Medical Surgical Nursing Review Notes 30pgs

MEDICAL-SURGICAL NURSING
NERVOUS SYSTEM
Overview of structures and functions:
Central Nervous System
 Brain
 Spinal Cord
Peripheral Nervous System
 Cranial Nerves
 Spinal Nerves
Autonomic Nervous System
 Sympathetic nervous system
 Parasympathetic nervous system
AUTONOMIC NERVOUS SYSTEM

Sympathetic Nervous System Parasympathetic Nervous System
(ADRENERGIC) (CHOLINERGIC, VAGAL, SYMPATHOLYTIC)
- Involved in fight or aggression response. - Involved in fight or withdrawal response.
- Release of Norepinephrine (cathecolamines) - Release of Acetylcholine.
from adrenal glands and causes
vasoconstriction.
- Increase all bodily activity except GIT - Decreases all bodily activities except GIT.
EFFECTS OF SNS EFFECTS OF PNS

- Dilation of pupils(mydriasis) in order to be aware. - Constriction of pupils (meiosis).
- Dry mouth (thickened saliva). - Increase salivation.
- Increase BP and Heart Rate. - Decrease BP and Heart Rate.
- Bronchodilation, Increase RR - Bronchoconstriction, Decrease RR.
- Constipation. - Diarrhea
- Urinary Retention. - Urinary frequency.
- Increase blood supply to brain, heart and skeletal
muscles.
- SNS
I. Adrenergic Agents I. Cholinergic Agents

- Give Epinephrine. - Mestinon, Neostigmine.
Signs and Symptoms: Side Effects
- SNS - PNS
Contraindication:
- Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis,
Emphysema, Asthma).
II. Beta-adrenergic Blocking Agents II. Anti-cholinergic Agents

- Also called Beta-blockers. - To counter cholinergic agents.
- All ending with “lol” - Atropine Sulfate
- Propranolol, Atenelol, Metoprolol. Side Effects
Effects of Beta-blockers - SNS
B – roncho spasm
E – licits a decrease in myocardial contraction.
T – reats hypertension.
A – V conduction slows down.
 Should be given to patients with Angina Pectoris, Myocardial Infarction,
Hypertension.
ANTI- HYPERTENSIVE AGENTS

1. Beta-blockers – “lol”
2. Ace Inhibitors – Angiotensin, “pril” (Captopril, Enalapril)
3. Calcium Antagonist – Nifedipine (Calcibloc)
 In chronic cases of arrhythmia give Lidocaine(Xylocaine)
CENTRAL NERVOUS SYSTEM B. NEUROGLIA

 Brain and Spinal Cord.  Support and protection of neurons.
I. CELLS TYPES
A. NEURONS 1. Astrocytes – maintains blood brain barrier semi-permeable.
 Basic cells for nerve impulse and conduction.  Majority of brain tumors (90%) arises from called
PROPERTIES astrocytoma.
Excitability – ability of neuron to be affected by changes in external environment. 2. Oligodendria
Conductivity – ability of neuron to transmit a wave of excitation from one cell to 3. Microglia
another. 4. Epindymal
Permanent Cell – once destroyed not capable of regeneration.

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Ammonia
1. Labile  Cerebral toxin
 Capable of regeneration.  Hepatic Encephalopathy (Liver Cirrhosis)
 Epidermal cells, GIT cells, GUT cells, cells of lungs.  Ascites

2. Stable  Esophageal Varices
 Capable of regeneration with limited time, survival period. Early Signs of Hepatic Encephalopathy
 Kidney cells, Liver cells, Salivary cells, pancreas.  asterixis (flapping hand tremors).
3. Permanent Late Signs of Hepatic Encephalopathy
 Not capable of regeneration.  Headache
 Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal  Dizziness

Cells.  Confusion
 Fetor hepaticus (ammonia like breath)
 Decrease LOC
1
PATHOGNOMONIC SIGNS
1. PTB – low-grade afternoon fever.
2. PNEUMONIA – rusty sputum.
3. ASTHMA – wheezing on expiration.
4. EMPHYSEMA – barrel chest.
5. KAWASAKI SYNDROME – strawberry tongue.
6. PERNICIOUS ANEMIA – red beefy tongue.
7. DOWN SYNDROME – protruding tongue.
8. CHOLERA – rice watery stool.
9. MALARIA – stepladder like fever with chills.
10. TYPHOID – rose spots in abdomen.
11. DIPTHERIA – pseudo membrane formation
12. MEASLES – koplik’s spots.
13. SLE – butterfly rashes.
14. LIVER CIRRHOSIS – spider like varices.
15. LEPROSY – lioning face.
16. BULIMIA – chipmunk face.
17. APPENDICITIS – rebound tenderness.
18. DENGUE – petechiae or (+) Herman’s sign.
19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain).
20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm).
21. TETANUS – risus sardonicus.
22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots.
23. PYLORIC STENOSIS – olive like mass.
24. PDA – machine like murmur.
25. ADDISON’S DISEASE – bronze like skin pigmentation.
26. CUSHING’S SYNDROME – moon face appearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus.
28. INTUSSUSCEPTION – sausage shaped mass
2
. Carbon Monoxide and Lead Poisoning  Resulting to acetone breath odor/fruity odor.
 Can lead to Parkinson’s Disease.  KUSSMAUL’S respiration, a rapid shallow respiration.
 Epilepsy  Which may lead to diabetic coma.
 Treat with ANTIDOTE: Calcium EDTA. 4. Hepatitis
3. Type 1 DM (IDDM)  Signs of jaundice (icteric sclerae).
 Causes diabetic ketoacidosis.  Caused by bilirubin (yellow pigment)
 And increases breakdown of fats. 5. Bilirubin
 And free fatty acids  Increase bilirubin in brain (Kernicterus).
 Resulting to cholesterol and (+) to Ketones (CNS  Causing irreversible brain damage.
depressant).
Astrocites
 Maintains integrity of blood brain barrier.
Oligodendria DEMYELINATING DISORDERS
 Produces
1. ALZHEIMER’S DISEASE myelin sheath in CNS
 Atrophy of brain tissues.
 Act as insulator and facilitates rapid nerve impulse transmission.
Sign and Symptoms
4 A’s of Alzheimer  Hypothyroidism
a. Amnesia – loss of memory.  GBS
b. Agnosia – no recognition of inanimate objects.
c. Apraxia – no recognition of objects function.
Ig G – only antibody that pass placental circulation causing passive immunity.
d. Aphasia – no speech (nodding).
- short term protection.
*Expressive aphasia
- Immediate action.
 “motor speech center” Ig A – present in all bodily secretions (tears, saliva, colostrums).
 Broca’s Aphasia Ig M – acute in inflammation.
*Receptive aphasia Ig E – for allergic reaction.
 inability to understand spoken words. Ig D – for chronic inflammation.
 Wernicke’s Aphasia * Give palliative or supportive care.

Signs and Symptoms
 General Knowing Gnostic Area or General Interpretative
1. Visual disturbances
Area.
 blurring of vision (primary)
DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX.
 diplopia (double vision)
2. MULTIPLE SCLEROSIS  scotomas (blind spots)

 Chronic intermittent disorder of CNS characterized by white patches of
demyelination in brain and spinal cord. 2. Impaired sensation
 Characterized by remission and exacerbation.  to touch, pain, pressure, heat and cold.
 Women ages 15-35 are prone  tingling sensation
 Unknown Cause  paresthesia
 Slow growing virus  numbness
 Autoimmune disorders 3. Mood swings
 Pernicious anemia  euphoria (sense of well being)

4. Impaired motor function
 Myasthenia gravis
 weakness
 Lupus
 spasticity
2
 paralysis 5. Impaired cerebral function
 scanning speech
TRIAD SIGNS OF MS
Ataxia
(Unsteady gait, (+) Romberg’s test)
CHARCOTS
TRIAD
Intentional tremors IAN Nystagmus
6. Urinary retention/incontinence  Monitor side effects bronchospasm and wheezing.
7. Constipation  Monitor breath sounds 1 hour after subcutaneous administration.
8. Decrease sexual capacity
c. For Urinary Incontinence
Anti spasmodic agent
DIAGNOSTIC PROCEDURE
a. Prophantheline Bromide (Promanthene)
 CSF analysis (increase in IgG and Protein).
 Acid ash diet like cranberry juice, plums, prunes,
 MRI (reveals site and extent of demyelination). pineapple, vitamin C and orange.
 (+) Lhermitte’s sign a continuous and increase contraction of spinal  To acidify urine and prevent bacterial multiplication.
column.
COMMON CAUSE OF UTI

NURSING MANAGEMENT Female
1. Administer medications as ordered  short urethra (3-5 cm, 1-1 ½ inches)
a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute
 poor perineal hygiene
exacerbation to reduce edema at site
of demyelination to prevent paralysis.
 vaginal environment is moist
b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle Nursing Management
relaxants.  avoid bubble bath (can alter Ph of vagina).
c. Interferons – alter immune response.  avoid use of tissue papers

d. Immunosupresants  avoid using talcum powder and perfume.
2. Maintain side rails to prevent injury related to falls.
Male
3. Institute stress management techniques.
 Urethra (20 cm, 8 inches)
a. Deep breathing exercises
 urinate after intercourse
b. Yoga
4. Increase fluid intake and increase fiber to prevent constipation.
MICROGLIA
5. Catheterization to prevent retention.
a. Diuretics  stationary cells that carry on phagocytosis (engulfing of
b. Bethanicol Chloride (Urecholine) bacteria or cellular debris, eating), pinocytosis (cell
Nursing Management drinking).
 Only given subcutaneous.


MACROPHAGE ORGAN
Microglia Brain
Monocytes Blood
Kupffers cells Kidney
Histiocytes Skin
Alveolar Macrophage Lung
EPINDYMAL CELLS
 Secretes a glue called chemo attractants that concentrate 2. Temporal
the bacteria.  hearing
COMPOSITION OF BRAIN  short term memory
 80% brain mass 3. Parietal
 10% blood  for appreciation
 10% CSF  discrimination of sensory impulses to pain, touch, pressure,
I. Brain Mass heat, cold, numbness.
PARTS OF THE BRAIN 4. Occipital
1. CEREBRUM  for vision
 largest part Insula (Island of Reil)
 composed of the Right Cerebral Hemisphere and Left  visceral function activities of internal organ like gastric
Cerebral Hemisphere enclosed in the Corpus Callosum. motility.
Functions of Cerebrum Limbic System (Rhinencephalon)
 integrative  controls smell and if damaged results to Anosmia (absence
 sensory of smell).
 motor  controls libido
Lobes of Cerebrum  controls long term memory
1. Frontal
 higher cortical thinking 2. BASAL GAGLIA
 controls personality  areas of grey matter located deep within each cerebral
hemisphere.
 controls motor activity
 release dopamine (controls gross voluntary movement.
 Broca’s Area (motor speech area) when damaged results to
garbled speech.
NEURO TRANSMITTER DECREASE INCREASE

Acethylcholine Myasthenia Gravis Bi-polar Disorder
3
Dopamine Parkinson’s Disease Schizophrenia
3. MIDBRAIN/ MESENCEPHALON  androgenic hormones promotes secondary sex

 acts as relay station for sight and hearing. characteristics.
 size of pupil is 2 – 3 mm.  early sign for males are testicular and penile enlargement
 equal size of pupil is isocoria.  late sign is deepening of voice.
 unequal size of pupil is anisocoria.  early sign for females telarche and late sign is menarche.
 hearing acuity is 30 – 40 dB.

5. BRAIN STEM
 positive PERRLA
 located at lowest part of brain
4. INTERBRAIN/ DIENCEPHALON Parts of Brain Stem
Parts of Diencephalon 1. Pons
A. Thalamus  pneumotaxic center controls the rate, rhythm and depth of
 acts as relay station for sensation. respiration.

2. Medulla Oblongata
B. Hypothalamus
 controls temperature (thermoregulatory center).
 controls respiration, heart rate, swallowing, vomiting,
hiccup, vasomotor center (dilation and constriction of
 controls blood pressure
bronchioles).
 controls thirst
 appetite/satiety
 sleep and wakefulness 3. Cerebellum
 controls some emotional responses like fear, anxiety and  smallest part of the brain.
excitement.  lesser brain.
 controls pituitary functions  controls balance, equilibrium, posture and gait.
INTRA CRANIAL PRESSURE
Monroe Kellie Hypothesis
Skull is a closed container
Any alteration or increase in one of the intracranial components
Increase intra-cranial pressure

(normal ICP is 0 – 15 mmHg)
Cervical 1 – also known as ATLAS.

Cervical 2 – also known as AXIS.
Foramen Magnum
Medulla Oblongata
Brain Herniation
Increase intra cranial pressure

* Alternate hot and cold compress to prevent HEMATOMA
 CSF cushions brain (shock absorber)

 Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus.
 Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.
NEUROLOGIC DISORDERS Causes:

INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought
about by an increase in one of the 3 major intra cranial components.
 head trauma/injury  inflammatory condition (stroke)
 localized abscess  hydrocephalus
 cerebral edema  tumor (rarely)
 hemorrhage
Signs and Symptoms (Early)
 decrease LOC  lethargy/stupor
 restlessness/agitation  coma
 irritability
Signs and Symptoms (Late)  abnormal posturing
 changes in vital signs  decorticate posturing (damage to cortex and spinal cord).
 blood pressure (systolic blood pressure increases but  decerebrate posturing (damage to upper brain stem that
diastolic remains the same). includes pons, cerebellum and midbrain).
 widening of pulse pressure is neurologic in nature (if  unilateral dilation of pupils called uncal herniation
narrow cardiac in nature).
 bilateral dilation of pupils called tentorial herniation
 heart rate decrease
 resulting to mild headache
 respiratory rate decrease
 possible seizure activity
 temperature increase directly proportional to blood
pressure.
Nursing Management
 projective vomiting 1. Maintain patent and adequate ventilation by:
 headache a. Prevention of hypoxia and hypercarbia
 papilledema (edema of optic disc) Early signs of hypoxia

 restlessness
4
 agitation  given early morning
 tachycardia  immediate effect of 10 – 15 minutes.

