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Medical Surgical Nursing Notes

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MEDICAL-SURGICAL NURSING
By: Anthony T. Villegas R.N.

period.


Overview of structures and functions:

3.

NERVOUS SYSTEM


The functional unit of the nervous system is the nerve cells

Kidney cells, Liver cells, Salivary cells, pancreas.

Permanent


Not capable of regeneration.



Myocardial cells, Neurons, Bone cells, Osteocytes,

or neurons


Capable of regeneration with limited time, survival

Retinal Cells.

The nervous system is composed of the ff:

Central Nervous System


Brain



Spinal Cord – serves as a connecting link between the brain

B.

NEUROGLIA


& the periphery.
Peripheral Nervous System

Support and protection of neurons.

TYPES
1.

Astrocytes



Cranial Nerves –12 pairs; carry impulses to & from the brain.



maintains blood brain barrier semi-permiable.



Spinal Nerves – 31 pairs; carry impulses to & from spinal



majority of brain tumors (90%) arises from called

cord.

astrocytoma.

Autonomic Nervous System


subdivision of the PNS that automatically controls body


2.

integrity of blood brain barrier.

Oligodendria

function such as breathing & heart beat.



produces myelin sheath in CNS.



Special senses of vision and hearing are also covered in this
section



act as insulator and facilitates rapid nerve impulse



Sympathetic nervous system – generally accelerate some

transmission.
3.

body functions in response to stress.




stationary cells that carry on phagocytosis (engulfing of

Parasympathetic nervous system – controls normal body

bacteria or cellular debris, eating), pinocytosis (cell

functioning.

drinking).
4.

CELLS
A.

Microglia

Epindymal


NEURONS

secretes a glue called chemo attractants that
concentrate the bacteria.



Primary component of nervous system



Composed of cell body (gray matter), axon, and dendrites



Basic cells for nerve impulse and conduction.

Axon


Elongated process or fiber extending from the cell body



Transmits impulses (messages) away from the cell body to

MACROPHAGE
Microglia

ORGAN
Brain

Monocytes

Blood

Kupffers

Kidney

Histiocytes

Skin

Alveolar Macrophage

Lung

dendrites or directly to the cell bodies of other neurons


Neurons usually has only one axon

Central Nervous System

Dendrites



Short, blanching fibers that receives impulses and conducts

Composition Of Brain

them toward the nerve cell body.



80% brain mass

Neurons may have many dendrites.



10% blood



10% CSF

Synapse


Junction between neurons where an impulse is transmitted

Neurotransmitter


Chemical agent (ex. Acetylcholine, norepinephrine) involved

Brain Mass
Parts Of The Brain
1.

Cerebrum


largest part of the brain

Myelin Sheath



outermost area (cerebral cortex) is gray matter



A wrapping of myelin (whitish, fatty material) that protects



deeper area is composed of white matter

and insulates nerve fibers and enhances the speed of



function of cerebrum: integration, sensory, motor

impulse conduction.



composed of two hemisphere the Right Cerebral

in the transmission of impulse across synapse.

o
o

Both axons and dendrites may or may not have a

Hemisphere and Left Cerebral Hemisphere enclosed in

myelin sheath (myelinated/unmyelinated)

the Corpus Callosum.

Most axons leaving the CNS are heavily myelinated



by schwann cells

Each hemisphere divided into four lobes; many of the
functional areas of the cerebrum have been located in
these lobes:

Functional Classification
1.

Afferent (sensory) neurons


2.

3.

Transmit impulses from peripheral receptors to the CNS

Lobes of Cerebrum
1.

Frontal Lobe

Efferent (motor) neurons



controls personality, behavior



Conduct impulses from CNS to muscle and glands



higher cortical thinking, intellectual functioning

Internuncial neurons (interneurons)



precentral gyrus: controls motor function





Broca’s Area: specialized motor speech area - when

Connecting links between afferent and efferent neurons

Properties
1.

Excitability – ability of neuron to be affected by changes in

damaged results to garbled speech.
2.

external environment.
2.

Conductility – ability of neuron to transmit a wave of
excitetation from one cell to another.

3.

Permanent Cell – once destroyed not capable of
regeneration.

2.



hearing, taste, smell



short term memory



Wernicke’s area: sensory speech area
(understanding/formulation of language)

3.

Pareital Lobe


for appreciation

Labile



integrates sensory information



Capable of regeneration.



discrimination of sensory impulses to pain, touch,



Epidermal cells, GIT cells, GUT cells, cells of lungs.

TYPES OF CELLS BASED ON REGENERATIVE CAPACITY
1.

Temporal Lobe

Stable

pressure, heat, cold, numbness.


Postcentral gyrus: registered general sensation (ex.
Touch, pressure)

1

2
4.

Occipital Lobe


5.

for vision

Cerebellum


smallest part of the brain, lesser brain.



coordinates muscle tone and movements and maintains

Insula (Island of Reil)


position in space (equilibrium)

visceral function activities of internal organ like gastric



controls balance, equilibrium, posture and gait.

motility.
Limbic System (Rhinencephalon)


Spinal Cord

controls smell - if damaged results to anosmia (absence



of smell).


controls libido



controls long term memory

periphery


extends from foramen magnum to second lumbar
vertebra



Corpus Callosum


serves as a connecting link between the brain and

H-shaped gray matter in the center (cell bodies)
surrounded by white matter (nerve tract and fibers)

large fiber tract that connects the two cerebral
hemisphere

Basal Ganglia

Gray Matter



island of gray matter within white matter of cerebrum

1.



regulate & integrate motor activity originating in the

Anterior Horns


fibers

cerebral cortex


part of extrapyramidal system



area of gray matter located deep within each cerebral

2.

Posterior Horns


2.

3.

release dopamine (controls gross voluntary movement).

Lateral Horns


Connecting part of the brain, between the cerebrum &

White Matter

the brain stem


In thoracic region, contain cells giving rise to
autonomic fibers of sympathetic nervous system

Diencephalon/interbrain


Contains cell bodies connecting with afferent
(sensory) fibers from dorsal root ganglion

hemisphere.


Contains cell bodies giving rise to efferent (motor)

1.

Contains several small structures: the thalamus &

Ascending Tracts (sensory pathways)
a.

hypothalamus are most important

Posterior Column


Thalamus


pressure, vibration, & position sense

acts as relay station for discrimination of sensory signals

b.

(ex. Pain, temperature, touch)


Spinocerebellar


controls primitive emotional responses (ex. Rage, fear)

found immediately beneath the thalamus



plays a major role in regulation/controls of vital function:

c.

Lateral Spinothalamic


blood pressure, thirst, appetite, sleep & wakefulness,
d.

Anterior Spinothlamic

acts as controls center for pituitary gland and affects



both divisions of the autonomic nervous system.


2.

Descending Tracts (motor pathways)
a.

Corticospinal (pyramidal, upper motor neurons)

androgenic hormones promotes secondary sex



characteristics.


the medulla)

enlargement
late sign is deepening of voice.



early sign for females telarch and late sign is menarch.

Conduct motor impulses from motor
cortex to anterior horn cells (cross in

early sign for males are testicular and penile



Carry impulses concerned with crude
touch & pressure

controls some emotional responses like fear, anxiety
and excitement.



Carry impulses resulting in pain &
temperature sensations

temperature (thermoregulatory center)


Carry impulses concerned with muscle
tension & position sense to cerebellum

Hypothalamus


Carry impulses concerned with touch,

b.

Extrapyramidal


Help to maintain muscle tone & to
control body movement, especially
gross automatic movements such as

3.

4.

Mesencephalon/Midbrain

walking



acts as relay station for sight and hearing.



size of pupil is 2 – 3 mm.

Reflex Arc



equal size of pupil is isocoria.





unequal size of pupil is anisocoria.



hearing acuity is 30 – 40 dB.



positive PERRLA

occurring over a neural pathway called a reflex arc.


located at lowest part of brain.



contains midbrain, pons, medulla oblongata.



extends from the cerebral hemispheres to the foramen

a.

b.

c.

d.

e.

contains vital center of respiratory, vasomotor, and

Pons


pneumotaxic center controls the rate, rhythm and depth

1.

Skull

Medulla Oblongata
controls respiration, heart rate, swallowing, vomiting,
hiccup, vasomotor center (dilation and constriction of

Muscle or organ that responds to stimulus

Supporting Structures

of respiration.


Transmits impulses from motor neuron to effector

Effectors


cardiac functions.

Synapses with a motor neuron (anterior horn cell)

Efferent Pathways


cerebrum and the spinal cord.

Transmits impulses to spinal cord

Interneurons


contains nuclei of the cranial nerves and the long

Receives/reacts to stimulus

Afferent Pathways


ascending and descending tracts connecting the


Sensory Receptors


magnum at the base of the skull.


Not relayed to & from brain: take place at cord levels

Components

Brain Stem


Reflex consists of an involuntary response to a stimulus

2.



Rigid; numerous bones fused together



Protects & support the brain

Spinal Column


Consists of 7 cervical, 12 thoracic, & 5 lumbar vertebrae
as well as sacrum & coccyx

bronchioles).


Supports the head & protect the spinal cord

2

3
3.

Meninges


Membranes between the skull & brain & the vertebral
column & spinal cord

5.



Signs of jaundice (icteric sclerae).



Caused by bilirubin (yellow pigment)

Bilirubin



3 fold membrane that covers brain and spinal cord.



Increase bilirubin in brain (kernicterus).



For support and protection; for nourishment; blood



Causing irreversible brain damage.

supply


Area between arachnoid & pia mater is called
subarachnoid space: CSF aspiration is done



Subdural space between the dura and arachnoid



Layers:
Dura Mater


outermost layer, tough, leathery

Arachnoid Mater


4.

Spinal Nerves


31 pairs: carry impulses to & from spinal cord



Each segment of the spinal cord contains a pair of spinal
nerves (one of each side of the body)

middle layer, weblike

Pia Mater


Peripheral Nervous System



Each nerve is attached to the spinal by two roots:
1.

innermost layer, delicate, clings to surface of brain



Ventricles


5.

2.

Surrounds brain & spinal cord



Offer protection by functioning as a shock absorber



Allows fluid shifts from the cranial cavity to the spinal



Carries nutrient to & waste product away from nerve
cells



Component of CSF: CHON, WBC, Glucose

Contains efferent (motor) nerve whose nerve
fibers originate in the anterior horn cell of the

Cerebrospinal Fluid (CSF)

cavity

6.

Ventral (anterior) roots


Produce & circulate cerebrospinal fluid



contains afferent (sensory) nerve whose cell
body is in the dorsal roots ganglion

Four fluid-filled cavities connecting with one
another & spinal canal



Dorsal (posterior) roots

spinal cord (lower motor neuron)
Cranial Nerves


12 pairs: carry impulses to & from the brain.



May have sensory, motor, or mixed functions.

Name & Number
Olfactory

Function
: CN I

Sensory: carries impulses for

Vascular Supply

sense of smell.



Two internal carotid arteries anteriorly

Optic

: CN II

Sensory: carries impulses for vision.



Two vertebral arteries leading to basilar artery

Oculomotor

: CN III

Motor: muscles for papillary

posteriorly

constriction, elevation of upper eyelid;






These arteries communicate at the base of the brain

4 out of 6 extraocular

through the circle of willis

movement.

Anterior, middle, & posterior cerebral arteries are the

Trochlear

main arteries for distributing blood to each hemisphere

inward, movement of the eye

of the brain

Trigeminal

Brain stem & cerebellum are supplied by branches of

of eyes (corneal reflex); muscle

: CN IV

Motor: muscles for downward,

: CN V

Mixed: impulses from face, surface
Controlling mastication.

the vertebral & basilar arteries

7.

Venous blood drains into dural sinuses & then into

Abducens

jugular veins

of eye

Blood-Brain-Barrier (BBB)


Facial

: CN VI

Motor: muscles for lateral deviation

: CN VII

Mixed: impulses for taste from

anterior tongue; muscles for facial

Protective barrier preventing harmful agents from

Movement.

entering the capillaries of the CNS; protect brain &
spinal cord

Acoustic

: CN VIII

Sensory: impulses for

hearing (cochlear division) & balance (vestibular
Division).

Substance That Can Pass Blood-Brain Barrier
1.

Amonia


Cerebral toxin



Hepatic Encephalopathy (Liver Cirrhosis)



Ascites



Esophageal Varices

Glossopharyngeal

: CN IX

Mixed: impulses for

sensation to posterior tongue & pharynx; muscle
For movement of pharynx
(elevation) & swallowing.
Vagus

: CN X

Mixed: impulses for sensation to

lower pharynx & larynx; muscle for

Early Signs of Hepatic Encephalopathy


Late Signs of Hepatic Encephalopathy

2.

3.

Movement of soft palate,

Asterexis (flapping hand tremors).



Headache



Dizziness



Confusion



Fetor hepaticus (amonia like breath)



decrease LOC

Carbon Monoxide and Lead Poisoning


Can lead to Parkinson’s Disease.



Epilepsy



Treated with calcium EDTA.

Type 1 DM (IDDM)


Causes diabetic ketoacidosis.



And increases breakdown of fats.



And free fatty acids



Resulting to cholesterol and positive to ketones (CNS

pharynx, & larynx.
Spinal Accessory

: CN XI

Motor: movement of

sternomastoid muscles & upper part of trapezius
Muscles.
Hypoglossal

: CN XII

Motor: movement of tongue.

Autonomic Nervous System


Part of the peripheral nervous system



Include those peripheral nerves (both cranial & spinal) that
regulates smooth muscles, cardiac muscles, & glands.



Component:
1.

Sympathetic Nervous System


Generally

accelerates

some

body

function

in

response to stress.
2.

Parasympathetic Nervous System


Controls normal body functioning

depressant).

4.



Resulting to acetone breath odor/fruity odor.



And kusshmauls respiration a rapid shallow respiration.



Which may lead to diabetic coma.

Hepatitis

Sympathetic Nervous System

Parasympathetic Nervous System

(Adrenergic) Effect

(Cholinergic) Effect, Vagal,

- Involved in fight or aggression

Sympatholytic
- Involved in flight or withdrawal

response.

response.

3

4
- Release of Norepinephrine

- Release of Acetylcholine.

(cathecolamines) from adrenal

- Decreases all bodily activities

glands and causes

except GIT.

decrease motility

increase motility

vasoconstriction.

Constrict sphincters

relaxed sphincters

- Increase all bodily activity

Possibly inhibits secretions

except GIT

GI Tract

stimulate

EFFECTS OF PNS

secretions

- Constriction of pupils (miosis).

Inhibits activity of gallbladder & ducts stimulate activity of

EFFECTS OF SNS

- Increase salivation.

gallbladder&

- Dilation of pupils (mydriasis) in

- Decrease BP and Heart Rate.

ducts

order to be aware.

- Bronchoconstriction, Decrease

- Dry mouth (thickened saliva).

RR.

- Increase BP and Heart Rate.

- Diarrhea

- Bronchodilation, Increase RR

- Urinary frequency.

Inhibits glycogenolysis in liver
Adrenal Gland stimulates secretion of epinephrine &

no effect

Norepinephrine

- Constipation.
Urinary Tract

- Urinary Retention.

contract detrusor muscles

- Increase blood supply to brain,

Contract trigone sphincter (prevent voiding)

heart and skeletal muscles.
- SNS

relaxes detrusor muscles

relaxes trigone sphincter (allows voiding)

I. Cholinergic Agents
- Mestinon, Neostignin.

I. Adrenergic Agents

SE:

- Give Epinephrine.

- PNS effect

NEURO TRANSMITTER
Acethylcholine
Dopamine

Decrease
Myesthenia Gravis
Parkinson’s Disease

Increase
Bi-polar Disorder
Schizophrenia

SE:
- SNS effect

Physical Examination

Contraindication:

Comprehensive Neuro Exam

- Contraindicated to patients

Neuro Check
1.

Level of Consciousness (LOC)

suffering from COPD

II. Anti-cholinergic Agents

(Broncholitis, Bronchoectasis,

- To counter cholinergic agents.

a.

Orientation to time, place, person

Emphysema, Asthma).

- Atrophine Sulfate

b.

Speech: clear, garbled, rambling

c.

Ability to follow command

d.

If does not respond to verbal stimuli, apply a painful

II. Beta-adrenergic Blocking

SE:

Agents

- SNS effect

stimulus

(ex.

Pressure

on

the

nailbeds,

- Also called Beta-blockers.

trapezius muscle); note response to pain

- all ending with “lol”



Appropriate: withdrawal, moaning

- Propranolol, Atenelol,



Inappropriate: non-purposeful

Metoprolol.

e.

squeeze

Abnormal posturing (may occur spontaneously or in

Effect of Beta-blockers

response to stimulus)

B – broncho spasm



Decorticate Posturing: extension of leg, internal

E – elicits a decrease in

rotation & abduction of arms with flexion of elbows,

myocardial contraction.

wrist, & finger: (damage to corticospinal tract;

T – treats hypertension.

cerebral hemisphere)

A – AV conduction slows down.



Decerebrate Posturing: back arched, rigid extension

- Should be given to patients

of all four extremities with hyperpronation of arms &

with Angina, Myocardial

plantar flexion of feet: (damage to upper brain stem,

Infarction, Hypertension

midbrain, or pons)

ANTI- HYPERTENSIVE AGENTS

2.

1. Beta-blockers – “lol”

Glasgow Coma Scale


2. Ace Inhibitors – Angiotensin

Objective measurement of LOC sometimes called as the
quick neuro check

“pril” (Captopril, Enalapril)



Objective evaluation of LOC, motor / verbal response

3. Calcium Antagonist –



A standardized system for assessing the degree of

Nifedipine (Calcibloc)

neurologic impairment in critically ill client

- In chronic cases of arrhythmia
give Lidocane, Xylocane.
Effectors

:Sympathetic (Adrenergic) Effect

Parasympathetic (Cholinergic)
Eye

Components

Effect

dilate pupil (mydriasis)

constrict

Gland of Head
no effect

stimulate secretions
Salivary

scanty thick, viscous secretions copious thin watery

secretions

3.

Dry mouth
Heart

Eye opening

2.

Verbal response

3.

Motor response

GCS Grading / Scoring

pupil (miosis)

Lacrimal

1.

1.

Conscious

15 – 14

2.

Lethargy

13 – 11

3.

Stupor

10 – 8

4.

Coma

5.

Deep Coma

7
3

Pupillary Reaction & Eye Movement
a.

Observe size, shape, & equality of pupil (note size in
millimeter)

increase rate & force of contraction
decrease rate

b.

Reaction to light: pupillary constriction

c.

Corneal reflex: blink reflex in response to light stroking
of cornea

Blood Vessel

constrict smooth muscles of the skin,

d.

no effect

Abdominal blood vessels, and
Cutaneous blood vessels

unconscious client with intact brainstem
4.

Dilates smooth muscles of bronchioles,
Blood vessels of the heart & skeletal muscles
Lungs

bronchodilation

Oculocephalic reflex (doll’s eyes): present in

5.

Motor Function
a.

Movement of extremities (paralysis)

b.

Muscle strength

Vital Signs: respiratory patterns (may help localize possible
lesion)

bronchoconstriction

4

5
a.

Cheyne-Stokes Respiration: regular rhythmic alternating

Cranial Nerves

between hyperventilation & apnea; may be caused by
structural cerebral dysfunction or by metabolic problems
such as diabetic coma
b.

Central Neurogenic Hyperventilation: sustained, rapid,
regular respiration (rate of 25/min) with normal O2 level;
usually due to brainstem dysfunction

c.

Apneustic Breathing: prolonged inspiratory phase,
followed by a 2-to-3 sec pause; usually indicates
dysfunction respiratory center in pons

d.

Cluster Breathing: cluster of irregular breathing,

1.
2.
3.
4.

Cranial Nerves
Olfactory
Optic
Oculomotor
Trochlear

Function
S
S
M
M

5.
6.
7.
8.
9.
10.
11.
12.

Trigeminal
Abducens
Facial
Acoustic
Glossopharengeal
Vagus
Spinal Accessory
Hypoglossal

(smallest)
B (largest)
M
B
S
B
B (longest)
M
M

irregularly followed by periods of apnea; usually caused
CRANIAL NERVE I: OLFACTORY

by a lesion in upper medulla & lower pons
e.

Ataxic Breathing: breathing pattern completely irregular;
indicates damage to respiratory center of the medulla



Material Used


Don’t use alcohol, ammonia, perfume because it is irritating
and highly diffusible.

Neurologic Exam
1.

Sensory function for smell



Mental status and speech (Cerebral Function)
a.

General appearance & behavior

b.

LOC

c.

Intellectual

Procedure


Function:

memory

Use coffee granules, vinegar, bar of soap, cigarette

(recent

&

remote),

Test each nostril by occluding each nostril

Abnormal Findings

attention span, cognitive skills

1.

Hyposnia: decrease sensitivity to smell

d.

Emotional status

2.

Dysosmia: distorted sense of smell

e.

Thought content

3.

Anosmia: absence of smell

f.

Language / speech

Either of the 3 may indicate head injury damaging the cribriform

2.

Cranial nerve assessment

plate of ethmoid bone where olfactory cells are located may indicate

3.

Cerebellar Function: posture, gait, balance, coordination

inflammatory conditions (sinusitis)

4.

a.

Romberg’s Test: 2 nurses, positive for ataxia

b.

Finger to Nose Test: positive result mean dimetria
(inability of body to stop movement at desired point)



Sensory Function: light touch, superficial pain, temperature,

Functions

vibration & position sense
5.
6.

CRANIAL NERVE II: OPTIC

1.

Motor Function: muscle size, tone, strength; abnormal or

Test visual acuity or central vision or distance


Use Snellen’s Chart

involuntary movements



Snellen’s Alphabet chart: for literate client

Reflexes



Snellen’s E chart: for illiterate client

a.



Snellen’s Animal chart: for pediatric client

Deep tendon reflex: grade from 0 (no response); to 4
(hyperactive); 2 (normal)

b.

Superficial

c.

Pathologic: babinski reflex (dorsiflexion of the great toe

2.

Lethargy: lethargic (drowsy, sleepy, obtunded)

3.

Stupor


Stuporous: (awakened by vigorous stimulation)



Generalized body weakness



Decrease body reflex



Numerator: is constant, it is the distance of person from



20/200 indicates blindness



20/20 visual acuity if client is able to read letters above
the red line.

2.

Test of visual field or peripheral vision

Coma


Comatose



light coma: positive to all forms of painful stimulus



deep coma: negative to all forms of painful stimulus

Denominator: changes, indicates distance by which the
person normally can see letter in the chart.

Level Of Consciouness (LOC)
Conscious: awake

Normal visual acuity 20/20



tracts

1.



the chart (6-7 m, 20 feet)

with fanning of toes): indicates damage to corticospinal

4.

Sensory function for vision or sight

a.

Superiorly

b.

Bitemporaly

c.

Nasally

d.

Inferiorly

CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS


Controls or innervates the movement of extrinsic ocular
muscle (EOM)



6 muscles:

Different Painful Stimulation
1.

Deep sternal stimulation / deep sternal pressure

2.

Orbital pressure

3.

Pressure on great toes

4.

Corneal or blinking reflex


Conscious Client: use a wisp of cotton



Unconscious Client: place 1 drop of saline solution

Superior Rectus

Superior Oblique

Lateral Rectus

Medial

Inferior Oblique

Inferior

Rectus
Test of Memory
1.

Short term memory


Ask most recent activity



Positive result mean anterograde amnesia and damage
Rectus

to temporal lobe
2.

Long term memory



Trochlear: controls superior oblique



Ask for birthday and validate on profile sheet



Abducens: controls lateral rectus



Positive result mean retrograde amnesia and damage to



Oculomotor: controls the 4 remaining EOM

limbic system


Consider educational background

Level of Orientation

Oculomotor


Controls the size and response of pupil



Normal pupil size is 2 – 3 mm

1.

Time: first asked



Equal size of pupil: Isocoria

2.

Person: second asked



Unequal size of pupil: Anisocoria

3.

Place: third asked



Normal response: positive PERRLA

5

6
CRANIAL NERVE V: TRIGEMINAL

S/sx



Largest cranial nerve

4 A’s of Alzheimer



Consists of ophthalmic, maxillary, mandibular

a.

Amnesia – loss of memory.



Sensory: controls sensation of face, mucous membrane,

b.

