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Title: medical surgical nursing
Description: medical surgical notes, by Anthony.t
Description: medical surgical notes, by Anthony.t
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1
MEDICAL-SURGICAL NURSING
By: Anthony T
...
N
...
Overview of structures and functions:
3
...
Permanent
Not capable of regeneration
...
The nervous system is composed of the ff:
Central Nervous System
Brain
Spinal Cord – serves as a connecting link between the brain
B
...
Peripheral Nervous System
Support and protection of neurons
...
Astrocytes
Cranial Nerves –12 pairs; carry impulses to & from the brain
...
Spinal Nerves – 31 pairs; carry impulses to & from spinal
majority of brain tumors (90%) arises from called
cord
...
Autonomic Nervous System
subdivision of the PNS that automatically controls body
2
...
Oligodendria
function such as breathing & heart beat
...
Special senses of vision and hearing are also covered in this
section
act as insulator and facilitates rapid nerve impulse
Sympathetic nervous system – generally accelerate some
transmission
...
body functions in response to stress
...
drinking)
...
CELLS
A
...
Primary component of nervous system
Composed of cell body (gray matter), axon, and dendrites
Basic cells for nerve impulse and conduction
...
80% brain mass
Neurons may have many dendrites
...
Acetylcholine, norepinephrine) involved
Brain Mass
Parts Of The Brain
1
...
composed of two hemisphere the Right Cerebral
in the transmission of impulse across synapse
...
Most axons leaving the CNS are heavily myelinated
by schwann cells
Each hemisphere divided into four lobes; many of the
functional areas of the cerebrum have been located in
these lobes:
Functional Classification
1
...
3
...
Frontal Lobe
Efferent (motor) neurons
controls personality, behavior
Conduct impulses from CNS to muscle and glands
higher cortical thinking, intellectual functioning
Internuncial neurons (interneurons)
precentral gyrus: controls motor function
Broca’s Area: specialized motor speech area - when
Connecting links between afferent and efferent neurons
Properties
1
...
2
...
2
...
3
...
2
...
Pareital Lobe
for appreciation
Labile
integrates sensory information
Capable of regeneration
...
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY
1
...
Postcentral gyrus: registered general sensation (ex
...
Occipital Lobe
5
...
coordinates muscle tone and movements and maintains
Insula (Island of Reil)
position in space (equilibrium)
visceral function activities of internal organ like gastric
controls balance, equilibrium, posture and gait
...
Limbic System (Rhinencephalon)
Spinal Cord
controls smell - if damaged results to anosmia (absence
of smell)
...
regulate & integrate motor activity originating in the
Anterior Horns
fibers
cerebral cortex
part of extrapyramidal system
area of gray matter located deep within each cerebral
2
...
3
...
Lateral Horns
Connecting part of the brain, between the cerebrum &
White Matter
the brain stem
In thoracic region, contain cells giving rise to
autonomic fibers of sympathetic nervous system
Diencephalon/interbrain
Contains cell bodies connecting with afferent
(sensory) fibers from dorsal root ganglion
hemisphere
...
Contains several small structures: the thalamus &
Ascending Tracts (sensory pathways)
a
...
(ex
...
Rage, fear)
found immediately beneath the thalamus
plays a major role in regulation/controls of vital function:
c
...
Anterior Spinothlamic
acts as controls center for pituitary gland and affects
both divisions of the autonomic nervous system
...
Descending Tracts (motor pathways)
a
...
the medulla)
enlargement
late sign is deepening of voice
...
Conduct motor impulses from motor
cortex to anterior horn cells (cross in
early sign for males are testicular and penile
Carry impulses concerned with crude
touch & pressure
controls some emotional responses like fear, anxiety
and excitement
...
Extrapyramidal
Help to maintain muscle tone & to
control body movement, especially
gross automatic movements such as
3
...
Mesencephalon/Midbrain
walking
acts as relay station for sight and hearing
...
Reflex Arc
equal size of pupil is isocoria
...
hearing acuity is 30 – 40 dB
...
located at lowest part of brain
...
extends from the cerebral hemispheres to the foramen
a
...
c
...
e
...
Skull
Medulla Oblongata
controls respiration, heart rate, swallowing, vomiting,
hiccup, vasomotor center (dilation and constriction of
Muscle or organ that responds to stimulus
Supporting Structures
of respiration
...
Synapses with a motor neuron (anterior horn cell)
Efferent Pathways
cerebrum and the spinal cord
...
Not relayed to & from brain: take place at cord levels
Components
Brain Stem
Reflex consists of an involuntary response to a stimulus
2
...
Supports the head & protect the spinal cord
2
3
3
...
Signs of jaundice (icteric sclerae)
...
Increase bilirubin in brain (kernicterus)
...
supply
Area between arachnoid & pia mater is called
subarachnoid space: CSF aspiration is done
Subdural space between the dura and arachnoid
Layers:
Dura Mater
outermost layer, tough, leathery
Arachnoid Mater
4
...
innermost layer, delicate, clings to surface of brain
Ventricles
5
...
Surrounds brain & spinal cord
Offer protection by functioning as a shock absorber
Allows fluid shifts from the cranial cavity to the spinal
Carries nutrient to & waste product away from nerve
cells
Component of CSF: CHON, WBC, Glucose
Contains efferent (motor) nerve whose nerve
fibers originate in the anterior horn cell of the
Cerebrospinal Fluid (CSF)
cavity
6
...
May have sensory, motor, or mixed functions
...
Two internal carotid arteries anteriorly
Optic
: CN II
Sensory: carries impulses for vision
...
Anterior, middle, & posterior cerebral arteries are the
Trochlear
main arteries for distributing blood to each hemisphere
inward, movement of the eye
of the brain
Trigeminal
Brain stem & cerebellum are supplied by branches of
of eyes (corneal reflex); muscle
: CN IV
Motor: muscles for downward,
: CN V
Mixed: impulses from face, surface
Controlling mastication
...
Venous blood drains into dural sinuses & then into
Abducens
jugular veins
of eye
Blood-Brain-Barrier (BBB)
Facial
: CN VI
Motor: muscles for lateral deviation
: CN VII
Mixed: impulses for taste from
anterior tongue; muscles for facial
Protective barrier preventing harmful agents from
Movement
...
Substance That Can Pass Blood-Brain Barrier
1
...
Vagus
: CN X
Mixed: impulses for sensation to
lower pharynx & larynx; muscle for
Early Signs of Hepatic Encephalopathy
Late Signs of Hepatic Encephalopathy
2
...
Movement of soft palate,
Asterexis (flapping hand tremors)
...
Epilepsy
Treated with calcium EDTA
...
And increases breakdown of fats
...
Spinal Accessory
: CN XI
Motor: movement of
sternomastoid muscles & upper part of trapezius
Muscles
...
Autonomic Nervous System
Part of the peripheral nervous system
Include those peripheral nerves (both cranial & spinal) that
regulates smooth muscles, cardiac muscles, & glands
...
Sympathetic Nervous System
Generally
accelerates
some
body
function
in
response to stress
...
Parasympathetic Nervous System
Controls normal body functioning
depressant)
...
Resulting to acetone breath odor/fruity odor
...
Which may lead to diabetic coma
...
response
...
(cathecolamines) from adrenal
- Decreases all bodily activities
glands and causes
except GIT
...
Constrict sphincters
relaxed sphincters
- Increase all bodily activity
Possibly inhibits secretions
except GIT
GI Tract
stimulate
EFFECTS OF PNS
secretions
- Constriction of pupils (miosis)
...
gallbladder&
- Dilation of pupils (mydriasis) in
- Decrease BP and Heart Rate
...
- Bronchoconstriction, Decrease
- Dry mouth (thickened saliva)
...
- Increase BP and Heart Rate
...
Inhibits glycogenolysis in liver
Adrenal Gland stimulates secretion of epinephrine &
no effect
Norepinephrine
- Constipation
...
contract detrusor muscles
- Increase blood supply to brain,
Contract trigone sphincter (prevent voiding)
heart and skeletal muscles
...
Cholinergic Agents
- Mestinon, Neostignin
...
Adrenergic Agents
SE:
- Give Epinephrine
...
Level of Consciousness (LOC)
suffering from COPD
II
...
a
...
- Atrophine Sulfate
b
...
Ability to follow command
d
...
Beta-adrenergic Blocking
SE:
Agents
- SNS effect
stimulus
(ex
...
trapezius muscle); note response to pain
- all ending with “lol”
Appropriate: withdrawal, moaning
- Propranolol, Atenelol,
Inappropriate: non-purposeful
Metoprolol
...
squeeze
Abnormal posturing (may occur spontaneously or in
Effect of Beta-blockers
response to stimulus)
B – broncho spasm
Decorticate Posturing: extension of leg, internal
E – elicits a decrease in
rotation & abduction of arms with flexion of elbows,
myocardial contraction
...
cerebral hemisphere)
A – AV conduction slows down
...
1
...
Ace Inhibitors – Angiotensin
Objective measurement of LOC sometimes called as the
quick neuro check
“pril” (Captopril, Enalapril)
Objective evaluation of LOC, motor / verbal response
3
...
Effectors
:Sympathetic (Adrenergic) Effect
Parasympathetic (Cholinergic)
Eye
Components
Effect
dilate pupil (mydriasis)
constrict
Gland of Head
no effect
stimulate secretions
Salivary
scanty thick, viscous secretions copious thin watery
secretions
3
...
Verbal response
3
...
1
...
Lethargy
13 – 11
3
...
Coma
5
...
Observe size, shape, & equality of pupil (note size in
millimeter)
increase rate & force of contraction
decrease rate
b
...
Corneal reflex: blink reflex in response to light stroking
of cornea
Blood Vessel
constrict smooth muscles of the skin,
d
...
Dilates smooth muscles of bronchioles,
Blood vessels of the heart & skeletal muscles
Lungs
bronchodilation
Oculocephalic reflex (doll’s eyes): present in
5
...
Movement of extremities (paralysis)
b
...
Cheyne-Stokes Respiration: regular rhythmic alternating
Cranial Nerves
between hyperventilation & apnea; may be caused by
structural cerebral dysfunction or by metabolic problems
such as diabetic coma
b
...
Apneustic Breathing: prolonged inspiratory phase,
followed by a 2-to-3 sec pause; usually indicates
dysfunction respiratory center in pons
d
...
2
...
4
...
6
...
8
...
10
...
12
...
Ataxic Breathing: breathing pattern completely irregular;
indicates damage to respiratory center of the medulla
Material Used
Don’t use alcohol, ammonia, perfume because it is irritating
and highly diffusible
...
Sensory function for smell
Mental status and speech (Cerebral Function)
a
...
LOC
c
...
Hyposnia: decrease sensitivity to smell
d
...
Dysosmia: distorted sense of smell
e
...
Anosmia: absence of smell
f
...
Cranial nerve assessment
plate of ethmoid bone where olfactory cells are located may indicate
3
...
a
...
Finger to Nose Test: positive result mean dimetria
(inability of body to stop movement at desired point)
Sensory Function: light touch, superficial pain, temperature,
Functions
vibration & position sense
5
...
CRANIAL NERVE II: OPTIC
1
...
Snellen’s Animal chart: for pediatric client
Deep tendon reflex: grade from 0 (no response); to 4
(hyperactive); 2 (normal)
b
...
Pathologic: babinski reflex (dorsiflexion of the great toe
2
...
Stupor
Stuporous: (awakened by vigorous stimulation)
Generalized body weakness
Decrease body reflex
Numerator: is constant, it is the distance of person from
20/200 indicates blindness
20/20 visual acuity if client is able to read letters above
the red line
...
Test of visual field or peripheral vision
Coma
Comatose
light coma: positive to all forms of painful stimulus
deep coma: negative to all forms of painful stimulus
Denominator: changes, indicates distance by which the
person normally can see letter in the chart
...
the chart (6-7 m, 20 feet)
with fanning of toes): indicates damage to corticospinal
4
...
Superiorly
b
...
Nasally
d
...
Deep sternal stimulation / deep sternal pressure
2
...
Pressure on great toes
4
...
Short term memory
Ask most recent activity
Positive result mean anterograde amnesia and damage
Rectus
to temporal lobe
2
...
Time: first asked
Equal size of pupil: Isocoria
2
...
Place: third asked
Normal response: positive PERRLA
5
6
CRANIAL NERVE V: TRIGEMINAL
S/sx
Largest cranial nerve
4 A’s of Alzheimer
Consists of ophthalmic, maxillary, mandibular
a
...
Sensory: controls sensation of face, mucous membrane,
b
...
teeth, soft palate and corneal reflex
Motor: controls the muscle of mastication or chewing
Damage to CN V leads to Trigeminal Neuralgia / Tic
c
...
d
...
Medication: Carbamezapine (Tegretol)
*Expressive aphasia
CRANIAL NERVE VII: FACIAL
“motor speech center” unable to speak
Broca’s Aphasia
Sensory: controls taste, anterior 2/3 of tongue
Pinch of sugar and cotton applicator placed on tip of tongue
Motor: controls muscle of facial expression
inability to understand spoken words
...
General
*Receptive aphasia
Knowing
Gnostic
Area
or
General
Interpretative Area
...
Aricept (taken at bedtime)
Cognex
CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS
Glosopharenageal: controls taste, posterior 1/3 of tongue
Management
Vagus: controls gag reflex
1
...
(shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL
Controls the movement of tongue
Let client protrude tongue and it should be midline and if
Chronic intermittently progressive disorder of CNS
Characterized by remission and exacerbation
...
Cause unknown: maybe a slow growing virus or
possibly autoimmune disorders
...
Incident: Affects women more than men ages 20-40
are prone & more frequent in cool or temperate
climate
...
PTB – low grade afternoon fever
2
...
3
...
4
...
5
...
PERNICIOUS ANEMIA – red beefy tongue
7
...
CHOLERA – rice watery stool
...
MALARIA – step ladder like fever with chills
...
Ig M - acute in inflammation
...
* Give palliative or supportive care
...
TYPHOID – rose spots in abdomen
...
DIPTHERIA – pseudo membrane
...
MEASLES – koplick’s spots
13
...
1
...
LIVER CIRRHOSIS – spider like varices
blurring of vision (primary)
15
...
BOLIMIA – chipmunk face
...
APPENDICITIS – rebound tenderness
2
...
DENGUE – petichae or positive herman’s sign
...
MENINGITIS – kernig’s sign (leg pain), brudzinski sign (neck
paresthesia such as tingling sensation, numbness
pain)
...
TETANY – hypocalcemia (+) trousseu’s sign or carpopedal
3
...
Impaired motor function
spasm/ (+) chvostek sign (facial spasm)
...
TETANUS – risus sardonicus
spasticity
22
...
5
...
PYLORIC STENOSIS – olive like mass
...
PDA – machine like murmur
ataxic gait
nystagmus
dysarthria
intentional tremor
25
...
26
...
27
...
6
...
Constipation
8
...
Ataxia
CHARCOTS TRIAD
6
7
(unsteady gait,
a
...
positive romberg’s test)
Balance between activity & rest
Regular exercise such as walking, swimming,
biking in mild case
...
2
...
3
...
4
...
Use of medication & side effects
...
Alternative methods for sexual counseling if indicated
...
- avoid use of tissue papers
- avoid using talcum powder and perfume
...
- short urethra (3-5 cm, 1-1 ½ inches)
contraction of spinal column
...
Well-balance diet
Female
delayed
Lhermittes
COMMON CAUSE OF UTI
1
...
Intentional tremors
5
...
Muscles stretching & strengthening exercises
b
...
Assistive devices: canes, walker, rails, wheelchair as
INTRACRANIAL PRESSURE ICP
Monroe Kelly Hypothesis
necessary
3
...
(prednisone) for acute exacerbations: to reduce edema
at site of demyelination to prevent paralysis
...
Skull is a closed container
ACTH (adreno chorticotropic hormone), Corticosteroids
Any alteration or increase in one of the intracranial components
Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam
Increase intracranial pressure
(Valium) - muscle relaxants: for spacity
c
...
Cervical 1 – also known as atlas
...
Encourage independence in self-care activities
5
...
Institute bowel program
7
...
8
...
9
...
Deep breathing exercises
b
...
Foramen Magnum
Medulla Oblongata
fiber
to
Brain Herniation
prevent
constipation
...
Maintain urinary elimination
1
...
perform intermittent catheterization as ordered: to
prevent retention
...
Bethanecol Chloride (Urecholine) as ordered
Nursing Management
only given subcutaneous
...
monitor breath sounds 1 hour after subcutaneous
administration
...
Urinary Incontinence
a
...
Anti spasmodic agent Prophantheline Bromide (Pro-
Increase intra cranial pressure
Nursing Intervention
1
...
enlargement of skull in hydrocephalus
...
4
...
CSF, Blood
...
b
...
c
...
d
...
nerve
...
tumor (rarely)
antibodies
13
...
b
...
Prepare client for plasma exchange if indicated: to remove
a
...
11
...
a
...
Early closure of posterior fontanels causes posterior
Provide compassion in helping client adapt to changes
in body image & self-concept
...
Do not encourage false hope during remission
...
Refer to MS societies & community agencies
...
(Early signs)
Decrease LOC
14
...
Irritability / agitation
7
8
3
...
Systolic blood pressure increases while diastolic
pressure remains the same (widening pulse
e
...
Prevent complications of immobility
...
Administer medications as ordered:
c
...
Hyperosmotic agent / Osmotic Diuretic [Mannitol
respiration)
(Osmitrol)]: to reduce cerebral edema
temperature increase directly proportional to blood
Nursing Management
pressure
...
Monitor strictly input and output every hour: (output
Pupillary Changes
b
...
unilateral dilation of pupils called uncal
herniation
c
...
bilateral dilation of pupils called tentorial
d
...
c
...
Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral
drug of choice for CHF (pulmonary edema)
loop of henle in kidneys
...
edema
herniation
abnormal posturing
Monitor V/S especially BP: SE hypotension
...
spinal cord)
...
decerebrate posturing (damage to upper brain
Administered IV push or oral
...
Immediate effect of 10-15 minutes
...
4
...
Projective Vomiting
6
...
Possible seizure activity
c
...
Prevention
of
hypoxia
(decrease
O2)
Small dose of Codein SO4
Strong opiates may be contraindicated since they
potentiate respiratory depression, alter LOC, &
and
cause papillary changes
...
Hypoxia may cause brain swelling which
increase ICP
8
...
cranial cavity by the brain, cerebral blood, & CSF
b
...
measurement of ICP
...
Assist with mechanical hyperventilation as
9
...
a
...
Provide comfortable and quite environment
...
Avoid use of restraints
...
Maintain side rails
...
Instruct client to avoid forms of valsalva maneuver like:
Straining stool: administer stool softener & mild
laxatives as ordered (Dulcolax, Duphalac)
Intravenous administration of barbiturates may be
ordered: to induce coma artificially in the client who has
not responded to conventional treatment
...
Paralytic agents such as [vercuronium bromide
(Norcuron)]: may be administered to paralyzed the
with neck in neutral position unless contraindicated to
Prevent further increase ICP by:
Assess system for CSF leakage, loose connections,
air bubbles in he line, & occluded tubing
...
Check insertion site for signs of infection; monitor
temperature
...
Position the client with head of bed elevated to 30-45o angle
Use strict aseptic technique when handling any part
of the monitoring system
...
Before and after suctioning hyperventilate the client
detect increase in ICP
Monitor ICP pressure readings frequently & prevent
complications:
decrease O2 stimulates respiration
...
Subarachnoid screw (bolt): inserted through the
skull & dura matter into subarachnoid space
...
c
...
Anti-convulsants [Phenytoin (Dilantin)]: to prevent
seizures
...
Analgesics for headache as needed:
Maintain patent airway and adequate ventilation by:
a
...
Corticosteroids [Dexamethasone (Decadron)]: antiinflammatory effect reduces cerebral edema
Nursing Intervention
3
...
Avoid clustering of nursing care activity together
...
Avoid stooping/bending
b
...
3
...
2
...
Excessive vomiting: administer anti-emetics as
client
c
...
d
...
e
...
Provide appropriate nursing care for the client on a
ventilator
8
9
10
...
e
Spinach
Oranges
2
...
