pain).
20. TETANY – hypocalcemia (+) trousseu’s sign or carpopedal
3.
Mood swings or euphoria (sense of elation)
4.
Impaired motor function
spasm/ (+) chvostek sign (facial spasm).
weakness
21. TETANUS – risus sardonicus
spasticity
22. PANCREATITIS – cullen’s sign (echymosis of umbilicus) / (+)
paralysis
grey turners spots.
5.
Impaired cerebral function
23. PYLORIC STENOSIS – olive like mass.
scanning speech
24. PDA – machine like murmur
ataxic gait
nystagmus
dysarthria
intentional tremor
25. ADDISON’S DISEASE – bronze like skin pigmentation.
26. CUSHING’S SYNDROME – moon face appearance and buffalo
hump.
27. HYPERTHYROIDSM/GRAVES DISEASE – exopthalmus.
6.
Bladder
DEMYELINATING DISORDERS
Urinary retention or incontinence
7.
Constipation
8.
Sexual impotence in male / decrease sexual capacity
Alzheimer’s disease
Atrophy of brain tissue due to deficiency of
TRIAD SIGNS OF MS
acetylcholine.
Ataxia
CHARCOTS TRIAD
6
7
(unsteady gait,
a.
General measures to ensure optimum health.
positive romberg’s test)
Balance between activity & rest
Regular exercise such as walking, swimming,
biking in mild case.
Nystagmus
Dx
CSF Analysis: increase in IgG and Protein.
2.
MRI: reveals site and extent of demyelination.
3.
CT Scan: increase density of white matter.
4.
Visual Evoked Response (VER) determine by EEG: maybe
Sign:
a
continuous
and
increase
Fresh air & sunshine
Avoiding fatigue, overheating or chilling, stress,
b.
Use of medication & side effects.
c.
Alternative methods for sexual counseling if indicated.
- poor perineal hygiene
- vaginal environment is moist
Nursing Management
- avoid bubble bath (can alter Ph of vagina).
- avoid use of tissue papers
- avoid using talcum powder and perfume.
Nursing Intervention
Assess the client for specific deficit related to location of
demyelination
2.
- short urethra (3-5 cm, 1-1 ½ inches)
contraction of spinal column.
1.
Well-balance diet
Female
delayed
Lhermittes
COMMON CAUSE OF UTI
1.
Positive
Use energy conservation techniques
infection.
Intentional tremors
5.
Male
- urethra (20 cm, 8 inches)
- do not urinate after intercourse
Promote optimum mobility
a.
Muscles stretching & strengthening exercises
b.
Walking exercises to improve gait: use wide-base gait
c.
Assistive devices: canes, walker, rails, wheelchair as
INTRACRANIAL PRESSURE ICP
Monroe Kelly Hypothesis
necessary
3.
Administer medications as ordered
a.
(prednisone) for acute exacerbations: to reduce edema
at site of demyelination to prevent paralysis.
b.
Beta Interferons - Immunosuppresants: alter immune
response.
Cervical 1 – also known as atlas.
4.
Encourage independence in self-care activities
5.
Prevent complications of immobility
6.
Institute bowel program
7.
Maintain side rails to prevent injury related to falls.
8.
Institute stress management techniques.
9.
a.
Deep breathing exercises
b.
Yoga
Increase
fluid
intake
and
increase
Cervical 2 – also known as axis.
Foramen Magnum
Medulla Oblongata
fiber
to
Brain Herniation
prevent
constipation.
10. Maintain urinary elimination
1.
Urinary Retention
a.
perform intermittent catheterization as ordered: to
prevent retention.
b.
Bethanecol Chloride (Urecholine) as ordered
Nursing Management
only given subcutaneous.
monitor side effects bronchospasm and wheezing.
monitor breath sounds 1 hour after subcutaneous
administration.
2.
Urinary Incontinence
a.
Establish voiding schedule
b.
Anti spasmodic agent Prophantheline Bromide (Pro-
Increase intra cranial pressure
Nursing Intervention
1.
alternate hot and cold compress to prevent hematoma
CSF cushions brain (shock absorber)
Obstruction of flow of CSF will lead to enlargement of skull
posteriorly called hydrocephalus.
enlargement of skull in hydrocephalus.
DISORDERS
Increase Intracranial Pressure (IICP)
Force fluid to 3000 ml/day.
4.
Promote use of acid ash diet like cranberry juice, plums,
prunes, pineapple, vitamin C and orange: to acidify
urine and prevent bacterial multiplication.
CSF, Blood.
Test bath water with thermometer.
b.
Avoid heating pads, hot water bottles.
c.
Inspect body parts frequently for injury.
d.
Make frequent position changes.
nerve.
Increase ICP may be caused:
head trauma/injury
localized abscess
cerebral edema
hemorrhage
inflammatory condition (stroke)
Encourage positive attitude & assist client in setting
hydrocephalus
realistic goals.
tumor (rarely)
antibodies
13. Provide psychologic support to client/significant others.
b.
Present life threatening situation because of pressure on
vital structures in the brain stem, nerve tracts & cranial
12. Prepare client for plasma exchange if indicated: to remove
a.
Untreated increase ICP can lead to displacement of brain
tissue (herniation).
11. Prevent injury related to sensory problems.
a.
Increase in intracranial bulk brought due to an increase in
any of the 3 major intracranial components: Brain Tissue,
banthine) if ordered
3.
Early closure of posterior fontanels causes posterior
Provide compassion in helping client adapt to changes
in body image & self-concept.
S/sx
c.
Do not encourage false hope during remission.
d.
Refer to MS societies & community agencies.
1.
(Early signs)
Decrease LOC
14. Provide client teaching & discharge planning concerning:
2.
Irritability / agitation
7
8
3.
Progresses from restlessness to confusion & disorientation
to lethargy & coma
ordered (Plasil - Phil only, Phenergan)
(Late signs)
1.
Systolic blood pressure increases while diastolic
pressure remains the same (widening pulse
e.
6.
Prevent complications of immobility.
7.
Administer medications as ordered:
c.
Abnormal respiratory patterns (cheyne-stokes
a.
Hyperosmotic agent / Osmotic Diuretic [Mannitol
respiration)
(Osmitrol)]: to reduce cerebral edema
temperature increase directly proportional to blood
Nursing Management
pressure.
Monitor V/S especially BP: SE hypotension.
Monitor strictly input and output every hour: (output
Pupillary Changes
b.
Ipsilateral (same side) dilatation of pupil with
should increase): notify physician if output is less 30
cc/hr.
unilateral dilation of pupils called uncal
herniation
c.
b.
bilateral dilation of pupils called tentorial
d.
Pupil eventually becomes fixed & dilated
Motor Abnormalities
a.
c.
Administered via side drip
Regulate fast drip to prevent crystal formation.
Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral
drug of choice for CHF (pulmonary edema)
loop of henle in kidneys.
Nursing Management
Contralateral (opposite side) hemiparesis from
compression of corticospinal tract
b.
edema
herniation
abnormal posturing
Monitor V/S especially BP: SE hypotension.
Monitor strictly input and output every hour: (output
should increase): notify physician if output is less 30
decorticate posturing (damage to cortex and
cc/hr.
spinal cord).
d.
decerebrate posturing (damage to upper brain
Administered IV push or oral.
stem that includes pons, cerebellum and
Given early morning
midbrain).
Immediate effect of 10-15 minutes.
Maximum effect of 6 hours.
4.
Headache
5.
Projective Vomiting
6.
Papilledema (edema of optic disc)
7.
Possible seizure activity
c.
d.
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.
hypercarbia (increase CO2) important:
e.
Hypoxia may cause brain swelling which
increase ICP
8.
Early signs of hypoxia:
Restlessness
Tachycardia
Agitation
Assist with ICP monitoring when indicated:
a.
cranial cavity by the brain, cerebral blood, & CSF
b.
Extreme restlessness
Bradycardia
Dyspnea
Cyanosis
allows for drainage of CSF if needed.
measurement of ICP.
c.
Assist with mechanical hyperventilation as
9.
Provide intensive nursing care for clients treated with
barbiturates therapy or administration of paralyzing agents.
a.
a.
Provide comfortable and quite environment.
b.
Avoid use of restraints.
c.
Maintain side rails.
d.
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.
b.
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.
Maintain fluid balance: fluid restriction to 1200-1500 ml/day
improve venous drainage from brain.
Check insertion site for signs of infection; monitor
temperature.
suctioning to 10 – 15 seconds only.
Position the client with head of bed elevated to 30-45o angle
Use strict aseptic technique when handling any part
of the monitoring system.
with resuscitator bag connected to 100% O2 & limit
may be ordered
Normal ICP reading is 0-15 mmHg; a sustained
increase above 15 mmHg is considered abnormal.
Before and after suctioning hyperventilate the client
Magnesium Sulfate
Magnesium Sulfate toxicity
S/S
BP
Urine output
DECREASE
Respiratory rate
Patellar relfex absent
3. Hyponatremia
- decrease sodium level
- normal value is 135 – 145 meq/L
Signs and Symptoms
- hypotension
- dehydration signs (initial sign in adult is thirst, in infant
tachycardia)
- agitation
- dry mucous membrane
- poor skin turgor
- weakness and fatigue
Nursing Management
- force fluids
- administer isotonic fluid solution as ordered
- pruritus
- esophageal varices
- anorexia and general body malaise
4. Hyperglycemia
- normal FBS is 80 – 100 mg/dl
Signs and Symptoms
- polyuria
- polydypsia
- polyphagia
Nursing Management
- monitor FBS
5. Hyperuricemia
- increase uric acid (purine metabolism)
- foods high in uric acid (sardines, organ meats and anchovies)
*Increase in tophi deposit leads to gouty arthritis.
Signs and Symptoms
Signs and Symptoms of Lasix in terms of electrolyte
imbalances
1. Hypokalemia
- decrease potassium level
- normal value is 3.4 – 5.5 meq/L
Sign and Symptoms
- weakness and fatigue
- constipation
- positive U wave on ECG tracing
Nursing Management
- administer potassium supplements as ordered (Kalium Durule,
Oral Potassium Chloride)
- increase intake of foods rich in potassium
- joint pain (great toes)
- swelling
Nursing Management
- force fluids
- administer medications as ordered
a. Allopurinol (Zylopril)
- drug of choice for gout.
- mechanism of action: inhibits synthesis of uric acid.
b. Colchesine
- acute gout
- mechanism of action: promotes excretion of uric acid.
* Kidney stones
Signs and Symptoms
- renal cholic
- cool moist skin
FRUITS
VEGETABLE
Apple
S
Asparagus
Banana
Brocolli
- administer medications as ordered
Cantalop
Carrots
a. Narcotic Analgesic
Nursing Management
- force fluids
9
10
- Morphine Sulfate
a.
- antidote: Naloxone (Narcan) toxicity leads to tremors.
Levodopa (L-dopa) short acting
b. 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.
Chronic progressive disorder of CNS characterized by
CI: narrow-angled glaucoma; client taking MAOI
degeneration of dopamine producing cells in the substantia
inhibitor; reserpine; guanethidine; methyldopa;
nigra of the midbrain and basal ganglia.
antipsychotic; acute psychoses
Progressive disorder with degeneration of the nerve cell in
the basal ganglia resulting in generalized decline in
Use in clients who do not respond to other types of
symmetrical, peripheral polyneuritis characterized by
therapy.
ascending muscle paralysis.
Nursing Interventions
1.
a disorder of the CNS characterized by bilateral,
Can occur at any age; affects women and men equally
Progression of disease is highly individual; 90% of clients
Administer anti-cholinesterase drugs as ordered:
stop progression in 4 weeks; recovery is usually from 3-6
a.
Give medication exactly on time.
months; may have residual deficits.
b.
Give with milk & crackers to decrease GI upset
Causes:
c.
Monitor effectiveness of drugs: assess muscle strength
1.
Unknown / idiopathic
& vital capacity before & after medication.
2.
May be autoimmune process
d.
Avoid use of the ff drugs:
Morphine SO4 & Strong Sedatives: respiratory
Predisposing Factors
depressant effects
1.
Immunization
Quinine, Curare, Procainamide, Neomycin,
2.
Antecedent viral infections such as LRT infections
Streptomycine, Kanamycine & other
aminoglycosides: skeletal muscle blocking effect
e.
2.
3.
Observe for side effects
S/sx
1.
Mild Sensory Changes: in some clients severe
Promote optimal nutrition:
misinterpretation of sensory stimuli resulting to extreme
a.
discomfort
Mealtime should coincide with the peak effect of the
drugs: give medication 30 minutes before meals.
