Ms New Lecture 2012

AUGUST 17, 2012
Medical Surgical Nursing

MEDICAL SURGICAL
HARLEY L. DELA CRUZ RN MAN

Overview of the Structures & Functions of Nervous System
Central NS PNS ANS
Brain & spinal cord 31 spinal & cranial sympathetic NS
Parasypathatic NS

Somatic NS
C- 8
T- 12
L- 5
S- 5
C- 1

ANS (or adrenergic of parasympatholitic response)

SNS involved in fight or aggression response Effects of SNS (anti-cholinergic/adrenergic)
1. Dilate pupil to aware of surroundings
Release of norepinephrine (adrenaline cathecolamine) - medriasis
Adrenal medulla (potent vasoconstrictor) 2. Dry mouth
Increases body activities VS = Increase 3. BP & HR= increased
Except GIT decrease GITmotility bronchioles dilated to take more oxygen
4. RR increased
* Why GIT is not increased = GIT is not important! 5. Constipation & urinary retention
Increase blood flow to skeletal muscles, brain & heart.

I. Adrenergic Agents Epinephrine (adrenaline)
SE: SNS effect
II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in lol)
- Blocks release of norepinephrine.
- Decrease body activities except GIT (diarrhea)
Ex. Propanolol, Metopanolol

SE:
B broncho spasm (bronchoconstriction)
E elicits a decrease in myocardial contraction
T treats HPN
A AV conduction slows down

Given to angina & MI beta-blockers to rest heart
Anti HPN agents:
1. Beta blockers (-lol)
2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL
3. Calcium antagonist
ex CALCIBLOC or NEFEDIPINE

Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic)
- Involved in fly or withdrawal response 1. Meiosis contraction of pupils
- Release of acetylcholine (ACTH) 2. Increase salivation
- Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased
4. RR decrease broncho constriction
I Cholinergic agents 5. Diarrhea increased GI motility
ex 1. Mestinon 6. Urinary frequency
Antidote anti cholinergic agents Atropine Sulfate S/E SNS

S/E- of anti-hpn drugs:
1. orthostatic hpn
2. transient headache & dizziness.
-Mgt. Rise slowly. Assist in ambulation.

CNS (brain & spinal cord)
I. Cells A. neurons
Properties and characteristics
a. Excitability ability of neuron to be affected in external environment.
b. Conductivity ability of neuron to transmit a wave of excitation from one cell to another
c. Permanent cells once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
Regenerative capacity
A. Labile once destroyed cant regenerate
- Epidermal cells, GIT cells, resp (lung cells). GUT
B. Stable capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cells
C. Permanent cells retina, brain, heart, osteocytes cant regenerate.

3.) Neuroglia attached to neurons. Supports neurons. Where brain tumors are found.
Types:
1. Astrocyte
2. Oligodendria

Astrocytoma 90 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.
Astrocyte maintains integrity of blood brain barrier (BBB).
BBB semi permeable / selective
-Toxic substance that destroys astrocyte & destroy BBB.
Toxins that can pass in BBB:
1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide seizure & parkinsons.
3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. 4. Ketones DM.

OLIGODENDRIA Produces myelin sheath wraps around a neuron acts as insulator facilitates rapid nerve impulse transmission.
No myelin sheath degenerates neurons

Damage to myelin sheath demyellenating disorders

DEMYELLENATING DSE
1.)ALZHEIMERS DISEASE atrophy of brain tissue due to a deficiency of acetylcholine.

S&Sx:
A amnesia loss of memory
A apraxia unable to determine function & purpose of object
A agnosia unable to recognize familiar object
A aphasia
- Expressive broccas aphasia unable to speak
- Receptive wernickes aphasia unable to understand spoken words
Common to Alzheimer receptive aphasia
Drug of choice ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.

Microglia stationary cells, engulfs bacteria, engulfs cellular debris.

II. Compositions of Cord & Spinal cord
80% - brain mass
10% - CSF
10% - blood
MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP.
Normal ICP: 0-15mmHg
Brain mass

1. Cerebrum largest - Connects R & L cerebral hemisphere
- Corpus collusum
Rt cerebral hemisphere, Lt cerebral hemisphere
Function:
1. Sensory
2. Motor
3. Integrative
Lobes
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reflexes are inhibited
d. Site of development of sense of umor
e. Broccas area speech center
Damage - expressive aphasia
2.) Temporal
a. Hearing
b. Short term memory
c. Wernickes area gen interpretative or knowing Gnostic area
Damage receptive aphasia
3.) Parietal lobe appreciation & discrimation of sensory imp
- Pain, touch, pressure, heat & cold
4.) Occipital - vision
5.) Insula/island of reil/ Central lobe- controls visceral fx
Function: - activities of internal organ
6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory

Basal Ganglia areas of gray matte located deep within a cerebral hemisphere
- Extra pyramidal tract
- Releases dopamine-
- Controls gross voluntary unit

Decrease dopamine (Parkinsons) pin rolling of extremities & Huntingtons Dse.
Decrease acetylcholine Myasthenia Gravis & Alzheimers
Increased neurotransmitter = psychiatric disorder Increase dopamine schizo

MID BRAIN relay station for sight & hearing
Controls size & reaction of pupil 2 3 mm
Controls hearing acuity
CN 3 4
Isocoria normal size (equal)
Anisocoria uneven size damage to mid brain
PERRLA normal reaction

DIENCEPHALON- between brain
Thalamus acts as a relay station for sensation
Hypothalamus (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional responses, controls pituitary function.

BRAIN STEM- a. Pons or pneumotaxic center controls respiration
Cranial 5 8 CNS

MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12

CEREBELLUM lesser brain
- Controls posture, gait, balance, equilibrium

Cerebellar Tests:
a.) R Rombergs test- needs 2 RNs to assist
- Normal anatomical position 5 10 min
(+) Rombergs test (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test
(+) To FTNT dymetria inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to cerebellum dymentrium

Composition of brain - based on Monroe Kellie Hypothesis
- Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP

Normal ICP 0 15 mmHg
Foramen Magnum
C1 atlas
C2 axis

(+) Projectile vomiting = increase ICP
Observe for 24 - 48 hrs
CSF cushions the brain, shock absorber
Obstruction of flow of CSF = increase ICP
Hydrocephalus posteriorly due to closure of posterior fontanel
CVA partial/ total obstruction of blood supply

INCREASED ICP increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis

B. S&Sx change in VS = always late symptoms
Earliest Sx:
a.) Change or decrease LOC Restlessness to confusion Wide pulse pressure: Increased ICP
- Disorientation to lethargy Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)
4. Temp increase

Increased ICP: Increase BP Shock decrease BP
Decrease HR Increase HR CUSHINGS EFFECT
Decrease RR Increase RR
Increase Temp Decrease temp

b.) Headache
Projectile vomiting

Papilledima (edema of optic disk outer surface of retina)
Decorticate (abnormal flexion) = Damage to cortico spinal tract /
Decerebrate (abnormal extension) = Damage to upper brain stem-pons/

c.) Uncal herniation unilateral dilation of pupil. (Bilateral dilation of pupil tentorial herniation.)
d.) Possible seizure.

Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).

Hypoxia cerebral edema - increase ICP
Hypoxia inadequate tissue oxygenation
Late symptoms of hypoxia
B bradycardia
E extreme restlessness
D dyspnea
C cyanosis
Early symptoms R restlessness
A agitation
T tachycardia

Increase CO2 retention/ hypercarbia cerebral vasodilatation = increase ICP
Most powerful respiratory stimulant increase in CO2
Hyperventilate decrease CO2 excrete CO2

Respiratory Distress Syndrome (RDS) decrease Oxygen
Suctioning 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.
Ambu bag pump upon inspiration

c. Assist in mechanical ventilation
1. Maintain patent a/w
2. Monitor VS & I&O
3. Elevate head of bed 30 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage
4. Limit fluid intake 1,200 1,500 ml/day
(FORCE FLUID means:Increase fluid intake/day 2,000 3,000 ml/day)- not for inc ICP.
5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
-Valsalva maneuver or bearing down, avoid straining of stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
- Excessive cough antitussive
Dextrometorpham
-Excessive vomiting anti emetic (Plasil Phil only)/ Phenergan
- Lifting of heavy objects
- Bending & stooping
e. Avoid clustering of nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue

Nursing considerations:
1.) Mannitol
1. Monitor BP SE of hypotension
2. Monitor I&O every hr. report if < 30cc out put
3. Administer via side drip
4. Regulate fast drip to prevent formation of crystals or precipitate

2.) Loop diuretic - Lasix (Furosemide)
Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt will urinate at 7:15
Immediate effect of Lasix within 15 minutes. Max effect 6 hrs due (7am 1pm)
S/E of Lasix
Hypokalemia (normal K-3.5 5.5 meg/L)
S&Sx
1. Weakness & fatigue
2. Constipation
3. (+) U wave in ECG tracing

Nursing Mgt:
1.) Administer K supplements ex Kalium Durule, K chloride
Potassium Rich food:
ABCs of K
Vegetables Fruits
A asparagus A apple
B broccoli (highest) B banana green
C carrots C cantalope/ melon
O orange (highest) for digitalis toxicity also.
Vit A squash, carrots yellow vegetables & fruits, spinach, chesa
Iron raisins,
Food appropriate for toddler spaghetti! Not milk increase bronchial secretions
Dont give grapes may choke

S/E of Lasix:
1.) Hypokalemia
2.) Hypocalcemia (Normal level Ca = 8.5 11mg/100ml) or Tetany:
S&Sx
weakness
Paresthesia
(+) Trousseau sign pathognomonic or carpopedal spasm. Put bp cuff on arm=hand spasm.
(+) Chevosteks sign
Arrhythmia
Laryngospasm
Administer Ca gluconate IV slowly

Ca gluconate toxicity: Sx seizure administer Mg SO4
Mg SO4 toxcicity administer Ca gluconate
B BP decrease
U urine output decrease
R RR decrease
P patellar reflexes absent

3.) Hyponatremia Normal Na level = 135 145 meg/L
S/Sx Hypotension
Signs of Dehydration: dry skin, poor skin turgor, gen body malaise.
Early signs Adult: thirst and agitation / Child: tachycardia
Mgt: force fluid
Administer isotonic fluid sol

4.) Hyperglycemia increase blood sugar level
P polyuria
P polyphagia
P polydipsia

Nsg Mgt:
a. Monitor FBS (N=80 120 mg/dl)

5.) Hyperurecemia increase serum uric acid. Tophi- urate crystals in joint.

Gouty arthritis kidney stones- renal colic (pain)
Cool moist skin
Sx joint pain & swelling usually at great toe.

Nsg Mgt of Gouty Arthritis
a.) Cheese (not sardines, anchovies, organ meat)
(Not good if pt taking MAO)
b.) Force fluid
c.) Administer meds Allopurinol/ Zyloprim inhibits synthesis of uric acid drug of choice for gout
Colchicene excretes uric acid. Acute gout drug of choice.
Kidney stones renal colic (pain). Cool moist skin
Mgt:
1.) Force fluid
2.) Meds narcotic analgesic
Morphine SO4

SE of Morphine SO4 toxicity
Respiratory depression (check RR 1st)
Antidote for morphine SO4 toxicity Narcan (NALOXONE)
Naloxone toxicity tremors

Increase ICP meds:
3.) Corticosteroids - Dexamethsone decrease cerebral edema (Decadrone)
4.) Mild analgesic codeine SO4. For headache.
5.) Anti consultants Dilantin (Phenytoin)

Question: Increase ICP what is the immediate nsg action?
a. Administer Mannitol as ordered
b. Elevate head 30 45 degrees
c. Restrict fluid
d. Avoid use of restraints

Nsg Priority ABC & safety

Pt suffering from epiglotitis. What is nsg priority?
a. Administer steroids least priority
b. Assist in ET temp, a/w
c. Assist in tracheotomy permanent (Answer)
d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET cant pass. Need tracheostomy only-

Magic 2s of drug monitoring

Drug N range Toxicity Classification Indication
D digoxin .5 1.5 meq/L 2 cardiac glycosides CHF
L - lithium .6 1.2 meq/L 2 antimanic bipolar
A aminophylline 10 19 mg/100ml 20 bronchodilator COPD
D Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizures
A acetaminophen 10 30 mg/100ml 200 narcotic analgesic osteoarthritis

Digitalis increase cardiac contraction = increase CO
Nursing Mgt
1. Check PR, HR (if HR below 60bpm, dont giveDigoxin)
Digitalis toxicity antidote - Digivine
a. Anorexia -initial sx.
b. n/v GIT
c. Diarrhea
d. Confusion
e. Photophobia
f. Changes in color perception yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)

L lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine
Antimanic agent
Lithium toxicity
S/Sx -
a.) Anorexia
b.) n/s
c.) Diarrhea
d.) Dehydration force fluid, maintain Na intake 4 10g daily
e.) Hypothyroidism
(CRETINISM the only endocrine disorder that can lead to mental retardation)

A aminophyline (theophylline) dilates bronchioles.
Take bp before giving aminophylline.
S/Sx : Aminophylline toxicity:
1. Tachycardia
2. Hyperactivity restlessness, agitation, tremors

Question: Avoid giving food with Aminophylline
a. Cheese/butter food rich in tyramine, avoided only if pt is given MAOI
b. Beer/ wine -
c. Hot chocolate & tea caffeine CNS stimulant tachycardia
d. Organ meat/ box cereals anti parkinsonian

MAOI antidepressant
m AR plan
n AR dil can lead to CVA or hypertensive crisis
p AR nate
3 4 weeks - before MAOI will take effect
Anti Parkinsonian agents Vit B6 Pyridoxine reverses effect of Levodopa

D dilatin (Phenytoin) anti convulsant/seizure
Nursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate
- Do sandwich method
- Give NSS then Dilantin, then NSS!
2. Instruct the pt to avoid alcohol bec alcohol + dilantin can lead to severe CNS depression
Dilantin toxicity:
S/Sx:
G gingival hyperplasia swollen gums
i. Oral hygiene soft toothbrush
ii. Massage gums
H hairy tongue
A - ataxia
N nystagmus abnormal movement of eyeballs
A acetaminophen/ Tylenol non-opoid analgesic & antipyretic febrile pts

Acetaminophen toxicity :
1. Hepato toxicity
2. Monitor liver enzymes
SGPT (ALT) Serum Glutamic Piruvate Tyranase
SGOT- Serum Glutamic Acetate Tyranase
3. Monitor BUN (10 20)
Crea (.8-1)
Acetaminophen toxicity can lead to hypoglycemia
T tremors, Tachycardia
I irritability
R restlessness
E extreme fatigue
D depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity Acetylcesteine = causes outporing of secretions. Suction.
Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:
a. Nightmares
b. Extreme thirst hyperglycemia symptoms
c. Weakness d. Diaphoresis

PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine producing cells in substancia nigra at mid
brain & basal ganglia
- Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
2. Hypoxia
3. Arteriosclerosis
4. Encephalitis

High doses of the ff:
a. Reserpine (serpasil) anti HPN, SE 1.) depression - suicidal 2.) breast cancer
b. Methyldopa (aldomet) - promote safety
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide - anti psychotic

SE of anti psychotic drugs Extra Pyramidal Symptom
Over meds of anti psychotic drugs neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism
1. Pill rolling tremors of extremities early sign
2. Bradykinesia slow movement
3. Over fatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. Shuffling most common
c. Propulsive gait
5. Mask like facial expression with decrease blinking eyes
6. Monotone speech
7. Difficulty rising from sitting position
8. Mood labilety always depressed suicide
Nsg priority: Promote safety
9. Increase salivation drooling type
10. Autonomic signs:
- Increase sweating
- Increase lacrimation
- Seborrhea (increase sebaceous gland)
- Constipation
- Decrease sexual activity

Nsg Mgt
1.) Anti parkinsonian agents
- Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)
Mechanism of action
Increase levels of dopa relieving tremors & bradykinesia
S/E of anti parkinsonian
- Anorexia
- n/v
- Confusion
- Orthostatic hypotension
- Hallucination
- Arrhythmia
Contraindication:
1. Narrow angled closure glaucoma
2. Pt taking MAOI (Parnate, Marplan, Nardil)

Nsg Mgt when giving anti-parkinsonian
1. Take with meals to decrease GIT irritation
2. Inform pt urine/ stool may be darkened
3. Instruct pt- dont take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg
- Cause B6 reverses therapeutic effects of levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.
2.) Anti cholinergic agents relieves tremors
Artane mech inhibits acetylcholine
Cogentin action , S/E - SNS

3.) Antihistamine Diphenhydramine Hcl (Benadryl) take at bedtime
S/E: adult drowsiness, avoid driving & operating heavy equipt. Take at bedtime.
Child hyperactivity CNS excitement for kids.
4.) Dopamine agonist
Bromotriptine Hcl (Parlodel) respiratory depression. Monitor RR.