Late signs of hypoxia  maximum effect of 6 hours.
 Bradycardia c. Corticosteroids
 Extreme restlessness  Dexamethasone (Decadron)
 Dyspnea  Hydrocortisone
 Cyanosis  Prednisone (to reduce edema that may lead to increase

HYPERCARBIA ICP)
 Increase CO2 (most powerful respiratory stimulant)  Mild Analgesics (Codeine Sulfate for respiratory
retention. depression)
 In chronic respiratory distress syndrome decrease O2  Anti Convulsants (Dilantin, Phenytoin)

stimulates respiration.
b. Before and after suctioning hyper oxygenate client 100% and *CONGESTIVE HEART FAILURE
done 10 – 15 seconds only. Signs and Symptoms
c. Assist in mechanical ventilation  dyspnea
2. Elevate bed of client 30 – 35 o angle with neck in neutral position unless  orthopnea
contraindicated to promote venous drainage.
 paroxysmal nocturnal dyspnea
3. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day).
4. Monitor strictly input and output and neuro check
 productive cough
5. Prevent complications of  frothy salivation
6. Prevent further increase ICP by:  cyanosis

a. provide an comfortable and quite environment.  rales/crackles
b. avoid use of restraints.
 bronchial wheezing
c. maintain side rails.
 pulsus alternans
d. instruct client to avoid forms of valsalva maneuver like:
 straining stool
 anorexia and general body malaise
 excessive vomiting (use anti emetics)

 PMI (point of maximum impulse/apical pulse rate) is
displaced laterally
 excessive coughing (use anti tussive like
 S3 (ventricular gallop)
dextromethorphan)
 avoid stooping/bending
 Predisposing Factors/Mitral Valve
 RHD
 avoid lifting heavy objects
 Aging
e. avoid clustering of nursing activity together.
TREATMENT
Morphine Sulfate
7. Administer medications like:
Aminophelline
a. Osmotic diuretic (Mannitol)
Digoxin
 for cerebral diuresis
Diuretics
Nursing Management
Oxygen
 monitor vital signs especially BP (hypotension). Gases, blood monitor
 monitor strictly input and output every 1 hour notify
physician if output is less 30 RIGHT CONGESTIVE HEART FAILURE (Venous congestion)
cc/hr. Signs and Symptoms
 administered via side drip  jugular vein distention (neck)
 regulated fast drip to prevent crystal formation.  ascites

b. Loop diuretic (Lasix, Furosemide)  pitting edema
 Drug of choice for CHF (pulmonary edema)  weight gain
 Loop of Henle in kidneys.  hepatosplenomegaly
Nursing Management  jaundice
 Monitor vital signs especially BP (hypotension).
 pruritus
 monitor strictly input and output every 1 hour notify
 esophageal varices
physician if output is less 30 cc/hr.
 anorexia and general body malaise
 administered IV push or oral.
Signs and Symptoms of Lasix in terms of electrolyte imbalances

1. Hypokalemia
 decrease potassium level
 normal value is 3.4 – 5.5 meq/L

Sign and Symptoms
 weakness and fatigue
 constipation
 positive U wave on ECG tracing

Nursing Management
 administer potassium supplements as ordered (Kalium Durule, Oral Potassium Chloride)
 increase intake of foods rich in potassium

FRUITS VEGETABLES
Apple Asparagus
Banana Brocolli
Cantalope Carrots
Oranges Spinach
2. Hypocalcemia/ Tetany
 decrease calcium level
 normal value is 8.5 – 11 mg/100 ml

Signs and Symptoms
5
 tingling sensation
 paresthesia
 numbness
 (+) Trousseau’s sign/ Carpopedal spasm
 (+) Chvostek’s sign

Complications
 Arrhythmia
 Seizures
Nursing Management
 Calcium Gluconate per IV slowly as ordered
* Calcium Gluconate toxicity – results to SEIZURE
Magnesium Sulfate
Magnesium Sulfate toxicity

S/S
BP
Urine output DECREASE
Respiratory rate
Patellar relfex absent
3. Hyponatremia
 decrease sodium level
 normal value is 135 – 145 meq/L

Signs and Symptoms
 hypotension
 dehydration signs (Initial sign in adult is THIRST, in infant TACHYCARDIA)
 agitation
 dry mucous membrane
 poor skin turgor
 weakness and fatigue
Nursing Management
 force fluids
 administer isotonic fluid solution as ordered

a. Allopurinol (Zyloprim)
4. Hyperglycemia  Drug of choice for gout.
 normal FBS is 80 – 100 mg/dl  Mechanism of action: inhibits synthesis of uric acid.
Signs and Symptoms b. Colchecine
 polyuria  Acute gout
 polydypsia  Mechanism of action: promotes excretion
 polyphagia of uric acid.
Nursing Management * KIDNEY STONES
 monitor FBS Signs and Symptoms

 renal colic
5. Hyperuricemia  Cool moist skin

 increase uric acid (purine metabolism) Nursing Management
 foods high in uric acid (sardines, organ meats and  force fluids
anchovies)  administer medications as ordered
 *Increase in tophi deposit leads to Gouty arthritis. a. Narcotic Analgesic
Signs and Symptoms  Morphine Sulfate
 joint pain (great toes)  ANTIDOTE: Naloxone (Narcan) toxicity
 swelling leads to tremors.
Nursing Management b. Allopurinol (Zyloprim)
 force fluids Side Effects
 administer medications as ordered  Respiratory depression (check for RR)
6
PARKINSON’S DISEASE/ PARKINSONISM
 Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia.
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
2. Arteriosclerosis
3. Hypoxia
4. Encephalitis
5. Increase dosage of the following drugs:
a. Reserpine(Serpasil)
b. Methyldopa(Aldomet) AntihypertensiveS
c. Haloperidol(Haldol)
d. Phenothiazine AntipsychoticS
SIDE EFFECTS RESERPINE  Major depression leading to suicide
Aloneness
Multiple loss
Loss of spouse
causes suicide Loss of Job
 direct approach towards the client
 close surveillance is a nursing priority
 time to commit suicide is on weekends early morning

 arrhythmia
Signs and Symptoms for Parkinson’s  hallucinations
 pill rolling tremors of extremities especially the hands. Contraindications
 bradykinesia (slowness of movement)  clients with narrow angle closure glaucoma
 rigidity (cogwheel type)  clients taking MAOI’s (no foods with triptophan and
 stooped posture thiamine)
 shuffling and propulsive gait  urine and stool may be darkened
 over fatigue  no Vitamin B6 (Pyridoxine) reverses the therapeutic
 mask like facial expression with decrease blinking of the effects of Levodopa
eyes.
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide
 difficulty rising from sitting position.
 Monotone type speech

Anti Cholinergic Agents (ARTANE and COGENTIN) - to relieve tremors
 mood lability (in state of depression) Mechanism of Action
 increase salivation (drooling type)  inhibits action of acethylcholine
 autonomic changes Side Effects
a. increase sweating  SNS
b. increase lacrimation
c. seborrhea Anti Histamine (Dipenhydramine Hydrochloride)
d. constipation Side Effects
e. decrease sexual capacity Adult: drowsiness
Nursing Management Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully
1. Administer medications as ordered developed.
Anti Parkinsonian agents Dopamine Agonist - relieves tremor rigidity
 Levodopa (L-dopa) short acting Bromocriptene Hydrochloride (Parlodel)
 Amantadine Hydrochloride (Symmetrel) Side Effects
 Carbidopa (Sinemet)  Respiratory depression
Mechanism of Action 2. Maintain side rails to prevent injury
 increase level of dopamine 3. Prevent complications of immobility

4. Decrease protein in morning and increase protein in afternoon to induce sleep
Side Effects
5. Encourage increase fluid intake and fiber.
 GIT irritation (should be taken with meals
6. Assist/supervise in ambulation
 orthostatic hypotension
7. Assist in Stereotaxic Thalamotomy
MAGIC 2’s IN DRUG MONITORING

DRUG NORMAL RANGE TOXICITY INDICATION CLASSIFICATION
LEVEL
Digoxin/ Lanoxin .5 – 1.5 meq/L 2 CHF Cardiac Glycoside
(Increase force of
cardiac output)
Lithium/ Lithane .6 – 1.2 meq/L 2 Bipolar Anti-Manic Agents
(Decrease level of
Ach/NE/Serotonin)
Aminophylline 10 – 19 mg/100 ml 20 COPD Bronchodilators
(Dilates bronchial tree)
Dilantin/ Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-Convulsant
Acetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteo Non-narcotic Analgesic
Arthritis
Nursing Management
1. Digitalis Toxicity  only mixed with plain NSS or 0.9 NaCl to prevent
Signs and Symptoms development of crystals or precipitate.
 nausea and vomiting  administered sandwich method
 diarrhea  avoid taking alcohol because it can lead to severe CNS
 confusion depression
 photophobia  avoid caffeine
 changes in color perception (yellowish spots)

4. Dilantin Toxicity
Antidote: Digibind
Signs and Symptoms
2. Lithium Toxicity
Signs and Symptoms  gingival hyperplasia (swollen gums)
 anorexia  hairy tongue
 nausea and vomiting  ataxia
 diarrhea  nystagmus
 dehydration causing fine tremors Nursing Management
 hypothyroidism
 provide oral care
Nursing Management  massage gums
 force fluids
5. Acetaminophen Toxicity
 increase sodium intake to 4 – 10 g% daily
Signs and Symptoms
 hepatotoxicity (monitor for liver enzymes)
3. Aminophylline Toxicity
Signs and Symptoms  SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
 tachycardia  SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
 palpitations  nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 –
 CNS excitement (tremors, irritability, agitation and 1)
restlessness)  hypoglycemia
Tremors, tachycardia
Irritability  initial sign is ptosis a clinical parameter to determine
Restlessness ptosis is palpebral fissure.
Extreme fatigue  diplipia
Diaphoresis, depression
 mask like facial expression
Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.
 dysphagia
MYASTHENIA GRAVIS
 neuromuscular disorder characterized by a disturbance in
 hoarseness of voice
the transmission of impulses from nerve to muscle cells at  respiratory muscle weakness that may lead to respiratory
the neuromuscular junction leading to descending muscle arrest

weakness.  extreme muscle weakness especially during exertion and
Incidence rate: women 20 – 40 years old morning
Predisposing factors Diagnostic Procedure
 unknown  Tensilon test (Edrophonium Hydrochloride) provides
 autoimmune: it involves release of cholinesterase an temporary relief of signs and symptoms for about 5 – 10
enzyme that destroys Ach. minutes and a maximum of 15 minutes.
Signs and Symptoms  if there is no effect there is damage to

occipital lobe and midbrain and is negative
for M.G.
Nursing Management
1. airway
2. aspiration maintain patent airway and adequate ventilation
3. mmobility
* assist in mechanical ventilation and monitor pulmonary function test
* monitor strictly vital signs, input and output and neuro check
* monitor strength or motor grading scale
4. maintain side rails to prevent injury related to falls
5. institute NGT feeding
6. administer medications as ordered
a. Cholinergic (Mestinon)
b. Anti Cholenisterase (Neostegmin)
Mechanism of Action
 increase level of Ach
Side Effects
 PNS
 Cortocosteroids suppress immune response
 monitor for 2 types of crisis:

MYASTHENIC CRISIS CHOLINERGIC CRISIS
Causes: Cause:
- under medication - over medication
- stress
- infection
Signs and Symptoms Signs and Symptoms
- The client is unable to see, swallow, speak, breathe - PNS
Treatment
- administer cholinergic agents as ordered Treatment
- Administer anti cholinergic agents
(Atropine Sulfate)
7. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.G.
8. Assist in plasma paresis and removing auto immune anti bodies
9. Prevent complications
INFLAMMATORY CONDITIONS OF THE BRAIN  fever, chills, anorexia, general body malaise and weight
MENINGITIS loss
Meninges  Possible increase in ICP and seizure activity
 3 fold membrane that covers brain and spinal
 Abnormal posturing (decorticate and decerebrate)
cord.
 Signs of meningeal irritation
 for support and protection
a. Nuchal rigidity or stiff neck
 for nourishment b. Opisthotonus (arching of back)
 blood supply c. (+) Kernig’s sign (leg pain)
LAYERS OF THE MENINGES d. (+) Brudzinski sign (neck pain)
1. Dura matter – outer layer
2. Arachnoid – middle layer D. Diagnostic Procedures
3. Pia matter – inner layer  Lumbar puncture: a hollow spinal needle is inserted in the
 subdural space between the dura and subarachnoid space between the L3 – L4 to L5.
arachnoid Nursing Management for LP
 subarachnoid space between the arachnoid Before Lumbar Puncture
1. Secure informed consent and explain procedure.
and pia, CSF aspiration is done. 2. Empty bladder and bowel to promote comfort.
3. Encourage to arch back to clearly visualize L3-L4.
Post Lumbar Puncture
A. Etiology 1. Place flat on bed 12 – 24 o
1. Meningococcus – most dangerous 2. Force fluids
3. Check punctured site for any discoloration, drainage and leakage to tissues.
2. Pneumococcus 4. Assess for movement and sensation of extremities.
3. Streptococcus - causes adult meningitis CSF analysis reveals
1. Increase CHON and WBC
4. Hemophilus Influenzae – causes pediatric meningitis 2. Decrease glucose
3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)
4. (+) cultured microorganism (confirms meningitis)
B. Mode of transmission
 airborne transmission (droplet nuclei) CBC reveals
1. Increase wbc
C. Signs and Symptoms
 headache E. Nursing Management
 photophobia 1. Enforce complete bed rest

2. Administer medications as ordered
 projectile vomiting
a. Broad spectrum antibiotics (Penicillin, Tetracycline)  paresis (plegia)
b. Mild analgesics  possible increase ICP
c. Anti pyretics
2. Stroke in evolution
3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy
o
 progression of signs and symptoms of stroke
4. Elevate head 30-45
3. Complete stroke
5. Monitor strictly V/S, input and output and neuro check
6. Institute measures to prevent increase ICP and seizure.
 resolution phase characterized by:
7. Provide a comfortable and darkened environment. Signs and Symptoms
8. Maintain fluid and electrolyte balance.  headache and dizziness
9. Provide client health care and discharge planning concerning:  Cheyne Stokes Respiration
a. Maintain good diet of increase CHO, CHON, calories with small  anorexia, nausea and vomiting
frequent feedings.
 dysphagia
b. Prevent complications
 (+) Kernig’s sign and Brudzinski sign which may lead to
 most feared is hydrocephalus
hemorrhagic stroke
 hearing loss/nerve deafness is second complication
 focal neurological deficits
 consult audiologist
a. phlegia
c. Rehabilitation for neurological deficit b. aphasia
 mental retardation c. dysarthria (inability to articulate words)
 delayed psychomotor development d. alexia (difficulty reading)
e. agraphia (difficulty writing)
CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) f. homonymous hemianopsia (loss of half of
 a partial or complete disruption in the brains blood supply. visual field)

E. Diagnostic Procedure
 2 most common cerebral artery affected by stroke
1. CT Scan – reveals brain lesions
a. Mid Cerebral Artery
2. Cerebral Arteriography
b. Internal Cerebral Artery – the 2 largest artery
 reveals the site and extent of malocclusion
A. Incidence Rate
 men are 2-3 times high risk
 uses dye for visualization
 most of dye are iodine based
B. Predisposing Factors  check for shellfish allergy

 thrombus (attached)  after diagnostic exam force fluids to release dye because it
 embolus (detached and most dangerous because it can go is nephro toxic
to the lungs and cause pulmonary embolism or the brain  check for distal pulse (femoral)
and cause cerebral embolism.  check for hematoma formation
Signs and Symptoms of Pulmonary Embolism F. Nursing Management

 Sudden sharp chest pain 1. Maintain patent airway and adequate ventilation by:
 Unexplained dyspnea a. assist in mechanical ventilation
 Tachycardia b. administrate O2 inhalation

2. Restrict fluids to prevent cerebral edema that might increase ICP
 Palpitations
3. Elevate head 30 – 45o
 Diaphoresis
4. Monitor strictly vitals signs, I & O and neuro check
 Mild restlessness 5. Prevent complications of immobility by:
Signs and Symptoms of Cerebral Embolism a. turn client to side
 Headache and dizziness b. provide egg crate mattresses or water bed
 Confusion c. provide sand bag or food board.

