CBR in semi-fowlers position without bathroom privileges (use bedside headache
commode): to decrease cardiac workload 14. Provide client health teaching & discharge planning concerning:
4. Instruct client to avoid forms of valsalva maneuver a. Effects of MI healing process & treatment regimen
5. Place client on semi fowlers position b. Medication regimen including time name purpose, schedule, dosage, side
6. Monitor strictly V/S, I&O, ECG tracing & hemodynamic procedures effects
 c. Dietary restrictions: low Na, low cholesterol, avoidance of caffeine 2. Right Sided Heart Failure
d. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy: to 3. High-Output Failure
induce vasodilation
e. Avoidance of modifiable risk factors Left Sided Heart Failure
f. Prevent Complication  Left ventricular damage causes blood to back up through the left atrium & into
 Arrhythmia: caused by premature ventricular contraction the pulmonary veins: Increased pressure causes transudation into interstitial
 Cardiogenic shock: late sign is oliguria tissues of the lungs which result pulmonary congestion.
 Left Congestive Heart Failure
 Thrombophlebitis: homan’s sign Predisposing Factors
 Stroke / CVA 1. 90% is mitral valve stenosis due to RHD: inflammation of mitral valve due to
 Dressler’s Syndrome (Post MI Syndrome): client is resistant to invasion of Group A beta-hemolytic streptococcus
pharmacological agents: administer 150,000-450,000 units of 2. Myocardial Infarction
streptokinase as ordered 3. Ischemic heart disease
g. Importance of participation in a progressive activity program 4. Hypertension
h. Resumption of ADL particularly sexual intercourse: is 4-6 weeks post cardiac 5. Aortic valve stenosis
rehab, post CABG & instruct to:
 Make sex as an appetizer rather than dessert S/sx
 Instruct client to assume a non weight bearing position 1. Dyspnea
 Client can resume sexual intercourse: if can climb or use the staircase 2. Paroxysmal nocturnal dyspnea (PND): client is awakened at night due to
i. Need to report the ff s/sx: difficulty of breathing
3. Orthopnea: use 2-3 pillows when sleeping or place in high fowlers
 Increased persistent chest pain
4. Tiredness
 Dyspnea
5. Muscle Weakness
 Weakness
6. Productive cough with blood tinged sputum
 Fatigue
7. Tachycardia
 Persistent palpitation
8. Frothy salivation
 Light headedness 9. Cyanosis
j. Enrollment of client in a cardiac rehabilitation program 10. Pallor
k. Strict compliance to mediation & importance of follow up care 11. Rales / Crackles
12. Bronchial wheezing
Congestive Heart Failure 13. Pulsus Alternans: weak pulse followed by strong bounding pulse
 Inability of the heart to pump an adequate supply of blood to meet the 14. PMI is displaced laterally: due to cardiomegaly
metabolic needs of the body 15. Possible S3: ventricular gallop
 Inability of the heart to pump blood towards systemic circulation
Dx
Types of Heart Failure 1. Chest X-ray (CXR): reveals cardiomegaly
1. Left Sided Heart Failure
 2. Pulmonary Arterial Pressure (PAP): measures pressure in right ventricle or 11. Pruritus
cardiac status: increased 12. Esophageal varices
3. Pulmonary Capillary Wedge Pressure (PCWP): measures end systolic and Dx
dyastolic pressure: increased 1. Chest X-ray (CXR): reveals cardiomegaly
4. Central Venous Pressure (CVP): indicates fluid or hydration status 2. Central Venous Pressure (CVP): measure fluid status: elevated
 Increase CVP: decreased flow rate of IV  Measure pressure in right atrium: 4-10 cm of water
 Decrease CVP: increased flow rate of IV  If CVP is less than 4 cm of water: Hypovolemic shock: increase IV flow rate
5. Swan-Ganz catheterization: cardiac catheterization  If CVP is more than 10 cm of water: Hypervolemic shock: Administer loop
6. Echocardiography: shows increased sized of cardiac chamber (cardiomyopathy): diuretics as ordered
dependent on extent of heart failure  Nursing Intervention:
7. ABG: reveals PO2 is decreased (hypoxemia), PCO2 is increased (respiratory  When reading CVP patient should be flat on bed
acidosis)  Upon insertion place client in trendelendberg position: to promote
ventricular filling and prevent pulmonary embolism
Right Sided Heart Failure 3. Echocardiography: reveals increased size of cardiac chambers (cardiomyopathy)
 Weakened right ventricle is unable to pump blood into he pulmonary system: 4. Liver enzymes: SGPT & SGOT: is increased
systemic venous congestion occurs as pressure builds up 5. ABG: decreased pO2

Predisposing Factors Medical Management

1. Right ventricular infarction 1. Determination & elimination / control of underlying cause
2. Atherosclerotic heart disease 2. Drug therapy: digitalis preparations, diuretics, vasodilators
3. Tricuspid valve stenosis 3. Sodium-restricted diet: to decrease fluid retention
4. Pulmonary embolism 4. If medical therapies unsuccessful: mechanical assist devices (intra-aortic balloon
5. Related to COPD pump), cardiac transplantation, or mechanical heart may be employed
6. Pulmonic valve stenosis 5. Treatment for Left Sided Heart Failure Only:
7. Left sided heart failure  M – Morphine SO4
 A – Aminophylline
S/sx  D – Digitalis
1. Anorexia  D – Diuretics
2. Nausea  O – O2
3. Weight gain  G – Gases
4. Neck / jugular vein distension
5. Pitting edema Nursing Intervention
6. Bounding pulse Goal: Increase cardiac contractility thereby increasing cardiac output of 3-6 L / min
7. Hepatomegaly / Slenomegaly
8. Cool extremities 1. Monitor respiratory status & provide adequate ventilation (when HF progress to
9. Ascites pulmonary edema)
10. Jaundice a. Administer O2 therapy: high inflow 3-4 L / min delivered via nasal cannula
 b. Maintain client in semi or high fowlers position: maximize oxygenation by  Action: relieve bronchospasm, increase urinary output & increase
promoting lung expansion cardiac output
c. Monitor ABG c. Administer Anti-arrythmic as ordered
d. Assess for breath sounds: noting any changes  Anti-arrythmic: Lidocaine (Xylocane)
2. Provide physical & emotional rest 6. Assist in bloodless phlebotomy: rotating tourniquet, rotated clockwise every 15
a. Constantly assess level of anxiety minutes: to promote decrease venous return or reducing preload
b. Maintain bed rest with limited activity 7. Provide client teaching & discharge planning concerning:
c. Maintain quiet & relaxed environment a. Need to monitor self daily for S/sx of Heart Failure (pedal edema, weight
d. Organized nursing care around rest periods gain, of 1-2 kg in a 2 day period, dyspnea, loss of appetite, cough)
3. Increase cardiac output b. Medication regimen including name, purpose, dosage, frequency & side
a. Administer digitalis as ordered & monitor effects effects (digitalis, diuretics)
 Cardiac glycosides: Digoxin (Lanoxin) c. Prescribe diet plan (low Na, cholesterol, caffeine: small frequent meals)
 Action: Increase force of cardiac contraction d. Need to avoid fatigue & plan for rest periods
 Contraindication: If heart rate is decreased do not give e. Prevent complications
b. Monitor ECG & hemodynamic monitoring  Arrythmia
c. Administer vasodilators as ordered  Shock
 Vasodilators: Nitroglycerine (NTG)  Right ventricular hypertrophy
d. Monitor V/S  MI
4. Reduce / eliminate edema  Thrombophlebitis
a. Administer diuretics as ordered f. Importance of follow-up care
 Loop Diuretics: Lasix (Furosemide)
b. Daily weight Peripheral Vascular Disorder
c. Maintain accurate I&O
d. Assess for peripheral edema Arterial Ulcer
e. Measure abdominal girth daily 1. Thromboangiitis Obliterans (Buerger’s Disease)
f. Monitor electrolyte levels 2. Raynaud’s Phenomenon
g. Monitor CVP & Swan-Ganz reading
h. Provide Na restricted diet as ordered Venous Ulcer
i. Provide meticulous skin care 1. Varicose Veins
5. If acute pulmonary edema occurs: For Left Sided Heart Failure only 2. Thrombophlebitis (deep vein thrombosis)
a. Administer Narcotic Analgesic as ordered
 Narcotic analgesic: Morphine SO4 Thromboangiitis Obliterans (Buerger’s Disease)
 Action: to allay anxiety & reduce preload & afterload  Acute inflammatory disorder affecting the small / medium sized arteries & veins
b. Administer Bronchodilator as ordered of the lower extremities
 Bronchodilators: Aminophylline IV  Occurs as focal, obstructive, process; result in occlusion of a vessel with a
subsequent development of collateral circulation
 1. Encourage a slow progressive physical activity
Predisposing Factors  Walking at least 2 times / day
1. High risk groups - men 25-40 years old  Out of bed at least 3-4 times / day
2. High incident among smokers 2. Administer medications as ordered
 Analgesics
S/sx  Vasodilators
1. Intermittent claudication: leg pain upon walking  Anti-coagulants
st
2. Cold sensitivity & changes in skin color 1 white (pallor) changing to blue 3. Foot care management:
(cyanosis) then red (rubor)  Need to avoid trauma to the affected extreminty
3. Decreased or absent peripheral pulses (posterior tibial & dorsalis pedis) 4. Importance of stop smoking
4. Trophic changes 5. Need to maintain warmth especially in cold weather
5. Ulceration & Gangrene formation (advanced) 6. Prepare client for surgery: below knee amputation (BKA)
7. Importance of follow-up care
Dx
1. Oscillometry: may reveal decrease in peripheral pulse volume Raynaud’s Phenomenon
2. Doppler (UTZ): reveals decrease blood flow to the affected extremity  Intermittent episodes of arterial spasm most frequently involving the fingers or
3. Angiography: reveals location & extent of obstructive process digits of the hands