5 – 11 mg/100 ml
*CONGESTIVE HEART FAILURE
Signs and Symptoms
Signs and Symptoms
- tingling sensation
-
dyspnea
- paresthesia
-
orthopnea
- numbness
-
paroxysmal nocturnal dyspnea
- (+) Trousseus sign/Carpopedal spasm
-
productive cough
- (+) Chvostek’s sign
-
frothy salivation
Complications
-
cyanosis
- arrythmia
-
rales/crackles
- seizures
-
bronchial wheezing
Nursing Management
-
pulsus alternans
- Calcium Glutamate per IV slowly as ordered
-
anorexia and general body malaise
* Calcium Glutamate toxicity – results to seizure
-
PMI (point of maximum impulse/apical pulse rate) is
displaced laterally
-
S3 (ventricular gallop)
-
Predisposing Factors/Mitral Valve
o
RHD
o
Aging
Treatment
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (venous congestion)
Signs and Symptoms
- jugular vein distention (neck)
- ascites
- pitting edema
- weight gain
- hepatosplenomegaly
- jaundice
Magnesium Sulfate
Magnesium Sulfate toxicity
S/S
BP
Urine output
DECREASE
Respiratory rate
Patellar relfex absent
3
...
Hyperglycemia
- normal FBS is 80 – 100 mg/dl
Signs and Symptoms
- polyuria
- polydypsia
- polyphagia
Nursing Management
- monitor FBS
5
...
Signs and Symptoms
Signs and Symptoms of Lasix in terms of electrolyte
imbalances
1
...
4 – 5
...
Allopurinol (Zylopril)
- drug of choice for gout
...
b
...
* Kidney stones
Signs and Symptoms
- renal cholic
- cool moist skin
FRUITS
VEGETABLE
Apple
S
Asparagus
Banana
Brocolli
- administer medications as ordered
Cantalop
Carrots
a
...
- antidote: Naloxone (Narcan) toxicity leads to tremors
...
Allopurinol (Zylopril)
MOA: Increase level of dopamine in the brain;
relieves tremors; rigidity; bradykinesia
Side Effects
- respiratory depression (check for RR)
SE: GIT irritation (should be taken with meal);
anorexia; N/V; postural hypotension; mental
changes: confusion, agitation, hallucination; cardiac
Parkinson’s Disease/ Parkinsonism
arrhythmias; dyskinesias
...
antipsychotic; acute psychoses
Progressive disorder with degeneration of the nerve cell in
the basal ganglia resulting in generalized decline in
Avoid multi-vitamins preparation containing vitamin
B6 & food rich in vitamin B6 (Pyridoxine): reverses
muscular function
the therapeutic effects of Levodopa
Disorder of the extrapyramidal system
Urine and stool may be darkened
Usually occurs in the older population
Be aware of any worsening of symptoms with
Cause Unknown: predominantly idiopathic, but sometimes
prolonged high-dose therapy: “on-off” syndrome
...
traumatic, or drug induced (reserpine, methyldopa
Carbidopa-levodopa (Sinemet)
(aldomet) haloperidol (haldol), phenothiazines)
...
c
...
Benztropine Mesylate (Cogentin)
ganglia
b
...
Trihexyphenidyl (Artane)
Predisposing Factors
MOA: inhinit the action of acetylcholine; used in mild
1
...
Arteriosclerosis
& rigidity
3
...
Encephalitis
5
...
Reserpine (Serpasil)
a
...
Methyldopa (Aldomet)
Antihypertensive
c
...
Phenothiazine ___________________ Antipsychotic
(hyperactivity) because blood brain barrier is not yet
fully developed
...
Aloneness
Bromocriptine (Parlodel)
MOA:
stimulate
release
of
dopamine
in
the
substantia nigra
MAOI Inhibitor
Multiple loss
causes
suicide
a
...
Tricyclic
MOA: given to treat depression commonly seen in
Parkinson’s disease
2
...
Tremor: mainly of the upper limbs “pill rolling tremors” of
Rails & handlebars in the toilet, bathtub, & hallways
extremities especially the hands; resting tremor: most
No scattered rugs
Hard-back or spring-loaded chair to make getting up
common initial symptoms
2
...
Rigidity: cogwheel type
4
...
Fatigue
6
...
Difficulty rising from sitting position
...
Quite, monotone speech
9
...
7
...
Encourage independence in self-care activities:
10
...
Cramped, small handwriting
12
...
alter clothing for ease in dressing
use assistive device
do not rush the client
Improve communication abilities:
a
...
increase lacrimation
Instruct the client to practice reading a loud
c
...
constipation
6
...
e
...
Maintain adequate nutrition
...
Allow sufficient time for meals, use warming tray
Administer medications as ordered
Anti-Parkinson Drug
8
...
Provide significant support to client/ significant others:
- nephrotoxicity monitor BUN (10 – 20) and Creatinine (
...
Provide client teaching & discharge planning concerning:
Irritability
a
...
Use prescribed medications & side effects
Extreme fatigue
c
...
e
...
MYASTHENIA GRAVIS (MG)
Activities/ methods to limit postural deformities:
neuromuscular disorder characterized by a disturbance in
Firm mattress with small pillow
the transmission of impulses from nerve to muscle cells at
Keep head & neck as erected as possible
the neuromuscular junction leading to descending muscle
Use broad-based gait
Raise feet while walking
weakness
...
for men
...
5 – 1
...
(increase force of
cardiac output)
Lithium/Lithane
highest between 15 & 35 years old for women, over 40
Voluntary muscles are affected, especially those muscles
innervated by the cranial nerve
...
6 – 1
...
Digitalis Toxicity
Acetylcholine: activate muscle contraction
Autoimmune: it involves release of cholinesterase an
enzyme that destroys Ach
Cholinesterase: an enzyme that destroys ACH
Signs and Symptoms
- nausea and vomiting
- diarrhea
S/sx
1
...
Diplopia
Antidote: Digibind
3
...
Lithium Toxicity
4
...
Hoarseness of voice, weakness of voice
- anorexia
6
...
- dehydration causing fine tremors
Extreme muscle weakness especially during exertion and
morning; increase activity & reduced with rest
...
Tensilon Test (Edrophonium Hydrochloride): IV injection of
- force fluids
tensilon provides temporary relief of S/sx for about 5-10
- increase sodium intake to 4 – 10 g% daily
minutes and a maximum of 15 minutes
...
Aminophelline Toxicity
Signs and Symptoms
- tachycardia
and midbrain and is negative for M
...
2
...
3
...
- only mixed with plain NSS or 0
...
1
...
Anti-cholinesterase Drugs: [Ambenonium (Mytelase),
- avoid taking alcohol because it can lead to severe CNS depression
Neostigmine (Prostigmin), Pyridostigmine (Mestinon)]
- avoid caffeine
MOA: block the action of cholinesterase & increase
4
...
- gingival hyperplasia (swollen gums)
SE: excessive salivation & sweating, abdominal
- hairy tongue
cramps, N/V, diarrhea, fasciculations (muscle
- ataxia
twitching)
...
Corticosteroids: Prednisone
Nursing Management
MOA: suppress autoimmune response
- provide oral care
Used if other drugs are not effective
- massage gums
2
...
Acetaminophen Toxicity
Surgery (Thymectomy)
a
...
- hepatotoxicity (monitor for liver enzymes)
b
...
3
...
Removes circulating acetylcholine receptor antibodies
...
Use in clients who do not respond to other types of
symmetrical, peripheral polyneuritis characterized by
therapy
...
Nursing Interventions
1
...
Give medication exactly on time
...
b
...
Monitor effectiveness of drugs: assess muscle strength
1
...
2
...
Avoid use of the ff drugs:
Morphine SO4 & Strong Sedatives: respiratory
Predisposing Factors
depressant effects
1
...
Antecedent viral infections such as LRT infections
Streptomycine, Kanamycine & other
aminoglycosides: skeletal muscle blocking effect
e
...
3
...
Mild Sensory Changes: in some clients severe
Promote optimal nutrition:
misinterpretation of sensory stimuli resulting to extreme
a
...
2
...
Check gag reflex & swallowing ability before feeding
...
Progressive motor weakness in more than one limb
c
...
d
...
Dysphagia: cranial nerve involvement
not leave alone at mealtime; keep emergency airway &
5
...
6
...
Absence or decreased deep tendon reflex
Assess muscle strength frequently; plan activity to take
8
...
9
...
Observe for signs of myasthenic or cholinergic crisis
...
Autonomic disfunction: symptoms that includes
MYASTHENIC CRISIS
Abrupt onset of severe, generalized
4
...
Symptoms will improve temporarily with
tensilon test
...
increase salivation
Symptoms similar to myasthenic crisis &
b
...
constipation
cholinesterase drugs (excessive
salivation & sweating, abdominal carmp,
Dx
N/V, diarrhea, fasciculation)
1
...
EMG: slowed nerve conduction
keep Atropine Sulfate & emergency
equipment on hand
...
Mechanical Ventilation: if respiratory problems present
over medication with 2
...
Continuous ECG monitoring to detect alteration in heart rate
Signs and Symptoms
the client is unable to see, swallow,
& rhythm
Signs and Symptoms
4
...
Atropine SO4: may be given to prevent episodes of
speak, breathe
Treatment
bradycardia during endotracheal suctioning & physical
administer cholinergic agents as ordered
Treatment
therapy
administer anti-cholinergic agents
(Atrophine Sulfate)
Nursing Intervention
1
...
Monitor rate & depth of respiration; serial vital capacity
a
...
Observe for ventilatory insufficiency
mechanical ventilation as indicated
...
Maintain mechanical ventilation as needed
b
...
Keep airway free of secretions & prevent pneumonia
c
...
2
...
Assess cranial nerve function:
Cholinergic Crisis: discontinue anti-
a
...
Swallowing ability
recovers
...
Ability to handle secretion
d
...
Established method of communication
e
...
4
...
Provide nursing care for the client with thymectomy
...
Vital signs
7
...
Input and output
a
...
Neuro check
b
...
ECG: due to arrhythmia
toxicity
e
...
d
...
Importance of checking with physician before taking any
hypertension fluctuating with hypotension
new medication including OTC drugs
f
...
Arrhythmias
energy peaks & of scheduling frequent rest period
5
...
Prevent complications of immobility: turning the client every
respiratory infection
2 hrs
f
...
Assist in passive ROM exercise
g
...
Promote comfort (especially in clients with sensory
h
...
Foot cradle
b
...
Guided imagery
Guillain-Barre Syndrome
12
13
d
...
Relaxation techniques
3
...
a
...
Start with pureed food
c
...
10
...
Corticosteroids: suppress immune response
b
...
Assess for movement and sensation of extremities
...
Increase CHON and WBC
2
...
Increase CSF opening pressure (normal pressure is 50 –
100 mmHg)
Atrophine Sulfate
4
...
Increase WBC
prevent increase of BP
Nursing Management
11
...
autoimmune anti-bodies)
a
...
Mild analgesics: for headaches
Paralysis of respiratory muscles / respiratory arrest
c
...
Prevent complications:
a
...
13
...
Enforced strict respiratory isolation 24 hours after initiation
of anti biotic therapy (for some type of meningitis)
significant others
14
...
Provide
nursing
care
for
increase
ICP,
seizure
4
...
Cause by bacteria, viruses, & other M
...
Etiology / Most Common M
...
1
...
Pneumococcus
3
...
Enforce complete bed rest
6
...
Monitor strictly V/S, I & O & neuro check
8
...
Prevent complication of immobility
10
...
Importance of good diet: high CHON, high calories with
small frequent feedings
...
Hemophilus Influenzae: cause of pediatric meningitis
Rehabilitation program for residual deficit
Mode of transmission
c
...
Airborne transmission (droplet nuclei)
2
...
By direct extension from adjacent cranial structures (nasal,
hearing loss/nerve deafness is second
complication
sinuses, mastoid bone, ear, skull fracture)
4
...
4
...
Headache, photophobia, general body malaise, irritability,
Attack/Apoplexy/Cerebral Thrombosis)
3
...
Fever & chills
5
...
6
...
Abnormal posturing: (decorticate and decerebrate)
a
...
Signs of Meningeal Irritation:
b
...
Nuchal rigidity or stiff neck: initial sign
b
...
backward & body arched forward
c
...
risk; Incidence increase with age
Causes:
a
...
Embolism (detached): most dangerous because it can
PS: Brudzinski sign (neck pain): flexion at the hip & knee
go to the lungs & cause pulmonary embolism or the
in response to forward flexion of the neck
Dx
1
...
c
...
Compartment Syndrome: compression of nerves &
arteries
Lumbar Puncture:
Measurement & analysis of CSF shows increased
S/sx Pulmonary Embolism
pressure, elevated WBC & CHON, decrease glucose &
1
...
O
...
Unexplained dyspnea
A hollow spinal needle is inserted in the subarachnoid
3
...
4
...
Palpitations
Nursing Management Before Lumbar Puncture
6
...
Secure informed consent and explain procedure
...
Mild restlessness
2
...
3
...
S/sx of Cerebral Embolism
1
...
disorientation
1
...
Confusion
2
...
Decrease LOC
o
13
14
1
...
Confusion
Yellow bone marrow are produced from the
Disorientation
medullary cavity of the long bones and produces
Decrease LOC
fat cells
...
Risk Factors
Disease:
1
...
Diabetes Mellitus
3
...
stroke
3
...
Mitral valve replacement
Sensory loss
6
...
Chronic atrial Fibrillation
Dysarthia: inability to articulate words
8
...
Smoking
2
...
CT & Brain Scan: reveals brain lesions
3
...
EEG: abnormal changes
4
...
Cerebral Arteriography: invasive procedure due to injection
5
...
Dx
cholesterol
of dye (iodine based); Uses dye for visualization
Type A personality
May show occlusion or malformation of blood vessels
a
...
Can do multiple tasks
c
...
Related stress physical and emotional
8
...
Pathophysiology
1
...
Interruption of cerebral blood flow for 5 min or more causes
death of neurons in affected area with irreversible loss of
function
...
Nursing Intervention: Acute Stage
Modifying Factors:
a
...
May help to maintain cerebral blood flow when there
Maintain fluid & electrolyte balance & ensure adequate
nutrition:
5
...
Brief period of neurologic deficit:
c
...
3
...
Fluid restriction as ordered: to decrease cerebral edema
Maintain proper positioning & body alignment:
a
...
Turn & reposition every 2 hrs (20 min only on the
promote body alignment
6
...
Turn client to side
Slurred Speech / Speech disturbance
b
...
Provide sand bag or food board
...
8
...
Offer bed pan or urinal every 2 hrs; catheterized only if
necessary
b
...
Provide quiet, restful environment
complete resolution of symptoms
10
...
Non verbal cues
Progressive development of stroke symptoms over a
b
...
If positive to hemianopsia: approach client on
unaffected side
Complete Stroke
Passive ROM exercise every 4 hrs: prevent contractures;
Stroke in Evolution
b
...
Transient Ischemic Attack (TIA)
Initial / warning signs of impending CVA / stroke
IV therapy for the first few days
affected side)
Stages of Development
a
...
& might also increase ICP
is compromise of main blood supply
1
...
Constriction of cerebral blood vessel may occur,
Collateral Circulation:
Administer O2 inhalation
Provide CBR as ordered
causing further decrease in blood flow
c
...
3
...
increase ICP, shock, hyperthermia, & seizure
impairment
b
...
Administer medications as ordered:
a
...
Headache
2
...
Hyperosmotic agent: to decrease cerebral edema
Osmotic Diuretics (Mannitol)
Loop Diuretics Furosemide (Lasix)
Corticosteroids (Dexamethazone)
Anti-convulsants: to prevent or treat seizures
14
15
c
...
Streptokinase, Urokinase: SE: chest pain
7
...
Assist with self-care
Antidote: Protamine SO4
b
...
Initially arrange objects in environment on unaffected
side
Give simultaneously with Heparin cause
d
...
Apraxia: loss of ability to perform purposeful, skilled acts
a
...
PASA (Aspirin)
Contraindicated for dengue, ulcer and unknown
9
...
Mild Analgesics: for pain
Generalizations about the clients with left hemiplegia vs
...
bleeding
Antihypertensive: if indicated for elevated BP
modifiable
risk
factors
(diet,
Use safety measures, verbal cues, simplicity in all
area of care
b
...
Perceptual, sensory deficits: quick & impulsive
behavior
concerning
Avoid
Left Hemiplegia
12
...
Keep repeating the movement
right hemiplegia & nursing care
cause of headache because it may potentiate
e
...
Take
object such as wash cloth & guide client through
Anti Platelet: to inhibit platelet aggregation in
Gradually teach client to take care of the affected & turn
frequently & look at affected side
Check for Prothrombin Time (PT): if prolonged
there is a risk for bleeding
Sensory / Perceptual Deficit: more common in left
of disabilities, visual neglect (neglect of affected side &
Warfarin (Comadin): long acting / long term therapy
Allow sufficient time for client to answer
hemiplegics; characterized by impulsiveness unawareness
Heparin: short acting
Anticipate client’s needs to decrease frustrations &
feeling of helplessness
Anticoagulants: for stroke in evolution or embolic stroke
Listen & watch very carefully when the client
Prevent complication (subarachnoid hemorrhage is
Right Hemiplegia
Speech-language deficits: slow & cautious behavior
Use pantomime & demonstration
the most feared complication)
c
...
CONVULSIVE DISORDER/CONVULSION
disorder of CNS characterized by paroxysmal seizure with or
without loss of consciousness abnormal motor activity
Importance of follow up care
alternation in sensation and perception and changes in
behavior
...
Hemiplegia: results from injury to cell in the cerebral motor
Seizure: first convulsive attack
cortex or to corticospinal tract (causes contralateral
Epilepsy: second or series of attacks
hemiplegia since tracts crosses medulla)
Febrile seizure: normal in children age below 5 years
a
...
Use proper positioning & repositioning to prevent
c
...
3
...
Predisposing Factors
deformities (foot drop, external rotation of hips, flexion
1
...
Genetics
Support paralyzed arm on pillow or use sling while out of
3
...
Toxicity from the ff:
d
...
Lead
e
...
Carbon monoxide
Susceptibility to hazard
5
...
Keep side rails up at all times
6
...
Institute safety measures
7
...
Inspect body parts frequently for signs of injury
factor for status epilepticus: DOC: Diazepam (Valium) &
Glucose
Dysphagia: difficulty of swallowing
a
...
Maintain a calm, unhurried approach
S/sx
c
...
Place food in unaffected side of the mouth
e
...
Give mouth care before & after meals
Homonymous Hemianopsia: loss of right or left half of each
1
...
a
...
Approach the client on unaffected side
b
...
, on unaffected side
c
...
Turning the head to see things on affected side)
5
...
6
...
Explain to family that client’s behavior is not purposeful
Aphasia: most common in right hemiplegics; may be
receptive / expressive
Receptive Aphasia
Give simple, slow directions
Give one command at a time; gradually shift topics
Use non-verbal techniques of communication (ex
...
Epileptic cry: is characterized by fall and loss of
Create a quiet, restful environment with a reduction in
b
...
Signs or aura with auditory, olfactory, visual, tactile,
Expressive Aphasia
last 20-40 sec
Tonic contractions: direct symmetrical extension of
extremities
Clonic Phase:
repetitive movement
increase mucus production
slowly tapers
15
16
Clonic contractions: contraction of extremities
Postictal sleep: unresponsive sleep
Seizure ends with postictal period of confusion,
a
...
Conjunctiva:
drowsiness
b
...
covers anterior sclera
c
...
The movement of the eye is controlled by 6 extraocular
muscles (EOM)
Internal Structure of Eye
A
...
Begins in focal area of brain & symptoms are related to
May progress into a generalized seizure
a
...
a dysfunction of that area
b
...
Middle Layer
a
...
Purposeful but inappropriate repetitive motor acts
Aura is present: daydreaming like
Automatism: stereotype repetitive and non
b
...