6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment
 Restlessness
and prevent contractures
 Decrease LOC
7. Institute NGT feeding
8. Provide alternative means of communication
 Fat embolism is the most feared complications after femur fracture.
a. non verbal cues
 Yellow bone marrow are produced from the medullary cavity of the long bones
b. magic slate
and produces fat cells.
9. If positive to hemianopsia approach client on unaffected side
 If there is bone fracture there is hemorrhage and there would be escape of the
fat cells in the circulation.
a. Osmotic Diuretics (Mannitol)
 Compartment syndrome (compression of arteries and nerves)
b. Loop Diuretics (Lasix, Furosemide)
c. Cortecosteroids
C. Risk Factors
d. Mild Analgesics
1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular
e. Thrombolytic/Fibrinolytic Agents – dissolves thrombus
Heart Disease, Post Cardiac Surgery (mitral valve replacement)
 Streptokinase
2. Lifestyle (smoking), sedentary lifestyle
 Side Effect: Allergic
3. Obesity (increase 20% ideal body weight)
Reaction
4. Hyperlipidemia more on genetics/genes that binds to cholesterol
5. Type A personality
 Urokinase
a. deadline driven  Tissue Plasminogen Activating Factor

b. can do multiple tasks  Side Effect: Chest Pain
c. usually fells guilty when not doing anything f. Anti Coagulants
6. Related to diet: increase intake of saturated fats like whole milk  Heparin (short acting)
7. Related stress physical and emotional  check for partial thromboplastin time
8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading if prolonged there is a
to atherosclerosis that will lead to hypertension and eventually CVA. risk for bleeding.
 give Protamine Sulfate
D. Signs and Symptoms  Comadin/ Warfarin (long acting)
 dependent on stages of development  give simultaneously because
1. TIA Coumadin will take
 Initial sign of stroke or warning sign effect after 3 days
Signs and Symptoms  check for prothrombin time if
 headache and dizziness prolonged there is a risk

for bleeding
 tinnitus
 give Vit. K (Aqua Mephyton)
 visual and speech disturbances
g. Anti Platelet alternation in sensation and perception and changes in
 PASA (Aspirin) behavior.
 Contraindicated for dengue, ulcer and  Seizure – first convulsive attack
unknown cause of headache because it may  Epilepsy – second or series of attacks

potentiate bleeding  Febrile seizure – normal in children age below 5 years
11. Provide client health teachings and discharge planning concerning
a. avoidance of modifiable risk factors (diet, exercise, smoking) A. Predisposing Factors
b. prevent complication (subarachnoid hemorrhage is the most feared 1. Head injury due to birth trauma
complication) 2. Genetics
c. dietary modification (decrease salt, saturated fats and caffeine) 3. Presence of brain tumor
d. importance of follow up care 4. Toxicity from
a. lead
b carbon monoxide
5. Nutritional and Metabolic deficiencies
6. Physical and emotional stress
7. Sudden withdrawal to anti convulsant drug is predisposing factor for status
epilepticus (drug of choice is Diazepam, Valium)
B. Signs and Symptoms

GUILLAIN BARRE SYNDROME
 Dependent on stages of development or types of seizure
 a disorder of the CNS characterized by bilateral symmetrical polyneuritis
I. Generalized Seizure
leading to ascending muscle paralysis.
1. Grand mal Seizure (tonic-clonic seizure)
a. Signs or aura with auditory, olfactory, visual, tactile, sensory
A. Predisposing Factors
experience
1. Autoimmune
b. Epileptic cry – is characterized by fall and loss of consciousness for 3
2. Antecedent viral infections such as LRT infections
– 5 minutes
c. Tonic contractions - direct symmetrical extension of extremities
1. Clumsiness (initial sign)
Clonic contractions - contraction of extremities
2. Dysphagia
d. Post ictal sleep – unresponsive sleep
3. Ascending muscle weakness leading to paralysis
2. Petit mal Seizure – absence of seizure common among pediatric clients
4. Decreased of diminished deep tendon reflex
characterized by
5. Alternate hypotension to hypertension
a. blank stare
** ARRYTHMIA (most feared complication)
b. decrease blinking of eyes
6. Autonomic symptoms that includes
c. twitching of mouth
a. increase salivation
d. loss of consciousness (5 – 10 seconds)
b. increase sweating
c. constipation
II. Partial or Localized Seizure
1. Jacksonian Seizure (focal seizure)
C. Diagnostic Procedures
 Characterized by tingling and jerky movement of index
1. CSF analysis reveals increase in IgG and protein
finger and thumb that spreads to the shoulder and other side of the body.
2. Psychomotor Seizure (focal motor seizure)
D. Nursing Management
a. automatism – stereotype repetitive and non propulsive behavior
1. Maintain patent airway and adequate ventilation by:
b. clouding of consciousness – not in contact with environment
a. assist in mechanical ventilation
c. mild hallucinatory sensory experience
b. monitor pulmonary function test
2. Monitor strictly the following
III. Status Epilepticus
a. vital signs
 A continuous uninterrupted seizure activity, if left
b. intake and output
untreated can lead to hyperpyrexia and lead to coma and
c. neuro check
eventually death.
d. ECG
3. Maintain side rails to prevent injury related to fall
 Drug of choice: Diazepam, Valium and Glucose
4. Prevent complications of immobility by turning the client every 2 hours

5. Institute NGT feeding to prevent aspiration C. Diagnostic Procedures
6. Assist in passive ROM exercise 1. CT Scan – reveals brain lesions
7. Administer medications as ordered 2. EEG – reveals hyper activity of electrical brain waves
a. Corticosteroids – suppress immune response

b. Anti Cholinergic Agents – Atrophine Sulfate
c. Anti Arrythmic Agents D. Nursing Management
1. Maintain patent airway and promote safety before seizure activity
 Lidocaine, Zylocaine
a. clear the site of blunt or sharp objects
 Bretylium – blocks release of norepinephrine to prevent
b. loosen clothing of client
increase of BP
c. maintain side rails
8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies)
d. avoid use of restrains
9. Prevent complications
e. turn clients head to side to prevent aspiration
a. Arrythmia
f. place mouth piece of tongue guard to prevent biting or tongue
b. Paralysis or respiratory muscles/Respiratory arrest
2. Avoid precipitating stimulus such as bright/glaring lights and noise
* Sengstaken Blakemore Tube
a. Anti convulsants (Dilantin, Phenytoin)
 for liver cirrhosis
b. Diazepam, Valium
 to decompress bleeding esophageal verices (prepare scissor c. Carbamazepine (Tegretol) – Trigeminal neuralgia
to cut tube incase of difficulty in breathing to release air in d. Phenobarbital, Luminal
the balloon 4. Institute seizure and safety precaution post seizure attack
 for hemodialysis prepare bulldog clips to prevent air a. administer O2 inhalation
embolism. b. provide suction apparatus
5. Document and monitor the following
a. onset and duration
CONVULSIVE DISORDER/ CONVULSION b. types of seizures
 disorder of CNS characterized by paroxysmal seizure with c. duration of post ictal sleep may lead to status epilepticus
or without loss of consciousness abnormal motor activity d. assist in surgical procedure cortical resection
COMPREHENSIVE NEURO EXAM

GLASGOW COMA SCALE
 objective measurement of LOC sometimes called as the quick neuro check
Components
1. Motor response
2. Verbal response
3. Eye opening
Conscious 15 – 14
Lethargy 13 – 11
Stupor 10 – 8
Coma 7
 Survey of mentalDeep
status andComa
speech 3
a. LOC  light coma (positive to all forms of painful stimulus)

b. Test of memory  deep coma (negative to all forms of painful stimulus)
 Levels of orientation
 Cranial nerve assessment DIFFERENT PAINFUL STIMULATION

 Sensory nerve assessment 1. Deep sternal stimulation/ deep sternal pressure
 Motor nerve assessment 2. Orbital pressure

3. Pressure on great toes
 Deep tendon reflex
4. Corneal or blinking reflex
 Autonimics
 Conscious client use a
 Cerebellar test wisp of cotton
a, Romberg’s test – 2 nurses, positive for  Unconscious client
ataxia place 1 drop of saline
b. Finger to nose test – positive result mean solution
dimetria
(inability of body to II. TEST OF MEMORY
stop movement at desired point) 1. Short term memory
c. Alternate supination and pronation –  ask most recent activity
positive result mean dimetria
 positive result mean anterograde amnesia and damage to
temporal lobe
2. Long term memory
I. LEVEL OF CONSCIOUSNESS
 ask for birthday and validate on profile sheet
1. Conscious - awake
2. Lethargy – lethargic (drowsy, sleepy, obtunded)
 positive result mean retrograde amnesia and damage to
limbic system
3. Stupor
 stuporous (awakened by vigorous stimulation)
 consider educational background
 generalized body weakness

III. LEVELS OF ORIENTATION
 decrease body reflex
1. Time – first asked
4. Coma
2. Person – second asked
 comatose 3. Place – third asked
CRANIAL NERVES
CRANIAL NERVES FUNCTION
I. OLFACTORY S
II. OPTIC S
III OCCULOMOTOR M
IV. TROCHLEAR M (Smallest)
V. TRIGEMINAL B (Largest)
VI. ABDUCENSE M
VII. FACIAL B
VIII. ACOUSTIC S
IX. GLOSSOPHARYNGEAL B
X. VAGUS B (Longest)
XI. SPINAL ACCESSORY M
XII. HYPOGLOSSAL M
CRANIAL NERVE I: OLFACTORY  Snellen’s Alphabet chart: for literate clients
 sensory function for smell  Snellen’s E chart: for illiterate clients
Material Used  Snellen’s Animal chart: for pediatric clients
 don’t use alcohol, ammonia, perfume because it is irritating
 normal visual acuity 20/20
and highly diffusible.
 numerator is constant, it is the distance of person from the
 use coffee granules, vinegar, bar of soap, cigarette
chart (6 – 7 m, 20 feet)
Procedure
 denominator changes, indicates distance by which the
 test each nostril by occluding each nostril
person normally can see letter in the chart.
Abnormal Findings
 - 20/200 indicates blindness
1. Hyposnia – decrease sensitivity to smell
 20/20 visual acuity if client is able to read letters above the
2. Dysosmia – distorted sense of smell
red line.
3. Anosmia – absence of smell
2. Test of visual field or peripheral vision
Indicative of
a. Superiorly
1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells
b. Bitemporaly
are located
c. Nasally
2. may indicate inflammatory conditions (sinusitis)
d. Inferiorly
CRANIAL NERVE II: OPTIC

COMMON VISUAL DISORDERS
 sensory function for vision or sight
1. Glaucoma
Functions
 increase IOP
1. Test visual acuity or central vision or distance
 normal IOP is 12 – 21 mmHg
 use Snellen’s Chart
 preventable but not curable
A. Predisposing Factors E. Surgical Procedures
 Common among 40 years old and above 1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor
 Hereditary
 Hypertension
2. Cataract
 Obesity  Decrease opacity of lens
B. Signs and Symptoms A. Predisposing Factor
1. Loss of peripheral vision 1. Aging 65 years and above
 pathognomonic sign is tunnel vision 2. Related to congenital
2. Headache, nausea, vomiting, eye pain (halos around light) 3. Diabetes Mellitus
 steamy cornea 4. Prolonged exposure to UV rays
 may lead to blindness

1. Loss of central vision
C. Pathognomonic Signs
1. Tonometry
1. Blurring or hazy vision
2. Perimetry
2. Milky white appearance at center of pupils
3. Gonioscopy
3. Decrease perception to colors
D. Treatment  Complication is blindness
1. Miotics – constricts pupil

a. Pilocarpine Sodium, Carbachol D. Diagnostic Procedure
2. Epinephrine eyedrops – decrease formation of aqueous humor 1. Opthalmoscopic exam
3. Carbonic Anhydrase Inhibitors
a. Acetazolamide (Diamox) – promotes increase outflow of aqueous E. Treatment
humor or drainage 1. Mydriatics (Mydriacyl) – constricts pupils
4. Timoptics (Timolol Maleate) 2. Cyclopegics (Cyclogyl) – paralyses cilliary muscle
1. Post Lens Extraction
F. Surgical Procedure 2. Myopia (near sightedness)
Extra Intra
Capsular Capsular B. Signs and Symptoms
Cataract Cataract 1. Curtain veil like vision
Lens Lens 2. Floaters
Extraction Extraction
- Partial removal - Total removal of cataract with its C. Surgical Procedures
surrounding capsules 1. Scleral Buckling
 Most feared complication post op is RETINAL DETACHMENT 2. Cryosurgery – cold application
3. Diathermy – heat application
4. Macular Degeneration
 Degeneration of the macula lutea (yellowish spot at the
3. Retinal Detachment center of retina)
 Separation of epithelial surface of retina

A. Signs and Symptoms
A. Predisposing Factors 1. Black Spots
CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

 Controls or innervates the movement of extrinsic ocular muscle (EOM)
 6 muscles
Superior Rectus Superior Oblique
Lateral Rectus Medial Rectus
Inferior Oblique Inferior Rectus
 trochlear controls superior oblique
 abducens controls lateral rectus
 oculomotor controls the 4 remaining EOM
Oculomotor
 controls the size and response of pupil
 normal pupil size is 2 – 3 mm
 equal size of pupil: Isocoria
 Unequal size of pupil: Anisocoria
 Normal response: positive PERRLA
CRANIAL NERVE V: TRIGEMINAL

 largest cranial nerve o initiates milk let down reflex with help of
 consists of ophthalmic, maxillary, mandibular hormone prolactin
 sensory: controls sensation of face, mucous membrane,

2. Antidiuretic Hormone
teeth, soft palate and corneal reflex)
o Pitressin (Vasopressin)
 motor: controls the muscle of mastication or chewing
o Function: prevents urination thereby conserving water
 damage to CN V leads to trigeminal
o Diabetes Insipidus/ Syndrome of Inappropriate Anti
neuralgia/thickdolorum
Diuretic Hormone
 medication: Carbamezapine(Tegretol)
DIABETES INSIPIDUS
CRANIAL NERVE VII: FACIAL o Decrease production of anti diuretic hormone
 Sensory: controls taste, anterior 2/3 of tongue
 pinch of sugar and cotton applicator placed on tip of A. Predisposing Factor

tongue o Related to pituitary surgery
 Motor: controls muscle of facial expression o Trauma
 instruct client to smile, frown and if results are negative o Inflammation
there is facial paralysis or Bell’s Palsy and the primary o Presence of tumor
cause is forcep delivery. B. Signs and Symptoms
1. Polyuria
CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR 2. Signs of dehydration
 Controls balance particularly kinesthesia or position sense, a. Adult: thirst
refers to movement and orientation of the body in space. b. Agitation
Parts of the Ear c. Poor Skin turgor
1. Outer Ear d. Dry mucous membrane
 Pinna 3. Weakness and fatigue

4. Hypotension
 Eardrum
5. Weight loss
2. Middle Ear
6. If left untreated results to hypovolemic shock (sign is anuria)
 Hammer Malleus
 Anvil Incus 1. Urine Specific Gravity
 Stirrup Stapes o Normal value: 1.015 – 1.030
3. Inner Ear o Ph 4 – 8
 Vestibule: Meinere’s Disease 2. Serum Sodium
 Cochlea o Increase resulting to hypernatremia