Agnosia – unable to recognized inanimate/familiar
objects.

teeth, soft palate and corneal reflex


Motor: controls the muscle of mastication or chewing



Damage to CN V leads to Trigeminal Neuralgia / Tic

c.

objects.
d.

Douloureux


Apraxia – unable to determine purpose/ function of
Aphasia – no speech (nodding).

Medication: Carbamezapine (Tegretol)
*Expressive aphasia

CRANIAL NERVE VII: FACIAL



“motor speech center” unable to speak



Broca’s Aphasia



Sensory: controls taste, anterior 2/3 of tongue



Pinch of sugar and cotton applicator placed on tip of tongue



Motor: controls muscle of facial expression



inability to understand spoken words.



Instruct client to smile, frown and if results are negative



Common to Alzheimer’s

there is facial paralysis or Bell’s Palsy and the primary cause



Wernike’s Aphasia

is forcep delivery.



General

*Receptive aphasia

Knowing

Gnostic

Area

or

General

Interpretative Area.
CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR


Controls balance particularly kinesthesia or position sense,

DOC

refers to movement and orientation of the body in space.



Aricept (taken at bedtime)



Cognex

CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS


Glosopharenageal: controls taste, posterior 1/3 of tongue

Management



Vagus: controls gag reflex

1.



Uvula should be midline and if not indicative of damage to

Palliative & supportive

cerebral hemisphere


Effects of vagal stimulation is PNS

Multiple Sclerosis (MS)


CRANIAL NERVE XI: SPINAL ACCESSORY


characterized by scattered white patches of

Innervates with sternocleidomastoid (neck) and trapezius

demyelination in brain and spinal cord.

(shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL


Controls the movement of tongue



Let client protrude tongue and it should be midline and if

Chronic intermittently progressive disorder of CNS



Characterized by remission and exacerbation.



S/sx are varied & multiple, reflecting the location of
demyelination within the CNS.



Cause unknown: maybe a slow growing virus or
possibly autoimmune disorders.

unable to do indicative of damage to cerebral hemisphere


and/or has short frenulum.

Incident: Affects women more than men ages 20-40
are prone & more frequent in cool or temperate
climate.

Pathognomonic Signs:
1.

PTB – low grade afternoon fever

2.

PNEUMONIA – rusty sputum.

3.

ASTHMA – wheezing on expiration.

4.

EMPHYSEMA – barrel chest.

5.

KAWASAKI SYNDROME – strawberry tongue

6.

PERNICIOUS ANEMIA – red beefy tongue

7.

DOWN SYNDROME – protruding tongue

8.

CHOLERA – rice watery stool.

9.

MALARIA – step ladder like fever with chills.



Ig G - only antibody that pass placental circulation causing
passive immunity, short term protection



Ig A - present in all bodily secretions (tears, saliva,
colostrums).



Ig M - acute in inflammation.



Ig E - for allergic reaction



Ig D - for chronic inflammation.
* Give palliative or supportive care.

10. TYPHOID – rose spots in abdomen.
11. DIPTHERIA – pseudo membrane.

S/sx

12. MEASLES – koplick’s spots
13. SLE – butterfly rashes.

1.

Visual disturbances

14. LIVER CIRRHOSIS – spider like varices



blurring of vision (primary)

15. LEPROSY – lioning face



diplopia (double vision)

16. BOLIMIA – chipmunk face.



scotomas (blind spots)

17. APPENDICITIS – rebound tenderness

2.

Impaired sensation

18. DENGUE – petichae or positive herman’s sign.



touch, pain, pressure, temperature, or position sense

19. MENINGITIS – kernig’s sign (leg pain), brudzinski sign (neck



paresthesia such as tingling sensation, numbness

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.

Skull is a closed container

ACTH (adreno chorticotropic hormone), Corticosteroids

Any alteration or increase in one of the intracranial components

Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam

Increase intracranial pressure

(Valium) - muscle relaxants: for spacity
c.

(normal ICP is 0 – 15 mmHg)

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

detect increase in ICP

Monitor ICP pressure readings frequently & prevent
complications:

decrease O2 stimulates respiration.

Monitor V/S, input and output & neuro check frequently to

Epidural Sensor: least invasive method; placed in
space between skull & dura matter for indirect

In chronic respiratory distress syndrome

causing cerebral constriction & decrease ICP.

Subarachnoid screw (bolt): inserted through the
skull & dura matter into subarachnoid space.

Increase CO2 (most powerful respiratory

indicated: produces hypocarbia (decease CO2)

Intraventricular Catheter: inserted in lateral
ventricle to give direct measurement of ICP; also

Late signs of hypoxia:

Hypercabia





Types of monitoring devices:


stimulant) retention.

c.

ICP monitoring records the pressure exerted within the

Hypercarbia may cause cerebral vasodilation



b.

Anti-convulsants [Phenytoin (Dilantin)]: to prevent
seizures.

which increase ICP

5.

Analgesics for headache as needed:

Maintain patent airway and adequate ventilation by:
a.

4.

Corticosteroids [Dexamethasone (Decadron)]: antiinflammatory effect reduces cerebral edema

Nursing Intervention

3.

Avoid lifting heavy objects

Pulse rate decrease

cranial nerve III

2.



Avoid clustering of nursing care activity together.

sluggish reaction to light from compression of

1.

Avoid stooping/bending

b.

a.

3.



pressure)

d.
2.

Excessive coughing: administer anti-tussive
(dextromethorphan)

Changes in Vital Signs (may be a late signs)
a.

Excessive vomiting: administer anti-emetics as

client
c.

Reduces metabolic demand that may protect the brain
from further injury.

d.

Constant monitoring of the client’s ICP, arterial blood
gas, serum barbiturates level, & ECG is necessary.

e.

EEG monitoring as necessary

f.

Provide appropriate nursing care for the client on a
ventilator

8

9
10. Observe for hyperthermia secondary to hypothalamus
damage.

e

Spinach

Oranges
2. Hypocalcemia/Tetany
- decrease calcium level
- normal value is 8.5 – 11 mg/100 ml

*CONGESTIVE HEART FAILURE

Signs and Symptoms

Signs and Symptoms

- tingling sensation

-

dyspnea

- paresthesia

-

orthopnea

- numbness

-

paroxysmal nocturnal dyspnea

- (+) Trousseus sign/Carpopedal spasm

-

productive cough

- (+) Chvostek’s sign

-

frothy salivation

Complications

-

cyanosis

- arrythmia

-

rales/crackles

- seizures

-

bronchial wheezing

Nursing Management

-

pulsus alternans

- Calcium Glutamate per IV slowly as ordered

-

anorexia and general body malaise

* Calcium Glutamate toxicity – results to seizure

-

PMI (point of maximum impulse/apical pulse rate) is
displaced laterally

-

S3 (ventricular gallop)

-

Predisposing Factors/Mitral Valve
o

RHD

o

Aging

Treatment
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (venous congestion)
Signs and Symptoms
- jugular vein distention (neck)
- ascites
- pitting edema
- weight gain
- hepatosplenomegaly
- jaundice

Magnesium Sulfate
Magnesium Sulfate toxicity
S/S
BP
Urine output

DECREASE

Respiratory rate
Patellar relfex absent
3. 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

Avoid multi-vitamins preparation containing vitamin
B6 & food rich in vitamin B6 (Pyridoxine): reverses

muscular function

the therapeutic effects of Levodopa



Disorder of the extrapyramidal system



Urine and stool may be darkened



Usually occurs in the older population



Be aware of any worsening of symptoms with



Cause Unknown: predominantly idiopathic, but sometimes

prolonged high-dose therapy: “on-off” syndrome.

disorder is postencephalitic, toxic, arteriosclerotic,

b.

traumatic, or drug induced (reserpine, methyldopa

Carbidopa-levodopa (Sinemet)


(aldomet) haloperidol (haldol), phenothiazines).

causes fewer side effects.
c.

Pathophysiology


Prevents breakdown of dopamine in the periphery &

Amantadine Hydrochloride (Symmetrel)


Disorder causes degeneration of dopamine producing

Used in mild cases or in combination with L-dopa to
reduce rigidity, tremors, & bradykinesia

neurons in the substantia nigra in the midbrain


Dopamine: influences purposeful movement

Anti-Cholinergic Drug



Depletion of dopamine results in degeneration of the basal

a.

Benztropine Mesylate (Cogentin)

ganglia

b.

Procyclidine (Kemadrine)

c.

Trihexyphenidyl (Artane)

Predisposing Factors



MOA: inhinit the action of acetylcholine; used in mild

1.

Poisoning (lead and carbon monoxide)

cases or in combination with L-dopa; relived tremors

2.

Arteriosclerosis

& rigidity

3.

Hypoxia

4.

Encephalitis

5.

Increase dosage of the following drugs:

Anti-Histamines Drug

a. Reserpine (Serpasil)

a.



SE: dry mouth; blurred vision; constipation; urinary
retention; confusion; hallucination; tachycardia

b. Methyldopa (Aldomet)

Antihypertensive

c. Haloperidol (Haldol)

_______

Diphenhydramine (benadryl)


MOA: decrease tremors & anxiety



SE: Adult: drowsiness Children: CNS excitement

d. Phenothiazine ___________________ Antipsychotic

(hyperactivity) because blood brain barrier is not yet
fully developed.

Side Effects Reserpine: Major depression lead to suicide

b.

Aloneness

Bromocriptine (Parlodel)


MOA:

stimulate

release

of

dopamine

in

the

substantia nigra


MAOI Inhibitor

Multiple loss
causes
suicide

a.

Eldepryl (Selegilene)


Loss of spouse

Often employed when L-dopa loses effectiveness

Loss

MOA:

inhibit

dopamine

breakdown

&

slow

progression of disease

of Job
Nursing Intervention for Suicide


direct approach towards the client



close surveillance is a nursing priority



time to commit suicide is on weekends early morning

Anti-Depressant Drug
a.

Tricyclic


MOA: given to treat depression commonly seen in
Parkinson’s disease

2.

Provide safe environment

S/sx



Side rails on bed

1.

Tremor: mainly of the upper limbs “pill rolling tremors” of



Rails & handlebars in the toilet, bathtub, & hallways

extremities especially the hands; resting tremor: most



No scattered rugs



Hard-back or spring-loaded chair to make getting up

common initial symptoms
2.

Bradykinesia: slowness of movement

3.

Rigidity: cogwheel type

4.

Stooped posture: shuffling, propulsive gait

5.

Fatigue

6.

Mask like facial expression with decrease blinking of the

easier
3.



Difficulty rising from sitting position.

8.

Quite, monotone speech

9.

Emotional lability: state of depression

Physical Therapy: active & passive ROM exercise;
stretching exercise; warm baths

eyes.
7.

Provide measures to increase mobility



Assistive devices



If client “freezes” suggest thinking of something to walk
over

4.

Encourage independence in self-care activities:

10. Increase salivation: drooling type
11. Cramped, small handwriting
12. Autonomic Symptoms
5.



alter clothing for ease in dressing



use assistive device



do not rush the client

Improve communication abilities:

a.

excessive sweating

b.

increase lacrimation



Instruct the client to practice reading a loud

c.

seborrhea



Listen to own voice & enunciate each syllable clearly

d.

constipation

6.

Refer for speech therapy when indicated.

e.

decrease sexual capacity

7.

Maintain adequate nutrition.


Cut food into bite-size pieces

Nursing Intervention



Provide small frequent feeding

1.



Allow sufficient time for meals, use warming tray

Administer medications as ordered
Anti-Parkinson Drug

8.

Avoid constipation & maintain adequate bowel elimination

10

11
9.

Provide significant support to client/ significant others:


- nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)

Depression is common due to changes in body image &

- hypoglycemia

self-concept

Tremors, tachycardia

10. Provide client teaching & discharge planning concerning:

Irritability

a.

Nature of the disease

Restlessness

b.

Use prescribed medications & side effects

Extreme fatigue

c.

Importance of daily exercise as tolerated: balanced

Diaphoresis, depression

activity & rest

Antidote: Acetylceisteine (mucomyst) prepare suction apparatus as

d.

e.



walking



swimming



gardening

bedside.
MYASTHENIA GRAVIS (MG)


Activities/ methods to limit postural deformities:

neuromuscular disorder characterized by a disturbance in



Firm mattress with small pillow

the transmission of impulses from nerve to muscle cells at



Keep head & neck as erected as possible

the neuromuscular junction leading to descending muscle



Use broad-based gait



Raise feet while walking

weakness.


Incidence rate:


Promotion of active participation in self-care activities.

for men.

* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid


Hydrazide


* Dopamine Agonist relieves tremor rigidity
MAGIC 2’s IN DRUG MONITORING
DRUG

NORMAL RANGE

TOXICITY

INDICATION

Digoxin/Lanoxin

.5 – 1.5 meq/L

LEVEL
2

CHF

Affects women more than men

Cause:


Unknown/ idiopathic



Thought to be autoimmune disorder whereby antibodies
destroy acetylcholine receptor sites on the postsynaptic
membrane of the neuromuscular junction.



(increase force of
cardiac output)
Lithium/Lithane

highest between 15 & 35 years old for women, over 40

Voluntary muscles are affected, especially those muscles
innervated by the cranial nerve.

.6 – 1.2 meq/L

2

Bipolar

(decrease level of

Pathophysiology


Ach/NE/Serotonin)
Aminophelline

10 – 19 mg/100 ml

20

COPD

(dilates bronchial tree)
Dilantin/Phenytoin
Acetaminophen/Tylen

10 – 19 mg/100 ml
10 – 30 mg/100 ml

20
200

Seizures
Osteo

Autoimmune = Release of Cholinesterase Enzymes =
Cholinesterase destroy Acetylcholine (ACH) = Decrease of
Acetylcholine (ACH)

ol

Arthritis

1. Digitalis Toxicity



Acetylcholine: activate muscle contraction



Autoimmune: it involves release of cholinesterase an
enzyme that destroys Ach



Cholinesterase: an enzyme that destroys ACH

Signs and Symptoms
- nausea and vomiting
- diarrhea

S/sx
1.

Initial sign is ptosis a clinical parameter to determine ptosis

- confusion

is palpebral fissure: cracked or cleft in the lining or

- photophobia

membrane of the eyelids

- changes in color perception (yellowish spots)

2.

Diplopia

Antidote: Digibind

3.

Dysphagia

2. Lithium Toxicity

4.

Mask like facial expression

Signs and Symptoms

5.

Hoarseness of voice, weakness of voice

- anorexia

6.

Respiratory muscle weakness that may lead to respiratory

- nausea and vomiting
- diarrhea

arrest
7.

- dehydration causing fine tremors

Extreme muscle weakness especially during exertion and
morning; increase activity & reduced with rest.

- hypothyroidism
Dx
Nursing Management

1.

Tensilon Test (Edrophonium Hydrochloride): IV injection of

- force fluids

tensilon provides temporary relief of S/sx for about 5-10

- increase sodium intake to 4 – 10 g% daily

minutes and a maximum of 15 minutes.

3. Aminophelline Toxicity



Signs and Symptoms
- tachycardia

and midbrain and is negative for M.G.
2.

- palpitations
- CNS excitement (tremors, irritability, agitation and restlessness)

If there is no effect there is no damage to occipital lobe

Electromyography (EMG): amplitudes of evoked potentials
decrease rapidly.

3.

Presence of anti-acetlycholine receptors antibodies in the

Nursing Management

serum.

- only mixed with plain NSS or 0.9 NaCl to prevent development of

Medical Management

crystals of precipitate.

1.

- administered sandwich method

Drug Therapy
a.

Anti-cholinesterase Drugs: [Ambenonium (Mytelase),

- avoid taking alcohol because it can lead to severe CNS depression

Neostigmine (Prostigmin), Pyridostigmine (Mestinon)]

- avoid caffeine

 MOA: block the action of cholinesterase & increase

4. Dilantin Toxicity

the level of acetylcholine at the neuromuscular

Signs and Symptoms

junction.

- gingival hyperplasia (swollen gums)

 SE: excessive salivation & sweating, abdominal

- hairy tongue

cramps, N/V, diarrhea, fasciculations (muscle

- ataxia

twitching).

- nystagmus

b.

Corticosteroids: Prednisone

Nursing Management

 MOA: suppress autoimmune response

- provide oral care

 Used if other drugs are not effective

- massage gums

2.

5. Acetaminophen Toxicity

Surgery (Thymectomy)
a.

Signs and Symptoms

in the production of acetylcholine receptor antibodies.

- hepatotoxicity (monitor for liver enzymes)

b.

- SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
- SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)

Surgical removal of thymus gland: thought to be involve
May cause remission in some clients especially if
performed early in the disease.

3.

Plasma Exchange (Plasmapheresis)

11

12
a.

Removes circulating acetylcholine receptor antibodies.

b.

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

1.

Increase CHON and WBC

2.

Decrease glucose

3.

Increase CSF opening pressure (normal pressure is 50 –
100 mmHg)

Atrophine Sulfate

4.

(+) cultured microorganism (confirms meningitis)

Anti Arrythmic Agents:


Lidocaine (Xylocaine)



Bretylium: blocks release of norepinephrine; to

CBC reveals
1.

Increase WBC

prevent increase of BP
Nursing Management

11. Assist in plasmapheresis (filtering of blood to remove
1.

autoimmune anti-bodies)

a.

Broad spectrum antibiotics (Penicillin, Tetracycline)

Arrythmia

b.

Mild analgesics: for headaches

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

Maintain fluid & electrolyte balance & ensure adequate
nutrition:

5.

b.

Brief period of neurologic deficit:

c.
2.

3.

NGT for feeding the client who is unable to swallow

c.

Fluid restriction as ordered: to decrease cerebral edema

Maintain proper positioning & body alignment:
a.

Elevate head 30-45 degree to decrease ICP

b.

Turn & reposition every 2 hrs (20 min only on the

promote body alignment
6.

Promote optimum skin integrity: turn client & apply lotion
every 2 hrs

Visual loss / Visual disturbance



Hemiparesis

a.

Turn client to side



Slurred Speech / Speech disturbance

b.

Provide egg crate mattresses or water bed



Vertigo

c.

Provide sand bag or food board.



Aphasia



Headache: initial sign



Dizziness



Tinnitus



Possible Increase ICP

7.

8.

Prevent complications of immobility by:

Maintain adequate elimination:
a.

Offer bed pan or urinal every 2 hrs; catheterized only if
necessary

b.

Administer stool softener & suppositories as ordered: to
prevent constipation & fecal impaction

May last less than 30 sec, but no more than 24 hrs with

9.

Provide quiet, restful environment

complete resolution of symptoms

10. Provide alternative means of communication to the client:
a.

Non verbal cues

Progressive development of stroke symptoms over a

b.

Magic slate: not paper & pen tiring for client

period of hours to days

c.

If positive to hemianopsia: approach client on
unaffected side

Complete Stroke


Passive ROM exercise every 4 hrs: prevent contractures;



Stroke in Evolution


b.

c.

Transient Ischemic Attack (TIA)
Initial / warning signs of impending CVA / stroke

IV therapy for the first few days

affected side)

Stages of Development
a.

a.

& might also increase ICP

is compromise of main blood supply

1.

Monitor strictly V/S, I & O, neuro check & observe signs of

4.

Constriction of cerebral blood vessel may occur,

Collateral Circulation:

Administer O2 inhalation

Provide CBR as ordered

causing further decrease in blood flow
c.

Assist in mechanical ventilation

b.

3.

Vasospasm:


a.

increase ICP, shock, hyperthermia, & seizure

impairment
b.

Maintain patent airway and adequate ventilation by:

Neurologic deficit remains unchanged for 2-3-days
period

11. Administer medications as ordered:
a.

S/sx
1.

Headache

2.

Generalized Signs:

b.

Hyperosmotic agent: to decrease cerebral edema


Osmotic Diuretics (Mannitol)



Loop Diuretics Furosemide (Lasix)



Corticosteroids (Dexamethazone)

Anti-convulsants: to prevent or treat seizures

14

15
c.

Thrombolytic / Fibrinolytic Agents: given to dissolve clot



(hemorrhage must be ruled out)


attempts to speak

Tissue Plasminogen Activating Factor (tPA,



Alteplase): SE: allergic Reaction

d.

Streptokinase, Urokinase: SE: chest pain


7.

(hemorrhage must be ruled out)




Check for Partial Thromboplastin Time (PTT): if

visual space on affected side)

prolonged there is a risk for bleeding

a.

Assist with self-care

Antidote: Protamine SO4

b.

Provide safety measures

c.

Initially arrange objects in environment on unaffected
side

Give simultaneously with Heparin cause
d.

Warfarin (Coumadin) will take effect after 3 days




8.

Apraxia: loss of ability to perform purposeful, skilled acts
a.

Antidote: Vitamin K (Aqua Mephyton)

movement of washing)

treating TIA’s

b.

PASA (Aspirin)



Contraindicated for dengue, ulcer and unknown

9.

f.

Mild Analgesics: for pain

Generalizations about the clients with left hemiplegia vs.
a.

bleeding
Antihypertensive: if indicated for elevated BP

modifiable

risk

factors

(diet,



Use safety measures, verbal cues, simplicity in all
area of care

b.

exercise,

smoking)
b.

Perceptual, sensory deficits: quick & impulsive
behavior

concerning
Avoid

Left Hemiplegia


12. Provide client health teachings and discharge planning
a.

Keep repeating the movement

right hemiplegia & nursing care

cause of headache because it may potentiate
e.

Guide client through intended movement (ex. Take
object such as wash cloth & guide client through

Anti Platelet: to inhibit platelet aggregation in



Gradually teach client to take care of the affected & turn
frequently & look at affected side

Check for Prothrombin Time (PT): if prolonged
there is a risk for bleeding



Sensory / Perceptual Deficit: more common in left
of disabilities, visual neglect (neglect of affected side &

Warfarin (Comadin): long acting / long term therapy


Allow sufficient time for client to answer

hemiplegics; characterized by impulsiveness unawareness

Heparin: short acting


Anticipate client’s needs to decrease frustrations &
feeling of helplessness

Anticoagulants: for stroke in evolution or embolic stroke


Listen & watch very carefully when the client

Prevent complication (subarachnoid hemorrhage is

Right Hemiplegia


Speech-language deficits: slow & cautious behavior



Use pantomime & demonstration

the most feared complication)
c.

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

Error of Refraction
1.

Myopia: nearsightedness: Treatment: biconcave lens

2.

Hyperopia: farsightedness: Treatment: biconvex lens

3.

Astigmatisim: distorted vision: Treatment: cylindrical

4.

Presbyopia: “old sight” inelasticity of lens due to aging:

4.

Perimetry: reveals defects in visual field

5.

Gonioscopy: examine angle of anterior chamber
Medical Management

1.

Treatment: bifocal lens or double vista

Chronic (open-angle) Glaucoma
a.

Drug Therapy: one or a combination of the following


Accommodation of lenses: based on thelmholtz theory of

Miotics eye drops (Pilocarpine): to increase outflow
of aqueous humor

accommodation



Near Vision: Ciliary muscle contracts: Lens bulges

Epinephrine eye drops: to decrease aqueous humor
production & increase outflow



Far Vision: ciliary muscle dilates / relaxes: lens is flat

Carbonic Anhydrase Inhibitor: Acetazolamide
(Diamox): to decrease aqueous humor production


Convergence of the eye:

blocker: to decrease intraocular pressure (IOP)

Error:

b.

1.

Exotropia:1 eye normal

2.

Esophoria:

Surgery (if no improvement with drug)


corrected by

Strabismus: squint eye

4.

Amblyopia: prolong squinting

humor




Characterized by increase intraocular pressure resulting in

out-client basis; procedure similar result as
trabeculectomy
2.

May cause blindness if not recognized & treated



Early detection is very important



preventable but not curable



Regular eye exam including tonometry for person over age

Acute (close-angle) Glaucoma
a.

progressive loss of vision


Drug Therapy: before surgery





b.

Hereditary

3.

Hypertension

4.

Obesity

5.

History of previous eye surgery, trauma, inflammation

Narcotic Analgesic: for pain

Surgery


2.

Osmotic Agent (Glycerin oral, Mannitol IV): to
decrease intraocular pressure (IOP)

Predisposing Factors
Common among 40 years old and above

Miotics eye drops (Pilocarpine): to cause pupil to
contract & draw iris away from cornea

40 is recommended

1.

Laser Trabeculoplasty: non-invasive procedure
performed with argon laser that can be done on an

Common Visual Disorder
Glaucoma

Filtering procedure (Trabeculectomy / Trephining): to
create artificial openings for the outflow of aqueous

corrective eye surgery
3.