Nsg Mgt Parkinson
1.) Maintain siderails
2.) Prevent complications of immobility
- Turn pt every 2h
Turn pt every 1 h elderly
3.) Assist in passive ROM exercises to prevent contractures
4.) Maintain good nutrition
CHON in am
CHON in pm to induce sleep due Tryptopan Amino Acid
5.) Increase fluid in take, high fiber diet to prevent constipation
6.) Assist in surgery Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis

MULTIPLE SCLEROSIS (MS)
Chronic intermittent disorder of CNS white patches of demyelenation in brain & spinal cord.
- Remission & exacerbation
- Common women, 15 35 yo cause unknown
Predisposing factor:
1. Slow growing virus
2. Autoimmune (supportive & palliative treatment only)
Normal Resident Antibodies:
Ig G can pass placenta passive immunity. Short acting.
Ig A body secretions saliva, tears, colostrums, sweat
Ig M acute inflammation
Ig E allergic reactions
IgD chronic inflammation

S & Sx of MS: (everything down)
1. Visual disturbances
a. Blurring of vision
b. Diplopia/ double vision
c. Scotomas (blind spots) initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbness
b. Tingling
c. Paresthesia
3. Mood swings euphoria (sense of elation )
4. Impaired motor function:
a. Weakness
b. Spasiticity tigas
c. Paralysis major problem
5. Impaired cerebellar function
Triad Sx of MS
I intentional tremors
N nystagmus abnormal rotation of eyes Charcots triad
A Ataxia
& Scanning speech
6. Urinary retention or incontinence
7. Constipation
8. Decrease sexual ability
Dx MS
1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG
2. MRI reveals site & extent of demyelination
3. Lhermittes response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS
- Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH adenocorticotopic
Steroids to reduce edema at the site of demyelination to prevent paralysis
Spinal Cord Injury
Administer drug to prevent paralysis due to edema
a. Give ACTH steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)
To decrease muscle spasticity
c. Interferone to alter immune response
d. Immunosuppresants
2. Maintain siderails
3. Assist passive ROMexercises promote proper body alignment
5. Encourage fluid intake & increase fiber diet to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence give Prophantheline bromide (probanthene)

Antispasmodic anti cholinergic
8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.
9. Provide acid-ash diet to acidify urine & prevent bacteria multiplication
Grape, Cranberry, Orange juice, Vit C

MYASTHENIA GRAVIS (MG) disturbance in transmission of impulses from nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 40 yo, unknown cause or idiopathic
Autoimmune release of cholenesterase enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness
(Ascending muscle weakness Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
1.) Ptosis drooping of upper lid ( initial sign)
Check Palpebral fissure opening of upper & lower lids = to know if (+) of MG.
2.) Diplopia double vision
3.) Mask like facial expression
4.) Dysphagia risk for aspiration!
5.) Weakening of laryngeal muscles hoarseness of voice
6.) Resp muscle weakness lead respiratory arrest. Prepare at bedside tracheostomy set
7.) Extreme muscle weakness during activity especially in the morning.
Dx test
1. Tensilon test (Edrophonium Hcl) temporarily strengthens muscles for 5 10 mins. Short term- cholinergic. PNS effect.
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent attach to ventilator
b.) Monitor pulmonary function test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr.
5. NGT feeding
Administer meds
a.) Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) Long term
- Increase acetylcholine
s/e PNS
b.) Corticosteroids to suppress immune resp
Decadron (dexamethasone)

Monitor for 2 types of Crisis:
Myastinic crisis Cholinergic crisis
A cause 1. Under medication
2. Stress
3. Infection
B S&Sx 1. Unable to see Ptosis & diplopia
2. Dysphagia- unable to swallow.
3. Unable to breath
C Mgt adm cholinergic agents Cause: 1 over meds
S/Sx - PNS

Mgt. adm anti-cholinergic
- Atropine SO4
- SNS dry mouth
7. Assist in surgical proc thymectomy. Removal of thymus gland. Thymus secretes auto immune antibody.
8. Assist in plasmaparesis filter blood
9. Prevent complication respiratory arrest
Prepare tracheostomy set at bedside.

GBS Guillain Barre Syndrome
- Disorder of CNS
- Bilateral symmetrical polyneuritis
- Ascending paralysis
Cause unknown, idiopathic
- Auto immune
- r/t antecedent viral infection
- Immunizations

S&Sx
Initial :
1. Clumsiness
2. Ascending muscle weakness lead to paralysis
3. Dysphagia
4. Decrease or diminished DTR (deep tendon reflexes)
- Paralysis
5. Alternate HPN to hypotension lead to arrhythmia - complication
6. Autonomic changes increase sweating, increase salivation.
Increase lacrimation
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)

Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding due dysphagia

7. Adm meds (GBS) as ordered: 1. Anti cholinergic atropine SO4
2. Corticosteroids to suppress immune response
3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine SE confusion = VTach
b.) Bretyllium
c.) Quinines/Quinidine anti malarial agent. Give with meals.
- Toxic effect cinchonism
Quinidine toxicity
S/E anorexia, n/v, headache, vertigo, visual disturbances
8. Assist in plasmaparesis (MG. GBS)
9. Prevent comp arrhythmias, respiratory arrest
Prepare tracheostomy set at bedside.

INFL CONDITONS OF BRAIN
Meninges 3-fold membrane cover brain & spinal cord
Fx:
Protection & support
Nourishment
Blood supply
3 layers
1. Duramater sub dural space
2. Arachmoid matter
3. Pia matter sub arachnoid space where CSF flows L3 & L4. Site for lumbar puncture.

MENINGITIS inflammation of meningitis & spinal cord

Etiology Meningococcus
Pneumococcus
Hemophilous influenza child
Streptococcus adult meningitis
MOT direct transmission via droplet nuclei

S&Sx
- Stiff neck or nuchal rigidity (initial sign)
- Headache
- Projectile vomiting due to increase ICP
- Photophobia
- Fever chills, anorexia
- Gen body malaise
- Wt loss
- Decorticate/decerebration abnormal posturing
- Possible seizure
Sx of meningeal irritation nuchal rigidity or stiffness
Opisthotonus- rigid arching of back

Pathognomonic sign (+) Kernigs & Brudzinski sign

Leg pain neck pain

Dx:
1. Lumbar puncture lumbar/ spinal tap use of hallow spinal needle sub arachnoid space L3 & L4 or L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture invasive
1. Consent / explain procedure to pt
- RN dx procedure (lab)
- MD operation procedure
2. Empty bladder, bowel promote comfort
3. Arch back to clearly visualize L3, L4

Nsg Ngt post lumbar
1. Flat on bed 12 24 h to prevent spinal headache & leak of CSF
2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue
4. Assess for movement & sensation of extremeties

Result
1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose
b. Decrease glucose
Confirms meningitis c. increase CSF opening pressure
N 50 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
1. GIT irritation take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection alteration in normal bacterial flora
- N flora throat streptococcus
- N flora intestine e coli
Sx of superinfxn of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapy
A Cushings synd reverse isolation - due to increased corticosteroid in body.
B Aplastic anemia reverse isolation - due to bone marrow depression.
C Cancer anytype reverse isolation immunocompromised.
D Post liver transplant reverse isolation takes steroids lifetime.
E Prolonged use steroids reverse isolation
F Meningitis strict respiratory isolation safe after 24h of antibiotic therapy
G Asthma not to be isolated

3. Comfy & dark room due to photophobia & seizure
5. Maintain F & E balance
6. Monitor vs, I&O , neuro check
7. Provide client health teaching & discharge plan
a. Nutrition increase cal & CHO, CHON-for tissue repair. Small freq feeding
b. Prevent complication hydrocephalus, hearing loss or nerve deafness.
8. Prevent seizure.
Where to bring 2 yo post meningitis
- Audiologist due to damage to hearing- post repair myelomeningocele
- Urologist -Damage to sacral area spina bifida controls urination
9. Rehab for neurological deficit. Can lead to mental retardation or a delay in psychomotor development.

CEREBRO VASCULAR ACCIDENT stroke, brain attack or cerebral thrombosis, apoplexy
- Partial or complete disruption in the brains blood supply
- 2 largest & common artery in stroke
Middle cerebral artery
Internal carotid artery
- Common to male 2 3x high risk

1. Thrombosis clot (attached)
2. Embolism dislodged clot pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness

S/Sx: cerebral embolism
Headache, disorientation, confusion & decrease in LOC

Femur fracture complications: fat embolism most feared complication w/in 24hrs
Yellow bone marrow produces fat cells at meduallary cavity of long bone
Red bone marrow provides WBC, platelets, RBC found at epiphisis
2.) Hemorrhage
3.) Compartment syndrome compression of nerves/ arteries

Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery mitral valve replacement

Lifestyle: 1. Smoking nicotine potent vasoconstrictor
2. Sedentary lifestyle
3. Hyperlipidemia genetic
4. Prolonged use of oral contraceptives
- Macro pill has large amt estrogen
- Mini pill has large amt of progestin
- Promote lipolysis (breakdown of lipids/fats) artherosclerosis HPN - stroke
5. Type A personality
a. Deadline driven person
b. 2 5 things at the same time
c. Guilty when not dong anything
6. Diet increase saturated fats
7. Emotional & physical stress
8. Obesity
S & Sx
1. TIA- warning signs of impending stroke attacks
- Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia (monoplegia 1 extreme)
Increase ICP
2. Stroke in evolution progression of S & Sx of stroke
3. Complete stroke resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp
c.) Anorexia, n/v
d.) Dysphagia
e.) Increase BP
f.) (+) Kernigs & Brudzinski sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria inability to vocalize, articulate words
3. Aphasia
4. Agraphia diff writing
5. Alesia diff reading
6. Homoninous hemianopsia loss of half of field of vision
Left sided hemianopsia approach Right side of pt the unaffected side

Dx
1. CT Scan reveals brain lesion
2. Cerebral arteriography site & extent of mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All graphy invasive due to iodine dye
Post
1.) Force fluid to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal

Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
- To prevent decubitus ulcer
- To prevent hypostatic pneumonia after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding if pt cant swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia approach on unaffected side
9. Meds
Osmotic diuretics Mannitol
Loop diuretics Lasix/ Furosemide
Corticosteroids dextamethazone
Mild analgesic
Thrombolytic/ fibrolitic agents tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants Heparin & Coumadin sabay
Coumadin will take effect after 3 days
Heparin monitor PTT partial thromboplastin time if prolonged bleeding give Protamine SO4- antidote.
Coumadin Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K Aquamephyton- antidote.
Antiplatelet PASA aspirin paraanemo aspirin, dont give to dengue, ulcer, and unknown headache.

Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking
2. Dietary modification
- Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit physical therapy
1. Mental retardation
2. Delay in psychomotor development

CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of consciousness, abnormal motor
activity, alteration in sensation & perception & change in behavior.

Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attack
Febrile seizure Normal if < 5 yo Epilepsy 2nd and with history of seizure
Pathologic if > 5 yo

Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide
Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus drug of choice: Diazepam & glucose

S & Sx
I. Generalized Seizure
a.) Grand mal / tonic clonic seizures
With or without aura warning symptoms of impending seizure attack- Epigastric pain- associated with olfactory, tactile, visual, auditory sensory
experience
- Epileptic cry fall
- Loss of consciousness 3 5 min
- Tonic clonic contractions
- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
- Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching of mouth
- Loss of consciousness 5 10 secs (quick & short)

II. Localized/partial seizure
a.) Jacksonian seizure or focal seizure tingling/jerky movement of index finger/thumb & spreads to shoulder & 1 sideof the body with janksonian
march
b.) Psychomotor/ focal motor - seizure
-Automatism stereotype repetitive & non-purposive behavior
- Clouding of consciousness not in control with environment
- Mild hallucinatory sensory experience

HALLUCINATIONS
1. Auditory schitzo paranoid type
2. Visual korsakoffs psychosis chronic alcoholism
3. Tactile addict substance abuse

III. Status epilecticus continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia coma death
Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2.
Tx:Diazepam (drug of choice), glucose
Dx-Convulsion- get health history!
1. CT scan brain lesion
2. EEG electroencephalography
- Hyperactivity brain waves
Nsg Mgt
Priority Airway & safety
1. Maintain patent a/w & promote safety
Before seizure:
1. Remove blunt/sharp objects
2. Loosen clothing
3. Avoid restraints
5. Turn head to side to prevent aspiration
6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at home.
7. Avoid precipitating stimulus bright glaring lights & noises
8. Administer meds
a. Dilantin (Phenytoin) ( toxicity level 20 )

SE Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Dont give alcohol lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations

2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration
- Type of seizure
- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status epilepticus!
4. Assist in surgical procedure. Cortical resection
5. Complications: Subarachnoid hemorrhage and encephalitis

Question: 1 yo grand mal immediate nursing action = a/w & safety
a. Mouthpiece 1 yr old little teeth only
b. Adm o2 inhalation post!
c. Give pillow safety (answer)
d. Prepare suction

Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale obj measurement of LOC or quick neuro check
3 components of ECS
M motor 6
V verbal resp 5
E eye opening 4
15

15 14 conscious
13 11 lethargy
10 8 stupor
7 coma
3 deep coma lowest score

Survey of mental status & speech (Comprehensice Neuro Exam)
1.) LOC & test of memory
2.) Levels of orientation
3.) CN assessment
4.) Motor assessment
5.) Sensory assessment
6.) Cerebral test Romhberg, finger to nose
7.) DTR
8.) Autonomics

Levels of consciousness (LOC)
1. Conscious (conscious) awake levels of wakefulness
2. Lethargy (lethargic) drowsy, sleepy, obtunded
3. Stupor (stuporous) awakened by vigorous stimulation
Pt has gen body weakness, decrease body reflex
4. Coma (Comatose) light (+) all forms of painful stimulations
Deep (-) to painful stimulation
Question: Describe a conscious pt ?
a. Alert not all pt are alert & oriented to time & place
b. Coherent
c. Awake- answer
d. Aware

Different types of pain stimulation
- Dont prick
1. Deep sternal stimulation/ pressure 3x fist knuckle
With response light coma
Without response deep coma
2. Pressure on great toe 3x
3. Orbital pressure pressure on orbits only below eye
4. Corneal reflex/ blinking reflex
Wisp of cotton used to illicit blinking reflex among conscious patients
Instill 1-drop saline solution unconscious pt if (-) response pt is in deep coma
5. Test of memory considered educational background
a.) Short term memory
- What did you eat for breakfast?
Damage to temporal lobe (+) antero grade amnesia
b.) Long term memory
(+) Retrograde amnesia damage to limbic system
6. Levels of orientation
Time Place Person

Graphesthesia- can identify numbers or letters written on palm with a blunt object.
Agraphesthesia cant identify numbers or letters written on palm with a blunt object.

CN assessment:
I Olfactory s
II Optic s
III Oculomotor m
IV Trocheal m smallest CN
V Trigeminal b largest CN
VI Abducens m
VII Facial b
VIII Acustic/auditory s
IX Glassopharyngeal b
X Vagus b longest CN
XI Spinal accessory m
XII Hypoglossal m

I. Olfactory dont use ammonia, alcohol, cologne irritating to mucosa use coffee, bar soap, vinegar, cigarette tar
- Hyposmia decrease sensitivity to smell
- Diposmia distorted sense of smell
- Anosmia absence of sense of smell
Either of 3 might indicate head injury damage to cribriform plate of ethmoid bone where olfactory cells are located or indicate inflammation condition
sinusitis

II optic- test of visual acuity Snellens chart central or distance vision
Snellens E chart used for illiterate chart
N 20/20 vision distance by w/c person can see letters- 20 ft
Numerator distance to snellens chart
Denominator distance the person can see the letters
OD Rt eye 20/20 20/200 blindness cant read E biggest
OS left eye 20/20
OU both eye 20/20

2. Test of peripheral vision/ visual field
a. Superiority
b. Bitemporally
c. Inferiorly
d. Nasally

Common Disorders see page 85-87 for more info on glaucoma, etc.
1. Glaucoma Normal 12 21 mmHg pressure
- Increase IOP - Loss of peripheral vision tunnel vision
2. Cataract opacity of lens - Loss of central vision, Blurring or hazy vision
3. Retinal detachment curtain veil like vision & floaters
4. Macular degeneration black spots

III, IV, VI tested simultaneously
- Innervates the movementt of extrinsic ocular muscle
6 cardinal gaze EOM

Rt eye N left eye
IO SO O
S
LR MR E
SR

3 4 EOM
IV sup oblique
VI lateral rectus
Normal response PERRLA (isocoria equal pupil)
Anisocoria unequal pupil

Oculomotor
1. Raising of eyelid Ptosis
2. Controls pupil size 2 -3 cm or 1.5 2 mm

V Trigeminal Largest consists of - ophthalmic, maxillary, mandibular
Sensory controls sensation of the face, mucus membrane; teeth & cornea reflex

Unconscious instill drop of saline solution
Motor controls muscles of chewing/ muscles of mastication
Trigeminal neuralgia diff chewing & swallowing extreme food temp is not recommended

Question: Trigeminal neuralgia, RN should give
a. Hot milk, butter, raisins
b. Cereals
c. Gelatin, toast, potato all correct but
d. Potato, salad, gelatin salad easier to chew

VI Facial: Sensory controls taste ant 2/3 of tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group 40 yrs old
Motor- controls muscles of facial expression, smile frown, raise eyebrow
Damage Bells palsy facial paralysis
Cause bells palsy pedia R/T forcep delivery
Temporary only
Most evident clinical sign of facial symmetry: Nasolabial folds

VIII Acoustic/ vestibule cochlear (controls hearing) controls balance (kenesthesia or position sense)
- Movement & orientation of body in space
- Organ of Corti for hearing true sense organ of hearing

Outer tympanic membrane, pinna, oricle (impacted cerumen), cerumen
Middle hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media
- Eustachean ear
Inner ear- meniere dse, sensory hearing loss (research parts! & dse)
Remove vestibule menieres dse disease inner ear

Archimedes law buoyancy (pregnancy fetus)
Daltons law partial pressure of gases
Inertia law of motion (dizziness, vertigo)

1.) Pt with multiple stab wound - chest
- Movement of air in & out of lungs is carried by what principle?
- Diffusion Daltons law
2.) Pregnant check up ultrasound reveals fetus is carried by amniotic fluid
- Archimedes
3.) Severe vertigo due- Inertia

Test for acoustic nerve:
- Repeat words uttered

IX Glossopharyngeal controls taste posterior 1/3 of tongue
X Vagus controls gag reflex

Test 9 10
Pt say ah check uvula should be midline
Damage cerebral hemisphere is L or R
Gag reflex place tongue depression post part of tongue
Dont touch uvula

XI Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)
- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia
XII Hypoglossal controls movement of tongue say ah. Assess tongue position=midline
L or R deviation
- Push tongue against cheek
- Short frenulum lingue
Tongue tied bulol

ENDOCRINE

Fx of endocrine ductless gland
Main gland Pituitary gland located at base of brain of Stella Turcica
Master gland of body
Master clock of body

Anterior pituitary gland adenohypophysis
Posterior pituitary gland neurohypophysis