 Mastoid Cells
1. Force fluids
 Endolymph and Perilymph
2. Monitor strictly vital signs and intake and output
 COCHLEA: controls hearing, contains the Organ of Corti (the true organ of
hearing)
a. Pitressin (Vasopresin Tannate) – administered IM Z-tract
 Let client repeat words uttered
4. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared
complication
CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE
 Glosopharyngeal: controls taste, posterior 1/3 of tongue
 Vagus: controls gag reflex SIADH

 Uvula should be midline and if not indicative of damage to o hypersecretion of anti diuretic hormone
cerebral hemisphere
 Effects of vagal stimulation is PNS A. Predisposing Factors
1. Head injury
CRANIAL NERVE XI: SPINAL ACCESSORY 2. Related to presence of bronchogenic cancer

o initial sign of lung cancer is non productive cough
 Innervates with sternocleidomastoid (neck) and trapezius
(shoulder) o non invasive procedure is chest x-ray
3. Related to hyperplasia (increase size of organ brought about by increase of number
CRANIAL NERVE XII: HYPOGLOSSAL of cells) of pituitary gland.
 Controls the movement of tongue

 Let client protrude tongue and it should be midline and if
1. Fluid retention
unable to do indicative of damage to cerebral hemisphere
a. Hypertension
and/or has short frenulum.
b. Edema
c. Weight gain
2. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead
to seizure activity
C. Diagnostic Procedure
1. Urine specific gravity is increased
ENDOCRINE SYSTEM
2. Serum Sodium is decreased
Overview of the structures and functions
1. Pituitary Gland (Hypophysis Cerebri)
o Located at base of brain particularly at sella turcica
1. Restrict fluid
o Master gland or master clock
o Controls all metabolic function of body
a. Loop diuretics (Lasix)
PARTS OF THE PITUITARY GLAND b. Osmotic diuretics (Mannitol)
1. Anterior Pituitary Gland 3. Monitor strictly vital signs, intake and output and neuro check
o called as adenohypophysis 4. Weigh patient daily and assess for pitting edema
2. Posterior Pituitary Gland 5. Provide meticulous skin care
o called as neurohypophysis 6. Prevent complications
o secretes hormones oxytocin -promotes
uterine contractions preventing bleeding/ hemorrhage ANTERIOR PITUITARY GLAND
o administrate oxytocin immediately after o also called ADENOHYPOPHYSIS secretes
delivery to prevent uterine atony. 1. Growth hormones (somatotropic hormone)
o Promotes elongation of long bones
o Hyposecretion of GH among children results to Dwarfism
o Hypersecretion of GH results to Gigantism B. Signs and Symptoms
o Hypersecretion of GH among adults results to 1. Enlarged thyroid gland
Acromegaly (square face) 2. Mild dysphagia
o Drug of choice: Ocreotide (Sandostatin) 3. Mild restlessness
2. Melanocyte Stimulating hormone C. Diagnostic Procedures
o for skin pigmentation 1. Serum T3 and T4 – reveals normal or below normal

2. Thyroid Scan – reveals enlarged thyroid gland.
o Hyposecretion of MSH results to Albinism
3. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic
o Most feared complications of albinism
test)
a. Lead to blindness due to severe photophobia
b. Prone to skin cancer
o Hypersecretion of MSH results to Vitiligo
1. Enforce complete bed rest
3. Adrenochorticotropic hormone (ACTH)
a. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine)
o promotes development of adrenal cortex
o color purple or violet and administered via straw to prevent
staining of teeth.
o 4 Medications to be taken via straw: Lugol’s, Iron,
4. Lactogenic homone (Prolactin)
Tetracycline, Nitrofurantoin (drug of choice for
o promotes development of mammary gland
pyelonephritis)
o with help of oxytocin it initiates milk let down reflex
b. Thyroid Hormones
5. Leutinizing hormone
o Levothyroxine (Synthroid)
o secretes estrogen
o Liothyronine (Cytomel)
6. Follicle stimulating hormone
o Thyroid Extracts
o secretes progesterone
Nursing Management when giving Thyroid Hormones
1. Instruct client to take in the morning to prevent insomnia
PINEAL GLAND
2. Monitor vital signs especially heart rate because drug causes
o secretes melatonin
tachycardia and palpitations
o inhibits LH secretion
3. Monitor side effects
o it controls/regulates circadian rhythm (body clock) o insomnia
o tachycardia and palpitations
THYROID GLAND
o hypertension
o located anterior to the neck
o heat intolerance
3 Hormones secreted
4. Increase dietary intake of foods rich in iodine
1. T3 (Tri iodothyronine) - 3 molecules of iodine (more potent)
o seaweeds
2. T4 (tetra iodothyronine, Thyroxine)
o seafood’s like oyster, crabs, clams and lobster but not
o T3 and T4 are metabolic or calorigenic hormone
shrimps because it contains lesser amount of iodine.
o promotes cerebration (thinking)
o iodized salt, best taken raw because it it is easily destroyed
3. Thyrocalcitonin – antagonizes the effects of parathormone to
by heat
promote calcium resorption.
5. Assist in surgical procedure of subtotal thyroidectomy
HYPOTHYROIDISM
HYPOTHYROIDISM
o all are decrease except weight and menstruation
o hyposecretion of thyroid hormone
o memory impairment
o adults: MYXEDEMA non pitting edema
Signs and Symptoms
o children: CRETINISM the only endocrine disorder that
o there is loss of appetite but there is weight gain
can lead to mental retardation
o menorrhagia
o cold intolerance
o constipation 1. Iatrogenic Cause – disease caused by medical intervention such as
surgery
HYPERTHYROIDISM 2. Related to atrophy of thyroid gland due to trauma, presence of
o all are increase except weight and menstruation tumor, inflammation
Signs and Symptoms 3. Iodine deficiency
o increase appetite but there is weight loss 4. Autoimmune (Hashimotos Disease)
o amenorrhea
o exophthalmos
THYROID DISORDERS (Early Signs)
SIMPLE GOITER 1. Weakness and fatigue
o enlargement of thyroid gland due to iodine deficiency 2. Loss of appetite but with weight gain which promotes lipolysis
leading to atherosclerosis and MI
A. Predisposing Factors 3. Dry skin
1. Goiter belt area 4. Cold intolerance
a. places far from sea 5. Constipation
b. Mountainous regions (Late Signs)
2. Increase intake of goitrogenic foods 1. Brittleness of hair and nails
o contains pro-goitrin an anti thyroid agent that has no 2. Non pitting edema (Myxedema)
iodine. 3. Hoarseness of voice
o cabbage, turnips, radish, strawberry, carrots, sweet potato, 4. Decrease libido
broccoli, all nuts 5. Decrease in all vital signs – hypotension, bradycardia, bradypnea,
o soil erosion washes away iodine hypothermia

6. CNS changes
o goitrogenic drugs
o lethargy
a. Anti Thyroid Agent – Prophylthiuracil
o memory impairment
(PTU)
b. Lithium Carbonate o psychosis
c. PASA (Aspirin) o menorrhagia
d. Cobalt
e. Phenylbutazones (NSAIDs) C. Diagnostic Procedures
- if goiter is caused by 1. Serum T3 and T4 is decreased
2. Serum Cholesterol is increased o infection
3. RAIU (Radio Active Iodine Uptake) is decreased o cold intolerance
o use of anesthetics, narcotics, and sedatives
D. Nursing Management o prevent complications (myxedema coma, hypovolemic
1. Monitor strictly vital signs and intake and output to determine shock
presence of o hormonal replacement therapy for lifetime
o Myxedema coma is a complication of hypothyroidism and
o importance of follow up care
an emergency case
HYPERTHYROIDISM
o a severe form of hypothyroidism is characterized by severe
o increase in T3 and T4
hypotension, bradycardia, bradypnea, hypoventilation,
o Grave’s Disease or Thyrotoxicosis
hyponatremia, hypoglycemia, hypothermia leading to
o developed by Robert Grave
pregressive stupor and coma.
Nursing Management for Myxedema Coma
 Assist in mechanical
1. Autoimmune – it involves release of long acting thyroid stimulator
ventilation
causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of
 Administer thyroid hormones
dehydration among infants)
as ordered
2. Excessive iodine intake
 Force fluids
3. Related to hyperplasia (increase size)
2. Force fluids
3. Administer isotonic fluid solution as ordered
1. Increase appetite (hyperphagia) but there is weight loss
Thyroid Hormones
2. Moist skin
a. Levothyroxine
3. Heat intolerance
b. Leothyronine
4. Diarrhea
c. Thyroid Extracts
5. All vital signs are increased
5. Provide dietary intake that is low in calories
6. CNS involvement
6. Provide comfortable and warm environment
a. Irritability and agitation
7. Provide meticulous skin care
b. Restlessness
8. Provide client health teaching and discharge planning concerning
c. Tremors
a. Avoid precipitating factors leading to myxedema coma
d. Insomnia
o stress
e. Hallucinations
7. Goiter
8. Exopthalmus
9. Amenorrhea
1. Serum T3 and T4 is increased
2. RAIU (Radio Active Iodine Uptake) is increased
3. Thyroid Scan- reveals an enlarged thyroid gland
Anti Thyroid Agent
a. Prophythioracill (PTU)
b. Methymazole (Tapazole)
Side Effects of Agranulocytosis
o increase lymphocytes and monocytes
o fever and chills
o sore throat (throat swab/culture)
o leukocytosis (CBC)
3. Provide dietary intake that is increased in calories.
5. Comfortable and cold environment
6. Maintain side rails
7. Provide bilateral eye patch to prevent drying of the eyes.
8. Assist in surgical procedures known as subtotal thyroidectomy
** Before thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroid
gland to prevent bleeding and hemorrhage.
POST OPERATIVELY,
1. Watch out for signs of thyroid storm/ thyrotoxicosis
Agitation
TRIAD SIGNS
Hyperthermia Tachycardia
o administer medications as ordered
a. Anti Pyretics
b. Beta-blockers
o monitor strictly vital signs, input and output and neuro check.
o maintain side rails
o offer TSB
2. Watch out for accidental removal of parathyroid gland that may a. inflammation
lead to b. tumor
Hypocalcemia (tetany) c. trauma
Signs and Symptoms B. Signs and Symptoms
o (+) trousseau’s sign 1. Acute tetany
o (+) chvostek sign a. tingling sensation
o Watch out for arrhythmia, seizure give Calcium Gluconate IV b. paresthesia
slowly as ordered c. numbness

d. dysphagia
3. Watch out for accidental Laryngeal damage which may lead to e. positive trousseu’s sign/carpopedal spasm
hoarseness of voice f. positive chvostek sign
Nursing Management g. laryngospasm/broncospasm
o encourage client to talk/speak immediately after operation and h. seizure feared complications
notify physician i. arrhythmia

2. Chronic tetany
4. Signs of bleeding (feeling of fullness at incisional site) a. photophobia and cataract formation
Nursing Management b. loss of tooth enamel
o Check the soiled dressings at the back or nape area. c. anorexia, nausea and vomiting
d. agitation and memory impairment
5. Hormonal replacement therapy for lifetime
6. Importance of follow up care
1. Serum Calcium is decreased (normal value: 8.5 – 11 mg/100 ml)
PARATHYROID GLAND
2. Serum Phosphate is decreased (normal value: 2.5 – 4.5 mg/100 ml)
o A pair of small nodules behind the thyroid gland
3. X-ray of long bones reveals a decrease in bone density
o Secretes parathormone
4. CT Scan – reveals degeneration of basal ganglia
o Promotes calcium reabsorption
o Hypoparathyroidism
o Hyperparathyroidism
1. Administer medications as ordered such as:
a. Acute Tetany
HYPOPARATHYROIDISM
 Calcium Gluconate IV slowly
o Decrease secretion of parathormone leading to hypocalcemia
b. Chronic Tetany
o Resulting to hyperphospatemia  Oral Calcium supplements
 Calcium Gluconate
A. Predisposing Factors  Calcium Lactate
1. Following subtotal thyroidectomy  Calcium Carbonate
2. Atrophy of parathyroid gland due to: c. Vitamin D (Cholecalciferol) for absorption of calcium
CHOLECALCIFEROL ARE DERIVED FROM
Drug Diet (Calcidiol) Sunlight (Calcitriol)
d. Phosphate binder
 Aluminum Hydroxide Gel (Ampogel)
 Side effect: constipation
ANTACID
A.A.C MAD
▼ ▼
Aluminum Containing Magnesium Containing
Antacids Antacids
▼ ▼
Aluminum
Hydroxide
Gel
▼
Side Effect: Constipation Side Effect: Diarrhea
2. Avoid precipitating stimulus such as glaring lights and noise B. Signs and Symptoms
3. Encourage increase intake of foods rich in calcium 1. Bone pain especially at back (bone fracture)
a. anchovies 2. Kidney stones
b. salmon a. renal cholic
c. green turnips b. cool moist skin
4. Institute seizure and safety precaution 3. Anorexia, nausea and vomiting
5. Encourage client to breathe using paper bag to produce mild respiratory 4. Agitation and memory impairment
acidosis result.
6. Prepare trache set at bedside for presence of laryngo spasm C. Diagnostic Procedures
7. Prevent complications 1. Serum Calcium is increased
8. Hormonal replacement therapy for lifetime 2. Serum Phosphate is decreased
9. Importance of follow up care. 3. X-ray of long bones reveals bone demineralization
HYPERTHYROIDISM 1. Force fluids to prevent kidney stones
o Decrease parathormone 2. Strain all the urine using gauze pad for stone analysis
o Hypercalcemia: bone demineralization leading to bone fracture (calcium 3. Provide warm sitz bath
is stored 99% in bone and 1% blood) 4. Administer medications as ordered
o Kidney stones a. Morphine Sulfate (Demerol)
5. Encourage increase intake of foods rich in phosphate but decrease in calcium
A. Predisposing Factors 6. Provide acid ash in the diet to acidify urine and prevent bacterial growth
1. Hyperplasia of parathyroid gland 7. Assist/supervise in ambulation
2. Over compensation of parathyroid gland due to vitamin D deficiency 8. Maintain side rails
a. Children: Ricketts 9. Prevent complications (seizure and arrhythmia)
b. Adults: Osteomalacia 10. Assist in surgical procedure known as parathyroidectomy