Medical Management Predisposing Factors

1. Drug Therapy 1. High risk group: female between the teenage years & age 40 years old & above
a. Vasodilators: to improve arterial circulation (effectiveness ?) 2. Smoking
 Papaverine 3. Collagen diseases
 Isoxsuprine HCL (Vasodilan) a. Systemic Lupus Erythematosus (SLE): butterfly rash
 Nylidrin HCL (Arlidin) b. Rheumatoid Arthritis
 Nicotinyl Alcohol (Roniacol) 4. Direct hand trauma
 Cyclandelate (Cyclospasmol) a. Piano playing
 Tolazoline HCL (Priscoline) b. Excessive typing
b. Analgesic: to relieve ischemic pain c. Operating chainsaw
c. Anti-coagulant: to prevent thrombus formation
2. Surgery S/sx
a. Bypass Grafting 1. Coldness
b. Endarterectomy 2. Numbness
c. Balloon Catheter Dilation 3. Tingling in one or more digits
d. Lumbar Sympathectomy: to increase blood flow 4. Pain: usually precipitated by exposure to cold, Emotional upset & Tobacco use
e. Amputation: may be necessary 5. Intermittent color changes: pallor (white), cyanosis (blue), rubor (red)
6. Small ulceration & gangrene a tips of digits (advance)
Nursing Intervention
Dx 4. Heaviness in legs
1. Doppler UTZ: decrease blood flow to the affected extremity
2. Angiography: reveals site & extent of malocclusion Dx
1. Venography
Medical Management 2. Trendelenburg Test: veins distends quickly in less than 35 seconds
1. Administer medications as ordered 3. Doppler Ultrasound: decreased or no blood flow heard after calf or thigh
a. Catecholamine-depliting antihypertinsive drugs: compression
 Reserpine
 Guanethidine Monosulfate (Ismelin) Medical Management
b. Vasodilators 1. Vein Ligation: involves ligating the saphenous vein where it joins the femoral
Nursing Intervention vein & stripping the saphenous vein system fro groin to ankles
1. Importance of stop smoking 2. Sclerotherapy: can recur & only done in spider web varicosities & danger of
2. Need to maintain warmth especially in cold weather thrombosis (2-3 years for embolism)
3. Need to wear gloves when handling cold object / opening a freezer or
refrigerator door Nursing Intervention
1. Elevate legs above heart level: to promote increased venous return by placing 2-
Varicose Veins 3 pillows under the legs
 Dilated veins that occurs most often in the lower extremities & trunk. As the 2. Measure the circumference of ankle & calf muscle daily: to determine if swollen
vessel dilates the valves become stretched & incompetent with result venous 3. Apply anti-embolic / knee-length stockings
pooling / edema 4. Provide adequate rest
 Abnormal dilation of veins of lower extremities and trunks due to incompetent 5. Administer medications as ordered
valve resulting to increased venous pooling resulting to venous stasis causing a. Analgesics: for pain
decrease venous return 6. Prepare client for vein ligation if necessary
a. Provide routine pre-op care: usually OPD
Predisposing Factors b. In addition to routine post-op care:
1. Hereditary  Keep affected extremity elevated above the level of the heart: to
2. Congenital weakness of the veins prevent edema
3. Thrombophlebitis  Apply elastic bandage & stockings which should be removed every 8
4. Cardiac disorder hours for short periods & reapplied
5. Pregnancy  Assist out of bed within 24 hours ensuring the elastic stockings is
6. Obesity applied
7. Prolonged standing or sitting  Assess for increase of bleeding particularly in groin area
7. Provide client teaching & discharge planning
S/sx
1. Pain after prolonged standing: relieved by elevation
2. Swollen dilated tortuous skin veins Thrombophlebitis (Deep vein thrombosis)
3. Warm to touch
  Inflammation of the vessel wall with formation of clot (thrombus), may affect 3. Venous pressure measurement: high in affected limb until collateral circulation
superficial or deep veins is developed
 Inflammation of the veins with thrombus formation
 Most frequent veins affected are the saphenous, femoral & popliteal Medical Management
 Can result in damage to the surrounding tissue, ischemia & necrosis 1. Anti-coagulant therapy
a. Heparin
Predisposing Factors  Action: block conversion of prothrombin to thrombin & reduces
1. Obesity formation or extension of thrombus
2. Smoking  Side effects:
3. Related to pregnancy  Spontaneous bleeding
4. Severe anemia  Injection site reaction
5. Prolong use of oral contraceptives: promotes lipolysis  Ecchymoses
6. Prolonged immobility  Tissue irritation & sloughing
7. Trauma  Reversible transient alopecia
8. Dehydration  Cyanosis
9. Sepsis  Pan in the arms or legs
10. Congestive heart failure  Thrombocytopenia
11. Myocardial infarction b. Warfarin (Coumadin)
12. Post-op complication: surgery  Action: block prothrombin synthesis by interfering with vit. K synthesis
13. Venous cannulation: insertion of various cardiac catheter  Side effects:
14. Increase in saturated fats in the diet.  GI:
 Anorexia
S/sx
 N/V
1. Pain in the affected extremity
 Diarrhea
2. Superficial vein: Tenderness, redness induration along course of the vein
 Stomatitis
3. Deep vein:
 Hypersensitivity:
 Swelling
 Dermatitis
 Venous distention of limb
 Urticaria
 Tenderness over involved vein
 Pruritus
 Positive homan’s sign: pain at the calf or leg muscle upon dorsi flexion of
the foot  Fever
 Cyanosis  Other:
 Transient hair loss
Dx  Burning sensation of feet
1. Venography (Phlebography): increased uptake of radioactive material  Bleeding complication
2. Doppler ultrasonography: impairment of blood flow ahead of thrombus 2. Surgery
a. Vein ligation & stripping
 b. Venous thrombectomy: removal of cloth in the iliofemoral region  Alert client to factors that may affect the anticoagulant response (high-
c. Plication of the inferior vena cava: insertion of an umbrella-like prosthesis fat diet or sudden increased in vit. K-rich food)
into the lumen of the vena cava: to filter incoming cloth  Instruct the client to wear medic-alert bracelet
4. Assess V/S every 4 hours
Nursing Intervention 5. Monitor chest pain or shortness of breath: possible pulmonary embolism
1. Elevate legs above heart level: to promote increase venous return & decreased 6. Measure thigh, calves, ankles & instep every morning
edema 7. Provide client teaching & discharge planning
2. Apply warm moist pack: to reduce lymphatic congestion a. Need to avoid standing, sitting for long period, constrictive clothing,
3. Administer anti-coagulant as ordered: crossing legs at the knee, smoking, oral contraceptives
a. Heparin b. Importance of adequate hydration: to prevent hypercoagubility
 Monitor PTT: dosage should be adjusted to keep PTT between 1.5-2.5 c. Use elastic stockings when ambulatory
times normal control level d. Importance of planned rest periods with elevation of the feet
 Use infusion pump to administer heparin e. Drug regimen
 Ensure proper injection technique f. Plan for exercise / activity
 Use 26 or 27 gauge syringe with ½-5/8 inch needle, inject into fatty  Begin with dorsiflexion of the feet while sitting or lying down
layer of abdomen above iliac crest  Swim several times weekly
 Avoid injecting within 2 inches of umbilicus  Gradually increased walking distance
 Insert needle at 45-90 to skin
o
g. Importance of weight reduction: if obese
 Do not withdraw plunger to assess blood return h. Monitor for signs of complications
 Apply gentle pressure after removal of needle: avoid massage a. Pulmonary Embolism
 Assess for increased bleeding tendencies (hematuria, hematemesis,  Sudden sharp chest pain
bleeding gums, petechiae of soft palate, conjunctiva retina,  Unexplained dyspnea
ecchymoses, epistaxis, bloody spumtum, melena) & instruct the client  Tachycardia
to observe for & report these  Palpitations
 Have antidote (Protamine Sulfate) available  Diaphoresis
 Instruct the client to avoid aspirin, antihistamines 7 cough preparations  Restlessness
containing glyceryl guaiacolate & obtain MD permission before using
other OTC drugs Overview of Anatomy & Physiology of the Respiratory System
b. Warfarin (Coumadin)
 Assess PT daily: dosage should be adjusted to maintain PT at 1.5-2.5 Upper Respiratory System
times normal control level; INR of 2  Structure of the respiratory system, primarily an air conduction system, include
 Obtain careful medication history (there are many drug-drug the nose, pharynx & larynx. Air is filtered warmed & humidified in the upper
interaction) airway before passing to lower airway.
 Advise client to withhold dose & notify MD immediately if bleeding
occur Nose
 Have antidote (Vitamin K) available
 1. External nose is a frame work of bone & cartilage , internally divided into two  Consist of trachea, bronchi & branches, & the lungs & associated structures
passages or nares (nasal cavity) by the septum: air enters the system through  For gas exchange
the nares
2. The septum is covered with mucous membrane, where the olfactory receptors Trachea
are located. Turbinates, located internally, assist in warming & moistening the  AKA “Windpipe”
air  Air move from the pharynx to larynx to trachea (length 11-13 cm, diameter 1.5-
3. The major function of the nose are warming, moistening & filtering air. 2.5 cm in adult)
4. Consist of anastomosis of capillaries known as Keissel Rach Plexus: the site of  Extend from the larynx to the second costal cartilage, where it bifurcates & is
nose bleeding supported by 16-20 C-shaped cartilage rings
 The area where the trachea divides into two branches is called the carina
Pharynx  Consist of cartilaginous rings
1. A muscular passageway commonly called the throat  Serves as passageway of air going to the lungs
2. Air passes through the nose to the pharynx  Site of tracheostomy
3. Serves as a muscular passageway for both food and air
Bronchi
Composed of three section  Right main bronchus
1. Nasopharynx: located above the soft palate of the mouth, contains the adenoids  Larger & straighter than the left
& opening to the eustachian tubes  Divided into three lobar branches (upper, middle & lower bronchi) to supply
2. Oropharynx: located directly behind the mouth & tongue, contains the palatine the three lobes of right lung
tonsils; air & food enter the body through oropharynx  Left main bronchus
3. Laryngopharynx: extends from the epiglotitis to the sixth cervical level  Divides into the upper & lower lobar bronchi to supply the left lobes

Larynx Bronchioles
1. Sometimes called “voice Box” connects upper & lower airways  In the bronchioles, airway patency is primarily dependent upon elastic recoil
2. Framework is formed by the hyoid bone, epiglotitis & thyroid, cricoid & formed by network of smooth muscles
arytenoids cartilages  The tracheobronchial tree ends at the terminal bronchials. Distal to the terminal
3. Larynx opens to allow respiration & closes to prevent aspiration when food bronchioles the major function is no longer air conduction but gas exchange
passes through the pharynx between blood & alveolar air
4. Vocal cords of larynx permit speech & are involved in the cough reflex  The respiratory bronchioles serves as the transition to the alveolar epithelium
5. For phonation (voice production)
Glottis Lungs
1. Opening of larynx  Right lung (consist of 3 lobes, 10 segments)
2. Opens to allow passage of air  Left lung (consist of 2 lobes, 8 segments)
3. Closes to allow passage of food going to the esophagus  Main organ of respiration, lie within the thoracic cavity on either side of the
4. The initial sign of complete airway obstruction is the inability to cough heart
 Broad area of lungs resting on diaphragm is called the base & the narrow
Lower Respiratory System superior portion called the apex
  Arises from the respiratory bronchioles & lead to the alveoli
Pleura
 Serous membranes covering the lungs, continuous with the parietal pleura that Alveolar Sac
lines the chest wall  Form the last part of the airway
 Functionally the same as the alveolar ducts they are surrounded by alveoli & are
Parietal Pleura responsible for the 65% of the alveolar gas exchange
 Lines the chest walls & secretes small amounts of lubricating fluid into the Type II Cells of Alveoli
intrapleural space (space between the parietal pleura & visceral pleura) this  Secretes surfactant
fluid holds the lungs & chest wall together as a single unit while allowing them  Decrease surface tension
to move separately  Prevent collapse of alveoli
 Composed of lecithin and spingomyelin
Chest Wall  Lecitin / Spingomyelin ratio: to determine lung maturity
 Includes the ribs cage, intercostal muscles & diaphragm  Normal Lecitin / Spingomyelin ratio: is 2:1
 Chest is a C shaped & supported by 12 pairs of ribs & costal cartilages, the ribs  In premature infants: 1:2
have several attached muscles  Give oxygen of less 40% in premature: to prevent atelectasis and retrolental
 Contraction of the external intercostal muscles raises the ribs cage during fibroplasias
inspiration & helps increase the size of the thoracic cavity  Retinopathy & blindness: in premature
 The internal intercoastal muscles tends to pull ribs down & in & play a role
in forced expiration Pulmonary Circulation
 Provides for reoxygenation of blood & release of CO2
Diaphragm  Gas transfers occurs in the pulmonary capillary bed
 A major muscle of ventilation (the exchange of air between the atmosphere &
the alveoli). Respiratory Distress Syndrome
 Decrease oxygen stimulates breathing
Alveoli  Increase carbon dioxide is a powerful stimulant for breathing
 Are functional cellular unit of the lungs; about half arise directly from alveolar
ducts & are responsible for about 35% of alveolar gas exchange Pneumonia
 Produces surfactants  Inflammation of the alveolar spaces of the lungs, resulting in consolidation of
 Site of gas exchange (CO2 and O2) lung tissue as the alveoli fill with exudates
 Diffusion (Dalton’s law of partial pressure of gases)  Inflammation of the lung parenchyma leading to pulmonary consolidation as the
alveoli is filled with exudates
Surfactant
 A phospholipids substance found in the fluid lining the alveolar epithelium Etiologic Agents
 Reduces surface tension & increase stability of the alveoli & prevents their 1. Streptococcus Pneumonae: causing pneumococal pneumonia
collapse 2. Hemophylus Influenzae: causing broncho pneumonia
3. Diplococcus Pneumoniae
Alveolar Ducts 4. Klebsella Pneumoniae
 5. Escherichia Pneumoniae 3. ABG analysis: reveals decrease PO2
6. Pseudomonas 4. CBC: reveals increase WBC, erythrocyte sedimentation rate is increased