Iris: pigmented membrane behind cornea, gives
color to eye; located anteriorly
d
...
environment
Choroid: highly vascular layer, nourishes retina;
located posteriorly
Psychomotor Seizure (focal motor seizure)
May follow trauma, hypoxia, drug use
Cornea: transparent tissue through which light
enters the eye; located anteriorly
characterized by tingling and jerky movement of
Sclera: tough, white connective tissue (“white of the
eye”); located anteriorly & posteriorly
index finger and thumb that spreads to the shoulder
b
...
Mild hallucinatory sensory experience
Light-sensitive layer composed of rods & cones
(visual cell)
3
...
treatment
Cones: specialized for fine discrimination &
Optic Disk: area in retina for entrance of optic nerve,
has no photoreceptors
Can result in decrease in O2 supply & possible cardiac
arrest
A continuous uninterrupted seizure activity
B
...
Fluid of the eye
1
...
Lens: transparent body that focuses image on retina
Aqueous Humor: clear, watery fluid in anterior &
posterior chambers in anterior part of eye; serves as
DOC: Diazepam (Valium) & Glucose
refracting medium & provides nutrients to lens &
cornea; contribute to maintenance of intraocular
C
...
CT Scan – reveals brain lesions
2
...
EEG – reveals hyper activity of electrical brain waves
D
...
Maintain patent airway and promote safety before seizure activity
a
...
loosen clothing of client
c
...
Retina (rods & cones) translates light waves into neural
impulses that travel over the optic nerves
b
...
avoid use of restrains
Fibers from median halves of the retinas cross here
& travel to the opposite side of the brain
e
...
place mouth piece of tongue guard to prevent biting or
Fibers from lateral halves of retinas remain
uncrossed
tongue
2
...
Optic nerves continue from optic chiasm as optic tracts &
noise
travels to the cerebrum (occipital lobe) where visual
3
...
Anti convulsants (Dilantin, Phenytoin)
b
...
Carbamazepine (Tegnetol) – trigeminal neuralgia
Canal of schlemm: site of aqueous humor drainage
d
...
Institute seizure and safety precaution post seizure attack
a
...
provide suction apparatus
5
...
onset and duration
Circular smooth muscle fiber: Constricts the pupil
b
...
duration of post ictal sleep may lead to status epilepticus
d
...
Refraction of light rays: bending of light rays
2
...
Constriction & dilation of pupils
16
17
4
...
Visual Acuity: reduced
2
...
Ophthalmoscopic exam: reveals narrowing of small vessels
of optic disk, cupping of optic disk
Error of Refraction
1
...
Hyperopia: farsightedness: Treatment: biconvex lens
3
...
Presbyopia: “old sight” inelasticity of lens due to aging:
4
...
Gonioscopy: examine angle of anterior chamber
Medical Management
1
...
Drug Therapy: one or a combination of the following
Accommodation of lenses: based on thelmholtz theory of
Miotics eye drops (Pilocarpine): to increase outflow
of aqueous humor
accommodation
Near Vision: Ciliary muscle contracts: Lens bulges
Epinephrine eye drops: to decrease aqueous humor
production & increase outflow
Far Vision: ciliary muscle dilates / relaxes: lens is flat
Carbonic Anhydrase Inhibitor: Acetazolamide
(Diamox): to decrease aqueous humor production
Convergence of the eye:
blocker: to decrease intraocular pressure (IOP)
Error:
b
...
Exotropia:1 eye normal
2
...
Amblyopia: prolong squinting
humor
Characterized by increase intraocular pressure resulting in
out-client basis; procedure similar result as
trabeculectomy
2
...
progressive loss of vision
Drug Therapy: before surgery
b
...
Hypertension
4
...
History of previous eye surgery, trauma, inflammation
Narcotic Analgesic: for pain
Surgery
2
...
Laser Trabeculoplasty: non-invasive procedure
performed with argon laser that can be done on an
Common Visual Disorder
Glaucoma
Filtering procedure (Trabeculectomy / Trephining): to
create artificial openings for the outflow of aqueous
corrective eye surgery
3
...
3
...
Chronic (open-angle) Glaucoma:
Most common form
Due to obstruction of the outflow of aqueous humor, in
Chronic (close-angle) Glaucoma
b
...
Occurs suddenly & is an emergency situation
If untreated it will result to blindness
Chronic (close-angle) Glaucoma:
Nursing Intervention
1
...
Provide quite, dark environment
3
...
Prepare client for surgery if indicated
similar to acute (close-angle) glaucoma, with the
5
...
Provide client teaching & discharge planning
S/sx
1
...
3
...
Drug Therapy:
a
...
Need to avoid stooping, heavy lifting or pushing,
Chronic (open-angle) Glaucoma: symptoms develops slowly
emotional upsets, excessive fluid intake, constrictive
Impaired peripheral vision (PS: tunnel vision)
Halos around light
Mild discomfort in the eye
sympathomimetic drugs (found in cold preparation) in
Loss of central vision if unarrested
close-angle glaucoma since they may cause mydriasis
clothing around the neck
c
...
Importance of follow-up care
e
...
Aging 65 years and above
2
...
Related to congenital
17
18
4
...
certain drugs (corticosteroids)
5
...
Prolonged exposure to UV rays
S/sx
Administer medication as ordered:
a
...
b
...
Mild analgesic as needed
Provide client teaching & discharge planning concerning:
1
...
Technique of eyedrop administration
2
...
Use of eye shield at night
3
...
No bending, stooping, or lifting
4
...
Report signs & symptoms of complication immediately
5
...
Decrease perception to colors
Severe eye pain
Decrease vision
Diagnostic Procedure
Excessive drainage
Ophthalmoscopic exam: confirms presence of cataract
Swelling of eyelid
1
...
Nursing Intervention
1
...
will need glasses or contact lenses
Performed when client can no longer remain
independent because of reduced vision
b
...
Types of cataract surgery:
becomes familiar
Phacoemulsification: type of extracapsular
Intracapsular Extraction: lens is totally removed
within its capsules, may be delivered from eye by
Retinal Detachment
Separation of epithelial surface of retina
Detachment or the sensory retina from the pigment
epithelium of the retina
cryoextraction (lens is frozen with metal probe &
removed); total removal of lens & surrounding
capsules
e
...
Intraocular Lens Implant: often performed at the time of
surgery
2
...
Trauma
2
...
Severe diabetic retinopathy
4
...
Severe myopia (near sightedness)
Nursing Intervention Pre-op
a
...
Pathophysiology
Administer medication as ordered:
Topical Mydriatics (Mydriacyl) & Cyclopegics
(Cyclogyl): to dilate the pupil
Topical antibiotics: to prevent infection
Acetazolamide (Diamox) & osmotic agent (Oral
Glycerin or Mannitol IV): to decrease intraocular
S/sx
1
...
Flashes of light
3
...
Floaters
5
...
Nursing Intervention Post-op
a
...
Provide safety measures:
Elevate side rails
Provide call bells
Assist with ambulation when fully recovered from
Dx
1
...
Bed rest with eye patched & detached areas dependent to
prevent further detachment
2
...
Prevent intraocular pressure & stress on the suture line:
Photocoagulation: light beam (argon laser) through
dilated pupil creates an inflammatory reaction &
Elevate head of the bed 30-40 degree
Have the client lie on back or unaffected side
Avoid having the client cough, sneeze, bend over, or
heat to external globe; inflammatory reaction causes
move head too rapidly
scarring & healing of area
scarring to heal the area
b
...
prevent vomiting
Give stool softener as ordered: to prevent straining
Observe for & report signs of intraocular pressure
(IOP):
4
...
Tear in the retina allows vitreous humor to seep behind the
sensory retina & separate it from the pigment epithelium
Provide pre-op teaching regarding measures to prevent
intraocular pressure (IOP) post-op
c
...
If a lens implant has not been performed the client
Severe eye pain
Restlessness
Increased pulse
Protect eye from injury:
a
...
Eyeglasses or eye shield used during the day
c
...
Maintain bed rest as ordered with head of bed flat &
detached area in a dependent position
2
...
Identify yourself when entering the room
4
...
Provide diversional activities to provide sensory stimulation
18
19
Nursing Intervention Post-op
1
...
May be on bed rest for 1-2 days
1
...
May need to position client so that detached area is in
2
...
3
...
Topical mydriatics
b
...
Provide client teaching & discharge planning concerning:
Techniques of eyedrop administration
replacement with prosthesis to conduct vibrations
b
...
No bending from waist; no heavy work or lifting for 6
Usually performed under local anesthesia
weeks
Used to treat otoscrlerosis
d
...
May watch TV
f
...
Nursing Intervention Pre-op
1
...
Explain to the client that hearing may improve during
surgery & then decrease due to edema & packing
Overview of Anatomy & Physiology Of Ear (Hearing)
Nursing Intervention Post-op
External Ear
1
...
cerumen (wax), providing protection; transmits sound waves
3
...
middle ear
Middle Ear
Ossicles
a
...
Ossicles are set in motion by sound waves from
6
...
Analgesic
Antibiotics
Anti-emetics
Anti-motion sickness drug: Meclesine Hcl
Check for dressing frequently for excessive drainage or
bleeding
tympanic membrane
c
...
Elevate side rails; assist the client with ambulation &
move slowly: may have some vertigo
vibrates in response to sound & transmits vibrations to
1
...
Provide general pre-op nursing care, including an
explanation of post-op expectation
detachment
2
...
shampooing hair & shaving
1
...
bring air into middle ear, thus equalizing pressure on both
Assess facial nerve function: Ask the client to do the ff:
Wrinkle forehead
Close eyelids
Puff out checks for any asymmetry
Question the client about the ff: report existence to
physicians
sides of eardrum
Pain
Inner Ear
Headaches
1
...
Provide client teaching & discharge planning
the receptor end-organ for hearing
concerning:
Transmit sound waves from the oval window &
a
...
(acoustic branch) to the brain (temporal lobe of
3
...
Especially if upper respiratory
tract infection is present
d
...
c
...
Warning against blowing nose or coughing; sneeze
Meniere’s Disease
Disease of the inner ear resulting from dilatation of the
endolymphatic system & increase volume of endolymph
Disorder of the Ear
Otosclerosis
Characterized by recurrent & usually progressive triad of
symptoms: vertigo, tinnitus, hearing loss
Formation of new spongy bone in the labyrinth of the
Predisposing Factor
ear causing fixation of the stapes in the oval window
This prevent transmission of auditory vibration to the
1
...
Predisposing Factor
2
...
Theories include the ff:
a
...
Toxicity
1
...
Localized ischemia
2
...
Hemorrhage
3
...
Viral infection
f
...
Progressive hearing loss
2
...
Sudden attacks of vertigo lasting hours or days; attacks
pituitary gland; this hormones in turn stimulates its
occurs several times a year
target organ to produce hormones
2
...
3
...
Progressive hearing loss
decreased secretion of the target organ hormone
5
...
Increased concentration of a hormones inhibits
Some hormones are controlled by changing blood levels of
specific substances (ex
...
1
...
Vestibular Test: reveals decrease function
Certain hormones (ex
...
Autonomic & CNS control (pituitary-hypothalamic axis):
hypothalamus controls release of the hormones of the
1
...
Atropine (decreases autonomic nervous system
activity)
Hormone Function
Diazepam (Valium)
Endocrine G
Fentanyl & Droperidol (Innovar)
Pituitary G
Chronic:
a
...
3
...
Lactation
Posterior lobe
: ADH
Or in response to an
increase in plasma
Endolymphatic sac decompression or shunt to
osmolality
equalize pressure in endolymphatic space
To stimulate
reabsorption of H2O &
Nursing Intervention
1
...
Only move the client for essential care (bath may not be
essential)
3
...
Monitor IV Therapy; maintain accurate I&O
5
...
Administer medication as ordered
7
...
Provide client care & discharge planning concerning:
a
...
Low sodium diet & decrease fluid intake
c
...
Its major function, together with the nervous system: is to
: Oxytocin
1
...
Adrenal Cortex
General: hormones transported in the blood to distant
sites where they exert their effects (ex
...
Negative Feedback Mechanisms: major means of regulating
hormone levels
a
...
Aldosterone)
reabsoption
of sodium, chloride, & H2O; stimulate
potassium excretion
: Glucocorticoids
: increase
blood glucose level by increasing rate of
(ex
...
Secretin, cholecystokinin, panceozymin
b
...
: stimulate
development of mammary gland &
Surgical destruction of labyrinth causing loss of
vestibular & cochlear function (if disease is
: stimulate growth of
body tissues & bones
Surgery:
a
...
lowers
2
...
Beta Cells
: Insulin
: allows glucose to
Adrenal Cortex (outer portion): produces mineralocorticoids,
glucocorticoids, sex hormones
diffuse across cell membrane;
Converts glucose to
3 Zones/Layers
glycogen
Alpha Cells
: Glucagon
controls glucose metabolism: Sugar
: increase blood
glucose by causing glyconeogenisis
characteristics: Sex
the liver; secreted in
(aldosterone): promotes sodium and water
low blood sugar
reabsorption and excretion of potassium: Salt
: Estrogen, Progesterone
:
Female,
Adrenal Medulla (inner portion): produces epinephrine,
norepinephrine (secretes catecholamines a power
development of secondary sex characteristics in the
hormone): vasoconstrictor
maturation
of sex organ, sexual functioning
Maintenance of
2 Types of Catecholamines:
Epinephrine (vasoconstrictor)
Norepinephrine (vasoconstrictor)
pregnancy
: Testosterone
Zona Glumerulosa: secretes mineralocorticoids
response to
2
...
thyrocalcitonin
Anterior Lobe PG (Adenohypophysis)
a
...
ACTH: promotes development of adrenal cortex
LH: secretes estrogen
FSH: secretes progesterone
Somatotropic / GH: promotes elongation of long
bones
Hyposecretion of GH: among children results to
dwarfism
Hypersecretion of GH: among children results to
gigantism
Hypersecretion of GH: among adults results to
acromegaly (square face)
DOC: Ocreotide (Sandostatin)
Prolactin: promotes development of mammary
gland; with help of oxytocin it initiates milk let
Does not produce hormones
Store & release anti-diuretic hormones (ADH) & oxytocin
produced by hypothalamus
Secretes hormones oxytocin (promotes uterine
contractions preventing bleeding or hemorrhage)
Initiates milk let down reflex with help of hormone
prolactin
3
...
T4: 4 molecule of iodine
parathormone to promote calcium reabsorption
...
activity; promotes cerebration (thinking); increase
down reflex
c
...
increase ICP; may lead to seizure activity
Dx
in deficiency of ADH
Characterized by excessive thirst & urination
1
...
Serum Sodium: is decreased
Medical Management
Anti-diuretic Hormone: Pitressin (Vasopressin)
Function: prevents urination thereby conserving water
Note: Alcohol inhibits release of ADH
1
...
Diuretics & fluid restriction
Nursing Intervention
Predisposing Factor
1
...
Trauma
3
...
Presence of tumor
1
...
Severe polyuria with low specific gravity
2
...
Fatigue
4
...
Irritability
6
...
Hypotension
8
...
Water intoxication: may lead to cerebral edema: lead to
a
...
Agitation
c
...
Dry mucous membrane
Tachycardia, eventually shock if fluids is not replaced
10
...
Administer medications as ordered:
a
...
Osmotic diuretics (Mannitol)
3
...
Weigh patient daily and assess for pitting edema
5
...
Provide meticulous skin care
7
...
Urine Specific Gravity (NV: 1
...
030): less than 1
...
Serum Na: increase resulting to hypernatremia
3
...
2
...
Maintain F&E balance / Force fluids 2000-3000 ml/day
a
...
Weigh daily
c
...
inflammation of neoplasm
Vasopressin (Pitressin) & Vasopressin Tannate (Pitressin
Tannate Oil): administered by IM injection
Low level of thyroid hormones stimulate increased secretion
Warm to body temperature before giving
of TSH by pituitary; under TSH stimulation the thyroid
Shake tannate suspension to ensure uniform
increases in size to compensate & produce more thyroid
dispersion
hormone
Lypressin (Diapid): nasal spray
Predisposing Factors
Prevent complications: hypovolemic shock is the most
feared complication
5
...
4
...
Endemic: caused by nutritional iodine deficiency, most
Provide client teaching & discharge planning concerning:
common in the “goiter belt” area, areas where soil & H2O
a
...
Goiter belt area:
a
...
Places far from sea
Hypersecretion of anti-diuretic hormone (ADH) from the PPG
c
...
Sporadic: caused by
Increase intake of goitrogenic foods (contains agent that
Predisposing Factors
decrease the thyroxine production: pro-goitrin an anti-
1
...
Ex
...
Related to presence of bronchogenic cancer
radish, strawberry, carrots, sweet potato, rutabagas,
3
...
Anti-Thyroid Agent: Propylthiouracil (PTU)
b
...
Phenylbutazone
1
...
Para-amino salicylic acid
2
...
Lithium Carbonate
a
...
PASA (Aspirin)
b
...
Cobalt
c
...
Genetic defects that prevents synthesis of thyroid hormones
22
23
Precipitating factors: failure to take prescribed
S/sx
medications; infection; trauma; exposure to cold; use of
1
...
Dysphagia
3
...
Mild restlessness
Predisposing Factors
1
...
Secondary hypothyroidism: caused by decreased
1
...
Thyroid Scan: reveals enlarged thyroid gland
...
Serum Thyroid Stimulating Hormone (TSH): is increased
treatment of hyperthyroidism with drugs or radioactive
(confirmatory diagnostic test)
iodine; disease caused by medical intervention such as
RAIU (Radio Active Iodine Uptake): normal or increased
surgery
4
...
4
...
Drug Therapy:
3
...
Iodine deficiency
Hormone replacement with levothyroxine (Synthroid)
6
...
Occurs more often to women ages 30 & 60
Small dose of iodine (Lugol’s or potassium iodide
S/sx
Avoidance of goitrogenic food or drugs in sporadic goiter
1
...
Anorexia
3
...
Related to atrophy of thyroid gland due to trauma,
presence of tumor, inflammation
solution): for goiter resulting from iodine deficiency
2
...
Constipation
Nursing Intervention
5
...
Dry scaly skin
a
...
Spares hair
Iodine)
8
...
Decrease in all V/S: except wt gain & menses
b
...
a
...
Bradycardia
Tetracycline, Nitrofurantoin (DOC: for pyelonephritis)
c
...
Hypothermia
Thyroid Hormones:
Levothyroxine (Synthroid)
10
...
Slowed mental processes
Thyroid Extracts
12
...
Slow clumsy movement
Nursing Intervention when giving Thyroid Hormones:
1
...
Monitor vital signs especially heart rate because drug
causes tachycardia and palpitations
3
...
Monitor side effects:
Insomnia
Tachycardia and palpitations
Hypertension
Heat intolerance
Increase dietary intake of foods rich in iodine:
Seaweeds
Seafood’s like oyster, crabs, clams and lobster but
14
...
Generalized interstitial non-pitting edema (Myxedema)
16
...
Decrease libido
18
...
Psychosis
20
...
Serum T3 and T4: is decreased
2
...
RAIU (Radio Active Iodine Uptake): is decreased
Medical Management
1
...
Iodized salt: best taken raw because it is easily
destroyed by heat
3
...
Provide client teaching & discharge planning concerning:
2
...
Monitor strictly V/S & I&O, daily weights; observe for
edema & signs of cardiovascular complication & to
determine presence of myxedema coma
2
...
to mental retardation
In severe or untreated cases myxedema coma may occur:
Characterized by intensification of S/sx of
hypothyroidism & neurologic impairment leading to
coma
Mortality rate high; prompt recognition & treatment
essential
b
...
Provide comfortable and warm environment: due to cold
intolerance
f
...
Hyperactive movement
4
...
Goiter
5
...
PS: Exopthalmus (protrusion of eyeballs)
sedatives, narcotics, or anesthetic agent by half as
12
...
7
...
Provide meticulous skin care: to prevent skin
Dx
breakdown
1
...
RAIU (Radio Active Iodine Uptake): is increased
constipation; administer stool softener as ordered
3
...
a
...
Maintain vital functions:
Medical Management
1
...
Anti-thyroid drugs: Propylthiouracil (PTU) &
Correct hypothermia
methimazole (Tapazole): blocke synthesis of thyroid
Maintain adequate ventilation
hormone; toxic effect include agranulocytosis
b
...