Posterior pituitary:
1.) Oxytocin a.) Promotes uterine contraction preventing bleeding/ hemorrhage.
- Give after placental delivery to prevent uterine atony.
b.) Milk letdown reflex with help of prolactin.
2.) ADH antidiuretic hormone (vasopressin) -Prevents urination conserve H2O

A. DIABETIS INSIPIDUS (DI- dalas ihi) hyposecretion of ADH
Cause: idiopathic/ unknown
1. Pituitary surgery
2. Trauma/ head injury
3. Tumor
4. Inflammation

* alcohol inhibits release of ADH

S & Sx:
1. Polyuria
2. Sx of dehydration (1st sx of dehydration in children-tachycardia)
- Excessive thirst (adult)
- Agitation
- Poor skin turgor
- Dry mucus membrane
3. Weakness & fatigue
4. Hypotension if left untreated -
5. Hypovolemic shock
Anuria late sign hypovolemic shock

Dx Proc:
1. Decrease urine specific gravity- concentrated urine
N= 1.015 1.035
2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia

Mgt:
1. Force fluid 2,000 3,000ml/day
2. Administer IV fluid replacement as ordered
3. Monitor VS, I&O
4. Administer meds as ordered
a.) Pitresin (vasopressin) IM
5. Prevent complications
Most feared complication Hypovolemic shock

B.) SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone
- Increase ADH
- Idiopathic/ unknown

Predisposing factor
1. Head injury
2. Related to Bronchogenic cancer or lung caner-
Early Sign of Lung Ca - Cough 1. non productive 2. productive
3. Hyperplasia of Pit gland
Increase size of organ

S&Sx
1. Fluid retention
2. Increase BP HPN
3. Edema
4. Wt gain
5. Danger of H2O intoxication Complications: 1. cerebral edema increase ICP 2. seizure

Dx Proc:
1. Urine specific gravity increase diluted urine
2. Hyponatremia Decreased Na

Nsg Mgt:
1. Restrict fluid
2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
3. Monitorstrictly V/S, I&O, neuro check increase ICP
4. Weigh daily
5. Assess for presence edema
6. Provide meticulous skin care
7. Prevent complications increase ICP & seizures activity

Anterior Pituitary Gland adeno
1. Growth hormone (GH) (Somatotropic hormone)
Fx: Elongation of long bones
Decrease GH dwarfism children
Increase GH gigantism
Increase GH acromegaly adult
Puberty 9 yo 21 yo
Epiphyseal plate closes at 21 yo

Square face
Square jaw

Drug of choice in acromegaly: Ocreotide (Sandostatin) SE dizziness
- Somatostatin Hormone antagonizes the release of of GH
2. Melanocytes stimulating hormone - MSH
- Skin pigmentation
3. Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland
(Oxytocin-Initiates milk letdown reflex)
4. Adrenocorticotropic hormone ACTH - Development & maturation of adrenal cortex
5. Luteinizing hormone produces progesterone.
6. FSH- produces estrogen

PINEAL GLAND
1. Secretes Melatonin inhibits lutenizing hormone (LH) secretion

THYROID GLAND (TG)
Question: Normal physical finding on TG:
a. With tenderness thyroid never tender
b. With nodular consistency- answer
c. Marked asymmetry only 1 TG
d. Palpable upon swallowing - Normal TG never palpable unless with goiter

TG hormones:
T3 T4 Thyrocalcitonin
- Triodothyronine -Tetraiodothyronine/ Tyroxine FX antagonizes effects of parathormone

- 3 molecules of iodine - 4 molecules of iodine

Metabolic hormone

Increase metabolism brain inc cerebration, inc v/s all v/s down, constipation

Hypo T3 T4 - lethargy & memory impairment
Hyper T3 T4 - agitation, restlessness, and hallucination
7. Increase VS, increase motility

HYPOTHYROIDISM all decreased except wt & menstruation, loss of appetite but with wt gain menorrhagia increase in mens
HYPERTHYROIDISM - Increase appetite wt loss, amenorrhea

SIMPLE GOITER enlarged thyroid gland - iodine deficiency
Predisposing factors
1. Goiter belt area - Place far from sea no iodine. Seafoods rich in iodine
2. Mountainous area increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake)
Cabbage has progoitrin an anti thyroid agent with no iodine
Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops), all nuts.
3. Goitrogenic drugs:
Anti thyroid agents :(PTU) prephyl thiupil
Lithium carbonate, Aspirin PASA
Cobalt, Phenyl butasone
Endemic goiter cause # 1
Sporadic goiter caused by #2 & 3

S & Sx enlarged TG
Mild restlessness
Mild dysphagia

Dx Proc.
1. Thyroid scan reveals enlarged TG
2. Serum TSH increase (confirmatory)
3. Serum T3, T4 N or below N

Nsg Mgt:
1. Administer meds
a.) Iodine solution Logols solution or saturated sol of K iodide SSKI
Nsg Mgt Lugols sol violet color
1. use straw prevent staining teeth
2. Prophylaxis 2 -3 drops Treatment 5 to 6 drops
Use straw to prevernt staining of teeth
1. Lugols sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron solution.

B. Thyroid h / Agents
1. Levothyroxine (Synthroid)
2. Liothyronine (cytomel)
3. Thyroid extract

Nsg Mgt: for TH/agents
1. Monitor vs. HR due tachycardia & palpitation
2. Take it early AM SE insomnia
3. Monitor s/e
Tachycardia, palpitations
Signs of insomnia
Hyperthyroidism restlessness agitation
Heat intolerance
HPN

3. Encourage increase intake iodine iodine is extracted from seaweeds (!)
Seafood- highest iodine content oysters, clams, crabs, lobster
Lowest iodine shrimps
Iodized salt easily destroyed by heat take it raw not cooked

4. Assist surgery- Sub total thyroidectomy-
Complication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at incision site.Check nape for wet blood. 4.Laryngeal spasm
DOB, SOB trache set ready at bedside.

2.) HYPOTHYROIDISM decrease secretion of T3, T4 can lead to MI / Atherosclerosis
Adult myxedema
Child- cretinism only endocrine dis lead to mental retardation
1. `Iatrogenic causes caused by surgery
2. Atrophy of TG due to:
a. Irradiation
b. Trauma
c. Tumor, inflammation
3. Iodine def
4. Autoimmune Hashimoto disease

S&Sx everything decreased except wt gain & mens increase)
Early signs weakness and fatigue
Loss of appetite increased lypolysis breakdown of fats causing atherosclerosis = MI
Wt gain
Cold intolerance myxedema - coma
Constipation
Late Sx brittle hair/ nails
Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Myxedema
Horseness voice
Decrease libido
Decrease VS hypotension bradycardia, bradypnea, and hypothermia
Lethargy
Memory impairment leading to psychosis-forgetfulness
Menorrhagia

Dx:
1. Serum T3 T4 decrease
2. Serum cholesterol increase can lead to MI
3. RA IU radio iodine uptake decrease

Nsg Mgt:
1. Monitor strictly V/S. I&O to determine presence of myxedema coma!
Myxedema Coma - Severe form of hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia
Might lead to progressive stupor & coma
Impt mgt for Myxedema coma
1. Assist mech vent priority a/w
2. Adm thyroid hormone
3. Adm IVF replacement force fluid

Mgt myxedema coma
1. Monitor VS, I&O
2. Provide dietary intake low in calories due to wt gain
3. Skin care due to dry skin
4. Comfortable & warm environment due to cold intolerance
5. Administer IVF replacements
6. Force fluid
7. Administer meds take AM SE insomia. Monitor HR.
Thyroid hormones
Levothyroxine(Synthroid), Liothyronine (cytomel)
Thyroid extracts
8. Health teaching & discharge plan
a. Avoidance precipitating factors leading to myxedema coma:
1. Exposure to cold environment
2. Stress 3. Infection
4. Use of sedative, narcotics, anesthetics not allowed CNS depressants V/S already down
Complications:
9. Hypovolemic shock, myxedema coma
10. Hormonal replacement therapy - lifetime
11. Importance of follow up care

HYPERTHYROIDISM - Graves dse or thyrotoxicosis ( everything up except wt and mens)
-Increased T3 & T4
1. Autoimmune disease release of long acting thyroid stimulator (LATS)
Exopthalmos
Enopthalmos severe dehydration depressed eye
2. Excessive iodine intake
3. Hyperplasia of TG

S&Sx:
1. Increase in appetite hyperphagia wt loss due to increase metabolism
2. Skin is moist - perspiration
3. Heat intolerance
4. Diarrhea increase motility
5. All VS increase = HPN, tachycardia, tachypnea, hyperthermia
6. CNS changes
8. Irritability & agitation, restlessness, tremors, insomnia, hallucinations
7. Goiter
8. Exopthalmos pathognomonic sx
9. Amenorrhea

Dx:
1. Serum T3 & T4 - increased
2. Radio iodine uptake increase
3. Thyroid scan reveals enlarged TG

Nsg Mgt:
1. Monitor VS & I & O determine presence of thyroid storm or most feared complication: Thyrotoxicosis
2. Administer meds
a. Antithyroid agents
1. Prophylthiuracil (PTU)
2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture
Most feared complication : Thrombosis stroke CVS

3. Diet increase calorie to correct wt loss
4. Skin care
5. Comfy & cool environment
6. Maintain siderails- due agitation/restlessness
7. Provide bilateral eye patch to prevent drying of eyes- exopthalmos
8. Assist in surgery subtotal thyroidectomy

Nsg Mgt: pre-op
Adm Lugols solution (SSKI) K iodide
9. To decrease vascularity of TG
10. To prevent bleeding & hemorrhage
Mgt post op:
Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis
Triad signs of thyroidstorm;
a. Tachycardia /palpitation
b. Hyperthermia
c. Agitation

Nsg Mgt Thyroid Storm:
1. Monitor VS & neuro check
Agitated might decrease LOC
2. Antipyretic fever
blockers (-lol)Tachycardia -
3. Siderails agitated

Comp 2. Watch for inadvertent (accidental) removal of parathyroid gland

Secretes Para hormone
If removed, hypocalcemia - classic sign tetany 1. .(+) Trousseau sign/ 2. Chvostecks sign
Nsg Mgt:
Adm calcium gluconate slowly to prevent arrhythmia
Ca gluconate toxicity antidote MgSO4
3.Laryngeal (voice box) nerve damage (accidental)
Sx: hoarseness of voice
***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage
Notify physician!

4. Signs of bleeding post subtotal thyroidectomy
- Feeling of fullness at incision site
Nsg mgt:
Check soiled dressing at nape area

5. Signs of laryngeal spasm
a. DOB
b. SOB
Prepare at bedside tracheostomy

7. Importance of follow up care
(Liver cirrhosis bedside scissor if pt complaints of DOB)

(Cut cystachean tube to deflate balloon)

Parathyroid gland pair of small nodules located behind the TG
11. Secrets parathyroid hormone promotes Ca reabsorption

Thyrocalcitonin antagonises secretion of parathyroid hormone

1. Hypoparthroidism decrease of parathyroid hormone
2. Hyperparathroidsm

HYPOPARATHYROIDISM decreased parathormone

Hypocalcemia Hyperphosphatemia
(Or tetany)

[If Ca decreases, phosphate increases]

A. Predisposing, factors:
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to
a. Irradiation
b. Trauma
S&Sx:
1. Acute tetany
a. Tingling sensation
b. Paresthesia
c. Dysphagia
d. Laryngospasm
e. Bronchospasm

Pathognomonic Sign of tetany:
a. (+) Trousseaus or carpopedial spasm
b. (+) Chvostecks sign

f. Seizure most feared complication
g. Arrhythmia

2. Chronic tetany
a. Loss of tooth enamel
b. Photophobia & cataract formation
c. GIT changes anorexia, n/v, general body malaise
d. CNS changes memory impairment, irritability

Dx:
1. Serum calcium decrease (N 8.5 11 mg/100ml)
2. Serum phosphate increase (N 2.5 4.5 mg/100ml)
3. X-ray of long bone decrease bone density
4. CT Scan reveals degeneration of basal ganglia

Nsg Mgt:
1. Administration of meds:
a.) Acute tetany
Ca gluconate IV, slowly
b.) Chronic tetany
1. Oral Ca supplements
Ex. Ca gluconate
Ca carbonate
Ca lactate

Vit D (Cholecalceferol)

Drug diet sunlight

Cholecalceferol calcidiol calcitriol 7am 9am

2. Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC MAD
Aluminum containing acids Mg containing antacids
Ex. Milk or magnesia
Aluminum OH gel Diarrhea

Constipation Maalox magnesium & aluminum - Less s/e
2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure
3. Diet increase Ca & decrease phosphorus
- Dont give milk due to increase phosphorus
Good = anchovies increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.
4. Bedside tracheostomy set due to laryngospasm
5. Encourage to breath with paper bag in order to produce mild respiratory acidosis to promote increase ionized Ca levels
6. Most feared complication : Seizure & arrhythmia
8. Important fallow up care

HYPERPARATHYROIDISM - increase parathormone. Complication: Renal failure
Hypercalcemia can lead to Hypophosphatemia

Bone dse - kidney stones
Mineralization

Leading to bone fracture

Ca 99% bones
1% serum blood

1. Hyperplasia parathyroid gland (PTG)
2. Over compensation of PTG due to Vit D deficiency
Children Rickets Vit D
Adults Osteomalacia deficiency

Sippys diet Vit D diet not good for pt with ulcer
2 -4 cups of milk & butter
Karrels diet Vit D diet not good for pt with ulcer
6 cups of milk & whole cream

Food rich in CHON eggnog combination of egg & milk

S/Sx:
Bone fracture
1. Bone pain (especially at back), bone fracture
2. Kidney stone
a. Renal colic
b. Cool moist skin
3. GIT changes anorexia, n/v, ulcerations
4. CNS involvement irritability, memory impairment

Dx Proc:
1. Serum Ca increase
2. Serum phosphorus decreases
3. X-ray long bones reveals bone demineralization

Nsg Mgt: Kidney Stone

1. Force fluids 2,000 3,000/day or 2-3L/day
2. Isotonic solution
3. Warm sitz bath for comfort
4. Strain all urine with gauze pad
5. Acid ash diet cranberry, plum, grapefruit, vit C, calamansi to acidify urine
6. Adm meds
a. Narcotic analgesic Morphine SO4, Demerol (Meperidine Hcl)
S/E resp depression. Monitor RR)
Narcan/ Naloxone antidote
Naloxone toxicity tremors
7. Siderails
8. Assist in ambulation
9. Diet low in Ca, increase phosphorus lean meat
10. Prevent complication
Most feared renal failure
11. Assist surgical procedure parathyroidectomy
12. Impt ff up care
13. Hormonal replacement- lifetime

ADRENAL GLAND
12. Atop of @ kidney
13. 2 parts
Adrenal cortex outermost layer
Adrenal medulla - innermost layer
14. Secrets cathecolamines
a.) Epinephrine / Norephinephrine potent vasoconstrictor adrenaline=Increase BP

Adrenal Medullas only disease:
PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla
-increase nor/epinephrine
-with HPN and resistant to drugs
-drug of choice: beta blockers
-complication: HPN crisis = lead to stroke
-no valsalva maneuver

Adrenal Cortex
1. Zona fasiculata secrets glucocorticoids
Ex. Cortisol - Controls glucose metabolism (SUGAR)
2. Zona reticularis secrets traces of glucocorticoids & androgenic hormones
M testosterone
F estrogen & progesterone
Fx promotes development of secondary sexual characteristics
3. Zona glomerulosa - secretes mineralcortisone
Ex. Aldosterone
Fx: promotes Na & H2O reabsorption & excretion of potassium (SALT)

ADDISONS DISEASE Steroids-lifetime
Decreased adrenocortical hormones leading to:
a.) Metabolic disturbances (sugar)
b.) F&E imbalances- Na, H2O, K
c.) Deficiency of neuromuscular function (salt & sex)

1. Atrophy of adrenal gland
2. Fungal infections
3. Tubercular infections

S/Sx:
1. Decrease sugar Hypoglycemia Decreased glucocorticoids - cortisol

T tremors, tachycardia
I - irritability
R - restlessness
E extreme fatigue
D diaphoresis, depression

2. Decrease plasma cortisol
Decrease tolerance to stress lead to Addisonians crisis

3. Decrease salt Hyponatermia Decreased mineralocorticoids - Aldosterone
Hypovolemia
a.) Hypotension
b.) Signs of dehydration extreme thirst, agitation
c.) Wt loss
4. Hyperkalemia
a.) Irritability
b.) Diarrhea
c.) Arrhythmia
5. Decrease sexual urge or libido- Decreased Androgen
6. Loss of pubic and axillary hair

To Prevent STD Local practice monogamous relationship
CGFNS/NCLEX condom
7. Pathognomonic sign bronze like skin pigmentation due to decrease cortisol will stimulate pituitary gland to release melanocyte stimulating
hormone.