2.
Clumsiness (initial sign)
b.
Check gag reflex & swallowing ability before feeding.
3.
Progressive motor weakness in more than one limb
c.
Provide mechanical soft diet.
d.
If the client has difficulty in chewing & swallowing, do
4.
Dysphagia: cranial nerve involvement
not leave alone at mealtime; keep emergency airway &
5.
Ascending muscle weakness leading to paralysis
suctioning equipment nearby.
6.
Ventilatory insufficiency if paralysis ascends to respiratory
(classically is ascending & symmetrical)
Monitor respiratory status frequently: Rate, Depth, Vital
muscles
Capacity; ability to deep breathe & cough
7.
Absence or decreased deep tendon reflex
Assess muscle strength frequently; plan activity to take
8.
Alternate hypotension to hypertension
advantage of energy peaks & provide frequent rest periods.
9.
Arrythmia (most feared complication)
5.
Observe for signs of myasthenic or cholinergic crisis.
10. Autonomic disfunction: symptoms that includes
MYASTHENIC CRISIS
Abrupt onset of severe, generalized
4.
muscle weakness with inability to
swallow, speak, or maintain respirations.
Symptoms will improve temporarily with
tensilon test.
Causes:
CHOLINERGIC CRISIS a. increase salivation
Symptoms similar to myasthenic crisis &
b. increase sweating
in addition the side effect of antic. constipation
cholinesterase drugs (excessive
salivation & sweating, abdominal carmp,
Dx
N/V, diarrhea, fasciculation)
1. CSF analysis: reveals increased in IgG and protein
Symptoms worsen with tensilon test:
2. EMG: slowed nerve conduction
keep Atropine Sulfate & emergency
equipment on hand.
under medication
physical or emotional stress
infection
Cause:
Medical Management
1. Mechanical Ventilation: if respiratory problems present
over medication with 2.
the Plasmapheresis: to reduce circulating antibodies
drugs (anti-cholinesterase)
3. Continuous ECG monitoring to detect alteration in heart rate
Signs and Symptoms
the client is unable to see, swallow,
& rhythm
Signs and Symptoms
4.
Propranolol: to prevent tachycardia
PNS
5.
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.
Maintain patent airway & adequate ventilation:
Nursing Care in Crisis:
a.
Monitor rate & depth of respiration; serial vital capacity
a.
Maintain tracheostomy set or endotracheal tube with
b.
Observe for ventilatory insufficiency
mechanical ventilation as indicated.
c.
Maintain mechanical ventilation as needed
b.
Monitor ABG & Vital Capacity
d.
Keep airway free of secretions & prevent pneumonia
c.
Administer medication as ordered:
cholinesterase drug as ordered.
2.
Myasthenic Crisis: increase doses of anti-
Check individual muscle groups every 2 hrs in acute phase
to check progression of muscle weakness
3.
Assess cranial nerve function:
Cholinergic Crisis: discontinue anti-
a.
Check gag reflex
cholinesterase drugs as ordered until the client
b.
Swallowing ability
recovers.
c.
Ability to handle secretion
d.
Voice
d.
Established method of communication
e.
Provide support & reassurance.
4.
Monitor strictly the following:
6.
Provide nursing care for the client with thymectomy.
a.
Vital signs
7.
Provide client teaching & discharge planning concerning:
b.
Input and output
a.
Nature of the disease
c.
Neuro check
b.
Use of prescribe medications their side effects & sign of
d.
ECG: due to arrhythmia
toxicity
e.
Observe signs of autonomic dysfunction: acute period of
c.
d.
e.
Importance of checking with physician before taking any
hypertension fluctuating with hypotension
new medication including OTC drugs
f.
Tachycardia
Importance of planning activities to take advantage of
g.
Arrhythmias
energy peaks & of scheduling frequent rest period
5.
Maintain side rails to prevent injury related to fall
Need o avoid fatigue, stress, people with upper
6.
Prevent complications of immobility: turning the client every
respiratory infection
2 hrs
f.
Use of eye patch for diplopia (alternate eyes)
7.
Assist in passive ROM exercise
g.
Need to wear medic-alert bracelet
8.
Promote comfort (especially in clients with sensory
h.
Myasthenia Gravis foundation & other community
changes):
agencies
a.
Foot cradle
b.
Sheepskin
c.
Guided imagery
Guillain-Barre Syndrome
12
13
d.
9.
Relaxation techniques
3.
Promote optimum nutrition:
leakage to tissues.
a.
Check gag reflex before feeding
b.
Start with pureed food
c.
Assess need for NGT feeding: if unable to swallow; to
4.
10. Administer medications as ordered
a.
Corticosteroids: suppress immune response
b.
Anti Cholinergic Agents:
c.
Assess for movement and sensation of extremities.
CSF analysis reveals
prevent aspiration
Check punctured site for any discoloration, drainage and
Paralysis of respiratory muscles / respiratory arrest
c.
Antipyretics: for fever
12. Prevent complications:
a.
b.
13. Provide psychologic support & encouragement to client /
2.
Enforced strict respiratory isolation 24 hours after initiation
of anti biotic therapy (for some type of meningitis)
significant others
14. Refer for rehabilitation to regain strength & treat any
3.
Provide
nursing
care
for
increase
ICP,
seizure
4.
Meningitis
Inflammation of the meninges of the brain & spinal cord.
Cause by bacteria, viruses, & other M.O.
Etiology / Most Common M.O.
1.
Meningococcus: most dangerous
2.
Pneumococcus
3.
Streptococcus: cause of adult meningitis
Provide nursing care for delirious or unconscious client as
needed
INFLAMMATORY CONDITIONS OF THE BRAIN
5.
Enforce complete bed rest
6.
Keep room quiet & dark: if the client has headache &
photophobia
7.
Monitor strictly V/S, I & O & neuro check
8.
Maintain fluid & electrolyte balance
9.
Prevent complication of immobility
10. Provide client teaching & discharge planning concerning:
a.
Importance of good diet: high CHON, high calories with
small frequent feedings.
b.
Hemophilus Influenzae: cause of pediatric meningitis
Rehabilitation program for residual deficit
Mode of transmission
c.
mental retardation
delayed psychomotor development
Prevent complications
1.
Airborne transmission (droplet nuclei)
2.
Via blood, CSF, lymph
most feared is hydrocephalus
3.
By direct extension from adjacent cranial structures (nasal,
hearing loss/nerve deafness is second
complication
sinuses, mastoid bone, ear, skull fracture)
4.
&
hyperthermia if they occur
residual deficits.
4.
Administer large doses of antibiotic IV as ordered:
By oral or nasopharyngeal route
consult audiologist
Signs and Symptoms
Cerebrovascular Accident (CVA) (Stroke/Brain
2.
Headache, photophobia, general body malaise, irritability,
Attack/Apoplexy/Cerebral Thrombosis)
3.
Projectile vomiting: due to increase ICP
4.
Fever & chills
5.
Anorexia & weight loss
A partial or complete disruption in the brains blood supply.
6.
Possible seizure activity & decrease LOC
2 largest & most common cerebral artery affected by stroke:
7.
Abnormal posturing: (decorticate and decerebrate)
a.
Mid Cerebral Artery
8.
Signs of Meningeal Irritation:
b.
Internal Cerebral Artery
Destruction (infarction) of brain cells caused by a reduction
in cerebral blood flow and oxygen
a.
Nuchal rigidity or stiff neck: initial sign
b.
Opisthotonos (arching of back): head & heels bent
Incidence Rate:
a.
backward & body arched forward
c.
PS: Kernig’s sign (leg pain): contraction or pain in the
hamstring muscles when attempting to extend the leg
when the hip is flexed
d.
risk; Incidence increase with age
Causes:
a.
Thrombosis (attached)
b.
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.
Affects men more than women; Men are 2-3 times high
brain & cause cerebral embolism.
c.
Hemorrhage
d.
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.
Sudden sharp chest pain
culture positive for specific M.O.
2.
Unexplained dyspnea
A hollow spinal needle is inserted in the subarachnoid
3.
SOB
space between the L3-L4 or L4-L5.
4.
Tachycardia
5.
Palpitations
Nursing Management Before Lumbar Puncture
6.
Diaphoresis
1.
Secure informed consent and explain procedure.
7.
Mild restlessness
2.
Empty bladder and bowel to promote comfort.
3.
Encourage to arch back to clearly visualize L3-L4.
S/sx of Cerebral Embolism
1.
Headache
Nursing Management Post Lumbar Puncture
2.
disorientation
1.
Place flat on bed 12 – 24
3.
Confusion
2.
Force fluids
4.
Decrease LOC
o
13
14
1.
S/sx Compartment syndrome
Vomiting
Fat embolism is the most feared complications w/in
Seizure
24 hrs after a femur fracture.
Confusion
Yellow bone marrow are produced from the
Disorientation
medullary cavity of the long bones and produces
Decrease LOC
fat cells.
Nuchal Rigidity
Fever
Hypertension
Slow Bounding Pulse
Cheyne-Strokes Respiration
(+) Kernig’s & Brudzinski sign: may lead to hemorrhagic
If there is bone fracture there is hemorrhage and
there would be escape of the fat cells in the
circulation.
Risk Factors
Disease:
1.
Hypertension
2.
Diabetes Mellitus
3.
Atherosclerosis / Arteriosclerosis
4.
stroke
3.
Focal Signs (related to site of infarction):
Hemiplegia
Myocardial Infarction
Homonymous hemianopsia: loss of half of visual field
5.
Mitral valve replacement
Sensory loss
6.
Valvular Disease / replacement
Aphasia
7.
Chronic atrial Fibrillation
Dysarthia: inability to articulate words
8.
Post Cardiac Surgery
Alexia: difficulty reading
Agraphia: difficulty writing
Lifestyle:
1.
Smoking
2.
Sedentary lifestyle
1.
CT & Brain Scan: reveals brain lesions
3.
Obesity (increase 20% ideal body weight)
2.
EEG: abnormal changes
4.
Hyperlipidemia more on genetics/genes that binds to
3.
Cerebral Arteriography: invasive procedure due to injection
5.
6.
Dx
cholesterol
of dye (iodine based); Uses dye for visualization
Type A personality
May show occlusion or malformation of blood vessels
a.
Deadline driven
Reveals the site and extent of malocclusion
b.
Can do multiple tasks
c.
Usually fells guilty when not doing anything
Nursing Management Post Cerebral Arteriography
Related to diet: increase intake of saturated fats like whole
Allergy Test (shellfish)
milk
Force fluids to release dye because it is nephro toxic
Check for peripheral pulse: distal (femoral)
Check for hematoma formation
7.
Related stress physical and emotional
8.
Prolong use of oral contraceptives: promotes lypolysis
(breakdown of lipids) leading to atherosclerosis that will lead
to hypertension & eventually CVA.
Pathophysiology
1.
1.
Interruption of cerebral blood flow for 5 min or more causes
death of neurons in affected area with irreversible loss of
function.
2.
Nursing Intervention: Acute Stage
Modifying Factors:
a.
Cerebral Edema:
Develops around affected area causing further
2.
May help to maintain cerebral blood flow when there
Dietary modification (decrease salt, saturated fats
and caffeine)
d.
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.
Nursing Intervention: Rehabiltation
1.
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.
Turn every 2 hrs (20 min only on affected side)
b.
Use proper positioning & repositioning to prevent
c.
2.
3.
4.
Predisposing Factors
deformities (foot drop, external rotation of hips, flexion
1.
Head injury due to birth trauma
of fingers, wrist drop, abduction of shoulder & arms)
2.
Genetics
Support paralyzed arm on pillow or use sling while out of
3.
Presence of brain tumor
bed to prevent subluxation of shoulders
4.
Toxicity from the ff:
d.
Elevate extremities to prevent dependent edema
a.
Lead
e.
Provide active & passive ROM exercises every 4 hrs
b.
Carbon monoxide
Susceptibility to hazard
5.
Nutritional and Metabolic deficiencies
a.
Keep side rails up at all times
6.
Physical and emotional stress
b.
Institute safety measures
7.
Sudden withdrawal to anti-convulsant drug: is predisposing
c.
Inspect body parts frequently for signs of injury
factor for status epilepticus: DOC: Diazepam (Valium) &
Glucose
Dysphagia: difficulty of swallowing
a.
Check for gag reflex before feeding client
b.
Maintain a calm, unhurried approach
S/sx
c.
Place client in upright position
d.
Place food in unaffected side of the mouth
e.