Timolol Maleate (Timoptic): topical beta-adrenergic

Peripheral Iridectomy: portion of the iris is excised to
facilitate outflow of aqueous humor



Argon Laser Beam Surgery: non-invasive procedure
using laser produces same effect as iridectomy;
done in out-client basis



Iridectomy: usually performed on second eye later
since a large number of client have an acute acute
attack in the other eye

Types of Glaucoma:
1.

3.

a.

Chronic (open-angle) Glaucoma:


Most common form



Due to obstruction of the outflow of aqueous humor, in

Chronic (close-angle) Glaucoma

b.

Due to forward displacement of the iris against the
cornea, obstructing the outflow of the aqueous humor

3.



Occurs suddenly & is an emergency situation



If untreated it will result to blindness

Chronic (close-angle) Glaucoma:


Nursing Intervention
1.

Administer medication as ordered

2.

Provide quite, dark environment

3.

Maintain accurate I & O with the use of osmotic agent

4.

Prepare client for surgery if indicated

similar to acute (close-angle) glaucoma, with the

5.

Provide post-op care

potential for an acute attack

6.

Provide client teaching & discharge planning

S/sx
1.

2.

3.

bilateral peripheral iridectomy: to prevent acute
attacks

Acute (close-angle) Glaucoma:


miotics (pilocarpine)

Surgery:


trabecular meshwork or canal of schlemm
2.

Drug Therapy:

a.

Self-administration of eye drops

b.

Need to avoid stooping, heavy lifting or pushing,

Chronic (open-angle) Glaucoma: symptoms develops slowly

emotional upsets, excessive fluid intake, constrictive



Impaired peripheral vision (PS: tunnel vision)



Halos around light



Mild discomfort in the eye

sympathomimetic drugs (found in cold preparation) in



Loss of central vision if unarrested

close-angle glaucoma since they may cause mydriasis

clothing around the neck
c.

Acute (close-angle) Glaucoma

Need to avoid the use antihistamines or

d.

Importance of follow-up care

e.

Need to wear medic-alert tag



Severe eye pain



Blurred cloudy vision



Halos around light



N/V



Decrease opacity of ocular lens



Steamy cornea



Incidence increases with age



Moderate pupillary dilation

Cataract

Predisposing Factor

Chronic (close-angle) Glaucoma


Transient blurred vision



Slight eye pain



Halos around lights

1.

Aging 65 years and above

2.

May caused by changes associated with aging (“senile”
cataract)

3.

Related to congenital

17

18
4.

May develop secondary to trauma, radiation, infection,

5.

certain drugs (corticosteroids)
5.

Diabetes Mellitus

6.

Prolonged exposure to UV rays
S/sx

Administer medication as ordered:
a.

Topical mydriatics & cycloplegic: to decrease spasm of
ciliary body & relieve pain

6.

b.

Topical antibiotics & corticosteroids

c.

Mild analgesic as needed

Provide client teaching & discharge planning concerning:

1.

Loss of central vision

a.

Technique of eyedrop administration

2.

Blurring or hazy vision

b.

Use of eye shield at night

3.

Progressive decrease of vision

c.

No bending, stooping, or lifting

4.

Glare in bright lights

d.

Report signs & symptoms of complication immediately

5.

Milky white appearance at center of pupils

to physician:

6.

Decrease perception to colors



Severe eye pain



Decrease vision

Diagnostic Procedure



Excessive drainage

Ophthalmoscopic exam: confirms presence of cataract



Swelling of eyelid

1.

e.
Nursing Intervention
1.

Cataract glasses / contact lenses


Prepare client for cataract surgery:
a.

will need glasses or contact lenses

Performed when client can no longer remain



independent because of reduced vision
b.



same day surgery unit
Local anesthesia & intravenous sedation usually used

d.

Types of cataract surgery:




becomes familiar




Phacoemulsification: type of extracapsular

Intracapsular Extraction: lens is totally removed
within its capsules, may be delivered from eye by

Retinal Detachment


Separation of epithelial surface of retina



Detachment or the sensory retina from the pigment
epithelium of the retina

cryoextraction (lens is frozen with metal probe &
removed); total removal of lens & surrounding
capsules
e.

Peripheral Iridectomy: may be performed at the time of
surgery; small hole cut in iris to prevent development of
secondary glaucoma

f.

Intraocular Lens Implant: often performed at the time of
surgery

2.

Predisposing Factors
1.

Trauma

2.

Aging process

3.

Severe diabetic retinopathy

4.

Post-cataract extraction

5.

Severe myopia (near sightedness)

Nursing Intervention Pre-op
a.

Assess vision in the unaffected eye since the affected
eye will be patched post-op

b.

Pathophysiology


Administer medication as ordered:


Topical Mydriatics (Mydriacyl) & Cyclopegics
(Cyclogyl): to dilate the pupil



Topical antibiotics: to prevent infection



Acetazolamide (Diamox) & osmotic agent (Oral
Glycerin or Mannitol IV): to decrease intraocular

S/sx
1.

Curtain veil like vision coming across field of vision

2.

Flashes of light

3.

Visual field loss

4.

Floaters

5.

Gradual decrease of central vision

pressure to provide soft eyeball for surgery
3.

Nursing Intervention Post-op
a.

Reorient the client to surroundings

b.

Provide safety measures:


Elevate side rails



Provide call bells



Assist with ambulation when fully recovered from

Dx
1.

1.

Bed rest with eye patched & detached areas dependent to
prevent further detachment

2.

Surgery: necessary to repair detachment
a.

Prevent intraocular pressure & stress on the suture line:

Photocoagulation: light beam (argon laser) through
dilated pupil creates an inflammatory reaction &



Elevate head of the bed 30-40 degree



Have the client lie on back or unaffected side



Avoid having the client cough, sneeze, bend over, or

heat to external globe; inflammatory reaction causes

move head too rapidly

scarring & healing of area



scarring to heal the area
b.

Treat nausea with anti-emetics as ordered: to

c.

prevent vomiting


Give stool softener as ordered: to prevent straining



Observe for & report signs of intraocular pressure
(IOP):

4.

Ophthalmoscopic exam: confirms diagnosis
Medical Management

anesthesia
c.

Tear in the retina allows vitreous humor to seep behind the
sensory retina & separate it from the pigment epithelium

Provide pre-op teaching regarding measures to prevent
intraocular pressure (IOP) post-op

c.

Contact lenses cause less distortion of vision;
prescribe at one month

extraction; a hollow needle capable of ultrasonic
the lens, which is aspirated

Have client practice walking, using stairs,
reaching for articles

implant); partial removal of lens

vibration is inserted into lens, vibrations emulsify

Have the client practice manual coordination
with assistance until new spatial relationship

Extracapsular Extraction: lens capsule is excised &
place (may be used to support new artificial lens



Cataract glasses magnify object by 1/3 & distortion
peripheral vision

the lens is expressed; posterior capsule is left in



Temporary glasses are worn for 1-4 weeks then
permanent glasses fitted

Surgery performed on one eye at a time; usually in a

c.

If a lens implant has not been performed the client



Severe eye pain



Restlessness



Increased pulse

Protect eye from injury:
a.

Dressing usually removed the day after the surgery

b.

Eyeglasses or eye shield used during the day

c.

Always use eye shield during the night

Cryosurgery or diathermy: application of extreme cold or

Scleral buckling: shortening of sclera to force pigment
epithelium close to retina

Nursing Intervention Pre-op
1.

Maintain bed rest as ordered with head of bed flat &
detached area in a dependent position

2.

Use bilateral eye patches as ordered; elevate side rails to
prevent injury

3.

Identify yourself when entering the room

4.

Orient the client frequently to time of date & surroundings;
explain procedures

5.

Provide diversional activities to provide sensory stimulation

18

19
Nursing Intervention Post-op
1.

Check orders for positioning & activity level:

Dx

a.

May be on bed rest for 1-2 days

1.

Audiometry: reveals conductive hearing loss

b.

May need to position client so that detached area is in

2.

Weber’s & Rinne’s Test: show bone conduction is greater

dependent position
2.

3.

than air conduction

Administer medication as ordered:
a.

Topical mydriatics

b.

Analgesic as needed

Medical Management
1.

Provide client teaching & discharge planning concerning:



Techniques of eyedrop administration

replacement with prosthesis to conduct vibrations

b.

Use eye shield at night

from the middle ear to inner ear

c.

No bending from waist; no heavy work or lifting for 6



Usually performed under local anesthesia

weeks



Used to treat otoscrlerosis

d.

Restriction of reading for 3 weeks or more

e.

May watch TV

f.

Need to check to physician regarding combing &

g.

Nursing Intervention Pre-op
1.

Need to report complications such as recurrence of

2.

Explain to the client that hearing may improve during
surgery & then decrease due to edema & packing

Overview of Anatomy & Physiology Of Ear (Hearing)

Nursing Intervention Post-op

External Ear

1.

Position the client according to the surgeon’s orders

Auricle (Pinna): outer projection of ear composed of

(possibly with operative ear uppermost to prevent

cartilage & covered by skin; collects sound waves

displacement of the graft)

External Auditory Canal: lined with skin; glands secretes

2.

cerumen (wax), providing protection; transmits sound waves
3.

Tympanic Membrane (Eardrum): at end of external canal;
4.

middle ear
Middle Ear
Ossicles
a.

3 small bones: malleus (Hammer) attached to
5.

Ossicles are set in motion by sound waves from

6.

Sound waves are conducted by vibration to the
footplate of the stapes in the oval widow (an opening
between the middle ear & the inner ear)

2.



Analgesic



Antibiotics



Anti-emetics



Anti-motion sickness drug: Meclesine Hcl

Check for dressing frequently for excessive drainage or
bleeding

tympanic membrane
c.

Administer medication as ordered:

(Bonamine)

tympanic membrane, incus (anvil), stapes (stirrup)
b.

Elevate side rails; assist the client with ambulation &
move slowly: may have some vertigo

vibrates in response to sound & transmits vibrations to

1.

Have the client deep breathe every 2 hours while in bed,
but no coughing

to tympanic membrane
3.

Provide general pre-op nursing care, including an
explanation of post-op expectation

detachment

2.

Removal of diseased portion of stapes &

a.

shampooing hair & shaving

1.

Stapedectomy: procedure of choice

Eustachian Tube: connects nasopharynx & middle ear;

7.

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,

glyconeogenesis;

increase CHON catabolism; increase
corticosterone)

mobilization of fatty

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







V/S

Posterior Lobe PG (Neurohypophysis)



T3: 3 molecules of iodine (more potent)



& by negative feedback system
2.



activity; promotes cerebration (thinking); increase

down reflex
c.

3 Hormones Secreted:

Also secretes hormones that have direct effects on
tissues: somatotropic or growth H, prolactin

Pheochromocytoma (adrenal medulla): Increase



Testes: located in scrotum; produces testosterone

Pineal Gland


Secretes melatonin



Inhibits LH secretion



It controls & regulates circadian rhythm (body clock)

Diabetes Incipidus (DI)


DI: dalas-ihi

21

22



Decrease of anti-diuretic hormone (ADH)



Hyposecretion of ADH



Hypofunction of the posterior pituitary gland (PPG) resulting

3.

increase ICP; may lead to seizure activity
Dx

in deficiency of ADH


Characterized by excessive thirst & urination

1.

Urine specific gravity: is increase

2.

Serum Sodium: is decreased
Medical Management

Anti-diuretic Hormone: Pitressin (Vasopressin)
Function: prevents urination thereby conserving water


Note: Alcohol inhibits release of ADH

1.

Treat underlying cause if possible

2.

Diuretics & fluid restriction
Nursing Intervention

Predisposing Factor
1.

Related to pituitary surgery

2.

Trauma

3.

Inflammation

4.

Presence of tumor

1.

Restrict fluid: to promote fluid loss & gradual increase in
serum Na

S/sx
1.

Severe polyuria with low specific gravity

2.

Polydipsia (excessive thirst)

3.

Fatigue

4.

Muscle weakness

5.

Irritability

6.

Weight loss

7.

Hypotension

8.

Signs of dehydration

9.

Water intoxication: may lead to cerebral edema: lead to

a.

Adult: thirst; Children: tachycardia

b.

Agitation

c.

Poor Skin turgor

d.

Dry mucous membrane

Tachycardia, eventually shock if fluids is not replaced

10. If left untreated results to hypovolemic shock (late sign

2.

Administer medications as ordered:
a.

Loop diuretics (Lasix)

b.

Osmotic diuretics (Mannitol)

3.

Monitor strictly V/S, I&O & neuro check

4.

Weigh patient daily and assess for pitting edema

5.

Monitor serum electrolytes & blood chemistries carefully

6.

Provide meticulous skin care

7.

Prevent complications

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

dispersion

hormone

Lypressin (Diapid): nasal spray
Predisposing Factors

Prevent complications: hypovolemic shock is the most
feared complication

5.

- exophthalmos

hypovolemia
a.

4.

- amenorrhea

1.

Endemic: caused by nutritional iodine deficiency, most

Provide client teaching & discharge planning concerning:

common in the “goiter belt” area, areas where soil & H2O

a.

Lifelong hormone replacement: Lypressin (Diapid) as

are deficient in iodine; occurs most frequently during

needed to control polyuria & polydipsia

adolescence & pregnancy

Need to wear medic-alert bracelet



b.

Goiter belt area:
a.

Midwest, northwest & great lakes region

Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH)

b.

Places far from sea

Hypersecretion of anti-diuretic hormone (ADH) from the PPG

c.

Mountainous regions



even when the client has abnormal serum osmolality

2.

Sporadic: caused by


Increase intake of goitrogenic foods (contains agent that

Predisposing Factors

decrease the thyroxine production: pro-goitrin an anti-

1.

Head injury

thyroid agent that has no iodine). Ex. cabbage, turnips,

2.

Related to presence of bronchogenic cancer

radish, strawberry, carrots, sweet potato, rutabagas,

3.



Initial sign of lung cancer is non productive cough



Non invasive procedure is chest x-ray

peaches, peas, spinach, broccoli, all nuts

Related to hyperplasia of pituitary gland (increase size of



Soil erosion washes away iodine



Goitrogenic drugs:
a.

Anti-Thyroid Agent: Propylthiouracil (PTU)

b.

Large doses of iodine

S/sx

c.

Phenylbutazone

1.

Person with SIADH cannot excrete a dilute urine

d.

Para-amino salicylic acid

2.

Fluid retention & Na deficiency

e.

Lithium Carbonate

a.

Hypertension

f.

PASA (Aspirin)

b.

Edema

g.

Cobalt

c.

Weight gain

organ brought about by increase of number of cells)

3.

Genetic defects that prevents synthesis of thyroid hormones

22

23



Precipitating factors: failure to take prescribed

S/sx

medications; infection; trauma; exposure to cold; use of

1.

Enlarged thyroid gland

sedatives, narcotics or anesthetics

2.

Dysphagia

3.

Respiratory distress

4.

Mild restlessness

Predisposing Factors
1.

Primary hypothyroidism: atrophy of the gland possibly
caused by an autoimmune process

Dx

2.

Secondary hypothyroidism: caused by decreased

1.

Serum T4: reveals normal or below normal

2.

Thyroid Scan: reveals enlarged thyroid gland.

3.

Serum Thyroid Stimulating Hormone (TSH): is increased

treatment of hyperthyroidism with drugs or radioactive

(confirmatory diagnostic test)

iodine; disease caused by medical intervention such as

RAIU (Radio Active Iodine Uptake): normal or increased

surgery

4.

stimulation from pituitary TSH
3.

4.
Medical Management
1.

Drug Therapy:




3.

5.

Iodine deficiency

Hormone replacement with levothyroxine (Synthroid)

6.

Autoimmune (Hashimotos Disease)

(T4), dessicated thyroid, or liothyronine (Cytomel) (T3)

7.

Occurs more often to women ages 30 & 60

Small dose of iodine (Lugol’s or potassium iodide
S/sx

Avoidance of goitrogenic food or drugs in sporadic goiter

1.

Loss of appetite: but there is wt gain

Surgery:

2.

Anorexia

3.

Weight gain: which promotes lipolysis leading to



Subtotal thyroidectomy: (if goiter is large) to relieve

atherosclerosis and MI

pressure symptoms & for cosmetic reasons

1.

Related to atrophy of thyroid gland due to trauma,
presence of tumor, inflammation

solution): for goiter resulting from iodine deficiency
2.

Iatrogenic: surgical removal of the gland or over

4.

Constipation

Nursing Intervention

5.

Cold intolerance

Administer Replacement therapy as ordered:

6.

Dry scaly skin

a.

Lugol’s Solution / SSKI (Saturated Solution of Potassium

7.

Spares hair

Iodine)

8.

Brittleness of nails

9.

Decrease in all V/S: except wt gain & menses




b.

Color purple or violet and administered via straw to
prevent staining of teeth.

a.

Hypotension

4 Medications to be taken via straw: Lugol’s, Iron,

b.

Bradycardia

Tetracycline, Nitrofurantoin (DOC: for pyelonephritis)

c.

Bradypnea

d.

Hypothermia

Thyroid Hormones:


Levothyroxine (Synthroid)

10. Weakness and fatigue



Liothyronine (Cytomel)

11. Slowed mental processes



Thyroid Extracts

12. Dull look
13. Slow clumsy movement

Nursing Intervention when giving Thyroid Hormones:
1.

Instruct client to take in the morning to prevent
insomnia

2.

Monitor vital signs especially heart rate because drug
causes tachycardia and palpitations

3.

2.

Monitor side effects:


Insomnia



Tachycardia and palpitations



Hypertension



Heat intolerance

Increase dietary intake of foods rich in iodine:


Seaweeds



Seafood’s like oyster, crabs, clams and lobster but

14. Lethargy
15. Generalized interstitial non-pitting edema (Myxedema)
16. Hoarseness of voice
17. Decrease libido
18. Memory impairment
19. Psychosis
20. Menorrhagia
Dx
1.

Serum T3 and T4: is decreased

2.

Serum Cholesterol: is increased

3.

RAIU (Radio Active Iodine Uptake): is decreased
Medical Management

1.

not shrimps because it contains lesser amount of
iodine.


Iodized salt: best taken raw because it is easily
destroyed by heat

3.

Assist in surgical procedure of subtotal thyroidectomy

4.

Provide client teaching & discharge planning concerning:


2.

Used of iodized salt in preventing & treating endemic
goiter



Thyroid hormone replacement

Hypothyroidism (Myxedema)


Slowing of metabolic processes caused by hypofunction of
the thyroid gland with decreased thyroid hormone secretion



Hyposecretion of thyroid hormone



Decrease in all V/S except wt & menses



Adults: myxedema non pitting edema



Children: cretinism the only endocrine disorder that can lead

Drug Therapy:


Levothyroxine (Synthroid)



Thyroglobulin (Proloid)



Dessicated thyroid



Liothyronine (Cytomel)

Myxedema coma is a medical emergency:


IV thyroid hormones



Correction of hypothermina



Maintenance of vital function



Treatment of precipitating cause

Nursing Intervention
1.

Monitor strictly V/S & I&O, daily weights; observe for
edema & signs of cardiovascular complication & to
determine presence of myxedema coma

2.

Administer thyroid hormone replacement therapy as
ordered & monitor effects:
a.

to mental retardation


In severe or untreated cases myxedema coma may occur:


Characterized by intensification of S/sx of
hypothyroidism & neurologic impairment leading to
coma



Mortality rate high; prompt recognition & treatment
essential
b.

Observe signs of thyrotoxicosis:


Tachycardia & palpitation



N/V



Diarrhea



Sweating



Tremors



Agitation



Dyspnea

Increase dosage gradually, especially in clients with
cardiac complication

23

24
3.

Provide comfortable and warm environment: due to cold
intolerance

f.

Sweating

g.

Hyperactive movement

4.

Provide a low calorie diet

10. Goiter

5.

Avoid the use of sedatives; reduce the dose of any

11. PS: Exopthalmus (protrusion of eyeballs)

sedatives, narcotics, or anesthetic agent by half as

12. Amenorrhea

ordered
6.
7.
8.

Provide meticulous skin care: to prevent skin

Dx

breakdown

1.

Serum T3 and T4: is increased

Increase fluid & food high in fiber: to prevent

2.

RAIU (Radio Active Iodine Uptake): is increased

constipation; administer stool softener as ordered

3.

Thyroid Scan: reveals an enlarged thyroid gland

Observe for signs of myxedema coma; provide
appropriate nursing care

9.

a.

Administer medication as ordered

b.

Maintain vital functions:

Medical Management
1.

a.



Anti-thyroid drugs: Propylthiouracil (PTU) &



Correct hypothermia

methimazole (Tapazole): blocke synthesis of thyroid



Maintain adequate ventilation

hormone; toxic effect include agranulocytosis
b.

Myxedema coma:


Drug Therap:

Adrenergic Blocking Agent: Propranolol (Inderal):

A complication of hypothyroidism & an emergency

used to decrease sympathetic activity & alleviate

case

symptoms such as tachycardia
2.

A severe form of hypothyroidism is characterized by:


Severe hypotension



Bradycardia



Bradypnea



Hypoventilation



Hyponatremia



Hypoglycemia



Hypothermia



Leading to progressive stupor and coma

Radioactive Iodine Therapy
a.

Radioactive isotope of iodine (ex. 131I): given to
destroy the thyroid gland, thereby decreasing
production of thyroid hormone

b.

Used in middle-aged or older clients who are
resistant to, or develop toxicity from drug therapy

c.
3.

Hypothyroidism is a potential complication

Surgery: Thyroidectomy performed in younger client for
whom drug therapy has not been effective
Nursing Intervention

Nursing Management for Myxedema Coma

1.

Monitor strictly V/s & I&O, daily weight

1.

Assist in mechanical ventilation

2.

Administer anti-thyroid medications as ordered:

2.

Administer thyroid hormones as ordered

3.

Administer IVF replacement isotonic fluid solution as
ordered / Force fluids

3.

10. Provide client health teaching and discharge planning
concerning:

a.

Propylthiouracil (PTU)

b.

Methimazole (Tapazole)

Provide for period of uninterrupted rest:
a.

Assign a private room away from excessive activity

b.

Administer medication to promote sleep as ordered

a.

Thyroid hormone replacement

4.

Provide comfortable and cold environment

b.

Importance of regular follow-up care

5.

Minimized stress in the environment

c.

Need in additional protection in cold weather

6.

Encourage quiet, relaxing diversional activities

d.

Measures to prevent constipation

7.

Provide dietary intake that is high in CHO, CHON,

e.

Avoid precipitating factors leading to myxedema

calories, vitamin & minerals with supplemental feeding

coma & hypovolemic shock

between meals & at bedtime; omit stimulant

f.

Stress & infection

g.

Use of anesthetics, narcotics, and sedatives

8.

Observe for & prevent complication
a.

Exophthalmos: protects eyes with dark glasses &
artificial tears as ordered

Hyperthyroidism

b.

Thyroid Storm

Secretion of excessive amounts of thyroid hormone in the

9.

blood causes an increase in metabolic process

10. Maintain side rails



Increase in T3 and T4

11. Provide bilateral eye patch to prevent drying of the eyes



Grave’s Disease or Thyrotoxicosis

12. Assist in surgical procedures subtotal Thyroidectomy:



Increase in all V/S except wt & menses

13. Provide client teaching & discharge planning



Provide meticulous skin care

concerning:
a.

Predisposing Factors

Need to recognized & report S/sx of agranulocytosis

1.

More often seen in women between ages 30 & 50

(fever, sore throat, skin rash): if taking anti-thyroid

2.

Autoimmune: involves release of long acting thyroid

drugs
b.

stimulator causing exopthalmus (protrusion of eyeballs)

S/sx of hyperthyroidism & hypothyroidism

enopthalmus (late sign of dehydration among infants)
3.

Excessive iodine intake

4.

Related to hyperplasia (increase size of TG)

Thyroid Storm


Uncontrolled & potentially life-threatening hyperthyroidism
caused by sudden & excessive release of thyroid hormone

S/sx

into the bloodstream

1.

Increase appetite (hyperphagia): but there is weight loss

2.

Heat intolerance

3.

Weight loss

1.

Stress

4.

Diarrhea: increase motility

2.

Infection

5.

Increased in all V/S: except wt & menses

3.

unprepared thyroid surgery

Precipitating Factors

a.

Tachycardia

b.

Increase systolic BP

c.

Palpitation

1.