Dx Proc:
1. FBS decrease FBS (N 80 120 mg/dL)
2. Plasma cortisol decreased
Serum Na decreased (N 135 145 meg/L)
3. Serum K increased (N 3.5 5.5 meg/L)

Nsg Mgt:
1. Monitor VS, I&O to determine presence of Addisonian crisis
15. Complication of Addisons dse : Addisonian crisis
16. Results the acute exacerbation of Addisons dse characterized by :
Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia
17. Lead to progressive stupor & coma

Nsg Mgt Addisonian Crisis (Coma)
1. Assist in mechanical ventilation
2. Adm steroids
3. Force fluids

2. Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone

Nsg Mgt with Steroids
1. Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm.
2. Taper the dose (w/draw, gradually from drug) sudden withdrawal can lead to addisonian crisis
3. Monitor S/E (Cushings syndrome S/Sx)
a.) HPN
b.) Hirsutism
c.) Edema
d.) Moon face & buffalo hump
e.) Increase susceptibility to infection sue to steroids- reverse isolation

b.) Mineralocorticoids ex. Flourocortisone

3. Diet increase calorie or CHO
Increase Na, Increase CHON, Decrease K
4. Force fluid
5. Administer isotonic fluid as ordered
6. Meticulous skin care due to bronze like
7. HT & discharge planning
a) Avoid precipitating factors leading to Addisonian crisis
1. Sudden withdrawal crisis
2. Stress
3. Infection
b) Prevent complications
Addisonian crisis & Hypovolemic shock
8. Hormonal replacement therapy lifetime
9. Important: follow up care

CUSHINGS SYNDROME increase secretion of adrenocortical hormone
1. Hyperplasia of adrenal gland
2. Tubercular infection milliary TB
S/Sx
1. Increase sugar Hyperglycemia
3 Ps
1. Polyuria
2. Polydipsia increase thirst
3. Polyphagia increase appetite
Classic Sx of DM 3 Ps & glycosuria + wt loss
2. Increase susceptibility to infection due to increased corticosteroid
3. Hypernatrermia
a. HPN
b. Edema
c. Wt gain
d. Moon face
Buffalo hump
Obese trunk classic signs
Pendulous abdomen
Thin extremities

4. Hypokalemia
a. Weakness & fatigue
b. Constipation
c. ECG (+) U wave
5. Hirsutism increase sex
6. Acne & striae
7. Increase muscularity of female
Dx:
1. FBS increase (N: 80-120mg/dL)
2. Plasma cortisol increase
3. Na increase (135-145 meq/L)
4. K- decrease (3.5-5.5 meq/L)

Nsg Mgt:
1. Monitor VS, I&O
2. Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone
- promotes excretion of NA while conserving potassium

Not lasix due to S/E hypoK & Hyperglycemia!

3. Restrict Na
4. Provide Dietary intake low in CHO, low in Na & fats
High in CHON & K
5. Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc.
6. Reverse isolation
7. Skin care due acne & striae
8. Prevent complication
- Most feared arrhythmia & DM
(Endocrine disorder lead to MI Hypothyroidism & DM)
9. Surgical bilateral Adrenolectomy
10. Hormonal replacement therapy lifetime due to adrenal gland removal- no more corticosteroid!

PANCREAS behind the stomach, mixed gland both endocrine and exocrine gland

Acinar cells (exocrine gland) Islets of Langerhans (endocrine gland ductless)

cellsSecrete pancreatic juices at pancreatic ducts.

Aids in digestion (in stomach) secrets glucagon

Fxn: hyperglycemia (high glucose)

Cells

Secrets insulin

Fxn: hypoglycemia

Delta Cells

Secrets somatostatin

Fxn: antagonizes growth hormone

3 disorders of the Pancreas
1. DM
2. Pancreatic Cancer
3. Pancreatitis

Overview only:
PANCREATITIS (check page 72) acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion self-digestion
Cause: unknown/idiopathic
18. Or alcoholism

Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turners sign ecchymosis of flank area

Both sx means hemorrhage

CHRONIC HEMORRHAGIC PANCREATITIS- bangugot
Predisposing factors - unknown
Risk factor:
1. History of hepatobiliary disorder
2. Alcohol
3. Drugs thiazide diuretics, oral contraceptives, aspirin, penthan
4. Obesity
5. Hyperlipidemia
6. Hyperthyroidism
7. High intake of fatty food saturated fats

DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism

Classification:
I. Type I DM (IDDM) Juvenile onset, common in children, non-obese brittle dse
-Insulin dependent diabetes mellitus
Incidence rate
1.) 10% of population with DM have Type I
Predisposing Factor:
1. 90% hereditary total destruction of pancreatic dells
2. Virus
3. Toxicity to carbon tetrachloride
4. Drugs Steroids both cause hyperglycemia
Lasix - loop diuretics

S/Sx:
3 PS + G
1.) Polyuria
2.) Poydipsia
3.) Polyphagia
4.) Glycosuria
5.) Weight loss
6.) Anorexia
7.) N/V
8.) Blurring of vision
9.) Increase susceptibility to infection
10.) Delayed/ poor wound healing

Mgt:
1. Insulin Therapy
Diet
Exercise

Complications Diabetic Ketoacidosis (DKA)
Diabetic Ketoacidosis (DKA) due to increase fat catabolism or breakdown of fats

DKA (+) fruity or acetone breath odor
Kassmauls respiration rapid, shallow breathing

Diabetic coma (needs oxygen)

II. Type II DM (NIDDM)
Adult/ maturity onset type age 40 & above, obese
Incidence Rate
1. 90% of pop with DM have Type II
Mid 1980s marked increase in type II because of increase proliferation of fast food chains!

1. Obesity obese people lack insulin receptors binding site
2. Hereditary

S/Sx:
1. Asymptomatic
2. 3 Ps and 1G

Tx:
1. Oral Hypoglycemic Agents (OHA)
2. Diet
3. Exercise

Complication: HONKC
H hyper
O osmolar
N non
K ketotic
C coma

III. GESTATIONAL DM occurs during pregnancy & terminates upon delivery of child

1. Unknown/ idiopathic
2. Influence of maternal hormones
S/Sx :
Same as type II
1. Asymptomatic
2. 3 Ps & 1G

Type of delivery CS due to large baby
Sx of hypoglycemia on infant
1. High pitched shrill cry
2. Poor sucking reflex
IV. DM ASSOCIATED WITH OTHER DISORDER
a.) Pancreatic tumor
b.) Cancer
c.) Cushings syndrome

3 MAIN FOOD GROUPS
Anabolism Catabolism
1. CHON glucose glycogen
2. CHON amino acids nitrogen
3. Fats fatty acids free fatty acids (FFA) Cholesterol & Ketones

Pancreas glucose ATP (Main fuel/energy of cell )
Reserve glucose glycogen
Liver will undergo glucogenesis synthesis of glucagons
& Glycogenolysis breakdown of glucagons
& Gluconeogenesis formation of glucose form CHO sources CHON & fats

Hyperglycemia pancreas will not release insulin. Glucose cant go to cell, stays at circulation causing hyperglycemia.
increase osmotic diuresis glycosuria
Lead to cellular starvation

Lead to wt loss stimulates the appetite/ satiety center polyuria
(Hypothalamus)
Cellular dehydration
Polyphagia
Stimulates thirst center (hypothalamus)

Polydipsia

Increased CHON catabolism

Lead to (-) nitrogen balance

Tissue wasting (cachexia)

Increase fat catabolism

Free fatty acids

Cholesterol ketones DKA

Atherosclerosis coma

HPN death

MI stroke

DIABETIC KETOACIDOSIS (DKA)
- Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma.
- Ketones- a CNS depressant

1. Stress between stress and infection, stress causes DKA more.
2. Hyperglycemia
3. Infection

S/Sx: 3 Ps & 1G
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glycosuria
5. Wt loss
6. Anorexia, N/V
7. (+) Acetone breath odor- fruity odor pathognomonic DKA
8. Kussmaul's resp-rapid shallow respiration
9. CNS depression
10. Coma

Dx Proc:
1. FBS increase, Hct increase (compensate due to dehydration)
N =BUN 10 -20 mg/100ml --increased due to severe dehydration
Crea - .8 1 mg/100ml

Hct 42% (should be 3x high)-nto hgb

Nsg Mgt:
1. Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3. Monitor VS, I&O, blood sugar levels
4. Administer meds as ordered:
a.) Insulin therapy IV push
Regular Acting Insulin clear (2-4hrs, peak action)
b.) To counteract acidosis Na HCO3
c.) Antibiotic to prevent infection

Insulin Therapy
A. Sources:
1. Animal source beef/ pork-rarely used. Causes severe allergic reaction.
2. Human has less antigenecity property
Cause less allergic reaction. Humulin

If kid is allergic to chicken dont give measles vaccine due it comes from chicken embryo.
3. Artificially compound

B. Types of Insulin
1. Rapid Acting Insulin - Ex. Regular acting I
2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)
3. Long acting I - Ex. Ultra lente

Types of Insulin color & consistency onset peak duration
1. Rapid clear - 2-4h -
2. Intermediate cloudy - 6-12h -
3. Long acting cloudy - 12-24h -

Ex. 5am Hemoglucose test (HGT)

250 mg/dl
Adm 5 units of RA I
Peak 7-9am monitor hypoglycemic reaction at this time- TIRED

Nsg Mgt: upon injection of insulin:
1.Administer insulin at room temp! To prevent lipodystrophy = atrophy/ hypertrophy of SQ tissues
2. Insulin is only refrigerated once opened!
3. Gently roll vial bet palms. Avoid shaking to prevent formation of bubbles.
4. Use gauge 25 26needle tuberculin syringe
(taba pt)depending on the client tissue deposit.5. Administer insulin at either 45(for skinny pt) or 90
6. Dont aspirate after injection
7. Rotate injection site to prevent lipodystrophy
8. Most accessible site abdomen
9. When mixing 2 types of insulin, aspirate
1st regular/ clear before cloudy to prevent contaminating clear insulin & to promote accurate calibration.
10. Monitor signs of complications:
a. Allergic reactions lipodystrophy
b. Somogyis phenomenon hypoglycemia followed by periods of hyperglycemia or rebound effect of insulin.

11. 1ml or cc of tuberculin = 100 units of insulin

- - 1 cc = 100 units

- - .5cc = 50 units

- - .1 cc = 10 units

6 units RA

Most Feared Complication of Type II DM
Hyper osmolarity = severe dehydration
Osmolar
Non - absence of lipolysis
Ketotic - no ketone formation
Coma S/Sx: headache, restlessness, seizure, decrease LOC = coma

Nsg Mgt; - same as DKA except dont give NaHCO3!

1.Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3.Monitor VS, I&O, blood sugar levels
4.Administer meds
a.) Insulin therapy IV
b.) Antibiotic to prevent infection
Tx:
O ral
H ypoglycemic
A gents
19. Stimulates pancreas to secrete insulin

Classifications of OHA
1. First generation Sulfonylurear
a. Chlorpropamide (diabenase)
b. Tolbutamide (orinase)
c. Tolazamide (tolinase)

2. 2nd generation sulfonylurear
a. Diabeta (Micronase)
b. Glipside (Glucotrol)

Nsg Mgt or OHA
1. Administer with meals to lessen GIT irritation & prevent hypoglycemia
2. Avoid alcohol (alcohol + OHA = severe hypoglycemic reaction=CNS depression=coma) Antabuse-Disufram

Dx for DM
1. FBS N 80 120 mg/dl = Increased for 3 consecutive times =confirms DM!!
+ 3 Ps & 1G
2. Oral glucose tolerance (OGTT) - Most sensitive test
3. Random blood sugar increased
4. Alpha Glucosylated Hgb elevated

Nsg Mgt;
1. Monitor for PEAK action of OHA & insulin
Notify Doc
2. Monitor VS, I&O, neurocheck, blood sugar levels.
3. Administer insulin & OHA therapy as ordered.
4. Monitor signs of hyper & hypoglycemia.

Pt DM hinimatay
20. You dont know if hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain cant tolerate low sugar!)
Cold, clammy skin hypo Orange Juice or simple sugar / warm to touch hyper adm insulin
5. Provide nutritional intake of diabetic diet:
CHO 50%
CHON 30%
Fats 20%
-Or offer alternative food products or beverage.
-Glass of orange juice.
6. Exercise after meals when blood glucose is rising.
7. Monitor complications of DM
a. Atherosclerosis HPN, MI, CVA
b. Microangiopathy small blood vessels
Eyes diabetic retinopathy , premature cataract & blindness
Kidneys recurrent pyelonephritis & Renal Failure
(2 common causes of Renal Failure : DM & HPN)
c. Gangrene formation
d. Peripheral neuropathy
1. Diarrhea/ constipation
2. Sexual impotence
e. Shock due to cellular dehydration
8. Foot care mgt
a. Avoid waking barefooted
b. Cut toe nails straight
c. Apply lanolin lotion prevent skin breakdown
d. Avoid wearing constrictive garments

9. Annual eye & kidney exam
10. Monitor urinalysis for presence of ketones
Blood or serum more accurate
11. Assist in surgical wound debridement
12. Monitor signs or DKA & HONKC
13. Assist surgical procedure
BKA or above knee amputation

Overview: HEMATOLOGICAL SYSTEMS
I Blood
II Blood vessels
III Blood forming organs
1. Thymus removed myasthenia gravis
2. Liver largest gland
3. Lymph nodes
4. Lymphoid organs payers patch
5. Bone marrow
6. Spleen destroys RBC
Blood vessels
1. Veins SVC, IVC, Jugular vein blood towards the heart
2. Artery carries blood away from the
21. Aorta, carotid
3. Capillaries

Blood 45% formed elements 55% plasma fluid portion of vlood. Yellow color.

Serum Plasma CHONs (Produced in Liver)
1. Albumin- largest, most abundant plasma
Maintains osmotic pressure preventing edema
FXN: promotes skin integrity
2. Globulins alpha transports steroids Hormones & bilirubin
- Transports iron & copper
Gamma transport immunoglobulins or antibodies
3. Prothrombin fibrinogen clotting factor to prevent bleeding
Formed Elements:
1. RBC (erythrocytes) Spleen life span = 120 days
(N) 3 6 M/mm3
- Anucleated
- Biconcave discs
- Has molecules of Hgb (red cell pigment)
Transports & carries O2

SICKLE CELL ANEMIA sickle shaped RBC. Should be round. Impaired circulation of RBC.
-immature cells=hemolysis of RBC=decreased hgb
3 Nsg priority
1. a/w avoid deoxygenating activities
- High altitude is bad
2. Fluid deficit promote hydration
3. Pain & comfort

Hgb ( hemoglobin)

F= 12 14 gms %
M = 14-16 gms %

Hct 3x hgb 12 x 3 = 36
(hamatocrit) F 36 42% 14 x 3 = 42
M 42 48%
Average 42%
- Red cell percentage in whole red

Substances needed for maturation of RBC
a.) Folic acid
b.) Iron
c.) Vit C
d.) Vit B12 (cyanocobalamin)
e.) Vit B6 (Pyridoxine)
f.) Intrinsic factor

Pregnant: 1st trimester- Folic acid prevent neural tube deficit
3rd tri iron
Life span of rbc 80 120 days. Destroyed at spleen.

WBC leucocytes 5,000 10,000/mm3
GRANULOCYTES
1. Polymorphonuclearneutrophils
Most abundant 60-70% WBC
- fx short term phagocytosis
For acute inflammation

2. PM Basophils

-Involved in Parasitic infection
- Release of chem. Mediator for inflammation
Serotonin, histamine, prostaglandin, bradykinins

3. PM eosinophils
- Allergic reactions NON-GRANULOCYTES
1. Monocytes (macrophage) - largest WBC
- involved in long term phagocytes
- For chronic inflammation
- Other name macrophage

Macrophage in CNS- microglia
Macrophage in skin Histiocytes
Macrophage in lungs alveolar macrophage
Macrophage in Kidneys Kupffer cells

2. Lymphocytes
B Cell L bone marrow or bursa dependent
T cell devt of immunity- target site for HIV
NK cell natural killer cell
Have both antiviral & anti-tumor properties

3.Platelets (thrombocytes)
N- 150,000 450, 000/ mm3
it promotes hemostasis prevention of blood loss by activating clotting
- Consists of immature or baby platelets known as megakaryocytes target of virus dengue
- Normal lifespan 9 12 days

Drug of choice for HIV Zidovudine (AZT or Retrovir)
Standard precaution for HIV gloves, gown, goggles & mask

Malaria night biting mosquito
Dengue day biting mosquito

Signs of platelet dis function:
a.) Petecchiae
b.) Ecchemosis/ bruises
c.) Oozing or blood from venipuncture site

ANEMIA
Iron deficiency Anemia chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption of iron leading to hypoxemic injury.

Incidence rate:
1. Common developed country due to high cereal intake
Due to accidents common on adults
2. Common tropical countries blood sucking parasites
3. Women 15 35yo reproductive yrs
4. Common among the poor poor nutritional intake

Suicide - common in teenager
Poisoning common in children (aspirin)
Aspiration common in infant
Accidents common in adults
Choking common in toddler
SIDS common in infant in US
22. Common in tropical zone Phil due blood sucks

1. Chronic blood loss
a. Trauma
b. Mens
c. GIT bleeding:
i. Hematemesis-
ii. Melena upper GIT duodenal cancer
iii. Hematochezia lower GIT large intestine fresh blood from rectum
2. Inadequate intake of food rich in iron
3. Inadequate absorption of iron due to :
a. Chronic diarrhea
b. Malabsorption syndrome celiac disease-gluten free diet. Food for celiac pts- sardines
c. High cereal intake with low animal CHON ingestion
d. Subtotal gastrectomy
4. Improper cooking of food

S/Sx:
1. Asymptomatic
2. Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
3. Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells
4. Atropic glossitis, dysphagia, stomatitis
5. Pica abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior)

Brittle hair, spoon shaped nail atrophy of epidermal cells
N = capillary refill time < 2 secs
N = shape nails biconcave shape, 180
Atrophy of cells Plummer Vinsons Syndrome due to cerebral hypoxia
1. Atropic glossiti inflammation of tongue due to atrophy of pharyngeal and tongue cells
2. Stomatitis mouth sores
3. Dysphagia

Dx Proc:
1. RBC
2. Hgb
3. Reticulocyte
4. Hct
5. Iron
6. Ferritin

Nsg Mgt
1. Monitor signs of bleeding of all hema test including urine & stool
2. Complete bed rest dont overtire pt =weakness and fatigue=activity intolerance
3. Encourage iron rich food
23. Raisins, legumes, egg yolk
4. Instruct the pt to avoid taking tea - impairs iron absorption
5. Administer meds
a.) Oral iron preparation
Ferrous SO4
Fe gluconate
Fe Fumarate
Nsg Mgt oral iron meds:
1. Administer with meals to lessen GIT irritation
2. If diluting in iron liquid prep adm with straw

Straw
1. Lugols
2. Tetracycline
3. Oral iron
4. Macrodantine

3. Give Orange juice for iron absorption
4. Monitor & inform pts S/E
a. Anorexia
b. n/v
c. Abdominal pain
d. Diarrhea or constipation
e. Melena

If pt cant tolerate oral iron prep administer parenteral iron prep example:
1. Iron dextran (IV, IM)
2. Sorbitex (IM)

Nsg Mgt parenteral iron prep
1. Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues.
2. Dont massage injection site. Ambulate to facilitate absorption.
3. Monitor S/E:
a.) Pain at injury site
b.) Localized abscess (nana)
c.) Lymphadenopathy
d.) Fever/ chills
e.) Urticaria itchiness
f.) Hypotension anaphylactic shock

Anaphylactic shock give epinephrine

PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to
Hypochlorhydria decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement.

