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NURSING NOTES
NERVOUS SYSTEM
Overview of the Structures & Functions of Nervous System
Central NS
PNS
ANS
Brain & spinal cord
31 spinal & cranial
sympathetic NS
Parasypathatic NS
Somatic NS
C- 8
T- 12
L- 5
S- 5
C- 1
ANS (or adrenergic of parasympatholitic response)
SNS involved in fight or aggression response
cholinergic/adrenergic)
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3. Calcium antagonist
ex CALCIBLOC or NEFEDIPINE
Peripheral nervous system: cholinergic/ vagal or sympatholitic response
Effect of PNS:
(cholinergic)
- Involved in fly or withdrawal response
1. Meiosis contraction of pupils
- Release of acetylcholine (ACTH)
2. Increase salivation
- Decrease all bodily activities except GIT (diarrhea)
3. BP & HR decreased
4. RR decrease broncho constriction
I Cholinergic agents
5. Diarrhea increased GI motility
ex 1. Mestinon
6. Urinary frequency
Antidote anti cholinergic agents Atropine Sulfate S/E SNS
S/E- of anti-hpn drugs:
1. orthostatic hpn
2. transient headache & dizziness.
-Mgt. Rise slowly. Assist in ambulation.
CNS (brain & spinal cord)
I. Cells A. neurons
Properties and characteristics
a. Excitability ability of neuron to be affected in external environment.
b. Conductivity ability of neuron to transmit a wave of excitation from one cell to another
c. Permanent cells once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
Regenerative capacity
A. Labile once destroyed cant regenerate
- Epidermal cells, GIT cells, resp (lung cells). GUT
B. Stable capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver,
kidney cells
C. Permanent cells retina, brain, heart, osteocytes cant regenerate.
3.) Neuroglia attached to neurons. Supports neurons. Where brain tumors are found.
Types:
1. Astrocyte
2. Oligodendria
Astrocytoma 90 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.
Astrocyte maintains integrity of blood brain barrier (BBB).
BBB semi permeable / selective
-Toxic substance that destroys astrocyte & destroy BBB.
Toxins that can pass in BBB:
1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide seizure & parkinsons.
3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. 4. Ketones DM.
OLIGODENDRIA Produces myelin sheath wraps around a neuron acts as insulator facilitates rapid
nerve impulse transmission.
No myelin sheath degenerates neurons
Damage to myelin sheath demyellenating disorders
DEMYELLENATING DSE
A. ALZHEIMERS DISEASE
atrophy of brain tissue due to a deficiency of acetylcholine.
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S&Sx:
A amnesia loss of memory
A apraxia unable to determine function & purpose of object
A agnosia unable to recognize familiar object
A aphasia
- Expressive broccas aphasia unable to speak
- Receptive wernickes aphasia unable to understand spoken words
Common to Alzheimer receptive aphasia
Drug of choice ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.
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disorder
Increase dopamine schizo
Increase acetylcholine bipolar
B. INCREASED ICP
increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
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4.)
5.)
6.)
7.)
Hemorrhage (stroke)
Cerebral edema
Hydrocephalus
Inflammatory conditions - Meningitis, encephalitis
B. S&Sx
change in VS = always late symptoms
Earliest Sx:
a.) Change or decrease LOC Restlessness to confusion
Wide pulse pressure: Increased ICP
- Disorientation to lethargy
Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)
4. Temp increase
Increased ICP: Increase BP
Shock decrease BP
Decrease HR
Increase HR
CUSHINGS EFFECT
Decrease RR
Increase RR
Increase Temp
Decrease temp
b.) Headache
Projectile vomiting
Papilledima (edema of optic disk outer surface of retina)
Decorticate (abnormal flexion) = Damage to cortico spinal tract /
Decerebrate (abnormal extension) = Damage to upper brain stem-pons/
c.) Uncal herniation unilateral dilation of pupil. (Bilateral dilation of pupil tentorial herniation.)
d.) Possible seizure.
Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia (decrease tissue oxygenation) & hypercarbia (increase in CO2
retention).