Apprehension

6.

Warm smooth skin

2.

Restlessness

7.

Fine soft hair

3.

Extremely high temp (up to 106 F / 40.7 C)

8.

Pliable nails

4.

Tahchycardia

9.

CNS involvement

5.

HF

a.

Irritability & agitation

6.

Respiratory Distress

b.

Restlessness

7.

Delirium

c.

Tremors

8.

Coma

d.

Insomnia

e.

Hallucinations

S/sx

Nursing Intervention

24

25
1.

Maintain patent airway & adequate ventilation;

12. Assist the client with ambulation: instruct the client to

administer O2 as ordered

place the hands behind the neck: to decrease stress on

2.

Administer IV therapy as ordered

suture line if added support is necessary

3.

Administer medication as ordered:

13. Hormonal replacement therapy for lifetime

a.

Anti-thyroid drugs

14. Watch out for accidental laryngeal damage which may

b.

Corticosteroids

lead to hoarseness of voice: encourage client to

c.

Sedatives

talk/speak immediately after operation and notify

d.

Cardiac Drugs

physician
15. Provide client teaching& discharge planning concerning:

Thyroidectomy


Partial or total removal of thyroid gland



Indication:
Subtotal Thyroidectomy: hyperthyroidism



Total Thyroidectomy: thyroid cancer

Self administration of thyroid hormone: if total
Application of lubricant to the incision once suture is
removed

d.

Perform ROM neck exercise 3-4 times a day

e.

Importance of follow up care with periodic serum
calcium level

Ensure that the client is adequately prepared for surgery
a.

Cardiac status is normal

b.

Weight & nutritional status is normal

Administer anti-thyroid drugs as ordered: to suppressed
the production of thyroid hormone & to prevent thyroid

Hypoparathyroidism


storm
3.

b.
c.

Nursing Intervention Pre-op

2.

S/sx of hyperthyroidism & hypothyroidism
thyroidectomy is performed



1.

a.

deficiency of parathormone (PTH) production

Administer iodine preparation Lugol’s Solution (SSKI) or
Potassium Iodide Solution: to decrease vascularity of the

Disorder characterized by hypocalcemia resulting from a



Decrease secretion of parathormone: leading to
hypocalcemia: resulting to hyperphospatemia

thyroid gland & to prevent hemorrhage.


If calcium decreases phosphate increases

Nursing Intervention Post-Op
1.
2.
3.

Predisposing Factors

Monitor V/S & I&O
Check dressing for signs of hemorrhage: check for

1.

May be hereditary

wetness behind the neck

2.

Idiopathic

Place client in semi-fowlers position & support head with

3.

Caused by accidental damage to or removal of
parathyroid gland during thyroidectomy surgery

pillow
4.

4.

Observe for respiratory distress secondary to

Atrophy of parathyroid gland due to: inflammation,
tumor, trauma

hemorrhage, edema of glottis, laryngeal nerve damage,
or tetany: keep tracheostomy set, O2 & suction nearby
5.

S/sx

Assess for signs of tetany: due to hypocalcemia: due to
secondary accidental removal of parathyroid glands:

1.

a.

Paresthesia: tingling sensation of finger & around lip

Watch out for accidental removal of parathyroid

b.

Muscle spasm

which may lead to hypocalcemia (tetany)

c.

laryngospasm/broncospasm

Classic S/sx of Tetany

d.

Dysphagia

keep Calcium Gluconate available:






Positive trousseu’s sign

e.

Seizure: feared complications



Positive chvostek sign

f.

Cardiac arrhythmia: feared complications

g.

Numbness

h.

Positive trousseu’s sign: carpopedal spasm

i.

Positive chvostek sign

Observe for arrhythmia, seizure: give Calcium
Gluconate IV slowly as ordered

6.

Ecourage clients voice to rest:
2.

a.

Some hoarseness is common

b.

Check every 30-60 min for extreme hoarseness or
any accompanying respiratory distress

7.

Acute hypocalcemia (tetany)

Observe for signs of thyroid storm / thyrotoxicosis: due
to release of excessive amount of thyroid hormone
during surgery
Agitation

TRIAD SIGNS

Chronic hypocalcemia (tetany)
a.

Fatigue

b.

Weakness

c.

Muscle cramps

d.

Personality changes

e.

Irritability

f.

Memory impairment

g.

Agitation

h.

Dry scaly skin

i.

Hair loss

j.

Loss of tooth enamel

k.

Tremors

l.

Cardiac arrhythmias

m. Cataract formation

Hyperthermia
Tachycardia




Photophobia

o.

Anorexia

p.

N/V

Administer medications as ordered:


Anti Pyretics



Beta-blockers

Monitor strictly vital signs, input and output and
neuro check.

8.

n.



Maintain side rails



Offer TSB

Administer IV fluids as ordered: until the client is

Diagnostic Procedures
1.

Serum Calcium level: decreased (normal value: 8.5 – 11
mg/100 ml)

2.

Serum Phosphate level: increased (normal value: 2.5 –
4.5 mg/100 ml)

3.

Skeletal X-ray of long bones: reveals a increased in bone
density

4.

CT Scan: reveals degeneration of basal ganglia

tolerating fluids by mouth
9.

Administer analgesics as ordered: for incisional pain

10. Relieve discomfort from sore throat:
a.

Cool mist humidifier to thin secretions

b.

Administer analgesic throat lozenges before meals
prn as ordered

Nursing Management
1.

Administer medications as ordered such as:
a.

Acute Tetany: Calcium Gluconate slow IV drip as
ordered

b.

Chronic Tetany:

11. Encourage coughing & deep breathing every hour

25

26



Oral calcium preparation: Calcium Gluconate,

1.

Pathologic fracture

Calcium Lactate, Calcium Carbonate (Os-Cal)


2.

Large dose of vitamin D (Calciferol): to help

CHOLECALCIFEROL ARE DERIVED FROM

3.

Anorexia; N/V; Gastric Ulcer; Constipation

4.

Muscle weakness; Fatigue

5.

Irritability / Agitation; Personality changes; Depression;
Memory impairment

Diet (Calcidiol)
6.

Sunlight (Calcitriol)


Kidney stones; Renal colic; Polyuria; Polydipsia; Cool
moist skin

absorption of calcium

Drug

Bone pain (especially at back); Bone demineralization;

Cardiac arrhythmias; HPN
Dx

Phosphate Binder: Aluminum Hydroxide Gel
(Amphogel) or aluminum carbonate gel, basic

1.

Serum Calcium: is increased

(basaljel): to decrease phosphate levels

2.

Serum Phosphate: is decreased

3.

Skeletal X-ray of long bones: reveals bone
demineralization

ANTACID

Nursing Intervention

A.A.C
1.

MAD

Administer IV infusions of normal saline solution & give
diuretics as ordered:

2.

Aluminum
Magnesium

Monitor I&O & observe fluid overload & electrolytes
imbalance

Containing
3.

Containing

Assist client with self care: Provide careful handling,
Moving, Ambulation: to prevent pathologic fracture

Antacids
Antacids

4.

Monitor V/S: report irregularities

5.

Force fluids 2000-3000 L/day: to prevent kidney stones

6.

Provide acid-ash juices (ex. Cranberry, orange juice): to

Aluminum

acidify urine & prevent bacterial growth

Hydroxide

7.

Strain urine: using gauze pad: for stone analysis

Gel

8.

Provide low-calcium & high-phosphorus diet

9.

Provide warm sitz bath: for comfort

Side Effect: Constipation

10. Administer medications as ordered: Morphine Sulfate

Side Effect: Diarrhea

(Demerol)

2.

Institute seizure & safety precaution

11. Maintain side rails

3.

Provide quite environment free from excessive stimuli

12. Assist in surgical procedure: Parathyroidectomy

4.

Avoid precipitating stimulus such as glaring lights and

13. Provide client teaching & discharge planning

5.
6.

noise

concerning:

Monitor signs of hoarseness or stridor; check for signs

a.

Need to engage in progressive ambulatory activities

for Chvostek’s & Trousseau’s sign

b.

Increase fluid intake

Keep emergency equipment (tracheostomy set,

c.

Use of calcium preparation & importance of high-

injectable Calcium Gluconate) at bedside: for presence
7.

calcium diet following a parathyroidectomy

of laryngospasm

d.

Prevent complications: renal failure

For tetany or generalized muscle cramp: may use

e.

Hormonal replacement therapy for lifetime

rebreathing bag or paper bag to produce mild

f.

Importance of follow up care

respiratory acidosis: to promote increase ionized Ca
levels
8.

Monitor serum calcium & phosphate level

9.

Provide high-calcium & low-phosphorus diet

Addison’s Disease


adrenal cortex causes decrease secretion of the

10. Provide client teaching & discharge planning
concerning:
a.

Medication regimen: oral calcium preparation & vit
D to be taken with meal to increase absorption

b.

Need to recognized & report S/sx of
hypo/hypercalcemia

c.

Primary adrenocortical insufficiency; hypofunction of the
mineralcorticoids, glucocorticoids, & sex hormones



Hyposecretion of adrenocortical hormone leading to:


Metabolic disturbance: Sugar



Fluid and electrolyte imbalance: Na, H2O, K



Deficiency of neuromascular function: Salt, Sex

1.

Relatively rare disease caused by:

Importance of follow-up care with periodic serum
calcium level

d.

Prevent complications

e.

Hormonal replacement therapy for lifetime

Predisposing Factors


autoimmune process


Hyperparathyroidism


calcium, phosphate & bone metabolism
Decrease parathormone



Hypercalcemia: bone demineralization leading to bone
fracture (calcium is stored 99% in bone and 1% blood)



Kidney stones
Predisposing Factors
1.

Most commonly affects women between ages 35 & 65

2.

Primary Hyperparathyroidism: caused by tumor &
hyperplasia of parathyroid gland

3.

Secondary Hyperparathyroidism: cause by
compensatory over secretion of PTH in response to
hypocalcemia from:
a.

Children: Ricketts

b.

Adults: Osteomalacia

c.

Chronic renal disease

d.

Malabsorption syndrome

Destruction of the gland secondary to TB or fungal
infections

Increase secretion of PTH that results in an altered state of



Idiopathic atrophy of the adrenal cortex: due to an

S/sx
1.

Fatigue, Muscle weakness

2.

Anorexia, N/V, abdominal pain, weight loss

3.

History of hypoglycemic reaction / Hypoglycemia:
tremors, tachycardia, irritability, restlessness, extreme
fatigue, diaphoresis, depression

4.

Hyponatremia: hypotension, signs of dehydration,
weight loss, weak pulse

5.

Decrease tolerance to stress

6.

Hyperkalemia: agitation, diarrhea, arrhythmia

7.

Decrease libido

8.

Loss of pubic and axillary hair

9.

Bronze like skin pigmentation

1.

FBS: is decreased (normal value: 80 – 100 mg/dl)

2.

Plasma Cortisol: is decreased

Dx

S/sx

26

27
3.

Serum Sodium: is decrease (normal value: 135 – 145

k.

Importance of follow up care

meq/L)
4.

Serum Potassium: is increased (normal value: 3.5 – 4.5
meq/L)
Nursing Intervention

1.

Addisonian Crisis

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

Formation of glucose from non-CHO sources

(Aldactone): potassium sparring diuretics
15. Provide client teaching & discharge planning

Increase protein formation

concerning:
a.

Diet modification

b.

Importance of adequate rest

c.

Need to avoid stress & infection

d.

Change in medication regimen (alternate day

Negative Nitrogen balance
Tissue wasting (Cachexia)

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)

MAIN FOODSTUFF
1. CHO

ANABOLISM
Glucose

CATABOLISM
Glycogen

3.

Related to viruses

2. CHON

Amino Acids

Nitrogen

4.

Drugs: diuretics (Lasix), Steroids, oral contraceptives

3. Fats

Fatty Acids

Free Fatty Acids

5.

Related to carbon tetrachloride toxicity

: cholesterol
S/sx

: ketones
1.

Polyuria

7.

Anorexia

2.

Polydipsia

8.

N/V

3.

Polyphagia

9.

Blurring of vision

4.

Glucosuria

10. Increase susceptibility to infection

5.

Weight loss

11. Delayed / poor wound healing

6.

Fatigue
b.
Dx

1.

FBS:
a.

2.

Postprandial Blood Sugar: elevated

3.

Oral Glucose Tolerance Test (most sensitve test):

A level of 140 mg/dl of greater on at two occasions
confirms DM

May be normal in Type II DM

elevated
4.

Glycosolated Hemoglobin (hemoglobin A1c): elevated

28

29
S/sx
1.

Usually asymptomatic

1.

Insulin therapy

Medical Management

2.

Polyuria

2.

Exercise

3.

Polydypsia

3.

Diet:

4.

Polyphagia

a.

Consistency is imperative to avoid hypoglycemia

5.

Glycosuria

b.

High-fiber, low-fat diet also recommended

6.

Weight gain / Obesity

Drug therapy:

7.

Fatigue

a.

8.

Blurred Vision

Short Acting: used in treating ketoacidosis;

9.

Increase susceptibility to infection

during surgery, infection, trauma; management

10. Delayed / poor wound healing

4.

Insulin:


of poorly controlled diabetes; to supplement
Dx

long-acting insulins


Intermediate: used for maintenance therapy



Long Acting: used for maintenance therapy in

5.

FBS:
c.

confirms DM

clients who experience hyperglycemia during
d.

the night with intermediate-acting insulin
b.

May be normal in Type II DM

Insulin preparation can consist of mixture of pure

6.

Postprandial Blood Sugar: elevated

pork, pure beef, or human insulin. Human insulin is

7.

Oral Glucose Tolerance Test (most sensitve test):
elevated

the purest insulin & has the lowest antigenic effect
c.

A level of 140 mg/dl of greater on at two occasions

8.

Human Insulin: is recommended for all newly

Glycosolated Hemoglobin (hemoglobin A1c): elevated

diagnosed Type I & Type II DM who need short-term
Medical Management

insulin therapy; the pregnant client & diabetic client
d.

with insulin allergy or severe insulin resistance

1.

Ideally manage by diet & exercise

Insulin Pumps: externally worn device that closely

2.

Oral Hypoglycemic agents or occasionally insulin: if diet
& exercise are not effective in controlling hyperglycemia

mimic normal pancreatic functioning
5.

Exercise: helpful adjunct to therapy as exercise

3.

Insulin is needed in acute stress: ex. Surgery, infection

decrease the body’s need for insulin

4.

Diet: CHO 50%, CHON 30% & Fats 20%
a.

resistance

Characteristics of Insulin Preparation
Drug

Synonym
Duration

Appearance

Onset

b.

Peak
5.

Compatible Mixed

Rapid Acting
Insulin Injection Regular Ins

Clear

½-1

Weight loss is important since it decreases insulin

2-4

6-8

High-fiber, low-fat diet also recommended

Drug therapy:
a.

Occasional use of insulin

b.

Oral hypoglycemic agent:


All insulin prep

Used by client who are not controlled by diet &
exercise



except lente

Increase the ability of islet cells of the pancreas
to secret insulin; may have some effect on cell

Insulin, Zinc

Semilente Ins

16

Lente prep

Cloudy

½-1

4-6

receptors to decrease resistance to insulin

126.

Exercise: helpful adjunct to therapy as exercise
decrease the body’s need for insulin

suspension,
prompt

Oral Hypoglycemic Agent
Drug

Intermediate Acting
Isophane Ins

NPH Ins

24

Regular Ins

Cloudy

1-1 ½

8-12

Onset

Oral Sulfonylureas
Acetohexamide (Dymelor)
Chlorpropamide (Diabinase)

24

Regular Ins &

1

4-6

12-

24

injection
Lente Ins

Duration

Comments

18-

injection

Insulin Zinc

Peak

Cloudy

1-1 ½

8-12

18-

1

Glyburide (Micronase, Diabeta) 15 min- 1 hr

4-6

40-60

2-8

10-24

Oral Biguanides

Suspension

Metformin (Glucophage)

semilente prep

16

2-2.5

10-

:Decrease glucose

Long Acting
Insulin Zinc

Ultralente Ins

36

Regular Ins &

Cloudy

4-8

16-20

30-

production in liver
:Decrease intestinal

suspension,
semilente prep

absorption of glucose &

extended
Complication
1.

improves insulin sensitivity

Diabetic Ketoacidosis (DKA)
Oral Alpha-glucosidose Inhibitor

2.

Type II Non-insulin-dependent Diabetes Mellitus (NIDDM)


May result to partial deficiency of insulin production &/or

Acarbose (Precose)

Unknown

1

Unknown

:Delay glucose absorption

an insensitivity of the cells to insulin


Obese adult over 40 years old



Maturity onset type

& digestion of CHO,
lowering blood sugar

Incidence Rate
1.

90% of general population has Type II DM

Miglitol (Glyset)
Troglitazone (Rezulin)

2-3
Rapid

2-3

Unknown

:Reduce plasma glucose &
Predisposing Factors
1.

Genetics

2.

Obesity: because obese persons lack insulin receptor
binding sites

insulin
:Potetiates action of insulin
in skeletal muscle &

29

30


decrease glucose

GIT irritation & prevent hypoglycemia
e.

production in liver

Urine testing (not very accurate reflection of blood
glucose level)


Complications
1.

Instruct the client to take it with meals: to lessen

May be satisfactory for Type II diabetics since
they are more stable

Hyper Osmolar Non-Ketotic Coma (HONKC)



Use clinitest, tes-tape, diastix, for glucose
testing

Nursing Intervention
1.



Perform test before meals & at bedtime

Administer insulin or oral hypoglycemic agent as



Use freshly voided specimen

ordered: monitor hypoglycemia especially during period



Be consistent in brand of urine test used



Report results in percentage



Report result to physician if results are greater

of drug peak action
2.

Provide special diet as ordered:
a.

Ensure that the client is eating all meals

b.

If all food is not ingested: provide appropriate

that 1%, especially if experiencing symptoms of
hyperglycemia

substitute according to the exchange list or give



measured amount of orange juice to substitute for

Type I diabetic clients when there is persistent

leftover food; provide snack later in the day
3.

glycosuria, increase blood glucose level or if the

Monitor urine sugar & acetone (freshly voided

client is not feeling well (acetest, ketostix)

specimen)
4.

f.

Perform finger sticks to monitor blood glucose level as
Observe signs of hypo/hyperglycemia

6.

Provide meticulous skin care & prevent injury

7.

Maintain I&O; weight daily

8.

Provide emotional support: assist client in adapting



utilization of test results
g.

General care


Atherosclerosis: leads to CAD, MI, CVA & Peripheral
Vascular Disease

c.

d.

e.

Perform good oral hygiene & have regular dental
exam

accordingly:

b.

Instruct client in finger stick technique: use of
monitor device (if used), & recording &

Observe for chronic complications & plan of care
a.

Use for Type I diabetic client: since it gives exact
blood glucose level & also detects hypoglycemia

change in lifestyle & body image
9.

Blood glucose monitoring


ordered (more accurate than urine test)
5.

Urine testing for ketones should be done by



Have regular eye exam



Care for “sick days” (ex. Cold or flu)


Microangiopathy: most commonly affects eyes &

Do not omit insulin or oral hypoglycemic

kidneys

agent: since infection causes increase blood

Kidney Disease

sugar



Recurrent Pyelonephritis



Notify physician



Diabetic Nephropathy



Monitor urine or blood glucose level & urine
ketones frequently

Ocular Disorder


Premature Cataracts



Diabetic Retinopathy



If N/V occurs: sip on clear liquid with simple
sugar

h.

Peripheral Neuropathy

Foot care



Affects PNS & ANS



Wash foot with mild soap & water & pat dry



Cause diarrhea, constipation, neurogenic



Apply lanolin lotion to feet: to prevent drying &
cracking

bladder, impotence, decrease sweating


Cut toenail straight across

concerning:



Avoid constrictive garments such as garters

a.

Disease process



Wear clean, absorbent socks (cotton or wool)

b.

Diet



Purchase properly fitting shoes & break new

10. Provide client teaching & discharge planning





shoes in gradually

Client should be able to plan a meal using
exchange lists before discharge



Never go barefoot

Emphasize importance of regularity of meals;



Inspect foot daily & notify physician: if cut,
blister, or break in skin occurs

never skip meals
c.

i.

Insulin


How to draw up into syringe


Use insulin at room temp



Gently roll the vial between palms



Draw up insulin using sterile technique



If mixing insulin, draw up clear insulin,

Exercise


vigorous exercise




blood sugar is rising
j.

Systematically rotate the site: to prevent

Complication


lipodystrophy: (hypertrophy or atrophy of


Learn to recognized S/sx of hypo/hyperglycemia:
for hypoglycemia (cold and clammy skin), for

tissue)

hyperglycemia (dry and warm skin): administer

Insert needle at a 45 (skinny clients) or 90

simple sugars

(fat or obese clients) degree angle


depending on amount of adipose tissue

Eat candy or drink orange juice with sugar
added for insulin reaction (hypoglycemia)

May store current vial of insulin at room


temperature; refrigerate extra supplies


Exercise is best performed after meals when the

Injection technique




Food intake may need to be increased before
exercising

before cloudy insulin


Undertake regular exercise; avoid sporadic,

k.

Somogyi’s phenomenon: hypoglycemia followed

Monitor signs of DKA & HONKC

Need to wear a Medic-Alert bracelet

by periods of hyperglycemia or rebound effect of
insulin.


Provide many opportunities for return

Diabetic Ketoacidosis (DKA)


accumulation of ketones in the body: cause metabolic

demonstration
d.

acidosis

Oral hypoglycemic agent


Stress importance of taking the drug regularly



Avoid alcohol intake while on medication: it can
lead to severe hypoglycemia reaction

Acute complication of DM characterized by hyperglycemia &



Acute complication of Type I DM: due to severe
hyperglycemia leading to severe CNS depression



Occurs in insulin-dependent diabetic clients



Onset slow: maybe hours to days

30

31
Predisposing Factors

5.

Hyperglycemia

6.

Physical & Emotional Stress: number one precipitating

1.

Undiagnosed DM

2.

Neglect to treatment

3.

Infection

4.

cardiovascular disorder

1.

Polyuria

10. Dry mucous membrane; soft eyeballs

2.

Polydipsia

11. Blurring of vision

3.

Polyphagia

12. PS: Acetone breath odor

4.

Glucosuria

13. PS: Kussmaul’s Respiration (rapid shallow breathing) or

5.

Weight loss

6.

Anorexia

14. Alteration in LOC

7.

N/V

15. Hypotension

8.

Abdominal pain

16. Tachycardia

9.

Skin warm, dry & flushed

17. CNS depression leading to coma

factor
S/sx

tachypnea

b.
Dx

If given IV drip: give small amount of albumin since
insulin adheres to IV tubing

1.

FBS: is increased

2.

Serum glucose & ketones level: elevated

3.

BUN (normal value: 10 – 20): elevated: due to

a.

Sodium Bicarbonate: to counteract acidosis

dehydration

b.

Antibiotics: to prevent infection

4.

c.
5.

Monitor blood glucose level frequently

Administer medications as ordered:

Creatinine (normal value: .8 – 1): elevated: due to

6.

Check urine output every hour

dehydration

7.

Monitor V/S, I&O & blood sugar levels

Hct (normal value: female 36 – 42, male 42 – 48):

8.

Assist client with self-care

elevated: due to dehydration

9.

Provide care for unconscious client if in a coma

6.

Serum Na: decrease

10. Discuss with client the reasons ketosis developed &

7.

Serum K: maybe normal or elevated at first

8.

ABG: metabolic acidosis with compensatory respiratory

5.

alkalosis

provide additional diabetic teaching if indicated
Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC)


Nursing Intervention

Characterized by hyperglycemia & a hyperosmolar state
without ketosis

1.

Maintain patent airway

2.

Assist in mechanical ventilation

3.

Maintain F&E balance:



Hyperosmolar: increase osmolarity (severe dehydration)

a.



Non-ketotic: absence of lypolysis (no ketones)

Administer IV therapy as ordered:




Occurs in non-insulin-dependent diabetic or non-diabetic
persons (typically elderly clients)

Normal saline (0.9% NaCl), followed by
hypotonic solutions (.45% NaCl) sodium
chloride: to counteract dehydration & shock

1.

Undiagnosed diabetes

When blood sugar drops to 250 mg/dl: may add

2.

Infection or other stress

5% dextrose to IV

3.

Certain medications (ex. dilantin, thiazide, diuretics)

Potassium will be added: when the urine output

4.