Predisposing factor
1. Subtotal gastrectomy removal stomach
2. Hereditary
3. Infl dse of ileum
4. Autoimmune
5. Strict vegetable diet

STOMACH

Parietal or ergentaffen Oxyntic cells

Fxn produce intrinsic factor Fxn secrets Hcl acid

For reabsorption of B12 Fx aids in digestion

For maturation of RBC

Diet high caloric or CHO to correct wt loss

S/Sx:
1. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
2. GIT changes
a. Red beefy tongue PATHOGNOMONIC mouth sores
b. Dyspepsia indigestion
c. Wt loss
d. Jaundice
3. CNS
Most dangerous anemia: pernicious due to neuroglogic involvement.
a. Tingling sensation
b. Paresthesia
c. (+) Rombergs test
Ataxia
d. Psychosis
Dx:- Shillings test

Nsg Mgt Pernicious anemia
1. Enforce CBR
2. Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or ventrogluteal. Not given oral due pt might have tolerance
to drug
3. Diet high calorie or CHO. Increase CHON, iron & Vit C
4. Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged.
5. Avoid applying electric heating pads can lead to burns

APLASTIC ANEMIA stem cell disorder due to bone marrow depression leading to pancytopenia all RBC are decreased

Decrease RBC decrease WBC decrease platelets
Anemia leukopenia thrombocytopenia
Increase WBC leukocytocys
Increase RBC polycythemia vera complication stroke, CVA, thrombosis

Predisposing factors leading to Aplastic Anemia
1. Chemicals Banzene & its derivatives
2. radiation
3. Immunologic injury
4. Drugs cause bone marrow depression
a. Broad spectrum antibiotic - Chlorampenicol
- Sulfonamides bactrim
b. Chemo therapeutic agents
Methotrexate alkylating agents
Nitrogen mustard anti metabolic
Vincristine plant alkaloid

S/Sx:
1. Anemia:
a. Weakness & fatigue
b. Headache, dizziness, dyspnea
c. cold sensitivity, pallor
d. palpitations
2. Leucopenia increase susceptibility to infection
3. Thrombocytopenia
a. Peticchiae
b. Oozing ofblood from venipuncture site
c. ecchymosis
Dx:
1. CBC pancytopenia
2. Bone marrow biopsy/ aspiration at post iliac crest reveals fatty streaks in bone marrow
Nsg Mgt:
1. Removal of underlying cause
2. Blood transfusion as ordered
3. Complete bed rest
4. O2 inhalation
5. Reverse isolation due leukopenia
6. Monitor signs of infection
7. Avoid SQ, IM or any venipuncture site = HEPLOCK
8. Use electric razor when shaving to prevent bleeding
9. Administer meds
Immunosuppresants
Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days 3 weeks to achieve max therapeutic effect of drug.

BLOOD TRANSFUSION:
Objectives:
1. To replace circulating blood volume
2. To increase O2 carrying capacity of blood
3. To combat infection if theres decrease WBC
4. To prevent bleeding if theres platelet deficiency

Nsg Mgt & principles in Blood Transfusion
1. Proper refrigeration
2. Proper typing & crossmatching
Type O universal donor
AB universal recipient
85% of people is RH (+)
3. Asceptically assemble all materials needed:
a.) Filter set
b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis

Hypotonic sol swell or burst
Hypertonic sol will shrink or crenate
c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis.
d.) Instruct another RN to recheck the following .
Pts name, blood typing & cross typing expiration date, serial number.
e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments indicates bacterial contamination. Dont dispose. Return to blood
bank.
f.) Never warm blood products may destroy vital factors in blood.
- Warming is done if with warming device only in EMERGENCY! For multiple BT.
- Within 30 mins room temp only!
g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for > 2h causes blood deterioration.
h.) Avoid mixing or administering drug at BT line leads to hemolysis
i.) Regulate BT 10 15 gtts/min KVO or 100cc/hr to prevent circulatory overload
j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min for 1st 15min.
- Majority of BT reaction occurs within 1h.

BT reactions S/Sx Hemolytic reaction:
H hemolytic Reaction 1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ flank pain,
A allergic Reaction hypotension, flushed skin , (red) port wine urine.
P pyrogenic Reaction
C circulatory overload
A air embolism
T - thrombocytopenia
C citrate intoxication expired blood =hyperkalemia
H hyperkalemia

Nsg Mgt: Hemolytic Reaction:
1. Stop BT
2. Notify Doc
3. Flush with plain NSS
4. Administer isotonic fluid sol to prevent acute tubular necrosis & conteract shock
5. Send blood unit to blood bank for reexamination
6. Obtain urine & blood samples of pt & send to lab for reexamination
7. Monitor VS & Allergic Rxn
Allergic Reaction:
S/Sx
1. Fever/ chills
2. Urticaria/ pruritus
3. Dyspnea
4. Laryngospasm/ bronchospasm
5. Bronchial wheezing

Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antihistamine diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive
If (+) Hypotension anaphylactic shock administer epinephrine
5. Send blood unit to blood bank
6. Obtain urine & blood samples send to lab
7. Monitor VS & IO
8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension indicates anaphylactic shock
24. administer epinephrine
9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB

Pyrogenic Reaction:

S/Sx
a.) Fever/ chills d. tachycardia
b.) Headache e. palpitations
c.) Dyspnea f. diaphoresis

Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antipyretics, antibiotics
5. Send blood unit to blood bank
6. Obtain urine & blood samples send to lab
7. Monitor VS & IO
8. Tepid sponge bath offer hypothermic blanket

Circulatory Overload:
Sx
a. Dyspnea
b. Orthopnea
c. Rales or crackles
d. Exertional discomfort

Nsg Mgt:
1. Stop BT
2. Notify Doc. Dont flush due pt has circulatory overload.
3. Administer diuretics
Priority cases:
Hemolytic Rxn 1st due to hypotension 1st priority attend to destruction of Hgb O2 brain damage
Allergic 3rd
Pyrogenic 4th
Circulatory 2nd

Hemolytic 2nd
Anaphylitic 1st priority

DIC DISSEMINATED INTRAVASCULAR COAGULATION
25. Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting factors (Prothrombin & Fibrinogen).

1. Rapid BT
2. Massive trauma
3. Massive burns
4. Septicemia
5. Hemolytic reaction
6. Anaphylaxis
7. Neoplasia growth of new tissue
8. Pregnancy

S/Sx
1. Petechiae widespread & systemic (lungs, lower & upper trunk)
2. Ecchymosis widespread
3. Oozing of blood from venipunctured site
4. Hemoptysis cough blood
5. Hemorrhage
6. Oliguria late sx

Dx Proc
1. CBC reveals decrease platelets
2. Stool for occult blood (+)
Specimen stool
3. Opthalmoscopic exam sub retinal hemorrhage
4. ABG analysis metabolic acidosis

pH HCO3
R pH PCO2 respiratory alkalosis

O ph PCO2 respiratory acidosis

M ph HCO3 metabolic alkalosis

E ph HCO3 metabolic acidosis

Diarrhea met acidosis
Vomitting met alk
Pyloric stenosis met alkalosis vomiting
Ileostomy or intestinal tubing met acidosis
Cushings met alk
DM met acid
Chronic bronchitis resp acid with hypoxemia, cyanosis

Nsg Mgt DIC
1. Monitor signs of bleeding hema test + urine, stool, GIT
2. Administer isotonic fluid solution to prevent shock.
3. Administer O2 inhalation
4. Administer meds
a. Vit K aquamephyton
b. Pitressin or vasopressin to conserve water.
5. NGT lavage
- Use iced saline lavage
6. Monitor NGT output
7. Provide heplock
8. Prevent complication: hypovolemic shock
Late signs of hypovolemic shock : anuria
Oncologic Nsg:
Oncology study of neoplasia new growth

Benign (tumor) Malignancy (cancer)

Diff - well differentiated poorly or undifferentiated
Encapulation (+) (-)
Metastasis (-) (+)
Prognosis good poor
Therapeutic modality surgery 1. Chemotherapy plenty S/E
2. Radiation
3. Surgery most preferred treatment
4. Bone marrow transplant - Leukemia only
Predisposing factors: (carcinogenesis)
G genetic factors
I immunologic factors
V viral factors
a. Human papiloma virus causing warts
b. Epstein barr virus
E environmental Factors 90%
a. Physical irradiation, UV rays, nuclear explosion, chronic irritation, direct trauma
b. Chemical factors
- Food additives (nitrates
- Hydrocarbon vesicants, alkalies
- Drugs (stillbestrol)
- Uraehane
- Hormones
- Smoking
Male
3.) Prostate cancer - common 40 & above (middle age & above)
BPH 50 & above
1.) Lung cancer
2.) Liver cancer

Female
1. Breast cancer 40 yrs old & up mammography 15 20 mins (SBE 7 days after mens)
2. Cervical cancer 90% multi sexual partners
5% early pregnancy
3. Ovarian cancer

Classes of cancer
Tissue typing
1. Carcinoma arises from surface epithelium & glandular tissues
2. Sarcoma- from connective tissue or bones
3. Multiple myeloma from bone marrow
Pathological fracture of ribs & back pain
4. Lymphoma from lymph glands
5. Leukemia from blood

Warning / Danger Sx of CA
C change in bowel /bladder habits
A a sore that doesnt heal
U unusual bleeding/ Discharge
T thickening of lump breast or elsewhere
I indigestion? Dysphagia
O obvious change in wart/ mole
N nagging cough/ hoarseness
U unexplained anemia A - anemia
S sudden wt loss L loss of wt

Therapeutic Modality:
1. Chemotherapy use various chemotherapeutic agents that kills cancer cells & kills normal rapidly producing cells GIT, bone marrow, and hair
follicle.

Classification:
a.) Alkylating agents
b.) Plant alkaloids vincristine
c.) Anti metabolites nitrogen mustard
d.) Hormones DES
Steroids
e.) Antineoplastic antibiotics

S/E & mgt
GIT - -Nausea & vomiting
Nsg Mgt:
1. Administer anti emetic 4 6h before start of chemo
Plasil
2. Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
26. Non irritating / non spicy

- Diarrhea
1. Administer anti diarrheal 4 6h before start of chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care offer ice chips/ popsickles
2. Inform pt hair loss temporary alopecia
Hair will grow back after 4 6 months post chemo.
-Bone marrow depression anemia
1. Enforce CBR
2. O2 inhalation
4. Monitor signs of bleeding
Repro organ sterility
1. Do sperm banking before start of chemo
Renal system increase uric acid
1. Administer allopurinol/ xyloprin (gout)
27. Inhibits uric acid
28. Acute gout colchicines
29. Increase secretion of uric acid
Neurological changes peristalsis paralytic ileus
Most feared complication ff any abdominal surgery
Vincristine plant alkaloid causes peripheral neuropathy

2. Radiation therapy involves use of ionizing radiation that kills cancer cells & inhibit their growth & kill N rapidly producing cells.

Types of energy emitted
1. Alpha rays rarely used doesnt penetrate skin tissues
2. Beta rays internal radiation more penetration
3. Gamma ray external radiation penetrates deeper underlying tissues

Methods of delivery
1. External radiation- involves electro magnetic waves
Ex. cobalt therapy
2. Internal radiation injection/ implantation of radioisotopes proximal to CA site for a specific period of time.
2 types:
a.) Sealed implant radioisotope with a container & doesnt contaminate body fluid.
b.) Unsealed implant radioisotope without a container & contaminates body fluid.
Ex. Phosphorus 32

3 Factors affecting exposure:
A.) Half life time period required for half of radioisotopes to decay.
- At end of half life less exposure
B.) Distance the farther the distance lesser exposure
C. ) Time the shorter the time, the lesser exposure
D.) Shielding rays can be shielded or blocked by using rubber gloves & gamma use thick lead on concrete.

S/E & Mgt:
a.) Skin errythema, redness, sloughing
1. Assist in battling pt
2. Force fluid 2,000 3,000 ml/day
3. Avoid lotion or talcum powder skin irritation
4. Apply cornstarch or olive oil
b.) GIT nausea / vomiting -
1. Administer antiemetic 4 6h before start of chemo - Plasil
2 Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
Non irritating / non spicy
Dysglusia decrease taste sensitivity
-When atrophy papilla (taste buds) 40 yo
Stomatitis
c.) Bone marrow depression
1. Enforce CBR
2. O2 inhalation
4. Monitor signs of bleeding

Overview of function & structure of the heart
HEART
- Muscular, pumping organ of the body
- Left mediastinum
- Weigh 300 400 grams
- Resembles a closed fist
- Covered by serous membrane pericardium
Pericardium

Parietal layer Pericardial Visceral layer
Fluid prevent
Friction rub

Layer
1. Epicardium outermost
2. Myocardium inner responsible for pumping action/ most dangerous layer - cardiogenic shock
3. Endocardium innermost layer
Chambers
1. Upper collecting/ receiving chamber - Atria
2. Lower pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
Closure of AV valves gives rise to 1st heart sound or S1 or lub
2. Semi lunar valve
a.) Pulmonic
b.) Aortic
Closure of semilunar valve gives rise to 2nd heart sound or S2 or dub
Extra heart Sound
S3 ventricular Gallop CHF
S4 atrial gallop MI, HPN

Heart conduction system
1. Sino atrial node (SA node) (or Keith-Flock node)
Loc junction of SVC & Rt atrium
Fx- primary pace maker of heart
-Initiates electric impulse of 60 100 bpm
2. Atrioventicular node (AV node or Tawara node)
Loc inter atrial septum
Delay of electric impulse to allow ventricular filling
3. Bundle of His location interventricular septum
Rt main Bundle Branch
Lt main Bundle Branch
4. Purkenjie Fiber
Loc- walls of ventricles-- Ventricular contractions

SA node

Purkenjie Fibers
Bundle of His

Complete heart block insertion of pacemaker at Bundle Branch
Metal Pace Maker change q3 5 yo

Prolonged PR atrial fib T wave inversion MI
ST segment depression angina widening QRS arrhythmia
ST elev MI

CAD coronary artery dse or Ischemic Heart Dse (IHD)
Atherosclerosis Myocrdial injury
Angina Pectoris Myocardial ischemia
MI- myocardial necrosis

ATHEROSCLEROSIS ARTEROSCLEROSIS
- Hardening or artery due to fat/ lipid deposits at tunica intima. - Narrowing or artery due to calcium & CHON deposits at tunica media.

Artery tunica adventitia outer
- Tunica intima innermost
- Tunica media middle

ATHEROSCLEROSIS
Predisposing Factor
1. Sex male
2. Black race
3. Hyperlipidemia
4. Smoking
5. HPN
6. DM
7. Oral contraceptive- prolonged use
9. Obesity
10. Hypothyroidism
Signs & Symptoms
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P percutaneous
T tansluminar
C coronary
A angioplasty

Obj:
1. To revascularize the myocardium
2. To prevent angina
3. Increase survival rate

PTCA done to pt with single occluded vessel .
Multiple occluded vessels
C coronary
A arterial
B bypass
A and
G graft surgery

Nsg Mgt Before CABAG
1. Deep breathing cough exercises
2. Use of incentive spirometer
3. Leg exercises

ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT nitroglycerin, resulting fr temp
myocardial ischemia.
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10.hypothyroidism
Precipitating factors
4 Es
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake of food saturated fats.
Signs & Symptoms
1. Initial symptoms Levines sign hand clutching of chest
2. Chest pain sharp, stabbing excruciating pain. Location substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT
3. Dyspnea
4. Tachycardia
5. Palpitation
6.diaphoresis
Diagnosis
1.History taking & PE
2. ECG ST segment depression
3. Stress test treadmill = abnormal ECG
4. Serum cholesterol & uric acid - increase.
Nursing Management
1.) Enforce CBR
2.) Administer meds
NTG small doses venodilator
Large dose vasodilator
1st dose NTG give 3 5 min
2nd dose NTG 3 5 min
3rd & last dose 3 5 min
Still painful after 3rd dose notify doc. MI!

55 yrs old with chest pain:
1st question to ask pt: what did you do before you had chest pain.
2nd question: does pain radiate? If radiate heart in nature. If not radiate pulmonary origin

Venodilator veins of lower ext increase venous pooling lead to decrease venous return.

Meds:
A. NTG- Nsg Mgt:
1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug.
2. Monitor S/E:
orthostatic hypotension dec bp
transient headache
dizziness
3. Rise slowly from sitting position
4. Assist in ambulation.
5. If giving NTG via patch:
i. avoid placing it near hairy areas-will dec drug absorption
ii. avoid rotating transdermal patches- will dec drug absorption
iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch
B. Beta blockers propanolol
C. ACE inhibitors captopril
D. Ca antagonist - nefedipine
3.) Administer O2 inhalation
4.) Semi-fowler
5.) Diet- Decrease Na and saturated fats
6.) Monitor VS, I&O, ECG
7.) HT: Discharge planning:
a. Avoid precipitating factors 4 Es
b. Prevent complications MI
c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug
d. Importance of follow-up care.

MI MYOCARDIAL INFARCTION hear attack terminal stage of CAD
- Characterized by necrosis & scarring due to permanent mal-occlusion

Types:

1. Trasmural MI most dangerous MI Mal-occlusion of both R&L coronary artery
2. Sub-endocardial MI mal-occlusion of either R & L coronary artery

Most critical period upon dx of MI 48 to 72h
- Majority of pt suffers from PVC premature ventricular contraction.