11. Hormonal replacement therapy for lifetime
12. Importance of follow up care 2. Administer isotonic fluid solution as ordered
3. Force fluids
Corticosteroids
a. Dexamethasone (Decadrone)
ADRENAL GLAND b. Prednisone
o Located atop of each kidney c. Hydrocortisone (Cortison)
o 2 layers of adrenal gland Nursing Management when giving steroids
a. Adrenal Cortex – outermost 1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to
b. Adrenal Medulla – innermost (secretes catecholamines a power mimic the normal diurnal rhythm
hormone) 2. Taper dose (withdraw gradually from drug)
2 Types of Catecholamines a. hypertension
o Epinephrine and Norepinephrine (vasoconstrictor) b. edema
o Pheochromocytoma (adrenal medulla) c. hirsutism
o Increase secretion of norepinephrine d. increase susceptibility to infection

e. moon face appearance
o Leading to hypertension which is resistant to pharmacological agents
4. Mineralocorticoids (Flourocortisone)
leading to CVA
5. Provide dietary intake, increase calories, carbohydrates, protein but decrease in
o Use beta-blockers
potassium
ADRENAL CORTEX
7. Provide client health teaching and discharge planning
3 Zones/Layers
a. avoid precipitating factor leading to addisonian crisis leading to
1. Zona Fasciculata
- stress
- secretes glucocortocoids (cortisol)
- infection
- function: controls glucose metabolism
- sudden withdrawal to steroids
- Sugar
b. prevent complications
2. Zona Reticularis
- addisonian crisis
- secretes traces of glucocorticoids and androgenic hormones
- hypovolemic shock
- function: promotes secondary sex characteristics
c. hormonal replacement for lifetime
- Sex
d. importance of follow up care
3. Zona Glumerulosa
- secretes mineralocorticoids (aldosterone)
- function: promotes sodium and water reabsorption and excretion of potassium
- Salt
ADDISON’S DISEASE
o Hyposecretion of adreno cortical hormone leading to
CUSHING SYNDROME
a. metabolic disturbance – Sugar
o Hypersecretion of adenocortical hormones
b. fluid and electrolyte imbalance – Salt
c. deficiency of neuromuscular function – Salt/Sex
1 Related to hyperplasia of adrenal gland
2. Increase susceptibility to infections
1. Related to atrophy of adrenal glands
3. Hypernatremia
2. Fungal infections
a. hypertension
b. edema
c. weight gain
1. Hypoglycemia – TIRED
d. moon face appearance and buffalo hump
2. Decrease tolerance to stress
e. obese trunk
3. Hyponatremia
f. pendulous abdomen
- hypotension
g. thin extremities
- signs of dehydration
4. Hypokalemia
- weight loss
a. weakness and fatigue
4. Hyperkalemia
b. constipation
- agitation
c. U wave upon ECG (T wave hyperkalemia)
- diarrhea
5. Hirsutism
- arrhythmia
6. Acne and striae
5. Decrease libido
7. Easy bruising
6. Loss of pubic and axillary hair
8. Increase masculinity among females
7. Bronze like skin pigmentation
B. Diagnostic Procedures
1. FBS is increased
1. FBS is decreased (normal value: 80 – 100 mg/dl)
2. Plasma Cortisol is increased
2. Plasma Cortisol is decreased
3. Serum Sodium is increased
3. Serum Sodium is decrease (normal value: 135 – 145 meq/L)
4. Serum Potassium is decreased
4. Serum Potassium is increased (normal value: 3.5 – 4.5 meq/L)
C. Nursing Management
1. Monitor strictly vital signs, input and output to determine presence of Addisonian
2. Weigh patient daily and assess for pitting edema
crisis (complication of addison’s disease)
3. Measure abdominal girth daily and notify physician
o Addisonian crisis results from acute exacerbation of addison’s disease
4. Restrict sodium intake
characterized by
a. severe hypotension
b. hypovolemic shock
a. Spinarolactone – potassium sparring diuretics
c. hyponatremia leading to progressive stupor and coma
7. Prevent complications (DM)
Nursing Management for Addisonian Crisis
8. Assist in surgical procedure (bilateral adrenoraphy)
1. Assist in mechanical ventilation,
9. Hormonal replacement for lifetime
- administer steroids as ordered
10. Importance of follow up care
- force fluids
PANCREAS - Mixed gland (exocrine and endocrine)

- Located behind the stomach
- Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it
is an exocrine gland 3 Main Disorders of Pancreas
- Consist of islets of langerhans 1. Pancreatic Tumor/Cancer
- Has alpha cells that secretes glucagons (function: hyperglycemia) 2. Diabetes Mellitus
- Beta cells secretes insulin (function: hypoglycemia) 3. Pancreatitis
- Delta cells secretes somatostatin (function: antagonizes the effects of growth
hormones) DIABETES MELLITUS
- metabolic disorder characterized by non utilization of carbohydrates, protein and fat
metabolism
CLASSIFICATION OF DM
Type 1 (IDDM) Type 2 (NIDDM)
- Juvenile onset type - Adult onset
- Brittle disease - Maturity onset type
- Obese over 40 years old
A. Incidence Rate A. Incidence Rate
- 10% general population has type 1 DM - 90% of general population has type 2 DM
B. Predisposing Factors B. Predisposing Factors
1. Hereditary (total destruction of pancreatic cells) 1. Obesity – because obese persons lack insulin receptor binding sites
2. Related to viruses
3. Drugs
a. Lasix
b. Steroids
4. Related to carbon tetrachloride toxicity
C. Signs and Symptoms
C. Signs and Symptoms 1. Usually asymptomatic
1. Polyuria 2. Polyuria
2. Polydypsia 3. Polydypsia
3. Polyphagia 4. Polyphagia
4. Glucosuria 5. Glucosuria
5. Weight loss 6. Weight gain
6. Anorexia, nausea and vomiting
7. Blurring of vision
8. Increase susceptibility to infection
9. Delayed/poor wound healing D. Treatment
D. Treatment 1. Oral Hypoglycemic agents
1. Insulin therapy 2. Diet
2. Diet 3. Exercise
3. Exercise
E. Complications
E. Complication 1. Hyper
1. Diabetic Ketoacidosis 2. Osmolar
3. Non
4. Ketotic
5. Coma
MAIN FOODSTUFF ANABOLISM CATABOLISM
1. Carbohydrates Glucose Glycogen

2. Protein Amino Acids Nitrogen
3. Fats Fatty Acids Free Fatty Acids
- Cholesterol
- Ketones
HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria Polyuria
Cellular starvation – weight loss Cellular dehydration
Stimulates the appetite/satiety center Stimulates the thirst center

(Hypothalamus) (Hypothalamus)
Polyphagia Polydypsia
* Liver has glycogen that undergo glycogenesis/ glycogenolysis
GLUCONEOGENESIS
Formation of glucose from non-CHO sources
Increase protein formation
▼
Negative Nitrogen balance
▼
Tissue wasting (Cachexia)
▼
INCREASE FAT CATABOLISM
▼
Free fatty acids
Cholesterol Ketones
▼ ▼
Atherosclerosis Diabetic Keto Acidosis
▼
Hypertension
Acetone Breath Kussmaul’s Respiration
odor
MI CVA
Death Diabetic Coma
DIABETIC KETOACIDOSIS
- Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression
1. Hyperglycemia
2. Stress – number one precipitating factor
3. Infection

1. Polyuria
2. Polydypsia
3. Polyphagia
4. Glucosuria
5. Weight loss
6. Anorexia, nausea and vomiting
7. Blurring of vision 4. Administer medications as ordered
8. Acetone breath odor a. Insulin therapy (regular acting insulin peak action of 2 – 4 hours)
9. Kussmaul’s Respiration (rapid shallow breathing) - for DKA use rapid acting insulin
10 CNS depression leading to coma b. Antibiotics to prevent infection
C. Diagnostic Procedures INSULIN THERAPY

1. FBS is increased A. Sources of Insulin
2. BUN (normal value: 10 – 20) 1. Animal sources
3. Creatinine (normal value: .8 – 1) - Rarely used because it can cause severe allergic reaction
4. Hct (normal value: female 36 – 42, male 42 – 48) due to severe dehydration - Derived from beef and pork
2. Human Sources
D. Nursing Management - Frequently used type because it has less antigenicity property thus less allergic
1. Assist in mechanical ventilation reaction
2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract 3. Artificially Compound Insulin
dehydration and shock
3. Monitor strictly vital signs, intake and output and blood sugar levels B. Types of Insulin
4. Administer medications as ordered 1. Rapid Acting Insulin (clear)
a. Insulin therapy (regular acting insulin/rapid acting insulin peak action - Regular acting insulin (IV only)
of 2 – 4 hours) - Peak action is 2 – 4 hours
b. Sodium Bicarbonate to counteract acidosis 2. Intermediate Acting Insulin (cloudy)
c. Antibiotics to prevent infection - Non Protamine Hagedorn Insulin (NPH)
- Peak action is 8 – 16 hours
HYPER OSMOLAR NON KETOTIC COMA 3. Long Acting Insulin (cloudy)
- Hyperosmolar: increase osmolarity (severe dehydration) - Ultra Lente
- Non ketotic: absence of lypolysis (no ketones) - Peak action is 16 – 24 hours
A. Signs and Symptoms C. Nursing Management for Insulin Injections

1. Headache and dizziness 1. Administer at room temperature to prevent development of lipodystrophy (atrophy,
2. Restlessness hypertrophy of subcutaneous tissues)
3. Seizure activity 2. Place in refrigerator once opened
4. Decrease LOC – diabetic coma 3. Avoid shaking insulin vial vigorously instead gently roll vial between palm to
prevent formation of bubbles
B. Nursing Management 4. Use gauge 25 – 26 needle
1. Assist in mechanical ventilation 5. Administer insulin either 45o – 90o depending on amount of clients tissue deposit
2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract 6. No need to aspirate upon injection
dehydration and shock 7. Rotate insulin injection sites to prevent development of lipodystrophy
3. Monitor strictly vital signs, intake and output and blood sugar levels
8. Most accessible route is abdomen 2. Second Generation Sulfonylureas
9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to a. Glipzide (Glucotrol)
prevent contaminating the clear insulin and promote proper calibration. b. Diabeta (Micronase)
10. Monitor for signs of local complications such as Nursing Management when giving OHA
a. Allergic reactions 1. Instruct the client to take it with meals to lessen GIT irritation and prevent
b. Lipodystrophy hypoglycemia
c. Somogyis Phenomenon – rebound effect of insulin characterized by 2. Instruct the client to avoid taking alcohol because it can lead to severe
hypoglycemia to hyperglycemia hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms
ORAL HYPOGLYCEMIC AGENTS B. Diagnostic Procedures

- Stimulates the pancreas to secrete insulin 1. FBS is increased (3 consecutive times with signs or polyuria, polydypsia,
A. Classsification polyphagia and glucosuria confirmatory for DM)
1. First Generation Sulfonylureas 2. Random Blood Sugar is increased
a. Chlorpropamide (Diabenase) 3. Oral glucose tolerance test is increased – most sensitive test
b. Tolbutamide (Orinase) 4. Alpha Glycosylated Hemoglobin is increased
c. Tolamazide (Tolinase)
C. Nursing Management - administer simple sugars
1. Monitor for peak action of insulin and OHA and notify physician - for hypoglycemia (cold and clammy skin) give simple sugars
2. Administer insulin and OHA therapy as ordered - for hyperglycemia (dry and warm skin)
3. Monitor strictly vital signs, intake and output and blood sugar levels 5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein
4. Monitor for signs of hypoglycemia and hyperglycemia 30% and fats 20% or offer alternative food substitutes
6. Instruct client to exercise best after meals when blood glucose is rising b. Microangiopathy (affects small minute blood vessels of eyes and
7. Monitor signs for complications kidneys)
a. Atherosclerosis (HPN, MI, CVA)
EYES KIDNEY
-PREMATURE CATARACT -RECURRENT PYELONEPHRITIS
- Blindness - Renal failure
b. instruct client to cut toenails straight
c. HPN and DM major cause of renal failure c. instruct client to avoid wearing constrictive garments
d. Gangrene formation d. encourage client to apply lanolin lotion to prevent skin breakdown
e. Shock due to dehydration e. assist in surgical wound debriment (give analgesics 15 – 30 mins
- peripheral neuropathy prior)
- diarrhea/constipation 9. Instruct client to have an annual eye and kidney exam
- sexual impotence 10. Monitor for signs of DKA and HONKC
8. Institute foot care management 11. Assist in surgical procedure
a. instruct client to avoid walking barefooted
HEMATOLOGICAL SYSTEM
I. Blood II. Blood Vessels III. Blood Forming Organs
1. Arteries 1. Liver
55% Plasma 45% Formed 2. Veins 3. Spleen
4. Lymphoid Organ
Serum Plasma CHON 5. Lymph Nodes
(formed in liver) 6. Bone Marrow
1. Albumin
2. Globulins
3. Prothrombin and Fibrinogen
ALBUMIN b. iron
- Largest and numerous plasma CHON c. vitamin c
- Maintains osmotic pressure preventing edema d. vitamin b12 (cyanocobalamin)
e. vitamin b6 (pyridoxine)
GLOBULINS f. intrinsic factor
- Alpha globulins - transport steroids, bilirubin and hormones - Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen
- Beta globulins – iron and copper
- Gamma globulins 2. WBC (LEUKOCYTES)
a. anti-bodies and immunoglobulins - normal value: 5000 – 10000/mm3
b. prothrombin and fibrinogen clotting factors A. Granulocytes
1. Polymorpho Neutrophils
FORMED ELEMENTS - 60 – 70% of WBC
1. RBC (ERYTHROCYTES) - involved in short term phagocytosis for acute inflammation
- normal value: 4 – 6 million/mm3 2. Polymorphonuclear Basophils
- only unnucleated cell - for parasite infections
- biconcave discs - responsible for the release of chemical mediation for inflammation
- consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin 3. Polymorphonuclear Eosinophils
(green pigment) hemosiderin (golden brown pigment) - for allergic reaction
- transports and carries oxygen to tissues B. Non Granulocytes
- hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% 1. Monocytes
- hematocrit red cell percentage in wholeblood - macrophage in blood
- normal value: female 36 – 42% male 42 – 48% - largest WBC
- substances needed for maturation of RBC - involved in long term phagocytosis for chronic inflammation
a. folic acid 2. Lymphocytes
B-cell T-cell Natural killer cell