High Risk Groups Nursing Intervention

1. Children below 5 years old 1. Facilitate adequate ventilation
2. Elderly  Administer O2 as needed & assess its effectiveness: low inflow
 Place client semi fowlers position
Predisposing Factors  Turn & reposition frequently client who are immobilized
1. Smoking  Administer analgesic as ordered: DOC: codeine: to relieve pain associated
2. Air pollution with breathing
3. Immuno compromised  Auscultate breath sound every 2-4 hour
4. Related to prolonged immobility (CVA clients): causing hypostatic pneumonia  Monitor ABG
5. Aspiration of food: causing aspiration pneumonia 2. Facilitate removal of secretions
 General hydration
S/sx  Deep breathing & coughing exercise: tends to promote expectoration
1. Productive cough with greenish to rusty sputum  Tracheobronchial suctioning as needed
2. Rapid shallow respiration with expiratory grunt  Administer Mucolytic or Expectorant as ordered
3. Nasal flaring  Aerosol treatment via nebulizer
4. Intercostal rib retraction  Humidification of inhaled air
5. Use of accessory muscles of respiration  Chest physiotherapy (Postural Drainage): tends to promote expectoration
6. Dullness to flatness upon auscultation 3. Observe color characteristics of sputum & report any changes: encourage client
7. Possible pleural friction rub to perform good oral hygiene after expectoration
8. High-pitched bronchial breath sound 4. Provide adequate rest & relief control of pain
9. Rales / crackles (early) progressing to coarse (later)  Enforce CBR with limited activity
10. Fever  Limit visits & minimized conversation
11. Chills  Plan for uninterrupted rest periods
12. Anorexia  Maintain pleasant & restful environment
13. General body malaise 5. Administer antibiotic as ordered: monitor effects & possible toxicity
14. Weight loss  Broad Spectrum Antibiotic
15. Bronchial wheezing  Penicillin
16. Cyanosis  Tetracycline
17. Chest pain  Microlides (Zethromax)
18. Abdominal distention leading to paralytic ileus (absence of peristalsis)  Azethromycin: Side Effect: Ototoxicity
6. Prevent transmission: respiratory isolation client with staphylococcal
Dx pneumonia
1. Sputum Gram Staining & Culture Sensitivity: positive to cultured microorganisms 7. Control fever & chills:
2. Chest x-ray: reveals pulmonary consolidation over affected area  Monitor temperature A
  Administer antipyretic as ordered  Meningitis
 Increased fluid intake h. Importance of follow up care
 Provide frequent clothing & linen changing
8. Assist in postural drainage: uses gravity & various position to stimulate the Histoplasmosis
movement of secretions  Systemic fungal disease caused by inhalation of dust contaminated by
histoplasma capsulatum which is transmitted to bird manure
Nursing Management for Postural Drainage  Acute fungal infection caused by inhalation of contaminated dust or particles
a. Best done before meals or 2-3 hours: to prevent gastro esophageal reflux with histoplasma capsulatum derived from birds manure
b. Monitor vital signs
c. Encourage client deep breathing exercises S/sx
d. Administer bronchodilators 20-30 minutes before procedure 1. Similar to PTB or Pneumonia
e. Stop if client cannot tolerate procedure 2. Productive cough
f. Provide oral care after procedure 3. Fever, chills, anorexia, general body malaise
g. Contraindicated with 4. Chest and joint pains
 Unstable V/S 5. Dyspnea
 Hemoptysis 6. Cyanosis
 Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) 7. Hemoptysis
 Increase ICP 8. Sometimes asymptomatic
9. Provide increase CHO, calories, CHON & vitamin C
10. Provide client teaching & discharge planning Dx
a. Medication regimen / antibiotic therapy 1. Chest X-ray: often appears similar to PTB
b. Need for adequate rest, limited activity, good nutrition, with adequate fluid 2. Histoplasmin Skin Test: positive
intake & good ventilation 3. ABG analysis: PO2 decrease
c. Need to continue deep breathing & coughing exercise for at least 6-8 weeks
after discharge Medical Management
d. Availability of vaccines 1. Anti-fungal Agent: Amphotericin B (Fungizone)
e. Need to report S/sx of respiratory infection  Very toxic: toxicity includes anorexia, chills, fever, headaches & renal failure
 Persistent or recurrent fever  Acetaminophen, Benadryl & Steroids is given with Amphotericin B: to
 Changes in characteristics color of sputum prevent reaction
 Chills
 Increased pain Nursing Intervention
 Difficulty in breathing 1. Monitor respiratory status
 Weight loss 2. Enforce CBR
 Persistent fatigue 3. Administer oxygen inhalation
f. Avoid smoking 4. Administer medications as ordered
g. Prevent complications a. Antifungal: Amphotericin B (Fungizone)
 Atelectasis  Observe severe side effects:
  Fever: acetaminophen given prophylactically a. Leading to peripheral edema
 Anaphylactic reaction: Benadryl & Steroids given prophylactically b. Cor Pulmonale (right ventricular hypertrophy)
 Abnormal renal function with hypokalemia & azotemia:
Nephrotoxicity, check for BUN and Creatinine, Hypokalemia Dx
5. Force fluids to liquefy secretions 1. ABG analysis: reveals PO2 decrease (hypoxemia): causing cyanosis, PCO2 increase
6. Nebulize & suction as needed
7. Prevent complications: bronchiectasis Bronchial Asthma
8. Prevent the spread of infection by spraying of breeding places  Immunologic / allergic reaction results in histamine release which produces
three mainairway response: Edema of mucus membrane, Spasm of the smooth
Chronic Obstructive Pulmonary Disease (COPD) muscle of bronchi & bronchioles, Accumulation of tenacious secretions
 Reversible inflammatory lung condition due to hypersensitivity to allergens
Chronic Bronchitis leading to narrowing of smaller airways
 Excessive production of mucus in the bronchi with accompanying persistent
cough Predisposing Factors (Depending on Types)
 Characteristic include hypertrophy / hyperplasia of the mucus secreting gland in 1. Extrinsic Asthma (Atopic / Allergic)
the bronchi, decreased ciliary activity, chronic inflammation & narrowing of the Causes
airway  Pollen
 Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet  Dust
mucous producing cells leading to narrowing of smaller airways  Fumes
 AKA “Blue Bloaters”  Smoke
 Gases
Predisposing Factors  Danders
1. Smoking  Furs
2. Air pollution  Lints

S/sx 2. Intrinsic Asthma (Non atopic / Non allergic)

1. Productive copious cough (consistent to all COPD) Causes
2. Dyspnea on exertion  Hereditary
3. Use of accessory muscle of respiration  Drugs (aspirin, penicillin, beta blocker)
4. Scattered rales / rhonchi  Foods (seafoods, eggs, milk, chocolates, chicken)
5. Feeling of gastric fullness  Food additives (nitrates)
6. Slight Cyanosis  Sudden change in temperature, air pressure and humidity
7. Distended neck veins  Physical and emotional stress
8. Ankle edema
9. Prolonged expiratory grunt 3. Mixed Type: 90 – 95%
10. Anorexia and generalized body malaise
11. Pulmonary hypertension S/sx
 1. Cough that is non productive  Status Asthmaticus: severe attack of asthma which cause poor
2. Dyspnea controlled asthma
3. Wheezing on expiration  DOC: Epinephrine
4. Cyanosis  Steroids
5. Mild Stress or apprehension  Bronchodilators
6. Tachycardia, palpitations c. Regular adherence to medications: to prevent development of status
7. Diaphoresis asthmaticus
d. Importance of follow up care
Dx
1. Pulmonary Function Test Incentive spirometer: reveals decrease vital lung Bronchiectasis
capacity  Permanent abnormal dilation of the bronchi with destruction of muscular &
2. ABG analysis: PO2 decrease elastic structure of the bronchial wall
3. Before ABG test for positive Allens Test, apply direct pressure to ulnar & radial  Abnormal permanent dilation of bronchus leading to destruction of muscular
artery to determine presence of collateral circulation and elastic tissues of alveoli

Medical Management Predisposing Factors

1. Drug Therapy 1. Caused by bacterial infection
a. Bronchodilators: given via inhalation or metered dose inhaler or MDI for 5 2. Recurrent lower respiratory tract infections
minutes 3. Chest trauma
b. Steroids: decrease inflammation: given 10 min after bronchodilator 4. Congenital defects (altered bronchial structure)
c. Mucomysts (acetylceisteine): at bed side put suction machine 5. Related to presence of tumor (lung tumor)
d. Mucolytics / expectorants 6. Thick tenacious secretion
e. Anti histamine
2. Physical Therapy Sx
3. Hyposensitization 1. Productive cough with mucopurulent sputum
4. Execise 2. Dyspnea in exertion
Nursing Intervention 3. Cyanosis
1. Enforce CBR 4. Anorexia & generalized body malaise
2. O2 inhalation: low flow 2-3 L/min: to prevent respiratory distress 5. Hemoptysis (only COPD with sign)
3. Administer medications as ordered 6. Wheezing
4. Force fluids 2-3 L/day 7. Weight loss
5. Semi fowlers position: to promote lung expansion
6. Nebulize & suction when needed Dx
7. Provide client health teachings and discharge planning concerning 1. CBC: elevation in WBC
a. Avoidance of precipitating factor 2. ABG: PO2 decrease
b. Prevent complications 3. Bronchoscopy: reveals sources & sites of secretion: direct visualization of
 Emphysema bronchus using fiberscope
 S/sx
Nursing Management before Bronchoscopy 1. Productive cough
1. Secure inform consent and explain procedure to client 2. Sputum production
2. Maintain NPO 6-8 hours prior to procedure 3. Anorexia & generalized body malaise
3. Monitor vital signs & breath sound 4. Weight loss
5. Flaring of nostrils (alai nares)
Post Bronchoscopy 6. Use of accessory muscles
1. Feeding initiated upon return of gag reflex 7. Dyspnea at rest
2. Avoid talking, coughing and smoking, may cause irritation 8. Increased rate & depth of breathing
3. Monitor for signs of gross 9. Decrease respiratory excursion
4. Monitor for signs of laryngeal spasm: prepare tracheostomy set 10. Resonance to hyper resonance
11. Decrease or diminished breath sounds with prolong expiration
Medical Management 12. Decrease tactile fremitus
1. Surgery 13. Prolong expiratory grunt
 Pneumonectomy: 1 lung is removed & position on affected side 14. Rales or rhonchi
 Segmental Wedge Lobectomy: promote re-expansion of lungs 15. Bronchial wheezing
 Unaffected lobectomy: facilitate drainage 16. Barrel chest
17. Purse lip breathing: to eliminates excess CO2 (compensatory mechanism)
Emphysema
 Enlargement & destruction of the alveolar, bronchial & bronchiolar tissue with Dx
resultant loss of recoil, air tapping, thoracic overdistension, sputum 1. Pulmonary Function Test: reveals decrease vital lung capacity
accumulation & loss of diaphragmatic muscle tone 2. ABG analysis: reveals
 These changes cause a state of CO2 retention, hypoxia & respiratory acidosis  Panlobular/centrilobular
 Irreversible terminal stage of COPD characterized by  Decrease PO2 (hypoxemia leading to chronic bronchitis, “Blue
 Inelasticity of alveoli Bloaters”)
 Air trapping  Decrease ph
 Maldistribution of gases  Increase PCO2
 Overdistention of thoracic cavity (barrel chest)  Respiratory acidosis
 Panacinar/centriacinar
Predisposing Factors  Increase PO2 (hyperaxemia, “Pink Puffers”)
1. Smoking  Decrease PCO2
2. Inhaled irritants: air pollution  Increase ph
3. Allergy or allergic factor  Respiratory alkalosis
4. High risk: elderly
5. Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to release elastase for Nursing Intervention
recoil of alveoli 1. Enforce CBR
2. Administer oxygen inhalation via low inflow
3. Administer medications as ordered  Report of worsening of symptoms (increased tightness of chest,
a. Bronchodilators: used to treat bronchospam fatigue, increased dyspnea)
 Aminophylline b. Control of environment
 Isoproterenol (Isuprel)  Use home humidifier at 30-50%
 Terbutalin (Brethine)  Wear scarf over nose & mouth in cold weather: to prevent
 Metaproterenol (Alupent) bronchospasm
 Theophylline  Avoid smoking & contact with environmental smoke
 Isoetharine (Bronkosol)  Avoid abrupt change in temperature
b. Corticosteroids: c. Avoidance of inhaled irritants
 Prednisone  Stay indoor: if pollution level is high
c. Anti-microbial / Antibiotics: to treat bacterial infection  Use air conditioner with efficiency particulate air filter: to remove
 Tetracycline particles from air
 Ampicilline d. Increase activity tolerance
d. Mucolytics / expectorants  Start with mild exercise: such as walking & gradual increase in amount
4. Facilitate removal of secretions: & duration
a. Force fluids at least 3 L/day  Used breathing techniques: (pursed lip, diaphragmatic) during activities
b. Provide chest physiotherapy, coughing & deep breathing / exercise: to control breathing
c. Nebulize & suction when needed  Have O2 available as needed to assist with activities
d. Provide oral hygiene after expectoration of sputum  Plan activities that require low amount of energy
5. Improve ventilation  Plan rest period before & after activities
a. Position client to semi or high fowlers e. Prevent complications
b. Instruct the client diaphragmatic muscles to breathe  Atelectasis
c. Encourage productive cough after all treatment (splint abdomen to help  Cor Pulmonale: R ventricular hypertrophy
produce more expulsive cough)  CO2 narcosis: may lead to coma
d. Employ pursed-lip breathing techniques (prolonged slow relaxed expiration  Pneumothorax: air in the pleural space
against pursed lips) f. Strict compliance to medication
e. Institute pulmonary toilet g. Importance of follow up care
6. Institute PEEP (positive end expiratory pressure) in mechanical ventilation
promotes maximum alveolar lung expansion Oncology Nursing
7. Provide comfortable & humid environment Pathophysiology & Etiology of Cancer
8. Provide high carbohydrates, protein, calories, vitamins and minerals
9. Provide client teachings and discharge planning concerning Evolution of Cancer Cells
a. Prevention of recurrent infection  All cells constantly change through growth, degeneration, repair, & adaptation.
 Avoid crowds & individual with known infection Normal cells must divide & multiply to meet the needs of the organism as a
 Adhere to high CHON, CHO & increased vit C diet whole, & this cycle of cell growth & destruction is an integral part of life
 Received immunization for influenza & pneumonia processes. The activities of the normal cell in the human body are all
 Report changes in characteristic & color of sputum immediately coordinated to meet the needs of the organism as a whole, but when the
 regulatory control mechanisms of normal fail, & growth continues in excess of o Majority (over 80%) of human cancer related to environmental
the body needs, neoplasia results. carcinogens
 The term neoplasia refers to both benign & malignant growths, but malignant o Types:
cells behave very differently from normal cells & have special features  Physical
characteristics of the cancer process.  Radiation: X – ray, radium, nuclear explosion & waste,
 Since the growth control mechanism of normal cells is not entirely understood, UV
it is not clear what allows the uncontrolled growth, therefore no definitive cure  Trauma or chronic irritation
has been found.  Chemical
 Nitrates, & food additives, polycyclic hydrocarbons,
Characteristics of Malignant Cells dyes, alkylating agents
 Cancer cells are mutated stem cells that have undergone structural changes so  Drugs: arsenicals, stilbestol, urethane
that they are unable to perform the normal functions of specialized tissues.  Cigarette smoke
 They may function is a disorderly way to crease normal function completely,  hormones
only functioning for their own survival & growth. Classification of Cancer
 The most undifferentiated cells are also called anaplastic. Tissue Typing:
 Carcinoma – arises from surface, glandular, or parenchymal epithelium
Rate of Growth 1. Squamous Cell Carcinoma – surface epithelium
 Cancer cells have uncontrolled growth or cell division 2. Adenocarcinoma – glandular or parenchymal tissue
 Rate at which a tumor grows involves both increased cell division & increased  Sarcoma – arises from connective tissue
survival time of cells.  Leukemia – from blood
 Malignant cells do not form orderly layers, but pile on top of each other to  Lymphoma – from lymph glands
eventually form tumors.  Multiple Myeloma – from bone marrow
Stages of Tumor Growth
Pre-disposing Factors A. Staging System:
 G – Genetics  TNM System: uses letters & numbers to designate the extent of tumors
 Some cancers shows familial pattern o T– stands for primary growth; 1-4 with increasing size; T1S indicates
 Maybe caused by inherited genetics defects carcinoma in situ
 I – Immunologic o N – stands for lymph nodes involvement: 0-4 indicates progressively
 Failure of the immune system to respond & eradicate cancer cells advancing nodal disease
 Immunosuppressed individuals are more susceptible to cancer o M – stands for metastasis; 0 indicates no distant metastases, 1
 V – Viral indicates presence of metastases
o Viruses have been shown to be the cause of certain tumors in animals  Stages 0 – IV: all cancers divided into five stages incorporating size, nodal
o Viruses ( HTLV-I, Epstein Barr Virus, Human Papilloma Virus) linked to involvement & spread
human tumors
o Oncovirus (RNA – Type Viruses) thought to be culprit B. Cytologic Diagnosis of Cancer
 E – Environmental 1. Involves in the study of shed cells (ex. Pap smear)
 2. Classified by degree of cellular abnormality Treatment of Cancer
 Normal Therapeutic Modality
 Probably normal (slight changes)
 Doubtful (more severe changes) Chemotherapy
 Probably cancer or precancerous
 Definitely cancer  Ability of the drug to kill cancer cells; normal cells may also be damaged,
Client Factors producing side effects.
1. Seven warning signs of cancer  Different drug act on tumor cell in different stages of the cell growth cycle.
2. BSE – breast self – examination
3. Importance of retal exam for those over age 40 Types of Chemotherapeutic Drugs
4. Hazards of smoking
5. Oral self – examination as well as annual exam of mouth & teeth 1. Antimetabolites
6. Hazards of excess sun exposure o Foster cancer cell death by interfering with cellular metabolic process.
7. Importance of pap smear 2. Alkylating Agent
8. P.E. with lab work – up: every 3 years ages 20-40; yearly for age 40 & over o act with DNA to hinder cell growth & division.
9. TSE – testicular self – examination 3. Plant Alkaloids
 Testicular Cancer o obtained from periwinkle plant.
i. Most common cancer in men between the age of 15 & 34 o makes the host’s body a less favorable environment for the growth of
 Warning signs that men should look for: cancer cells.
i. Painless swelling 4. Antitumor Antibiotics
ii. Feeling of heaviness o affect RNA to make environment less favorable for cancer growth.
iii. Hard lump (size of a pea) 5. Steroids & Sex Hormones
iv. Sudden collection fluid in the scrotum o alter the endocrine environment to make it less conducive to growth of
v. Dull ache in the lower abdomen or in the groin cancer cells.
vi. Pain in the testicle or in the scrotum
vii. Enlargement or tenderness of the breasts Major Side Effects & Nursing Intervention