Dialysis

is adequate

5.

Hyperalimentation

Observe for F&E imbalance, especially fluid

6.

Major burns

overload, hyperkalemia & hypokalemia

7.

Pancreatic disease




b.
4.

Predisposing Factors

Administer insulin as ordered: regular acting
insulin/rapid acting insulin
a.

S/sx

Regular insulin IV (drip or push) & / or
subcutaneously (SC)

1.

Polyuria

10. Dry mucous membrane; soft eyeballs

2.

Polydipsia

11. Blurring of vision

3.

Polyphagia

12. Hypotension

4.

Glucosuria

13. Tachycardia

5.

Weight loss

14. Headache and dizziness

6.

Anorexia

15. Restlessness

7.

N/V

16. Seizure activity

8.

Abdominal pain

17. Alteration / Decrease LOC: diabetic coma

9.

Skin warm, dry & flushed
4.
Dx

Administer insulin as ordered:
a.

1.

Blood glucose level: extremely elevated

2.

BUN: elevated: due to dehydration

3.

Creatinine: elevted: due to dehydration

4.

Hct: elevated: due to dehydration

5.

Urine: (+) for glucose

Regular insulin IV (drip or push) & / or
subcutaneously (SC)

b.

If given IV drip: give small amount of albumin since
insulin adheres to IV tubing

c.
5.

Administer medications as ordered:
a.

Nursing Intervention

Monitor blood glucose level frequently
Antibiotics: to prevent infection

6.

Check urine output every hour

1.

Maintain patent airway

7.

Monitor V/S, I&O & blood sugar levels

2.

Assist in mechanical ventilation

8.

Assist client with self-care

3.

Maintain F&E balance:

9.

Provide care for unconscious client if in a coma

a.

10. Discuss with client the reasons ketosis developed &

Administer IV therapy as ordered:


Normal saline (0.9% NaCl), followed by

provide additional diabetic teaching if indicated

hypotonic solutions (.45% NaCl) sodium
chloride: to counteract dehydration & shock


When blood sugar drops to 250 mg/dl: may add
5% dextrose to IV



Potassium will be added: when the urine output
is adequate

b.

Overview of Anatomy & Physiology of Hematologic System


The structure of the hematological of hematopoietic system

Observe for F&E imbalance, especially fluid

includes the blood, blood vessels, & blood forming organs

overload, hyperkalemia & hypokalemia

(bone marrow, spleen, liver, lymph nodes, & thymus gland).

31

32



The major function of blood: is to carry necessary materials

a.

hormones

(O2, nutrients) to cells & remove CO2 & metabolic waste


Alpha: role in transport steroids, lipids, bilirubin &

products.

b.

Beta: role in transport of iron & copper

The hematologic system also plays an important role in

c.

Gamma: role in immune response, function of
antibodies

hormone transport, the inflammatory & immune responses,
3.

temperature regulation, F&E balance & acid-base balance.

Fibrinogens, Prothrombin, Plasminogens: clotting factors
to prevent bleeding

Cellular Components or Formed Elements

HEMATOLOGICAL SYSTEM

1.
I. Blood
III. Blood Forming Organs
Liver
55% Plasma
Thymus
(Fluid)
Spleen

II. Blood Vessels

45% Formed
cellular elements

1. Arteries

1.

2. Veins

2.

3. Capillaries

3.

Erythrocytes (RBC)
a.

Normal value: 4 – 6 million/mm3

b.

No nucleus, Biconcave shape discs, Chiefly sac of
hemoglobin

c.

Call membrane is highly diffusible to O2 & CO2

d.

Responsible for O2 transport via hemoglobin (Hgb)


portion is CHON

4.
Lymphoid Organ
Serum
Lymph Nodes


Plasma CHON

5.

(formed in liver)

6.

e.

Production


1. Albumin
2. Globulins
3. Prothrombin and Fibrinogen

erythrocytes



f.

Primary function is Hematopoiesis: the formation of blood

Hemolysis (Destruction)


cells

Normal life span of RBC is 80 – 120 days and is
killed in red pulp of spleen

All blood cells start as stem cells in the bone marrow; these



Immature RBCs destroyed in either bone marrow or

mature into different, specific types of cells, collectively

other reticuloendothelial organs (blood, connective

referred to as Formed Elements of Blood or Blood

tissue, spleen, liver, lungs and lymph nodes)

Components:



Mature cells remove chiefly by liver and spleen



Bilirubin (yellow pigment): by product of Hgb (red

1.

Erythrocytes

2.

Leukocytes

pigment) released when RBCs destroyed, excreted

3.

Thrombocytes

in bile

Two kinds of Bone Marrow:



Biliverdin (green pigment)

1.



Hemosiderin (golden brown pigment)



Iron: feed from Hgb during bilirubin formation;

Red Marrow



2.

Carries out hematopoiesis; production site of
erythroid, myeloid, & thrombocytic component of

transported to bone marrow via transferring and and

blood; one source of lymphocytes & macrophages

reclaimed for new Hgb production

Found in the ribs, vertebral column, other flat bones



Yellow Marrow


Premature destruction: may be caused by RBC
membrane abnormalities, Hgb abnormalities,

Red marrow that has changed to fats; found in long

extrinsic physical factors (such as the enzyme

bone; does not contribute to hematopoiesis

defects found in G6PD)


Blood

Normal age RBCs may be destroyed by gross
damage as in trauma or extravascular hemolysis (in



Composed of plasma (55%) & cellular components (45%)



Hematocrit
1.

Reflects portion of blood composed of red blood cells

2.

Centrifugation of blood results in separation into top

spleen, liver, bone marrow)
g.
h.

Hematocrit red cell percentage in wholeblood (normal
value: female 36 – 42% male 42 – 48%)

& bottom layer of erythrocytes
3.

Hemoglobin: normal value female 12 – 14 gms% male
14 – 16 gms%

layer of plasma, middle layer of leukocytes & platelets,



Iron, vitamin B12, folic acid, pyridoxine vitamin B6,
& other factors required for erythropoiesis

organs in the body (4-5% of total body weight)



Erythropoietin stimulates differentiation; produced
by kidneys & stimulated by hypoxia

Contained inside all bones, occupies interior of spongy
bones & center of long bones; collectively one of the largest



Start in bone marrow as stem cells, release as
reticulocytes (immature cells), mature into

Bone Marrow



Normal blood contains 12-18 g Hgb/100 ml blood;
higher (14-18 g) in men than in women (12-14 g)

Bone Marrow



Two portion: iron carried on heme portion; second

i.

Substances needed for maturation of RBC:

Majority of formed elements is erythrocytes; volume of

a.

Folic acid

leukocytes & platelets is negligible

b.

Iron

Distribution

c.

Vitamin c

1.

1300 ml in pulmonary circulation

d.

Vitamin b12 (Cyanocobalamin)

a.

400 ml arterial

e.

Vitamin b6 (Pyridoxine)

b.

60 ml capillary

f.

Intrinsic factor

c.

840 ml venous

2.

3000 ml in systemic circulation

2.

Leukocytes (WBC)

a.

550 ml arterial

a.

Normal value: 5000 – 10000/mm3

b.

300 ml capillary

b.

Granulocytes and mononuclear cells: involved in the

c.

2150 ml venous

protection from bacteria and other foreign substances
c.

Plasma

Granulocytes:


Polymorphonuclear Neutrophils



Liquid part of the blood; yellow in color because of pigments

-

60 – 70% of WBC



Consists of serum (liquid portion of plasma) & fibrinogen

-

Involved in short term phagocytosis for acute



Contains plasma CHON such as albumin, serum, globulins,

inflammation
-

fibrinogen, prothrombin, plasminogen
1.

neutrophils:

polymorphonuclear

leukocytes

Albumin
-

Immature

neutrophils:

band

cells

(bacterial



Largest & numerous plasma CHON



Involved in regulation of intravascular plasma

infection usually produces increased numbers of

volume

band cells)


2.

Mature

Maintains osmotic pressure: preventing edema

Serum Globulins



Polymorphonuclear Basophils
-

For parasite infections

32

33
-

Responsible

for

the

release

of

chemical

c.

mediation for inflammation
-

Involved

in

Important for Rh (-) woman carrying Rh (+) baby; 1st
pregnancy not affected, but subsequent pregnancy with

prevention

of

clotting

in

an Rh (+) baby, mother’s antibodies attack baby’s RBC

microcirculation and allergic reactions



Polymorphonuclear Eosinophils

Complication of Blood Transfusion

-

Type

Involved in phagocytosis and allergic reaction

Causes

Mechanism

Occurrence

Antibodies in

Acute:

S/sx

Intervention

Eosinophils & Basophils: are reservoirs of histamine,
serotonin & heparin

d.

Hemolytic

Non Granulocytes


Headache,

Mononuclear cells: large nucleated cells
a.

Involved in long-term phagocytosis for
chronic inflammation



Play a role in immune response



Macrophage in blood



Largest WBC



Produced by bone marrow: give rise to

lumbar or

continue saline IV

Rh

react w/ antigen

completion

sternal pain,

first 5 min
after

send blood unit &

Incompatibility; in donor cells.

of transfusion

diarrhea, fever,

client blood

Use of dextrose

Agglutinated cell

chills, flushing, sample to lab.

histiocytes (kupffer cells of liver),

solutions;

macrophages & other components of

block capillary Delayed:

heat along vein,

reticuloendothelial system
b.

Stop transfusion.

Incompatibility; recipient plasma

Monocytes:


ABO

Lymphocytes: immune cells; produce
substances against foreign cells; produced
primarily in lymph tissue (B cells) & thymus (T

Wide temp

blood flow to

restlessness,

hemoglobinuria.

fluctuation

organs.

anemia, jaundice,

cells)

Watch for
days to 2
weeks after
Treat or prevent

Hemolysis (Hgb

Lymphocytes

dyspnea, signs

shock, DIC, &
into plasma &

B-cell
T-cell
- bone marrow
- thymus
and anti-tumor property
for immunity

Natural killer cell
anti-viral

shock, renal

of

renal shutdown
urine)

shutdown, DIC

HIV
c.

Thrombocytes (Platelets)

Complication of Blood Transfusion



Normal value: 150,000 – 450,000/mm3

Type



Normal life span of platelet is 9 – 12 days



Fragments of megakaryocytes formed in
bone marrow



Production regulated by thrombopoietin



Essential factors in coagulation via
adhesion, aggregation & plug formation



Release substances involved in coagulation



Promotes hemostasis (prevention of blood
loss)



Causes

Occurrence

Immune

Within 30 min

S/sx

Intervention
Allergic

Transfer of an
Uticaria, larygeal
antigen &
edema, wheezing

Stop transfusion.
sensitivity to

start of

Administer

antibody from foreign serum
dyspnea,

antihistamine &

donor to

CHON

transfusion

bronchospasm, or epinephrine.

Consist of immature or baby platelets or
megakaryocytes which is the target of

Mechanism

recipient;
headache,

dengue virus

Treat

Allergic donor
anaphylaxis

life-threatening

Signs of Platelet Dysfunction
1.

Petechiae

2.

Echhymosis

3.

Oozing of blood from venipunctured site

Blood Groups


Erythrocytes carry antigens, which determine the different
blood group



reaction
_____________________________________________________________________
__________________
Pyrogenic

Fever, chills,
flushing,
palpitation,

involved in transfusion reactions

agglutination
bacterial

min

after

initiation

of

Transfuse with

directed against
tachycardia,

Within 15-90

Treat temp.

antibodies

ABO & Rh blood groups because they are most likely to be

Leukocytes

Stop transfusion.

possesses

Blood-typing system are based on the many possible
antigens, but the most important are the antigens of the

Recipient

organism

transfusion

leukocytes-poor

WBC; bacterial
1.

ABO Typing

occasional

Antigens of systems are labeled A & B

b.

Absence of both antigens results in type O blood

c.

Presence of both antigen is type AB

Multitransfused

d.

Presence of either type A or B results in type A & type B,

Administer

respectively

client;

e.

Type O: universal donor

antibiotics prn

f.

Antibodies are automatically formed against ABO

multiparous

contamination;
lumbar pain

antigens not on persons own RBC
2.

blood of washed

a.

RBC.

client

Rh Typing

_____________________________________________________________________

a.

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

_____________________________________________________________________



__________________

Also involved in antibody production by plasma cells & iron
metabolism (iron released from Hgb portion of destroyed

Large amount

Citrate binds

After large

erythrocytes returned to bone marrow)

Neuromascular Monitor/treat
of citrated blood

irritability

Important hematopoietic site in fetus; postnatally
procedures lymphocytes & monocytes

Use fresh blood.

Intoxication

1%-2% of red cell mass or 200 ml blood/minute stored in the
spleen; blood comes via splenic artery to the pulp for

rapidly in stored

Initiate bleeding

Citrate

White Pulp: scattered throughout the red pulp, produces
lymphocytes & sequesters lymphocytes, macrophages,

of bleeding.

banked blood
24 hr

Red Pulp: located between the fibrous strands,


ionic calcium

amount of

In the adult functions of the spleen can be taken over by the
reticuloendothelial system.

hypocalcemia.

in client with
Bleeding due to

banked

blood

Avoid large

Liver


decrease liver
decrease calcium

Involved in bile production (via erythrocyte destruction &
bilirubin production) & erythropoeisis (during fetal life &

amounts of

when bone marrow production is insufficient).

function



citrated blood.

Kupffer cells of liver have reticuloendothelial function as
histiocytes; phagocytic activity & iron storage.


Monitor liver fxn

Liver also involved in synthesis of clotting factors, synthesis
of antithrombins.

_____________________________________________________________________
__________________
Hyperkalemia

Blood Tranfusion

Potassium level Release of

Nausea, colic,

Purpose

Administer blood

increase in
diarrhea, muscle
stored blood
spasm, ECG

In client with
1.

RBC: Improve O2 transport

potassium into renal

2.

Whole Blood, Plasma, Albumin: volume expansion

less than 5-7

3.

Fresh Frozen Plasma, Albumin, Plasma Protein Fraction:

plasma with

insufficiency

provision of proteins

days old in client

4.

red cell lysis
changes (tall

Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole
Blood: provision of coagulation factors

with impaired

5.

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.

S/sx of Allergic reaction
1.

Fever

Volume Expander: albumin; percentage concentration

2.

Dyspnea

varies (50-100 ml/unit); hyperosmolar solution should

3.

Broncial wheezing

not be used in dehydrated clients

4.

Skin rashes

5.

Urticaria

6.

Laryngospasm & Broncospasm

Goals / Objectives
1.

Replace circulating blood volume

2.

Increase the O2 carrying capacity of blood

3.

Prevent infection: if there is a decrease in WBC

1.

Stop BT

4.

Prevent bleeding: if there is platelet deficiency

2.

Notify physician

3.

Flush with plain NSS

4.

Administer medications as ordered

Principles of blood transfusion
1.

2.

3.

4.

5.

Nursing Management

Proper refrigeration

a.

a.

Expiration of packed RBC is 3-6 days

hypotension, anaphylactic shock: treat with

b.

Expiration of platelet is 3-5 days

Epinephrine

Proper typing and cross matching

5.

Send the blood unit to blood bank for re examination

a.

Type O: universal donor

6.

Obtain urine & blood sample & send to laboratory for re-

b.

Type AB: universal recipient

c.

85% of population is RH positive

examination
7.

Monitor vital signs and intake and output

Aseptically assemble all materials needed for BT
a.

Filter set

b.

Gauge 18-19 needle

1.

Fever and chills

c.

Isotonic solution (0.9 NaCl / plain NSS): to prevent

2.

Headache

hemolysis

3.

Tachycardia

Instruct another RN to re check the following

4.

Palpitations

a.

Client name

5.

Diaphoresis

b.

Blood typing & cross matching

6.

Dyspnea

c.

Expiration date

d.

Serial number

S/sx Pyrogenic reactions

Nursing Management

Check the blood unit for bubbles cloudiness, sediments

1.

Stop BT

and darkness in color because it indicates bacterial

2.

Notify physician

contamination

3.

Flush with plain NSS

a.

4.

Administer medications as ordered

b.
c.

Never warm blood: it may destroy vital factors in
blood.

a.

Antipyretic

Warming is only done: during emergency situation &

b.

Antibiotic

if you have the warming device

5.

Send the blood unit to blood bank for re examination

Emergency rapid BT is given after 30 minutes & let

6.

Obtain urine & blood sample & send to laboratory for re-

natural room temperature warm the blood.
6.

Anti Histamine (Benadryl): if positive to

examination

BT should be completed less than 4 hours because

7.

Monitor vital signs & I&O

blood that is exposed at room temperature more than 2

8.

Render TSB

hours: causes blood deterioration that can lead to
bacterial contamination
7.
8.
9.

Avoid mixing or administering drugs at BT line: to

S/sx of Circulatory reaction

prevent hemolysis

1.

Orthopnea

Regulate BT 10-15 gtts/min or KVO rate or equivalent to

2.

Dyspnea

100 cc/hr: to prevent circulatory overload

3.

Rales / Crackles upon auscultation

Monitor strictly vital signs before, during & after BT

4.

Exertional discomfort

especially every 15 minutes for first hour because
majority of transfusion reaction occurs during this period

Nursing Management

a.

Hemolytic reaction

1.

Stop BT

b.

Allergic reaction

2.

Notify physician

c.

Pyrogenic reaction

3.

Administer medications as ordered

d.

Circulatory overload

e.

Air embolism

f.

Thrombocytopenia

a.

Loop diuretic (Lasix)

Nursing Care

35

36
1.

Assess client for history of previous blood transfusions &

3.

Headache & dizziness

any adverse reaction

4.

Pallor & cold sensitivity

Ensure that the adult client has an 18-19 gauge IV

5.

Dyspnea

catheter in place

6.

Palpitations

3.

Use 0.9% sodium chloride

7.

Brittleness of hair & nails, spoon shape nails

4.

At least two nurse should verify the ABO group, RH type,

2.

client & blood numbers & expiration date
5.

Take baseline V/S before initiating transfusion

6.

Start transfusion slowly (2 ml/min)

7.

Stay with the client during the first 15 min of the
transfusion & take V/S frequently

8.

9.

(koilonychias)
8.

Atrophic Glossitis (inflammation of tongue)
a.

Stomatitis

PLUMBER

VINSON’S SYNDROME
b.
9.

Dysphagia

PICA: abnormal appetite or craving for non edible foods

Maintain the prescribed transfusion rate:
a.

Whole Blood: approximately 3-4 hr

b.

RBC: approximately 2-4 hr

1.

RBC: small (microcytic) & pale (hypochromic)

c.

Fresh Frozen Plasma: as quickly as possible

2.

RBC: is decreased

d.

Platelet: as quickly as possible

3.

Hgb: decreased

e.

Cryoprecipitate: rapid infusion

4.

Hct: moderately decreased

f.

Granulocytes: usually over 2 hr

5.

Serum iron: decreased

g.

Volume Expander: volume-dependent rate

6.

Reticulocyte count: is decreased

7.

Serum ferritin: is decreased

8.

Hemosiderin: absent from bone marrow

Monitor for adverse reaction

10. Document the following:
a.

Dx

Blood component unit number (apply sticker if
available)

b.

Date of infusion starts & end

c.

Type of component & amount transfused

d.

Client reaction & vital signs

e.

Signature of transfusionist

Nursing Intervention
1.

Monitor for s/sx of bleeding through hematest of all
elimination including urine, stool & gastrict content

2.

Enforce CBR / Provide adequate rest: plan activities so
as not to over tire the client

3.

Provide thorough explanation of all diagnostic exam

HIV

used to determine sources of possible bleeding: help

- 6 months – 5 years incubation period

allay anxiety & ensure cooperation

- 6 months window period

4.

Instruct client to take foods rich in iron

- western blot opportunistic

a.

Organ meat

- ELISA

b.

Egg yolk

- drug of choice AZT (Zidon Retrovir)

c.

Raisin

d.

Sweet potatoes

2 Common fungal opportunistic infection in AIDS

e.

Dried fruits

1. Kaposis Sarcoma

f.

Legumes

2. Pneumocystic Carini Pneumonia

g.

Nuts

5.
Blood Disorder

Instruct the client to avoid taking tea and coffee:
because it contains tannates which impairs iron
absorption

Iron Deficiency Anemia (Anemias)






A chronic microcytic anemia resulting from inadequate

6.

Administer iron preparation as ordered:
a.

Oral Iron Preparations: route of choice

absorption of iron leading to hypoxemic tissue injury



Ferrous Sulfate

Chronic microcytic, hypochromic anemia caused by either



Ferrous Fumarate

inadequate absorption or excessive loss of iron



Ferrous Gluconate

Acute or chronic bleeding principal cause in adults (chiefly
from trauma, dysfunctional uterine bleeding & GI bleeding)



May also be caused by inadequate intake of iron-rich foods

Nursing Management when taking oral iron
preparations

or by inadequate absorption of iron




In iron-deficiency states, iron stores are depleted first,

Instruct client to take with meals: to lessen GIT
irritation

followed by a reduction in Hgb formation



Dilute in liquid preparations well & administer
using a straw: to prevent staining of teeth

Incidence Rate
1.
2.
3.



Common among developed countries & tropical zones

vitamin C (ascorbic acid): to enhance iron

(blood-sucking parasites)

absorption

Common among women 15 & 45 years old & children



Warn clients that iron preparations will change

affected more frequently, as are the poor

stool color & consistency (dark & tarry) & may

Related to poor nutrition

cause constipation


Predisposing Factors
1.

When possible administer with orange juice as

Antacid ingestion will decrease oral iron
effectiveness

Chronic blood loss due to:
a.

Trauma

b.

Heavy menstruation

preparations, who are noncompliant with therapy or

c.

Related to GIT bleeding resulting to hematemasis

who have continuing blood losses

b.

Parenteral: used in clients intolerant to oral

and melena (sign for upper GIT bleeding)
d.
2.

3.

Fresh blood per rectum is called hematochezia

Nursing Management when giving parenteral

Inadequate intake or absorption of iron due to:

iron preparation

a.

Chronic diarrhea

b.

Related to malabsorption syndrome

administer iron preparation as tissue staining &

c.

High cereal intake with low animal CHON digestion

irritation are a problem

d.

Partial or complete gastrectomy

e.

Pica

Related to improper cooking of foods





Use one needle to withdraw & another to

Use Z-track injection technique: to prevent
leakage into tissue



Do not massage injection site but encourage
ambulation as this will enhance absorption;

S/sx
1.

Usually asymptomatic (mild cases)

2.

Weakness & fatigue (initial signs)

advice against vigourous exercise & constricting
garments


Observe for local signs of complication:

36

37



Pain at the injection site

3.

Headache and dizziness



Development of sterile abscesses

4.

Pallor & cold sensitivity



Lymphadenitis

5.

Dyspnea & palpitations: as part of compensation



Fever & chills

6.

GIT S/sx:



Headache



Urticaria



Pruritus



Hypotension



Skin rashes



Anaphylactic shock

7.

Medications administered via straw

Mouth sore

b.

PS: Red beefy tongue

c.

Indigestion / dyspepsia

d.

Weight loss

e.

Constipation / diarrhea

f.

Jaundice

CNS S/sx:
a.

Tingling sensation

b.

Numbness



Lugol’s Solution

c.

Paresthesias of hands & feet



Iron

d.

Paralysis



Tetracycline

e.

Depression



Nitrofurantoin (Macrodentin)

f.

Psychosis

g.

Positive to Romberg’s test: damage to cerebellum

7.

Administer with Vitamin C or orange juice for absorption

8.

Monitor & inform client of side effects

9.

a.

resulting to ataxia

a.

Anorexia

b.

N/V

c.

Abdominal pain

1.

Erythrocytes count: decrease

d.

Diarrhea / constipation

2.

Blood Smear: oval, macrocytic erythrocytes with a

e.

Melena

Dx

proportionate amount of Hgb

If client can’t tolerate / no compliance administer

3.

Bilirubin (indirect): elevated unconjugated fraction

parenteral iron preparation

4.

Serum LDH: elevated

a.

Iron Dextran (IM, IV)

5.

Bone Marrow:

b.

Sorbitex (IM)

a.

Increased megaloblasts (abnormal erythrocytes)

10. Provide dietary teaching regarding food high in iron

b.

Few normoblasts or maturing erythrocytes

11. Encourage ingestion of roughage & increase fluid intake:

c.