Offer soft foods
f.
Give mouth care before & after meals
Homonymous Hemianopsia: loss of right or left half of each
1.
Dependent on stages of development or types of seizure
Generalized Seizure
Initial onset in both hemisphere, usually involves loss of
consciousness & bilateral motor activity.
a.
Major Motor Seizure (Grand mal Seizure): tonic-clonic
visual field
seizure
a.
Approach the client on unaffected side
b.
Place personal belongings, food etc., on unaffected side
c.
Gradually teach the client to compensate by scanning
sensory experience
(ex. Turning the head to see things on affected side)
5.
Emotional Lability: mood swings, frustrations
a.
6.
consciousness for 3-5 minutes
Tonic Phase:
Limbs contract or stiffens
excessive sensory stimuli
Pupils dilated & eye roll up to one side
Glottis closes: causing noise on exhalation
May be incontinent
Occurs at same time as loss of consciousness
Maintain a calm, non-threatening manner
c.
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.
Pantomime, demonstration)
b.
Epileptic cry: is characterized by fall and loss of
Create a quiet, restful environment with a reduction in
b.
a.
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.
Eyelids (Palpebrae) & Eyelashes: protect the eye from
foreign particles
b.
Conjunctiva:
drowsiness
b.
Usually non-organic brain damage present
Must be differentiated from daydreaming
Sudden onset with twitching & rolling of eyes that last
2.
covers anterior sclera
c.
Lacrimal Apparatus (lacrimal gland & its ducts & passage):
produces tears to lubricate the eye & moisten the cornea;
Common among pediatric clients characterized by:
tears drain into the nasolacrimal duct, which empties into
Blank stare
Decrease blinking of eyes
Twitching of mouth
Loss of consciousness (5 – 10 seconds)
nasal cavity
d.
The movement of the eye is controlled by 6 extraocular
muscles (EOM)
Internal Structure of Eye
A.
3 layers of the eyeball
1.
Begins in focal area of brain & symptoms are related to
May progress into a generalized seizure
a.
Jacksonian Seizure (focal seizure)
Outer Layer
a.
a dysfunction of that area
b.
2.
Middle Layer
a.
and other side of the body.
Purposeful but inappropriate repetitive motor acts
Aura is present: daydreaming like
Automatism: stereotype repetitive and non
b.
Ciliary Body: anterior to choroid, secrets aqueous
humor; muscle change shape of lens
c.
Iris: pigmented membrane behind cornea, gives
color to eye; located anteriorly
d.
Pupil: is circular opening in the middle of the iris that
propulsive behavior
constrict or dilates to regulate amount of light
Clouding of consciousness: not in contact with
entering the eye
3.
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.
Bulbar Conjunctiva: white with small blood vessels,
20-40 sec
Partial or Localized Seizure
eyelids
Absence Seizure (Petit mal Seizure):
Palpebral Conjunctiva: pink; lines inner surface of
Inner Layer
a.
Mild hallucinatory sensory experience
Light-sensitive layer composed of rods & cones
(visual cell)
3.
Status Epilepticus
Usually refers to generalized grand mal seizure
Seizure is prolong (or there are repeated seizures
color vision; (daylight / colored vision)
Rods: more sensitive to light than cones, aid
in peripheral vision; (night twilight vision)
without regaining consciousness) & unresponsive to
b.
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.
If left untreated can lead to hyperpyrexia and lead to
C. Fluid of the eye
1.
coma and eventually death.
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. Diagnostic Procedures
pressure
1. CT Scan – reveals brain lesions
2.
2. EEG – reveals hyper activity of electrical brain waves
D. Nursing Management
1. Maintain patent airway and promote safety before seizure activity
a. clear the site of blunt or sharp objects
b. loosen clothing of client
c. maintain side rails
Vitreous Humor: clear, gelatinous material that fills
posterior cavity of eye; maintains transparency & form
of eye
Visual Pathways
a.
Retina (rods & cones) translates light waves into neural
impulses that travel over the optic nerves
b.
Optic nerves for each eye meet at the optic chiasm
d. avoid use of restrains
Fibers from median halves of the retinas cross here
& travel to the opposite side of the brain
e. turn clients head to side to prevent aspiration
f. place mouth piece of tongue guard to prevent biting or
Fibers from lateral halves of retinas remain
uncrossed
tongue
2. Avoid precipitating stimulus such as bright/glaring lights and
c.
Optic nerves continue from optic chiasm as optic tracts &
noise
travels to the cerebrum (occipital lobe) where visual
3. Administer medications as ordered
impulses are perceived & interpreted
a. Anti convulsants (Dilantin, Phenytoin)
b. Diazepam, Valium
c. Carbamazepine (Tegnetol) – trigeminal neuralgia
Canal of schlemm: site of aqueous humor drainage
d. Phenobarbital, Luminal
Meibomian gland: secrets a lubricating fluid inside the eyelid
4. Institute seizure and safety precaution post seizure attack
a. administer O2 inhalation
Maculla lutea: yellow spot center of retina
Fovea centralis: area with highest visual acuity or acute vision
b. provide suction apparatus
5. Document and monitor the following
2 muscles of iris:
a. onset and duration
Circular smooth muscle fiber: Constricts the pupil
b. types of seizures
Radial smooth muscle fiber: Dilates the pupil
c. duration of post ictal sleep may lead to status epilepticus
d. assist in surgical procedure cortical resection
Physiology of vision
4 Physiological processes for vision to occur:
Overview Anatomy & Physiology of the Eye
External Structure of Eye
1.
Refraction of light rays: bending of light rays
2.
Accommodation of lens
3.
Constriction & dilation of pupils
16
17
4.
Convergence of eyes
Dx
Unit of measurements of refraction: diopters
1.
Visual Acuity: reduced
2.
Tonometry: reading of 24-32 mmHg suggest glaucoma; may
Normal eye refraction: emmetropia
be 50 mmHg of more in acute (close-angle) glaucoma
Normal IOP: 12-21 mmHg
3.
Ophthalmoscopic exam: reveals narrowing of small vessels
of optic disk, cupping of optic disk
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.
Vertigo
Unusual sensations in the ear
Cochlea
Controls hearing
Contains Organ of Corti (the true organ of hearing):
8.
Provide client teaching & discharge planning
the receptor end-organ for hearing
concerning:
Transmit sound waves from the oval window &
a.
with mouth open
initiates nerve impulses carried by cranial nerve VIII
b.
(acoustic branch) to the brain (temporal lobe of
3.
Organ of balance
Composed of three semicircular canals & the utricle
For static equilibrium
Mastoid air cells
Air filled spaces in temporal bone in skull
No flying for 6 mos. Especially if upper respiratory
tract infection is present
d.
Placement of cotton balls in auditory meatus after
packing is removed; change twice daily
Endolymph & Perilymph
4.
c.
Vestibular Apparatus
Need to keep ear dry in the shower; no shampooing
until allowed
cerebrum)
2.
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.
Incidence highest between ages 30 & 60
inner ear
Cause
1.
Predisposing Factor
2.
Unknown / idiopathic
Found more often in women
3.
Theories include the ff:
a.
Allergy
Cause
b.
Toxicity
1.
Unknown / idiopathic
c.
Localized ischemia
2.
There is familial tendency
d.
Hemorrhage
3.
Ear trauma & surgery
e.
Viral infection
f.
Edema
S/sx
1.
Progressive hearing loss
2.
Tinnitus
S/sx
19
20
1.
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.
N/V
b.
3.
Tinnitus
production of the stimulating hormone, resulting in
4.
Progressive hearing loss
decreased secretion of the target organ hormone
5.
Nystagmus
3.
Increased concentration of a hormones inhibits
Some hormones are controlled by changing blood levels of
specific substances (ex. Calcium, glucose)
Dx
4.
1.
Audiometry: reveals sensorineural hearing loss
2.
Vestibular Test: reveals decrease function
Certain hormones (ex. Cortisol or female reproductive
hormones) follow rhythmic patterns of secretion
5.
Autonomic & CNS control (pituitary-hypothalamic axis):
hypothalamus controls release of the hormones of the
1.
Medical Management
anterior pituitary gland through releasing & inhibiting
Acute:
factors that stimulate or inhibits hormone secretions
2.
Atropine (decreases autonomic nervous system
activity)
Hormone Function
Diazepam (Valium)
Endocrine G
Fentanyl & Droperidol (Innovar)
Pituitary G
Chronic:
a.
Hormone
Anterior lobe
Functions
: TSH
: stimulate
thyroid G to release thyroid hormones
Drug Therapy:
: ACTH
: stimulate adrenal
Vasodilators (nicotinic Acid)
Diuretics
cortex to produce &
Mild sedative or tranquilizers: Diazepam
release
adrenocoticoids
(Valium)
b.
3.
Antihistamines: Diphenhydramine (Benadryl)
Meclizine (antivert)
Diet:
Low sodium diet
Restricted fluid intake
Restrict caffeine & nicotine
: FSH, LH
maturation, & function of primary
& secondary sex
organ
: GH, Somatotropin
: Prolactin or LTH
unilateral)
b.
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.
decrease urine
Maintain bed rest in a quiet, darkened room in position
Output
of choice; elevate side rails as needed
2.
Only move the client for essential care (bath may not be
essential)
3.
Provide emesis basin for vomiting
4.
Monitor IV Therapy; maintain accurate I&O
5.
Assist in ambulation when the attack is over
6.
Administer medication as ordered
7.
Prepare client for surgery as indicated (pot-op care
includes using above measures)
8.
Provide client care & discharge planning concerning:
a.
Use of medication & side effects
b.
Low sodium diet & decrease fluid intake
c.
Importance of eliminating smoking
Overview of Anatomy & Physiology of Endocrine System
Endocrine System
Is composed of an interrelated complex of glands (Pituitary
G, Adrenal G, Thyroid G, Parathyroid G, Islets of langerhans
of the pancreas, Ovaries & Testes) that secretes a variety of
hormones directly into the bloodstream.
Its major function, together with the nervous system: is to
: Oxytocin
1.
Release of milk in
lactation
Intermediate lobe
inhibiting various processes
Two Major Categories
a.
Adrenal Cortex
General: hormones transported in the blood to distant
sites where they exert their effects (ex. Cortisol)
2.
Negative Feedback Mechanisms: major means of regulating
hormone levels
a.
Decreased concentration of a circulating hormones
triggers production of a stimulating hormones from
: Mineralocorticoid
: regulate fluid &
electrolyte balance; stimulate
(ex. Aldosterone)
reabsoption
of sodium, chloride, & H2O; stimulate
potassium excretion
: Glucocorticoids
: increase
blood glucose level by increasing rate of
(ex. Cortisol,
acid; promote sodium & H2O
retention; anti-inflammatory effect; aid body in
coping
with stress
: Sex Hormones
: influence
development of secondary sex
(androgens, estrogens characeristics
progesterones)
Adrenal Medulla
: Epinephrine,
: function in acute
stress; increase HR, BP; dilates
Norepinephrine
bronchioles;
convert glycogen to glucose when
secretion (ex. Secretin, cholecystokinin, panceozymin
b.
: affects skin
Adrenal G
Local: hormones with specific effect in the area of
[CCK-PZ])
: MSH
pigmentation
Hormones: chemical substance that acts s messenger to
specific cells & organs (target organs), stimulating &
: stimulate uterine
contractions during delivery & the
regulate body function
Hormones Regulation
: regulates H2O
metabolism; release during stress
Intracranial division of vestibular portion of cranial
nerve VIII
c.
: 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.
: stimulate growth,
Needed by the
muscles for energy
Thyroid G
: T3, T4
: regulate metabolic
rate; CHO, fats, & CHON
Metabolism;
aid
in
regulating physical & mental
20
21
Growth
&
1.
lowers
2.
development
Lead to blindness due to severe
photophobia
: Thyrocalcitonin
:
Prone to skin cancer
serum calcium & phosphate levels
Adrenal Glands
Parathyroid G
: PTH
:
regulates
serum
calcium & phosphate levels
top of each kidney
Pancreas (islets of
2 Sections of Adrenal Glands
Langerhans)
Two small glands, one above each kidney; Located at
1.
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.