7 Warning Signs of Cancer A. GI System

C: change in bowel or bladder habits  Nausea & Vomiting

A: a sore that doesn’t heal o Administer antiemetics routinely q 4-6 hrs as well as prophylactically
U: unusual bleeding or discharge before chemotherapy is initiated.
T: thickening of lump in breast or elsewhere o Withhold food/fluid 4-6 hrs before chemotherapy
I: indigestion or dysphagia o Provide bland food in small amounts after treatment
O: obvious change in wart or mole
N: nagging cough or hoarseness  Diarrhea
o Administer antidiarrheals.
 o Maintain good perineal care. C. Integumentary System
o Give clear liquids as tolerated.
o Monitor K, Na, Cl levels.  Alopecia
o Explain that hair loss is not permanent
 Stomatitis (mouth sore) o Offer support & encouragement
o Provide & teach the client good oral hygiene, including avoidance of o Scalp tourniquets or scalp hypothermia via ice pack may be ordered to
commercial mouthwashes. minimize hair loss with some agent
o Rinse with viscous lidocaine before meals to provide analgesic effect. o Advice client to obtain wig before initiating treatment
o Perform a cleansing rinse with plain H2O or dilute a H2O soluble
lubricant such as hydrogen peroxide after meal. D. Renal System
o Apply H2O lubricant such as K-Y jelly to lubricate cracked lips.
o Advice client to suck on Popsicles or ice chips to provide moisture.  Encourage fluid & frequent voiding to prevent accumulation of metabolites in
bladder; R: may cause direct damage to kidney by excretion of metabolites.
B. Hematologic System  Increased excretion of uric acid may damage kidney
 Administer allopurinol (Zyloprim) as ordered; R: to prevent uric acid formation;
 Thrombocytopenia encourage fluids when administering allopurinol
o Avoid bumping or bruising the skin.
o Protect client from physical injury. E. Reproductive System
o Avoid aspirin or aspirin products.
o Avoid giving IM injections.  Damage may occur to both men & women resulting infertility &/or mutagenic
o Monitor blood counts carefully. damage to chromosomes
o Assess for signs of increase bleeding tendencies (epistaxis, petechiae,  Banking sperm often recommended for men before chemotherapy
ecchymoses)  Clients & partners advised to use reliable methods of contraception during
chemotherapy
 Leukopenia
o Use careful handwashing technique. F. Neurologic System
o Maintain reverse isolation if WBC count drops below 1000/mm
o Assess for signs of respiratory infection  Plant alkaloids (vincristine) cause neurologic damage with repeated doses
o Avoid crowds/persons with known infection  Peripheral neuropathies, hearing loss, loss of deep tendon reflex, & paralytic
ileus may occur.
 Anemia
o Provide adequate rest period Radiation Therapy
o Monitor hemoglobin & hematocrit  Uses ionizing radiation to kill or limit the growth of cancer cells, maybe internal
o Protect client from injury or external.
o Administer O2 if needed  It not only injured cell membrane but destroy & alter DNA so that the cell
cannot reproduce.
  Effects cannot be limited to cancer cells only; all exposed cells including normal  Avoid use of medicated solution, ointment, or powders that contain heavy
cells will be injured causing side effects. metals such as zinc oxide.
 Localized effects are related to the area of the body being treated; generalized  Avoid pressure, trauma, infection to skin; use bed cradle.
effects maybe related to cellular breakdown products.  Wash affected areas with plain H2O & pat dry; avoid soap.
 Use cornstarch, olive oil for itching; avoid talcum powder.
Types of Energy Emitted  If sloughing occurs, use sterile dressing with micropore tape
 Alpha – particles cannot passed through skin, rarely used.  Avoid exposing skin to heat, cold, or sunlight & avoid constricting irritating
 Beta – particle cannot passed through skin, more penetrating than alpha, clothing.
generally emitted from radioactive isotopes, used for internal source. B. Anorexia, N/V
 Gamma – penetrate more deeper areas of the body, most common form of  Arrange meal time so they do not directly precede or follow therapy.
external radiotherapy (ex. Electromagnetic or X-ray)  Encourage bland foods.
 Provide small attractive meals.
Methods of Delivery  Avoid extreme temperature.
 External Radiation Therapy – beams high energy rays directly to the affected  Administer antiemetics as ordered before meals.
area. Ex. Cobalt therapy C. Diarrhea
 Internal Radiation Therapy – radioactive material is injected or implanted in the  Encourage low residue, bland, high CHON food.
client’s body for designated period of time.  Administer antidiarrheal as ordered.
o Sealed Implants – a radioisotope enclosed in a container so it does not  Provide good perineal care.
circulate in the body; client’s body fluids should not be contaminated.  Monitor electrolytes particularly Na, K, Cl
o Unsealed source – a radioisotope that is not encased in a container & D. Anemia, Leukopenia, Thrombocytopenia
does circulate in the body & contaminate body fluids.
 Isolate from those with known infection.
 Provide frequent rest period.
 Encourage high CHON diet.
Factors Controlling Exposure
 Avoid injury.
 Half-life – time required for half of radioactive atoms to decay.
 Assess for bleeding.
1. Each radioisotope has different half-life.
2. At the end of half-life the danger from exposure decreases.  Monitor CBC, WBC, & platelets.
 Time – the shorter the duration the less the exposure.
Burns
 Distance – the greater the distance from the radiation source the less the
 direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
exposure.
Type:
 Shielding – all radiation can be blocked; rubber gloves for alpha & usually beta
1. Thermal
rays; thick lead or concrete stop gamma rays.
2. Smoke Inhalation
3. Chemical
Side Effects of Radiation Therapy & Nursing Intervention
4. Electrical
A. Skin - itching, redness, burning, oozing, sloughing.
 Keep skin free from foreign substances.
Classification
  Partial Thickness  Cancellous bones covered by thin layer of compact bone (ex. Carpals &
1. Superficial partial thickness (1st degree) tarsals)
 Depth: epidermis only  Flat Bones
 Causes: sunburn, splashes of hot liquid  Two layers of compact bone separated by a layer of cancellous bone
 Sensation: painful (ex. Skull & ribs)
 Characteristics: erythema, blanching on pressure, no vesicles  Irregular Bones
2. Deep Partial Thickness (2nd degree)  Sizes and shapes vary (ex. Vertebrae & mandible)
 Depth: epidermis & dermis
 Causes: flash, scalding, or flame burn Joints
 Sensation: very painful  Articulation of bones occurs at joints
 Characteristics: fluid filled vesicles; red, shinny, wet after  Movable joints provide stabilization and permit a variety of movements
vesicles ruptures
 Full Thickness (3rd & 4th degree) Classification
1. Depth: all skin layers & nerve endings; may involve muscles, tendons & 1. Synarthroses: immovable joints
bones 2. Amphiarthroses: partially movable joints
2. Causes: flames, chemicals, scalding, electric current 3. Diarthroses (synovial): freely movable joints
3. Sensation: little or no pain  Have a joint cavity (synovial cavity) between the articulating bone surfaces
4. Characteristics: wound is dry, white, leathery, or hard  Articular cartilage covers the ends of the bones
 A fibrous capsule encloses the joint
Overview Of Anatomy & Physiology Of Musculoskeletal System
 Capsule is lined with synovial membrane that secretes synovial fluid to
 Consist of bones, muscles, joints, cartilages, tendons, ligaments, bursae lubricate the joint and reduce friction.
 To provide a structural framework for the body Muscles
 To provide a means for movement  Functions of Muscles
 Provide shape to the body
Bones  Protect the bones
 Function of Bones  Maintain posture
 Provide support to skeletal framework  Cause movement of body parts by contraction
 Assist in movement by acting as levers for muscles  Types of Muscles
 Protect vital organ & soft tissue  Cardiac: involuntary; found only in heart
 Manufacture RBC in the red bone marrow (hematopoiesis)  Smooth: involuntary; found in walls of hollow structures (e.g. intestines)
 Provide site for storage of calcium & phosphorus  Striated (skeletal): voluntary
1. Types of Bones
 Long Bones 1. Characteristics of skeletal muscles
 Central shaft (diaphysis) made of compact bone & two end (epiphyses)  Muscles are attached to the skeleton at the point of origin and to
composed of cancellous bones (ex. Femur & humerus) bones at the point of insertion.
 Short Bones
  Have properties of contraction and extension, as well as elasticity, to 5. Infection
permit isotonic (shortening and thickening of the muscle) and
isometric (increased muscle tension) movement. S/sx
 Contraction is innervated by nerve stimulation. 1. Fatigue
2. Anorexia & body malaise
3. Weight loss
Cartilage 4. Slight elevation in temperature
 A form of connective tissue 5. Joints are painful: warm, swollen, limited in motion, stiff in morning & after a
 Major functions are to cushion bony prominences and offer protection where period of inactivity & may show crippling deformity in long-standing disease.
resiliency is required 6. Muscle weakness secondary to inactivity
7. History of remissions and exacerbations
Tendons and Ligaments 8. Some clients have additional extra-articular manifestations: subcutaneous
 Composed of dense, fibrous connective tissue nodules; eye, vascular, lung, or cardiac problems.
 Functions
1. Ligaments attach bone to bone Dx
2. Tendons attach muscle to bone 1. X-rays: shows various stages of joint disease
2. CBC: anemia is common
Rheumatoid Arthritis (RA) 3. ESR: elevated
 Chronic systemic disease characterized by inflammatory changes in joints and 4. Rheumatoid factor positive
related structures. 5. ANA: may be positive
 Joint distribution is symmetric (bilateral): most commonly affects smaller 6. C-reactive protein: elevated
peripheral joints of hands & also commonly involves wrists, elbows, shoulders,
knees, hips, ankles and jaw. Medical Management
 If unarrested, affected joints progress through four stages of deterioration: 1. Drug therapy
synovitis, pannus formation, fibrous ankylosis, and bony ankylosis. a. Aspirin: mainstay of treatment: has both analgesic and anti-inflammatory
Cause effect.
1. Cause unknown or idiopathic b. Nonsteroidal anti-inflammatory drugs (NSAIDs): relieve pain and
2. Maybe an autoimmune process inflammation by inhibiting the synthesis of prostaglandins.
3. Genetic factors  Ibuprofen (Motrin)
4. Play a role in society (work)  Indomethacin (Indocin)
 Fenoprofen (Nalfon)
Predisposing factors  Mefenamic acid (Ponstel)
1. Occurs in women more often than men (3:1) between the ages 35-45.  Phenylbutazone (Butazolidin)
2. Fatigue  Piroxicam (Feldene)
3. Cold  Naproxen (Naprosyn)
4. Emotional stress  Sulindac (Clinoril)
c. Gold compounds (Chrysotherapy)
  Injectable form: given IM once a week; take 3-6 months to become c. Rest & support inflamed joints: if splints used: remove 1-2 times/day for
effective gentle ROM exercises.
 Sodium thiomalate (Myochrysine) 5. Ensure bed rest if ordered for acute exacerbations.
 Aurothioglucose (Solganal) a. Provide firm mattress.
 SI: monitor blood studies & urinalysis frequently b. Maintain proper body alignment.
 Proteinuria c. Have client lie prone for ½ hour twice a day.
 Mouth ulcers d. Avoid pillows under knees.
 Skin rash e. Keep joints mainly in extension, not flexion.
 Aplastic anemia. f. Prevent complications of immobility.
6. Provide heat treatments: warm bath, shower or whirlpool; warm, moist
 Oral form: smaller doses are effective; take 3-6 months to become
effective compresses; paraffin dips as ordered.
a. May be more effective in chronic pain.
 Auranofin (Ridaura)
b. Reduce stiffness, pain & muscle spasm.
 SI: blood & urine studies should be monitored.
7. Provide cold treatments as ordered: most effective during acute episodes.
 Diarrhea
8. Provide psychologic support and encourage client to express feelings.
d. Corticosteroids
9. Assists clients in setting realistic goals; focus on client strengths.
 Intra-articular injections: temporarily suppress inflammation in specific 10. Provide client teaching & discharge planning & concerning.
joints.
a. Use of prescribed medications & side effects
 Systemic administration: used only when client does not respond to b. Self-help devices to assist in ADL and to increase independence
less potent anti-inflammatory drugs. c. Importance of maintaining a balance between activity & rest
e. Methotrexate: given to suppress immune response d. Energy conservation methods
 Cytoxan e. Performance of ROM, isometric & prescribed exercises
 SI: bone marrow suppression. f. Maintenance of well-balanced diet
2. Physical therapy: to minimize joint deformities. g. Application of resting splints as ordered
3. Surgery: to remove severely damaged joints (e.g. total hip replacement; knee h. Avoidance of undue physical or emotional stress
replacement). i. Importance of follow-up care