Defective leukocytes maturation

to prevent constipation if oral iron preparation are being

6.

taken

Positive Schilling’s Test: reveals inadequate / decrease
absorption of Vitamin B12
a.

Pernicious Anemia






bothe before & after parenteral administration of

Chronic progressive, macrocytic anemia caused by a

intrinsic factor

deficiency of intrinsic factor; the result is abnormally large

b.

Definitive test for pernicious anemia

erythrocytes & hypochlorhydria (a deficiency of hydrochloric

c.

Used to detect lack of intrinsic factor

acid in gastric secretion)

d.

Fasting client is given radioactive vitamin B12 by

Chronic anemia characterized by a deficiency of intrinsic

mouth & non-radioactive vitamin B12 IM to permit

factor leading to hypochlorhydria (decrease hydrochloric

some excretion of radioactive vitamin B12 in the

acid secretion)

urine if it os absorbed
e.

Characterized by neurologic & GI symptoms; death usually

24-48 hour urine collection is obtained: client is
encourage to drink fluids

resuls if untreated


Measures absorption of radioactive vitamin B12

f.

Lack of intrinsic factor is caused by gastric mucosal atrophy

If indicated, second stage schilling test performed 1

(possibly due to heredity, prolonged iron deficiency, or an

week after first stage. Fasting client is given

autoimmune disorder); can also results in clients who have

radioactive vitamin B12 combined with human

had a total gastrctomy if vitamin B12 is not administer

intrinsic factor & test is repeated

Pathophysiology
1.

7.

Gastric Analysis: decrease free hydrochloric acid

8.

Large number of reticulocytes in the blood following

Intrinsic factor is necessary for the absorbtion of vitamin

parenteral vitamin B12 administration

B12 into small intestines
2.

B12 deficiency diminished DNA synthesis, which results
in defective maturation of cell (particularly rapidly

3.

Medical Management
1.

Drug Therapy:

dividing cells such as blood cells & GI tract cells)

a.

Vitamin B12 injection: monthly maintenance

B12 deficiency can alter structure & function of

b.

Iron preparation: (if Hgb level inadequate to meet

peripheral nerves, spinal cord, & the brain

increase numbers of erythrocytes)
c.

STOMACH
Pareital cells/Argentaffin or Oxyntic cells

Folic Acid


Controversial



Reverses anemia & GI symptoms but may
intensify neurologic symptoms

Produces intrinsic factors


Secretes hydrochloric acid
Promotes reabsorption of Vit B12
Aids in digestion
Promotes maturation of RBC

addition to vitamin B12
2.
1.

Enforce CBR: necessary if anemia is severe

2.

Adminster Vitamin B12 injections at monthly intervals for
lifetime as ordered




increase in blue-eyed person of Scandinavian decent
Subtotal gastrectomy

3.

Hereditary factors

4.

Inflammatory disorders of the ileum

5.

Autoimmune

6.

Strictly vegetarian diet
S/sx

1.

Anemia

2.

Weakness & fatigue

Never given orally because there is possibility of
developing tolerance

Usually occurs in men & women over age of 50 with an

2.

Transfusion Therapy
Nursing Intervention

Predisposing Factors
1.

May be safe if given in small amounts in

Site of injection for Vitamin B12 is dorsogluteal and
ventrogluteal


3.

No side effects

Provide a dietary intake that is high in CHON, vitamin c
and iron (fish, meat, milk / milk product & eggs)

4.

Avoid highly seasoned, coursed, or very hot foods: if
client has mouth sore

5.

Provide safety when ambulating (especially when
carrying hot item)

37

38
6.

Instruct client to avoid irritating mouth washes instead

7.

Administer medications as ordered:

use soft bristled toothbrush

a.

Corticosteroids: caused by immunologic injury

7.

Avoid heat application to prevent burns

b.

Immunosuppressants: Anti Lymphocyte Globulin

8.

Provide client teaching & discharge planning
Given via central venous catheter

concerning:

Given 6 days to 3 weeks to achieve maximum

a.

Dietery instruction

b.

Importance of lifelong vitamin B12 therapy

c.

Rehabilitation & physical therapy for neurologic

therapeutic effect of drug
8.

risk:

deficit, as well as instruction regarding safety
Aplastic Anemia


Monitor neuropenic precautions

b.

Encourage high CHON, vitamin diet: to help reduce
incidence of infection

Pancytopenia or depression of granulocytes, platelets &
erythrocytes production: due to fatty replacement of the

9.

bone marrow


a.

Stem cell disorder leading to bone marrow depression
leading to pancytopenia



Monitor for signs of infection & provide care to minimize

Provide mouth care before & after meals

d.

Fever

e.

Cough

Monitor signs of bleeding & provide measures to
minimize risk:

Bone marrow destruction may be idiopathic or secondary

a.

Use soft toothbrush when brushing teeth & electric
razor when shaving: prevent bleeding

PANCYTOPENIA
Decrease RBC
Decrease Platelet
(anemia)

c.

b.

Avoid IM, subcutaneous, venipunctured sites:
Instead provide heparin lock

Decrease WBC
(leukopenia)

c.

Hematest urine & stool

d.

Observe for oozing from gums, petechiae or

(thrombocytopenia)

ecchymoses
10. Provide client teaching & discharge planning

Predisposing Factors

concerning:

1.

Chemicals (Benzene and its derivatives)

a.

Self-care regimen

2.

Related to radiation / exposure to x-ray

b.

Identification of offending agent & importance of

3.

Immunologic injury

4.

Drugs:
a.

Broad Spectrum Antibiotics: Chloramphenicol
(Sulfonamides)

b.

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

2.

Blood Tranfusions: include whole blood, packed RBC,
platelets, plasma, cryoprecipitites & volume expanders

3.


Epicardium


Somewhat controversial

b.

Inhibits thrombin thus preventing further clot

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

2.

Modification of diet & other risk factors

3.

Surgery: Coronary artery bypass surgery

4.

Percutaneuos Transluminal Coronary Angioplasty (PTCA)

Nursing Intervention
1.

Enforce complete bed rest

2.

Give prompt pain relievers with nitrates or narcotic
analgesic as ordered

3.

Administer medications as ordered:
a.

as venodilator, but in large doses will act as vasodilator

3 Complications of CABG
1.

Pneumonia: encourage to perform deep breathing, coughing
exercise and use of incentive spirometer

2.

Shock

3.

Thrombophlebitis

Nitroglycerine (NTG): when given in small doses will act


Give 1st dose of NTG: sublingual 3-5 minutes



Give 2nd dose of NTG: if pain persist after giving 1st
dose with interval of 3-5 minutes



Give 3rd & last dose of NTG: if pain still persist at 3-5
minutes interval

Angina Pectoris


Nursing Management when giving NTG

Transient paroxysmal chest pain produced by insufficient

1.

blood flow to the myocardium resulting to myocardial



ischemia


NTG Tablets (sublingual)
Keep the drug in a dry place, avoid moisture and
exposure to sunlight as it may inactivate the drug

Clinical syndrome characterized by paroxysmal chest pain


that is usually relieved by rest or nitroglycerine due to

Relax for 15 minutes after taking a tablet: to prevent
dizziness

temporary myocardial ischemia


Monitor side effects:

Predisposing Factors



Orthostatic hypotension

1.

Sex: male



Transient headache & dizziness: frequent side

2.

Race: black

3.

Smoking



Instruct the client to rise slowly from sitting position

4.

Obesity



Assist or supervise in ambulation

5.

Hyperlipidemia

6.

Sedentary lifestyle

7.

Diabetes Mellitus

8.

Hypertension

9.

CAD: Atherosclerosis

effect

2.

NTG Nitrol or Transdermal patch


Avoid placing near hairy areas as it may decrease
drug absorption



Avoid rotating transdermal patches as it may
decrease drug absorption

10. Thromboangiitis Obliterans



11. Severe Anemia

Avoid placing near microwave ovens or during
defibrillation as it may lead to burns (most

12. Aortic Insufficiency: heart valve that fails to open & close

important thing to remember)

efficiently

b.

13. Hypothyroidism
14. Diet: increased saturated fats
15. Type A personality

c.

Beta-blockers


Propanolol: side effects PNS



Not given to COPD cases: it causes bronchospasm

ACE Inhibitors


Precipitating Factors
d.

4 E’s of Angina Pectoris

Enalapril

Calcium Antagonist


Nefedipine

1.

Excessive physical exertion: heavy exercises, sexual activity

2.

Exposure to cold environment: vasoconstriction

4.

Administer oxygen inhalation

3.

Extreme emotional response: fear, anxiety, excitement,

5.

Place client on semi-to high fowlers position

strong emotions

6.

Monitor strictly V/S, I&O, status of cardiopulmonary fuction

4.

Excessive intake of foods or heavy meal

S/sx
1.
2.

& ECG tracing
7.

Provide decrease saturated fats sodium and caffeine

8.

Provide client health teachings and discharge planning

Levine’s Sign: initial sign that shows the hand clutching the



Avoidance of 4 E’s

chest



Prevent complication (myocardial infarction)

Chest pain: characterized by sharp stabbing pain located at



Instruct client to take medication before indulging into

sub sterna usually radiates from neck, back, arms, shoulder

physical exertion to achieve the maximum therapeutic

and jaw muscles usually relieved by rest or taking

effect of drug

nitroglycerine (NTG)



Reduce stress & anxiety: relaxation techniques & guided

3.

Dyspnea

4.

Tachycardia



Avoid overexertion & smoking

5.

Palpitations



Avoid extremes of temperature

6.

Diaphoresis



Dress warmly in cold weather



Participate in regular exercise program



Space exercise periods & allow for rest periods



The importance of follow up care

imagery

Dx
1.

History taking and physical exam

2.

ECG: may reveals ST segment depression & T wave

9.

occurs & persists despite rest & medication administration

inversion during chest pain
3.

Stress test / treadmill test: reveal abnormal ECG during
exercise

4.

Increase serum lipid levels

5.

Serum cholesterol & uric acid is increased

Instruct the client to notify the physician immediately if pain

Myocardial Infarction


Death of myocardial cells from inadequate oxygenation,
often caused by sudden complete blockage of a coronary
artery

Medical Management

41

42


Characterized by localized formation of necrosis (tissue

1.

Decrease myocardial workload (rest heart)

destruction) with subsequent healing by scar formation &



Establish a patent IV line

fibrosis



Administer narcotic analgesic as ordered: Morphine



Heart attack

Sulfate IV: provide pain relief (given IV because after an



Terminal stage of coronary artery disease characterized by

infarction there is poor peripheral perfusion & because

malocclusion, necrosis & scarring.

serum enzyme would be affected by IM injection as
ordered)

Types



Side Effects: Respiratory Depression

1.

Transmural Myocardial Infarction: most dangerous type



Antidote: Naloxone (Narcan)

characterized by occlusion of both right and left coronary



Side Effects of Naloxone Toxicity: is tremors

artery
2.

2.

Subendocardial Myocardial Infarction: characterized by
occlusion of either right or left coronary artery

Administer oxygen low flow 2-3 L / min: to prevent
respiratory arrest or dyspnea & prevent arrhythmias

3.

Enforce CBR in semi-fowlers position without bathroom
privileges (use bedside commode): to decrease cardiac

The Most Critical Period Following Diagnosis of Myocardial Infarction


workload

6-8 hours because majority of death occurs due to

4.

Instruct client to avoid forms of valsalva maneuver

arrhythmia leading to premature ventricular contractions

5.

Place client on semi fowlers position

(PVC)

6.

Monitor strictly V/S, I&O, ECG tracing & hemodynamic
procedures

Predisposing Factors

7.

Perform complete lung / cardiovascular assessment

1.

Sex: male

8.

Monitor urinary output & report output of less than 30 ml /

2.

Race: black

3.

Smoking

4.

Obesity

5.

CAD: Atherosclerotic

10. Maintain quiet environment

6.

Thrombus Formation

11. Administer stool softeners as ordered: to facilitate bowel

7.

Genetic Predisposition

8.

Hyperlipidemia

9.

Sedentary lifestyle

10. Diabetes Mellitus
11. Hypothyroidism

hr: indicates decrease cardiac output
9.

Provide a full liquid diet with gradual increase to soft diet:
low in saturated fats, Na & caffeine

evacuation & prevent straining
12. Relieve anxiety associated with coronary care unit (CCU)
environment
13. Administer medication as ordered:
a.

12. Diet: increased saturated fats
13. Type A personality

Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate,
Isodil (ISD): sublingual

b.

Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium


S/sx
1.

Chest pain





Side Effects: confusion and dizziness

c.

Beta-blockers: Propanolol (Inderal)

d.

ACE Inhibitors: Captopril (Enalapril)

Excruciating visceral, viselike pain with sudden onset

e.

Calcium Antagonist: Nefedipine

located at substernal & rarely in precordial

f.

Thrombolytics / Fibrinolytic Agents: Streptokinase,

Usually radiates from neck, back, shoulder, arms, jaw &

Urokinase, Tissue Plasminogen Activating Factor (TIPAF)

abdominal muscles (abdominal ischemia): severe



Side Effects: allergic reaction, urticaria, pruritus

crushing



Nursing Intervention: Monitor for bleeding time

Not usually relieved by rest or by nitroglycerine

2.

N/V

3.

Dyspnea

4.

Increase in blood pressure & pulse, with gradual drop in

g.

Anti Coagulant


blood pressure (initial sign)

Heparin


Antidote: Protamine Sulfate



Nursing Intervention: Check for Partial Thrombin
Time (PTT)

5.

Hyperthermia: elevated temp

6.

Skin: cool, clammy, ashen

7.

Mild restlessness & apprehension



Antidote: Vitamin K

8.

Occasional findings:



Nursing Intervention: Check for Prothrombin



Pericardial friction rub



Split S1 & S2



Rales or Crackles upon auscultation



S4 or atrial gallop

Caumadin (Warfarin)

Time (PT)
h.

Anti Platelet: PASA (Aspirin): Anti thrombotic effect


Side Effects: Tinnitus, Heartburn, Indigestion /
Dyspepsia



Contraindication: Dengue, Peptic Ulcer Disease,
Unknown cause of headache

Dx
1.



Cardiac Enzymes


CPK-MB: elevated



Creatinine phosphokinase (CPK): elevated



Heart only, 12 – 24 hours



Lactic acid dehydrogenase (LDH): is increased



Serum glutamic pyruvate transaminase (SGPT): is
increased



14. Provide client health teaching & discharge planning
concerning:
a.

Effects of MI healing process & treatment regimen

b.

Medication regimen including time name purpose,
schedule, dosage, side effects

c.

of caffeine
d.

2.

Troponin Test: is increased

3.

ECG tracing reveals

Encourage client to take 20 – 30 cc/week of wine, whisky
and brandy: to induce vasodilation

Serum glutamic oxal-acetic transaminase (SGOT): is
increased

Dietary restrictions: low Na, low cholesterol, avoidance

e.

Avoidance of modifiable risk factors

f.

Prevent Complication


Arrhythmia: caused by premature ventricular



ST segment elevation



T wave inversion



Cardiogenic shock: late sign is oliguria



Widening of QRS complexes: indicates that there is



Left Congestive Heart Failure

arrhythmia in MI



Thrombophlebitis: homan’s sign

contraction

4.

Serum Cholesterol & uric acid: are both increased



Stroke / CVA

5.

CBC: increased WBC



Dressler’s Syndrome (Post MI Syndrome): client is
resistant to pharmacological agents: administer

Nursing Intervention


150,000-450,000 units of streptokinase as ordered

Goal: Decrease myocardial oxygen demand

42

43
g.
h.

Importance of participation in a progressive activity

6.

program

chamber (cardiomyopathy): dependent on extent of heart

Resumption of ADL particularly sexual intercourse: is 4-6

failure

weeks post cardiac rehab, post CABG & instruct to:


Make sex as an appetizer rather than dessert



Instruct client to assume a non weight bearing
position



7.

Right Sided Heart Failure


Client can resume sexual intercourse: if can climb or

Increased persistent chest pain



Dyspnea



Weakness



Fatigue



Persistent palpitation



Light headedness

Weakened right ventricle is unable to pump blood into he
pulmonary system: systemic venous congestion occurs as
pressure builds up

Need to report the ff s/sx:


ABG: reveals PO2 is decreased (hypoxemia), PCO2 is
increased (respiratory acidosis)

use the staircase
i.

Echocardiography: shows increased sized of cardiac

Predisposing Factors
1.

Right ventricular infarction

2.

Atherosclerotic heart disease

3.

Tricuspid valve stenosis

4.

Pulmonary embolism

5.

Related to COPD

j.

Enrollment of client in a cardiac rehabilitation program

6.

Pulmonic valve stenosis

k.

Strict compliance to mediation & importance of follow

7.

Left sided heart failure

up care
S/sx
Congestive Heart Failure



1.

Anorexia

Inability of the heart to pump an adequate supply of blood

2.

Nausea

to meet the metabolic needs of the body

3.

Weight gain

Inability of the heart to pump blood towards systemic

4.

Neck / jugular vein distension

circulation

5.

Pitting edema

6.

Bounding pulse

7.

Hepatomegaly / Slenomegaly

Types of Heart Failure
1.

Left Sided Heart Failure

8.

Cool extremities

2.

Right Sided Heart Failure

9.

Ascites

3.

High-Output Failure

10. Jaundice
11. Pruritus
12. Esophageal varices

Left Sided Heart Failure


Left ventricular damage causes blood to back up through

Dx

the left atrium & into the pulmonary veins: Increased

1.

Chest X-ray (CXR): reveals cardiomegaly

pressure causes transudation into interstitial tissues of the

2.

Central Venous Pressure (CVP): measure fluid status:
elevated

lungs which result pulmonary congestion.
Predisposing Factors
1.



Measure pressure in right atrium: 4-10 cm of water



If CVP is less than 4 cm of water: Hypovolemic shock:

90% is mitral valve stenosis due to RHD: inflammation of

increase IV flow rate

mitral valve due to invasion of Group A beta-hemolytic



streptococcus
2.

Myocardial Infarction

3.

Ischemic heart disease

4.

Hypertension

5.

Aortic valve stenosis

Administer loop diuretics as ordered


Nursing Intervention:


When reading CVP patient should be flat on bed



Upon insertion place client in trendelendberg
position: to promote ventricular filling and prevent
pulmonary embolism

S/sx
1.

Dyspnea

2.

Paroxysmal nocturnal dyspnea (PND): client is awakened at
night due to difficulty of breathing

3.

If CVP is more than 10 cm of water: Hypervolemic shock:

Orthopnea: use 2-3 pillows when sleeping or place in high
fowlers

4.

Tiredness

5.

Muscle Weakness

6.

Productive cough with blood tinged sputum

7.

Tachycardia

8.

Frothy salivation

9.

Cyanosis

10. Pallor
11. Rales / Crackles

3.

Echocardiography: reveals increased size of cardiac
chambers (cardiomyopathy)

4.

Liver enzymes: SGPT & SGOT: is increased

5.

ABG: decreased pO2

Medical Management
1.

Determination & elimination / control of underlying cause

2.

Drug therapy: digitalis preparations, diuretics, vasodilators

3.

Sodium-restricted diet: to decrease fluid retention

4.

If medical therapies unsuccessful: mechanical assist devices
(intra-aortic balloon pump), cardiac transplantation, or
mechanical heart may be employed

5.

Treatment for Left Sided Heart Failure Only:


M – Morphine SO4



A – Aminophylline



D – Digitalis

14. PMI is displaced laterally: due to cardiomegaly



D – Diuretics

15. Possible S3: ventricular gallop



O – O2



G – Gases

12. Bronchial wheezing
13. Pulsus Alternans: weak pulse followed by strong bounding
pulse

Dx
1.

Chest X-ray (CXR): reveals cardiomegaly

Nursing Intervention

2.

Pulmonary Arterial Pressure (PAP): measures pressure in

Goal: Increase cardiac contractility thereby increasing cardiac

right ventricle or cardiac status: increased

output of 3-6 L / min

3.

Pulmonary Capillary Wedge Pressure (PCWP): measures end
systolic and dyastolic pressure: increased

4.

5.

1.

Monitor respiratory status & provide adequate ventilation

Central Venous Pressure (CVP): indicates fluid or hydration

(when HF progress to pulmonary edema)

status

a.



Increase CVP: decreased flow rate of IV



Decrease CVP: increased flow rate of IV

Swan-Ganz catheterization: cardiac catheterization

Administer O2 therapy: high inflow 3-4 L / min delivered
via nasal cannula

b.

Maintain client in semi or high fowlers position:
maximize oxygenation by promoting lung expansion

c.

Monitor ABG

43

44
d.
2.

3.

Assess for breath sounds: noting any changes

a.

Constantly assess level of anxiety

b.

Maintain bed rest with limited activity

1.

Intermittent claudication: leg pain upon walking

c.

Maintain quiet & relaxed environment

2.

Cold sensitivity & changes in skin color 1st white (pallor)

d.

Organized nursing care around rest periods

changing to blue (cyanosis) then red (rubor)
dorsalis pedis)

Cardiac glycosides: Digoxin (Lanoxin)

4.

Trophic changes



Action: Increase force of cardiac contraction

5.

Ulceration & Gangrene formation (advanced)



Contraindication: If heart rate is decreased do not
1.

Oscillometry: may reveal decrease in peripheral pulse

Monitor ECG & hemodynamic monitoring

c.

Administer vasodilators as ordered
Vasodilators: Nitroglycerine (NTG)

Monitor V/S

Reduce / eliminate edema
a.

Dx
volume
2.

Loop Diuretics: Lasix (Furosemide)

b.

Daily weight

c.

Maintain accurate I&O

d.

Assess for peripheral edema

e.

Measure abdominal girth daily

f.

Monitor electrolyte levels

g.

Monitor CVP & Swan-Ganz reading

h.
i.

Doppler (UTZ): reveals decrease blood flow to the affected
extremity

3.

Angiography: reveals location & extent of obstructive
process

Administer diuretics as ordered


Medical Management
1.

Drug Therapy
a.

Vasodilators: to improve arterial circulation
(effectiveness ?)


Papaverine



Isoxsuprine HCL (Vasodilan)

Provide Na restricted diet as ordered



Nylidrin HCL (Arlidin)

Provide meticulous skin care



Nicotinyl Alcohol (Roniacol)

If acute pulmonary edema occurs: For Left Sided Heart



Cyclandelate (Cyclospasmol)

Failure only



Tolazoline HCL (Priscoline)

a.

b.

c.

Administer Narcotic Analgesic as ordered


Narcotic analgesic: Morphine SO4



Action: to allay anxiety & reduce preload & afterload

2.

Bronchodilators: Aminophylline IV

b.

Endarterectomy



Action: relieve bronchospasm, increase urinary

c.

Balloon Catheter Dilation

output & increase cardiac output

d.

Lumbar Sympathectomy: to increase blood flow

Administer Anti-arrythmic as ordered

e.

Amputation: may be necessary

Anti-arrythmic: Lidocaine (Xylocane)
Nursing Intervention
1.

Provide client teaching & discharge planning concerning:
Need to monitor self daily for S/sx of Heart Failure (pedal

2.

Encourage a slow progressive physical activity


Walking at least 2 times / day



Out of bed at least 3-4 times / day

Administer medications as ordered

edema, weight gain, of 1-2 kg in a 2 day period,



Analgesics

dyspnea, loss of appetite, cough)



Vasodilators

Medication regimen including name, purpose, dosage,



Anti-coagulants

frequency & side effects (digitalis, diuretics)

3.

Prescribe diet plan (low Na, cholesterol, caffeine: small
frequent meals)

d.

Need to avoid fatigue & plan for rest periods

e.

Prevent complications

f.

Anti-coagulant: to prevent thrombus formation

Surgery



return or reducing preload

c.

c.

Bypass Grafting

clockwise every 15 minutes: to promote decrease venous

b.

Analgesic: to relieve ischemic pain

a.

Assist in bloodless phlebotomy: rotating tourniquet, rotated

a.

b.

Administer Bronchodilator as ordered



7.

Decreased or absent peripheral pulses (posterior tibial &



b.

d.

3.

Administer digitalis as ordered & monitor effects



6.

S/sx

Increase cardiac output

give

5.

High incident among smokers

Provide physical & emotional rest

a.

4.

2.



Arrythmia



Shock



Right ventricular hypertrophy



MI



Thrombophlebitis

Foot care management:


Need to avoid trauma to the affected extreminty

4.

Importance of stop smoking

5.

Need to maintain warmth especially in cold weather

6.

Prepare client for surgery: below knee amputation (BKA)

7.