Testes
Zona Reticularis: secretes traces of glucocorticoids
& androgenic hormones: promotes secondary sex
& glycogenolysis in
Ovaries
Zona Fasciculata: secretes glucocortocoids (cortisol):
:
development
o
of
secretion of norepinephrine: Leading to
secondary sex characteristics in the
hypertension which is resistant to
Male maturation of
pharmacological agents leading to CVA: Use
the sex organs, sexual functioning
Pituitary Gland (Hypophysis)
Located in sella turcica at the base of brain
“Master Gland” or master clock
Controls all metabolic function of body
beta-blockers
Thyroid Gland
Located in anterior portion of the neck
Consist of 2 lobes connected by a narrow isthmus
Produces thyroxine (T4), triiodothyronine (T3),
3 Lobes of Pituitary Gland
1.
thyrocalcitonin
Anterior Lobe PG (Adenohypophysis)
a.
Secretes tropic hormones (hormones that stimulate
target glands to produce their hormones):
adrenocorticotropic H (ACTH), thyroid-stimulating H
(TSH), follicle-stimulating H (FSH), luteinizing H (LH)
b.
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.
Intermediate Lobe PG
T3 and T4 are metabolic hormone: increase brain
Secretes melanocytes stimulating H (MSH)
MSH: for skin pigmentation
Hyposecretion of MSH: results to albinism
Hypersecretion of MSH: results to vitiligo
2 feared complications of albinism:
Thyrocalcitonin: antagonizes the effects of
Parathyroid Gland
4 small glands located in pairs behind the thyroid gland
Produce parathormone (PTH)
Promotes calcium reabsorption
Pancreas
Located behind the stomach
Has both endocrine & exocrine function (mixed gland)
Consist of Acinar Cells (exocrine gland): which secretes
pancreatic juices: that aids in digestion
Islets of langerhans (alpha & beta cells) involved in
endocrine function:
Alpha Cell: produce glucagons: (function:
hyperglycemia)
Beta Cell: produce insulin: (function: hypoglycemia)
Delta Cells: produce somatostatin: (function:
antagonizes the effects of growth hormones)
Gonads
Ovaries: located in pelvic cavity; produce estrogen &
progesterone
Administer oxytocin immediately after delivery to
prevent uterine atony.
T4: 4 molecule of iodine
parathormone to promote calcium reabsorption.
Regulated by hypothalamic releasing & inhibiting factors
HYPOTHYROIDISM
- all are decrease except weight and menstruation
- memory impairment
Signs and Symptoms
- there is loss of appetite but there is weight gain
- menorrhagia
- cold intolerance
anuria)
- constipation
Dx
1.
Urine Specific Gravity (NV: 1.015 – 1.030): less than 1.004
2.
Serum Na: increase resulting to hypernatremia
3.
H2O deprivation test: reveals inability to concentrate urine
HYPERTHYROIDISM
- all are increase except weight and menstruation
Signs and Symptoms
- increase appetite but there is weight loss
Nursing Intervention
1.
2.
3.
Maintain F&E balance / Force fluids 2000-3000 ml/day
a.
Keep accurate I&O
b.
Weigh daily
c.
Administer IV/oral fluids as ordered to replace fluid loss
Monitor strictly V/S & observe for signs of dehydration &
Thyroid Disorder
Simple Goiter
Enlargement of thyroid gland due to iodine deficiency
Administer hormone replacement as ordered:
Enlargement of the thyroid gland not caused by
b.
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
Administer hormone replacement therapy as ordered:
a.
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.
Predisposing Factors
Corticosteroids: Dexamethasone (Decadrone)
1.
Strenuous activity
Hydrocortisone: Cortisone (Prednisone)
2.
Stress
3.
Trauma
4.
Infection
5.
Failure to take prescribe medicine
6.
Iatrogenic:
Mineralocorticoids:
Fludrocortisone Acetate (Florinef)
Nursing Management when giving steroids
1.
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.
Taper dose (withdraw gradually from drug)
3.
Monitor side effects:
S/sx
Hypertension
1.
Generalized muscle weakness
Edema
2.
Severe hypotension
Hirsutism
3.
Hypovolemic shock: vascular collapse
Increase susceptibility to infection
4.
Hyponatremia: leading to progressive stupor and
Moon face appearance
coma
2.
Monitor V/S
3.
Decrease stress in the environment
4.
Prevent exposure to infection
5.
Provide rest period: prevent fatigue
6.
Weight daily
7.
Provide small frequent feeding of diet: decrease in K,
Nursing Intervention
&
discharge
a.
Disease process: signs of adrenal insufficiency
b.
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.
Stress management technique
e.
Diet modification
f.
Use of salt tablet (if prescribe) or ingestion of salty
foods (potato chips): if experiencing increase
i.
j.
If crisis precipitate by infection: administer
Importance of alternating regular exercise with rest
Maintain strict bed rest & eliminate all forms of
7.
Monitor V/S, I&O & daily weight
8.
Protect client from infection
9.
Provide client teaching & discharge planning
Cushing Syndrome
Condition resulting from excessive secretion of
corticosteroids, particularly glucocorticoid cortisol
Hypersecretion of adrenocortical hormones
Predisposing Factors
1.
Primary Cushing’s Syndrome: caused by adrenocortical
tumors or hyperplasia
sweating
h.
5.
concerning: same as addison’s disease
need to be adjusted
g.
Force fluids
stressful stimuli
planning
concerning:
c.
4.
6.
Provide meticulous skin care
teaching
Administer IV glucocorticoids: Hydrocortisone (Solu-
antibiotics as ordered
(complication of addison’s disease)
client
Administer IV fluids (5% dextrose in saline, plasma)
Cortef) & vasopressors as ordered
Monitor I&O: to determine presence of addisonian crisis
10. Provide
2.
3.
& hyponatremia & provide proper nutrition
9.
Assist in mechanical ventilation
as ordered: to treat vascular collapse
increase cal, CHO, CHON, Na: to prevent hypoglycemia,
8.
1.
2.
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.
Iatrogenic: cause by prolonged use of corticosteroids
crisis: stress, infection, sudden withdrawal to
4.
Related to hyperplasia of adrenal gland
steroids
5.
Increase susceptibility to infections
Prevent complications: addisonian crisis,
S/sx
hypovolemic shock
1.
Muscle weakness
14. Signs of masculinization in women: menstrual
2.
Fatigue
3.
Obese trunk with thin arms & legs
15. Osteoporosis
4.
Muscle wasting
16. Decrease resistance to infection
5.
Irritability
17. Hypertension
6.
Depression
18. Edema
7.
Frequent mood swings
19. Hypernatremia
8.
Moon face
20. Weight gain
9.
Buffalo hump
21. Hypokalemia
dysfunction, decrease libido
10. Pendulous abdomen
22. Constipation
11. Purple striae on trunk
23. U wave upon ECG (T wave hyperkalemia)
12. Acne
24. Hirsutis
13. Thin skin
25. Easy bruising
Dx
Nursing Intervention
1.
FBS: is increased
1.
2.
Plasma Cortisol: is increased
a.
Provide ROM exercise
3.
Serum Sodium: is increased
b.
Assist in ambulation
4.
Serum Potassium: is decreased
2.
Maintain muscle tone
Prevent accidents fall & provide adequate rest
27
28
3.
Protect client from exposure to infection
4.
Maintain skin integrity
a.
Provide meticulous skin care
HYPERGLYCEMIA
b.
Prevent tearing of the skin: use paper tape if
Increase osmotic diuresis
necessary
5.
Minimize stress in the environment
6.
Monitor V/S: observe for hypertension & edema
7.
Monitor I&O & daily weight: assess for pitting edema:
Glycosuria
Polyuria
Cellular starvation: weight loss
dehydration
Measure abdominal girth: notify physician
8.
Provide diet low in Calorie & Na & high in CHON, K, Ca,
Stimulates the appetite / satiety center
Vitamin D
9.
Cellular
Monitor urine: for glucose & acetone; administer insulin
Stimulates the thirst center
(Hypothalamus)
as ordered
10. Provide psychological support & acceptance
(Hypothalamus)
11. Prepare client for hypophysectomy or radiation: if
Polyphagia
condition is caused by a pituitary tumor
Polydypsia
12. Prepare client for Adrenalectomy: if condition is caused
by an adrenal tumor or hyperplasia
* liver has glycogen that undergo glycogenesis/glycogenolysis
13. Restrict sodium intake
GLUCONEOGENESIS
14. Administer medications as ordered: Spironolactone
therapy or reduce dosage): if caused of condition is
INCREASE FAT CATABOLISM
prolonged corticosteroid therapy
e.
Prevent complications (DM)
f.
Hormonal replacement for lifetime: lifetime due to
Free fatty acids
adrenal gland removal: no more corticosteroid!
g.
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.
Type I Insulin-dependent Diabetes Mellitus (IDDM)
Secondary to destruction of beta cells in the islets of
leads to osmitic diuresis as large amounts of glucose pass through
langerhans in the pancreas resulting in little of no insulin
the kidney result polyuria & glycosuria = Diuresis leads to cellular
production
dehydration & F & E depletion causing polydipsia (excessive thirst)
= Polyphagia (hunger & increase appetite) result from cellular
starvation = The body turns to fat & CHON for energy but in the
absence of glucose in the cell fat cannot be completely metabolized
Non-obese adults
Requires insulin injection
Juvenile onset type (Brittle disease)
& ketones (intermediate products of fat metabolism) are produced =
This leads to ketonemia, ketonuria (contributes to osmotic diuresis)
& metabolic acidosis (ketones are acid bodies) = Ketone sacts as
Incidence Rate
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.
Predisposing Factors
1.
Autoimmune response
2.
Genetics / Hereditary (total destruction of pancreatic
cells)
Identifies presence or absence of Rh antigens (Rh + or
__________________
Rh -)
Circulatory
b.
Anti-Rh antibodies not automatically formed in Rh (-)
persons, but if Rh (+) blood is given, antibody formation
starts & second exposure to Rh antigen will trigger a
transfusion reaction
Too rapid
Dyspnea,
Overload
transfusion
Fluid volume
During & after
Slow infusion rate
infusion in
overload
increase BP,
Used packed cells
Susceptible
tachycardia,
instead of whole
33
34
Client
orthopnea,
blood.
Common Pathways: activated by either intrinsic or extrinsic
pathways
cyanosis, anxiety
1.
Platelet factor 3 (PF3) & calcium react with factor X & V
2.
Prothrombin converted to thrombin via thromboplastin
hro
3.
Thrombin acts on fibrinogens, forming soluble fibrin
ug
4.
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.
_____________________________________________________________________
proteolytic enzymes; clots dissolves as tissue repairs.
__________________
Air Embolism
Blood given
Dyspnea,
Bolus of air
Anytime
Spleen
Clamp tubing.
under air
blocks pulmonary
system & reservoir
increase pulse, Turn client on
pressure
wheezing, chest
Largest Lymphatic Organ: functions as blood filtration
artery outflow
Vascular bean shape; lies beneath the diaphragm, behind &
to the left of the stomach; composed of fibrous tissue
left side
capsule surrounding a network of fiber
following severe
pain, decrease BP,
blood loss
Contains two types of pulp:
a.
apprehension
composed of RBC, WBC & macrophages
_____________________________________________________________________
__________________ThromboWhen large
cytopenia
Used of large
Abnormal
amount of
bleeding
b.
Platelets
Assess for signs
deteriorate
& antigens
amount
of
blood
given
over
cleansing, then passes into splenic venules that are lined
with phagocytic cells & finally to the splenic vein to the liver.
blood
precautions.
Important in phagocytosis; removes misshapen
erythrocytes, unwanted parts of erythrocytes
Platelet Concentration, Fresh Whole Blood: provision of
platelets
peaked T-waves,
potassium
Blood & Blood Products
short Q-T
excretion
1.
seg
Whole Blood: provides all components
a.
ments)
& Hct to rise
b.
Blood Coagulation
Large volume can cause difficulty: 12-24 hr for Hgb
Complications: volume overload, transmission of
hepatitis or AIDS, transfusion reacion, infusion of
Conversion of fluid blood into a solid clot to reduce blood
excess potassium & sodium, infusion of
loss when blood vessels are ruptured
anticoagulant (citrate) used to keep stored blood
from clotting, calcium binding & depletion (citrate)
System that Initiating Clotting
1.
Intrinsic System: initiated by contact activation following
in massive transfusion therapy
2.
endothelial injury (“intrinsic” to vessel itself)
a.
a.
Factor XII: initiate as contact made between damaged
2.
b.
Factors VIII, IX & XI activated
b.
Indicate in cases of blood loss, pre-op & post-op
client & those with incipient congestive failure
Extrinsic System:
a.
Provide twice amount of Hgb as an equivalent
amount of whole blood
vessel & plasma CHON
b.
Red Blood Cell (RBC)
c.