Nursing Interventions Osteoarthritis

1. Assess joints for pain, swelling, tenderness & limitation of motion.  Chronic non-systemic disorder of joints characterized by degeneration of
2. Promote maintenance of joint mobility and muscle strength. articular cartilage
a. Perform ROM exercises several times a day: use of heat prior to exercise  Weight-bearing joints (spine, knees and hips) & terminal interphalangeal joints
may decrease discomfort; stop exercise at the point of pain. of fingers most commonly affected
b. Use isometric or other exercise to strengthen muscles.
3. Change position frequently: alternate sitting, standing & lying. Incident Rate
4. Promote comfort & relief / control of pain. 1. Women & men affected equally
a. Ensure balance between activity & rest. 2. Incidence increases with age
b. Provide 1-2 scheduled rest periods throughout day.
Predisposing Factors c. Measures to relieve strain on joints
1. Most important factor in development is aging (wear & tear on joints) d. ROM and isometric exercises
2. Obesity e. Maintenance of a well-balanced diet
3. Joint trauma f. Use of heat/ice as ordered.

S/sx
1. Pain: (aggravated by use & relieved by rest) & stiffness of joints Gout
2. Heberden’s nodes: bony overgrowths at terminal interphalangeal joints  A disorder of purine metabolism; causes high levels of uric acid in the blood &
3. Decreased ROM with possible crepitation (grating sound when moving joints) the precipitation of urate crystals in the joints
 Inflammation of the joints caused by deposition of urate crystals in articular
Dx tissue
1. X-rays: show joint deformity as disease progresses
2. ESR: may be slightly elevated when disease is inflammatory Incident Rate
1. Occurs most often in males
Nursing Interventions 2. Familial tendency
1. Assess joints for pain & ROM.
2. Relieve strain & prevent further trauma to joints. S/sx
a. Encourage rest periods throughout day. 1. Joint pain
b. Use cane or walker when indicated. 2. Redness
c. Ensure proper posture & body mechanics. 3. Heat
d. Promote weight reduction: if obese 4. Swelling
e. Avoid excessive weight-bearing activities & continuous standing. 5. Joints of foot (especially great toe) & ankle most commonly affected (acute
3. Maintain joint mobility and muscle strength. gouty arthritis stage)
a. Provide ROM & isometric exercises. 6. Headache
b. Ensure proper body alignment. 7. Malaise
c. Change client’s position frequently. 8. Anorexia
4. Promote comfort / relief of pain. 9. Tachycardia
a. Administer medications as ordered: 10. Fever
 Aspirin & NSAID: most commonly used 11. Tophi in outer ear, hands & feet (chronic tophaceous stage)
 Corticosteroids (Intra-articular injections): to relieve pain & improve
mobility. Dx
b. Apply heat or ice as ordered (e.g. warm baths, compresses, hot packs): to 1. CBC: uric acid elevated
reduce pain.
5. Prepare client for joint replacement surgery if necessary. Medical Management
6. Provide client teaching and discharge planning concerning 1. Drug therapy
a. Used of prescribed medications and side effects a. Acute attack:
b. Importance of rest periods  Colchicine IV or PO: discontinue if diarrhea occurs
  NSAID: Indomethacin (Indocin) 1. Cause unknown
 Naproxen (Naprosyn) 2. Immune
 Phenylbutazone (Butazolidin) 3. Genetic & viral factors have all been suggested
b. Prevention of attacks
 Uricosuric agents: increase renal excretion of uric acid Pathophysiology
 Probenecid (Benemid) 1. A defect in body’s immunologic mechanisms produces autoantibodies in the
 Sulfinpyrazone (Anturanel) serum directed against components of the client’s own cell nuclei.
 Allopurinal (Zyloprim): inhibits uric acid formation 2. Affects cells throughout the body resulting in involvement of many organs,
2. Low-purine diet may be recommended including joints, skin, kidney, CNS & cardiopulmonary system.
3. Joint rest & protection
4. Heat or cold therapy S/sx
1. Fatigue
Nursing Interventions 2. Fever
1. Assess joints for pain, motion & appearance. 3. Anorexia
2. Provide bed rest & joint immobilization as ordered. 4. Weight loss
3. Administer anti-gout medications as ordered. 5. Malaise
4. Administer analgesics as ordered: for pain 6. History of remissions & exacerbations
5. Increased fluid intake to 2000-3000 ml/day: to prevent formation of renal 7. Joint pain
calculi. 8. Morning stiffness
6. Apply local heat or cold as ordered: to reduce pain 9. Skin lesions
7. Apply bed cradle: to keep pressure of sheets off joints.  Erythematous rash on face, neck or extremities may occur
8. Provide client teaching and discharge planning concerning  Butterfly rash over bridge of nose & cheeks
a. Medications & their side effects  Photosensitivity with rash in areas exposed to sun
b. Modifications for low-purine diet: avoidance of shellfish, liver, kidney, 10. Oral or nasopharyngeal ulcerations
brains, sweetbreads, sardines, anchovies 11. Alopecia
c. Limitation of alcohol use 12. Renal system involvement
d. Increased in fluid intake  Proteinuria
e. Weight reduction if necessary  Hematuria
f. Importance of regular exercise  Renal failure
13. CNS involvement
Systemic Lupus Erythematosus (SLE)  Peripheral neuritis
 Chronic connective tissue disease involving multiple organ systems  Seizures
 Organic brain syndrome
Incident Rate  Psychosis
1. Occurs most frequently in young women 14. Cardiopulmonary system involvement
 Pericarditis
Predisposing Factors  Pleurisy
 15. Increase susceptibility to infection g. Need to avoid direct exposure to sunlight: wear hat & other protective
clothing
Dx h. Need to avoid exposure to persons with infections
1. ESR: elevated i. Importance of regular medical follow-up
2. CBC: RBC anemia, WBC & platelet counts decreased j. Availability of community agencies
3. Anti-nuclear antibody test (ANA): positive
4. Lupus Erythematosus (LE prep): positive Osteomyelitis
5. Anti-DNA: positive  Infection of the bone and surrounding soft tissues, most commonly caused by S.
6. Chronic false-positive test for syphilis aureus.
 Infection may reach bone through open wound (compound fracture or surgery),
Medical Management through the bloodstream, or by direct extension from infected adjacent
1. Drug therapy structures.
a. Aspirin & NSAID: to relieve mild symptoms such as fever & arthritis  Infections can be acute or chronic; both cause bone destruction.
b. Corticosteroids: to suppress the inflammatory response in acute
exacerbations or severe disease S/sx
c. Immunosuppressive agents: to suppress the immune response when client 1. Malaise
unresponsive to more conservative therapy 2. Fever
 Azathioprine (Imuran) 3. Pain & tenderness of bone
 Cyclophosphamide (Cytoxan) 4. Redness & swelling over bone
2. Plasma exchange: to provide temporary reduction in amount of circulating 5. Difficulty with weight-bearing
antibodies. 6. Drainage from wound site may be present.
3. Supportive therapy: as organ systems become involved.
Dx
Nursing Interventions 1. CBC: WBC elevated
1. Assess symptoms to determine systems involved. 2. Blood cultures: may be positive
2. Monitor vital signs, I&O, daily weights. 3. ESR: may be elevated
3. Administer medications as ordered.
4. Institute seizure precautions & safety measures: with CNS involvement. Nursing Interventions
5. Provide psychologic support to client / significant others. 1. Administer analgesics & antibiotics as ordered.
6. Provide client teaching & discharge planning concerning 2. Use sterile techniques during dressing changes.
a. Disease process & relationship to symptoms 3. Maintain proper body alignment & change position frequently: to prevent
b. Medication regimen & side effects. deformities.
c. Importance of adequate rest. 4. Provide immobilization of affected part as ordered.
d. Use of daily heat & exercises as prescribed: for arthritis. 5. Provide psychologic support & diversional activities (depression may result from
e. Need to avoid physical or emotional stress prolonged hospitalization)
f. Maintenance of a well-balanced diet 6. Prepare client for surgery if indicated.
 Incision & drainage: of bone abscess
  Sequestrectomy: removal of dead, infected bone & cartilage  Located on the left side of the abdominal cavity occupying the hypochondriac,
 Bone grafting: after repeated infections epigastric & umbilical regions
 Leg amputation  Stores & mixes food with gastric juices & mucus producing chemical &
7. Provide client teaching and discharge planning concerning mechanical changes in the bolus of food
 Use of prescribed oral antibiotic therapy & side effects  The secretion of digestive juice is stimulated by smelling, tasting & chewing
 Importance of recognizing & reporting signs & complications (deformity, food which is known as cephalic phase of digestion
fracture) or recurrence  The gastric phase is stimulated by the presence of food in the stomach &
regulated by neural stimulation via PNS & hormonal stimulation through
FRACTURES secretion of gastrin by the gastric mucosa
A. General information  After processing in the stomach the food bolus called chyme is released into
1. the small intestine through the duodenum
B. Medical management  Two sphincters control the rate of food passage
C. Assessment findings  Cardiac Sphincter: located at the opening between the esophagus &
D. Nursing interventions stomach
 Pyloric Sphincter: located between the stomach & duodenum
Overview of Anatomy & Physiology Gastro Intestinal Track System  Three anatomic division
 The primary function of GIT are the movement of food, digestion, absorption,  Fundus
elimination & provision of a continuous supply of the nutrients electrolytes &
 Body
H2O.
 Antrum
 Gastric Secretions:
Upper alimentary canal: function for digestion
 Pepsinogen: secreted by the chief cells located in the fundus aid in CHON
Mouth
digestion
 Consist of lips & oral cavity
 Hydrocholoric Acid: secreted by parietal cells, function in CHON digestion &
 Provides entrance & initial processing for nutrients & sensory data such as taste,
released in response to gastrin
texture & temperature
 Intrinsic Factor: secreted by parietal cell, promotes absorption of Vit B12
 Oral Cavity: contains the teeth used for mastication & the tongue which
 Mucoid Secretion: coat stomach wall & prevent auto digestion
assists in deglutition & the taste sensation & mastication
 Salivary gland: located in the mouth produce secretion containing pyalin for
1st half of duodenum
starch digestion & mucus for lubrication
 Pharynx: aids in swallowing & functions in ingestion by providing a route for
Middle Alimentary canal: Function for absorption; Complete absorption: large intestine
food to pass from the mouth to the esophagus
Small Intestines
 Composed of the duodenum, jejunum & ileum
Esophagus
 Extends from the pylorus to the ileocecal valve which regulates flow into the
 Muscular tube that receives foods from the pharynx & propels it into the
large intestines to prevent reflux to the into the small intestine
stomach by peristalsis
 Major function: digestion & absorption of the end product of digestion
Stomach  Structural Features:
  Villi (functional unit of the small intestines): finger like projections located
in the mucous membrane; containing goblet cells that secrets mucus & Accessory Organ
absorptive cells that absorb digested food stuff Liver
 Crypts of Lieberkuhn: produce secretions containing digestive enzymes  Largest internal organ: located in the right hypochondriac & epigastric regions of
 Brunner’s Gland: found in the submucosaof the duodenum, secretes mucus the abdomen
 Liver Loobules: functional unit of the liver composed of hepatic cells
2nd half of duodenum  Hepatic Sinusoids (capillaries): are lined with kupffer cells which carry out the
Jejunum process of phagocytosis
Ileum  Portal circulation brings blood to the liver from the stomach, spleen, pancreas &
1st half of ascending colon intestines
 Function:
Lower Alimentary Canal: Function: elimination  Metabolism of fats, CHO & CHON: oxidizes these nutrient for energy &
Large Intestine produces compounds that can be stored
 Divided into four parts:  Production of bile
 Cecum (with appendix)  Conjugation & excretion (in the form of glycogen, fatty acids, minerals, fat-
 Colon (ascending, transverse, descending, sigmoid) soluble & water-soluble vitamins) of bilirubin
 Rectum  Storage of vitamins A, D, B12 & iron
 Anus  Synthesis of coagulation factors
 Serves as a reservoir for fecal material until defecation occurs  Detoxification of many drugs & conjugation of sex hormones
 Function: to absorb water & electrolytes
 MO present in the large intestine: are responsible for small amount of further Salivary gland
breakdown & also make some vitamins Verniform appendix
 Amino Acids: deaminated by bacteria resulting in ammonia which is Liver
converted to urea in the liver Pancreas: auto digestion
 Bacteria in the large intestine: aid in the synthesis of vitamin K & some of Gallbladder: storage of bile
the vitamin B groups
 Feces (solid waste): leave the body via rectum & anus Biliary System
 Anus: contains internal sphincter (under involuntary control) & external  Consist of the gallbladder & associated ductal system (bile ducts)
sphincter (voluntary control)  Gallbladder: lies under the surface of the liver
 Fecal matter: usually 75% water & 25% solid wastes (roughage, dead  Function: to concentrate & store bile
bacteria, fats, CHON, inorganic matter)  Ductal System: provides a route for bile to reach the intestines
nd
a. 2 half of ascending colon  Bile: is formed in the liver & excreted into hepatic duct
b. Transverse  Hepatic Duct: joins with the cystic duct (which drains the gallbladder) to
c. Descending colon form the common bile duct
d. Sigmoid  If the sphincter of oddi is relaxed: bile enters the duodenum, if contracted: bile
e. Rectum is stored in gallbladder
 - Produces saliva – for mechanical digestion
Pancreas - 1200 -1500 ml/day - saliva produced
 Positioned transversely in the upper abdominal cavity
 Consist of head, body & tail along with a pancreatic duct which extends along Disorder of the GIT
the gland & enters the duodenum via the common bile duct Peptic Ulcer Disease (PUD)
 Has both exocrine & endocrine function Gastric Ulcer
 Function in GI system: is exocrine  Ulceration of the mucosal lining of the stomach
 Exocrine cells in the pancreas secretes:  Most commonly found in the antrum
 Trypsinogen & Chymotrypsin: for protein digestion  Excoriation / erosion of submucosa & mucosal lining due to:
 Amylase: breakdown starch to disacchardes  Hypersecretion of acid: pepsin
 Lipase: for fat digestion  Decrease resistance to mucosal barrier
 Endocrine function related to islets of langerhas  Caused by bacterial infection: Helicobacter Pylori