A severe form of hypothyroidism is characterized by:
Severe hypotension
Bradycardia
Bradypnea
Hypoventilation
Hyponatremia
Hypoglycemia
Hypothermia
Leading to progressive stupor and coma
Radioactive Iodine Therapy
a
...
131I): given to
destroy the thyroid gland, thereby decreasing
production of thyroid hormone
b
...
3
...
Monitor strictly V/s & I&O, daily weight
1
...
Administer anti-thyroid medications as ordered:
2
...
Administer IVF replacement isotonic fluid solution as
ordered / Force fluids
3
...
Provide client health teaching and discharge planning
concerning:
a
...
Methimazole (Tapazole)
Provide for period of uninterrupted rest:
a
...
Administer medication to promote sleep as ordered
a
...
Provide comfortable and cold environment
b
...
Minimized stress in the environment
c
...
Encourage quiet, relaxing diversional activities
d
...
Provide dietary intake that is high in CHO, CHON,
e
...
Stress & infection
g
...
Observe for & prevent complication
a
...
Thyroid Storm
Secretion of excessive amounts of thyroid hormone in the
9
...
Maintain side rails
Increase in T3 and T4
11
...
Assist in surgical procedures subtotal Thyroidectomy:
Increase in all V/S except wt & menses
13
...
Predisposing Factors
Need to recognized & report S/sx of agranulocytosis
1
...
Autoimmune: involves release of long acting thyroid
drugs
b
...
Excessive iodine intake
4
...
Increase appetite (hyperphagia): but there is weight loss
2
...
Weight loss
1
...
Diarrhea: increase motility
2
...
Increased in all V/S: except wt & menses
3
...
Tachycardia
b
...
Palpitation
1
...
Warm smooth skin
2
...
Fine soft hair
3
...
7 C)
8
...
Tahchycardia
9
...
HF
a
...
Respiratory Distress
b
...
Delirium
c
...
Coma
d
...
Hallucinations
S/sx
Nursing Intervention
24
25
1
...
Assist the client with ambulation: instruct the client to
administer O2 as ordered
place the hands behind the neck: to decrease stress on
2
...
Administer medication as ordered:
13
...
Anti-thyroid drugs
14
...
Corticosteroids
lead to hoarseness of voice: encourage client to
c
...
Cardiac Drugs
physician
15
...
Perform ROM neck exercise 3-4 times a day
e
...
Cardiac status is normal
b
...
b
...
Nursing Intervention Pre-op
2
...
a
...
If calcium decreases phosphate increases
Nursing Intervention Post-Op
1
...
3
...
May be hereditary
wetness behind the neck
2
...
Caused by accidental damage to or removal of
parathyroid gland during thyroidectomy surgery
pillow
4
...
Observe for respiratory distress secondary to
Atrophy of parathyroid gland due to: inflammation,
tumor, trauma
hemorrhage, edema of glottis, laryngeal nerve damage,
or tetany: keep tracheostomy set, O2 & suction nearby
5
...
a
...
Muscle spasm
which may lead to hypocalcemia (tetany)
c
...
Dysphagia
keep Calcium Gluconate available:
Positive trousseu’s sign
e
...
Cardiac arrhythmia: feared complications
g
...
Positive trousseu’s sign: carpopedal spasm
i
...
Ecourage clients voice to rest:
2
...
Some hoarseness is common
b
...
Acute hypocalcemia (tetany)
Observe for signs of thyroid storm / thyrotoxicosis: due
to release of excessive amount of thyroid hormone
during surgery
Agitation
TRIAD SIGNS
Chronic hypocalcemia (tetany)
a
...
Weakness
c
...
Personality changes
e
...
Memory impairment
g
...
Dry scaly skin
i
...
Loss of tooth enamel
k
...
Cardiac arrhythmias
m
...
Anorexia
p
...
8
...
Maintain side rails
Offer TSB
Administer IV fluids as ordered: until the client is
Diagnostic Procedures
1
...
5 – 11
mg/100 ml)
2
...
5 –
4
...
Skeletal X-ray of long bones: reveals a increased in bone
density
4
...
Administer analgesics as ordered: for incisional pain
10
...
Cool mist humidifier to thin secretions
b
...
Administer medications as ordered such as:
a
...
Chronic Tetany:
11
...
Pathologic fracture
Calcium Lactate, Calcium Carbonate (Os-Cal)
2
...
Anorexia; N/V; Gastric Ulcer; Constipation
4
...
Irritability / Agitation; Personality changes; Depression;
Memory impairment
Diet (Calcidiol)
6
...
Serum Calcium: is increased
(basaljel): to decrease phosphate levels
2
...
Skeletal X-ray of long bones: reveals bone
demineralization
ANTACID
Nursing Intervention
A
...
C
1
...
Aluminum
Magnesium
Monitor I&O & observe fluid overload & electrolytes
imbalance
Containing
3
...
Monitor V/S: report irregularities
5
...
Provide acid-ash juices (ex
...
Strain urine: using gauze pad: for stone analysis
Gel
8
...
Provide warm sitz bath: for comfort
Side Effect: Constipation
10
...
Institute seizure & safety precaution
11
...
Provide quite environment free from excessive stimuli
12
...
Avoid precipitating stimulus such as glaring lights and
13
...
6
...
Need to engage in progressive ambulatory activities
for Chvostek’s & Trousseau’s sign
b
...
Use of calcium preparation & importance of high-
injectable Calcium Gluconate) at bedside: for presence
7
...
Prevent complications: renal failure
For tetany or generalized muscle cramp: may use
e
...
Importance of follow up care
respiratory acidosis: to promote increase ionized Ca
levels
8
...
Provide high-calcium & low-phosphorus diet
Addison’s Disease
adrenal cortex causes decrease secretion of the
10
...
Medication regimen: oral calcium preparation & vit
D to be taken with meal to increase absorption
b
...
Primary adrenocortical insufficiency; hypofunction of the
mineralcorticoids, glucocorticoids, & sex hormones
Hyposecretion of adrenocortical hormone leading to:
Metabolic disturbance: Sugar
Fluid and electrolyte imbalance: Na, H2O, K
Deficiency of neuromascular function: Salt, Sex
1
...
Prevent complications
e
...
Most commonly affects women between ages 35 & 65
2
...
Secondary Hyperparathyroidism: cause by
compensatory over secretion of PTH in response to
hypocalcemia from:
a
...
Adults: Osteomalacia
c
...
Malabsorption syndrome
Destruction of the gland secondary to TB or fungal
infections
Increase secretion of PTH that results in an altered state of
Idiopathic atrophy of the adrenal cortex: due to an
S/sx
1
...
Anorexia, N/V, abdominal pain, weight loss
3
...
Hyponatremia: hypotension, signs of dehydration,
weight loss, weak pulse
5
...
Hyperkalemia: agitation, diarrhea, arrhythmia
7
...
Loss of pubic and axillary hair
9
...
FBS: is decreased (normal value: 80 – 100 mg/dl)
2
...
Serum Sodium: is decrease (normal value: 135 – 145
k
...
Serum Potassium: is increased (normal value: 3
...
5
meq/L)
Nursing Intervention
1
...
Glucocorticoids: stimulate diurnal rhythm of cortisol
Severe exacerbation of addison’s diseasecaused by acute
adrenal insufficiency
release, give 2/3 of dose in early morning & 1/3 of
dose in afternoon
b
...
Strenuous activity
Hydrocortisone: Cortisone (Prednisone)
2
...
Trauma
4
...
Failure to take prescribe medicine
6
...
Instruct client to take 2/3 dose in the morning and
Surgery of pituitary gland or adrenal gland
1/3 dose in the afternoon to mimic the normal
Rapid withdrawal of exogenous steroids in a
client on long-term steroid therapy
diurnal rhythm
2
...
Monitor side effects:
S/sx
Hypertension
1
...
Severe hypotension
Hirsutism
3
...
Hyponatremia: leading to progressive stupor and
Moon face appearance
coma
2
...
Decrease stress in the environment
4
...
Provide rest period: prevent fatigue
6
...
Provide small frequent feeding of diet: decrease in K,
Nursing Intervention
&
discharge
a
...
Use of prescribe medication for lifelong replacement
therapy: never omit medication
Need to avoid stress, trauma & infection: notify the
physician if these occurs as medication dosage may
d
...
Diet modification
f
...
j
...
Monitor V/S, I&O & daily weight
8
...
Provide client teaching & discharge planning
Cushing Syndrome
Condition resulting from excessive secretion of
corticosteroids, particularly glucocorticoid cortisol
Hypersecretion of adrenocortical hormones
Predisposing Factors
1
...
5
...
Force fluids
stressful stimuli
planning
concerning:
c
...
6
...
Provide
2
...
& hyponatremia & provide proper nutrition
9
...
1
...
Secondary Cushing’s Syndrome (also called Cushing’s
periods
disease): caused by functioning pituitary or nonpituitary
Avoidance of strenuous exercise especially in hot
neoplasm secreting ACTH, causing increase secretion of
weather
glucocorticoids
Avoid precipitating factor: leading to addisonian
3
...
Related to hyperplasia of adrenal gland
steroids
5
...
Muscle weakness
14
...
Fatigue
3
...
Osteoporosis
4
...
Decrease resistance to infection
5
...
Hypertension
6
...
Edema
7
...
Hypernatremia
8
...
Weight gain
9
...
Hypokalemia
dysfunction, decrease libido
10
...
Constipation
11
...
U wave upon ECG (T wave hyperkalemia)
12
...
Hirsutis
13
...
Easy bruising
Dx
Nursing Intervention
1
...
2
...
Provide ROM exercise
3
...
Assist in ambulation
4
...
Maintain muscle tone
Prevent accidents fall & provide adequate rest
27
28
3
...
Maintain skin integrity
a
...
Prevent tearing of the skin: use paper tape if
Increase osmotic diuresis
necessary
5
...
Monitor V/S: observe for hypertension & edema
7
...
Provide diet low in Calorie & Na & high in CHON, K, Ca,
Stimulates the appetite / satiety center
Vitamin D
9
...
Provide psychological support & acceptance
(Hypothalamus)
11
...
Prepare client for Adrenalectomy: if condition is caused
by an adrenal tumor or hyperplasia
* liver has glycogen that undergo glycogenesis/glycogenolysis
13
...
Administer medications as ordered: Spironolactone
Formation of glucose from non-CHO sources
(Aldactone): potassium sparring diuretics
15
...
Diet modification
b
...
Need to avoid stress & infection
d
...
Prevent complications (DM)
f
...
Cholesterol
Importance of follow up care
Ketones
Diabetes Mellitus (DM)
Hyperglycemia: due to total or partial insulin deficiency or
Hypertension
Acetone
insensitivity of the cells to insulin
Diabetic
Keto Acidosis
characterized by hyperglycemia
Atherosclerosis
Represent a heterogenous group of chronic disorders
Breath
Kussmaul’s Respiration
odor
Characterized by disorder in the metabolism of CHO, fats,
MI
CHON, as well as changes in the structure & function of
CVA
blood vessels
Metabolic disorder characterized by non utilization of
Death
carbohydrates, protein and fat metabolism
Diabetic Coma
Pathophysiology
Classification Of DM
Lack of insulin causes hyperglycemia (insulin is necessary for the
transport of glucose across the cell membrane) = Hyperglycemia
1
...
10% general population has Type I DM
CNS depressants & can cause coma = Excess loss of F & E leads to
hypovolemia, hypotension, renal failure & decease blood flow to the
brain resulting in coma & death unless treated
...
Autoimmune response
2
...
CHO
ANABOLISM
Glucose
CATABOLISM
Glycogen
3
...
CHON
Amino Acids
Nitrogen
4
...
Fats
Fatty Acids
Free Fatty Acids
5
...
Polyuria
7
...
Polydipsia
8
...
Polyphagia
9
...
Glucosuria
10
...
Weight loss
11
...
Fatigue
b
...
FBS:
a
...
Postprandial Blood Sugar: elevated
3
...
Glycosolated Hemoglobin (hemoglobin A1c): elevated
28
29
S/sx
1
...
Insulin therapy
Medical Management
2
...
Exercise
3
...
Diet:
4
...
Consistency is imperative to avoid hypoglycemia
5
...
High-fiber, low-fat diet also recommended
6
...
Fatigue
a
...
Blurred Vision
Short Acting: used in treating ketoacidosis;
9
...
Delayed / poor wound healing
4
...
FBS:
c
...
the night with intermediate-acting insulin
b
...
Postprandial Blood Sugar: elevated
pork, pure beef, or human insulin
...
Oral Glucose Tolerance Test (most sensitve test):
elevated
the purest insulin & has the lowest antigenic effect
c
...
Human Insulin: is recommended for all newly
Glycosolated Hemoglobin (hemoglobin A1c): elevated
diagnosed Type I & Type II DM who need short-term
Medical Management
insulin therapy; the pregnant client & diabetic client
d
...
Ideally manage by diet & exercise
Insulin Pumps: externally worn device that closely
2
...
Exercise: helpful adjunct to therapy as exercise
3
...
Surgery, infection
decrease the body’s need for insulin
4
...
resistance
Characteristics of Insulin Preparation
Drug
Synonym
Duration
Appearance
Onset
b
...
Compatible Mixed
Rapid Acting
Insulin Injection Regular Ins
Clear
½-1
Weight loss is important since it decreases insulin
2-4
6-8
High-fiber, low-fat diet also recommended
Drug therapy:
a
...
Oral hypoglycemic agent:
All insulin prep
Used by client who are not controlled by diet &
exercise
except lente
Increase the ability of islet cells of the pancreas
to secret insulin; may have some effect on cell
Insulin, Zinc
Semilente Ins
16
Lente prep
Cloudy
½-1
4-6
receptors to decrease resistance to insulin
126
...
5
10-
:Decrease glucose
Long Acting
Insulin Zinc
Ultralente Ins
36
Regular Ins &
Cloudy
4-8
16-20
30-
production in liver
:Decrease intestinal
suspension,
semilente prep
absorption of glucose &
extended
Complication
1
...
Type II Non-insulin-dependent Diabetes Mellitus (NIDDM)
May result to partial deficiency of insulin production &/or
Acarbose (Precose)
Unknown
1
Unknown
:Delay glucose absorption
an insensitivity of the cells to insulin
Obese adult over 40 years old
Maturity onset type
& digestion of CHO,
lowering blood sugar
Incidence Rate
1
...
Genetics
2
...
production in liver
Urine testing (not very accurate reflection of blood
glucose level)
Complications
1
...
Perform test before meals & at bedtime
Administer insulin or oral hypoglycemic agent as
Use freshly voided specimen
ordered: monitor hypoglycemia especially during period
Be consistent in brand of urine test used
Report results in percentage
Report result to physician if results are greater
of drug peak action
2
...
Ensure that the client is eating all meals
b
...
glycosuria, increase blood glucose level or if the
Monitor urine sugar & acetone (freshly voided
client is not feeling well (acetest, ketostix)
specimen)
4
...
Perform finger sticks to monitor blood glucose level as
Observe signs of hypo/hyperglycemia
6
...
Maintain I&O; weight daily
8
...
General care
Atherosclerosis: leads to CAD, MI, CVA & Peripheral
Vascular Disease
c
...
e
...
Instruct client in finger stick technique: use of
monitor device (if used), & recording &
Observe for chronic complications & plan of care
a
...
Blood glucose monitoring
ordered (more accurate than urine test)
5
...
Cold or flu)
Microangiopathy: most commonly affects eyes &
Do not omit insulin or oral hypoglycemic
kidneys
agent: since infection causes increase blood
Kidney Disease
sugar
Recurrent Pyelonephritis
Notify physician
Diabetic Nephropathy
Monitor urine or blood glucose level & urine
ketones frequently
Ocular Disorder
Premature Cataracts
Diabetic Retinopathy
If N/V occurs: sip on clear liquid with simple
sugar
h
...
Disease process
Wear clean, absorbent socks (cotton or wool)
b
...
Provide client teaching & discharge planning
shoes in gradually
Client should be able to plan a meal using
exchange lists before discharge
Never go barefoot
Emphasize importance of regularity of meals;
Inspect foot daily & notify physician: if cut,
blister, or break in skin occurs
never skip meals
c
...
Insulin
How to draw up into syringe
Use insulin at room temp
Gently roll the vial between palms
Draw up insulin using sterile technique
If mixing insulin, draw up clear insulin,
Exercise
vigorous exercise
blood sugar is rising
j
...
Somogyi’s phenomenon: hypoglycemia followed
Monitor signs of DKA & HONKC
Need to wear a Medic-Alert bracelet
by periods of hyperglycemia or rebound effect of
insulin
...
acidosis
Oral hypoglycemic agent
Stress importance of taking the drug regularly
Avoid alcohol intake while on medication: it can
lead to severe hypoglycemia reaction
Acute complication of DM characterized by hyperglycemia &
Acute complication of Type I DM: due to severe
hyperglycemia leading to severe CNS depression
Occurs in insulin-dependent diabetic clients
Onset slow: maybe hours to days
30
31
Predisposing Factors
5
...
Physical & Emotional Stress: number one precipitating
1
...
Neglect to treatment
3
...
cardiovascular disorder
1
...
Dry mucous membrane; soft eyeballs
2
...
Blurring of vision
3
...
PS: Acetone breath odor
4
...
PS: Kussmaul’s Respiration (rapid shallow breathing) or
5
...
Anorexia
14
...
N/V
15
...
Abdominal pain
16
...
Skin warm, dry & flushed
17
...
Dx
If given IV drip: give small amount of albumin since
insulin adheres to IV tubing
1
...
Serum glucose & ketones level: elevated
3
...
Sodium Bicarbonate: to counteract acidosis
dehydration
b
...
c
...
Monitor blood glucose level frequently
Administer medications as ordered:
Creatinine (normal value:
...
Check urine output every hour
dehydration
7
...
Assist client with self-care
elevated: due to dehydration
9
...
Serum Na: decrease
10
...
Serum K: maybe normal or elevated at first
8
...
alkalosis
provide additional diabetic teaching if indicated
Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC)
Nursing Intervention
Characterized by hyperglycemia & a hyperosmolar state
without ketosis
1
...
Assist in mechanical ventilation
3
...
Non-ketotic: absence of lypolysis (no ketones)
Administer IV therapy as ordered:
Occurs in non-insulin-dependent diabetic or non-diabetic
persons (typically elderly clients)
Normal saline (0
...
45% NaCl) sodium
chloride: to counteract dehydration & shock
1
...
Infection or other stress
5% dextrose to IV
3
...
dilantin, thiazide, diuretics)
Potassium will be added: when the urine output
4
...
Hyperalimentation
Observe for F&E imbalance, especially fluid
6
...
Pancreatic disease
b
...
Predisposing Factors
Administer insulin as ordered: regular acting
insulin/rapid acting insulin
a
...
Polyuria
10
...
Polydipsia
11
...
Polyphagia
12
...
Glucosuria
13
...
Weight loss
14
...
Anorexia
15
...
N/V
16
...
Abdominal pain
17
...
Skin warm, dry & flushed
4
...
1
...
BUN: elevated: due to dehydration
3
...
Hct: elevated: due to dehydration
5
...
If given IV drip: give small amount of albumin since
insulin adheres to IV tubing
c
...
Administer medications as ordered:
a
...
Check urine output every hour
1
...
Monitor V/S, I&O & blood sugar levels
2
...
Assist client with self-care
3
...
Provide care for unconscious client if in a coma
a
...
Discuss with client the reasons ketosis developed &
Administer IV therapy as ordered:
Normal saline (0
...
45% NaCl) sodium
chloride: to counteract dehydration & shock
When blood sugar drops to 250 mg/dl: may add
5% dextrose to IV
Potassium will be added: when the urine output
is adequate
b
...
31
32
The major function of blood: is to carry necessary materials
a
...
b
...
Gamma: role in immune response, function of
antibodies
hormone transport, the inflammatory & immune responses,
3
...
Fibrinogens, Prothrombin, Plasminogens: clotting factors
to prevent bleeding
Cellular Components or Formed Elements
HEMATOLOGICAL SYSTEM
1
...
Blood
III
...
Blood Vessels
45% Formed
cellular elements
1
...