Complication: transfusion reaction (less common
Initiated by tissue thromboplastins released from injured
than with whole blood: due to removal of plasma
vessels (“extrinsic” to vessel)
protein)
Factor VII activated
3.
Fresh Frozen Plasma
34
35
a.
Contains all coagulation factors including V & VIII
g.
Cytrate intoxication
b.
Can be stored frozen for 12 months; takes 20
h.
Hyperkalemia (caused by expired blood)
minutes to thaw
c.
Hang immediately upon arrival to unit (loses its
S/sx of Hemolytic reaction
coagulation factor rapidly)
4.
5.
Platelets
1.
Headache and dizziness
2.
Dyspnea
3.
Diarrhea / Constipation
a.
Will raise recipient’s platelet count by 10,000/mm
b.
Pooled from 4-8 units of whole blood
4.
Hypotension
c.
Single-donor platelet transfusion may be necessary
5.
Flushed skin
for clients who have developed antibodies;
6.
Lumbasternal / Flank pain
compatibilities testing may be necessary
7.
Urine is color red / portwine urine
3
Factor VIII Fractions (Cryoprecipitate): contains factor
VIII, fibrinogens & XIII
6.
Nursing Management
Granulocytes
1.
Stop BT
a.
Do not increase WBC: increase marginal pool (at
2.
Notify physician
tissue level) rather than circulating pool
3.
Flush with plain NSS
Premedication with steroids, antihistamine &
4.
Administer isotonic fluid solution: to prevent shock and
b.
acetaminophen
c.
acute tubular necrosis
Respiratory distress with shortness of breath,
5.
Send the blood unit to blood bank for re-examination
cyanosis & chest pain may occur; requires cessation
6.
Obtain urine & blood sample & send to laboratory for re-
of transfusion & immediate attention
d.
Shaking chills or rigors common, require brief
examination
7.
Monitor vital signs & I&O
cessation of therapy, administration of meperdine IV
until rigors are diminished & resumption of
transfusion when symptoms relieved
7.
avoiding it (if possible) in future
Disseminated Intravascular Coagulation (DIC)
Cytotoxic agent / Chemotherapeutic Agents:
widespread coagulation all over the body & subsequent
Methotrexate (Alkylating Agent)
Vincristine (Plant Alkaloid)
Nitrogen Mustard (Antimetabolite)
bleeding and thrombosis due to a deficiency of prothrombin
Phenylbutazones (NSAIDS)
and fibrinogen
depletion of clotting factors
S/sx
1.
2.
Anemia
a.
Weakness & fatigue
b.
Headache & dizziness
c.
Pallor & cold sensitivity
d.
Dyspnea & palpitations
Acute hemorrhagic syndrome characterized by wide spread
Hemorrhage from kidneys, brain, adrenals, heart & other
organs
May be linked with entry of thromboplasic substance into
the blood
Mortality rate is high usually because underlying disease
cannot be corrected
Leukopenia
a.
3.
Diffuse fibrin deposition within arterioles & capillaries with
Increase susceptibility to infection
Thrombocytopenia
Pathophysiology
1.
Underlying disease (ex. toxemia of pregnancy, cancer)
a.
Petechiae (multiple petechiae is called purpura)
cause release of thromboplastic substance that promote
b.
Ecchymosis
the deposition of fibrin throughout the microcirculation
c.
Oozing of blood from venipunctured sites
2.
Dx
Microthrombi form in many organs, causing
microinfarcts & tissue necrosis
1.
CBC: reveals pancytopenia
3.
RBC are trapped in fibrin strands & are hemolysed
2.
Normocytic anemia, granulocytopenia,
4.
Platelets, prothrombin & other clotting factors are
thrombocytopenia
3.
Bone marrow biopsy: aspiration (site is the posterior iliac
destroyed, leading to bleeding
5.
crest): marrow is fatty & contain very few developing
Excessive clotting activates the fibrinolytic system,
which inhibits platelet function, causing futher bleeding.
cells; reveals fat necrosis in bone marrow
Predisposing Factors
Medical Management
1.
Related to rapid blood transfusion
Blood transfusion: key to therapy until client’s own
2.
Massive burns
marrow begins to produce blood cells
3.
Massive trauma
2.
Aggressive treatment of infection
4.
Anaphylaxis
3.
Bone marrow transplantation
5.
Septecemia
4.
Drug Therapy:
6.
Neoplasia (new growth of tissue)
a.
7.
Pregnancy
1.
Corticosteroids & / or androgens: to stimulate bone
marrow function & to increase capillary resistance
(effective in children but usually not in adults)
b.
Estrogen & / or progesterone: to prevent
S/sx
1.
amenorrhea in female clients
5.
Petechiae & Ecchymosis on the skin, mucous
membrane, heart, eyes, lungs & other organs
Identification & withdrawal of offending agent or drug
(widespread and systemic)
2.
Nursing Intervention
Prolonged bleeding from breaks in the skin: oozing of
blood from punctured sites
1.
Removal of underlying cause
2.
Administer Blood Transfusion as ordered
3.
Administer O2 inhalation
4.
Hemoptysis
4.
Enforce CBR
5.
Oliguria & acute renal failure (late sign)
5.
Institute reverse isolation
6.
Convulsion, coma, death
6.
Provide nursing care for client with bone marrow
transplant
3.
Severe & uncontrollable hemorrhage during childbirth or
surgical procedure
Dx
38
39
1.
PT: prolonged
2.
PTT: usually prolonged
3.
Thrombin Time: usually prolonged
4.
Fibrinogen level: usually depressed
5.
Fibrin splits products: elevated
6.
Protamine Sulfate Test: strongly positive
7.
Factor assay (II, V, VII): depressed
8.
CBC: reveals decreased platelets
9.
Stool occult blood: positive
10. ABG analysis: reveals metabolic acidosis
11. Opthamoscopic exam: reveals sub retinal hemorrhages
Medical Management
1.
Identification & control the underlying disease is key
Covers surface of the heart, becomes continuous with
visceral layer of serous pericardium
Outer layer
Myocardium
Middle muscular layer
Myocarditis can lead to cardiogenic shock and rheumatic
heart disease
Endocardium
Thin, inner membrabous layer lining the chamber of the
heart
Inner layer
Papillary Muscle
Arise from the endocardial & myocardial surface of the
ventricles & attach to the chordae tendinae
Heparin administration
a.
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 blood loss & attemp to quantify
2.
Monitor for signs of additional bleeding or thrombus
formation
3.
4.
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.
Avoid IM injection
b.
Apply pressure to bleeding site
c.
Turn & position the client frequently & gently
d.
Provide frequent nontraumatic mouth care (ex. soft
Administer isotonic fluid solution as ordered: to prevent
shock
6.
Administer oxygen inhalation
7.
Force fluids
8.
Administer medications as ordered:
9.
a.
Vitamin K
b.
Pitressin / Vasopresin: to conserve fluids
c.
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. Monitor NGT output
12. Prevent complication
a.
Hypovolemic shock: Anuria (late sign of
Left Ventricle: propels blood into the systemic circulation
via aortaduring ventricular systole; Left ventricle has
increased pressure which is 120 – 180 mmHg in order to
propel blood to the systemic circulation
10. 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.
Right Atrium: receives systemic venous blood through
Valves
To promote unidimensional flow or prevent backflow
Atrioventricular Valve
Guards opening between
hypovolemic shock)
Mitral Valve: located between the left atrium & left
13. Provide emotional support to client & significant other
ventricle; contains 2 leaflets attached to the chordae
14. Teach client the importance of avoiding aspirin or
tandinae
aspirin-containing compounds
Tricuspid Valve: located between the right atrium & right
ventricle; contains 3 leaflets attached to the chordae
tandinae
Overview of the Structure & Functions of the Heart
Functions
Cardiovascular system consists of the heart, arteries, veins
specific ventricle during ventricular diastole
& capillaries. 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.
Located on the left mediastinum
Resemble like a close fist
Weighs approximately 300 – 400 grams
Covered by a serous membrane called the pericardium
Semi-lunar Valve
Composed of fibrous (outermost layer) & serous pericardium
Located between left ventricle & aorta
Function
Pemit unidirectional flow of the blood from specific ventricle
to arterial vessel during ventricular diastole
Prevent reflux blood flow during ventricular diastole
Valve open when ventricle contract & close during
(parietal & visceral); a sac that function to protect the heart
ventricular diastole; Closure of SV valve produces second
from friction
heart sound (S2 “dub”)
In between is the pericardial fluid which is 10 – 20 cc:
Prevent pericardial friction rub
Located between the left ventricle & pulmonary artery
Aortic Valve
Heart Wall / Layers of the Heart
Pericardium
Pulmonary Valve
Permit unidirectional flow of blood from specific atrium to
2 layers of pericardium
Parietal: outer layer
Extra Heart Sounds
S3: ventricular gallop usually seen in Left Congestive Heart
Failure
39
40
S4: atrial gallop usually seen in Myocardial Infarction and
Peak T wave: Hyperkalemia
Hypertension
ST segment depression: Angina Pectoris
ST segment elevation: Myocardial Infarction
T wave inversion: Myocardial Infarction
Widening of QRS complexes: Arrythmia
Coronary Circulation
Coronary Arteries
Branch off at the base of the aorta & supply blood to the
myocardium & the conduction system
Arises from base of the aorta
Types of Coronary Arteries
Major function of the blood vessels isto supply the tissue
with blood, remove wastes, & carry unoxygenated blood
Right Main Coronary Artery
Left Main Coronary Artery
back to the heart
Coronary Veins
Vascular System
Types of Blood Vessels
Return blood from the myocardium back to the right atrium
Arteries
via the coronary sinus
Elastic-walled vessels that can stretch during systole &
recoil during diastole; they carry blood away from the heart
Conduction System
& distribute oxygenated blood throughout the body
Sinoatrial Node (SA node or Keith Flack Node)
Located at the junction of superior vena cava and right
Arterioles
Small arteries that distribute blood to the capillaries &
atrium
function in controlling systemic vascular resistance &
Acts as primary pacemaker of the heart
therefore arterial pressure
Initiates the cardiac impulse which spreads across the atria
& into AV node
Capilliaries
The following exchanges occurs in the capilliaries
Initiates electrical impulse of 60-100 bpm
Atrioventricular Node (AV node or Tawara Node)
Located at the inter atrial septum
Delays the impulse from the atria while the ventricles fill
Venules
Delay of electrical impulse for about .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.
When the skeletal surrounding veins contract, the veins are
Located at the interventricular septum
Right Bundle Branch: divided into anterior lateral &
compressed, promoting movement of blood back to the
posterior; transmits impulses down the right side of 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 Injury: Atherosclerosis
2.
Myocardial Ischemia: Angina Pectoris
3.
Myocardial Necrosis: Myocardial Infarction
ATHEROSCLEROSIS
Located at the walls of the ventricles for ventricular
ATHEROSCLEROSIS
Narrowing of artery
ARTERIOSCLEROSIS
Hardening of artery
contraction
Lipid or fat deposits
Calcium and protein
Tunica intima
deposits
Tunica media
Predisposing Factors
SA NODE
AV NODE
BUNDLE OF HIS
JLJLJLJJLJLJL
PURKINJE FIBERS
1.
Sex: male
2.
Race: black
3.
Smoking
4.
Obesity
5.
Hyperlipidemia
6.
Sedentary lifestyle
7.
Diabetes Mellitus
8.
Hypothyroidism
9.
Diet: increased saturated fats
10. Type A personality
Electrical activity of heart can be visualize by attaching electrodes
S/sx
to the skin & recording activity by ECG
1.
Chest pain
Electrocadiography (ECG) Tracing
2.
Dyspnea
3.
Tachycardia
4.
Palpitations
5.
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.
Drug Therapy: if cholesterol is elevated
C - Coronary
Nitrates: Nitroglycerine (NTG)
A - Arterial
Beta-adrenergic blocking agent: Propanolol
B - Bypass
Calcium-blocking agent: nefedipine
Ace Inhibitor: Enapril
A - And
G - Graft
S - Surgery
Objectives
1.
Revascularize myocardium
2.
To prevent angina
3.
Increase survival rate
4.
Done to single occluded vessels
5.
If there is 2 or more occluded blood vessels CABG is done
Acute inflammatory disorder affecting the small / medium
sized arteries & veins of the lower extremities
Occurs as focal, obstructive, process; result in occlusion of a
vessel with a subsequent development of collateral
circulation
Predisposing Factors
1.
High risk groups - men 25-40 years old
S/sx
1.