- bone marrow - thymus - anti viral and anti tumor property
for immunity
HIV 2. Echhymosis
- 6 months – 5 years incubation period 3. Oozing of blood from venipunctured site
- 6 months window period
- western blot opportunistic BLOOD DISORDERS
- ELISA Iron Deficiency Anemia
- drug of choice AZT (Zidon Retrovir) - A chronic microcytic anemia resulting from inadequate absorption of iron leading to
hypoxemic tissue injury
2 Common fungal opportunistic infection in AIDS A. Incidence Rate
1. Kaposi’s Sarcoma 1. Common among developed countries
2. Pneumocystis Carinii Pneumonia 2. Common among tropical zones
3. Common among women 15 – 35 years old
3. Platelets (THROMBOCYTES) 4. Related to poor nutrition
- Normal value: 150,000 – 450,000/mm3 B. Predisposing Factors
- Promotes hemostasis (prevention of blood loss) 1. Chronic blood loss due to trauma
- Consist of immature or baby platelets or megakaryocytes which is the target of a. Heavy menstruation
dengue virus b. Related to GIT bleeding resulting to hematemesis and melena (sign
- Normal life span of platelet is 9 – 12 days for upper GIT bleeding)
c. fresh blood per rectum is called hematochezia
Signs of Platelet Dysfunction 2. Inadequate intake of iron due to
1. Petechiae a. Chronic diarrhea
b. Related to malabsorption syndrome 2. Weakness and fatigue (initial signs)
c. High cereal intake with low animal protein digestion 3. Headache and dizziness
d. Subtotal gastrectomy 4. Pallor and cold sensitivity
4. Related to improper cooking of foods 5. Dyspnea
C. Signs and Symptoms 6. Palpitations
1. Usually asymptomatic 7. Brittleness of hair and spoon shape nails (koilonychias)
8. Atropic Glossitis (inflammation of tongue)
- Stomatitis PLUMBER VINSON’S SYNDROME
- Dysphagia
9. PICA (abnormal appetite or craving for non edible foods
D. Diagnostic Procedures a. Anorexia
1. RBC is decreased b. Nausea and vomiting
2. Hgb is decreased c. Abdominal pain
3. Hct is deceased d. Diarrhea/constipation
4. Iron is decreased e. Melena
5. Reticulocyte is decreased 5. If client cant tolerate/no compliance administer parenteral iron
6. Ferritin is decreased preparation
E. Nursing Management a. Iron Dextran (IM, IV)
1. Monitor for signs of bleeding of all hema test including urinw, stool and GIT b. Sorbitex (IM)
2. Enforce CBR so as not to over tire client Nursing Management when giving parenteral iron preparations
3. Instruct client to take foods rich in iron 1. Administer Z tract technique to prevent discomfort, discoloration and
a. Organ meat leakage to tissues
b. Egg (yolk)
2. Avoid massaging the injection site instead encourage to ambulate to
c. Raisin
d. Sweet potatoes facilitate absorption
e. Dried fruits
f. Legumes
g. Nuts a. Pain at injection site
4. Instruct the client to avoid taking tea and coffee because it contains tannates which
b. Localized abscess
impairs iron absorption
c. Lymphadenopathy
d. Fever and chills
Oral Iron Preparations
e. Skin rashes
a. Ferrous Sulfate
f. Pruritus/orticaria
b. Ferrous Fumarate
g. Hypotension (anaphylactic shock)
c. Ferrous Gluconate
- 300 mg/day
Nursing Management when taking oral iron preparations
PERNICIOUS ANEMIA
1. Instruct client to take with meals to lessen GIT irritation
- Chronic anemia characterized by a deficiency of intrinsic factor leading to
2. When diluting it in liquid iron preparations administer with straw to
hypochlorhydria (decrease hydrochloric acid secretion)
prevent staining of teeth
Medications administered via straw
- Lugol’s solution
1. Subtotal gastrectomy
- Iron
2. Hereditary factors
- Tetracycline
3. Inflammatory disorders of the ileum
- Nitrofurantoin (Macrodentin)
4. Autoimmune
3. Administer with Vitamin C or orange juice for absorption
5. Strictly vegetarian diet
4. Monitor and inform client of side effects
STOMACH
▼
Pareital cells/ Argentaffin or Oxyntic cells
Produces intrinsic factors Secretes hydrochloric acid

▼ ▼
Promotes reabsorption of Vit B12 Aids in digestion
▼
Promotes maturation of RBC
B. Signs and Symptoms e. result to psychosis

1. Weakness and fatigue
2. Headache and dizziness C. Diagnostic Procedure
3. Pallor and cold sensitivity Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B 12
4. Dyspnea and palpitations as part of compensation
5. GIT changes that includes
1. Enforce CBR
a. mouth sore
2. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered
b. red beefy tongue
- Never given orally because there is possibility of developing tolerance
c. indigestion/dyspepsia
- Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal
d. weight loss
- No side effects
e. jaundice
3. Provide a dietary intake that is high in carbohydrates, protein, vitamin c and iron
6. CNS changes
4. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush
a. tingling sensation
5. Avoid heat application to prevent burns
b. numbness
c. paresthesia
APLASTIC ANEMIA
d. positive to Romberg’s test – damage to cerebellum resulting to ataxia
- Stem cell disorder leading to bone marrow depression leading to pancytopenia
PANCYTOPENIA
Decrease RBC Decrease WBC Decrease Platelet

(anemia) (leucopenia) (thrombocytopenia)
3. Immunologic injury
A. Predisposing Factors 4. Drugs
1. Chemicals (Benzine and its derivatives) Broad Spectrum Antibiotics
2. Related to irradiation/exposure to x-ray a. Chloramphenicol (Sulfonamides)
Chemotherapeutic Agents 7. Institute NGT decompression by performing gastric lavage by using ice or cold
a. Methotrexate (Alkylating Agent) saline solution of 500 – 1000 ml
b. Vincristine (Plant Alkaloid) 8. Monitor NGT output
c. Nitrogen Mustard (Antimetabolite) 9. Prevent complication
Phenylbutazones (NSAIDS) a. Hypovolemic shock
b. Anuria – late sign
1. Anemia
a. Weakness and fatigue
b. Headache and dizziness
c. Pallor and cold sensitivity
d. Dyspnea and palpitations
2. Leukopenia BLOOD TRANSFUSION
a. Increase susceptibility to infection Goals/Objectives
3. Thrombocytopenia 1. Replace circulating blood volume
a. Petechiae (multiple petechiae is called purpura) 2. Increase the oxygen carrying capacity of blood
b. Ecchymosis 3. Prevent infection in there is a decrease in WBC
c. Oozing of blood from venipunctured sites 4. Prevent bleeding if there is platelet deficiency
C. Diagnostic Procedures Principles of blood transfusion

1. CBC reveals pancytopenia 1. Proper refrigeration
2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis - Expiration of packed RBC is 3 – 6 days
in bone marrow - Expiration of platelet is 3 – 5 days
2. Proper typing and cross matching
D. Nursing Management a. Type O – universal donor
1. Removal of underlying cause b. Type AB – universal recipient
2. Institute BT as ordered c. 85% of population is RH positive
3. Administer oxygen inhalation 3. Aseptically assemble all materials needed for BT
4. Enforce CBR a. Filter set
5. Institute reverse isolation b. Gauge 18 – 19 needle
6. Monitor for signs of infection c. Isotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis
a. fever 4. Instruct another RN to re check the following
b. cough a. Client name
7. Avoid IM, subcutaneous, venipunctured sites b. Blood typing and cross matching
8 Instead provide heparin lock c. Expiration date
9. Instruct client to use electric razor when shaving d. Serial number
10. Administer medications as ordered 5. Check the blood unit for bubbles cloudiness, sediments and darkness in color
a. Corticosteroids – caused by immunologic injury because it indicates bacterial contamination
b. Immunosuppressants - Never warm blood as it may destroy vital factors in blood.
- Warming is only done during emergency situation and if you have the
Anti Lymphocyte Globulin warming device
▼
- Emergency rapid BT is given after 30 minutes and let natural room
Given via central venous catheter
temperature warm the blood.
▼
Given 6 days to 3 weeks to achieve 6. BT should be completed less than 4 hours because blood that is exposed at
Maximum therapeutic effect of drug
room temperature more
than 2 hours causes blood deterioration that can lead to BACTERIAL
DISSEMINATED INTRAVASCULAR COAGULATION
CONTAMINATION
Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis
7. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS
due to a deficiency of prothrombin and fibrinogen
8. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent
circulatory overload
9. Monitor strictly vital signs before, during and after BT especially every 15
1. Related to rapid blood transfusion
minutes for first hour
2. Massive burns
because majority of transfusion reaction occurs during this period
3. Massive trauma
a. Hemolytic reaction
4. Anaphylaxis
b. Allergic reaction
5. Septecemia
c. Pyrogenic reaction
6. Neoplasia (new growth of tissue)
d. Circulatory overload
7. Pregnancy
e. Air embolism
f. Thrombocytopenia
g. Cytrate intoxication
1. Petechiae (widespread and systemic) eye, lungs and lower extremities
h. Hyperkalemia (caused by expired blood)
2. Ecchymosis
\
3. Oozing of blood from punctured sites
Signs and Symptoms of Hemolytic reaction
4. Hemoptysis
1. Headache and dizziness
6. Oliguria (late sign)
2. Dyspnea
3. Diarrhea/Constipation
4. Hypotension
1. CBC reveals decreased platelets
5. Flushed skin
2. Stool occult blood positive
6. Lumbasternal/ Flank pain
3. ABG analysis reveals metabolic acidosis
7. Urine is color red/ portwine urine
4. Opthamoscopic exam reveals sub retinal hemorrhages
Nursing Management
1. Stop BT
2. Notify physician
1. Monitor for signs of bleeding of all hema test including stool and GIT
3. Flush with plain NSS
2. Administer isotonic fluid solution as ordered
4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis
3. Administer oxygen inhalation
5. Send the blood unit to blood bank for re examination
4. Force fluids
6. Obtain urine and blood sample and send to laboratory for re examination
7. Monitor vital signs and intake and output
a. Vitamin K
b. Pitressin/ Vasopresin to conserve fluids
SIGNS AND SYMPTOMS OF ALLERGIC REACTION
c. Heparin/Coumadin is ineffective
1. Fever
6. Provide heparin lock
2. Dyspnea 2. Dyspnea
3. Broncial wheezing 3. Rales/Crackles upon auscultation
4. Skin rashes 4. Exertional discomfort
5. Urticaria Nursing Management
6. Laryngospasm and Broncospasm 1. Stop BT
Nursing Management 2. Notify physician
1. Stop BT 3. Administer medications as ordered
2. Notify physician a. Loop diuretic (Lasix)
3. Flush with plain NSS CARDIOVASCULAR SYSTEM
4. Administer medications as ordered OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART
a. Anti Histamine (Benadryl) - if positive to hypotension, anaphylactic HEART
shock treat with Epinephrine - Muscular pumping organ of the body.
5. Send the blood unit to blood bank for re examination - Located on the left mediastinum
6. Obtain urine and blood sample and send to laboratory for re examination - Resemble like a close fist
7. Monitor vital signs and intake and output - Weighs approximately 300 – 400 grams
- Covered by a serous membrane called the pericardium
SIGNS AND SYMPTOMS PYROGENIC REACTIONS 2 layers of pericardium
1. Fever and chills a. Parietal – outer layer
2. Headache b. Visceral – inner layer
3. Tachycardia - In between is the pericardial fluid which is 10 – 20 cc
4. Palpitations - Prevent pericardial friction rub
5. Diaphoresis - Common among MI, pericarditis, Cardiac tamponade
6. Dyspnea
Nursing Management A. Layers of Heart
1. Stop BT 1. Epicardium – outer layer
2. Notify physician 2. Myocardium – middle layer
3. Flush with plain NSS 3. Endocardium – inner layer
4. Administer medications as ordered - Myocarditis can lead to cardiogenic shock and rheumatic heart disease
a. Antipyretic
b. Antibiotic B. Chambers of the Heart
5. Send the blood unit to blood bank for re examination 1. Upper Chamber (connecting or receiving)
6. Obtain urine and blood sample and send to laboratory for re examination a. Atria
7. Monitor vital signs and intake and output 2. Lower Chamber (contracting or pumping)
8. Render TSB a. Ventricles
- Left ventricle has increased pressure which is 120 – 180 mmHg
SIGNS AND SYMPTOMS OF CIRCULATORY REACTION - In order to propel blood to the systemic circulation
1. Orthopnea - Right atrium has decreased pressure which is 60 – 80 mmHg
2. Left Main Coronary Artery
C. Valves - Supplies the myocardium
- To promote unidimensional flow or prevent backflow E. Cardiac Conduction System
1. Sino – Atrial Node (SA or Keith Flack Node)
1. Atrioventricular Valves – guards opening between - Located at the junction of superior vena cava and right atrium
a. tricuspid valve - Acts as primary pacemaker of the heart
b. mitral valve - Initiates electrical impulse of 60 – 100 bpm
- Closure of AV valves give rise to first heart sound (S1 “lub”)
2. Atrio – Ventricular Node (AV or Tawara Node)
2. Semi – lunar Valves - Located at the inter atrial septum
a. pulmonic - Delay of electrical impulse for about .08 milliseconds to allow ventricular filling
b. aortic
- Closure of SV valve give rise to second heart sound (S2 “dub”) 3. Bundle of His
- Right Main Bundle of His
Extra Heart Sounds - Left Main Bundle of His
1. S3 – ventricular gallop usually seen in Left Congestive Heart Failure - Located at the interventricular septum
2. S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension
4. Purkinje Fibers
D. Coronary Arteries - Located at the walls of the ventricles for ventricular contraction
- Arises from base of the aorta
Types of Coronary Arteries
1. Right Main Coronary Artery
SA NODE
AV NODE
BUNDLE OF HIS
PURKINJE FIBERS
- P WAVE (atrial depolarization) contraction 1. Positive U wave - Hypokalemia

- QRS WAVE (ventricular depolarization) 2. Peak T wave – Hyperkalemia
- T WAVE (ventricular repolarization) 3. ST segment depression – Angina Pectoris
JLJLJLJJLJLJL
 Insert pacemaker if there is complete heart block 4. ST segment elevation – Myocardial Infarction
 Most common pacemaker is the metal pacemaker and lasts up to 2 – 5. T wave inversion – Myocardial Infarction
5 years 6. Widening of QRS complexes – Arrythmia
ABNORMAL ECG TRACING CARDIAC DISORDERS

Coronary Arterial Disease/ Ischemic Heart Disease 2. Myocardial Ischemia – Angina Pectoris
Stages of Development of Coronary Artery Disease 3. Myocardial Necrosis – Myocardial Infarction
1. Myocardial Injury - Atherosclerosis
ATHEROSCLEROSIS
ATHEROSCLEROSIS ARTERIOSCLEROSIS
- narrowing of artery - hardening of artery
- lipid or fat deposits - calcium and protein deposits
- tunica intima - tunica media
A. Predisposing Factors 3. Tachycardia

1. Sex – male 4. Palpitations
2. Race – black 5. Duaphoresis
3. Smoking
4. Obesity C. Treatment
5. Hyperlipidemia Percutaneous Transluminal Coronary Angioplasty
6. sedentary lifestyle Objectives of PTCA
7. Diabetes Mellitus 1. Revascularize myocardium
2. To prevent angina
8. Hypothyroidism
3. Increase survival rate
9. Diet – increased saturated fats - Done to single occluded vessels
10. Type A personality - If there is 2 or more occluded blood vessels CABG is done
Coronary Arterial Bypass And Graft Surgery
B. Signs and Symptoms 3 Complications of CABG
1. Chest pain 1. Pneumonia – encourage to perform deep breathing, coughing exercise and use of
2. Dyspnea incentive spirometer
2. Shock 5. Hyperlipidemia
3. Thrombophlebitis 6. sedentary lifestyle
7. Diabetes Mellitus
ANGINA PECTORIS (SYNDROME) 8. Hypothyroidism
Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or 9. Diet – increased saturated fats
nitroglycerine due to temporary myocardial ischemia 10. Type A personality
A. Predisposing Factors B. Precipitating Factors