Predisposing factors Signs & symptoms Diagnostic Exam
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10. hypothyroidism 1. chest pain excruciating, vice like, visceral pain located substernal or precodial area (rare)
- radiates back, arm, shoulders, axilla, jaw & abd muscles.
- not usually relived by rest r NTG
2. dyspnea
3. erthermia
4. initial increase in BP
5. mild restlessness & apprehensions
6. occasional findings
a.) split S1 & S2
b.) pericardial friction rub
c.) rales /crackles
d.) S4 (atrial gallop) 1. cardiac enzymes
a.) CPK MB Creatinine Phosphokinase
b.) LDH lactic acid dehydrogenase
c.) SGPT (ALT) Serum Glutanic Pyruvate Transaminase- increased
d.) SGOT (AST) Serum Glutamic Oxalo-acetic - increased
2. Troponin test increase
3. ECG tracing ST segment increase,
widening or QRS complexes means arrhythmia in MI indicating PVC
4. serum cholesterol & uric acid - increase
5. CBC increase WBC

Nursing Management
1. Narcotic analgesics Morphine SO4 to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias PVC
2. Shock cardiogenic shock. Late signs of cardiogenic shock in MI oliguria
3. thrombophlebitis - deep vein
4. CHF left sided
5. Dresslers syndrome post MI syndrome
-Resistant to medications
-Administer 150,000 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. Isordil
- Antiarrythmic
1. Lydocaine blocks release of norepenephrine
2. Brithylium
- Beta-blockers lol
1. Propanolol (inderal)
- ACE inhibitors - pril
1. Captopril (enalapril)
- Ca antagonist
1. Nifedipine
- Thrombolitics or fibrinolytics to dissolve clots/ thrombus

S/E allergic reactions/ uticaria
1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting factor

Monitor for bleeding:
- Anticoagulants
1. Heparin 2. Caumadin delayed reaction 2 3 days

PTT PT

If prolonged bleeding prolonged bleeding

Antidote antidote Vit K
Protamine sulfate
- Anti platelet PASA (aspirin)
d.) Resume ADL sex/ activity 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert
Before meals not after, due after meals increase metabolism heart is pumping hard after meals.
2.) Position non-weight bearing position.

When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet decrease Na, Saturated fats, and caffeine
f.) Follow up care.

CHF CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.
- Backflow
1.) Left sided heart failure:

1.) 90% mitral valve stenosis due RHD, aging
RHD affects mitral valve streptococcal infection
Dx: - Aso titer anti streptolysine O > 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis

S/Sx
Pulmonary congestion/ Edema
1. Dyspnea
2. Orthopnea (Diff of breathing sitting pos platypnea)
3. Paroxysmal nocturnal dysnea PNO- nalulunod
4. Productive cough with blood tinged sputum
5. Frothy salivation (from lungs)
6. Cyanosis
7. Rales/ crackles due to fluid
9. PMI displaced lateral due cardiomegaly
10. Pulsus alternons weak-strong pulse
11. Anorexia & general body malaise
12. S3 ventricular gallop

Dx
1. CXR cardiomegaly
2. PAP Pulmonary Arterial Pressure
PCWP Pulmonary CapillaryWedge Pressure

PAP measures pressure of R ventricle. Indicates cardiac status.
PCWP measures end systolic/ diastolic pressure
PAP & PCWP:
Swan ganz catheterization cardiac catheterization is done at bedside at ICU
(Trachesostomy bedside) - Done 5 20 mins scalpel & trachesostomy set

CVP indicates fluid or hydration status
Increase CVP decrease flow rate of IV
Decrease CVP increase flow rate of IV
3. Echocardiography reveals enlarged heart chamber or cardiomayopathy

4. ABG PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

2.) Right sided HF

Predisposing factor
1. 90% - tricuspid stenosis
2. COPD
3. Pulmonary embolism
4. Pulmonic stenosis
5. Left sided heart failure

S/Sx
Venous congestion
- Neck or jugular vein distension
- Pitting edema
- Ascites
- Wt gain
- Hepatomegalo/ splenomegaly
- Jaundice
- Pruritus
- Esophageal varies
- Anorexia, gen body malaise

Diagnosis:
1. CXR cardiomegaly
2. CVP measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 hypervolemia
Decrease CVP < 4 hypovolemia
Flat on bed post of pt when giving CVP
Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote ventricular filling.

3. Echocardiography enlarged heart chamber / cardiomyopathy
4.Liver enzyme
SGPT ( ALT)
SGOT AST

Nsg mgt: Increase force of myocardial contraction = increase CO
3 6L of CO

1. Administer meds:
Tx for LSHF: M morphine SO4 to induce vasodilatation
A aminophylline & decrease anxiety
D digitalis (digoxin)
D - diuretics
O - oxygen
G - gases

a.) Cardiac glycosides
Increase myocardial = increase CO
Digoxin (Lanoxin). Antidote: digivine
Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure.
b.) Loop diuretics: Lasix effect with in 10-15 min. Max = 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety
e.) Vasodilators NTG
f.) Anti-arrythmics Lidocaine

2. Administer O2 inhalation high! @ 3 -4L/min via nasal cannula
3. High fowlers
4. Restrict Na!
5. Provide meticulous skin care
6. Weigh pt daily. Assess for pitting edema.
Measure abdominal girth daily & notify MD
7. Monitor V/S, I&O, breath sounds
8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote decrease venous return
9. Diet decrease salt, fats & caffeine
10. HT:
a) Complications :shock
Arrhythmia
Thrombophlebitis
MI
Cor Pulmonale RT ventricular hypertrophy
b.) Dietary modifications
c.) Adherence to meds

PERIPHERAL MUSCULAR DISEASE

Arterial ulcers venous ulcer
1. Thromboangiitis Obliterans male/ feet 1. Varicose veins
2. Reynauds female/ hands 2. Thrombophlebitis

1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small to medium sized arteries & veins of lower
extremities. Male/ feet

- Male
- Smokers

S/Sx
1. Intermittent claudication leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes

White bluish red

Pallor cyanosis rubor

3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis
4. Tropic changes
5. Ulcerations
6. Gangrene formation

Dx:
1. Oscillometry decrease peripheral pulse volume.
2. Doppler UTZ decrease blood flow to affected extremities.
3. Angiography reveals site & extent of mal-occulsion.

Nsg Mgt:
1. Encourage a slow progression of physical activity
a.) Walk 3 -4 x / day
b.) Out of bed 2 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM
a.) Avoid walking barefoot
b.) Cut toe nails straight
c.) Apply lanolin lotion prevent skin breakdown
d.) Avoid wearing constrictive garments
4. Avoid smoking & exposure to cold environment
5. Surgery: BKA (Below the knee amputation)

2.)REYNAUDS PHENOMENON acute episodes of arterial spasm affecting digits of hands & fingers


1. Female, 40 yrs
2. Smoking
3. Collagen dse
a.) SLE pathognomonic sign butterfly rash on face
Chipmunk face bulimia nervosa
Cherry red skin carbon monoxide poisoning
Spider angioma liver cirrhosis
Caput medusae leg & trunk umbilicus- Liver cirrhosis
Lion face leprosy

b.) Rheumatoid arthritis
4. Direct hand trauma piano playing, excessive typing, operating chainsaw
S/Sx:
1. Intermittent claudication - leg pain upon walking - Relieved by rest
2. Cold sensitivity

Nsg Mgt:
a. Analgesics
b. Vasodilators
c. Encourage to wear gloves especially when opening a refrigerator.
d. Avoid smoking & exposure to cold environment

VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return

a. Hereditary
b. Congenital weakness of veins
c. Thrombophlebitis
d. Heart dse
e. Pregnancy
f. Obesity
g. Prolonged immobility - Prolonged standing
S/Sx:
1. Pain especially after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs

Dx:
1. Venography
2. Trendelenbergs test vein distend quickly < 35 secs

Nsg Mgt:
1. Elevate legs above heart level to promote venous return 1 to 2 pillows
2. Measure circumference of leg muscles to determine if swollen.
3. Wear anti embolic or knee high stockings. Women panty hose
4. Meds: Analgesics
5. Surgery: vein sweeping & ligation
Sclerotherapy spider web varicosities
S/E thrombosis

THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation
1. Smoking
2. Obesity
3. Hyperlipedemia
4. Prolonged use of oral contraceptives
5. Chronic anemia
6. DM
7. MI
8. CHF
9. Postop complications
10. Post cannulation insertion of various cardiac catheters

S/Sx:
1. Pain at affected extremities
2. Cyanosis
3. (+) Homans sign - Pain at leg muscles upon dorsiflexion of foot.
Dx:
1. Angiography
2. Doppler UTZ
Nsg Mgt:
1. Elevate legs above heart level.
2. Apply warm, moist packs to decrease lymphatic congestion.
3. Measure circumference of leg muscles to detect if swollen.
4. Use anti embolic stockings.
5. Meds: Analgesics.
Anticoagulant: Heparin
6. Complication:
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
- Mild restlessness

OVERVIEW OF RESPIRATORY SYSTEM:
I. Upper respiratory tract:
Fx:
1. Filtering of air
2. Warming & moistening
3. Humidification
a. Nose cartilage
- Parts: Rt nostril separated by septum
Lt nostril

- Consists of anastomosis of capillaries
Kessel Bach Plexus site of epistaxis
b. Pharynx (throat) muscular passageway for air& food
Branches:
1. Oropharynx
2. Nasopharynx
3. Layngopharynx

c. Larynx voice box
Fx:
1. For phonation
2. Cough reflex

Glottis opening
Opens to allow passage of air
Closes to allow passage of food

II. Lower Rt Fx for gas exchange
a. Trachea windpipe
- has cartillagenous rings
- site for permanent/ artificial a/w tracheostomy
b. Bronchus R & L main bronchus
c. Lungs R 3 lobes = 10 segments
L 2 lobes 8 segments

Post pneumonectomy - position affected side to promote expansion of lungs
Post segmental lobectomy position unaffected side to promote drainage

Lungs covered by pleural cavity, parietal lobe & visceral lobe
Alveoli acinar cells
- site of gas exchange (O2 & CO2)
- diffusion: Daltons law of partial pressure of gases

Ventilation movement of air in & out of lungs
Respiration movement of air into cells

Type II cells of alveoli secrets surfactant
Surfactant - decrease surface tension of alveoli

Lecithin & spinogometer
L/S ratio 2:1 indicator of lung maturity

If 1:2 adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.

I. PNEUMONIA inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.

Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Hemophilus pneumoniae(Bronchopneumonia)
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.

High risk elderly & children below 5 yo

1. Smoking
2. Air pollution
3. Immuno-compromised
a. AIDS PLP
b. Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue

S/Sx:
1. Productive cough pathognomonic: greenish to rusty sputum
2. Dyspnea with prolonged respiratory grunt
3. Fever, chills, anorexia, gen body malaise
4. Wt loss
5. Pleuritic friction rub
6. Rales/ crackles
7. Cyanosis
8. Abdominal distension leading to paralytic ileus

Sputum exam could confirm presence of TB & pneumonia

Dx:
1. Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism.
2. CXR pulmo consolidation
3. CBC increase WBC
Erythrocyte sedimentation rate
4. ABG PO2 decrease

Nsg Mgt:
1. Enforce CBR
2. Strict respiratory isolation
3. Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
4. Force fluids 2 to 3 L/day
5. Institute pulmonary toilet-
a.) Deep breathing exercise
b.) Coughing exercise
c.) Chest physiotherapy cupping
d.) Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfy & humid environment
9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt for postural drainage:
a.) Best done before meals or 2 4 hrs after meals to prevent Gastroesophageal Reflux
b.) Monitor VS & breath sounds
Normal breath sound bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 30 min before procedure
e.) Stop if pt cant tolerate procedure
f.) Provide oral care it may alter taste sensation
g.) C/I pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)
Normal IOP 12 21 mmHg
11. HT:
a.) Avoidance of precipitating factors
b.) Complication: Atelectacies & meningitis
c.) Compliance to meds

PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB or tubercle bacilli or acid fast
bacilli gram (+) aerobic, motile & easily destroyed by heat or sunlight.

1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle (mycobacterium BOVIS)
5. Virulence
6. Over fatigue

S/Sx:
1. Productive cough yellowish
2. Low fever
3. Night sweats
4. Dyspnea
5. Anorexia, general body malaise, wt loss
6. Chest/ back pain
7. Hempotysis

Diagnosis:
1. Skin test mantoux test infection of Purified CHON Derivative PPD
DOH 8-10 mm induration
WHO 10-14 mm induration
Result within 48 72h
(+) Mantoux test previous exposure to tubercle bacilli

Mode of transmission droplet infection
2. Sputum AFB (+) to cultured microorganism
3. CXR pulmonary infiltrate caseosis necrosis
4. CBC increase WBC

Nursing Mgt:
1. CBR
2. Strict resp isolation
3. O2 inhalation
4. Semi fowler
5. Force fluid to liquefy secretions
6. DBCE
8. Comfy & humid environment
9. Diet increase CHO & calories, CHON, Vit, minerals
10. Short course chemotherapy

- Intensive phase

INH isoniazide - give before meals for absorption
Rifampicin - given within 4 months, given simultaneously to prevent resistance
-S/E: peripheral neutitis vit B6
Rifampicin -All body secretions turn to red orange color urine, stool, saliva, sweat & tears.

PZA Pyrazinamide given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity

Standard regimen
1. Injection of streptomycin aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
a.) Ototoxicity damage CN # 8 tinnitus hearing loss
b.) Nephrotoxicicity monitor BUN & Crea
HT:
a.) Avoid pred factors
b.) Complications:
1.) Atelectasis
2.) Miliary TB spread of Tb to other system
c.) Compliance to meds
- Religiously take meds

HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted to birds manure.
S/Sx: Same as pneumonia & PTB like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis

Dx:
1. Histoplasmin skin test = (+)
2. ABG pO2 decrease

Nsg Mgt:
1. CBR
2. Meds:
a.) Anti fungal agents
Amphotericin B (Fungizone)
S/E :
a.) Nephrotoxcicity check BUN
b.) Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.

COPD Chronic Obstructive Pulmonary Disease
1. Chronic bronchitis
2. Bronchial asthma
3. Bronchiectasis
4. Pulmonary emphysema terminal stage

CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet mucus producing cells
leading to narrowing of smaller airways.

1. Smoking all COPD types
2. Air pollution
S/Sx:
1. Prod cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmo HPN a.)Leading to peripheral edema
b.) Cor pulmonary respiratory in origin
7. Anorexia, gen body malaise

Dx:
1. ABG
PO2 PCO2 Resp acidosis

Hypoxemia causing cyanosis
Nsg Mgt:
(Same as emphysema)

2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller airway.
1. Extrinsic Asthma called Atropic/ allergic asthma
a.) Pallor
b.) Dust
c.) Gases
d.) Smoke
e.) Dander
f.) Lints

2. Intrinsic Asthma-
Cause:
Herediatary
Drugs aspirin, penicillin, b blockers
Food additives nitrites
Foods seafood, chicken, eggs, chocolates, milk
Physical/ emotional stress
Sudden change of temp, humidity &air pressure
3. mixed type: combi of both ext & intr. Asthma
90% cause of asthma

S/Sx:
1. C cough non productive to productive
2. D dyspnea
3. W wheezing on expiration
4. Cyanosis
5. Mild apprehension & restlessness
6. Tachycardia & palpitation
7. Diaphoresis
Dx:
1. Pulmo function test decrease lung capacity
2. ABG PO2 decrease

Nsg Mgt:
1. CBR all COPD
2. Meds-
a.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids
b.) Corticosteroids due inflammatory. Given 10 min after adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist at bedside put suction machine.
e.) Antihistamine
3. Force fluid
4. O2 all COPD low inflow to prevent resp distress
6. Semifowler all COPD except emphysema due late stage
7. HT
a.) Avoid pred factors
b.) Complications:
- Status astmaticus- give epinephrine & bronchodilators
- Emphysema
c.) Adherence to med

BRONCHIECTASIS abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.

1. Recurrent upper & lower RI
2. Congenital anomalies
3. Tumors
4. Trauma
S/Sx:
1. Productive cough
2. Dyspnea
3. Anorexia, gen body malaise- all energy are used to increase respiration.
4. Cyanosis
5. Hemoptisis

Dx:
1. ABG PO2 decrease
2. Bronchoscopy direct visualization of bronchus using fiberscope.
Nsg Mgt: before bronchoscopy
1. Consent, explain procedure MD/ lab explain RN
2. NPO
3. Monitor VS
Nsg Mgt after bronchoscopy
1. Feeding after return of gag reflex
2. Instruct client to avoid talking, smoking or coughing
3. Monitor signs of frank or gross bleeding
4. Monitor of laryngeal spasm
- DOB
- Prepare at bedside tracheostomy set

Mgt: same as emphysema except Surgery
Pneumonectomy removal of affected lung
Segmental lobectomy position of pt unaffected side

PULMONARY EMPHYSEMA irreversible terminal stage of COPD
- Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases.
- Body will compensate over distension of thoracic cavity
- Barrel chest
1. Smoking
2. Allergy
3. Air pollution
4. High risk elderly
5. Hereditary - a 1 anti trypsin to release elastase for recoil of alveoli.