Coldness
2.
Numbness
3.
Tingling in one or more digits
4.
Pain: usually precipitated by exposure to cold, Emotional
upset & Tobacco use
5.
Intermittent color changes: pallor (white), cyanosis (blue),
rubor (red)
44
45
6.
Small ulceration & gangrene a tips of digits (advance)
1.
Doppler UTZ: decrease blood flow to the affected extremity
2.
Angiography: reveals site & extent of malocclusion
7.
Provide client teaching & discharge planning
Dx
Thrombophlebitis (Deep vein thrombosis)
Inflammation of the vessel wall with formation of clot
(thrombus), may affect superficial or deep veins
Medical Management
1.
Administer medications as ordered
a.
b.
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.
Importance of stop smoking
1.
Obesity
2.
Need to maintain warmth especially in cold weather
2.
Smoking
3.
Need to wear gloves when handling cold object / opening a
3.
Related to pregnancy
freezer or refrigerator door
4.
Severe anemia
5.
Prolong use of oral contraceptives: promotes lipolysis
6.
Prolonged immobility
7.
Trauma
Varicose Veins
8.
Dehydration
Dilated veins that occurs most often in the lower extremities
9.
Sepsis
& trunk. As the vessel dilates the valves become stretched
10. Congestive heart failure
& incompetent with result venous pooling / edema
11. Myocardial infarction
Abnormal dilation of veins of lower extremities and trunks
12. Post-op complication: surgery
due to incompetent valve resulting to increased venous
13. Venous cannulation: insertion of various cardiac catheter
pooling resulting to venous stasis causing decrease venous
14. Increase in saturated fats in the diet.
return
S/sx
Predisposing Factors
1.
Pain in the affected extremity
2.
Superficial vein: Tenderness, redness induration along
1.
Hereditary
2.
Congenital weakness of the veins
3.
Thrombophlebitis
4.
Cardiac disorder
Swelling
5.
Pregnancy
Venous distention of limb
6.
Obesity
Tenderness over involved vein
7.
Prolonged standing or sitting
Positive homan’s sign: pain at the calf or leg muscle
course of the vein
3.
upon dorsi flexion of the foot
S/sx
1.
Pain after prolonged standing: relieved by elevation
2.
Swollen dilated tortuous skin veins
3.
Warm to touch
4.
Heaviness in legs
Dx
1.
Venography
2.
Trendelenburg Test: veins distends quickly in less than 35
1.
calf or thigh compression
Medical Management
1.
Venography (Phlebography): increased uptake of radioactive
material
Doppler ultrasonography: impairment of blood flow ahead of
thrombus
3.
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.
Anti-coagulant therapy
a.
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.
Measure the circumference of ankle & calf muscle daily: to
determine if swollen
3.
Apply anti-embolic / knee-length stockings
4.
Provide adequate rest
5.
Administer medications as ordered
a.
6.
Side effects:
Sclerotherapy: can recur & only done in spider web
Nursing Intervention
1.
Action: block conversion of prothrombin to thrombin
& reduces formation or extension of thrombus
joins the femoral vein & stripping the saphenous vein
2.
Cyanosis
Dx
2.
3.
Deep vein:
b.
Warfarin (Coumadin)
with vit. K synthesis
Analgesics: for pain
Prepare client for vein ligation if necessary
Action: block prothrombin synthesis by interfering
Side effects:
GI:
a.
Provide routine pre-op care: usually OPD
b.
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.
Sudden sharp chest pain
Other:
Unexplained dyspnea
Transient hair loss
Tachycardia
Burning sensation of feet
Palpitations
Bleeding complication
Diaphoresis
Restlessness
Fever
Surgery
a.
Vein ligation & stripping
b.
Venous thrombectomy: removal of cloth in the
Overview of Anatomy & Physiology of the Respiratory System
iliofemoral region
c.
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. Air
is filtered warmed & humidified in the upper airway before
Nursing Intervention
1.
passing to lower airway.
Elevate legs above heart level: to promote increase venous
return & decreased edema
Nose
2.
Apply warm moist pack: to reduce lymphatic congestion
3.
Administer anti-coagulant as ordered:
divided into two passages or nares (nasal cavity) by the
a.
septum: air enters the system through the nares
1.
Heparin
Monitor PTT: dosage should be adjusted to keep PTT
2.
External nose is a frame work of bone & cartilage , internally
The septum is covered with mucous membrane, where the
between 1.5-2.5 times normal control level
olfactory receptors are located. Turbinates, located
Use infusion pump to administer heparin
internally, assist in warming & moistening the air
Ensure proper injection technique
3.
filtering air.
Use 26 or 27 gauge syringe with ½-5/8 inch
needle, inject into fatty layer of abdomen above
4.
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.
A muscular passageway commonly called the throat
2.
Air passes through the nose to the pharynx
3.
Serves as a muscular passageway for both food and air
Use air conditioner with efficiency particulate air
filter: to remove particles from air
16. Barrel chest
d.
17. 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.
2.
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.
bronchitis, “Blue Bloaters”)
Have O2 available as needed to assist with activities
Plan activities that require low amount of energy
Plan rest period before & after activities
Prevent complications
Decrease ph
Atelectasis
Increase PCO2
Cor Pulmonale: R ventricular hypertrophy
Respiratory acidosis
CO2 narcosis: may lead to coma
Pneumothorax: air in the pleural space
Panacinar/centriacinar
Increase PO2 (hyperaxemia, “Pink Puffers”)
f.
Strict compliance to medication
Decrease PCO2
g.
Importance of follow up care
Increase ph
Respiratory alkalosis
Oncology Nursing
Pathophysiology & Etiology of Cancer
Nursing Intervention
Evolution of Cancer Cells
All cells constantly change through growth, degeneration,
1.
Enforce CBR
2.
Administer oxygen inhalation via low inflow
repair, & adaptation. Normal cells must divide & multiply to
3.
Administer medications as ordered
meet the needs of the organism as a whole, & this cycle of
a.
cell growth & destruction is an integral part of life
b.
Bronchodilators: used to treat bronchospam
Aminophylline
Isoproterenol (Isuprel)
Terbutalin (Brethine)
Metaproterenol (Alupent)
Theophylline
Isoetharine (Bronkosol)
d.
4.
5.
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.
normal cells & have special features characteristics of the
Prednisone
Anti-microbial / Antibiotics: to treat bacterial infection
Tetracycline
Ampicilline
cancer process.
uncontrolled growth, therefore no definitive cure has
been found.
Facilitate removal of secretions:
Force fluids at least 3 L/day
b.
Provide chest physiotherapy, coughing & deep breathing
c.
Nebulize & suction when needed
d.
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.
The term neoplasia refers to both benign & malignant
growths, but malignant cells behave very differently from
Corticosteroids:
c.
processes. The activities of the normal cell in the human
Characteristics of Malignant Cells
Cancer cells are mutated stem cells that have undergone
structural changes so that they are unable to perform the
normal functions of specialized tissues.
Improve ventilation
They may function is a disorderly way to crease normal
a.
Position client to semi or high fowlers
b.
Instruct the client diaphragmatic muscles to breathe
function completely, only functioning for their own survival
c.
Encourage productive cough after all treatment (splint
& growth.
abdomen to help produce more expulsive cough)
d.
The most undifferentiated cells are also called anaplastic.
Different drug act on tumor cell in different stages of the cell
growth cycle.
Types of Chemotherapeutic Drugs
Tissue Typing:
Ability of the drug to kill cancer cells; normal cells may also
Carcinoma – arises from surface, glandular, or parenchymal
epithelium
1.
Squamous Cell Carcinoma – surface epithelium
2.
Adenocarcinoma – glandular or parenchymal tissue
1.
Antimetabolites
o
Foster cancer cell death by interfering with cellular
metabolic process.
2.
Alkylating Agent
Sarcoma – arises from connective tissue
Leukemia – from blood
Lymphoma – from lymph glands
o
obtained from periwinkle plant.
Multiple Myeloma – from bone marrow
o
makes the host’s body a less favorable environment
o
3.
Plant Alkaloids
Stages of Tumor Growth
for the growth of cancer cells.
A. Staging System:
4.
TNM System: uses letters & numbers to designate the
Antitumor Antibiotics
o
extent of tumors
o
affect RNA to make environment less favorable for
cancer growth.
T– stands for primary growth; 1-4 with increasing
5.
size; T1S indicates carcinoma in situ
o
act with DNA to hinder cell growth & division.
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.
indicates progressively advancing nodal disease
o
M – stands for metastasis; 0 indicates no distant
Major Side Effects & Nursing Intervention
metastases, 1 indicates presence of metastases
Stages
0 – IV: all cancers
divided into five stages
A. GI System
incorporating size, nodal involvement & spread
B. Cytologic Diagnosis of Cancer
Nausea & Vomiting
o
Administer antiemetics routinely q 4-6 hrs as well as
1.
Involves in the study of shed cells (ex. Pap smear)
2.
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.
Definitely cancer
o
Maintain good perineal care.
o
Give clear liquids as tolerated.
o
Monitor K, Na, Cl levels.
prophylactically before chemotherapy is initiated.
Client Factors
1.
Seven warning signs of cancer
2.
BSE – breast self – examination
3.
Importance of retal exam for those over age 40
4.
Hazards of smoking
5.
Oral self – examination as well as annual exam of mouth
& teeth
6.
Hazards of excess sun exposure
7.
Importance of pap smear
Diarrhea
Stomatitis (mouth sore)
o
Provide & teach the client good oral hygiene,
including avoidance of commercial mouthwashes.
o
Rinse with viscous lidocaine before meals to provide
analgesic effect.
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.
effects.
Apply H2O lubricant such as K-Y jelly to lubricate
Localized effects are related to the area of the body being
cracked lips.
treated; generalized effects maybe related to cellular
Advice client to suck on Popsicles or ice chips to
breakdown products.
provide moisture.
Types of Energy Emitted
B. Hematologic System
Alpha – particles cannot passed through skin, rarely used.
Beta
Thrombocytopenia
–
particle
cannot
passed
through
skin,
more
penetrating than alpha, generally emitted from radioactive
o
Avoid bumping or bruising the skin.
o
Protect client from physical injury.
o
Avoid aspirin or aspirin products.
common form of external radiotherapy (ex. Electromagnetic
o
Avoid giving IM injections.
or X-ray)
o
Monitor blood counts carefully.
o
Assess for signs of increase bleeding tendencies
(epistaxis, petechiae, ecchymoses)
isotopes, used for internal source.
Gamma – penetrate more deeper areas of the body, most
Methods of Delivery
External Radiation Therapy – beams high energy rays
directly to the affected area. Ex. Cobalt therapy
Leukopenia
Internal Radiation Therapy – radioactive material is injected
o
Use careful handwashing technique.
or implanted in the client’s body for designated period of
o
Maintain reverse isolation if WBC count drops below
time.
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.
o
o
Provide adequate rest period
o
Monitor hemoglobin & hematocrit
o
Protect client from injury
o
Administer O2 if needed
Alopecia
o
Explain that hair loss is not permanent
o
Offer support & encouragement
o
Scalp tourniquets or scalp hypothermia via ice pack
contaminate body fluids.
Factors Controlling Exposure
Half-life – time required for half of radioactive atoms to
decay.
treatment
D. Renal System
Each radioisotope has different half-life.
2.
At the end of half-life the danger from exposure
Time – the shorter the duration the less the exposure.
Distance – the greater the distance from the radiation
source the less the exposure.
Shielding – all radiation can be blocked; rubber gloves for
alpha & usually beta rays; thick lead or concrete stop
gamma rays.
agent
Advice client to obtain wig before initiating
1.
decreases.
may be ordered to minimize hair loss with some
o
Unsealed source – a radioisotope that is not encased
in a container & does circulate in the body &
Anemia
C. Integumentary System
Sealed Implants – a radioisotope enclosed in a
Side Effects of Radiation Therapy & Nursing Intervention
A. Skin - itching, redness, burning, oozing, sloughing.
Keep skin free from foreign substances.
Avoid use of medicated solution, ointment, or powders that
contain heavy metals such as zinc oxide.
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.
kidney by excretion of metabolites.
Wash affected areas with plain H2O & pat dry; avoid soap.
Increased excretion of uric acid may damage kidney
Use cornstarch, olive oil for itching; avoid talcum powder.
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.
B. Anorexia, N/V
E. Reproductive System
Arrange meal time so they do not directly precede or
follow therapy.
Damage may occur to both men & women resulting
Encourage bland foods.
infertility &/or mutagenic damage to chromosomes
Provide small attractive meals.