1. Sex – male 4 E’s of Angina Pectoris
2. Race – black 1. Excessive physical exertion – heavy exercises
3. Smoking 2. Exposure to cold environment
4. Obesity 3. Extreme emotional response – fear, anxiety, excitement
4. Excessive intake of foods rich in saturated fats – skimmed milk 1. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of
both right and left coronary artery
C. Signs and Symptoms 2. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left
1. Levine’s Sign – initial sign that shows the hand clutching the chest coronary artery
2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from
back, shoulder, arms, axilla and jaw muscles, usually relieved by rest or taking nitroglycerine B. The Most Critical Period Following Diagnosis of Myocardial Infarction
3. Dyspnea ** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’s
4. Tachycardia
5. Palpitations C. Predisposing Factors
6. Diaphoresis 1. Sex – male
2. Race – black
D. Diagnostic Procedure 3. Smoking
1. History taking and physical exam 4. Obesity
2. ECG tracing reveals ST segment depression 5. Hyperlipidemia
3. Stress test – treadmill test, reveal abnormal ECG 6. sedentary lifestyle
4. Serum cholesterol and uric acid is increased 7. Diabetes Mellitus
8. Hypothyroidism
E. Nursing Management 9. Diet – increased saturated fats
1. Enforce complete bed rest 10. Type A personality
a. Nitroglycerine (NTG) – when given in small doses will act as venodilator, but
in large doses will act as vasodilator
- Give first dose of NTG (sublingual) 3 – 5 minutes D. Signs and Symptoms
- Give second dose of NTG if pain persist after giving first dose with 1. Chest pain
interval of 3 - 5 minutes - Excruciating visceral, viselike pain located at substernal and rarely in
- Give third and last dose of NTG if pain still persist at 3 – 5 minutes precordial
interval - Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles
Nursing Management when giving NTG (abdominal ischemia)
- Keep the drug in a dry place, avoid moisture and exposure to sunlight as it - Not usually relieved by rest or by nitroglycerine
may inactivate the drug 2. Dyspnea
- Monitor side effects 3. Increase in blood pressure (initial sign)
o Orthostatic hypotension 4. Hyperthermia
o Transient headache and dizziness 5. Ashen skin
- Instruct the client to rise slowly from sitting position 6. Mild restlessness and apprehension
7. Occasional findings
- Assist or supervise in ambulation
a. Pericardial friction rub
- When giving nitrol or transdermal patch
b. Split S1 and S2
o Avoid placing near hairy areas as it may decrease drug
c. Rales/Crackles upon auscultation
absorption
d. S4 or atrial gallop
o Avoid rotating transdermal patches as it may decrease drug
absorption
E. Diagnostic Procedure
o Avoid placing near microwave ovens or duting defibrillation
1. Cardiac Enzymes
as it may lead to burns (most important thing to remember)
a. CPK – MB
- Creatinine phosphokinase is increased
b. Beta-blockers
- Heart only, 12 – 24 hours
- Propanolol - side effects PNS
b. LDH – Lactic acid dehydroginase is increased
- Not given to COPD cases because it causes bronchospasm
c. SGPT – Serum glutamic pyruvate transaminase is increased
d. SGOT – Serum glutamic oxal-acetic transaminase is increased
c. ACE Inhibitors
2. Troponin Test – is increased
- Enalapril
3. ECG tracing reveals
a. ST segment elevation
d. Calcium Antagonist
b. T wave inversion
- NIfedipine
c. Widening of QRS complexes indicates that there is arrhythmia in MI
4. Serum Cholesterol and uric acid are both increased
3. Administer oxygen inhalation
5. CBC – increased WBC
4. Place client on semi fowlers position
5. Monitor strictly vital signs, intake and output and ECG tracing
F. Nursing Management
6. Provide decrease saturated fats sodium and caffeine
Goal: Decrease myocardial oxygen demand
7. Provide client health teachings and discharge planning
a. Avoidance of 4 E’s
1. Decrease myocardial workload (rest heart)
b. Prevent complication (myocardial infarction)
- Administer narcotic analgesic/morphine sulfate
c. Instruct client to take medication before indulging into physical exertion to
- Side Effects: respiratory depression
achieve the maximum therapeutic effect of drug
- Antidote: Narcan/Naloxone
d. The importance of follow up care
- Side Effects of Naloxone Toxicity is tremors
2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min
MYOCARDIAL INFARCTION
3. Enforce CBR without bathroom privileges
Heart attack
a. Using bedside commode
Terminal stage of coronary artery disease characterized by malocclusion, necrosis and scarring.
4. Instruct client to avoid forms of valsalva maneuver
5. Place client on semi fowlers position
A. Types
6. Monitor strictly vital signs, intake and output and ECG tracing
7. Provide a general liquid to soft diet that is low in saturated fats, sodium and caffeine 4. Hypertension
8. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy to induce 5. Aortic valve stenosis
vasodilation B. Signs and Symptoms
9. Administer medication as ordered 1. Dyspnea
a. Vasodilators 2. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing
- Nitroglycerine 3. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers
- ISD (Isosorbide Dinitrate, Isodil) sublingual 4. Productive cough with blood tinged sputum
5. Frothy salivation
b. Anti Arrythmic Agents 6. Cyanosis
- Lidocaine (Xylocane 7. Rales/Crackles
- Side Effects: confusion and dizziness 8. Bronchial wheezing
- Brutylium 9. Pulsus Alternans – weak pulse followed by strong bounding pulse
c. Beta-blockers 10. PMI is displaced laterally due to cardiomegaly
11. There is anorexia and generalized body malaise
d. ACE Inhibitors 12. S3 – ventricular gallop
e. Calcium Antagonist 1. Chest x-ray – reveals cardiomegaly
2. PAP (pulmonary arterial pressure) – measures pressure in right ventricle or cardiac status
f. Thrombolytics/ Fibrinolytic Agents PCWP (pulmonary capillary wedge pressure) – measures end systolic and dyastolic pressure
- Streptokinase - both are increased
- Side Effects: allergic reaction, pruritus - done by cardiac catheterization (insertion of swan ganz catheter)
- Urokinase 3. Ecocardiography – enlarged heart chamber (cardiomyopathy), dependent on extent of heart
- TIPAF (tissue plasminogen activating factor) failure
- Side Effects: chest pain 4. ABG – reveals PO2 is decreased (hypoxemia), PCO2 is increased (respiratory acidosis)
- Monitor for bleeding time
2. RIGHT SIDED HEART FAILURE
g. Anti Coagulant A. Predisposing Factors
- Heparin (check for partial thrombin time) 1. Tricuspid valve stenosis
- Antidote: protamine sulfate 2. Pulmonary embolism
- Coumadin/ Warfarin Sodium (check for prothrombin time) 3. Related to COPD
- Antidote: Vitamin K 4. Pulmonic valve stenosis
5. Left sided heart failure
h. Anti Platelet
- PASA (Aspirin)
- Anti thrombotic effect B. Signs and Symptoms (venous congestion)
- Side Effects of Aspirin 1. Neck/jugular vein distension
 Tinnitus 2. Pitting edema
 Heartburn 3. Ascites
 Indigestion/Dyspepsia 4. Weight gain
- Contraindication 5. Hepatosplenomegaly
 Dengue 6. Jaundice
 Peptic Ulcer Disease 7. Pruritus
 Unknown cause of headache 8. Anorexia
9. Esophageal varices
10. Provide client health teaching and discharge planning concerning C. Diagnostic Procedures
a. Avoidance of modifiable risk factors 1. Chest x-ray – reveals cardiomegaly
- arrhythmia (caused by premature ventricular contraction) 2. Central venous pressure (CVP)
b. Cardiogenic shock - Measure pressure in right atrium (4 – 10 cm of water)
- late sign is oliguria - CVP fluid status measure
c. Left Congestive Heart Failure - If CVP is less than 4 cm of water hypovolemic shock
d. Thrombophlebitis - Do the fluid challenge (increase IV flow rate)
- homan’s sign - If CVP is more than 10 cm of water hypervolemic shock
e. Stroke/CVA - Administer loop diuretics as ordered
f. Post MI Syndrome/Dressler’s Syndrome - When reading CVP patient should be flat on bed
- client is resistant to pharmacological agents, administer 150,000 – - Upon insertion place client in trendelendberg position to promote ventricular
450,000 units of streptokinase as ordered filling and prevent pulmonary embolism
g. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac 3. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy
rehab, post CABG and instruct to 4. Liver enzymes – SGPT and SGOT is increased
- make sex as an appetizer rather than dessert
- instruct client to assume a non weight bearing position D. Nursing Management
- client can resume sexual intercourse if can climb staircase Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min)
- dietary modification 1. Enforce CBR
h. Strict compliance to mediation and importance of follow up care 2. Administer medications as ordered
a. Cardiac glycosides
CONGESTIVE HEART FAILURE - Digoxin (Lanoxin)
Inability of the heart to pump blood towards systemic circulation - Increase force of cardiac contraction
- If heart rate is decreased do not give
Types of Heart Failure b. Loop Diuretics
1. LEFT SIDED HEART FAILURE - Lasix (Furosemide)
c. Bronchodilators
A. Predisposing Factors d. Narcotic analgesics
1. 90% is mitral valve stenosis due to - Morphine Sulfate
a. RHD – inflammation of mitral valve due to invasion of Grp. A beta-hemolytic e. Vasodilators
streptococcus - Nitroglycerine
- Formation of aschoff bodies in the mitral valve f. Anti Arrhythmic
- Common among children - Lidocaine (Xylocane)
- ASO Titer (Anti streptolysin O titer)
- Penicillin 3. Administer oxygen inhalation with high inflow, 3 – 4 L/min, delivered via nasal cannula
- Aspirin 4. High fowlers position
b. Aging 5. Monitor strictly vital signs, intake and output and ECG tracing
2. Myocardial Infarction 6. Measure abdominal girth daily and notify physician
3. Ischemic heart disease 7. Provide a dietary intake of low sodium, cholesterol and caffeine
8. Provide meticulous skin care 2. Angiography – reveals site and extent of malocclusion
9. Assist in bloodless phlebotomy – rotating tourniquet, rotated clockwise every 15 minutes to
promote decrease venous return D. Nursing Management
10. Provide client health teaching and discharge planning 1. Administer medications as ordered
a. Prevent complications a. Analgesics
- Arrythmia b. Vasodilators
- Shock 2. Encourage to wear gloves
- Right ventricular hypertrophy 3. Instruct client on importance of cessation of smoking and exposure to cold environment
- MI
- Thrombophlebitis VARICOSITIES
b. Dietary modification Abnormal dilation of veins of lower extremities and trunks due to
c. Strict compliance to medications Incompetent valve resulting to
Increased venous pooling resulting to
PERIPHERAL VASCULAR DISORDER Venous stasis causing
Arterial Ulcer Decrease venous return
I. Thrombo Angitis Obliterans
 Burger’s Disease A. Predisposing Factors
 Reynaud’s Disease 1. Hereditary
2. Congenital weakness of veins
Venous Ulcer 3. Thrombophlebitis
1. Varicose Veins 4. Cardiac disorder
2. Thrombophlebitis (deep vein thrombosis) 5. Pregnancy
6. Obesity
THROMBOANGITIS OBLITERANS 7. Prolonged standing or sitting
Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the
lower extremities B. Signs and Symptoms
1. Pain after prolonged standing
A. Predisposing Factors 2. Dilated tortuous skin veins
1. High risk groups – men 30 years old and above 3. Warm to touch
2. Smoking 4. Heaviness in legs
B. Signs and Symptoms 1. Venography
1. Intermittent claudication – leg pain upon walking 2. Trendelenburg’s Test - veins distends quickly in less than 35 seconds
2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)
3. Decreased peripheral pulses D. Nursing Management
4. Trophic changes 1. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows
5. Ulceration under the legs
6. Gangrene formation 2. Measure the circumference of leg muscle to determine if swollen
3. Wear anti embolic stockings
C. Diagnostic Procedures 4. Administer medications as ordered
1. Oscillometry – decrease in peripheral pulses a. Analgesics
2. Doppler UTZ – decrease blood flow to the affected extremity 5. Assist in surgical procedure
3. Angiography – reveals site and extent of malocclusion a. Vein stripping and ligation (most effective)
b. Sclerotherapy – can recur and only done in spider web varicosities and danger
D. Nursing Management of thrombosis (2 – 3 years for embolism)
1. Encourage a slow progressive physical activity
a. walking 3 – 4 times a day
b. out of bed 3 – 4 times a day THROMBOPHLEBITIS
2. Administer medications as ordered Deep vein thrombosis
a. Analgesics Inflammation of the veins with thrombus formation
b. Vasodilators
c. Anti coagulants A. Predisposing Factors
3. Institute foot care management 1. Obesity
4. Instruct client to avoid smoking and exposure to cold environment 2. Smoking
5. Assist in surgical procedure – bellow knee amputation 3. Related to pregnancy
4. Chronic anemia
5. Prolong use of oral contraceptives – promotes lipolysis
6. Diabetes mellitus
REYNAUD’S DISEASE 7. Congestive heart failure
Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the 8. Myocardial infarction
hands 9. Post op complication
10. Post cannulation – insertion of various cardiac catheter
A. Predisposing Factors 11. Increase in saturated fats in the diet.
1. High risk group – female 40 years old and above
2. Smoking B. Signs and Symptoms
3. Collagen diseases 1. Pain at affected extremity
a. SLE (butterfly rash) 2. Warm to touch
b. Rheumatoid Arthritis 3. Dilated tortuous skin veins
4. Direct hand trauma 4. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot
a. Piano playing
b. Excessive typing C. Diagnostic Procedure
c. Operating chainsaw 1. Venography
2. Angiography
1. Intermittent claudication – leg pain upon walking
2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor) D. Nursing Management
3. Trophic changes 1. Elevate legs above heart level to promote increase venous return
4. Ulceration 2. Apply warm moist pack – to reduce lymphatic congestion
5. Gangrene formation 3. Measure circumference of leg muscle to determine if swollen
4. Encourage to wear anti embolic stockings or knee elastic stockings
C. Diagnostic Procedures 5. Administer medications as ordered
1. Doppler UTZ – decrease blood flow to the affected extremity a. Analgesics
b. Anti Coagulant Disorders of Respiratory System
- Heparin 1. PTB/Pulmonary Tuberculosis (Koch’s Disease)
6. Monitor for signs of complications - Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli
Embolism - An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight
a. Pulmonary
- Sudden sharp chest pain A. Precipitating Factors
- Unexplained dyspnea 1. Malnutrition
- Tachycardia 2. Overcrowded places
- Palpitations 3. Alcoholism
- Diaphoresis 4. Over fatigue
- Restlessness 5. Ingestion of an infected cattle with mycobacterium bovis
b. Cerebral 6. Virulence (degree of pathogenecity) of microorganism
- Headache
- Dizziness B. Mode of Transmission
- Decrease LOC 1. Airborne transmission via droplet nuclei
 MURPHY’S SIGN is seen in clients with cholelithiasis, cholecystitis
characterized by pain at the right upper quadrant with tenderness C. Signs and Symptoms
1. Low grade afternoon fever, night sweats
RESPIRATORY SYSTEM 2. Productive cough (yellowish sputum)
OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY 3. Anorexia, generalized body malaise
SYSTEM 4. Weight loss
I. Upper Respiratory System 5. Dyspnea
1. Filtering of air 6. Chest pain
2. Warming and moistening of air 7. Hemoptysis (chronic)
3. Humidification
A. Nose
- Cartillage D. Diagnostic Procedure
- Right nostril 1. Mantoux Test (skin test)
- Left nostril - Purified protein derivative
- Separated by septum - DOH 8 – 10 mm induration, 48 – 72 hours
- Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) - WHO 10 – 14 mm induration, 48 – 72 hours
B. Pharynx/Throat - Positive Mantoux test (previous exposure to tubercle bacilli but without active TB)
- Serves as a muscular passageway for both food and air
C. Larynx 2. Sputum Acid Fast Bacillus
- For phonation (voice production) - Positive to cultured microorganism
- For cough reflex
Glottis 3. Chest X-ray
- Opening of larynx - Reveals pulmonary infiltrates
- Opens to allow passage of air
- Closes to allow passage of food going to the esophagus 4. CBC
- The initial sign of complete airway obstruction is the inability to cough - Reveals increase WBC
II. Lower Respiratory System E. Nursing Management