Physiology of Digestion & Absorption Doudenal Ulcer

 Digestion: physical & chemical breakdown of food into absorptive substance  Most commonly found in the first 2 cm of the duodenum
 Initiate in the mouth where the food mixes with saliva & starch is broken  Characterized by gastric hyperacidity & a significant rate of gastric emptying
down
 Food then passes into the esophagus where it is propelled into the stomach Predisposing factor
 In the stomach food is processed by gastric secretions into a substance  Smoking: vasoconstriction: effect GIT ischemia
called chyme  Alcohol Abuse: stimulates release of histamine: Parietal cell release Hcl acid =
 In the small intestines CHO are hydrolyzed to monosaccharides, fats to Ulceration
glycerol & fatty acid & CHON to amino acid to complete the digestive  Emotional Stress
process  Drugs:
 When chymes enters the duodenum, mucus is secreted to neutralized  Salicylates (Aspirin)
hydrocholoric acid, in response to release secretin, pancreas releases  Steroids
bicarbonate to neutralized acid chyme  Butazolidin
 Cholecystokinin & Pancreozymin (CCKPZ)
 Are produced by the duodenal mucosa S/sx
 Stimulate contraction of the gallbladder along with relaxation of Gastric Ulcer Duodenal
the sphincter of oddi (to allow bile flow from common bile duct Ulcer
into the duodenum) & stimulate release of the pancreatic enzymes Site Antrum or lesser curvature Duodenal bulb
Salivary Glands  Pain  30 min-1 hr after  2-3 hrs after
1. Parotid – below & front of ear eating eating
2. Sublingual  Left epigastrium  Mid epigastrium
3. Submaxillary  Gaseous & burning  Cramping &
 Not usually burning
 relieved by food &  Usually relieved
antacid by food & antacid Maalox
 12 MN – 3am SE: fever
pain
 Hypersecretion  Normal gastric acid  Increased gastric  Histamines (H2) receptor antagonist: inhibits gastric acid secretion of
secretion acid secretion parietal cells
 Vomiting  Common  Not common  Ranitidine (Zantac): has some antibacterial action against H. pylori
 Hemorrhage  Hematemeis  Melena  Cimetidine (Tagamet)
 Weight  Weight loss  Weight gain  Famotidine (Pepcid)
 Complications  Stomach cause  Perforation  Anticholinergic:
 Hemorrhage  Atropine SO4: inhibit the action of acetylcholine at post ganglionic site
 High Risk  60 years old  20 years old (secretory glands) results decreases GI secretions
Dx  Propantheline: inhibit muscarinic action of acetylcholine resulting
 Hgb & Hct: decrease (if anemic) decrease GI secretions
 Endoscopy: reveals ulceration & differentiate ulceration from gastric cancer  Proton Pump Inhibitor: inhibit gastric acid secretion regardless of
 Gastric Analysis: normal gastric acidity acetylcholine or histamine release
 Upper GI series: presence of ulcer confirm  Omeprazole (Prilosec): diminished the accumulation of acid in the
gastric lumen & healing of duodenal ulcer
Medical Management  Pepsin Inhibitor: reacts with acid to form a paste that binds to ulcerated
1. Supportive: tissue to prevent further destruction by digestive enzyme pepsin
 Rest  Sucralfate (Carafate): provides a paste like subs that coats mucosal
 Bland diet lining of stomach
 Stress management  Metronidazole & Amoxacillin: for ulcer caused by Helicobacter Pylori
2. Drug Therapy: 3. Surgery:
 Antacids: neutralizes gastric acid  Gastric Resection
 Aluminum hydroxide: binds phosphate in the GIT & neutralized gastric  Anastomosis: joining of 2 or more hollow organ
acid & inactivates pepsin  Subtotal Gastrectomy: Partial removal of stomach
 Magnesium & aluminum salt: neutralized gastric acid & inactivate  Before surgery for BI or BII
pepsin if pH is raised to >=4  Do Vagotomy (severing or cutting of vagus nerve) & Pyloroplasty
(drainage) first
Aluminum containing Antacids Magnesium containing
Antacids Billroth I (Gastroduodenostomy) Billroth II (Gastrojejunostomy)
Ex. Aluminum OH gel (Amphojel) Ex. Milk of Magnesia  Removal of ½ of stomach &  Removal of ½ -3/4 of stomach &
SE: Constipation SE: Diarrhea anastomoses of gastric stump to duodenal bulb & anastomostoses of
the duodenum. gastric stump to jejunum.
Nursing Intervention Post op  Avoid late bedtime snacks
1. Monitor NGT output c. Avoidance of stress-producing situation & development of stress
 Immediately post op should be bright red production methods
 Within 36-42 hrs: output is yellow green  Relaxation techniques
 After 42 hrs: output is dark red  Exercise
2. Administer medication  Biofeedback
 Analgesic
 Antibiotic Dumping syndrome
 Antiemetics  Abrupt emptying of stomach content into the intestine
3. Maintain patent IV line  Rapid gastric emptying of hypertonic food solutions
4. Monitor V/S, I&O & bowel sounds  Common complication of gastric surgery
5. Complications:  Appears 15-20 min after meal & last for 20-60 min
 Hemorrhage: Hypovolemic shock: Late signs: anuria  Associated with hyperosmolar CHYME in the jejunum which draws fluid by
 Peritonitis osmosis from the extracellular fluid into the bowel. Decreased plasma volume &
 Paralytic ileus: most feared distension of the bowel stimulates increased intestinal motility
 Hypokalemia
 Thromobphlebitis S/sx
 Pernicious anemia 1. Weakness
2. Faintness
Nursing Intervention 3. Feeling of fullness
1. Administer medication as ordered 4. Dizziness
2. Diet: bland, non irritating, non spicy 5. Diaphoresis
3. Avoid caffeine & milk / milk products: Increase gastric acid secretion 6. Diarrhea
4. Provide client teaching & discharge planning 7. Palpitations
a. Medical Regimen
 Take medication at prescribe time Nursing Intervention
 Have antacid available at all times 1. Avoid fluids in chilled solutions
 Recognized situation that would increase the need for antacids 2. Small frequent feeding: six equally divided feedings
 Avoid ulcerogenic drugs: salicylates, steroids 3. Diet: decrease CHO, moderate fats & CHON
 Know proper dosage, action & SE 4. Flat on bed 15-30 min after q feeding
b. Proper Diet
 Bland diet consist of six meals / day Disorders of the Gallbladder
Cholecystitis / Cholelithiasis
 Eat slowly
 Cholecystitis:
 Avoid acid producing substance: caffeine, alcohol, highly seasoned food
 Acute or chronic inflammation of the gallbladder
 Avoid stressfull situation at mealtime
 Most commonly associated with gallstones
 Plan rest period after meal
  Inflammation occurs within the walls of the gallbladder & creates thickening 3. Drug Therapy
accompanied by edema  Narcotic analgesic: DOC: Meperdipine Hcl (Demerol): for pain
 Consequently there is impaired circulation, ischemia & eventually necrosis  (Morpine SO4: is contraindicated because it causes spasm of the
 Cholelithiasis: Sphincter of Oddi)
 Formation of gallstones & cholesterol stones  Antocholinergic: (Atrophine SO4): for pain
 Inflammation of gallbladder with gallstone formation.  (Anticholinergic: relax smooth muscles & open bile ducts)
 Antiemetics: Phenothiazide (Phenergan): with anti emetic properties
Predisposing Factor: 4. Surgery: Cholecystectomy / Choledochostomy
1. High risk: women 40 years old
2. Post menopausal women: undergoing estrogen therapy Nursing Intervention
3. Obesity 1. Administer pain medication as ordered & monitor effects
4. Sedentary lifestyle 2. Administer IV fluids as ordered
5. Hyperlipidemia 3. Diet: increase CHO, moderate CHON, decrease fats
6. Neoplasm 4. Meticulous skin care: to relieved priritus