Importance of follow-up care

Raynaud’s Phenomenon


Intermittent episodes of arterial spasm most frequently
involving the fingers or digits of the hands

Importance of follow-up care
Predisposing Factors

Peripheral Vascular Disorder

1.

High risk group: female between the teenage years & age
40 years old & above

Arterial Ulcer
1.

Thromboangiitis Obliterans (Buerger’s Disease)

2.

Raynaud’s Phenomenon

Venous Ulcer

2.

Smoking

3.

Collagen diseases

4.

a.

Systemic Lupus Erythematosus (SLE): butterfly rash

b.

Rheumatoid Arthritis

Direct hand trauma

1.

Varicose Veins

a.

Piano playing

2.

Thrombophlebitis (deep vein thrombosis)

b.

Excessive typing

c.

Operating chainsaw

Thromboangiitis Obliterans (Buerger’s Disease)


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

Composed of three section
1.

petechiae of soft palate, conjunctiva retina,
ecchymoses, epistaxis, bloody spumtum, melena) &

Consist of anastomosis of capillaries known as Keissel Rach
Plexus: the site of nose bleeding

iliac crest


The major function of the nose are warming, moistening &

Nasopharynx: located above the soft palate of the mouth,
contains the adenoids & opening to the eustachian tubes

2.

Oropharynx: located directly behind the mouth & tongue,

instruct the client to observe for & report these

contains the palatine tonsils; air & food enter the body



Have antidote (Protamine Sulfate) available

through oropharynx



Instruct the client to avoid aspirin, antihistamines 7

3.

cough preparations containing glyceryl guaiacolate

Laryngopharynx: extends from the epiglotitis to the sixth
cervical level

& obtain MD permission before using other OTC
drugs
b.

Warfarin (Coumadin)


Larynx
1.

Assess PT daily: dosage should be adjusted to
maintain PT at 1.5-2.5 times normal control level;

airways
2.

Obtain careful medication history (there are many

3.

Advise client to withhold dose & notify MD

4.

Have antidote (Vitamin K) available



Alert client to factors that may affect the
anticoagulant response (high-fat diet or sudden
increased in vit. K-rich food)



Instruct the client to wear medic-alert bracelet

4.

Assess V/S every 4 hours

5.

Monitor chest pain or shortness of breath: possible
pulmonary embolism

6.

Measure thigh, calves, ankles & instep every morning

7.

Provide client teaching & discharge planning
a.

Need to avoid standing, sitting for long period,
constrictive clothing, crossing legs at the knee, smoking,
oral contraceptives

b.

Importance of adequate hydration: to prevent
hypercoagubility

c.

Use elastic stockings when ambulatory

d.

Importance of planned rest periods with elevation of the

5.

For phonation (voice production)

Glottis
1.

Opening of larynx

2.

Opens to allow passage of air

3.

Closes to allow passage of food going to the esophagus

4.

The initial sign of complete airway obstruction is the
inability to cough

Lower Respiratory System


Consist of trachea, bronchi & branches, & the lungs &
associated structures



For gas exchange

Trachea


AKA “Windpipe”



Air move from the pharynx to larynx to trachea (length 1113 cm, diameter 1.5-2.5 cm in adult)



feet

Vocal cords of larynx permit speech & are involved in the
cough reflex

immediately if bleeding occur


Larynx opens to allow respiration & closes to prevent
aspiration when food passes through the pharynx

drug-drug interaction)


Framework is formed by the hyoid bone, epiglotitis &
thyroid, cricoid & arytenoids cartilages

INR of 2


Sometimes called “voice Box” connects upper & lower

Extend from the larynx to the second costal cartilage, where

e.

Drug regimen

it bifurcates & is supported by 16-20 C-shaped cartilage

f.

Plan for exercise / activity

rings



Begin with dorsiflexion of the feet while sitting or



The area where the trachea divides into two branches is
called the carina

lying down


Swim several times weekly



Consist of cartilaginous rings



Gradually increased walking distance



Serves as passageway of air going to the lungs



Site of tracheostomy

g.

Importance of weight reduction: if obese

h.

Monitor for signs of complications
a.

Pulmonary Embolism

Bronchi

46

47





Right main bronchus





Larger & straighter than the left



Lecitin / Spingomyelin ratio: to determine lung maturity



Divided into three lobar branches (upper, middle &



Normal Lecitin / Spingomyelin ratio: is 2:1

lower bronchi) to supply the three lobes of right lung



In premature infants: 1:2



Give oxygen of less 40% in premature: to prevent

Left main bronchus


Divides into the upper & lower lobar bronchi to supply

atelectasis and retrolental fibroplasias

the left lobes
Bronchioles






Pulmonary Circulation


Provides for reoxygenation of blood & release of CO2

upon elastic recoil formed by network of smooth muscles



Gas transfers occurs in the pulmonary capillary bed

The tracheobronchial tree ends at the terminal bronchials.
Respiratory Distress Syndrome

longer air conduction but gas exchange between blood &



Decrease oxygen stimulates breathing

alveolar air



Increase carbon dioxide is a powerful stimulant for breathing

The respiratory bronchioles serves as the transition to the
alveolar epithelium

Pneumonia


Lungs
Right lung (consist of 3 lobes, 10 segments)



Left lung (consist of 2 lobes, 8 segments)



Main organ of respiration, lie within the thoracic cavity on
either side of the heart



Inflammation of the lung parenchyma leading to pulmonary
consolidation as the alveoli is filled with exudates

Etiologic Agents

Broad area of lungs resting on diaphragm is called the base

1.

Streptococcus Pneumonae: causing pneumococal
pneumonia

& the narrow superior portion called the apex
2.

Hemophylus Influenzae: causing broncho pneumonia

3.

Diplococcus Pneumoniae

Serous membranes covering the lungs, continuous with the

4.

Klebsella Pneumoniae

parietal pleura that lines the chest wall

5.

Escherichia Pneumoniae

6.

Pseudomonas

Pleura


Inflammation of the alveolar spaces of the lungs, resulting in
consolidation of lung tissue as the alveoli fill with exudates





Retinopathy & blindness: in premature

In the bronchioles, airway patency is primarily dependent

Distal to the terminal bronchioles the major function is no



Composed of lecithin and spingomyelin

Parietal Pleura


Lines the chest walls & secretes small amounts of

High Risk Groups

lubricating fluid into the intrapleural space (space between

1.

Children below 5 years old

the parietal pleura & visceral pleura) this fluid holds the

2.

Elderly

lungs & chest wall together as a single unit while allowing
them to move separately

Predisposing Factors
1. Smoking
2. Air pollution

Chest Wall


Includes the ribs cage, intercostal muscles & diaphragm

3. Immuno compromised



Chest is a C shaped & supported by 12 pairs of ribs & costal

4. Related to prolonged immobility (CVA clients): causing
hypostatic pneumonia

cartilages, the ribs have several attached muscles


5. Aspiration of food: causing aspiration pneumonia

Contraction of the external intercostal muscles raises
the ribs cage during inspiration & helps increase the size
of the thoracic cavity



S/sx

The internal intercoastal muscles tends to pull ribs down
& in & play a role in forced expiration

Diaphragm


A major muscle of ventilation (the exchange of air between
the atmosphere & the alveoli).

Alveoli


Are functional cellular unit of the lungs; about half arise



Site of gas exchange (CO2 and O2)



Diffusion (Dalton’s law of partial pressure of gases)

3.

Nasal flaring

4.

Intercostal rib retraction

5.

Use of accessory muscles of respiration

6.

Dullness to flatness upon auscultation

7.

Possible pleural friction rub

8.

High-pitched bronchial breath sound

9.

Rales / crackles (early) progressing to coarse (later)

13. General body malaise
14. Weight loss
15. Bronchial wheezing
16. Cyanosis
17. Chest pain

A phospholipids substance found in the fluid lining the

18. Abdominal distention leading to paralytic ileus (absence of

alveolar epithelium


Rapid shallow respiration with expiratory grunt

12. Anorexia

Surfactant


2.

11. Chills

of alveolar gas exchange
Produces surfactants

Productive cough with greenish to rusty sputum

10. Fever

directly from alveolar ducts & are responsible for about 35%


1.

peristalsis)

Reduces surface tension & increase stability of the alveoli &
prevents their collapse

Dx
1.

Alveolar Ducts


Arises from the respiratory bronchioles & lead to the alveoli

Sputum Gram Staining & Culture Sensitivity: positive to
cultured microorganisms

2.

Chest x-ray: reveals pulmonary consolidation over affected
area

Alveolar Sac


Form the last part of the airway



Functionally the same as the alveolar ducts they are

3.

ABG analysis: reveals decrease PO2

4.

CBC: reveals increase WBC, erythrocyte sedimentation rate
is increased

surrounded by alveoli & are responsible for the 65% of the
alveolar gas exchange
Type II Cells of Alveoli


Secretes surfactant



Decrease surface tension



Prevent collapse of alveoli

Nursing Intervention
1.

Facilitate adequate ventilation


Administer O2 as needed & assess its effectiveness: low
inflow



Place client semi fowlers position

47

48



Turn & reposition frequently client who are immobilized



Administer analgesic as ordered: DOC: codeine: to

Histoplasmosis


relieve pain associated with breathing

2.



Auscultate breath sound every 2-4 hour



Monitor ABG

Systemic fungal disease caused by inhalation of dust
contaminated by histoplasma capsulatum which is
transmitted to bird manure



Facilitate removal of secretions

Acute fungal infection caused by inhalation of contaminated



General hydration

dust or particles with histoplasma capsulatum derived from



Deep breathing & coughing exercise: tends to promote

birds manure

expectoration


Tracheobronchial suctioning as needed



Administer Mucolytic or Expectorant as ordered



Aerosol treatment via nebulizer



Humidification of inhaled air



Chest physiotherapy (Postural Drainage): tends to

S/sx

promote expectoration
3.

Observe color characteristics of sputum & report any
changes: encourage client to perform good oral hygiene
after expectoration

4.

5.

Provide adequate rest & relief control of pain


Enforce CBR with limited activity



Limit visits & minimized conversation



Plan for uninterrupted rest periods



Maintain pleasant & restful environment

Administer antibiotic as ordered: monitor effects & possible
toxicity


6.
7.

8.

1.

Similar to PTB or Pneumonia

2.

Productive cough

3.

Fever, chills, anorexia, general body malaise

4.

Chest and joint pains

5.

Dyspnea

6.

Cyanosis

7.

Hemoptysis

8.

Sometimes asymptomatic

1.

Chest X-ray: often appears similar to PTB

2.

Histoplasmin Skin Test: positive

3.

ABG analysis: PO2 decrease

Dx

Medical Management
1.

Broad Spectrum Antibiotic


Penicillin



Tetracycline



Microlides (Zethromax)



Azethromycin: Side Effect: Ototoxicity

Prevent transmission: respiratory isolation client with

Anti-fungal Agent: Amphotericin B (Fungizone)


Very toxic: toxicity includes anorexia, chills, fever,
headaches & renal failure



Acetaminophen, Benadryl & Steroids is given with
Amphotericin B: to prevent reaction

Nursing Intervention

staphylococcal pneumonia

1.

Monitor respiratory status

Control fever & chills:

2.

Enforce CBR



Monitor temperature A

3.

Administer oxygen inhalation



Administer antipyretic as ordered

4.

Administer medications as ordered



Increased fluid intake



Provide frequent clothing & linen changing

a.

Antifungal: Amphotericin B (Fungizone)


Observe severe side effects:

Assist in postural drainage: uses gravity & various position



Fever: acetaminophen given prophylactically

to stimulate the movement of secretions



Anaphylactic reaction: Benadryl & Steroids given

Nursing Management for Postural Drainage



prophylactically

a.

Best done before meals or 2-3 hours: to prevent gastro

azotemia: Nephrotoxicity, check for BUN and

esophageal reflux

Creatinine, Hypokalemia

b.

Monitor vital signs

5.

Force fluids to liquefy secretions

c.

Encourage client deep breathing exercises

6.

Nebulize & suction as needed

d.

Administer bronchodilators 20-30 minutes before

7.

Prevent complications: bronchiectasis

procedure

8.

Prevent the spread of infection by spraying of breeding

e.

Stop if client cannot tolerate procedure

f.

Provide oral care after procedure

g.

Contraindicated with


Unstable V/S



Hemoptysis



Clients with increase intra ocular pressure (Normal

places
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Bronchitis




Increase ICP

Excessive production of mucus in the bronchi with
accompanying persistent cough

IOP 12 – 21 mmHg)
9.

Abnormal renal function with hypokalemia &



Characteristic include hypertrophy / hyperplasia of the
mucus secreting gland in the bronchi, decreased ciliary

Provide increase CHO, calories, CHON & vitamin C

activity, chronic inflammation & narrowing of the airway

10. Provide client teaching & discharge planning


Inflammation of bronchus resulting to hypertrophy or

a.

Medication regimen / antibiotic therapy

b.

Need for adequate rest, limited activity, good nutrition,

hyperplasia of goblet mucous producing cells leading to

with adequate fluid intake & good ventilation

narrowing of smaller airways

c.

Need to continue deep breathing & coughing exercise



AKA “Blue Bloaters”

for at least 6-8 weeks after discharge
d.

Availability of vaccines

e.

Need to report S/sx of respiratory infection


Persistent or recurrent fever



Changes in characteristics color of sputum



Chills



Increased pain



Difficulty in breathing



Weight loss



Persistent fatigue

f.

Avoid smoking

g.

Prevent complications

h.



Atelectasis



Meningitis

Importance of follow up care

Predisposing Factors
1.

Smoking

2.

Air pollution

S/sx
1.

Productive copious cough (consistent to all COPD)

2.

Dyspnea on exertion

3.

Use of accessory muscle of respiration

4.

Scattered rales / rhonchi

5.

Feeling of gastric fullness

6.

Slight Cyanosis

7.

Distended neck veins

8.

Ankle edema

9.

Prolonged expiratory grunt

10. Anorexia and generalized body malaise

48

49
11. Pulmonary hypertension
a.

Leading to peripheral edema

b.

Cor Pulmonale (right ventricular hypertrophy)

6.

Nebulize & suction when needed

7.

Provide client health teachings and discharge planning
concerning

Dx

a.

Avoidance of precipitating factor

b.

Prevent complications

1. ABG analysis: reveals PO2 decrease (hypoxemia): causing



Emphysema

cyanosis, PCO2 increase



Status Asthmaticus: severe attack of asthma which
cause poor controlled asthma

Bronchial Asthma




DOC: Epinephrine

Immunologic / allergic reaction results in histamine release



Steroids

which produces three mainairway response: Edema of



Bronchodilators

mucus membrane, Spasm of the smooth muscle of bronchi

c.

& bronchioles, Accumulation of tenacious secretions


Regular adherence to medications: to prevent
development of status asthmaticus

Reversible inflammatory lung condition due to

d.

Importance of follow up care

hypersensitivity to allergens leading to narrowing of smaller
airways

Bronchiectasis


Predisposing Factors (Depending on Types)
1.

of muscular & elastic structure of the bronchial wall

Extrinsic Asthma (Atopic / Allergic)



Causes

destruction of muscular and elastic tissues of alveoli

Pollen



Dust



Fumes

1.

Caused by bacterial infection



Smoke

2.

Recurrent lower respiratory tract infections



Gases

3.

Chest trauma



Danders

4.

Congenital defects (altered bronchial structure)



Furs

5.

Related to presence of tumor (lung tumor)

Lints

6.

Thick tenacious secretion

1.

Productive cough with mucopurulent sputum

Intrinsic Asthma (Non atopic / Non allergic)

Predisposing Factors

Sx

Causes


Hereditary

2.

Dyspnea in exertion



Drugs (aspirin, penicillin, beta blocker)

3.

Cyanosis



Foods (seafoods, eggs, milk, chocolates, chicken)

4.

Anorexia & generalized body malaise



Food additives (nitrates)

5.

Hemoptysis (only COPD with sign)



Sudden change in temperature, air pressure and

6.

Wheezing

7.

Weight loss

1.

CBC: elevation in WBC

2.

ABG: PO2 decrease

3.

Bronchoscopy: reveals sources & sites of secretion: direct

humidity

3.

Physical and emotional stress

Mixed Type: 90 – 95%

S/sx
1.

Cough that is non productive

2.

Dyspnea

3.

Wheezing on expiration

4.

Cyanosis

5.

Mild Stress or apprehension

6.

Tachycardia, palpitations

7.

Diaphoresis

Dx
1.

Pulmonary Function Test Incentive spirometer: reveals
decrease vital lung capacity

2.

ABG analysis: PO2 decrease

3.

Before ABG test for positive Allens Test, apply direct
pressure to ulnar & radial artery to determine presence of
collateral circulation

Dx

visualization of bronchus using fiberscope
Nursing Management before Bronchoscopy
1.

Secure inform consent and explain procedure to client

2.

Maintain NPO 6-8 hours prior to procedure

3.

Monitor vital signs & breath sound
Post Bronchoscopy

1.

Feeding initiated upon return of gag reflex

2.

Avoid talking, coughing and smoking, may cause irritation

3.

Monitor for signs of gross

4.

Monitor for signs of laryngeal spasm: prepare tracheostomy
set

Medical Management
1.

Surgery


Medical Management
1.

Abnormal permanent dilation of bronchus leading to




2.

Permanent abnormal dilation of the bronchi with destruction

affected side

Drug Therapy
a.



Bronchodilators: given via inhalation or metered dose

Segmental Wedge Lobectomy: promote re-expansion of
lungs

inhaler or MDI for 5 minutes
b.

Pneumonectomy: 1 lung is removed & position on



Steroids: decrease inflammation: given 10 min after

Unaffected lobectomy: facilitate drainage

bronchodilator
c.

Mucomysts (acetylceisteine): at bed side put suction
machine

Emphysema


Enlargement & destruction of the alveolar, bronchial &

d.

Mucolytics / expectorants

bronchiolar tissue with resultant loss of recoil, air tapping,

e.

Anti histamine

thoracic overdistension, sputum accumulation & loss of

2.

Physical Therapy

3.

Hyposensitization

4.

Execise

Nursing Intervention

diaphragmatic muscle tone


These changes cause a state of CO2 retention, hypoxia &
respiratory acidosis



Irreversible terminal stage of COPD characterized by

1.

Enforce CBR



Inelasticity of alveoli

2.

O2 inhalation: low flow 2-3 L/min: to prevent respiratory



Air trapping

distress



Maldistribution of gases

3.

Administer medications as ordered



Overdistention of thoracic cavity (barrel chest)

4.

Force fluids 2-3 L/day

5.

Semi fowlers position: to promote lung expansion

49

50
Predisposing Factors

6.

Institute PEEP (positive end expiratory pressure) in

1.

Smoking

mechanical ventilation promotes maximum alveolar lung

2.

Inhaled irritants: air pollution

expansion

3.

Allergy or allergic factor

7.

Provide comfortable & humid environment

4.

High risk: elderly

8.

Provide high carbohydrates, protein, calories, vitamins and

5.

Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to
release elastase for recoil of alveoli

minerals
9.

Provide client teachings and discharge planning concerning
a.

S/sx

Prevention of recurrent infection


Avoid crowds & individual with known infection

1.

Productive cough



Adhere to high CHON, CHO & increased vit C diet

2.

Sputum production



Received immunization for influenza & pneumonia

3.

Anorexia & generalized body malaise



Report changes in characteristic & color of sputum

4.

Weight loss

5.

Flaring of nostrils (alai nares)

6.

Use of accessory muscles

7.

Dyspnea at rest

8.

Increased rate & depth of breathing

9.

Decrease respiratory excursion

immediately


Report of worsening of symptoms (increased
tightness of chest, fatigue, increased dyspnea)

b.

Control of environment


Use home humidifier at 30-50%



Wear scarf over nose & mouth in cold weather: to

10. Resonance to hyper resonance

prevent bronchospasm

11. Decrease or diminished breath sounds with prolong
expiration
12. Decrease tactile fremitus

c.

13. Prolong expiratory grunt
14. Rales or rhonchi
15. Bronchial wheezing



Avoid smoking & contact with environmental smoke



Avoid abrupt change in temperature

Avoidance of inhaled irritants


Stay indoor: if pollution level is high



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.

Employ pursed-lip breathing techniques (prolonged slow
relaxed expiration against pursed lips)

e.



Institute pulmonary toilet

Rate of Growth


Cancer cells have uncontrolled growth or cell division



Rate at which a tumor grows involves both increased cell
division & increased survival time of cells.

50

51


8.

Malignant cells do not form orderly layers, but pile on top of

P.E. with lab work – up: every 3 years ages 20-40; yearly
for age 40 & over

each other to eventually form tumors.
9.

TSE – testicular self – examination


Pre-disposing Factors




Testicular Cancer
i.

G – Genetics

the age of 15 & 34



Some cancers shows familial pattern



Maybe caused by inherited genetics defects



Warning signs that men should look for:

Failure of the immune system to respond & eradicate
cancer cells



Immunosuppressed individuals are more susceptible to
cancer



Painless swelling

ii.

Feeling of heaviness

iii.

Hard lump (size of a pea)

iv.

Sudden collection fluid in the scrotum

v.

Dull ache in the lower abdomen or in the
groin

V – Viral
o

Viruses have been shown to be the cause of certain
tumors in animals

o

Viruses

(

HTLV-I,

Epstein

Barr

Virus,

o

o

Pain in the testicle or in the scrotum

vii.

Enlargement

or

tenderness

the

7 Warning Signs of Cancer

Oncovirus (RNA – Type Viruses) thought to be culprit

C: change in bowel or bladder habits
A: a sore that doesn’t heal

Majority (over 80%) of human cancer related to

U: unusual bleeding or discharge

environmental carcinogens

T: thickening of lump in breast or elsewhere

Types:

I: indigestion or dysphagia



of

breasts

E – Environmental
o

vi.

Human

Papilloma Virus) linked to human tumors


i.

I – Immunologic


Most common cancer in men between

Physical


O: obvious change in wart or mole
N: nagging cough or hoarseness

Radiation: X – ray, radium, nuclear
explosion & waste, UV




Treatment of Cancer

Trauma or chronic irritation

Therapeutic Modality

Chemical


Nitrates, & food additives, polycyclic
hydrocarbons,

dyes,

alkylating

Chemotherapy

agents


Drugs:

arsenicals,

stilbestol,



be damaged, producing side effects.

urethane


Cigarette smoke



hormones

Classification of Cancer



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.

b.

independence

Nonsteroidal anti-inflammatory drugs (NSAIDs): relieve

c.

pain and inflammation by inhibiting the synthesis of

c.

Importance of maintaining a balance between activity &
rest

prostaglandins.

d.

Energy conservation methods



Ibuprofen (Motrin)

e.

Performance of ROM, isometric & prescribed exercises



Indomethacin (Indocin)

f.

Maintenance of well-balanced diet



Fenoprofen (Nalfon)

g.

Application of resting splints as ordered



Mefenamic acid (Ponstel)

h.

Avoidance of undue physical or emotional stress



Phenylbutazone (Butazolidin)

i.

Importance of follow-up care



Piroxicam (Feldene)



Naproxen (Naprosyn)



Sulindac (Clinoril)

Osteoarthritis


degeneration of articular cartilage

Gold compounds (Chrysotherapy)


Chronic non-systemic disorder of joints characterized by



Injectable form: given IM once a week; take 3-6

Weight-bearing joints (spine, knees and hips) & terminal
interphalangeal joints of fingers most commonly affected

months to become effective


Sodium thiomalate (Myochrysine)



Aurothioglucose (Solganal)

1.

Women & men affected equally



2.

Incidence increases with age

Incident Rate

SI: monitor blood studies & urinalysis
frequently





Proteinuria



Mouth ulcers



Skin rash



Aplastic anemia.

Predisposing Factors
1.

on joints)



Obesity

3.

Joint trauma

S/sx

Auranofin (Ridaura)


1.

SI: blood & urine studies should be


Pain: (aggravated by use & relieved by rest) & stiffness of
joints

monitored.

2.

Heberden’s nodes: bony overgrowths at terminal
interphalangeal joints

Diarrhea
3.

Corticosteroids


2.

Oral form: smaller doses are effective; take 3-6
months to become effective

d.

Most important factor in development is aging (wear & tear

Decreased ROM with possible crepitation (grating sound
when moving joints)

Intra-articular injections: temporarily suppress
inflammation in specific joints.