2
...
3
...
Erythrocytes (RBC)
a
...
No nucleus, Biconcave shape discs, Chiefly sac of
hemoglobin
c
...
Responsible for O2 transport via hemoglobin (Hgb)
portion is CHON
4
...
(formed in liver)
6
...
Production
1
...
Globulins
3
...
Primary function is Hematopoiesis: the formation of blood
Hemolysis (Destruction)
cells
Normal life span of RBC is 80 – 120 days and is
killed in red pulp of spleen
All blood cells start as stem cells in the bone marrow; these
Immature RBCs destroyed in either bone marrow or
mature into different, specific types of cells, collectively
other reticuloendothelial organs (blood, connective
referred to as Formed Elements of Blood or Blood
tissue, spleen, liver, lungs and lymph nodes)
Components:
Mature cells remove chiefly by liver and spleen
Bilirubin (yellow pigment): by product of Hgb (red
1
...
Leukocytes
pigment) released when RBCs destroyed, excreted
3
...
Hemosiderin (golden brown pigment)
Iron: feed from Hgb during bilirubin formation;
Red Marrow
2
...
Reflects portion of blood composed of red blood cells
2
...
h
...
Hemoglobin: normal value female 12 – 14 gms% male
14 – 16 gms%
layer of plasma, middle layer of leukocytes & platelets,
Iron, vitamin B12, folic acid, pyridoxine vitamin B6,
& other factors required for erythropoiesis
organs in the body (4-5% of total body weight)
Erythropoietin stimulates differentiation; produced
by kidneys & stimulated by hypoxia
Contained inside all bones, occupies interior of spongy
bones & center of long bones; collectively one of the largest
Start in bone marrow as stem cells, release as
reticulocytes (immature cells), mature into
Bone Marrow
Normal blood contains 12-18 g Hgb/100 ml blood;
higher (14-18 g) in men than in women (12-14 g)
Bone Marrow
Two portion: iron carried on heme portion; second
i
...
Folic acid
leukocytes & platelets is negligible
b
...
Vitamin c
1
...
Vitamin b12 (Cyanocobalamin)
a
...
Vitamin b6 (Pyridoxine)
b
...
Intrinsic factor
c
...
3000 ml in systemic circulation
2
...
550 ml arterial
a
...
300 ml capillary
b
...
2150 ml venous
protection from bacteria and other foreign substances
c
...
neutrophils:
polymorphonuclear
leukocytes
Albumin
-
Immature
neutrophils:
band
cells
(bacterial
Largest & numerous plasma CHON
Involved in regulation of intravascular plasma
infection usually produces increased numbers of
volume
band cells)
2
...
mediation for inflammation
-
Involved
in
Important for Rh (-) woman carrying Rh (+) baby; 1st
pregnancy not affected, but subsequent pregnancy with
prevention
of
clotting
in
an Rh (+) baby, mother’s antibodies attack baby’s RBC
microcirculation and allergic reactions
Polymorphonuclear Eosinophils
Complication of Blood Transfusion
-
Type
Involved in phagocytosis and allergic reaction
Causes
Mechanism
Occurrence
Antibodies in
Acute:
S/sx
Intervention
Eosinophils & Basophils: are reservoirs of histamine,
serotonin & heparin
d
...
Involved in long-term phagocytosis for
chronic inflammation
Play a role in immune response
Macrophage in blood
Largest WBC
Produced by bone marrow: give rise to
lumbar or
continue saline IV
Rh
react w/ antigen
completion
sternal pain,
first 5 min
after
send blood unit &
Incompatibility; in donor cells
...
histiocytes (kupffer cells of liver),
solutions;
macrophages & other components of
block capillary Delayed:
heat along vein,
reticuloendothelial system
b
...
Incompatibility; recipient plasma
Monocytes:
ABO
Lymphocytes: immune cells; produce
substances against foreign cells; produced
primarily in lymph tissue (B cells) & thymus (T
Wide temp
blood flow to
restlessness,
hemoglobinuria
...
anemia, jaundice,
cells)
Watch for
days to 2
weeks after
Treat or prevent
Hemolysis (Hgb
Lymphocytes
dyspnea, signs
shock, DIC, &
into plasma &
B-cell
T-cell
- bone marrow
- thymus
and anti-tumor property
for immunity
Natural killer cell
anti-viral
shock, renal
of
renal shutdown
urine)
shutdown, DIC
HIV
c
...
sensitivity to
start of
Administer
antibody from foreign serum
dyspnea,
antihistamine &
donor to
CHON
transfusion
bronchospasm, or epinephrine
...
Petechiae
2
...
Oozing of blood from venipunctured site
Blood Groups
Erythrocytes carry antigens, which determine the different
blood group
reaction
_____________________________________________________________________
__________________
Pyrogenic
Fever, chills,
flushing,
palpitation,
involved in transfusion reactions
agglutination
bacterial
min
after
initiation
of
Transfuse with
directed against
tachycardia,
Within 15-90
Treat temp
...
possesses
Blood-typing system are based on the many possible
antigens, but the most important are the antigens of the
Recipient
organism
transfusion
leukocytes-poor
WBC; bacterial
1
...
Absence of both antigens results in type O blood
c
...
Presence of either type A or B results in type A & type B,
Administer
respectively
client;
e
...
Antibodies are automatically formed against ABO
multiparous
contamination;
lumbar pain
antigens not on persons own RBC
2
...
RBC
...
Identifies presence or absence of Rh antigens (Rh + or
__________________
Rh -)
Circulatory
b
...
Common Pathways: activated by either intrinsic or extrinsic
pathways
cyanosis, anxiety
1
...
Prothrombin converted to thrombin via thromboplastin
hro
3
...
Soluble fibrin polymerized by factor XIII to produce a stable,
Monitor CVP
t
insoluble fibrin clot
ha
Clot Resolution: takes place via fibrinolytic system by plasmin &
separate line
...
__________________
Air Embolism
Blood given
Dyspnea,
Bolus of air
Anytime
Spleen
Clamp tubing
...
apprehension
composed of RBC, WBC & macrophages
_____________________________________________________________________
__________________ThromboWhen large
cytopenia
Used of large
Abnormal
amount of
bleeding
b
...
blood
precautions
...
Intoxication
1%-2% of red cell mass or 200 ml blood/minute stored in the
spleen; blood comes via splenic artery to the pulp for
rapidly in stored
Initiate bleeding
Citrate
White Pulp: scattered throughout the red pulp, produces
lymphocytes & sequesters lymphocytes, macrophages,
of bleeding
...
hypocalcemia
...
function
citrated blood
...
Monitor liver fxn
Liver also involved in synthesis of clotting factors, synthesis
of antithrombins
...
RBC: Improve O2 transport
potassium into renal
2
...
Fresh Frozen Plasma, Albumin, Plasma Protein Fraction:
plasma with
insufficiency
provision of proteins
days old in client
4
...
Platelet Concentration, Fresh Whole Blood: provision of
platelets
peaked T-waves,
potassium
Blood & Blood Products
short Q-T
excretion
1
...
ments)
& Hct to rise
b
...
Intrinsic System: initiated by contact activation following
in massive transfusion therapy
2
...
a
...
b
...
Indicate in cases of blood loss, pre-op & post-op
client & those with incipient congestive failure
Extrinsic System:
a
...
Red Blood Cell (RBC)
c
...
Fresh Frozen Plasma
34
35
a
...
Cytrate intoxication
b
...
Hyperkalemia (caused by expired blood)
minutes to thaw
c
...
5
...
Headache and dizziness
2
...
Diarrhea / Constipation
a
...
Pooled from 4-8 units of whole blood
4
...
Single-donor platelet transfusion may be necessary
5
...
Lumbasternal / Flank pain
compatibilities testing may be necessary
7
...
Nursing Management
Granulocytes
1
...
Do not increase WBC: increase marginal pool (at
2
...
Flush with plain NSS
Premedication with steroids, antihistamine &
4
...
acetaminophen
c
...
Send the blood unit to blood bank for re-examination
cyanosis & chest pain may occur; requires cessation
6
...
Shaking chills or rigors common, require brief
examination
7
...
S/sx of Allergic reaction
1
...
Dyspnea
varies (50-100 ml/unit); hyperosmolar solution should
3
...
Skin rashes
5
...
Laryngospasm & Broncospasm
Goals / Objectives
1
...
Increase the O2 carrying capacity of blood
3
...
Stop BT
4
...
Notify physician
3
...
Administer medications as ordered
Principles of blood transfusion
1
...
3
...
5
...
a
...
Expiration of platelet is 3-5 days
Epinephrine
Proper typing and cross matching
5
...
Type O: universal donor
6
...
Type AB: universal recipient
c
...
Monitor vital signs and intake and output
Aseptically assemble all materials needed for BT
a
...
Gauge 18-19 needle
1
...
Isotonic solution (0
...
Headache
hemolysis
3
...
Palpitations
a
...
Diaphoresis
b
...
Dyspnea
c
...
Serial number
S/sx Pyrogenic reactions
Nursing Management
Check the blood unit for bubbles cloudiness, sediments
1
...
Notify physician
contamination
3
...
4
...
c
...
a
...
Antibiotic
if you have the warming device
5
...
Obtain urine & blood sample & send to laboratory for re-
natural room temperature warm the blood
...
Anti Histamine (Benadryl): if positive to
examination
BT should be completed less than 4 hours because
7
...
Render TSB
hours: causes blood deterioration that can lead to
bacterial contamination
7
...
9
...
Orthopnea
Regulate BT 10-15 gtts/min or KVO rate or equivalent to
2
...
Rales / Crackles upon auscultation
Monitor strictly vital signs before, during & after BT
4
...
Hemolytic reaction
1
...
Allergic reaction
2
...
Pyrogenic reaction
3
...
Circulatory overload
e
...
Thrombocytopenia
a
...
Assess client for history of previous blood transfusions &
3
...
Pallor & cold sensitivity
Ensure that the adult client has an 18-19 gauge IV
5
...
Palpitations
3
...
9% sodium chloride
7
...
At least two nurse should verify the ABO group, RH type,
2
...
Take baseline V/S before initiating transfusion
6
...
Stay with the client during the first 15 min of the
transfusion & take V/S frequently
8
...
(koilonychias)
8
...
Stomatitis
PLUMBER
VINSON’S SYNDROME
b
...
Dysphagia
PICA: abnormal appetite or craving for non edible foods
Maintain the prescribed transfusion rate:
a
...
RBC: approximately 2-4 hr
1
...
Fresh Frozen Plasma: as quickly as possible
2
...
Platelet: as quickly as possible
3
...
Cryoprecipitate: rapid infusion
4
...
Granulocytes: usually over 2 hr
5
...
Volume Expander: volume-dependent rate
6
...
Serum ferritin: is decreased
8
...
Document the following:
a
...
Date of infusion starts & end
c
...
Client reaction & vital signs
e
...
Monitor for s/sx of bleeding through hematest of all
elimination including urine, stool & gastrict content
2
...
Provide thorough explanation of all diagnostic exam
HIV
used to determine sources of possible bleeding: help
- 6 months – 5 years incubation period
allay anxiety & ensure cooperation
- 6 months window period
4
...
Organ meat
- ELISA
b
...
Raisin
d
...
Dried fruits
1
...
Legumes
2
...
Nuts
5
...
Administer iron preparation as ordered:
a
...
2
...
Common among developed countries & tropical zones
vitamin C (ascorbic acid): to enhance iron
(blood-sucking parasites)
absorption
Common among women 15 & 45 years old & children
Warn clients that iron preparations will change
affected more frequently, as are the poor
stool color & consistency (dark & tarry) & may
Related to poor nutrition
cause constipation
Predisposing Factors
1
...
Trauma
b
...
Related to GIT bleeding resulting to hematemasis
who have continuing blood losses
b
...
2
...
Fresh blood per rectum is called hematochezia
Nursing Management when giving parenteral
Inadequate intake or absorption of iron due to:
iron preparation
a
...
Related to malabsorption syndrome
administer iron preparation as tissue staining &
c
...
Partial or complete gastrectomy
e
...
Usually asymptomatic (mild cases)
2
...
Headache and dizziness
Development of sterile abscesses
4
...
Dyspnea & palpitations: as part of compensation
Fever & chills
6
...
Medications administered via straw
Mouth sore
b
...
Indigestion / dyspepsia
d
...
Constipation / diarrhea
f
...
Tingling sensation
b
...
Paresthesias of hands & feet
Iron
d
...
Depression
Nitrofurantoin (Macrodentin)
f
...
Positive to Romberg’s test: damage to cerebellum
7
...
Monitor & inform client of side effects
9
...
resulting to ataxia
a
...
N/V
c
...
Erythrocytes count: decrease
d
...
Blood Smear: oval, macrocytic erythrocytes with a
e
...
Bilirubin (indirect): elevated unconjugated fraction
parenteral iron preparation
4
...
Iron Dextran (IM, IV)
5
...
Sorbitex (IM)
a
...
Provide dietary teaching regarding food high in iron
b
...
Encourage ingestion of roughage & increase fluid intake:
c
...
taken
Positive Schilling’s Test: reveals inadequate / decrease
absorption of Vitamin B12
a
...
Definitive test for pernicious anemia
erythrocytes & hypochlorhydria (a deficiency of hydrochloric
c
...
Fasting client is given radioactive vitamin B12 by
Chronic anemia characterized by a deficiency of intrinsic
mouth & non-radioactive vitamin B12 IM to permit
factor leading to hypochlorhydria (decrease hydrochloric
some excretion of radioactive vitamin B12 in the
acid secretion)
urine if it os absorbed
e
...
Lack of intrinsic factor is caused by gastric mucosal atrophy
If indicated, second stage schilling test performed 1
(possibly due to heredity, prolonged iron deficiency, or an
week after first stage
...
7
...
Large number of reticulocytes in the blood following
Intrinsic factor is necessary for the absorbtion of vitamin
parenteral vitamin B12 administration
B12 into small intestines
2
...
Medical Management
1
...
Vitamin B12 injection: monthly maintenance
B12 deficiency can alter structure & function of
b
...
STOMACH
Pareital cells/Argentaffin or Oxyntic cells
Folic Acid
Controversial
Reverses anemia & GI symptoms but may
intensify neurologic symptoms
Produces intrinsic factors
Secretes hydrochloric acid
Promotes reabsorption of Vit B12
Aids in digestion
Promotes maturation of RBC
addition to vitamin B12
2
...
Enforce CBR: necessary if anemia is severe
2
...
Hereditary factors
4
...
Autoimmune
6
...
Anemia
2
...
Transfusion Therapy
Nursing Intervention
Predisposing Factors
1
...
No side effects
Provide a dietary intake that is high in CHON, vitamin c
and iron (fish, meat, milk / milk product & eggs)
4
...
Provide safety when ambulating (especially when
carrying hot item)
37
38
6
...
Administer medications as ordered:
use soft bristled toothbrush
a
...
Avoid heat application to prevent burns
b
...
Provide client teaching & discharge planning
Given via central venous catheter
concerning:
Given 6 days to 3 weeks to achieve maximum
a
...
Importance of lifelong vitamin B12 therapy
c
...
risk:
deficit, as well as instruction regarding safety
Aplastic Anemia
Monitor neuropenic precautions
b
...
bone marrow
a
...
Fever
e
...
Use soft toothbrush when brushing teeth & electric
razor when shaving: prevent bleeding
PANCYTOPENIA
Decrease RBC
Decrease Platelet
(anemia)
c
...
Avoid IM, subcutaneous, venipunctured sites:
Instead provide heparin lock
Decrease WBC
(leukopenia)
c
...
Observe for oozing from gums, petechiae or
(thrombocytopenia)
ecchymoses
10
...
Chemicals (Benzene and its derivatives)
a
...
Related to radiation / exposure to x-ray
b
...
Immunologic injury
4
...
Broad Spectrum Antibiotics: Chloramphenicol
(Sulfonamides)
b
...
2
...
Weakness & fatigue
b
...
Pallor & cold sensitivity
d
...
3
...
Underlying disease (ex
...
Petechiae (multiple petechiae is called purpura)
cause release of thromboplastic substance that promote
b
...
Oozing of blood from venipunctured sites
2
...
CBC: reveals pancytopenia
3
...
Normocytic anemia, granulocytopenia,
4
...
Bone marrow biopsy: aspiration (site is the posterior iliac
destroyed, leading to bleeding
5
...
cells; reveals fat necrosis in bone marrow
Predisposing Factors
Medical Management
1
...
Massive burns
marrow begins to produce blood cells
3
...
Aggressive treatment of infection
4
...
Bone marrow transplantation
5
...
Drug Therapy:
6
...
7
...
Corticosteroids & / or androgens: to stimulate bone
marrow function & to increase capillary resistance
(effective in children but usually not in adults)
b
...
amenorrhea in female clients
5
...
Nursing Intervention
Prolonged bleeding from breaks in the skin: oozing of
blood from punctured sites
1
...
Administer Blood Transfusion as ordered
3
...
Hemoptysis
4
...
Oliguria & acute renal failure (late sign)
5
...
Convulsion, coma, death
6
...
Severe & uncontrollable hemorrhage during childbirth or
surgical procedure
Dx
38
39
1
...
PTT: usually prolonged
3
...
Fibrinogen level: usually depressed
5
...
Protamine Sulfate Test: strongly positive
7
...
CBC: reveals decreased platelets
9
...
ABG analysis: reveals metabolic acidosis
11
...
Identification & control the underlying disease is key
2
...
Epicardium
Somewhat controversial
b
...
Visceral: inner layer
Chordae Tendinae
Attach to the tricuspid & mitral valves & prevent eversion
during systole
formation, allowing coagulation factors to
accumulate
Chambers of the Heart
Nursing Intervention
1
...
Monitor for signs of additional bleeding or thrombus
formation
3
...
Atria
2 chambers, function as receiving chambers, lies above the
ventricles
Monitor all hema test / laboratory data including stool
Upper Chamber (connecting or receiving)
and GIT
the superior vena cava, inferior vena cava & coronary
Prevent further injury
sinus
a
...
Apply pressure to bleeding site
c
...
Provide frequent nontraumatic mouth care (ex
...
Administer oxygen inhalation
7
...
Administer medications as ordered:
9
...
Vitamin K
b
...
Heparin / Comadin is ineffective
Ventricles
2 thick-walled chambers; major responsibility for forcing
blood out of the heart; lie below the atria
Lower Chamber (contracting or pumping)
ventricular systole; Right atrium has decreased pressure
which is 60 – 80 mmHg
11
...
Prevent complication
a
...
Institute NGT decompression by performing gastric
ml
Right Ventricle: contracts & propels deoxygenated blood
into pulmonary circulation via the aorta during
Provide heparin lock
lavage: by using ice or cold saline solution of 500-1000
Left Atrium: receives oxygenated blood returning to the
heart from the lungs trough the pulmonary veins
toothbrush or gauze sponge)
5
...
Provide emotional support to client & significant other
ventricle; contains 2 leaflets attached to the chordae
14
...
The major function are circulation of blood,
delivery of O2 & other nutrients to the tissues of the body &
Prevent reflux flow during ventricular systole
removal of CO2 & other cellular products metabolism
Valve leaflets open during ventricular diastole; Closure of AV
Heart
valves give rise to first heart sound (S1 “lub”)
Muscular pumping organ that propel blood into the arerial
system & receive blood from the venous system of the body
...
08 milliseconds to
O2 & CO2
Solutes between the blood & tissue
Fluid volume transfer between the plasma & interstitial
space
Small veins that receive blood from capillaries & function as
collecting channels between the capillaries & veins
allow ventricular filling
Veins
Bundle of His
Low-pressure vessels with thin small & less muscles than
Arises from the AV node & conduct impulse to the bundle
arteries; most contains valves that prevent retrograde blood
branch system
flow; they carry deoxygenated blood back to the heart
...
interventricular myocardium
Left Bundle Branch: divided into anterior & posterior
Anterior Portion: transmits impulses to the anterior
endocardial surface of the left ventricle
Posterior Portion: transmits impulse over the
posterior & inferior endocardial surface of the left
ventricle
Purkinje Fibers
Transmit impulses to the ventricle & provide for
depolarization after ventricular contraction
Cardiac Disorders
Coronary Arterial Disease / Ischemic Heart Disease
Stages of Development of Coronary Artery Disease
1
...