Banking sperm often recommended for men before
Avoid extreme temperature.
Administer antiemetics as ordered before meals.
chemotherapy
Clients & partners advised to use reliable methods of
contraception during chemotherapy
F. Neurologic System
Plant alkaloids (vincristine) cause neurologic damage with
repeated doses
Encourage low residue, bland, high CHON food.
Administer antidiarrheal as ordered.
Provide good perineal care.
Monitor electrolytes particularly Na, K, Cl
D. Anemia, Leukopenia, Thrombocytopenia
Peripheral neuropathies, hearing loss, loss of deep tendon
Isolate from those with known infection.
reflex, & paralytic ileus may occur.
Provide frequent rest period.
Encourage high CHON diet.
Avoid injury.
Uses ionizing radiation to kill or limit the growth of cancer
Assess for bleeding.
cells, maybe internal or external.
Monitor CBC, WBC, & platelets.
Radiation Therapy
C. Diarrhea
It not only injured cell membrane but destroy & alter DNA so
that the cell cannot reproduce.
52
53
Burns
Functions of Muscles
direct tissue injury caused by thermal, electric, chemical &
Provide shape to the body
smoke inhaled (TECS)
Protect the bones
Maintain posture
Cause movement of body parts by contraction
Type:
1.
Thermal
2.
Smoke Inhalation
3.
Chemical
4.
Electrical
Types of Muscles
Cardiac: involuntary; found only in heart
Smooth: involuntary; found in walls of hollow structures
(e.g. intestines)
Classification
Partial Thickness
1.
Striated (skeletal): voluntary
Superficial partial thickness (1st degree)
Depth: epidermis only
Causes: sunburn, splashes of hot liquid
Sensation: painful
Characteristics: erythema, blanching on
1.
Characteristics of skeletal muscles
origin and to bones at the point of insertion.
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.
Full Thickness (3rd & 4th degree)
1.
Contraction is innervated by nerve stimulation.
Cartilage
shinny, wet after vesicles ruptures
Have properties of contraction and extension, as
well as elasticity, to permit isotonic (shortening and
pressure, no vesicles
2.
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.
Causes: flames, chemicals, scalding, electric current
3.
Sensation: little or no pain
Composed of dense, fibrous connective tissue
4.
Characteristics: wound is dry, white, leathery, or
Functions
hard
1.
Ligaments attach bone to bone
2.
Tendons attach muscle to bone
Overview Of Anatomy & Physiology Of Musculoskeletal System
Consist of bones, muscles, joints, cartilages, tendons,
Rheumatoid Arthritis (RA)
ligaments, bursae
To provide a structural framework for the body
To provide a means for movement
Chronic systemic disease characterized by inflammatory
changes in joints and related structures.
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.
Function of Bones
Provide support to skeletal framework
Assist in movement by acting as levers for muscles
Protect vital organ & soft tissue
Manufacture RBC in the red bone marrow
deterioration: synovitis, pannus formation, fibrous ankylosis,
and bony ankylosis.
Cause
(hematopoiesis)
1.
Provide site for storage of calcium & phosphorus
Types of Bones
1.
Cause unknown or idiopathic
2.
Maybe an autoimmune process
3.
Genetic factors
4.
Play a role in society (work)
Long Bones
Central shaft (diaphysis) made of compact bone &
Predisposing factors
1.
two end (epiphyses) composed of cancellous bones
Short Bones
2.
Fatigue
Cancellous bones covered by thin layer of compact
3.
Cold
bone (ex. Carpals & tarsals)
4.
Emotional stress
5.
Infection
Flat Bones
Two layers of compact bone separated by a layer of
cancellous bone (ex. Skull & ribs)
Occurs in women more often than men (3:1) between the
ages 35-45.
(ex. Femur & humerus)
If unarrested, affected joints progress through four stages of
S/sx
Irregular Bones
Sizes and shapes vary (ex. Vertebrae & mandible)
Joints
Articulation of bones occurs at joints
Movable joints provide stabilization and permit a variety of
1.
Fatigue
2.
Anorexia & body malaise
3.
Weight loss
4.
Slight elevation in temperature
5.
Joints are painful: warm, swollen, limited in motion, stiff in
morning & after a period of inactivity & may show crippling
deformity in long-standing disease.
movements
Classification
6.
Muscle weakness secondary to inactivity
7.
History of remissions and exacerbations
8.
Some clients have additional extra-articular manifestations:
1.
Synarthroses: immovable joints
subcutaneous nodules; eye, vascular, lung, or cardiac
2.
Amphiarthroses: partially movable joints
problems.
3.
Diarthroses (synovial): freely movable joints
Muscles
Have a joint cavity (synovial cavity) between the
Dx
articulating bone surfaces
1.
X-rays: shows various stages of joint disease
Articular cartilage covers the ends of the bones
2.
CBC: anemia is common
A fibrous capsule encloses the joint
3.
ESR: elevated
Capsule is lined with synovial membrane that secretes
4.
Rheumatoid factor positive
synovial fluid to lubricate the joint and reduce friction.
5.
ANA: may be positive
6.
C-reactive protein: elevated
53
54
Medical Management
1.
10. Provide client teaching & discharge planning & concerning.
Drug therapy
a.
Use of prescribed medications & side effects
a.
b.
Self-help devices to assist in ADL and to increase
Aspirin: mainstay of treatment: has both analgesic and
anti-inflammatory effect.
Aspirin & NSAID: to relieve mild symptoms such as fever
1.
Assess joints for pain, motion & appearance.
2.
Provide bed rest & joint immobilization as ordered.
3.
Administer anti-gout medications as ordered.
4.
Administer analgesics as ordered: for pain
5.
Increased fluid intake to 2000-3000 ml/day: to prevent
response when client unresponsive to more
formation of renal calculi.
conservative therapy
6.
Apply local heat or cold as ordered: to reduce pain
Azathioprine (Imuran)
7.
Apply bed cradle: to keep pressure of sheets off joints.
Cyclophosphamide (Cytoxan)
8.
Provide client teaching and discharge planning concerning
a.
Medications & their side effects
b.
Modifications for low-purine diet: avoidance of shellfish,
liver, kidney, brains, sweetbreads, sardines, anchovies
c.
Limitation of alcohol use
d.
Increased in fluid intake
e.
Weight reduction if necessary
f.
Importance of regular exercise
Systemic Lupus Erythematosus (SLE)
Chronic connective tissue disease involving multiple organ
systems
& arthritis
b.
in acute exacerbations or severe disease
c.
2.
3.
2.
Immune
3.
Genetic & viral factors have all been suggested
Assess symptoms to determine systems involved.
2.
Monitor vital signs, I&O, daily weights.
3.
Administer medications as ordered.
4.
Institute seizure precautions & safety measures: with CNS
involvement.
5.
Provide psychologic support to client / significant others.
6.
Provide client teaching & discharge planning concerning
a.
Disease process & relationship to symptoms
b.
Medication regimen & side effects.
c.
Importance of adequate rest.
d.
Use of daily heat & exercises as prescribed: for arthritis.
e.
Need to avoid physical or emotional stress
f.
Maintenance of a well-balanced diet
g.
Need to avoid direct exposure to sunlight: wear hat &
other protective clothing
Pathophysiology
1.
Supportive therapy: as organ systems become involved.
1.
Predisposing Factors
Cause unknown
Plasma exchange: to provide temporary reduction in amount
Nursing Interventions
Occurs most frequently in young women
1.
Immunosuppressive agents: to suppress the immune
of circulating antibodies.
Incident Rate
1.
Corticosteroids: to suppress the inflammatory response
A defect in body’s immunologic mechanisms produces
autoantibodies in the serum directed against components of
h.
Need to avoid exposure to persons with infections
i.
Importance of regular medical follow-up
j.
Availability of community agencies
the client’s own cell nuclei.
2.
Affects cells throughout the body resulting in involvement of
many organs, including joints, skin, kidney, CNS &
cardiopulmonary system.
Fatigue
Infection of the bone and surrounding soft tissues, most
commonly caused by S. aureus.
S/sx
1.
Osteomyelitis
Infection may reach bone through open wound (compound
fracture or surgery), through the bloodstream, or by direct
extension from infected adjacent structures.
55
56
Infections can be acute or chronic; both cause bone
PNS & hormonal stimulation through secretion of gastrin
destruction.
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.
Malaise
2.
Fever
3.
Pain & tenderness of bone
4.
Redness & swelling over bone
5.
Difficulty with weight-bearing
6.
Drainage from wound site may be present.
duodenum
1.
CBC: WBC elevated
2.
Blood cultures: may be positive
3.
ESR: may be elevated
2.
Use sterile techniques during dressing changes.
3.
Maintain proper body alignment & change position
Provide immobilization of affected part as ordered.
5.
Provide psychologic support & diversional activities
Fundus
Body
Antrum
Gastric Secretions:
Pepsinogen: secreted by the chief cells located in the
fundus aid in CHON digestion
Hydrocholoric Acid: secreted by parietal cells, function in
CHON digestion & released in response to gastrin
frequently: to prevent deformities.
4.
Three anatomic division
Nursing Interventions
Administer analgesics & antibiotics as ordered.
Pyloric Sphincter: located between the stomach &
duodenum
1.
Cardiac Sphincter: located at the opening between the
esophagus & stomach
Dx
Two sphincters control the rate of food passage
Intrinsic Factor: secreted by parietal cell, promotes
absorption of Vit B12
Mucoid Secretion: coat stomach wall & prevent auto
(depression may result from prolonged hospitalization)
6.
7.
digestion
Prepare client for surgery if indicated.
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.
Major function: digestion & absorption of the end product of
digestion
General information
1.
Structural Features:
Villi (functional unit of the small intestines): finger like
B. Medical management
projections located in the mucous membrane;
C. Assessment findings
containing goblet cells that secrets mucus & absorptive
D. Nursing interventions
cells that absorb digested food stuff
Overview of Anatomy & Physiology Gastro Intestinal Track System
Crypts of Lieberkuhn: produce secretions containing
digestive enzymes
The primary function of GIT are the movement of food,
digestion, absorption, elimination & provision of a
Brunner’s Gland: found in the submucosaof the
duodenum, secretes mucus
continuous supply of the nutrients electrolytes & H2O.
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
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.
2
The gastric phase is stimulated by the presence of food
b.
Transverse
in the stomach & regulated by neural stimulation via
c.
Descending colon
d.
Sigmoid
e.
Rectum
nd
half of ascending colon
56
57
Stimulate contraction of the gallbladder along
Accessory Organ
with relaxation of the sphincter of oddi (to allow
Liver
bile flow from common bile duct into the
Largest internal organ: located in the right hypochondriac &
duodenum) & stimulate release of the
epigastric regions of the abdomen
pancreatic enzymes
Liver Loobules: functional unit of the liver composed of
Salivary Glands
hepatic cells
1. Parotid – below & front of ear
Hepatic Sinusoids (capillaries): are lined with kupffer cells
2. Sublingual
which carry out the process of phagocytosis
3. 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
Severe left upper epigastric pain radiates from back & flank
area: aggravated by eating with DOB
2.
N/V
3.
Tachycardia
4.
Palpitation: due to pain
5.
Dyspepsia: indigestion
6.
Decrease bowel sounds
7.
(+) Cullen’s sign: ecchymosis of umbilicus
Hemorrhage
8.
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.
Hypocalcemia
1.
Microbial infection
2.
Feacalith: undigested food particles like tomato seeds,
Dx
guava seeds etc.
1.
Serum amylase & lipase: increase
2.
Urinary amylase: increase
3.
Intestinal obstruction
59
60
S/Sx:
Fetor hepaticus: fruity, musty odor of chronic liver
1.
Pathognomonic sign: (+) rebound tenderness
2.
Low grade fever
Aterixis: flapping of hands & tremores
disease
3.
N/V
Hard nodular liver upon palpation
4.
Decrease bowel sound
Increased abdominal girth
5.
Diffuse pain at lower Right iliac region
Changes in moods
6.
Late sign: tachycardia: due to pain
Alertness & mental ability
Sensory deficits
Dx
Gynecomastia
1.
CBC: mild leukocytosis: increase WBC
Decrease of pubic & axilla hair in males
2.
PE: (+) rebound tenderness (flex Right leg, palpate Right
Amenorrhea in female
iliac area: rebound)
Jaundice
Urinalysis: elevated acetone in urine
Pruritus or urticaria
3.