S/Sx:
1. Productive cough
2. Dyspnea at rest due terminal
3. Anorexia & gen body malaise
4. Rales/ rhonchi
6. Decrease tactile fremitus (should have vibration) palpation 99. Decreased - with air or fluid
7. Resonance to hyperresonance percussion
8. Decreased or diminished breath sounds
9. Pathognomonic: barrel chest increase post/ anterior diameter of chest
10. Purse lip breathing to eliminated PCO2
11. Flaring of alai nares

Diagnosis:
1. Pulmonary function test decrease vital lung capacity
2. ABG
a.) Panlobular / centrolobular emphysema
pCO2 increase
pO2 decrease hypoxema resp acidosis Blue bloaters
b.) Panacinar/ Centracinar
pCO2 decrease
pO2 increase hyperaxemia resp alkalosis Pink puffers
Nursing Mgt:
1. CBR
2. Meds
a.) Bronchodilators
b.) Corticosteroids
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
3. O2 Low inflow
4. Force fluids
5. High fowlers
6. Neb & suction
7. Institute
P posture
E end
E expiratory to prevent collapse of alveoli
P pressure
8. HT
a.) Avoid smoking
b.) Prevent complications
1.) Cor pulmonary R ventricular hypertrophy
2.) CO2 narcosis lead to coma
3.) Atelectasis
4.) Pneumothorax air in pleural space
9. Adherence to meds

RESTRICTIVE LUNG DISORDER
PNEUMOTHORAX partial / or complete collapse of lungs due to entry or air in pleural space.
Types:
1. Spontaneous pneumothorax entry of air in pleural space without obvious cause.
Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
Eg. open pneumothorax air enters pleural space through an opening in chest wall
-Stab/ gun shot wound
2. Tension Pneumothorax air enters plural space with @ inspiration & cant escape leading to over distension of thoracic cavity resulting to shifting of
mediastinum content to unaffected side.
Eg. flail chest paradoxical breathing

1.Chest trauma
2.Inflammatory lung conditions
3.Tumor
S/Sx:
1. Sudden sharp chest pain
2. Dyspnea
3. Cyanosis
4. Diminished breath sound of affected lung
5. Cool moist skin
6. Mild restlessness/ apprehension
7. Resonance to hyper resonance
Diagnosis:
1. ABG pO2 decrease
2. CXR confirms pneumothorax
Nursing Mgt:
1. Endotracheal intubation
2. Thoracenthesis
3. Meds Morphine SO4
- Anti microbial agents
4. Assist in test tube thoracotomy
Nursing Mgt if pt is on CPT attached to H2O drainage
1. Maintain strict aseptic technique
2. DBE
3. At bedside
a.) Petroleum gauze pad if dislodged Hemostan
b.) If with air leakage clamp
c.) Extra bottle
4. Meds Morphine SO4
Antimicrobial
5. Monitor & assess for oscillation fluctuations or bubbling
a.) If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
1. Check for loop, clots, and kink
2. Milk towards H2O seal
3. Indicates re-expansion of lungs
When will MD remove chest tube:
1. If (-) fluctuations
2. (+) Breath sounds
3. CXR full expansion of lungs

Nursing Mgt of removal of chest tube
1. DBE
2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space.
3. Apply vaselinated air occlusive dressing
- Maintain dressing dry & intact
GIT
I. Upper alimentary canal - function for digestion
a. Mouth
b. Pharynx (throat)
c. Esophagus
d. Stomach
e. 1st half of duodenum
II. Middle Alimentary canal Function: for absorption
- Complete absorption large intestine
a. 2nd half of duodenum
b. Jejunum
c. Ileum
d. 1st half of ascending colon
III. Lower Alimentary Canal Function: elimination
a. 2nd half of ascending colon
b. Transverse
c. Descending colon
d. Sigmoid
e. Rectum
IV. Accessory Organ
a. Salivary gland
b. Verniform appendix
c. Liver
d. Pancreas auto digestion
e. Gallbladder storage of bile

I. Salivary Glands
1. Parotid below & front of ear
2. Sublingual
3. Submaxillary

- Produces saliva for mechanical digestion
- 1200 -1500 ml/day - saliva produced

PAROTITIS mumps inflammation of parotid gland
-Paramyxo virus

S/Sx:
1. Fever, chills anorexia, gen body malaise
2. Swelling of parotid gland
3. Dysphagia
4. Ear ache otalgia

Mode of transmission: Direct transmission & droplet nuclei
Incubation period: 14 21 days
Period of communicability 1 week before swelling & immediately when swelling begins.

Nursing Mgt:
1. CBR
2. Strict isolation
3. Meds: analgesic
Antipyretic
Antibiotics to prevent 2complications
4. Alternate warm & cold compress at affected part
5. Gen liquid to soft diet
6. Complications
Women cervicitis, vaginitis, oophoritis
Both sexes meningitis & encephalitis/ reason why antibiotics is needed
Men orchitis might lead to sterility if it occur during / after puberty.

VERNIFORM APPENDIX Rt iliac or Rt inguinal area
- Function lymphatic organ produces WBC during fetal life - ceases to function upon birth of baby

APENDICITIS inflamation of verniform appendix
1. Microbial infection
2. Feacalith undigested food particles tomato seeds, guava seeds
3. Intestinal obstruction

S/Sx:
1. Pathognomonic sign: (+) rebound tenderness
2. Low grade fever, anorexia, n/v
3. Diarrhea / & or constipation
4. Pain at Rt iliac region
5. Late sign due pain tachycardia

Diagnosis:
1. CBC mild leukocytosis increase WBC
2. PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area rebound)
3. Urinalysis

Treatment: - appendectomy 24 45
Nursing Mgt:
1. Consent
2. Routinary nursing measures:
a.) Skin prep
b.) NPO
c.) Avoid enema lead to rupture of appendix
3. Meds:
Antipyretic
Antibiotics
*Dont 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 Mgt: post op
1. If (+) to Pendrose drain indicates rupture of appendix
Position- affected side to drain
2. Meds: analgesic due post op pain
Antibiotics, Antipyretics PRN
3. Monitor VS, I&O, bowel sound
4. Maintain patent IV line
5. Complications- peritonitis, septicemia

Liver largest gland
- Occupies most of right hypochondriac region
- Color: scarlet red
- Covered by a fibrous capsule Glissons capsule
- Functional unit liver lobules

Function:
1. Produces bile
Bile emulsifies fats
- Composed of H2O & bile salts
-Gives color to urine urobilin
Stool stircobilin
2. Detoxifies drugs
3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins
Hypevitaminosis vit D & K
Vit A retinol
Def Vit A night blindness
Vit D cholecalciferon
- Helps calcium
- Rickets, osteoarthritis

4. It destroys excess estrogen hormone
5. For metabolism
A. CHO
1. Glycogenesis synthesis of glycogens
2. Glycogenolysis breakdown of glycogen
3. Gluconeogenesis formation of glucose from CHO sources
B. CHON-
1. Promotes synthesis of albumin & globulin
Cirrhosis decrease albumin
Albumin maintains osmotic pressure, prevents edema
2. Promotes synthesis of prothrombin & fibrinogen
3. Promotes conversion of ammonia to urea.
Ammonia like breath fetor hepaticus
C. FATS promotes synthesis of cholesterol to neutral fats called triglycerides

LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring

Early sign hepatic encephalopathy
1. Asterixis flapping hand tremors
Late signs headache, restlessness, disorientation, decrease LOC hepatic coma.
Nursing priority assist in mechanical ventilation

Decrease Laennacs cirrhosis caused by alcoholism
1. Chronic alcoholism
2. Malnutrition decreaseVit B, thiamin - main cause
3. Virus
4. Toxicity- eg. Carbon tetrachloride
5. Use of hepatotoxic agents
S/Sx:
Early signs:
a.) Weakness, fatigue
b.) Anorexia, n/v
c.) Stomatitis
d.) Urine tea color
Stool clay color
e.) Amenorrhea
f.) Decrease sexual urge
g.) Loss of pubic, axilla hair
h.) Hepatomegaly
i.) Jaundice
j.) Pruritus or urticaria

2. Late signs
a.) Hematological changes all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- decrease
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusate, Palmar errythema

c.) GIT changes
Ascitis, bleeding esophageal varices due to portal HPN
d.) Neurological changes:

Hepatic encephalopathy - ammonia (cerebral toxin)
Late signs: Early signs:
Headache asterexis
Fetor hepaticus (flapping hand tremors)
Confusion
Restlessness
Decrease LOC

Hepatic coma

Diagnosis:
1. Liver enzymes- increase

SGPT (ALT)
SGOT (AST)
2. Serum cholesterol & ammonia increase
3. Indirect bilirubin increase
4. CBC - pancytopenia
5. PTT prolonged
6. Hepatic ultrasonogram fat necrosis of liver lobules

Nursing Mgt
1. CBR
2. Restrict Na!
3. Monitor VS, I&O
4. With pt daily & assess pitting edema
5. Measure abdominal girth daily notify MD
6. Meticulous skin care
7. Diet increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
8. Complications:
a.) Ascites fluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics 10 15 min effect
2. Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted

b.) Bleeding esophageal varices
- Dilation of esophageal veins
1. Meds: Vit K
Pitrisin or Vasopresin (IM)
2. NGT decompression- lavage
- Give before lavage ice or cold saline solution
- Monitor NGT output
3. Assist in mechanical decompression
- Insertion of sengstaken-blackemore tube
- 3 lumen typed catheter
- Scissors at bedside to deflate balloon.
c.) Hepatic encephalopathy
1. Assist in mechanical ventilation due coma
2. Monitor VS, neuro check
3. Siderails due restless
4. Meds Laxatives to excrete ammonia

HEPATITIS- jaundice (icteric sclera)

Bilirubin

Kernicterus/ hyperbilirubinia

Irreversible brain damage

Pancreas mixed gland (exocrine & endocrine gland)

PANCREATITIS acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion.
Bleeding of pancreas - Cullens sign at umbilicus

1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam)
7. Diet increase saturated fats
S/Sx:
1. Severe Lt 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. (+) Cullens sign - ecchymosis of umbilicus hemorrhage
8. (+) Grey Turners spots ecchymosis of flank area
9. Hypocalcemia
Diagnosis:
1. Serum amylase & lipase increase
2. Urine lipase increase
3. Serum Ca decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine Hcl (Demerol)
Dont give Morphine SO4 will cause spasm of sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- Ex. Papavarine Hcl
Prophantheline Bromide (Profanthene)
c.) Vasodilator NTG
d.) Antacid Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation
f.) Ca gluconate

2. Withold food & fluid aggravates pain
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
Complications of TPN
1. Infection
2. Embolism
3. Hyperglycemia
4. Institute stress mgt tech
a.) DBE
b.) Biofeedback
5. Comfy position - Knee chest or fetal like position
6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON
7. Complications: Chronic hemorrhagic pancreatitis

GALLBLADDER storage of bile made up of cholesterol.
CHOLECYSTITIS/ CHOLELITHIASIS inflammation of gallbladder with gallstone formation.
1. High risk women 40 years old
2. Post menopausal women undergoing estrogen therapy
3. Obesity
5. Hyperlipidemia
6. Neoplasm
S/Sx:
1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night
2. Fatty intolerance
3. Anorexia, n/v
4. Jaundice
5. Pruritus
6. Easy bruising
7. Tea colored urine
8. Steatorrhea

Diagnosis:
1. Oral cholecystogram (or gallbladder series)- confirms presence of stones

Nursing Mgt:
1. Meds a.) Narcotic analgesic - Meperdipine Hcl Demerol
b.) Anti cholinergic - Atropine SO4
c.) Anti emetic
Phenergan Phenothiazide with anti emetic properties
2. Diet increase CHO, moderate CHON, decrease fats
3. Meticulous skin care
4. Surgery: Cholecystectomy
Nursing Mgt post cholecystectomy
-Maintain patency of T-tube intact & prevent infection

Stomach widest section of alimentary canal
- J shaped structures
1. Anthrum
2. Pylorus
3. Fundus
Valves
1. 1.cardiac sphincter
2. Pyloric sphincter

Cells
1. Chief/ Zymogenic cells secrets
a.) Gastric amylase - digest CHO
b.) Gastric lipase digest fats
c.) Pepsin CHON
d.) Rennin digests milk products
2. Parietal / Argentaffin / oxyntic cells
Function:
a.) Produces intrinsic factor promotes reabsorption of vit B12 cyanocobalamin promotes maturation of RBC
b.) Secrets Hcl acid aids in digestion
3. Endocrine cells - Secrets gastrin increase Hcl acid secretion

Function of the stomach
1.Mechanical
2.Chem. Digestion
3.Storage of food
-CHO, CHON- stored 1 -2 hrs. Fats stored 2 3 hrs

PEPTIC ULCER DISEASE (PUD) excoriation / erosion of submucosa & mucosal lining due to:
a.) Hypercecretion of acid pepsin
b.) Decrease resistance to mucosal barrier

Incidence Rate:
1. Men 40 55 yrs old
2. Aggressive persons

1. Hereditary
2. Emotional
3. Smoking vasoconstriction GIT ischemia
4. Alcoholism stimulates release of histamine = Parietal cell release Hcl acid = ulceration
5. Caffeine tea, soda, chocolate
6. Irregular diet
7. Rapid eating
8. Ulcerogenic drugs NSAIDS, aspirin, steroids, indomethacin, ibuprofen
Indomethacin - S/E corneal cloudiness. Needs annual eye check up.

9. Gastrin producing tumor or gastrinoma Zollinger Ellisons sign
10. Microbial invasion helicobacter pylori. Metromidazole (Flagyl)

Types of ulcers
Ascending to severity
1. Acute affects submucosal lining
2. Chronic affects underlying tissue heals & forms a scar

According to location
1. Stress ulcer
2. Gastric ulcer
3. Duodenal ulcer most common

Stress ulcers common among eritically ill clients

2 types
1.Curings ulcer cause: trauma & birth

hypovolemia

GIT schemia

Decrease resistance of mucosal barriers to Hcl acid

Ulcerations

2.Cushings ulcer cause stroke/CVA/ head injury

Increase vagal stimulation

Hyperacidity

Ulcerations

GASTRIC ULCER DUODENAL ULCER
SITE Intrum or lesser curvature Duodenal bulb
PAIN -30 min 1 hr after eating
- epigastrium
- gaseous & burning
- not usually relieved by food & antacid -2-3 hrs after eating
- mid epigastrium
- cramping & burning
- usually relieved by food & antacid
- 12 MN 3am pain
HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion
VOMITING Common Not common
HEMORRHAGE Hematemeis Melena
WT Wt loss Wt gain
COMPLICATIONS a. stomach cause
b. hemorrhage a. perforation
HIGH RISK 60 years old 20 years old
Diagnosis:
1. Endoscopic exam
2. Stool from occult blood
3. Gastric analysis N gastric
Increase duodenal
4. GI series confirms presence of ulceration

Nursing Mgt:
1. Diet bland, non irritating, non spicy
2. Avoid caffeine & milk/ milk products

Increase gastric acid secretion
3. Administer meds
a.) Antacids

AAC
Aluminum containing antacids Magnesium containing antacids
Ex. aluminum OH gel ex. milk of magnesia
(Ampho-gel) S/E diarrhea
S/E constipation

Maalox (fever S/E)

b.) H2 receptor antagonist
Ex
1. Ranitidine (Zantac)
2. Cimetidine (Tagamet)
3. Tamotidine (Pepcid)
- Avoid smoking decrease effectiveness of drug

Nursing Mgt:
1. Administer antacid & H2 receptor antagonist 1hr apart
-Cemetidine decrease antacid absorption & vise versa
c.) Cytoprotective agents
Ex
1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
2. Cytotec
d.) Sedatives/ Tranquilizers - Valium, lithium
e.)Anticholinergics
1. Atropine SO4
2. Prophantheline Bromide (Profanthene)

(Pt has history of hpn crisis With peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na.

4. Surgery: subtotal gastrectomy - Partial removal of stomach
Billroth I (Gastroduodenostomy)
-Removal of of stomach & anastomoses of gastric stump to the duodenum. Billroth II (Gastrojejunostomy)
- removal of -3/4 of stomach & duodenal bulb & anastomostoses of gastric stump to jejunum.

Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.

Nursing Mgt:
1. Monitor NGT output
a.) Immediately post op should be bright red
b.) Within 36- 42h output is yellow green
c.) After 42h output is dark red
2. Administer meds:
a.) Analgesic
b.) Antibiotic
c.) Antiemetics
3. Maintain patent IV line
4. VS, I&O & bowel sounds
5. Complications:
a.) Hemorrhage hypovolemic shock
Late signs anuria
b.) Peritonitis
c.) Paralytic ileus most feared
d.) Hypokalemia
e.) Thromobphlebitis
f.) Pernicious anemia

7.)Dumping syndrome common complication rapid gastric emptying of hypertonic food solutions CHYME leading to hypovolemia.
Sx of Dumping syndrome:
1. Dizziness
2. Diaphoresis
3. Diarrhea
4. Palpitations

Nursing mgt:
1. Avoid fluids in chilled solutions
2. Small frequent feeding s-6 equally divided feedings
3. Diet decrease CHO, moderate fats & CHON
4. Flat on bed 15 -30 minutes after q feeding

BURNS direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority infection (all kinds of burns)
Head burn-priority- a/w
2nd priority for 1st & 2nd - pain
2nd priority for 3rd - F&E

Thermal- direct contact flames, hot grease, sunburn.
Electric, wires
Chem. direct contact corrosive materials acids
Smoke gas / fume inhalation

Stages:
1. Emergent phase Removal of pt from cause of burn. Determine source or loc or burn
2. Shock phase 48 - 72. Characterized by shifting of fluids from intravascular to interstitial space
S/Sx:
- BP decrease
- Urine output
- HR increase
- Hct increase
- Serum Na decrease
- Serum K increase
- Met acidosis

3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
4. Recovery/ convalescent phase complete diuresis. Wound healing starts immediately after tissue injury.