Myocardial Ischemia: Angina Pectoris
3
...
Sex: male
2
...
Smoking
4
...
Hyperlipidemia
6
...
Diabetes Mellitus
8
...
Diet: increased saturated fats
10
...
Chest pain
Electrocadiography (ECG) Tracing
2
...
Tachycardia
4
...
Diaphoresis
P wave (atrail depolarization) contraction
QRS wave (ventricular depolarization)
T wave (ventricular repolarization)
Insert pacemaker if there is complete heart block
Most common pacemaker is the metal pacemaker and lasts
up to 2 – 5 years
Treatment
P - Percutaneous
T - Transluminal
C - Coronary
Abnormal ECG Tracing
A – Angioplasty
Positive U wave: Hypokalemia
40
41
1
...
Revascularize myocardium
2
...
Increase survival rate
4
...
If there is 2 or more occluded blood vessels CABG is done
2
...
Surgery: Coronary artery bypass surgery
4
...
Enforce complete bed rest
2
...
Administer medications as ordered:
a
...
Pneumonia: encourage to perform deep breathing, coughing
exercise and use of incentive spirometer
2
...
Thrombophlebitis
Nitroglycerine (NTG): when given in small doses will act
Give 1st dose of NTG: sublingual 3-5 minutes
Give 2nd dose of NTG: if pain persist after giving 1st
dose with interval of 3-5 minutes
Give 3rd & last dose of NTG: if pain still persist at 3-5
minutes interval
Angina Pectoris
Nursing Management when giving NTG
Transient paroxysmal chest pain produced by insufficient
1
...
Sex: male
Transient headache & dizziness: frequent side
2
...
Smoking
Instruct the client to rise slowly from sitting position
4
...
Hyperlipidemia
6
...
Diabetes Mellitus
8
...
CAD: Atherosclerosis
effect
2
...
Thromboangiitis Obliterans
11
...
Aortic Insufficiency: heart valve that fails to open & close
important thing to remember)
efficiently
b
...
Hypothyroidism
14
...
Type A personality
c
...
4 E’s of Angina Pectoris
Enalapril
Calcium Antagonist
Nefedipine
1
...
Exposure to cold environment: vasoconstriction
4
...
Extreme emotional response: fear, anxiety, excitement,
5
...
Monitor strictly V/S, I&O, status of cardiopulmonary fuction
4
...
2
...
Provide decrease saturated fats sodium and caffeine
8
...
Dyspnea
4
...
Palpitations
Avoid extremes of temperature
6
...
History taking and physical exam
2
...
occurs & persists despite rest & medication administration
inversion during chest pain
3
...
Increase serum lipid levels
5
...
Decrease myocardial workload (rest heart)
destruction) with subsequent healing by scar formation &
Establish a patent IV line
fibrosis
Administer narcotic analgesic as ordered: Morphine
Heart attack
Sulfate IV: provide pain relief (given IV because after an
Terminal stage of coronary artery disease characterized by
infarction there is poor peripheral perfusion & because
malocclusion, necrosis & scarring
...
Transmural Myocardial Infarction: most dangerous type
Antidote: Naloxone (Narcan)
characterized by occlusion of both right and left coronary
Side Effects of Naloxone Toxicity: is tremors
artery
2
...
Subendocardial Myocardial Infarction: characterized by
occlusion of either right or left coronary artery
Administer oxygen low flow 2-3 L / min: to prevent
respiratory arrest or dyspnea & prevent arrhythmias
3
...
Instruct client to avoid forms of valsalva maneuver
arrhythmia leading to premature ventricular contractions
5
...
Monitor strictly V/S, I&O, ECG tracing & hemodynamic
procedures
Predisposing Factors
7
...
Sex: male
8
...
Race: black
3
...
Obesity
5
...
Maintain quiet environment
6
...
Administer stool softeners as ordered: to facilitate bowel
7
...
Hyperlipidemia
9
...
Diabetes Mellitus
11
...
Provide a full liquid diet with gradual increase to soft diet:
low in saturated fats, Na & caffeine
evacuation & prevent straining
12
...
Administer medication as ordered:
a
...
Diet: increased saturated fats
13
...
Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium
S/sx
1
...
Beta-blockers: Propanolol (Inderal)
d
...
Calcium Antagonist: Nefedipine
located at substernal & rarely in precordial
f
...
N/V
3
...
Increase in blood pressure & pulse, with gradual drop in
g
...
Hyperthermia: elevated temp
6
...
Mild restlessness & apprehension
Antidote: Vitamin K
8
...
Anti Platelet: PASA (Aspirin): Anti thrombotic effect
Side Effects: Tinnitus, Heartburn, Indigestion /
Dyspepsia
Contraindication: Dengue, Peptic Ulcer Disease,
Unknown cause of headache
Dx
1
...
Provide client health teaching & discharge planning
concerning:
a
...
Medication regimen including time name purpose,
schedule, dosage, side effects
c
...
2
...
ECG tracing reveals
Encourage client to take 20 – 30 cc/week of wine, whisky
and brandy: to induce vasodilation
Serum glutamic oxal-acetic transaminase (SGOT): is
increased
Dietary restrictions: low Na, low cholesterol, avoidance
e
...
Prevent Complication
Arrhythmia: caused by premature ventricular
ST segment elevation
T wave inversion
Cardiogenic shock: late sign is oliguria
Widening of QRS complexes: indicates that there is
Left Congestive Heart Failure
arrhythmia in MI
Thrombophlebitis: homan’s sign
contraction
4
...
CBC: increased WBC
Dressler’s Syndrome (Post MI Syndrome): client is
resistant to pharmacological agents: administer
Nursing Intervention
150,000-450,000 units of streptokinase as ordered
Goal: Decrease myocardial oxygen demand
42
43
g
...
Importance of participation in a progressive activity
6
...
Right Sided Heart Failure
Client can resume sexual intercourse: if can climb or
Increased persistent chest pain
Dyspnea
Weakness
Fatigue
Persistent palpitation
Light headedness
Weakened right ventricle is unable to pump blood into he
pulmonary system: systemic venous congestion occurs as
pressure builds up
Need to report the ff s/sx:
ABG: reveals PO2 is decreased (hypoxemia), PCO2 is
increased (respiratory acidosis)
use the staircase
i
...
Right ventricular infarction
2
...
Tricuspid valve stenosis
4
...
Related to COPD
j
...
Pulmonic valve stenosis
k
...
Left sided heart failure
up care
S/sx
Congestive Heart Failure
1
...
Nausea
to meet the metabolic needs of the body
3
...
Neck / jugular vein distension
circulation
5
...
Bounding pulse
7
...
Left Sided Heart Failure
8
...
Right Sided Heart Failure
9
...
High-Output Failure
10
...
Pruritus
12
...
Chest X-ray (CXR): reveals cardiomegaly
pressure causes transudation into interstitial tissues of the
2
...
Predisposing Factors
1
...
Myocardial Infarction
3
...
Hypertension
5
...
Dyspnea
2
...
If CVP is more than 10 cm of water: Hypervolemic shock:
Orthopnea: use 2-3 pillows when sleeping or place in high
fowlers
4
...
Muscle Weakness
6
...
Tachycardia
8
...
Cyanosis
10
...
Rales / Crackles
3
...
Liver enzymes: SGPT & SGOT: is increased
5
...
Determination & elimination / control of underlying cause
2
...
Sodium-restricted diet: to decrease fluid retention
4
...
Treatment for Left Sided Heart Failure Only:
M – Morphine SO4
A – Aminophylline
D – Digitalis
14
...
Possible S3: ventricular gallop
O – O2
G – Gases
12
...
Pulsus Alternans: weak pulse followed by strong bounding
pulse
Dx
1
...
Pulmonary Arterial Pressure (PAP): measures pressure in
Goal: Increase cardiac contractility thereby increasing cardiac
right ventricle or cardiac status: increased
output of 3-6 L / min
3
...
5
...
Monitor respiratory status & provide adequate ventilation
Central Venous Pressure (CVP): indicates fluid or hydration
(when HF progress to pulmonary edema)
status
a
...
Maintain client in semi or high fowlers position:
maximize oxygenation by promoting lung expansion
c
...
2
...
Assess for breath sounds: noting any changes
a
...
Maintain bed rest with limited activity
1
...
Maintain quiet & relaxed environment
2
...
Organized nursing care around rest periods
changing to blue (cyanosis) then red (rubor)
dorsalis pedis)
Cardiac glycosides: Digoxin (Lanoxin)
4
...
Ulceration & Gangrene formation (advanced)
Contraindication: If heart rate is decreased do not
1
...
Administer vasodilators as ordered
Vasodilators: Nitroglycerine (NTG)
Monitor V/S
Reduce / eliminate edema
a
...
Loop Diuretics: Lasix (Furosemide)
b
...
Maintain accurate I&O
d
...
Measure abdominal girth daily
f
...
Monitor CVP & Swan-Ganz reading
h
...
Doppler (UTZ): reveals decrease blood flow to the affected
extremity
3
...
Drug Therapy
a
...
b
...
Administer Narcotic Analgesic as ordered
Narcotic analgesic: Morphine SO4
Action: to allay anxiety & reduce preload & afterload
2
...
Endarterectomy
Action: relieve bronchospasm, increase urinary
c
...
Lumbar Sympathectomy: to increase blood flow
Administer Anti-arrythmic as ordered
e
...
Provide client teaching & discharge planning concerning:
Need to monitor self daily for S/sx of Heart Failure (pedal
2
...
Prescribe diet plan (low Na, cholesterol, caffeine: small
frequent meals)
d
...
Prevent complications
f
...
c
...
Analgesic: to relieve ischemic pain
a
...
b
...
Decreased or absent peripheral pulses (posterior tibial &
b
...
3
...
S/sx
Increase cardiac output
give
5
...
4
...
Arrythmia
Shock
Right ventricular hypertrophy
MI
Thrombophlebitis
Foot care management:
Need to avoid trauma to the affected extreminty
4
...
Need to maintain warmth especially in cold weather
6
...
Importance of follow-up care
Raynaud’s Phenomenon
Intermittent episodes of arterial spasm most frequently
involving the fingers or digits of the hands
Importance of follow-up care
Predisposing Factors
Peripheral Vascular Disorder
1
...
Thromboangiitis Obliterans (Buerger’s Disease)
2
...
Smoking
3
...
a
...
Rheumatoid Arthritis
Direct hand trauma
1
...
Piano playing
2
...
Excessive typing
c
...
High risk groups - men 25-40 years old
S/sx
1
...
Numbness
3
...
Pain: usually precipitated by exposure to cold, Emotional
upset & Tobacco use
5
...
Small ulceration & gangrene a tips of digits (advance)
1
...
Angiography: reveals site & extent of malocclusion
7
...
Administer medications as ordered
a
...
Inflammation of the veins with thrombus formation
Most frequent veins affected are the saphenous, femoral &
Catecholamine-depliting antihypertinsive drugs:
Reserpine
Guanethidine Monosulfate (Ismelin)
popliteal
Can result in damage to the surrounding tissue, ischemia &
necrosis
Vasodilators
Nursing Intervention
Predisposing Factors
1
...
Obesity
2
...
Smoking
3
...
Related to pregnancy
freezer or refrigerator door
4
...
Prolong use of oral contraceptives: promotes lipolysis
6
...
Trauma
Varicose Veins
8
...
Sepsis
& trunk
...
Congestive heart failure
& incompetent with result venous pooling / edema
11
...
Post-op complication: surgery
due to incompetent valve resulting to increased venous
13
...
Increase in saturated fats in the diet
...
Pain in the affected extremity
2
...
Hereditary
2
...
Thrombophlebitis
4
...
Pregnancy
Venous distention of limb
6
...
Prolonged standing or sitting
Positive homan’s sign: pain at the calf or leg muscle
course of the vein
3
...
Pain after prolonged standing: relieved by elevation
2
...
Warm to touch
4
...
Venography
2
...
calf or thigh compression
Medical Management
1
...
Venous pressure measurement: high in affected limb until
collateral circulation is developed
seconds
Doppler Ultrasound: decreased or no blood flow heard after
Medical Management
1
...
Heparin
Vein Ligation: involves ligating the saphenous vein where it
system fro groin to ankles
Spontaneous bleeding
varicosities & danger of thrombosis (2-3 years for embolism)
Injection site reaction
Ecchymoses
Tissue irritation & sloughing
Reversible transient alopecia
Cyanosis
Pan in the arms or legs
Thrombocytopenia
Elevate legs above heart level: to promote increased venous
return by placing 2-3 pillows under the legs
2
...
Apply anti-embolic / knee-length stockings
4
...
Administer medications as ordered
a
...
Side effects:
Sclerotherapy: can recur & only done in spider web
Nursing Intervention
1
...
Cyanosis
Dx
2
...
Deep vein:
b
...
K synthesis
Analgesics: for pain
Prepare client for vein ligation if necessary
Action: block prothrombin synthesis by interfering
Side effects:
GI:
a
...
In addition to routine post-op care:
Anorexia
Keep affected extremity elevated above the level of
N/V
the heart: to prevent edema
Diarrhea
Apply elastic bandage & stockings which should be
Stomatitis
removed every 8 hours for short periods & reapplied
Assist out of bed within 24 hours ensuring the
elastic stockings is applied
Assess for increase of bleeding particularly in groin
area
Hypersensitivity:
Dermatitis
Urticaria
Pruritus
45
46
2
...
Vein ligation & stripping
b
...
Plication of the inferior vena cava: insertion of an
umbrella-like prosthesis into the lumen of the vena
Upper Respiratory System
cava: to filter incoming cloth
Structure of the respiratory system, primarily an air
conduction system, include the nose, pharynx & larynx
...
passing to lower airway
...
Apply warm moist pack: to reduce lymphatic congestion
3
...
septum: air enters the system through the nares
1
...
External nose is a frame work of bone & cartilage , internally
The septum is covered with mucous membrane, where the
between 1
...
5 times normal control level
olfactory receptors are located
...
filtering air
...
Avoid injecting within 2 inches of umbilicus
Insert needle at 45-90o to skin
Do not withdraw plunger to assess blood return
Apply gentle pressure after removal of needle:
avoid massage
Assess for increased bleeding tendencies
(hematuria, hematemesis, bleeding gums,
Pharynx
1
...
Air passes through the nose to the pharynx
3
...
petechiae of soft palate, conjunctiva retina,
ecchymoses, epistaxis, bloody spumtum, melena) &
Consist of anastomosis of capillaries known as Keissel Rach
Plexus: the site of nose bleeding
iliac crest
The major function of the nose are warming, moistening &
Nasopharynx: located above the soft palate of the mouth,
contains the adenoids & opening to the eustachian tubes
2
...
cough preparations containing glyceryl guaiacolate
Laryngopharynx: extends from the epiglotitis to the sixth
cervical level
& obtain MD permission before using other OTC
drugs
b
...
Assess PT daily: dosage should be adjusted to
maintain PT at 1
...
5 times normal control level;
airways
2
...
Advise client to withhold dose & notify MD
4
...
K-rich food)
Instruct the client to wear medic-alert bracelet
4
...
Monitor chest pain or shortness of breath: possible
pulmonary embolism
6
...
Provide client teaching & discharge planning
a
...
Importance of adequate hydration: to prevent
hypercoagubility
c
...
Importance of planned rest periods with elevation of the
5
...
Opening of larynx
2
...
Closes to allow passage of food going to the esophagus
4
...
5-2
...
Drug regimen
it bifurcates & is supported by 16-20 C-shaped cartilage
f
...
Importance of weight reduction: if obese
h
...
Pulmonary Embolism
Bronchi
46
47
Right main bronchus
Larger & straighter than the left
Lecitin / Spingomyelin ratio: to determine lung maturity
Divided into three lobar branches (upper, middle &
Normal Lecitin / Spingomyelin ratio: is 2:1
lower bronchi) to supply the three lobes of right lung
In premature infants: 1:2
Give oxygen of less 40% in premature: to prevent
Left main bronchus
Divides into the upper & lower lobar bronchi to supply
atelectasis and retrolental fibroplasias
the left lobes
Bronchioles
Pulmonary Circulation
Provides for reoxygenation of blood & release of CO2
upon elastic recoil formed by network of smooth muscles
Gas transfers occurs in the pulmonary capillary bed
The tracheobronchial tree ends at the terminal bronchials
...
Streptococcus Pneumonae: causing pneumococal
pneumonia
& the narrow superior portion called the apex
2
...
Diplococcus Pneumoniae
Serous membranes covering the lungs, continuous with the
4
...
Escherichia Pneumoniae
6
...
Children below 5 years old
the parietal pleura & visceral pleura) this fluid holds the
2
...
Smoking
2
...
Immuno compromised
Chest is a C shaped & supported by 12 pairs of ribs & costal
4
...
Aspiration of food: causing aspiration pneumonia
Contraction of the external intercostal muscles raises
the ribs cage during inspiration & helps increase the size
of the thoracic cavity
S/sx
The internal intercoastal muscles tends to pull ribs down
& in & play a role in forced expiration
Diaphragm
A major muscle of ventilation (the exchange of air between
the atmosphere & the alveoli)
...
Nasal flaring
4
...
Use of accessory muscles of respiration
6
...
Possible pleural friction rub
8
...
Rales / crackles (early) progressing to coarse (later)
13
...
Weight loss
15
...
Cyanosis
17
...
Abdominal distention leading to paralytic ileus (absence of
alveolar epithelium
Rapid shallow respiration with expiratory grunt
12
...
11
...
Fever
directly from alveolar ducts & are responsible for about 35%
1
...
Alveolar Ducts
Arises from the respiratory bronchioles & lead to the alveoli
Sputum Gram Staining & Culture Sensitivity: positive to
cultured microorganisms
2
...
ABG analysis: reveals decrease PO2
4
...
Facilitate adequate ventilation
Administer O2 as needed & assess its effectiveness: low
inflow
Place client semi fowlers position
47
48
Turn & reposition frequently client who are immobilized
Administer analgesic as ordered: DOC: codeine: to
Histoplasmosis
relieve pain associated with breathing
2
...
Observe color characteristics of sputum & report any
changes: encourage client to perform good oral hygiene
after expectoration
4
...
Provide adequate rest & relief control of pain
Enforce CBR with limited activity
Limit visits & minimized conversation
Plan for uninterrupted rest periods
Maintain pleasant & restful environment
Administer antibiotic as ordered: monitor effects & possible
toxicity
6
...
8
...
Similar to PTB or Pneumonia
2
...
Fever, chills, anorexia, general body malaise
4
...
Dyspnea
6
...
Hemoptysis
8
...
Chest X-ray: often appears similar to PTB
2
...
ABG analysis: PO2 decrease
Dx
Medical Management
1
...
Monitor respiratory status
Control fever & chills:
2
...
Administer oxygen inhalation
Administer antipyretic as ordered
4
...
Antifungal: Amphotericin B (Fungizone)
Observe severe side effects:
Assist in postural drainage: uses gravity & various position
Fever: acetaminophen given prophylactically
to stimulate the movement of secretions
Anaphylactic reaction: Benadryl & Steroids given
Nursing Management for Postural Drainage
prophylactically
a
...
Monitor vital signs
5
...
Encourage client deep breathing exercises
6
...
Administer bronchodilators 20-30 minutes before
7
...
Prevent the spread of infection by spraying of breeding
e
...
Provide oral care after procedure
g
...
Abnormal renal function with hypokalemia &
Characteristic include hypertrophy / hyperplasia of the
mucus secreting gland in the bronchi, decreased ciliary
Provide increase CHO, calories, CHON & vitamin C
activity, chronic inflammation & narrowing of the airway
10
...
Medication regimen / antibiotic therapy
b
...
Need to continue deep breathing & coughing exercise
AKA “Blue Bloaters”
for at least 6-8 weeks after discharge
d
...
Need to report S/sx of respiratory infection
Persistent or recurrent fever
Changes in characteristics color of sputum
Chills
Increased pain
Difficulty in breathing
Weight loss
Persistent fatigue
f
...