Easy bruising
Medical Management
Spider angiomas on nose, cheeks, upper thorax &
shoulder
Surgery: Appendectomy 24-45 hrs
Palmar erythema
Muscle atrophy
Nursing Intervention
1.
Administer antibiotics / antipyretic as ordered
2.
Routinary pre-op nursing measures:
3.
Skin prep
NPO
Avoid enema, cathartics: lead to rupture of appendix
Don’t give analgesic: will mask pain
Presence of pain means appendix has not ruptured
4.
Avoid heat application: will rupture appendix
5.
Monitor VS, I&O bowel sound
Nursing Intervention post op
1.
If (+) Pendrose drain (rubber drain inserted at surgical
wound for drainage of blood, pus etc): indicates rupture of
appendix
2.
Position the client semi-fowlers or side lying on right: to
facilitate drainage
3.
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.
Monitor VS, I&O, bowel sound
Keep nail short: to avoid skin excoriation from scratching
5.
Maintain patent IV line
Apply cool, moist compresses to pruritic area
6.
Complications: Peritonitis, Septicemia
Monitor VS, I & O
Prevent Infection
Liver Cirrhosis
Chronic progressive disease characterized by inflammation,
fibrosis & degeneration of the liver parenchymal cell
Destroyed liver cell are replaced by scar tissue, resulting in
architectural changes & malfunction of the liver
Lost of architectural design of liver leading to fat necrosis &
scarring
Prevent skin breakdown: by turning & skin care
Provide reverse isolation for client with severe leukopenia:
handwashing technique
Monitor WBC
Diet:
Small frequent meals
Restrict Na!
High calorie, low to moderate CHON, high CHO, low fats with
Types
supplemental Vit A, B-complex, C, D, K & folic acid
Laennec’s Cirrhosis:
Monitor / prevent bleeding
Associated with alcohol abuse & malnutrition
Measure abdominal girth daily: notify MD
Characterized by an accumulation of fat in the liver cell
With pt daily & assess pitting edema
progressing to widespread scar formation
Postnecrotic Cirrhosis
Result in severe inflammation with massive necrosis as a
complication of viral hepatitis
Cardiac Cirrhosis
Administer diuretics as ordered
Provide client teaching & discharge planning
Avoidance of hepatotoxicity drug: sedative, opiates or OTC
drugs detoxified by liver
How to assess weight gain & increase abdominal girth
Occurs as a consequence of right sided heart failure
Avoid person with upper respiratory infection
Manifested by hepatomegaly with some fibrosis
Reporting signs of reccuring illness (liver tenderness, increase
Biliary Cirrhosis
Associated with biliary obstruction usually in the common bile
duct
Results in chronic impairment of bile excretion
jaundice, increase fatigue, anorexia)
Avoid all alcohol
Avoid straining stool vigorous blowing of nose & coughing: to
decrease incidence of bleeding
Complications:
S/sx
Ascites: accumolation of free fluid in abdominal cavity
Fatigue
Anorexia
Nursing Intervention
N/V
Meds: Loop diuretics: 10-15 min effect
Dyspepsia: Indigestion
Assist in abdominal paracentesis: aspiration of fluid
Weight loss
Void before paracentesis: to prevent accidental puncture of
Flatulence
bladder as trochar is inserted
Change (Irregular) bowel habit
Ascites
Bleeding esophageal varices: Dilation of esophageal veins
Peripheral edema
Hepatomegaly: pain located in the right upper quadrant
Atrophy of the liver
Nursing Intervention
Administer meds:
60
61
Vit K
Located behind the symphisis pubis
Pitrisin or Vasopresin (IM)
Composed of muscular elastic tissue that makes it distensible
NGT decompression: lavage
Serve s as reservoir of urine (capable of holding 1000-1800 ml &
Give before lavage: ice or cold saline solution
Monitor NGT output
Assist in mechanical decompression
500 ml moderately full)
Internal & external urethral sphincter controls the flow of urine
Urge to void stimulated by passage of urine past the internal
Insertion of sengstaken-blackemore tube
3 lumen typed catheter
sphincter (involuntary) to the upper urethra
Relaxation of external sphincter (voluntary) produces emptying
Scissors at bedside to deflate balloon.
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.
Monitor VS, neuro check
Females: located behind the symphisis pubis & anterior
Siderails: due restless
Administer meds
vagina & approximately 3-5 cm
Males: extend the entire length of the penis & approximately
Laxatives: to excrete ammonia
Overview of Anatomy & Physiology Of GUT System
20 cm
Function of kidneys
Kidneys remove nitrogenous waste & regulates F & E
GUT: Genito-urinary tract
balance & acid base balance
GUT includes the kidneys, ureters, urinary bladder, urethra & the
Urine is the end product
male & female genitalia
Function:
Urine formation: 25 % of total cardiac output is received by kidneys
Promote excretion of nitrogenous waste products
Glomerular Filtration
Maintain F&E & acid base balance
Ultrafiltration of blood by the glomerulus, beginning of urine
formation
Kidneys
Requires hydrostatic pressure & sufficient circulating volume
Two of bean shaped organ that lie in the retroperitonial
space on either side of the vertebral column
Retroperitonially (back of peritoneum) on either side of
vertebral column
Adrenal gland is on top of each kidneys
Pressure in bowman’s capsule opposes hydrostatic pressure &
filtration
If glomerular pressure insufficient to force substance out of the
blood into the tubules filtrate formation stops
Glomerular Filtration Rate (GFR)
Encased in Bowmans’s capsule
Amount of blood filtered by the glomeruli in a given time
Normal: 125 ml / min
Renal Parenchyma
Filtrate formed has essentially same composition as blood
Cortex
plasma without the CHON; blood cells & CHON are
Outermost layer
usually too large to pass the glomerular membrane
Site of glomeruli & proximal & distal tubules of nephron
Medulla
Tubular Function
Middle layer
Tubules & collecting ducts carry out the function of
Formed by collecting tubules & ducts
reabsorption, secretion & excretion
Reabsorption of H2O & electrolytes is controlled by
Renal Sinus & Pelvis
anitdiuretics hormones (ADH) released by the
Papillae
pituitary & aldosterone secreted by the adrenal
Projection of renal tissues located at the tip of the renal
glands
pyramids
Calices
Proximal Convoluted Tubule
Reabsorb the ff:
Minor Calyx: collects urine flow from collecting ducts
80% of F & E
Major Calyx: directs urine from renal sinus to renal pelvis
H2O
Urine flows from renal pelvis to ureters
Glucose
Amino acids
Nephron
Bicarbonate
Functional unit of the kidney
Secretes the ff:
Basic living unit
Organic substance
Waste
Renal Corpuscle (vascular system of nephron)
Bowman’s Capsule:
Loop of Henli
Reabsorb the ff:
Portion of the proximal tubule surrounds the glomerulus
Glomerulus:
Capillary network permeable to water, electrolytes,
Na & Chloride in the ascending limb
H2O in the descending limb
Concentrate / dilutes urine
nutrients & waste
Impermeable to large CHON molecules
Filters blood going to kidneys
Distal Convoluted Tubule
Secretes the ff:
Potassium
Renal Tubule
Divided into proximal convoluted tubule, descending
Hydrogen ions
Ammonia
loop of Henle, acending loop of Henle, distal
Reabsorb the ff:
convoluted tubule & collecting ducts
H2O
Bicarbonate
Ureters
Regulate the ff:
Two tubes approximately 25-35 cm long
Extend from the renal pelvis to the pelvic cavity where they
enter the bladder, convey urine from the kidney to the
bladder
Passageway of urine to bladder
Ca
Phosphate concentration
Collecting Ducts
Received urine from distal convoluted tubules & reabsorb H2O
(regulated by ADH)
Ureterovesical valve: prevent backflow of urine into ureters
Normal Adult: produces 1 L /day of urine
Bladder
61
62
Regulation of BP
Nursing Intervention
Through maintenance of volume (formation / excretion of urine)
Force fluid: 3000 ml
Rennin-angiotensin system is the kidneys controlled mechanism
Warm sitz bath: to promote comfort
that can contribute to rise the BP
When the BP drops the cells of the glomerulus release rennin
Monitor & assess urine for gross odor, hematuria & sediments
Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent
which then activates angiotensin to cause vasoconstriction.
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 –
4.5 – 8
Specific gravity – 1.015 – 1.030
WBC/ RBC –
Predisposing factor:
Microbial invasion
E. 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
Anorexia
High risk: women
Gen body malaise
Obstruction
Urinary frequency & urgency
Urinary retention
Nocturia
Increase estrogen levels
Dsyuria
Sexual intercourse
Hematuria
Burning sensation on urination
S/Sx:
Pain: flank area
Chronic Pyelonephritis: client usually not aware of
Urinary frequency & urgency
disease
Burning pain upon urination
Bladder irritability
Dysuria
Slight dull ache over the kidney
Hematuria
Chronic Fatigue
Nocturia
Weight loss
Fever
Polyuria
Chills
Polydypsia
Anorexia
HPN
Gen body malaise
Atrophy of the kidney
Dx
Medical Management
Urine culture & sensitivity: (+) to 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. coli & streptococcus
Calcium Stones
Urinalysis: increase WBC, CHON & pus cells
Limit milk & dairy products
Cystoscopic exam: urinary obstruction
Provide acid ash diet (cranberry or prune juice, meat, fish,
eggs, poultry, grapes, whole grains): to acidify urine
Nursing Intervention
Take vitamin C
Provide CBR: acute phase
Oxalate Stone
Monitor I & O
Avoid excess intake of food / fluids high in oxalate
Chronic: possibility of dialysis & transplant if has renal
urine
deterioration
Uric Acid Stone
Complication: Renal Failure
Reduce food high in purine (liver, brain, kidney, venison,
shellfish, meat soup, gravies, legumes)
Nephrolithiasis / Urolithiasis
Maintain alkaline urine
Presence of stone anywhere in the urinary tract
Administer Allopurinol (Zyloprim) as ordered: to decrease uric
Formation of stones at urinary tract
acid production: push fluids when giving allopurinol
Frequent composition of stones
Provide client teaching & discharge planning
Calcium
Prevention of urinary stasis: increase fluid intake especially
Oxalate
during hot weather & illness
Uric acid
Mobility
Voiding whenever the urge is felt & at least twice during night
Calcium
Oxalate
Uric Acid
Adherence to prescribe diet
Complications: Renal Failure
Milk
Cabbage
Anchovies
Cranberries
Organ meat
Nuts tea
Nuts
Chocolates
Sardines
Benign Prostatic Hypertrophy (BPH)
Mild to moderate glandular enlargement, hyperplsia & over
growth of the smooth muscles & connective tissue
As the gland enlarges it compresses the urethra: resulting to
Predisposing factors:
urinary retention
Diet: increase Ca & oxalate
Enlarged prostate gland leading to
Increase uric acid level
Hydroureters: dilation of urethers
Hereditary: gout or calculi
Hydronephrosis: dilation of renal pelvis
Immobility
Kidney stones
Sedentary lifestyle
Renal failure
Hyperparathyroidism
Predisposing factor:
S/sx
High risk: 50 years old & above & 60-70 (3-4x at risk)
Abdominal or flank pain
Influence of male hormone
Renal colic
Cool moist skin (shock)
S/sx
Burning sensation upon urination
Urgency, frequency & hesitancy
Hematuria
Nocturia
Anorexia
Enlargement of prostate gland upon palpation by digital
N/V
rectal exam
Decrease force & amount of urinary stream
Dx
Dysuria
Intravenous Pyelography (IVP): identifies site of obstruction &
Hematuria
presence of non-radiopaque stones
Burning sensation upon urination
KUB: reveals location, number & size of stone
Terminal bubbling
Cytoscopic Exam: urinary obstruction
Backache
Stone Analysis: composition & type of stone
Sciatica: severe pain in the lower back & down the back
Urinalysis: indicates presence of bacteria, increase WBC, RBC &
of thigh & leg
CHON
Dx
Medical Management
Surgery
Digital rectal exam: enlarged prostate gland
KUB: urinary obstruction
Percutaneous Nephrostomy:
Tube is inserted through skin & underlying tissue into renal
pelvis to remove calculi
Cystoscopic Exam: reveals enlargement of prostate gland &
obstruction of urine flow
Urinalysis: alkalinity increase
Percutaneous Nephrostolithotomy
Specific Gravity: normal or elevated
Delivers ultrasound wave through a probe placed on the
BUN & Creatinine: elevated (if longstanding BPH)
calculus
Prostate-specific Antigen: elevated (normal is < 4 ng /ml)