Class:
I. Partial Burn
1. 1st degree superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure with no fluid filled vesicles
2. 2nd degree deep burns
- Affects epidermis & dermis
- Cause chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
1. Third & 4th degrees burn
- Affects all layers of skin, muscles, bones
- Cause electrical
- Less painful
- Dry, thick, leathery wound surface known as ESCHAR devitalized or necrotic tissue.
Assessment findings
Rule of nines
Head & neck = 9%
Ant chest = 18%
Post chest = 18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum= 1%
Total 100%

Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth Claustridium tetany

Tetany

Tetanolysin tetanospasmin

Hemolysis muscle spasm

b.) Morphine SO4
c.) Systemic antibiotics
1. Ampicillin
2. Cephalosporin
3. Tetracyclin
4. Topical antibiotic :
1. Silver Sulfadiazene (silvadene)
2. Sulfamylon
3. Silver nitrate
4. Povidone iodine (betadine)
2. Administer isotonic fluid sol & CHON replacements
3. Strict aseptic technique
4. Diet increase CHO, increase CHON, increase Vit C, and increase K- orange
5. If (+) to burns on head, neck, face - Assist in intubation
6. Assist in hydrotherapy
7. Assist in surgical wound debridement. Administer analgesic 15 30 minutes before debridement
8. Complications:
a.) Infection
b.) Shock
c.) Paralytic ileus - due to hypovolemia & hypokalemia
d.) Curlings ulcer H2 receptor antagonist
e.) Septicemia blood poisoning
f.) Surgery: skin grafting
GUT genito-urinary tract
Function:
1. Promote excretion of nitrogenous waste products
2. Maintain F&E & acid base balance
1. Kidneys pair of bean shaped organ
- Retro peritonially (back of peritoneum) on either side of vertebral column. Encased in Bowmanss capsule.

Parts:
1. Renal pelvis pyenophritis infl
2. Cortex
3. Medulla
Nephrones basic living unit
Glomerulus filters blood going to kidneys

Function of kidneys:
1. Urine formation
2. Regulation of BP

Urine formation 25% of total CO (Cardiac Output) is received by kidneys
1. Filtration
2. Tubular Reabsorption
3. Tubular Secretion

Filtration Normal GFR/ min is 125 ml of blood
Tubular reabsorption 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption)
Tubular secretion 1 ml is excreted in urine

Regulation of BP:

Ex CS hypovolemia decrease BP going to kidneys
Activation of RAAS

Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus

Angiotensin I mild vasoconstrictor

Angiotensin II vasoconstrictor

Adrenal cortex increase CO increase PR

Aldosterone
Increase BP
Increase Na &
H2O reabsorption

Hypervolemia

Ureters 25 35 cm long, passageway of urine to bladder
Bladder loc behind symphisis pubis. Muscular & elastic tissue that is distensible
- Function reservoir or urine
1200 1800 ml Normal adult can hold
200 500 ml needed to initiate micturition reflex

Color amber
Odor aromatic
Consistency clear or slightly turbid
pH 4.5 8
Specific gravity 1.015 1.030
WBC/ RBC (-)
Albumin (-)
E coli (-)
Mucus thread few
Amorphous urate (-)

Urethra extends to external surface of body. Passage of urine, seminal & vaginal fluids.
- Women 3 5 cm or 1 to 1
- Male 20cm or 8

UTI
CYSTITIS inflammation of bladder
1. Microbial invasion E. coli
2. High risk women
3. Obstruction
4. Urinary retention
5. Increase estrogen levels
6. Sexual intercourse
S/Sx:
1. Pain flank area
2. Urinary frequency & urgency
3. Burning upon urination
4. Dysuria & hematuria
5. Fever, chills, anorexia, gen body malaise
Diagnosis:
1. Urine culture & sensitivity - (+) to E. coli
Nursing Mgt:
1. Force fluid 2000 ml
2. Warm sitz bath to promote comfort
3. Monitor & assess for gross hematuria
4. Acid ash diet cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
5. Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides cotrimaxazole (Bactrim)
- Gantrism (ganthanol)
Urinary antiseptics Mitropurantoin (Macrodantin)
Urinary analgesic- Pyridum
6. Ht
a.) Importance of Hydration
b.) Void after sex
c.) Female avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications:
Pyelonephritis

PYELONEPHRITIS acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, interstitial abscess formation.
- Lead to Renal Failure

1. Microbial invasion
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary frequency, urgency
d.) Nocturia, dsyuria, hematuria
e.) Burning on urination

Chronic Pyelonephritis
a.) Fatigue, wt loss
b.) Polyuuria, polydypsia
c.) HPN

Diagnosis:
1. Urine culture & sensitivity (+) E. coli & streptococcus
2. Urinalysis
Increase WBC, CHON & pus cells
3. Cystoscopic exam urinary obstruction

Nursing Mgt:
1. Provide CBR acute phase
2. Force fluid
3. Acid ash diet
4. Meds:
a.) Urinary antiseptic nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
b.) Urinary analgesic Peridium
5. Complication- Renal Failure

NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract
- calcium , oxalate, uric acid

milk cabbage anchovies
cranberries organ meat
nuts tea nuts
chocolates sardines

1. Diet increase Ca & oxalate
2. Hereditary gout
3. Obesity
5. Hyperparathyroidism

S/Sx:
1. Renal colic
2. Cool moist skin (shock)
3. Burning upon urination
4. Hematuria
5. Anorexia, n/v
Diagnosis:
1. IVP intravenous pyelography. Reveals location of stone
2. KUB reveals location of stone
3. Cytoscopic exam- urinary obstruction
4. Stone analysis composition & type of stone
5. Urinalysis increase EBC, increase CHON
Nursing Mgt:
1.Force fluid
2.Strain urine using gauze pad
3.Warm sitz bath for comfort
4.Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent IV line
d.) Diet if + Ca stones acid ash diet
If + oxalate stone alkaline ash diet - (Ex milk/ milk products)
If + uric acid stones decrease organ meat / anchovies sardines
6. Surgery
a.) Nephectomy removal of affected kidney
Litholapoxy removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones
b.) Extracorporeal shock wave lithotripsy
- Non - invasive
- Dissolve stones by shock wave
7. Complications: Renal Failure

BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to
a.) Hydro ureters dilation of ureters
b.) Hydronephrosis dilation of renal pelvis
c.) Kidney stones
d.) Renal failure

1. High risk 50 years old & above
60 70 (3 to 4 x at risk)
2. Influence of male hormone
S/Sx:
1.Decrease force of urinary stream
2.Dysuria
3.Hematuria
4.Burning upon urination
5.Terminal bubbling
6.Backache
7.Sciatica
Diagnosis:
1. Digital rectal exam enlarged prostate gland
2. KUB urinary obstruction
3. Cystoscopic exam obstruction
4. Urinalysis increase WBC, CHON

Nursing Mgt:
1. Prostatic message promotes evacuation of prostatic fluid
2. Limit fluid intake
3. Provide catheterization
4. Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter
b. Fenasteride (Proscar) - Atrophy of Prostate Gland
5. Surgery: Prostatectomy TURP- Transurethral resection of Prostate- No incision
-Assist in cystoclysis or continuous bladder irrigation.
Nursing mgt:
c. Monitor symptoms of infection
d. Monitor symptoms gross/ flank bleeding. Normal bleeding within 24h.
3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention

ACUTE RENAL FAILURE sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E balance due to a decrease in GFR.
(N 125 ml/min)

Pre renal cause- decrease blood flow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension decrease flow to kidneys
4. CHF
5. Hemorrhage
6. Dehydration

Intra-renal cause involves renal pathology= kidney problem
1. Acute tubular necrosis-
2. Pyelonephritis
3. HPN
4. Acute GN

Post renal cause involves mechanical obstruction
1. Stricture
2. Urolithiasis
3. BPH

CHRONIC RF irreversible loss of kidney function
1. DM
2. HPN
3. Recurrent UTI/ nephritis
4. Exposure to renal toxins

Stages of CRF
1. Diminished Reserve Volume asymptomatic
Normal BUN & Crea, GFR < 10 30%
2. Renal Insufficiency
3. End Stage Renal disease

S/Sx:
1.) Urinary System
a.) polyuria
b.) nocturia
c.) hematuria
d.) Dysuria
e.) oliguria 2.) Metabolic disturbances
a.) azotemia (increase BUN & Crea)
b.) hyperglycemia
c.) hyperinulinemia
3.) CNS
a.) headache
b.) lethargy
c.) disorientation
d.) restlessness
e.) memory impairment 4.) GIT
a.) n/v
b.) stomatitis
c.) uremic breath
d.) diarrhea/ constipation
5.) Respiratory
a.) Kassmauls resp
b.) decrease cough reflex 6.) hematological
a.) Normocytic anemia
bleeding tendencies

7.) Fluid & Electrolytes
a.) hyperkalemia
b.) hypernatermia
c.) hypermagnesemia
d.) hyperposphatemia
e.) hypocalcemia
f.) met acidosis 8.) Integumentary
a.) itchiness/ pruritus
b.) uremic frost
Nursing Mgt:
1. Enforce CBR
2. Monitor VS, I&O
3. Meticulous skin care. Uremic frost assist in bathing pt
4. Meds:
a.) Na HCO3 due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
2.) Obtain baseline data & monitor VS, I&O, wt, blood exam
3.) Strict aseptic technique
4.) Monitor for signs of complications:
B bleeding
E embolism
D disequilibrium syndrome
S septicemia
S shock decrease in tissue perfusion
Disequilibrium syndrome from rapid removal of urea & nitrogenous waste prod leading to:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) Paresthesia

5. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
6. Maintain patency of shunt by:
i. Palpate for thrills & auscultate for bruits if (+) patent shunt!
ii. Bedside- bulldog clip
- If with accidental removal of fistula to prevent embolism.
- Infersole (diastole) common dialisate used
7. Complication
- Peritonitis
- Shock

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

EYES
External parts
1. Orbital cavity made up of connective tissue protects eye form trauma.
2. EOM extrinsic ocular muscles involuntary muscles of eye needed for gazing movement.
3. Eyelashes/ eyebrows esthetic purposes
4. Eyelids palpebral fissure opening upper & lower lid. Protects eye from direct sunlight

Meibomean gland secrets a lubricating fluid inside eyelid
b.) Stye/ sty or Hordeolum- inflamed Meibomean gland
5. Conjunctiva
6. Lacrimal apparatus tears

Process of grieving
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
2. Intrinsic coat
I. sclerotic coat outer most
a.) Sclera white. Occupies post of eye. Refracts light rays
b.) Canal of schlera site of aqueous humor drainage
c.) Cornea transparent structure of eye

II/ Uveal tract nutritive care
Uveitis infl of uveal tract
Consist of:
a.) Iris colored muscular ring of eye
2 muscles of iris:
1. Circular smooth muscle fiber - Constricts the pupil
2.radial smooth muscle fiber - Dilates the pupil

2 chambers of the eye
1. Anterior
a.) Vitereous Humor maintains spherical shape of the eye
b.) Aqueous Humor maintains intrinsic ocular pressure
Normal IOP= 12-21 mmHg

II. Retina (innermost layer)
i. Optic discs or blind spot nerve fibers only

No auto receptors

cones (daylight/ colored vision) rods night twilight vision

phototopic vision scotopic vision = vit A deficiency rods insufficient

ii. Maculla lutea yellow spot center of retina
iii. Fovea centralis area with highest visual acuity oracute vision

Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes

Unit of measurements of refraction diopters
Normal eye refraction emmetropia

ERROR of refraction
1. Myopia near sightedness Treatment: biconcave lens
2. Hyperopia/ or farsightedness Treatment: biconvex lens
3. Astigmatisim distorted vision Treatment: cylindrical
4. Prebyopia old slight inelasticity of lens due to aging Treatment: bifocal lens or double vista
Accommodation of lenses based on thelmholtz theory of accommodation

Near vision = far vision=
Ciliary muscle contracts= ciliary muscle dilates / relaxes=
Lens bulges lens is flat

Convergence of the eye:
Error:
1. Exotropia 1 eye normal
2. Esophoria corrected by corrective eye surgery
3. Strabismus- squint eye
4. Amblyopia prolong squinting

GLAUCOMA increase IOP if untreated, atrophy of optic nerve disc blindness
1. High risk group 40 & above
2. HPN
3. DM
4. Hereditary
5. Obesity
6. Recent eye trauma, infl, surgery

Type:
1. Chronic (open angle G.) most common type
Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema
2. Acute (close angle G.) Most dangerous type
Forward displacement of iris to cornea leading to blindness.
3. Chronic (closed angle) - Precipitated by acute attack

S/Sx:
1. Loss of peripheral vision tunnel vision
2. Halos around lights
3. Headache
4. n/v
5. Steamy cornea
6. Eye discomfort
7. If untreated gradual loss of central vision blindness

Diagnosis:
1. Tonometry increase IOP >12- 21 mmHg
2. Perimetry decrease peripheral vision
3. Gonioscopy abstruction in anterior chamber

Nursing mgt:
1. Enforce CBR
3. Administer meds
a.) Miotics lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)
b.) Epinephrine eye drops decrease secretion of aqueous humor
c.) Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
4. Surgery:
Invasive:
a.) Trabeculectomy eyetrephining removal of trabelar meshwork of canal or schlera to drain aqueous humor
b.) Peripheral Iridectomy portion of iris is excised to drain aqueous humor

Non-invasive:
Trabeculoctomy (eye laser surgery)

Nursing Mgt pre op- all types surgery
1. Apply eye patch on unaffected eye to force weaker eye to become stronger.

Nursing Mgt post op all types of surgery
1. Position unaffected/ unoperated side - to prevent tension on suture line.
2. Avoid valsalva maneuver
3. Monitor symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
4. Eye patch both eyes - post op

CATARACT partial/ complete opacity of lens
1. 90-95% - aging (degenerative/ senile cataract)
2. Congenital
3. Prolonged exposure to UV rays
4. DM-

S/Sx:
1. Loss of central vision - Hazy or blurring of vision
2. Painless
3. Milky white appearance at center of pupil
4. Decrease perception of colors

Diagnosis: Opthalmoscopic exam (+) opacity of lens
Nsg Mgt:
1. Reorient pt to environment due opacity
2. Siderails
3. Meds a.) Mydriatics dilate pupil not lifetime
Ex. Mydriacyl
c.) Cyslopegics paralyzes ciliary muscle. Ex. Cyclogye
4. Surgery

E extra
C - capsular
C cataract partial removal of lens
L - lens
E extraction

I - intra
C - capsular
C cataract total removal of lens &
L lens surrounding capsules
E extraction

Nursing Mgt:

1.Position unaffected/ unoperated side - to prevent tension on suture line.
2.Avoid valsalva maneuver

3.Monitor symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
4.Eye patch both eyes - post op

RETINAL DETACHMENT- separation of 2 layers of retina

1. Severe myopia nearsightedness
2. Diabetic Retinopathy
3. Trauma
4. Following lens extraction
5. HPN

S/Sx:
1. Curtain veil like vision
2. Flashes of lights
3. Floaters
4. Gradual decrease in central vision
5. Headache

Diagnosis- opthaloscopic exam
Nursing Mgt:
1. Siderails (all visual disease)
2. Surgery:
a.) Cryosurgery
b.) Scleral buckling

EAR
1. Hearing
2. Balance (Kinesthesia or position sense)

Parts:
1. Outer-
a.) Pinna/ auricle protects ear from direct trauma
b.) Ext. auditory meatus has ceruminous gland. Cerumen
c.) Tympanic membrane transmits sound waves to middle ear

Disorders of outer ear
Entry of insects put flashlight to give route of exit
Foreign objects beans (bring to MD)
H2O - drain
2. Middle ear

a.) Ear osssicle

1. Hammer -malleus
2. Anvil -Incus for bone conduction disorder conductive hearing loss
3. Stirrups -stapes

b. Eustachian tube - Opens to allow equalization of pressure on both ears
- Yawn, chew, and swallow
Children straight, wide, short
c.) Otitis media
Adult long, narrow & slanted

c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth for balance, vestibule

Utricle & succule

Otolithe or ear stone has Ca carbonate

Movement of head = Righting reflex = Kinesthesia
b. Membranous Labyrinth
1. Cochlea ( function for hearing) has organ of corti
2. Endolymph & perilymph for static equilibrium
3. Mastoid air cells air filled spaces in temporal bone in skull

Complications of Mastoditis meningitis

Types of hearing loss:
1. Conductive hearing loss transmission hearing loss
Causes:
a.) Impacted cerumen tinnitus & conduction hearing loss- assist in ear irrigaton
b.) Immobility of stapes OTOSCLEROSIS
d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes
e.) Stapes cant transmit sound waves

Surgery
Stapedectomy removal of stapes, spongy bone & implantation of graft/ ear prosthesis

1. Familiar tendency
2. Ear trauma & surgery

S/Sx:
1. Tinnitus
2. Conductive hearing loss

Diagnosis:
1. Audiometry various sound stimulates (+) conductive hearing loss
2. Webers test Normal AC> BC
result BC > AC

Stapedectomy
Nursing Mgt post op
1. Position pt unaffected side
2. DBE
No coughing & blowing of nose
- Night lead to removal of graft
3. Meds:
a.) Analgesic
b.) Antiemetic
c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)
4. Assess motor function facial nerve - (Smile, frown, raise eyebrow)
5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap

SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS
Cause:
1. Tumor on cocheal
2. Loud noises (gun shot)
3. Presbycusis bilateral progressive hearing loss especially at high frequencies elderly
Face elderly to promote lip reading
4. Menieres disease endolymphatic hydrops
f.) Inner ear disease char by dilation of endo lympathic system leading to increase volume of endolin

Predisposing factor of MENIERES DISEASE
Smoking
Hyperlipidemia
30 years old
Obesity (+) chosesteatoma
Allergy
Ear trauma & infection

S/Sx:
1. TRIAD symptoms of Menieres disease
a.) Tinnitus
b.) Vertigo
c.) Sensory neural hearing loss
2. Nystagmus
3. n/v
4. Mild apprehension, anxiety
5. Tachycardia
6. Palpitations
7. Diaphoresis

Diagnosis:
1. Audiometry (+) sensory hearing loss

Nursing mgt:
1. Comfy & darkened environment
2. Siderails
3. Emetic basin
4. Meds:
a.) Diuretics to remove endolymph
b.) Vasodilator
c.) Antihistamine
d.) Antiemetic
e.) Antimotion sickness agent
f.) Sedatives/ tranquilizers

5. Restrict Na
6. Limit fluid intake
7. Avoid smoking
8. Surgery endolymphatic sac decompression- Shunt

Ms New Lecture 2012

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AUGUST 17, 2012

Medical Surgical Nursing

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