Prevent complications
h
...
Smoking
2
...
Productive copious cough (consistent to all COPD)
2
...
Use of accessory muscle of respiration
4
...
Feeling of gastric fullness
6
...
Distended neck veins
8
...
Prolonged expiratory grunt
10
...
Pulmonary hypertension
a
...
Cor Pulmonale (right ventricular hypertrophy)
6
...
Provide client health teachings and discharge planning
concerning
Dx
a
...
Prevent complications
1
...
& bronchioles, Accumulation of tenacious secretions
Regular adherence to medications: to prevent
development of status asthmaticus
Reversible inflammatory lung condition due to
d
...
of muscular & elastic structure of the bronchial wall
Extrinsic Asthma (Atopic / Allergic)
Causes
destruction of muscular and elastic tissues of alveoli
Pollen
Dust
Fumes
1
...
Recurrent lower respiratory tract infections
Gases
3
...
Congenital defects (altered bronchial structure)
Furs
5
...
Thick tenacious secretion
1
...
Dyspnea in exertion
Drugs (aspirin, penicillin, beta blocker)
3
...
Anorexia & generalized body malaise
Food additives (nitrates)
5
...
Wheezing
7
...
CBC: elevation in WBC
2
...
Bronchoscopy: reveals sources & sites of secretion: direct
humidity
3
...
Cough that is non productive
2
...
Wheezing on expiration
4
...
Mild Stress or apprehension
6
...
Diaphoresis
Dx
1
...
ABG analysis: PO2 decrease
3
...
Secure inform consent and explain procedure to client
2
...
Monitor vital signs & breath sound
Post Bronchoscopy
1
...
Avoid talking, coughing and smoking, may cause irritation
3
...
Monitor for signs of laryngeal spasm: prepare tracheostomy
set
Medical Management
1
...
Abnormal permanent dilation of bronchus leading to
2
...
Bronchodilators: given via inhalation or metered dose
Segmental Wedge Lobectomy: promote re-expansion of
lungs
inhaler or MDI for 5 minutes
b
...
Mucomysts (acetylceisteine): at bed side put suction
machine
Emphysema
Enlargement & destruction of the alveolar, bronchial &
d
...
Anti histamine
thoracic overdistension, sputum accumulation & loss of
2
...
Hyposensitization
4
...
Enforce CBR
Inelasticity of alveoli
2
...
Administer medications as ordered
Overdistention of thoracic cavity (barrel chest)
4
...
Semi fowlers position: to promote lung expansion
49
50
Predisposing Factors
6
...
Smoking
mechanical ventilation promotes maximum alveolar lung
2
...
Allergy or allergic factor
7
...
High risk: elderly
8
...
Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to
release elastase for recoil of alveoli
minerals
9
...
S/sx
Prevention of recurrent infection
Avoid crowds & individual with known infection
1
...
Sputum production
Received immunization for influenza & pneumonia
3
...
Weight loss
5
...
Use of accessory muscles
7
...
Increased rate & depth of breathing
9
...
Control of environment
Use home humidifier at 30-50%
Wear scarf over nose & mouth in cold weather: to
10
...
Decrease or diminished breath sounds with prolong
expiration
12
...
13
...
Rales or rhonchi
15
...
Barrel chest
d
...
Purse lip breathing: to eliminates excess CO2 (compensatory
Increase activity tolerance
mechanism)
Start with mild exercise: such as walking & gradual
increase in amount & duration
Dx
1
...
Used breathing techniques: (pursed lip,
Pulmonary Function Test: reveals decrease vital lung
diaphragmatic) during activities / exercise: to control
capacity
breathing
ABG analysis: reveals
Panlobular/centrilobular
Decrease PO2 (hypoxemia leading to chronic
e
...
Strict compliance to medication
Decrease PCO2
g
...
Enforce CBR
2
...
Normal cells must divide & multiply to
3
...
cell growth & destruction is an integral part of life
b
...
4
...
body are all 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 the body needs,
neoplasia results
...
uncontrolled growth, therefore no definitive cure has
been found
...
Provide chest physiotherapy, coughing & deep breathing
c
...
Provide oral hygiene after expectoration of sputum
Since the growth control mechanism of normal cells is
not entirely understood, it is not clear what allows the
Mucolytics / expectorants
a
...
processes
...
Improve ventilation
They may function is a disorderly way to crease normal
a
...
Instruct the client diaphragmatic muscles to breathe
function completely, only functioning for their own survival
c
...
abdomen to help produce more expulsive cough)
d
...
Employ pursed-lip breathing techniques (prolonged slow
relaxed expiration against pursed lips)
e
...
50
51
8
...
E
...
9
...
G – Genetics
the age of 15 & 34
Some cancers shows familial pattern
Maybe caused by inherited genetics defects
Warning signs that men should look for:
Failure of the immune system to respond & eradicate
cancer cells
Immunosuppressed individuals are more susceptible to
cancer
Painless swelling
ii
...
Hard lump (size of a pea)
iv
...
Dull ache in the lower abdomen or in the
groin
V – Viral
o
Viruses have been shown to be the cause of certain
tumors in animals
o
Viruses
(
HTLV-I,
Epstein
Barr
Virus,
o
o
Pain in the testicle or in the scrotum
vii
...
Human
Papilloma Virus) linked to human tumors
i
...
urethane
Cigarette smoke
hormones
Classification of Cancer
Different drug act on tumor cell in different stages of the cell
growth cycle
...
Squamous Cell Carcinoma – surface epithelium
2
...
Antimetabolites
o
Foster cancer cell death by interfering with cellular
metabolic process
...
Alkylating Agent
Sarcoma – arises from connective tissue
Leukemia – from blood
Lymphoma – from lymph glands
o
obtained from periwinkle plant
...
Plant Alkaloids
Stages of Tumor Growth
for the growth of cancer cells
...
Staging System:
4
...
T– stands for primary growth; 1-4 with increasing
5
...
Steroids & Sex Hormones
o
N – stands for lymph nodes involvement: 0-4
alter the endocrine environment to make it less
conducive to growth of cancer cells
...
GI System
incorporating size, nodal involvement & spread
B
...
Involves in the study of shed cells (ex
...
Classified by degree of cellular abnormality
o
Withhold food/fluid 4-6 hrs before chemotherapy
Normal
o
Provide bland food in small amounts after treatment
Probably normal (slight changes)
Doubtful (more severe changes)
Probably cancer or precancerous
o
Administer antidiarrheals
...
o
Give clear liquids as tolerated
...
prophylactically before chemotherapy is initiated
...
Seven warning signs of cancer
2
...
Importance of retal exam for those over age 40
4
...
Oral self – examination as well as annual exam of mouth
& teeth
6
...
Importance of pap smear
Diarrhea
Stomatitis (mouth sore)
o
Provide & teach the client good oral hygiene,
including avoidance of commercial mouthwashes
...
51
52
o
o
o
Perform a cleansing rinse with plain H2O or dilute a
Effects cannot be limited to cancer cells only; all exposed
H2O soluble lubricant such as hydrogen peroxide
cells including normal cells will be injured causing side
after meal
...
Apply H2O lubricant such as K-Y jelly to lubricate
Localized effects are related to the area of the body being
cracked lips
...
provide moisture
...
Hematologic System
Alpha – particles cannot passed through skin, rarely used
...
o
Protect client from physical injury
...
common form of external radiotherapy (ex
...
or X-ray)
o
Monitor blood counts carefully
...
Gamma – penetrate more deeper areas of the body, most
Methods of Delivery
External Radiation Therapy – beams high energy rays
directly to the affected area
...
Cobalt therapy
Leukopenia
Internal Radiation Therapy – radioactive material is injected
o
Use careful handwashing technique
...
o
1000/mm
o
Assess for signs of respiratory infection
container so it does not circulate in the body;
o
Avoid crowds/persons with known infection
client’s body fluids should not be contaminated
...
Factors Controlling Exposure
Half-life – time required for half of radioactive atoms to
decay
...
Renal System
Each radioisotope has different half-life
...
At the end of half-life the danger from exposure
Time – the shorter the duration the less the exposure
...
Shielding – all radiation can be blocked; rubber gloves for
alpha & usually beta rays; thick lead or concrete stop
gamma rays
...
decreases
...
Integumentary System
Sealed Implants – a radioisotope enclosed in a
Side Effects of Radiation Therapy & Nursing Intervention
A
...
Keep skin free from foreign substances
...
Encourage fluid & frequent voiding to prevent accumulation
of metabolites in bladder; R: may cause direct damage to
Avoid pressure, trauma, infection to skin; use bed cradle
...
Wash affected areas with plain H2O & pat dry; avoid soap
...
Administer allopurinol (Zyloprim) as ordered; R: to prevent
If sloughing occurs, use sterile dressing with micropore tape
uric acid formation; encourage fluids when administering
Avoid exposing skin to heat, cold, or sunlight & avoid
allopurinol
constricting irritating clothing
...
Anorexia, N/V
E
...
Damage may occur to both men & women resulting
Encourage bland foods
...
Banking sperm often recommended for men before
Avoid extreme temperature
...
chemotherapy
Clients & partners advised to use reliable methods of
contraception during chemotherapy
F
...
Administer antidiarrheal as ordered
...
Monitor electrolytes particularly Na, K, Cl
D
...
reflex, & paralytic ileus may occur
...
Encourage high CHON diet
...
Uses ionizing radiation to kill or limit the growth of cancer
Assess for bleeding
...
Monitor CBC, WBC, & platelets
...
Diarrhea
It not only injured cell membrane but destroy & alter DNA so
that the cell cannot reproduce
...
Thermal
2
...
Chemical
4
...
g
...
Striated (skeletal): voluntary
Superficial partial thickness (1st degree)
Depth: epidermis only
Causes: sunburn, splashes of hot liquid
Sensation: painful
Characteristics: erythema, blanching on
1
...
thickening of the muscle) and isometric (increased
Deep Partial Thickness (2nd degree)
Depth: epidermis & dermis
Causes: flash, scalding, or flame burn
Sensation: very painful
Characteristics: fluid filled vesicles; red,
muscle tension) movement
...
Contraction is innervated by nerve stimulation
...
Muscles are attached to the skeleton at the point of
A form of connective tissue
Major functions are to cushion bony prominences and offer
protection where resiliency is required
Depth: all skin layers & nerve endings; may involve
muscles, tendons & bones
Tendons and Ligaments
2
...
Sensation: little or no pain
Composed of dense, fibrous connective tissue
4
...
Ligaments attach bone to bone
2
...
Joint distribution is symmetric (bilateral): most commonly
affects smaller peripheral joints of hands & also commonly
involves wrists, elbows, shoulders, knees, hips, ankles and
Bones
jaw
...
Cause
(hematopoiesis)
1
...
Cause unknown or idiopathic
2
...
Genetic factors
4
...
two end (epiphyses) composed of cancellous bones
Short Bones
2
...
Cold
bone (ex
...
Emotional stress
5
...
Skull & ribs)
Occurs in women more often than men (3:1) between the
ages 35-45
...
Femur & humerus)
If unarrested, affected joints progress through four stages of
S/sx
Irregular Bones
Sizes and shapes vary (ex
...
Fatigue
2
...
Weight loss
4
...
Joints are painful: warm, swollen, limited in motion, stiff in
morning & after a period of inactivity & may show crippling
deformity in long-standing disease
...
Muscle weakness secondary to inactivity
7
...
Some clients have additional extra-articular manifestations:
1
...
Amphiarthroses: partially movable joints
problems
...
Diarthroses (synovial): freely movable joints
Muscles
Have a joint cavity (synovial cavity) between the
Dx
articulating bone surfaces
1
...
CBC: anemia is common
A fibrous capsule encloses the joint
3
...
Rheumatoid factor positive
synovial fluid to lubricate the joint and reduce friction
...
ANA: may be positive
6
...
10
...
Drug therapy
a
...
b
...
b
...
pain and inflammation by inhibiting the synthesis of
c
...
d
...
Performance of ROM, isometric & prescribed exercises
Indomethacin (Indocin)
f
...
Application of resting splints as ordered
Mefenamic acid (Ponstel)
h
...
Importance of follow-up care
Piroxicam (Feldene)
Naproxen (Naprosyn)
Sulindac (Clinoril)
Osteoarthritis
degeneration of articular cartilage
Gold compounds (Chrysotherapy)
Chronic non-systemic disorder of joints characterized by
Injectable form: given IM once a week; take 3-6
Weight-bearing joints (spine, knees and hips) & terminal
interphalangeal joints of fingers most commonly affected
months to become effective
Sodium thiomalate (Myochrysine)
Aurothioglucose (Solganal)
1
...
Incidence increases with age
Incident Rate
SI: monitor blood studies & urinalysis
frequently
Proteinuria
Mouth ulcers
Skin rash
Aplastic anemia
...
on joints)
Obesity
3
...
SI: blood & urine studies should be
Pain: (aggravated by use & relieved by rest) & stiffness of
joints
monitored
...
Heberden’s nodes: bony overgrowths at terminal
interphalangeal joints
Diarrhea
3
...
Oral form: smaller doses are effective; take 3-6
months to become effective
d
...
Systemic administration: used only when client does
not respond to less potent anti-inflammatory drugs
...
Methotrexate: given to suppress immune response
Dx
1
...
ESR: may be slightly elevated when disease is inflammatory
Cytoxan
SI: bone marrow suppression
...
Physical therapy: to minimize joint deformities
...
Surgery: to remove severely damaged joints (e
...
total hip
Nursing Interventions
1
...
2
...
replacement; knee replacement)
...
Assess joints for pain, swelling, tenderness & limitation of
motion
...
Promote maintenance of joint mobility and muscle strength
...
Perform ROM exercises several times a day: use of heat
3
...
3
...
Change position frequently: alternate sitting, standing &
4
...
Use cane or walker when indicated
...
Ensure proper posture & body mechanics
...
Promote weight reduction: if obese
e
...
a
...
b
...
c
...
Promote comfort / relief of pain
...
a
...
b
...
c
...
5
...
a
...
4
...
standing
...
a
...
a
...
b
...
c
...
d
...
e
...
f
...
Administer medications as ordered:
Aspirin & NSAID: most commonly used
Corticosteroids (Intra-articular injections): to relieve
pain & improve mobility
...
Apply heat or ice as ordered (e
...
warm baths,
compresses, hot packs): to reduce pain
...
Prepare client for joint replacement surgery if necessary
...
Provide client teaching and discharge planning concerning
Provide heat treatments: warm bath, shower or whirlpool;
a
...
Importance of rest periods
c
...
ROM and isometric exercises
e
...
Use of heat/ice as ordered
...
7
...
May be more effective in chronic pain
...
Reduce stiffness, pain & muscle spasm
...
8
...
joints
Provide psychologic support and encourage client to express
feelings
...
54
55
Incident Rate
2
...
Occurs most often in males
3
...
Familial tendency
4
...
Malaise
6
...
Joint pain
7
...
Redness
8
...
Heat
9
...
Swelling
5
...
Headache
Photosensitivity with rash in areas exposed to sun
7
...
Oral or nasopharyngeal ulcerations
8
...
Alopecia
9
...
Renal system involvement
10
...
Tophi in outer ear, hands & feet (chronic tophaceous stage)
Hematuria
Renal failure
Dx
1
...
CNS involvement
CBC: uric acid elevated
Medical Management
1
...
b
...
Low-purine diet may be recommended
3
...
Heat or cold therapy
Peripheral neuritis
Seizures
Organic brain syndrome
Psychosis
14
...
Increase susceptibility to infection
Dx
1
...
CBC: RBC anemia, WBC & platelet counts decreased
3
...
Lupus Erythematosus (LE prep): positive
5
...
Chronic false-positive test for syphilis
Medical Management
1
...
Aspirin & NSAID: to relieve mild symptoms such as fever
1
...
2
...
3
...
4
...
Increased fluid intake to 2000-3000 ml/day: to prevent
response when client unresponsive to more
formation of renal calculi
...
Apply local heat or cold as ordered: to reduce pain
Azathioprine (Imuran)
7
...
Cyclophosphamide (Cytoxan)
8
...
Medications & their side effects
b
...
Limitation of alcohol use
d
...
Weight reduction if necessary
f
...
in acute exacerbations or severe disease
c
...
3
...
Immune
3
...
2
...
3
...
4
...
5
...
6
...
Disease process & relationship to symptoms
b
...
c
...
d
...
e
...
Maintenance of a well-balanced diet
g
...
Supportive therapy: as organ systems become involved
...
Predisposing Factors
Cause unknown
Plasma exchange: to provide temporary reduction in amount
Nursing Interventions
Occurs most frequently in young women
1
...
Incident Rate
1
...
Need to avoid exposure to persons with infections
i
...
Availability of community agencies
the client’s own cell nuclei
...
Affects cells throughout the body resulting in involvement of
many organs, including joints, skin, kidney, CNS &
cardiopulmonary system
...
aureus
...
Osteomyelitis
Infection may reach bone through open wound (compound
fracture or surgery), through the bloodstream, or by direct
extension from infected adjacent structures
...
by the gastric mucosa
After processing in the stomach the food bolus called
S/sx
chyme is released into the small intestine through the
1
...
Fever
3
...
Redness & swelling over bone
5
...
Drainage from wound site may be present
...
CBC: WBC elevated
2
...
ESR: may be elevated
2
...
3
...
5
...
4
...
Pyloric Sphincter: located between the stomach &
duodenum
1
...
7
...
Incision & drainage: of bone abscess
Sequestrectomy: removal of dead, infected bone &
1st half of duodenum
cartilage
Middle Alimentary canal: Function for absorption; Complete
Bone grafting: after repeated infections
absorption: large intestine
Leg amputation
Small Intestines
Provide client teaching and discharge planning concerning
Composed of the duodenum, jejunum & ileum
Use of prescribed oral antibiotic therapy & side effects
Extends from the pylorus to the ileocecal valve which
Importance of recognizing & reporting signs &
regulates flow into the large intestines to prevent reflux to
complications (deformity, fracture) or recurrence
the into the small intestine
FRACTURES
A
...
Structural Features:
Villi (functional unit of the small intestines): finger like
B
...
Assessment findings
containing goblet cells that secrets mucus & absorptive
D
...
Upper alimentary canal: function for digestion
Mouth
Consist of lips & oral cavity
Provides entrance & initial processing for nutrients &
2nd half of duodenum
Jejunum
Ileum
1st half of ascending colon
sensory data such as taste, texture & temperature
Lower Alimentary Canal: Function: elimination
Large Intestine
Oral Cavity: contains the teeth used for mastication &
the tongue which assists in deglutition & the taste
sensation & mastication
Salivary gland: located in the mouth produce secretion
containing pyalin for starch digestion & mucus for
lubrication
Pharynx: aids in swallowing & functions in ingestion by
providing a route for food to pass from the mouth to the
esophagus
Esophagus
Divided into four parts:
Cecum (with appendix)
Colon (ascending, transverse, descending, sigmoid)
Rectum
Anus
Serves as a reservoir for fecal material until defecation
occurs
Function: to absorb water & electrolytes
MO present in the large intestine: are responsible for small
Muscular tube that receives foods from the pharynx &
amount of further breakdown & also make some vitamins
propels it into the stomach by peristalsis
Amino Acids: deaminated by bacteria resulting in
ammonia which is converted to urea in the liver
Stomach
vitamin K & some of the vitamin B groups
Located on the left side of the abdominal cavity occupying
the hypochondriac, epigastric & umbilical regions
Bacteria in the large intestine: aid in the synthesis of
Feces (solid waste): leave the body via rectum & anus
Stores & mixes food with gastric juices & mucus producing
Anus: contains internal sphincter (under involuntary
control) & external sphincter (voluntary control)
chemical & mechanical changes in the bolus of food
The secretion of digestive juice is stimulated by
Fecal matter: usually 75% water & 25% solid wastes
(roughage, dead bacteria, fats, CHON, inorganic matter)
smelling, tasting & chewing food which is known as
cephalic phase of digestion
a
...
Transverse
in the stomach & regulated by neural stimulation via
c
...
Sigmoid
e
...
Parotid – below & front of ear
Hepatic Sinusoids (capillaries): are lined with kupffer cells
2
...