Systemic administration: used only when client does
not respond to less potent anti-inflammatory drugs.

e.

Methotrexate: given to suppress immune response


Dx
1.

X-rays: show joint deformity as disease progresses

2.

ESR: may be slightly elevated when disease is inflammatory

Cytoxan


SI: bone marrow suppression.

2.

Physical therapy: to minimize joint deformities.

3.

Surgery: to remove severely damaged joints (e.g. total hip

Nursing Interventions
1.

Assess joints for pain & ROM.

2.

Relieve strain & prevent further trauma to joints.

replacement; knee replacement).
Nursing Interventions
1.

Assess joints for pain, swelling, tenderness & limitation of
motion.

2.

Promote maintenance of joint mobility and muscle strength.
a.

Perform ROM exercises several times a day: use of heat

3.

at the point of pain.
3.

Use isometric or other exercise to strengthen muscles.

Change position frequently: alternate sitting, standing &

4.

6.

Use cane or walker when indicated.

c.

Ensure proper posture & body mechanics.

d.

Promote weight reduction: if obese

e.

Avoid excessive weight-bearing activities & continuous

Maintain joint mobility and muscle strength.
a.

Provide ROM & isometric exercises.

b.

Ensure proper body alignment.

c.

Change client’s position frequently.

Promote comfort / relief of pain.

Promote comfort & relief / control of pain.
a.

Ensure balance between activity & rest.

b.

Provide 1-2 scheduled rest periods throughout day.

c.

Rest & support inflamed joints: if splints used: remove 12 times/day for gentle ROM exercises.

5.

b.

a.

lying.
4.

Encourage rest periods throughout day.

standing.

prior to exercise may decrease discomfort; stop exercise
b.

a.

Ensure bed rest if ordered for acute exacerbations.
a.

Provide firm mattress.

b.

Maintain proper body alignment.

c.

Have client lie prone for ½ hour twice a day.

d.

Avoid pillows under knees.

e.

Keep joints mainly in extension, not flexion.

f.

Prevent complications of immobility.

Administer medications as ordered:


Aspirin & NSAID: most commonly used



Corticosteroids (Intra-articular injections): to relieve
pain & improve mobility.

b.

Apply heat or ice as ordered (e.g. warm baths,
compresses, hot packs): to reduce pain.

5.

Prepare client for joint replacement surgery if necessary.

6.

Provide client teaching and discharge planning concerning

Provide heat treatments: warm bath, shower or whirlpool;

a.

Used of prescribed medications and side effects

b.

Importance of rest periods

c.

Measures to relieve strain on joints

d.

ROM and isometric exercises

e.

Maintenance of a well-balanced diet

f.

Use of heat/ice as ordered.

warm, moist compresses; paraffin dips as ordered.

7.

a.

May be more effective in chronic pain.

b.

Reduce stiffness, pain & muscle spasm.

Provide cold treatments as ordered: most effective during

Gout


acid in the blood & the precipitation of urate crystals in the

acute episodes.
8.
9.

joints

Provide psychologic support and encourage client to express
feelings.
Assists clients in setting realistic goals; focus on client

A disorder of purine metabolism; causes high levels of uric



Inflammation of the joints caused by deposition of urate
crystals in articular tissue

strengths.

54

55
Incident Rate

2.

Fever

1.

Occurs most often in males

3.

Anorexia

2.

Familial tendency

4.

Weight loss

5.

Malaise

6.

History of remissions & exacerbations

S/sx
1.

Joint pain

7.

Joint pain

2.

Redness

8.

Morning stiffness

3.

Heat

9.

Skin lesions

4.

Swelling

5.

Joints of foot (especially great toe) & ankle most commonly



Erythematous rash on face, neck or extremities may
occur

affected (acute gouty arthritis stage)



Butterfly rash over bridge of nose & cheeks

6.

Headache



Photosensitivity with rash in areas exposed to sun

7.

Malaise

10. Oral or nasopharyngeal ulcerations

8.

Anorexia

11. Alopecia

9.

Tachycardia

12. Renal system involvement

10. Fever



Proteinuria

11. Tophi in outer ear, hands & feet (chronic tophaceous stage)



Hematuria



Renal failure

Dx
1.

13. CNS involvement

CBC: uric acid elevated

Medical Management
1.

Drug therapy
a.

b.

Acute attack:


Colchicine IV or PO: discontinue if diarrhea occurs



NSAID: Indomethacin (Indocin)



Naproxen (Naprosyn)



Phenylbutazone (Butazolidin)

Prevention of attacks


Uricosuric agents: increase renal excretion of uric
acid





Probenecid (Benemid)



Sulfinpyrazone (Anturanel)

Allopurinal (Zyloprim): inhibits uric acid formation

2.

Low-purine diet may be recommended

3.

Joint rest & protection

4.

Heat or cold therapy



Peripheral neuritis



Seizures



Organic brain syndrome



Psychosis

14. Cardiopulmonary system involvement


Pericarditis



Pleurisy

15. Increase susceptibility to infection
Dx
1.

ESR: elevated

2.

CBC: RBC anemia, WBC & platelet counts decreased

3.

Anti-nuclear antibody test (ANA): positive

4.

Lupus Erythematosus (LE prep): positive

5.

Anti-DNA: positive

6.

Chronic false-positive test for syphilis

Medical Management
1.

Nursing Interventions

Drug therapy
a.

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

Esophagus




Divided into four parts:


Cecum (with appendix)



Colon (ascending, transverse, descending, sigmoid)



Rectum



Anus

Serves as a reservoir for fecal material until defecation
occurs



Function: to absorb water & electrolytes



MO present in the large intestine: are responsible for small

Muscular tube that receives foods from the pharynx &

amount of further breakdown & also make some vitamins

propels it into the stomach by peristalsis



Amino Acids: deaminated by bacteria resulting in
ammonia which is converted to urea in the liver



Stomach


vitamin K & some of the vitamin B groups

Located on the left side of the abdominal cavity occupying
the hypochondriac, epigastric & umbilical regions



Bacteria in the large intestine: aid in the synthesis of



Feces (solid waste): leave the body via rectum & anus


Stores & mixes food with gastric juices & mucus producing

Anus: contains internal sphincter (under involuntary
control) & external sphincter (voluntary control)

chemical & mechanical changes in the bolus of food




The secretion of digestive juice is stimulated by

Fecal matter: usually 75% water & 25% solid wastes
(roughage, dead bacteria, fats, CHON, inorganic matter)

smelling, tasting & chewing food which is known as


cephalic phase of digestion

a.

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



gastric cancer


Gastric Analysis: normal gastric acidity



Upper GI series: presence of ulcer confirm

Medical Management
1.

Cholecystokinin & Pancreozymin (CCKPZ)


Are produced by the duodenal mucosa
2.

Supportive:


Rest



Bland diet



Stress management

Drug Therapy:

57

58


Antacids: neutralizes gastric acid

1.

Administer medication as ordered



Aluminum hydroxide: binds phosphate in the GIT &

2.

Diet: bland, non irritating, non spicy

neutralized gastric acid & inactivates pepsin

3.

Avoid caffeine & milk / milk products: Increase gastric acid



secretion

Magnesium & aluminum salt: neutralized gastric
acid & inactivate pepsin if pH is raised to >=4

4.

Provide client teaching & discharge planning
a.

Aluminum containing Antacids

Magnesium

containing Antacids
Ex. Aluminum OH gel (Amphojel)

Ex. Milk of Magnesia

SE: Constipation

SE: Diarrhea

b.
SE: fever
Histamines (H2) receptor antagonist: inhibits gastric
Ranitidine (Zantac): has some antibacterial action
against H. pylori





Cimetidine (Tagamet)



Famotidine (Pepcid)

c.

Atropine SO4: inhibit the action of acetylcholine at
post ganglionic site (secretory glands) results
decreases GI secretions



Propantheline: inhibit muscarinic action of
acetylcholine resulting decrease GI secretions







Avoid ulcerogenic drugs: salicylates, steroids



Know proper dosage, action & SE

Proper Diet


Bland diet consist of six meals / day



Eat slowly



Avoid acid producing substance: caffeine, alcohol,



Avoid stressfull situation at mealtime



Plan rest period after meal



Avoid late bedtime snacks

Avoidance of stress-producing situation & development


Relaxation techniques



Exercise



Biofeedback

Dumping syndrome

regardless of acetylcholine or histamine release



Rapid gastric emptying of hypertonic food solutions



Omeprazole (Prilosec): diminished the accumulation



Common complication of gastric surgery

of acid in the gastric lumen & healing of duodenal



Appears 15-20 min after meal & last for 20-60 min

ulcer



Associated with hyperosmolar CHYME in the jejunum which

Pepsin Inhibitor: reacts with acid to form a paste that

draws fluid by osmosis from the extracellular fluid into the

binds to ulcerated tissue to prevent further destruction

bowel. Decreased plasma volume & distension of the bowel

by digestive enzyme pepsin

stimulates increased intestinal motility

Sucralfate (Carafate): provides a paste like subs that
S/sx
1.

Weakness

Helicobacter Pylori

2.

Faintness

Surgery:

3.

Feeling of fullness



Gastric Resection

4.

Dizziness



Anastomosis: joining of 2 or more hollow organ

5.

Diaphoresis



Subtotal Gastrectomy: Partial removal of stomach

6.

Diarrhea

7.

Palpitations



Before surgery for BI or BII


Do Vagotomy (severing or cutting of vagus
nerve) & Pyloroplasty (drainage) first

Billroth I
(Gastroduodenostomy)

Billroth II (Gastrojejunostomy)


Removal of ½ -3/4 of

Nursing Intervention
1.

Avoid fluids in chilled solutions

2.

Small frequent feeding: six equally divided feedings

3.

Diet: decrease CHO, moderate fats & CHON

4.

Flat on bed 15-30 min after q feeding

Removal of ½ of

stomach & duodenal bulb

stomach &

& anastomostoses of

Disorders of the Gallbladder

anastomoses of gastric

gastric stump to jejunum.

Cholecystitis / Cholelithiasis

stump to the



duodenum.
Nursing Intervention Post op

2.

Recognized situation that would increase the need

Metronidazole & Amoxacillin: for ulcer caused by



1.



Abrupt emptying of stomach content into the intestine

coats mucosal lining of stomach



Have antacid available at all times



Proton Pump Inhibitor: inhibit gastric acid secretion



3.



of stress production methods

Anticholinergic:


Take medication at prescribe time

highly seasoned food

acid secretion of parietal cells




for antacids

Maalox



Medical Regimen

Monitor NGT output


Immediately post op should be bright red



Within 36-42 hrs: output is yellow green



After 42 hrs: output is dark red

Administer medication


Analgesic



Antibiotic



Antiemetics

3.

Maintain patent IV line

4.

Monitor V/S, I&O & bowel sounds

5.

Complications:


Hemorrhage: Hypovolemic shock: Late signs: anuria



Peritonitis



Paralytic ileus: most feared



Hypokalemia



Thromobphlebitis



Pernicious anemia

Cholecystitis:


Acute or chronic inflammation of the gallbladder



Most commonly associated with gallstones



Inflammation occurs within the walls of the gallbladder
& creates thickening accompanied by edema



Consequently there is impaired circulation, ischemia &
eventually necrosis



Cholelithiasis:




Formation of gallstones & cholesterol stones

Inflammation of gallbladder with gallstone formation.

Predisposing Factor:
1.

High risk: women 40 years old

2.

Post menopausal women: undergoing estrogen therapy

3.

Obesity

4.

Sedentary lifestyle

5.

Hyperlipidemia

6.

Neoplasm

S/sx:
1.

Severe Right abdominal pain (after eating fatty food):
Occurring especially at night

Nursing Intervention

2.

Intolerance of fatty food

58

59
3.

Anorexia

3.

Blood Sugar: increase

4.

N/V

4.

Lipids Level: increase

5.

Jaundice

5.

Serum Ca: decrease

6.

Pruritus

6.

CT Scan: shows enlargement of the pancreas

7.

Easy bruising

8.

Tea colored urine

9.

Steatorrhea

Medical Management
1.

Drug Therapy


Dx
1.

Direct Bilirubin Transaminase: increase

2.

Alkaline Phosphatase: increase

3.

WBC: increase

4.

Amylase: increase

5.

Lipase: increase

6.

Oral cholecystogram (or gallbladder series): confirms



2.

Diet modification with administration of fat soluble vitamins

3.

Drug Therapy










(Morpine SO4: is contraindicated because it causes



(Anticholinergic: relax smooth muscles & open bile
ducts)



Antiemetics: Phenothiazide (Phenergan): with anti

Smooth muscle relaxant: to relieve pain



Papaverine Hcl

Anticholinergic: to decrease pancreatic stimulation


Atrophine SO4



Propantheline Bromide (Profanthene)

Antacids: to decrease pancreatic stimulation
Maalox

H2 Antagonist: to decrease pancreatic stimulation
Ranitidin (Zantac)

Vasodilators: to decrease pancreatic stimulation


spasm of the Sphincter of Oddi)
Antocholinergic: (Atrophine SO4): for pain

Don’t give Morphine SO4: will cause spasm of



pain







Narcotic analgesic: DOC: Meperdipine Hcl (Demerol): for


Meperidine Hcl (Demerol)



Medical Management
Supportive Treatment: NPO with NGT & IV fluids



Sphincter of Oddi

presence of stones
1.

Narcotic Analgesic: for pain

Nitroglycerine (NTG)

Ca Gluconate: to decrease pancreatic stimulation

2.

Diet Modification

3.

NPO (usually)

4.

Peritoneal Lavage

5.

Dialysis

emetic properties
4.

Surgery: Cholecystectomy / Choledochostomy

Nursing Intervention
1.

Administer pain medication as ordered & monitor effects

2.

Administer IV fluids as ordered

3.

Diet: increase CHO, moderate CHON, decrease fats

4.

Meticulous skin care: to relieved priritus

Nursing Intervention
1.

Administer medication as ordered

2.

Withhold food & fluid & eliminate odor: to decrease
pancreatic stimulation / aggravates pain

3.

Assist in Total Parenteral Nutrition (TPN) or
hyperalimentation


Complication of TPN

Disorders of the Pancreas



Infection

Pancreatitis



Embolism



Hyperglycemia



An inflammatory process with varying degrees of pancreatic
edema, fat necrosis or hemorrhage



4.

Institute non-pharmacological measures: to decrease pain


Proteolytic & lipolytic pancreatic enzymes are activated in
the pancreas rather than in the duodenum resulting in

like position

tissue damage & auto digestion of pancreas




Acute or chronic inflammation of pancreas leading to
pancreatic edema, hemorrhage & necrosis due to auto

Teach relaxation techniques & provide quiet, restful
environment

5.

digestion


Assist client to comfortable position: Knee chest or fetal

Provide client teaching & discharge planning


Bleeding of Pancreas: Cullen’s sign at umbilicus

Predisposing factors:

Dietary regimen when oral intake permitted


High CHO, CHON & decrease fats



Eat small frequent meal instead of three large ones



Avoid caffeine products



Eliminate alcohol consumption



Maintain relaxed atmosphere after meals

1.

Chronic alcoholism

2.

Hepatobilary disease

3.

Trauma

4.

Viral infection

5.

Penetrating duodenal ulcer



Continued N/V

6.

Abscesses



Abdominal distension with feeling of fullness

7.

Obesity



Persistent weight loss

8.

Hyperlipidemia



Severe epigastric or back pain

9.

Hyperparathyroidism



Frothy foul smelling bowel movement



Irritability, confusion, persistent elevation of



10. Drugs: Thiazide, steroids, diuretics, oral contraceptives

temperature (2 day)

S/Sx:
1.

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

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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:

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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

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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

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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

Force fluid

(tea, chocolate, rhubarb, spinach)

Acid ash diet

Maintain alkaline-ash diet (milk, vegetable, fruits

Administer medication as ordered

except cranberry, plums & prune): to alkalinize

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)

Extracorporeal Shockwave Lithotripsy:
Non-invasive

Nursing Intervention

63

64
Prostate message: promotes evacuation of prostatic
fluid

BUN & Creatinine: elevated
Diuretic Phase: slow gradual increase in daily urine output

Force fluid intake: 2000-3000 ml unless contraindicated

Diuresis may occur (output 3-5 L / day): due to partially

Provide catheterization

regenerated tubules inability to concentrate urine

Administer medication as ordered:

Duration: 2-3 weeks

Terazosine (Hytrin): relaxes bladder sphincter & make it

S/sx

easier to urinate

Hyponatremia

Finasteride (Proscar): shrink enlarge prostate gland
Surgery: Prostatectomy

Hypokalemia
Hypovolemia

Transurethral Resection of Prostate (TURP): insertion of a

Dx

resectoscope into urethra to excise prostatic tissue
Assist in cystoclysis or continuous bladder irrigation.

BUN & Creatinine: elevated
Recovery or Covalescent Phase: renal function stabilized with

Nursing Intervention

gradual improvement over next 3-12 mos

Monitor symptoms of infection
Monitor symptoms gross / flank bleeding. Normal

Nursing Intervention

bleeding within 24h

Monitor / maintain F&E balance

Maintain irrigation or tube patent to flush out clots: to

Obtain baseline data on usual appearance & amount of

prevent bladder spasm & distention

client’s urine
Measure I&O every hour: note excessive losses
Administer IV F&E supplements as ordered
Weight daily

Acute Renal Failure

Monitor lab values: assess / treat F&E & acid base

Sudden inability of the kidney to regulate fluid & electrolyte

imbalance as needed

balance & remove toxic products from the body

Monitor alteration in fluid volume

Sudden immobility of kidneys to excrete nitrogenous waste

Monitor V/S. PAP, PCWP, CVP as needed

products & maintain F&E balance due to a decrease in GFR

Monitor I&O strictly

(N 125 ml/min)

Assess every hour fro hypervolemia
Maintain ventilation

Causes

Decrease fluid intake as ordered

Pre-renal cause: interfering with perfusion & resulting in

Administer diuretics, cardiac glycosides &

decreased blood flow & glomerular filtrate

hypertensive agent as ordered

Inter-renal cause: condiion that cause damage to the nephrons

Assess every hour for hypovolemia: replace fluid as

Post-renal cause: mechanical obstruction anywhere from the

ordered

tubules to the urethra

Monitor ECG
Check urine serum osmolality / osmolarity & urine

Pre renal cause: decrease blood flow & glomerular filtrate

specific gravity as ordered

Ischemia & oliguria

Promote optimal nutrition

Cardiogenic shock

Administer TPN as ordered

Acute vasoconstriction

Restrict CHON intake

Septicemia
Hypovolemia

Prevent complication from impaired mobility
Decrease

flow to kidneys

Pulmonary Embolism
Skin breakdown

Hypotension

Contractures

CHF

Atelectesis

Hemorrhage

Prevent infection / fever

Dehydration

Assess sign of infection
Use strict aseptic technique for wound & catheter care

Intra-renal cause: involves renal pathology: kidney problem

Take temperature via rectal

Acute tubular necrosis

Administer antipyretics as ordered & cooling blankets

Endocarditis

Support clients / significant others: reduce level of anxiety

DM

Provide care for client receiving dialysis

Tumors

Provide client teaching & discharge planning

Pyelonephritis

Adherence to prescribed dietary regime

Malignant HPN

S/sx of recurrent renal disease

Acute Glomerulonephritis

Importance of planned rest period

Blood transfision reaction

Use of prescribe drugs only

Hypercalemia

S/sx of UTI or respiratory infection: report to MD

Nephrotoxin (certain antibiotics, X-ray, dyes, pesticides,
anesthesia)

Chronic Renal Failure
Progressive, irreversible destruction of the kidneys that

Post renal cause: involves mechanical obstruction

continues until nephrons are replaced by scar tissue

Tumors

Loss of renal function gradual

Stricture

Irreversible loss of kidney function

Blood cloths
Urolithiasis

Predisposing factors:

BPH

DM

Anatomic malformation

HPN
Recurrent UTI/ nephritis

S/sx

Urinary Tract obstruction

Oliguric Phase: caused by reduction in glomerular filtration rate

Exposure to renal toxins

Urine output less than 400 ml / 24 hrs; duration 1-2 weeks
S/sx

Stages of CRF

Hypernatremia

Diminished Reserve Volume – asymptomatic

Hyperkalemia

Normal BUN & Crea, GFR < 10 – 30%

Hyperphosphotemia

2. Renal Insufficiency

Hypermagnesemia

3. End Stage Renal disease

Hypocalcemia
Metabolic acidosis
Dx

S/Sx:

64

65
N/V

Monitor for hyperphosphatemia: administer aluminum

Diarrhea / constipation

hydroxides gel (amphojel, alternagel) as ordered

Decreased urinary output

Paresthesias

Dyspnea

Muscle cramps

Stomatitis

Seizures

Hypotension (early)

Abnormal reflex

Hypertension (late)

Maintenance of skin integrity

Lethargy

Provide care for pruritus

Convulsion

Monitor uremic frost (urea crystallization on the skin): bathe

Memory impairment

in plain water

Pericardial Friction Rub

Monitor for bleeding complication & prevent injury to client

HF

Monitor Hgb, Hct, platelets, RBC
Hematest all secretions
Administer hematinics as ordered

Urinary System
Polyuria

Avoid IM injections

Metabolic Disturbance

Maintain maximal cardiovascular function

Azotemia (increase BUN

Nocturia

Monitor BP

& Creatinine)

Hematuria

Hyperglycemia

Auscultate for pericardial friction rub

Dysuria

Hyperinsulinemia

Perform circulation check routinely
Administer diuretics as ordered & monitor I&O

Oliguria
CNS

GIT

Modify digitalis dose as ordered (digitalis is excreted in

Headache

N/V

Lethargy

Stomatitis

Provide care for client receiving dialysis

Disorientation

Uremic breath

Disequilibrium syndrome: from rapid removal of urea &

Restlessness

Diarrhea /

Memory impairment
Respiratory

kidneys)

Kassmaul’s resp

Normocytic anemia

Decrease cough

Bleeding tendencies

reflex
Fluid & Electrolytes

nitrogenous waste prod leading to:

constipation
Hematological

N/V
HPN
Leg cramps
Disorientation
Paresthes

Integumentary

Hyperkalemia

Enforce CBR

Itchiness /

Hypernatermia

pruritus

Hypermagnese

Uremic frost

Monitor VS, I&O
Meticulous skin care. Uremic frost – assist in bathing
pt

mia

4. Meds:

Hyperposphate

a.) Na HCO3 – due Hyperkalemia

mia
Hypocalcemia

b.) Kagexelate enema

Metabolic

c.) Anti HPN – hydralazine
d.) Vit & minerals

acidosis

e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
Dx

f.) Decrease Ca – Ca gluconate
Urinalysis: CHON, Na & WBC: elevated

5. Assist in hemodialysis

Specific gravity: decrease

Consent/ explain procedure

Platelets: decrease

Obtain baseline data & monitor VS, I&O, wt,

Ca: decrease

blood exam
Strict aseptic technique

Medical Management

Monitor for signs of complications:

Diet restriction

B – bleeding

Multivitamins

E – embolism

Hematinics

D – disequilibrium syndrome

Aluminum Hydroxide Gels

S – septicemia

Antihypertensive

S – shock – decrease in tissue perfusion
Disequilibrium syndrome – from rapid removal of urea & nitrogenous

Nursing Intervention
Prevent neurologic complication
Monitor for signs of uremia
Fatigue

waste prod leading to:
n/v
HPN
Leg cramps

Loss of appetite

Disorientation

Decreased urine output

Paresthesia

Apathy
Confusion

Avoid BP taking, blood extraction, IV, at side of shunt or

Elevated BP
Edema of face & feet

fistula. Can lead to compression of fistula.
Maintain patency of shunt by:

Itchy skin

Palpate for thrills & auscultate for bruits if (+)

Restlessness

patent shunt!

Seizures

Bedside- bulldog clip

Monitor for changes in mental functioning

- If with accidental removal of fistula to prevent

Orient confused client to time, place, date & person

embolism.

Institute safety measures to protect the client from

- Infersole (diastole) – common dialisate used

falling out of bed
Monitor serum electrolytes, BUN & creatinine as ordered
Promote optimal GI function

7. Complication
- Peritonitis
- Shock

Provide care for stomatitis
Monitor N/V & anorexia: administer antiemetics as
ordered
Monitor signs of GI bleeding

8. Assist in surgery:
Renal transplantation : Complication – rejection.
Reverse isolation

Monitor & prevent alteration in F&E balance

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