- For gas exchange 1. Enforce CBR
A. Trachea/Windpipe 2. Institute strict respiratory isolation
- Consist of cartilaginous rings 3. Administer oxygen inhalation
- Serves as passageway of air going to the lungs 4. Force fluids to liquefy secretions
- Site of tracheostomy 5. Place client on semi fowlers position to promote expansion of lungs
B. Bronchus 6. Encourage deep breathing and coughing exercise
- Right main bronchus 7. Nebulize and suction when needed
- Left main bronchus 8. Comfortable and humid environment
C. Lungs 9. Institute short course chemotherapy
- Right lung (consist of 3 lobes, 10 segments) a. Intensive phase
- Left lung (consist of 2 lobes, 8 segments) - INH (Isonicotinic Acid Hydrazide)
- Serous membranes - Rifampicin (Rifampin)
Pleural Cavity - PZA (Pyrazinamide)
a. Pareital - Given everyday simultaneously to prevent resistance
b. Pleural fluid - INH and Rifampicin is given for 4 months, taken before meals to facilitate
c. Visceral absorption
With Pleuritic Friction Rub - PZA is given for 2 months, taken after meals to facilitate absorption
a. Pneumonia - Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin
b. Pleural effusion B6/Pyridoxine)
c. Hydrothorax (air and blood in pleural space - Side Effect Rifampicin: all bodily secretions turn to red orange color
Alveoli - Side Effect PZA: allergic reaction, hepatotoxicity, nephrotoxicity
- Site of gas exchange (CO2 and O2) - PZA can be replaced by Ethambutol
- Diffusion (Dalton’s law of partial pressure of gases) - Side Effect Ethambutol: optic neuritis
Respiratory Distress Syndrome b. Standard phase

- Decrease oxygen stimulates breathing - Injection of streptomycin (aminoglycoside)
- Increase carbon dioxide is a powerful stimulant for breathing - Kanamycin
- Amikacin
Type II Cells of Alveoli - Neomycin
- Secretes surfactant - Gentamycin
- Decrease surface tension - Side Effect:
- Prevent collapse of alveoli - Ototoxicity damage to the 8 th cranial nerve resulting to tinnitus leading to
- Composed of lecithin and spingomyelin hearing loss
- L/S ratio to determine lung maturity - Nephrotoxicity check for BUN and Creatinine
- Normal L/S ratio is 2:1 - Give aspirin if there is fever
- In premature infants 1:2 - Side Effect: tinnitus, dyspepsia, heartburn
- Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias 10. Provide increase carbohydrates, protein, vitamin C and calories
- retinopathy/blindness in prematurity 11. Provide client health teaching and discharge planning
a. Avoidance of precipitating factors - Drain uppermost area of lungs
b. Prevent complications (atelectasis, military tuberculosis) - Placed on various position
PTB Nursing Management for Postural Drainage
- Bones (potts) a. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux
- Meninges b. Monitor vital signs
- Eyes c. Encourage client deep breathing exercises
- Skin d. Administer bronchodilators 15 – 30 minutes before procedure
- Adrenal gland e. Stop if client cannot tolerate procedure
c. Strict compliance to medications f. Provide oral care after procedure
d. Importance of follow up care g. Contraindicated with
- Unstable vital signs
PNEUMONIA - Hemoptysis
Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled - Clients with increase intra ocular pressure (Normal IOP 12 – 21
with exudates mmHg)
- Increase ICP
A. Etiologic Agents 9. Provide increase carbohydrates, calories, protein and vitamin C
1. Streptococcus Pneumonae – causing pneumococal pneumonia 10. Health teaching and discharge planning
2. Hemophylus Influenzae – causing broncho pneumonia a. Avoid smoking
3. Diplococcus Pneumoniae b. Prevent complications
4. Klebsella Pneumoniae - Atelectasis
5. Escherichia Pneumoniae - Meningitis (nerve deafness, hydrocephalus)
6. Pseudomonas c. Regular adherence to medications
d. Importance of follow up care
B. High Risk Groups
1. Children below 5 years old
2. Elderly
C. Predisposing Factors HISTOPLASMOSIS

1. Smoking Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma
2. Air pollution capsulatum derived from birds manure
3. Immuno compromised
a. AIDS A. Signs and Symptoms
- Pneumocystic carini pneumonia PTB or Pneumonia like
- Drug of choice is Retrovir 1. Productive cough
b. Bronchogenic Cancer 2. Dyspnea
- Initial sign is non productive cough 3. Fever, chills, anorexia, general body malaise
- Chest x-ray confirms lung cancer 4. Cyanosis
4. Related to prolonged immobility (CVA clients), causing hypostatic pneumonia 5. Hemoptysis
5. Aspiration of food causing aspiration pneumonia 6. Chest and joint pains
D. Signs and Symptoms B. Diagnostic Procedures

1. Productive cough with greenish to rusty sputum 1. Histoplasmin Skin Test – positive
2. Dyspnea with prolong expiratory grunt 2. ABG analysis PO2 decrease
3. Fever, chills, anorexia and general body malaise
4. Weight loss C. Nursing Management
5. Rales/crackles 1. Enforce CBR
6. Bronchial wheezing 2. Administer oxygen inhalation
7. Cyanosis 3. Administer medications as ordered
8. Pleuritic friction rub a. Antifungal
9. Chest pain - Amphotericin B
10. Abdominal distention leading to paralytic ileus (absence of peristalsis) - Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia)
b. Steroids
c. Mucolytics
d. Antipyretics
4. Force fluids to liquefy secretions
E. Diagnostic Procedure 5. Nebulize and suction as needed
1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 6. Prevent complications – bronchiectasis
2. Chest x-ray – reveals pulmonary consolidation 7. Prevent the spread of infection by spraying of breeding places
3. ABG analysis – reveals decrease PO2
4. CBC – reveals increase WBC, erythrocyte sedimentation rate is increased COPD (Chronic Obstructive Pulmonary/Lung Disease)
Chronic Bronchitis
F. Nursing Management Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing
1. Enforce CBR cells leading to narrowing of smaller airways
2. Administer oxygen inhalation low inflow
3. Administer medications as ordered A. Predisposing Factors
Broad Spectrum Antibiotic 1. Smoking
a. Penicillin 2. Air pollution
b. Tetracycline B. Signs and Symptoms
c. Microlides (Zethromax) 1. Productive cough (consistent to all COPD)
- Azethromycin (Side Effect: Ototoxicity) 2. Dyspnea on exertion
- Antipyretics 3. Prolonged expiratory grunt
- Mucolytics/Expectorants 4. Anorexia and generalized body malaise
- Analgesics 5. Scattered rales/ronchi
4. Force fluid 6. Cyanosis
5. Place on semi fowlers position 7. Pulmonary hypertension
6. Institute pulmonary toilet (tends to promote expectoration) a. Peripheral edema
- Deep breathing exercises b. Cor Pulmonale (right ventricular hypertrophy)
- Coughing exercises C. Diagnostic Procedure
- Chest physiotherapy ABG analysis – reveals PO2 decrease (hypoxemia), PCO 2 increase, pH decrease
- Turning and reposition

7. Nebulize and suction as needed
8. Assist in postural drainage
Bronchial Asthma 5. Hemoptysis (only COPD with sign)
Reversible inflammatory lung condition due to hypersensitivity to allergens leading to
narrowing of smaller airways C. Diagnostic Procedure
1. ABG – PO2 decrease
A. Predisposing Factors (Depending on Types) 2. Bronchoscopy – direct visualization of bronchus using fiberscope
1. Extrinsic Asthma ( Atopic/ Allergic )
Causes Nursing Management PRE Bronchoscopy
a. Pollen 1. Secure inform consent and explain procedure to client
b. Dust 2. Maintain NPO 6 – 8 hours prior to procedure
c. Fumes 3. Monitor vital signs and breath sound
d. Smoke
e. Gases POST Bronchoscopy
f. Danders 1. Feeding initiated upon return of gag reflex
g. Furs 2. Avoid talking, coughing and smoking, may cause irritation
h. Lints 3. Monitor for signs of gross
4. Monitor for signs of laryngeal spasm – prepare tracheostomy set
2. Intrinsic Asthma (Non atopic/Non allergic)
Causes D. Treatment
a. Hereditary 1. Surgery (pneumonectomy , 1 lung is removed and position on affected side)
b. Drugs (aspirin, penicillin, beta blocker) 2. Segmental Wedge Lobectomy (promote re expansion of lungs)
c. Foods (seafoods, eggs, milk, chocolates, chicken - Unaffected lobectomy facilitate drainage
d. Food additives (nitrates)
e. Sudden change in temperature, air pressure and humidity EMPHYSEMA
f. Physical and emotional stress Irreversible terminal stage of COPD characterized by
a. Inelasticity of alveoli
3. Mixed Type  90 – 95% b. Air trapping
c. Maldistribution of gases
B. Signs and Symptoms d. Over distention of thoracic cavity (barrel chest)
1. Cough that is non productive
2. Dyspnea A. Predisposing Factors
3. Wheezing on expiration 1. Smoking
4. Cyanosis 2. Air pollution
5. Mild Stress/apprehension 3. Allergy
6. Tachycardia, palpitations 4. High risk: elderly
7. Diaphoresis 5. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase,
for recoil of alveoli)
1. Pulmonary Function Test B. Signs and Symptoms
- Incentive spirometer reveals decrease vital lung capacity 1. Productive cough
2. ABG analysis – PO2 decrease 2. Dyspnea at rest
- Before ABG test for positive Allens Test, apply direct pressure to ulnar and radial artery to 3. Prolong expiratory grunt
determine presence of collateral circulation 4. Anorexia and generalized body malaise
5. Resonance to hyperresonance
D. Nursing Management 6. Decrease tactile fremitus
1. Enforce CBR 7. Decrease or diminished breath sounds
2. Oxygen inhalation, with low inflow of 2 – 3 L/min 8. Rales or ronchi
3. Administer medications as ordered 9. Bronchial wheezing
a. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 10. Barrel chest
minutes 11. Flaring of alai nares
b. Steroids – decrease inflammation 12. Purse lip breathing to eliminates excess CO 2 (compensatory mechanism)
c. Mucomysts (acetylceisteine)
d. Mucolytics/expectorants C. Diagnostic Procedure
e. Anti histamine 1. Pulmonary Function Test – reveals decrease vital lung capacity
4. Force fluids 2. ABG analysis reveals
5. Semi fowlers position a. Panlobular/ centrilobular
6. Nebulize and suction when needed - Decrease PO2 (hypoxemia leading to chronic bronchitis, “Blue Bloaters”)
7. Provide client health teachings and discharge planning concerning - Decrease ph
a. Avoidance of precipitating factor - Increase PCO2
b. Prevent complications - Respiratory acidosis
- Emphysema b. Panacinar/ centriacinar
- Status Asthmaticus (give drug of choice) - Increase PO2 (hyperaxemia, “Pink Puffers”)
- Epinephrine - Decrease PCO2
- Steroids - Increase ph
- Bronchodilators - Respiratory alkalosis
c. Regular adherence to medications to prevent development of status asthmaticus
d. Importance of follow up care D. Nursing Management
1. Enforce CBR
BRONCHIECTASIS 2. Administer oxygen inhalation via low inflow
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues 3. Administer medications as ordered
of alveoli a. Bronchodilators
b. Steroids
A. Predisposing Factors c. Antibiotics
1. Recurrent lower respiratory tract infections d. Mucolytics/expectorants
2. Chest trauma 4. High fowlers position
3. Congenital defects 5. Force fluids
4. Related to presence of tumor 6. Institute pulmonary toilet
7. Nebulize and suction when needed
B. Signs and Symptoms 8. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes
1. Productive cough maximum alveolar lung expansion
2. Dyspnea 9. Provide comfortable and humid environment
3. Cyanosis 10. Provide high carbohydrates, protein, calories, vitamins and minerals
4. Anorexia and generalized body malaise 11. Health teachings and discharge planning concerning
a. Avoid smoking
b. Prevent complications
- Atelectasis
- Cor Pulmonale
- CO2 narcosis may lead to coma
- Pneumothorax
c. Strict compliance to medication
d. Importance of follow up care

Medical Surgical Nursing Review Notes 30pgs

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Medical Surgical Nursing Review Notes 30pgs

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MEDICAL-SURGICAL NURSING

 Parasympathetic nervous system

AUTONOMIC NERVOUS SYSTEM

EFFECTS OF SNS EFFECTS OF PNS

I. Adrenergic Agents I. Cholinergic Agents

II. Beta-adrenergic Blocking Agents II. Anti-cholinergic Agents

ANTI- HYPERTENSIVE AGENTS

CENTRAL NERVOUS SYSTEM B. NEUROGLIA

Excitability – ability of neuron to be affected by changes in external environment. 2. Oligodendria

Permanent Cell – once destroyed not capable of regeneration.

TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Ammonia

1. Labile  Cerebral toxin

 Capable of regeneration.  Hepatic Encephalopathy (Liver Cirrhosis)

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

 Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal  Dizziness

 Fetor hepaticus (ammonia like breath)

 Wernicke’s Aphasia * Give palliative or supportive care.

2. MULTIPLE SCLEROSIS  scotomas (blind spots)

 Women ages 15-35 are prone  tingling sensation

 Unknown Cause  paresthesia

 Slow growing virus  numbness

 Autoimmune disorders 3. Mood swings

 Pernicious anemia  euphoria (sense of well being)

COMMON CAUSE OF UTI

b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle Nursing Management

relaxants.  avoid bubble bath (can alter Ph of vagina).

c. Interferons – alter immune response.  avoid use of tissue papers

b. Bethanicol Chloride (Urecholine) bacteria or cellular debris, eating), pinocytosis (cell

Nursing Management drinking).

 Only given subcutaneous.

 motor  controls libido

Lobes of Cerebrum  controls long term memory

NEURO TRANSMITTER DECREASE INCREASE

3. MIDBRAIN/ MESENCEPHALON  androgenic hormones promotes secondary sex

 equal size of pupil is isocoria.  late sign is deepening of voice.

 hearing acuity is 30 – 40 dB.

4. INTERBRAIN/ DIENCEPHALON Parts of Brain Stem

Parts of Diencephalon 1. Pons

A. Thalamus  pneumotaxic center controls the rate, rhythm and depth of

 acts as relay station for sensation. respiration.

 sleep and wakefulness 3. Cerebellum

INTRA CRANIAL PRESSURE

Monroe Kellie Hypothesis

Skull is a closed container

Any alteration or increase in one of the intracranial components

Increase intra-cranial pressure

Cervical 1 – also known as ATLAS.

Increase intra cranial pressure

 CSF cushions brain (shock absorber)

NEUROLOGIC DISORDERS Causes:

 localized abscess  hydrocephalus

 cerebral edema  tumor (rarely)

 papilledema (edema of optic disc) Early signs of hypoxia

 tachycardia  immediate effect of 10 – 15 minutes.

 Cyanosis  Prednisone (to reduce edema that may lead to increase

 In chronic respiratory distress syndrome decrease O2  Anti Convulsants (Dilantin, Phenytoin)

5. Prevent complications of  frothy salivation

6. Prevent further increase ICP by:  cyanosis

 excessive vomiting (use anti emetics)

 regulated fast drip to prevent crystal formation.  ascites

Signs and Symptoms of Lasix in terms of electrolyte imbalances

 normal value is 3.4 – 5.5 meq/L

 positive U wave on ECG tracing