S/sx: Disorders of the Pancreas

1. Severe Right abdominal pain (after eating fatty food): Occurring especially at Pancreatitis
night  An inflammatory process with varying degrees of pancreatic edema, fat necrosis
2. Intolerance of fatty food or hemorrhage
3. Anorexia  Proteolytic & lipolytic pancreatic enzymes are activated in the pancreas rather
4. N/V than in the duodenum resulting in tissue damage & auto digestion of pancreas
5. Jaundice  Acute or chronic inflammation of pancreas leading to pancreatic edema,
6. Pruritus hemorrhage & necrosis due to auto digestion
7. Easy bruising  Bleeding of Pancreas: Cullen’s sign at umbilicus
8. Tea colored urine
9. Steatorrhea Predisposing factors:
1. Chronic alcoholism
Dx 2. Hepatobilary disease
1. Direct Bilirubin Transaminase: increase 3. Trauma
2. Alkaline Phosphatase: increase 4. Viral infection
3. WBC: increase 5. Penetrating duodenal ulcer
4. Amylase: increase 6. Abscesses
5. Lipase: increase 7. Obesity
6. Oral cholecystogram (or gallbladder series): confirms presence of stones 8. Hyperlipidemia
Medical Management 9. Hyperparathyroidism
1. Supportive Treatment: NPO with NGT & IV fluids 10. Drugs: Thiazide, steroids, diuretics, oral contraceptives
2. Diet modification with administration of fat soluble vitamins
  Nitroglycerine (NTG)
S/Sx:  Ca Gluconate: to decrease pancreatic stimulation
1. Severe left upper epigastric pain radiates from back & flank area: aggravated by 2. Diet Modification
eating with DOB 3. NPO (usually)
2. N/V 4. Peritoneal Lavage
3. Tachycardia 5. Dialysis
4. Palpitation: due to pain
5. Dyspepsia: indigestion Nursing Intervention
6. Decrease bowel sounds 1. Administer medication as ordered
7. (+) Cullen’s sign: ecchymosis of umbilicus Hemorrhage 2. Withhold food & fluid & eliminate odor: to decrease pancreatic stimulation /
8. (+) Grey Turner’s spots: ecchymosis of flank area aggravates pain
9. Hypocalcemia 3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
 Complication of TPN
Dx  Infection
1. Serum amylase & lipase: increase  Embolism
2. Urinary amylase: increase  Hyperglycemia
3. Blood Sugar: increase 4. Institute non-pharmacological measures: to decrease pain
4. Lipids Level: increase  Assist client to comfortable position: Knee chest or fetal like position
5. Serum Ca: decrease  Teach relaxation techniques & provide quiet, restful environment
6. CT Scan: shows enlargement of the pancreas 5. Provide client teaching & discharge planning
 Dietary regimen when oral intake permitted
Medical Management
 High CHO, CHON & decrease fats
1. Drug Therapy
 Eat small frequent meal instead of three large ones
 Narcotic Analgesic: for pain
 Avoid caffeine products
 Meperidine Hcl (Demerol)
 Eliminate alcohol consumption
 Don’t give Morphine SO4: will cause spasm of Sphincter of Oddi
 Maintain relaxed atmosphere after meals
 Smooth muscle relaxant: to relieve pain
 Report signs of complication
 Papaverine Hcl
 Continued N/V
 Anticholinergic: to decrease pancreatic stimulation
 Abdominal distension with feeling of fullness
 Atrophine SO4
 Persistent weight loss
 Propantheline Bromide (Profanthene)
 Severe epigastric or back pain
 Antacids: to decrease pancreatic stimulation
 Frothy foul smelling bowel movement
 Maalox
 Irritability, confusion, persistent elevation of temperature (2 day)
 H2 Antagonist: to decrease pancreatic stimulation
 Ranitidin (Zantac) Apendicitis
 Vasodilators: to decrease pancreatic stimulation  Inflammation of the appendix that prevents mucus from passing into the cecum
  Inflammation of verniform appendix 5. Monitor VS, I&O bowel sound
 If untreated: ischemia, gangrene, rupture & peritonitis
 May cause by mechanical obstruction (fecalith, intestinal parasites) or anatomic Nursing Intervention post op
defect 1. If (+) Pendrose drain (rubber drain inserted at surgical wound for drainage of
 May be related to decrease fiber in the diet blood, pus etc): indicates rupture of appendix
2. Position the client semi-fowlers or side lying on right: to facilitate drainage
Predisposing factor: 3. Administer Meds:
1. Microbial infection  Analgesic: due post op pain
2. Feacalith: undigested food particles like tomato seeds, guava seeds etc.  Antibiotics: for infection
3. Intestinal obstruction  Antipyretics: for fever (PRN)
4. Monitor VS, I&O, bowel sound
S/Sx: 5. Maintain patent IV line
1. Pathognomonic sign: (+) rebound tenderness 6. Complications: Peritonitis, Septicemia
2. Low grade fever
3. N/V Liver Cirrhosis
4. Decrease bowel sound Chronic progressive disease characterized by inflammation, fibrosis & degeneration
5. Diffuse pain at lower Right iliac region of the liver parenchymal cell
6. Late sign: tachycardia: due to pain Destroyed liver cell are replaced by scar tissue, resulting in architectural changes &
malfunction of the liver
Dx Lost of architectural design of liver leading to fat necrosis & scarring
1. CBC: mild leukocytosis: increase WBC
2. PE: (+) rebound tenderness (flex Right leg, palpate Right iliac area: rebound) Types
3. Urinalysis: elevated acetone in urine Laennec’s Cirrhosis:
Associated with alcohol abuse & malnutrition
Medical Management Characterized by an accumulation of fat in the liver cell progressing to widespread
 Surgery: Appendectomy 24-45 hrs scar formation
Postnecrotic Cirrhosis
Nursing Intervention Result in severe inflammation with massive necrosis as a complication of viral
1. Administer antibiotics / antipyretic as ordered hepatitis
2. Routinary pre-op nursing measures: Cardiac Cirrhosis
 Skin prep Occurs as a consequence of right sided heart failure
 NPO Manifested by hepatomegaly with some fibrosis
 Avoid enema, cathartics: lead to rupture of appendix Biliary Cirrhosis
3. Don’t give analgesic: will mask pain Associated with biliary obstruction usually in the common bile duct
 Presence of pain means appendix has not ruptured Results in chronic impairment of bile excretion
4. Avoid heat application: will rupture appendix
S/sx
 Fatigue PT: prolonged
Anorexia Hepatic Ultrasonogram: fat necrosis of liver lobules
N/V
Dyspepsia: Indigestion Nursing Intervention
Weight loss CBR with bathroom privileges
Flatulence Encourage gradual, progressive, increasing activity with planned rest period
Change (Irregular) bowel habit Institute measure to relieve pruritus
Ascites Do not use soap & detergent
Peripheral edema Bathe with tepid water followed by application of emollient lotion
Hepatomegaly: pain located in the right upper quadrant Provide cool, light, non-constrictive clothing
Atrophy of the liver Keep nail short: to avoid skin excoriation from scratching
Fetor hepaticus: fruity, musty odor of chronic liver disease Apply cool, moist compresses to pruritic area
Aterixis: flapping of hands & tremores Monitor VS, I & O
Hard nodular liver upon palpation Prevent Infection
Increased abdominal girth Prevent skin breakdown: by turning & skin care
Changes in moods Provide reverse isolation for client with severe leukopenia: handwashing technique
Alertness & mental ability Monitor WBC
Sensory deficits Diet:
Gynecomastia Small frequent meals
Decrease of pubic & axilla hair in males Restrict Na!
Amenorrhea in female High calorie, low to moderate CHON, high CHO, low fats with supplemental Vit A, B-
Jaundice complex, C, D, K & folic acid
Pruritus or urticaria Monitor / prevent bleeding
Easy bruising Measure abdominal girth daily: notify MD
Spider angiomas on nose, cheeks, upper thorax & shoulder With pt daily & assess pitting edema
Palmar erythema Administer diuretics as ordered
Muscle atrophy Provide client teaching & discharge planning
Avoidance of hepatotoxicity drug: sedative, opiates or OTC drugs detoxified by liver
How to assess weight gain & increase abdominal girth
Dx Avoid person with upper respiratory infection
Liver enzymes: increase Reporting signs of reccuring illness (liver tenderness, increase jaundice, increase
SGPT (ALT) fatigue, anorexia)
SGOT (AST) Avoid all alcohol
LDH Alkaline Phosphate Avoid straining stool vigorous blowing of nose & coughing: to decrease incidence of
Serum cholesterol & ammonia: increase bleeding
Indirect bilirubin: increase Complications:
CBC: pancytopenia Ascites: accumolation of free fluid in abdominal cavity
 Nursing Intervention Kidneys
Meds: Loop diuretics: 10-15 min effect Two of bean shaped organ that lie in the retroperitonial space on either
Assist in abdominal paracentesis: aspiration of fluid side of the vertebral column
Void before paracentesis: to prevent accidental puncture of bladder as trochar Retroperitonially (back of peritoneum) on either side of vertebral column
is inserted Adrenal gland is on top of each kidneys
Encased in Bowmans’s capsule
Bleeding esophageal varices: Dilation of esophageal veins
Renal Parenchyma
Nursing Intervention Cortex
Administer meds: Outermost layer
Vit K Site of glomeruli & proximal & distal tubules of nephron
Pitrisin or Vasopresin (IM) Medulla
NGT decompression: lavage Middle layer
Give before lavage: ice or cold saline solution Formed by collecting tubules & ducts
Monitor NGT output
Assist in mechanical decompression Renal Sinus & Pelvis
Insertion of sengstaken-blackemore tube Papillae
3 lumen typed catheter Projection of renal tissues located at the tip of the renal pyramids
Scissors at bedside to deflate balloon. Calices
Minor Calyx: collects urine flow from collecting ducts
Hepatic encephalopathy Major Calyx: directs urine from renal sinus to renal pelvis
Urine flows from renal pelvis to ureters
Nursing Intervention
Assist in mechanical ventilation: due coma Nephron
Monitor VS, neuro check Functional unit of the kidney
Siderails: due restless Basic living unit
Administer meds
Laxatives: to excrete ammonia Renal Corpuscle (vascular system of nephron)
Bowman’s Capsule:
Overview of Anatomy & Physiology Of GUT System Portion of the proximal tubule surrounds the glomerulus
Glomerulus:
GUT: Genito-urinary tract Capillary network permeable to water, electrolytes, nutrients & waste
GUT includes the kidneys, ureters, urinary bladder, urethra & the male & female genitalia Impermeable to large CHON molecules
Function: Filters blood going to kidneys
Promote excretion of nitrogenous waste products Renal Tubule
Maintain F&E & acid base balance
 Divided into proximal convoluted tubule, descending loop of Henle, Pressure in bowman’s capsule opposes hydrostatic pressure & filtration
acending loop of Henle, distal convoluted tubule & collecting ducts If glomerular pressure insufficient to force substance out of the blood into the tubules
filtrate formation stops
Ureters Glomerular Filtration Rate (GFR)
Two tubes approximately 25-35 cm long Amount of blood filtered by the glomeruli in a given time
Extend from the renal pelvis to the pelvic cavity where they enter the bladder, Normal: 125 ml / min
convey urine from the kidney to the bladder Filtrate formed has essentially same composition as blood plasma without the
Passageway of urine to bladder CHON; blood cells & CHON are usually too large to pass the glomerular
Ureterovesical valve: prevent backflow of urine into ureters membrane

Bladder Tubular Function

Located behind the symphisis pubis Tubules & collecting ducts carry out the function of reabsorption, secretion
Composed of muscular elastic tissue that makes it distensible & excretion
Serve s as reservoir of urine (capable of holding 1000-1800 ml & 500 ml moderately Reabsorption of H2O & electrolytes is controlled by anitdiuretics hormones
full) (ADH) released by the pituitary & aldosterone secreted by the adrenal
Internal & external urethral sphincter controls the flow of urine glands
Urge to void stimulated by passage of urine past the internal sphincter (involuntary) Proximal Convoluted Tubule
to the upper urethra Reabsorb the ff:
Relaxation of external sphincter (voluntary) produces emptying of the bladder 80% of F & E
(voiding) H2O
Glucose
Urethra Amino acids
Small tube that extends from the bladder to the exterior of the body Bicarbonate
Passage of urine, seminal & vaginal fluids. Secretes the ff:
Females: located behind the symphisis pubis & anterior vagina & approximately Organic substance
3-5 cm Waste
Males: extend the entire length of the penis & approximately 20 cm Loop of Henli
Reabsorb the ff:
Function of kidneys Na & Chloride in the ascending limb
Kidneys remove nitrogenous waste & regulates F & E balance & acid base H2O in the descending limb
balance Concentrate / dilutes urine
Urine is the end product Distal Convoluted Tubule
Secretes the ff:
Urine formation: 25 % of total cardiac output is received by kidneys Potassium
Glomerular Filtration Hydrogen ions
Ultrafiltration of blood by the glomerulus, beginning of urine formation Ammonia
Requires hydrostatic pressure & sufficient circulating volume Reabsorb the ff:
 H2O Aldosterone
Bicarbonate Increase BP
Regulate the ff: Increase Na &
Ca H2O reabsorption
Phosphate concentration
Collecting Ducts Hypervolemia
Received urine from distal convoluted tubules & reabsorb H2O (regulated by ADH)
Color – amber
Normal Adult: produces 1 L /day of urine Odor – aromatic
Consistency – clear or slightly turbid
Regulation of BP pH – 4.5 – 8
Through maintenance of volume (formation / excretion of urine) Specific gravity – 1.015 – 1.030
Rennin-angiotensin system is the kidneys controlled mechanism that can contribute WBC/ RBC – (-)
to rise the BP Albumin – (-)
When the BP drops the cells of the glomerulus release rennin which then activates E coli – (-)
angiotensin to cause vasoconstriction. Mucus thread – few
Amorphous urate (-)

Filtration – Normal GFR/ min is 125 ml of blood UTI

Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption) CYSTITIS
Tubular secretion – 1 ml is excreted in urine Inflammation of bladder due to bacterial infection

Regulation of BP: Predisposing factors:

Microbial invasion: E. coli
Predisposing factor: High risk: women
Ex CS – hypovolemia – decrease BP going to kidneys Obstruction
Activation of RAAS Urinary retention
Increase estrogen levels
Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus Sexual intercourse

Angiotensin I mild vasoconstrictor S/Sx:

Pain: flank area
Angiotensin II vasoconstrictor Urinary frequency & urgency
Burning pain upon urination
Dysuria
Adrenal cortex increase CO increase PR Hematuria
Nocturia
 Fever Acute / chronic inflammation of 1 or 2 renal pelvis of kidneys leading to
Chills tubular destruction & interstitial abscess formation
Anorexia Acute: infection usually ascends from lower urinary tract
Gen body malaise Chronic: a combination of structural alteration along with infection major
cause is ureterovesical reflux with infected urine backing up into
Dx ureters & renal pelvis
Urine culture & sensitivity: (+) to E. coli Recurrent infection will lead to renal parenchymal deterioration & Renal
Failure
Nursing Intervention
Force fluid: 3000 ml Predisposing factor:
Warm sitz bath: to promote comfort Microbial invasion
Monitor & assess urine for gross odor, hematuria & sediments E. Coli
Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent bacterial multiplication Streptococcus
Administer Medication as ordered: Urinary retention /obstruction
Systemic Antibiotics Pregnancy
Ampicillin DM
Cephalosporin Exposure to renal toxins
Aminoglycosides
Sulfonamides S/sx:
Co-trimaxazole (Bactrim) Acute Pyelonephritis
Gantrism (Gantanol) Severe flank pain or dull ache
Antibacterial Costovertibral angle pain / tenderness
Nitrofurantoin (Macrodantin) Fever
Methenamine Mandelate (Mandelamine) Chills
Nalixidic Acid (NegGram) N/V
Urinary Tract Anagesic Anorexia
Urinary antiseptics: Mitropurantoin (Macrodantin) Gen body malaise
Urinary analgesic: Pyridium Urinary frequency & urgency
Provide client teachings & discharge planning Nocturia
Importance of Hydration Dsyuria
Void after sex: to avoid stagnation Hematuria
Female: avoids cleaning back & front (should be front to back) Burning sensation on urination
Bubble bath, Tissue paper, Powder, perfume
Complications: Pyelonephritis Chronic Pyelonephritis: client usually not aware of disease
Bladder irritability
Pyelonephritis Slight dull ache over the kidney
Chronic Fatigue
Weight loss Presence of stone anywhere in the urinary tract
Polyuria Formation of stones at urinary tract
Polydypsia Frequent composition of stones
HPN Calcium
Atrophy of the kidney Oxalate
Uric acid
Medical Management
Urinary analgesic: Peridium Calcium Oxalate Uric Acid
Acute
Antibiotics Milk Cabbage Anchovies
Antispasmodic Cranberries Organ meat
Surgery: removal of any obstruction Nuts tea Nuts
Chronic Chocolates Sardines
Antibiotics
Urinary Antiseptics Predisposing factors:
Nitrofurantoin (macrodantin) Diet: increase Ca & oxalate
SE: peripheral neuropathy Increase uric acid level
GI irritation Hereditary: gout or calculi
Hemolytic anemia Immobility
Staining of teeth Sedentary lifestyle
Surgery: correction of structural abnormality if possible Hyperparathyroidism

Dx S/sx
Urine culture & sensitivity: (+) E. coli & streptococcus Abdominal or flank pain
Urinalysis: increase WBC, CHON & pus cells Renal colic
Cystoscopic exam: urinary obstruction Cool moist skin (shock)
Burning sensation upon urination
Nursing Intervention Hematuria
Provide CBR: acute phase Anorexia
Monitor I & O N/V
Force fluid
Acid ash diet Dx
Administer medication as ordered Intravenous Pyelography (IVP): identifies site of obstruction & presence of non-
Chronic: possibility of dialysis & transplant if has renal deterioration radiopaque stones
Complication: Renal Failure KUB: reveals location, number & size of stone
Cytoscopic Exam: urinary obstruction
Nephrolithiasis / Urolithiasis Stone Analysis: composition & type of stone
 Urinalysis: indicates presence of bacteria, increase WBC, RBC & CHON Administer Allopurinol (Zyloprim) as ordered: to decrease uric acid production: push
fluids when giving allopurinol
Medical Management Provide client teaching & discharge planning
Surgery Prevention of urinary stasis: increase fluid intake especially during hot weather &
Percutaneous Nephrostomy: illness
Tube is inserted through skin & underlying tissue into renal pelvis to remove Mobility
calculi Voiding whenever the urge is felt & at least twice during night
Percutaneous Nephrostolithotomy Adherence to prescribe diet
Delivers ultrasound wave through a probe placed on the calculus Complications: Renal Failure
Extracorporeal Shockwave Lithotripsy:
Non-invasive Benign Prostatic Hypertrophy (BPH)
Delivers shockwaves from outside of the body to the stone causing pulverization Mild to moderate glandular enlargement, hyperplsia & over growth of the
Pain management & diet modification smooth muscles & connective tissue
As the gland enlarges it compresses the urethra: resulting to urinary retention
Nursing Intervention Enlarged prostate gland leading to
Force fluid: 3000-4000 ml / day Hydroureters: dilation of urethers
Strain urine using gauze pad: to detect stones & crush all cloths Hydronephrosis: dilation of renal pelvis
Encourage ambulation: to prevent stasis Kidney stones
Warm sitz bath: for comfort Renal failure
Administer narcotic analgesic as ordered: Morphine SO4: to relieve pain
Application warm compress at flank area: to relieve pain Predisposing factor:
Monitor I & O High risk: 50 years old & above & 60-70 (3-4x at risk)
Provide modified diet depending upon the stone consistency Influence of male hormone
Calcium Stones
Limit milk & dairy products S/sx
Provide acid ash diet (cranberry or prune juice, meat, fish, eggs, poultry, grapes, Urgency, frequency & hesitancy
whole grains): to acidify urine Nocturia
Take vitamin C Enlargement of prostate gland upon palpation by digital rectal exam
Oxalate Stone Decrease force & amount of urinary stream
Avoid excess intake of food / fluids high in oxalate (tea, chocolate, Dysuria
rhubarb, spinach) Hematuria
Maintain alkaline-ash diet (milk, vegetable, fruits except cranberry, Burning sensation upon urination
plums & prune): to alkalinize urine Terminal bubbling
Uric Acid Stone Backache
Reduce food high in purine (liver, brain, kidney, venison, shellfish, meat Sciatica: severe pain in the lower back & down the back of thigh & leg
soup, gravies, legumes)
Maintain alkaline urine Dx
 Digital rectal exam: enlarged prostate gland
KUB: urinary obstruction Pre renal cause: decrease blood flow & glomerular filtrate
Cystoscopic Exam: reveals enlargement of prostate gland & obstruction of urine Ischemia & oliguria
flow Cardiogenic shock
Urinalysis: alkalinity increase Acute vasoconstriction
Specific Gravity: normal or elevated Septicemia
BUN & Creatinine: elevated (if longstanding BPH) Hypovolemia Decrease flow to kidneys
Prostate-specific Antigen: elevated (normal is < 4 ng /ml) Hypotension
CHF
Nursing Intervention Hemorrhage
Prostate message: promotes evacuation of prostatic fluid Dehydration
Force fluid intake: 2000-3000 ml unless contraindicated
Provide catheterization Intra-renal cause: involves renal pathology: kidney problem
Administer medication as ordered: Acute tubular necrosis
Terazosine (Hytrin): relaxes bladder sphincter & make it easier to urinate Endocarditis
Finasteride (Proscar): shrink enlarge prostate gland DM
Surgery: Prostatectomy Tumors
Transurethral Resection of Prostate (TURP): insertion of a resectoscope into urethra Pyelonephritis
to excise prostatic tissue Malignant HPN
Assist in cystoclysis or continuous bladder irrigation. Acute Glomerulonephritis
Nursing Intervention Blood transfision reaction
Monitor symptoms of infection Hypercalemia
Monitor symptoms gross / flank bleeding. Normal bleeding within 24h Nephrotoxin (certain antibiotics, X-ray, dyes, pesticides, anesthesia)
Maintain irrigation or tube patent to flush out clots: to prevent bladder
spasm & distention Post renal cause: involves mechanical obstruction
Tumors
Acute Renal Failure Stricture
Sudden inability of the kidney to regulate fluid & electrolyte balance & remove toxic Blood cloths
products from the body Urolithiasis
Sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E BPH
balance due to a decrease in GFR (N 125 ml/min) Anatomic malformation

Causes S/sx
Pre-renal cause: interfering with perfusion & resulting in decreased blood flow & Oliguric Phase: caused by reduction in glomerular filtration rate
glomerular filtrate Urine output less than 400 ml / 24 hrs; duration 1-2 weeks
Inter-renal cause: condiion that cause damage to the nephrons S/sx
Post-renal cause: mechanical obstruction anywhere from the tubules to the urethra Hypernatremia
 Hyperkalemia Monitor ECG
Hyperphosphotemia Check urine serum osmolality / osmolarity & urine specific gravity as
Hypermagnesemia ordered
Hypocalcemia Promote optimal nutrition
Metabolic acidosis Administer TPN as ordered
Dx Restrict CHON intake
BUN & Creatinine: elevated Prevent complication from impaired mobility
Diuretic Phase: slow gradual increase in daily urine output Pulmonary Embolism
Diuresis may occur (output 3-5 L / day): due to partially regenerated tubules inability Skin breakdown
to concentrate urine Contractures
Duration: 2-3 weeks Atelectesis
S/sx Prevent infection / fever
Hyponatremia Assess sign of infection
Hypokalemia Use strict aseptic technique for wound & catheter care
Hypovolemia Take temperature via rectal
Administer antipyretics as ordered & cooling blankets
Dx Support clients / significant others: reduce level of anxiety
BUN & Creatinine: elevated Provide care for client receiving dialysis
Recovery or Covalescent Phase: renal function stabilized with gradual improvement Provide client teaching & discharge planning
over next 3-12 mos Adherence to prescribed dietary regime
S/sx of recurrent renal disease
Nursing Intervention Importance of planned rest period
Monitor / maintain F&E balance Use of prescribe drugs only
Obtain baseline data on usual appearance & amount of client’s urine S/sx of UTI or respiratory infection: report to MD
Measure I&O every hour: note excessive losses
Administer IV F&E supplements as ordered Chronic Renal Failure
Weight daily Progressive, irreversible destruction of the kidneys that continues until nephrons are
Monitor lab values: assess / treat F&E & acid base imbalance as needed replaced by scar tissue
Monitor alteration in fluid volume Loss of renal function gradual
Monitor V/S. PAP, PCWP, CVP as needed Irreversible loss of kidney function
Monitor I&O strictly
Assess every hour fro hypervolemia Predisposing factors:
Maintain ventilation DM
Decrease fluid intake as ordered HPN
Administer diuretics, cardiac glycosides & hypertensive agent as Recurrent UTI/ nephritis
ordered Urinary Tract obstruction
Assess every hour for hypovolemia: replace fluid as ordered Exposure to renal toxins
Stages of CRF Fluid & Electrolytes Integumentary
Diminished Reserve Volume – asymptomatic Hyperkalemia Itchiness / pruritus
Normal BUN & Crea, GFR < 10 – 30% Hypernatermia Uremic frost
2. Renal Insufficiency Hypermagnesemia
3. End Stage Renal disease Hyperposphatemia
Hypocalcemia
Metabolic acidosis
S/Sx:
N/V Dx
Diarrhea / constipation Urinalysis: CHON, Na & WBC: elevated
Decreased urinary output Specific gravity: decrease
Dyspnea Platelets: decrease
Stomatitis Ca: decrease
Hypotension (early)
Hypertension (late) Medical Management
Lethargy Diet restriction
Convulsion Multivitamins
Memory impairment Hematinics
Pericardial Friction Rub Aluminum Hydroxide Gels
HF Antihypertensive

Urinary System Metabolic Disturbance Nursing Intervention

Polyuria Azotemia (increase BUN & Creatinine) Prevent neurologic complication
Nocturia Hyperglycemia Monitor for signs of uremia
Hematuria Hyperinsulinemia Fatigue
Dysuria Loss of appetite
Oliguria Decreased urine output
CNS GIT Apathy
Headache N/V Confusion
Lethargy Stomatitis Elevated BP
Disorientation Uremic breath Edema of face & feet
Restlessness Diarrhea / constipation Itchy skin
Memory impairment Restlessness
Respiratory Hematological Seizures
Kassmaul’s resp Normocytic anemia Monitor for changes in mental functioning
Decrease cough reflex Bleeding tendencies Orient confused client to time, place, date & person
 Institute safety measures to protect the client from falling out of bed Meticulous skin care. Uremic frost – assist in bathing pt
Monitor serum electrolytes, BUN & creatinine as ordered 4. Meds:
Promote optimal GI function a.) Na HCO3 – due Hyperkalemia
Provide care for stomatitis b.) Kagexelate enema
Monitor N/V & anorexia: administer antiemetics as ordered c.) Anti HPN – hydralazine
Monitor signs of GI bleeding d.) Vit & minerals
Monitor & prevent alteration in F&E balance e.) Phosphate binder
Monitor for hyperphosphatemia: administer aluminum hydroxides gel (Amphogel) Al OH gel - S/E constipation
(amphojel, alternagel) as ordered f.) Decrease Ca – Ca gluconate
Paresthesias 5. Assist in hemodialysis
Muscle cramps Consent/ explain procedure
Seizures Obtain baseline data & monitor VS, I&O, wt, blood exam
Abnormal reflex Strict aseptic technique
Maintenance of skin integrity Monitor for signs of complications:
Provide care for pruritus B – bleeding
Monitor uremic frost (urea crystallization on the skin): bathe in plain water E – embolism
Monitor for bleeding complication & prevent injury to client D – disequilibrium syndrome
Monitor Hgb, Hct, platelets, RBC S – septicemia
Hematest all secretions S – shock – decrease in tissue perfusion
Administer hematinics as ordered Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste prod leading
Avoid IM injections to:
Maintain maximal cardiovascular function n/v
Monitor BP HPN
Auscultate for pericardial friction rub Leg cramps
Perform circulation check routinely Disorientation
Administer diuretics as ordered & monitor I&O Paresthesia
Modify digitalis dose as ordered (digitalis is excreted in kidneys)
Provide care for client receiving dialysis Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to
Disequilibrium syndrome: from rapid removal of urea & nitrogenous waste prod compression of fistula.
leading to: Maintain patency of shunt by:
N/V Palpate for thrills & auscultate for bruits if (+) patent shunt!
HPN Bedside- bulldog clip
Leg cramps - If with accidental removal of fistula to prevent embolism.
Disorientation - Infersole (diastole) – common dialisate used
Paresthes 7. Complication
Enforce CBR - Peritonitis
Monitor VS, I&O - Shock
8. Assist in surgery:
Renal transplantation : Complication – rejection. Reverse isolation