Submaxillary
Portal circulation brings blood to the liver from the stomach,
spleen, pancreas & intestines
-
Produces saliva – for mechanical digestion
Function:
-
1200 -1500 ml/day - saliva produced
Metabolism of fats, CHO & CHON: oxidizes these
nutrient for energy & produces compounds that can be
stored
Production of bile
Conjugation & excretion (in the form of glycogen, fatty
Disorder of the GIT
Peptic Ulcer Disease (PUD)
Gastric Ulcer
acids, minerals, fat-soluble & water-soluble vitamins) of
bilirubin
Ulceration of the mucosal lining of the stomach
Most commonly found in the antrum
Excoriation / erosion of submucosa & mucosal lining due to:
Storage of vitamins A, D, B12 & iron
Hypersecretion of acid: pepsin
Synthesis of coagulation factors
Decrease resistance to mucosal barrier
Detoxification of many drugs & conjugation of sex
Caused by bacterial infection: Helicobacter Pylori
hormones
Doudenal Ulcer
Salivary gland
Most commonly found in the first 2 cm of the duodenum
Verniform appendix
Characterized by gastric hyperacidity & a significant rate of
gastric emptying
Liver
Pancreas: auto digestion
Gallbladder: storage of bile
Predisposing factor
Biliary System
Smoking: vasoconstriction: effect GIT ischemia
Alcohol Abuse: stimulates release of histamine: Parietal cell
Consist of the gallbladder & associated ductal system (bile
release Hcl acid = Ulceration
ducts)
Emotional Stress
Gallbladder: lies under the surface of the liver
Drugs:
Function: to concentrate & store bile
Salicylates (Aspirin)
Ductal System: provides a route for bile to reach the
Steroids
intestines
Butazolidin
Bile: is formed in the liver & excreted into hepatic duct
Hepatic Duct: joins with the cystic duct (which drains
S/sx
the gallbladder) to form the common bile duct
Gastric Ulcer
If the sphincter of oddi is relaxed: bile enters the duodenum,
Duodenal Ulcer
if contracted: bile is stored in gallbladder
Site
Pancreas
Positioned transversely in the upper abdominal cavity
Consist of head, body & tail along with a pancreatic duct
Pain
Antrum or lesser
Function in GI system: is exocrine
Exocrine cells in the pancreas secretes:
Trypsinogen & Chymotrypsin: for protein digestion
Amylase: breakdown starch to disacchardes
Lipase: for fat digestion
Left
Gaseous &
Not usually
Physiology of Digestion & Absorption
Digestion: physical & chemical breakdown of food into
absorptive substance
Hypersecretion
Initiate in the mouth where the food mixes with saliva &
Vomiting
Hemorrhage
Weight
Complications
relieved by
relieved by
food & antacid
food &
Normal gastric
12 MN – 3am
pain
Increased
Food then passes into the esophagus where it is
secretion
Not common
Melena
Weight gain
Perforation
Hemorrhage
60 years old
20 years old
High Risk
In the stomach food is processed by gastric secretions
Hgb & Hct: decrease (if anemic)
into a substance called chyme
Endoscopy: reveals ulceration & differentiate ulceration from
propelled into the stomach
Common
Hematemeis
Weight loss
Stomach
gastric acid
cause
starch is broken down
Usually
antacid
Endocrine function related to islets of langerhas
Cramping &
burning
acid secretion
Mid
epigastrium
burning
2-3 hrs after
eating
epigastrium
the common bile duct
Has both exocrine & endocrine function
after eating
which extends along the gland & enters the duodenum via
curvature
30 min-1 hr
Duodenal bulb
Dx
In the small intestines CHO are hydrolyzed to
monosaccharides, fats to glycerol & fatty acid & CHON
to amino acid to complete the digestive process
When chymes enters the duodenum, mucus is
secreted to neutralized hydrocholoric acid, in
response to release secretin, pancreas releases
bicarbonate to neutralized acid chyme
gastric cancer
Gastric Analysis: normal gastric acidity
Upper GI series: presence of ulcer confirm
Medical Management
1
...
Supportive:
Rest
Bland diet
Stress management
Drug Therapy:
57
58
Antacids: neutralizes gastric acid
1
...
Diet: bland, non irritating, non spicy
neutralized gastric acid & inactivates pepsin
3
...
Provide client teaching & discharge planning
a
...
Aluminum OH gel (Amphojel)
Ex
...
SE: fever
Histamines (H2) receptor antagonist: inhibits gastric
Ranitidine (Zantac): has some antibacterial action
against H
...
Atropine SO4: inhibit the action of acetylcholine at
post ganglionic site (secretory glands) results
decreases GI secretions
Propantheline: inhibit muscarinic action of
acetylcholine resulting decrease GI secretions
Avoid ulcerogenic drugs: salicylates, steroids
Know proper dosage, action & SE
Proper Diet
Bland diet consist of six meals / day
Eat slowly
Avoid acid producing substance: caffeine, alcohol,
Avoid stressfull situation at mealtime
Plan rest period after meal
Avoid late bedtime snacks
Avoidance of stress-producing situation & development
Relaxation techniques
Exercise
Biofeedback
Dumping syndrome
regardless of acetylcholine or histamine release
Rapid gastric emptying of hypertonic food solutions
Omeprazole (Prilosec): diminished the accumulation
Common complication of gastric surgery
of acid in the gastric lumen & healing of duodenal
Appears 15-20 min after meal & last for 20-60 min
ulcer
Associated with hyperosmolar CHYME in the jejunum which
Pepsin Inhibitor: reacts with acid to form a paste that
draws fluid by osmosis from the extracellular fluid into the
binds to ulcerated tissue to prevent further destruction
bowel
...
Weakness
Helicobacter Pylori
2
...
Feeling of fullness
Gastric Resection
4
...
Diaphoresis
Subtotal Gastrectomy: Partial removal of stomach
6
...
Palpitations
Before surgery for BI or BII
Do Vagotomy (severing or cutting of vagus
nerve) & Pyloroplasty (drainage) first
Billroth I
(Gastroduodenostomy)
Billroth II (Gastrojejunostomy)
Removal of ½ -3/4 of
Nursing Intervention
1
...
Small frequent feeding: six equally divided feedings
3
...
Flat on bed 15-30 min after q feeding
Removal of ½ of
stomach & duodenal bulb
stomach &
& anastomostoses of
Disorders of the Gallbladder
anastomoses of gastric
gastric stump to jejunum
...
Nursing Intervention Post op
2
...
Abrupt emptying of stomach content into the intestine
coats mucosal lining of stomach
Have antacid available at all times
Proton Pump Inhibitor: inhibit gastric acid secretion
3
...
Maintain patent IV line
4
...
Complications:
Hemorrhage: Hypovolemic shock: Late signs: anuria
Peritonitis
Paralytic ileus: most feared
Hypokalemia
Thromobphlebitis
Pernicious anemia
Cholecystitis:
Acute or chronic inflammation of the gallbladder
Most commonly associated with gallstones
Inflammation occurs within the walls of the gallbladder
& creates thickening accompanied by edema
Consequently there is impaired circulation, ischemia &
eventually necrosis
Cholelithiasis:
Formation of gallstones & cholesterol stones
Inflammation of gallbladder with gallstone formation
...
High risk: women 40 years old
2
...
Obesity
4
...
Hyperlipidemia
6
...
Severe Right abdominal pain (after eating fatty food):
Occurring especially at night
Nursing Intervention
2
...
Anorexia
3
...
N/V
4
...
Jaundice
5
...
Pruritus
6
...
Easy bruising
8
...
Steatorrhea
Medical Management
1
...
Direct Bilirubin Transaminase: increase
2
...
WBC: increase
4
...
Lipase: increase
6
...
Diet modification with administration of fat soluble vitamins
3
...
Narcotic Analgesic: for pain
Nitroglycerine (NTG)
Ca Gluconate: to decrease pancreatic stimulation
2
...
NPO (usually)
4
...
Dialysis
emetic properties
4
...
Administer pain medication as ordered & monitor effects
2
...
Diet: increase CHO, moderate CHON, decrease fats
4
...
Administer medication as ordered
2
...
Assist in Total Parenteral Nutrition (TPN) or
hyperalimentation
Complication of TPN
Disorders of the Pancreas
Infection
Pancreatitis
Embolism
Hyperglycemia
An inflammatory process with varying degrees of pancreatic
edema, fat necrosis or hemorrhage
4
...
digestion
Assist client to comfortable position: Knee chest or fetal
Provide client teaching & discharge planning
Bleeding of Pancreas: Cullen’s sign at umbilicus
Predisposing factors:
Dietary regimen when oral intake permitted
High CHO, CHON & decrease fats
Eat small frequent meal instead of three large ones
Avoid caffeine products
Eliminate alcohol consumption
Maintain relaxed atmosphere after meals
1
...
Hepatobilary disease
3
...
Viral infection
5
...
Abscesses
Abdominal distension with feeling of fullness
7
...
Hyperlipidemia
Severe epigastric or back pain
9
...
Drugs: Thiazide, steroids, diuretics, oral contraceptives
temperature (2 day)
S/Sx:
1
...
N/V
3
...
Palpitation: due to pain
5
...
Decrease bowel sounds
7
...
Report signs of complication
Apendicitis
Inflammation of the appendix that prevents mucus from
passing into the cecum
Inflammation of verniform appendix
If untreated: ischemia, gangrene, rupture & peritonitis
May cause by mechanical obstruction (fecalith, intestinal
parasites) or anatomic defect
May be related to decrease fiber in the diet
(+) Grey Turner’s spots: ecchymosis of flank area
Predisposing factor:
9
...
Microbial infection
2
...
1
...
Urinary amylase: increase
3
...
Pathognomonic sign: (+) rebound tenderness
2
...
N/V
Hard nodular liver upon palpation
4
...
Diffuse pain at lower Right iliac region
Changes in moods
6
...
CBC: mild leukocytosis: increase WBC
Decrease of pubic & axilla hair in males
2
...
Easy bruising
Medical Management
Spider angiomas on nose, cheeks, upper thorax &
shoulder
Surgery: Appendectomy 24-45 hrs
Palmar erythema
Muscle atrophy
Nursing Intervention
1
...
Routinary pre-op nursing measures:
3
...
Avoid heat application: will rupture appendix
5
...
If (+) Pendrose drain (rubber drain inserted at surgical
wound for drainage of blood, pus etc): indicates rupture of
appendix
2
...
Administer Meds:
Analgesic: due post op pain
Antibiotics: for infection
Antipyretics: for fever (PRN)
Dx
Liver enzymes: increase
SGPT (ALT)
SGOT (AST)
LDH Alkaline Phosphate
Serum cholesterol & ammonia: increase
Indirect bilirubin: increase
CBC: pancytopenia
PT: prolonged
Hepatic Ultrasonogram: fat necrosis of liver lobules
Nursing Intervention
CBR with bathroom privileges
Encourage gradual, progressive, increasing activity with
planned rest period
Institute measure to relieve pruritus
Do not use soap & detergent
Bathe with tepid water followed by application of emollient
lotion
Provide cool, light, non-constrictive clothing
4
...
Maintain patent IV line
Apply cool, moist compresses to pruritic area
6
...
Hepatic encephalopathy
of the bladder (voiding)
Urethra
Small tube that extends from the bladder to the exterior of
Nursing Intervention
the body
Assist in mechanical ventilation: due coma
Passage of urine, seminal & vaginal fluids
...
bacterial multiplication
Administer Medication as ordered:
Systemic Antibiotics
Filtration – Normal GFR/ min is 125 ml of blood
Ampicillin
Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes
Cephalosporin
is for reabsorption)
Aminoglycosides
Tubular secretion – 1 ml is excreted in urine
Sulfonamides
Co-trimaxazole (Bactrim)
Regulation of BP:
Gantrism (Gantanol)
Antibacterial
Predisposing factor:
Nitrofurantoin (Macrodantin)
Ex CS – hypovolemia – decrease BP going to kidneys
Methenamine Mandelate (Mandelamine)
Activation of RAAS
Nalixidic Acid (NegGram)
Urinary Tract Anagesic
Release of Renin (hydrolytic enzyme) at
Urinary antiseptics: Mitropurantoin (Macrodantin)
juxtaglomerular apparatus
Urinary analgesic: Pyridium
Provide client teachings & discharge planning
Angiotensin I mild vasoconstrictor
Importance of Hydration
Void after sex: to avoid stagnation
Angiotensin II vasoconstrictor
Female: avoids cleaning back & front (should be front to
back)
Bubble bath, Tissue paper, Powder, perfume
Adrenal cortex
increase CO
increase PR
Aldosterone
Complications: Pyelonephritis
Pyelonephritis
Increase BP
Acute / chronic inflammation of 1 or 2 renal pelvis of
Increase Na &
kidneys leading to tubular destruction & interstitial
H2O reabsorption
abscess formation
Acute: infection usually ascends from lower urinary tract
Hypervolemia
Chronic: a combination of structural alteration along
with infection major cause is ureterovesical reflux
with infected urine backing up into ureters & renal
pelvis
Recurrent infection will lead to renal parenchymal
deterioration & Renal Failure
Color –
amber
Odor –
aromatic
Consistency –
clear or slightly turbid
pH –
4
...
015 – 1
...
Coli
Streptococcus
(-)
Albumin –
Urinary retention /obstruction
(-)
E coli –
Pregnancy
(-)
DM
Mucus thread – few
Exposure to renal toxins
Amorphous urate (-)
S/sx:
Acute Pyelonephritis
UTI
Severe flank pain or dull ache
CYSTITIS
Costovertibral angle pain / tenderness
Inflammation of bladder due to bacterial infection
Fever
Chills
Predisposing factors:
N/V
Microbial invasion: E
...
coli
Urinary analgesic: Peridium
Acute
62
63
Antibiotics
Delivers shockwaves from outside of the body to the stone causing
Antispasmodic
pulverization
Surgery: removal of any obstruction
Pain management & diet modification
Chronic
Antibiotics
Nursing Intervention
Urinary Antiseptics
Force fluid: 3000-4000 ml / day
Nitrofurantoin (macrodantin)
Strain urine using gauze pad: to detect stones & crush all cloths
SE: peripheral neuropathy
Encourage ambulation: to prevent stasis
GI irritation
Warm sitz bath: for comfort
Hemolytic anemia
Administer narcotic analgesic as ordered: Morphine SO4: to
Staining of teeth
relieve pain
Surgery: correction of structural abnormality if possible
Application warm compress at flank area: to relieve pain
Monitor I & O
Dx
Provide modified diet depending upon the stone consistency
Urine culture & sensitivity: (+) E
...
BUN & Creatinine: elevated
Recovery or Covalescent Phase: renal function stabilized with
Nursing Intervention
gradual improvement over next 3-12 mos
Monitor symptoms of infection
Monitor symptoms gross / flank bleeding
...
PAP, PCWP, CVP as needed
products & maintain F&E balance due to a decrease in GFR
Monitor I&O strictly
(N 125 ml/min)
Assess every hour fro hypervolemia
Maintain ventilation
Causes
Decrease fluid intake as ordered
Pre-renal cause: interfering with perfusion & resulting in
Administer diuretics, cardiac glycosides &
decreased blood flow & glomerular filtrate
hypertensive agent as ordered
Inter-renal cause: condiion that cause damage to the nephrons
Assess every hour for hypovolemia: replace fluid as
Post-renal cause: mechanical obstruction anywhere from the
ordered
tubules to the urethra
Monitor ECG
Check urine serum osmolality / osmolarity & urine
Pre renal cause: decrease blood flow & glomerular filtrate
specific gravity as ordered
Ischemia & oliguria
Promote optimal nutrition
Cardiogenic shock
Administer TPN as ordered
Acute vasoconstriction
Restrict CHON intake
Septicemia
Hypovolemia
Prevent complication from impaired mobility
Decrease
flow to kidneys
Pulmonary Embolism
Skin breakdown
Hypotension
Contractures
CHF
Atelectesis
Hemorrhage
Prevent infection / fever
Dehydration
Assess sign of infection
Use strict aseptic technique for wound & catheter care
Intra-renal cause: involves renal pathology: kidney problem
Take temperature via rectal
Acute tubular necrosis
Administer antipyretics as ordered & cooling blankets
Endocarditis
Support clients / significant others: reduce level of anxiety
DM
Provide care for client receiving dialysis
Tumors
Provide client teaching & discharge planning
Pyelonephritis
Adherence to prescribed dietary regime
Malignant HPN
S/sx of recurrent renal disease
Acute Glomerulonephritis
Importance of planned rest period
Blood transfision reaction
Use of prescribe drugs only
Hypercalemia
S/sx of UTI or respiratory infection: report to MD
Nephrotoxin (certain antibiotics, X-ray, dyes, pesticides,
anesthesia)
Chronic Renal Failure
Progressive, irreversible destruction of the kidneys that
Post renal cause: involves mechanical obstruction
continues until nephrons are replaced by scar tissue
Tumors
Loss of renal function gradual
Stricture
Irreversible loss of kidney function
Blood cloths
Urolithiasis
Predisposing factors:
BPH
DM
Anatomic malformation
HPN
Recurrent UTI/ nephritis
S/sx
Urinary Tract obstruction
Oliguric Phase: caused by reduction in glomerular filtration rate
Exposure to renal toxins
Urine output less than 400 ml / 24 hrs; duration 1-2 weeks
S/sx
Stages of CRF
Hypernatremia
Diminished Reserve Volume – asymptomatic
Hyperkalemia
Normal BUN & Crea, GFR < 10 – 30%
Hyperphosphotemia
2
...
End Stage Renal disease
Hypocalcemia
Metabolic acidosis
Dx
S/Sx:
64
65
N/V
Monitor for hyperphosphatemia: administer aluminum
Diarrhea / constipation
hydroxides gel (amphojel, alternagel) as ordered
Decreased urinary output
Paresthesias
Dyspnea
Muscle cramps
Stomatitis
Seizures
Hypotension (early)
Abnormal reflex
Hypertension (late)
Maintenance of skin integrity
Lethargy
Provide care for pruritus
Convulsion
Monitor uremic frost (urea crystallization on the skin): bathe
Memory impairment
in plain water
Pericardial Friction Rub
Monitor for bleeding complication & prevent injury to client
HF
Monitor Hgb, Hct, platelets, RBC
Hematest all secretions
Administer hematinics as ordered
Urinary System
Polyuria
Avoid IM injections
Metabolic Disturbance
Maintain maximal cardiovascular function
Azotemia (increase BUN
Nocturia
Monitor BP
& Creatinine)
Hematuria
Hyperglycemia
Auscultate for pericardial friction rub
Dysuria
Hyperinsulinemia
Perform circulation check routinely
Administer diuretics as ordered & monitor I&O
Oliguria
CNS
GIT
Modify digitalis dose as ordered (digitalis is excreted in
Headache
N/V
Lethargy
Stomatitis
Provide care for client receiving dialysis
Disorientation
Uremic breath
Disequilibrium syndrome: from rapid removal of urea &
Restlessness
Diarrhea /
Memory impairment
Respiratory
kidneys)
Kassmaul’s resp
Normocytic anemia
Decrease cough
Bleeding tendencies
reflex
Fluid & Electrolytes
nitrogenous waste prod leading to:
constipation
Hematological
N/V
HPN
Leg cramps
Disorientation
Paresthes
Integumentary
Hyperkalemia
Enforce CBR
Itchiness /
Hypernatermia
pruritus
Hypermagnese
Uremic frost
Monitor VS, I&O
Meticulous skin care
...
Meds:
Hyperposphate
a
...
) Kagexelate enema
Metabolic
c
...
) Vit & minerals
acidosis
e
...
) Decrease Ca – Ca gluconate
Urinalysis: CHON, Na & WBC: elevated
5
...
Can lead to compression of fistula
...
Institute safety measures to protect the client from
- Infersole (diastole) – common dialisate used
falling out of bed
Monitor serum electrolytes, BUN & creatinine as ordered
Promote optimal GI function
7
...
Assist in surgery:
Renal transplantation : Complication – rejection
Title: medical surgical nursing
Description: medical surgical notes, by Anthony.t
Description: medical surgical notes, by Anthony.t