Hypoxia cerebral edema - increase ICP
Hypoxia inadequate tissue oxygenation
Late symptoms of hypoxia B bradycardia
E extreme restlessness
D dyspnea
C cyanosis
Early symptoms R restlessness
A agitation
T tachycardia
Increase CO2 retention/ hypercarbia cerebral vasodilatation = increase ICP
Most powerful respiratory stimulant increase in CO2
Hyperventilate decrease CO2 excrete CO2
Respiratory Distress Syndrome (RDS) decrease Oxygen
Suctioning 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.
Ambu bag pump upon inspiration
c. Assist in mechanical ventilation
1. Maintain patent a/w
2. Monitor VS & I&O
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inc ICP.
3. Elevate head of bed 30 45 degrees angle neck in neutral position unless contra
indicated to promote venous drainage
4. Limit fluid intake 1,200 1,500 ml/day
(FORCE FLUID means:Increase fluid intake/day 2,000 3,000 ml/day)- not for
5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
-Valsalva maneuver or bearing down, avoid straining of stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
- Excessive cough antitussive
Dextrometorpham
-Excessive vomiting anti emetic (Plasil Phil only)/ Phenergan
- Lifting of heavy objects
- Bending & stooping
e. Avoid clustering of nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic Mannitol./Osmitrol promotes cerebral diuresis by decompressing
brain tissue
Nursing considerations: Mannitol
1. Monitor BP SE of hypotension
2. Monitor I&O every hr. report if < 30cc out put
3. Administer via side drip
4. Regulate fast drip to prevent formation of crystals or
precipitate
2.) Loop diuretic - Lasix (Furosemide)
Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine after 10-15mins) should
be in the morning. If given at 7am. Pt will urinate at 7:15
Immediate effect of Lasix within 15 minutes. Max effect 6 hrs due
(7am 1pm)
S/E of Lasix
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joint.
Gouty arthritis
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N range
.5 1.5 meq/L
.6 1.2 meq/L
10 19 mg/100ml
10 -19 mg/100 ml
10 30 mg/100ml
2
2
20
200
Toxicity
Classification
Indication
cardiac glycosides
CHF
antimanic
bipolar
bronchodilator
COPD
20
anticonvulsant
seizures
narcotic analgesic
osteoarthritis
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)
L lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine
a.)
b.)
c.)
d.)
e.)
Antimanic agent
Lithium toxicity
S/Sx Anorexia
n/s
Diarrhea
Dehydration force fluid, maintain Na intake 4 10g daily
Hypothyroidism
(CRETINISM the only endocrine disorder that can lead to mental retardation)
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C. PARKINSONS DSE
(parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine
producing cells in substancia nigra at mid brain & basal ganglia
- Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
2. Hypoxia
3. Arteriosclerosis
4. Encephalitis
High doses of the ff:
a. Reserpine (serpasil)
anti HPN, SE 1.) depression - suicidal 2.) breast cancer
b. Methyldopa (aldomet)
- promote safety
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide
- anti psychotic
SE of anti psychotic drugs Extra Pyramidal Symptom
Over meds of anti psychotic drugs neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism
1. Pill rolling tremors of extremities early sign
2. Bradykinesia slow movement
3. Over fatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. Shuffling most common
c. Propulsive gait
5. Mask like facial expression with decrease blinking eyes
6. Monotone speech
7. Difficulty rising from sitting position
8. Mood labilety always depressed suicide
Nsg priority: Promote safety
9. Increase salivation drooling type
10. Autonomic signs:
- Increase sweating
- Increase lacrimation
- Seborrhea (increase sebaceous gland)
- Constipation
- Decrease sexual activity
Nsg Mgt
1.) Anti parkinsonian agents
- Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)
Mechanism of action
Increase levels of dopa relieving tremors & bradykinesia
S/E of anti parkinsonian
- Anorexia
- n/v
- Confusion
- Orthostatic hypotension
- Hallucination
- Arrhythmia
Contraindication:
1. Narrow angled closure glaucoma
2. Pt taking MAOI (Parnate, Marplan, Nardil)
Nsg Mgt when giving anti-parkinsonian
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Cholinergic crisis
Cause: 1 over meds
S/Sx - PNS
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- Paralysis
5. Alternate HPN to hypotension lead to arrhythmia - complication
6. Autonomic changes
increase sweating, increase salivation.
Increase lacrimation
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON
(same with MS)
Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding due dysphagia
7. Adm meds (GBS) as ordered: 1. Anti cholinergic atropine SO4
2. Corticosteroids to suppress immune response
3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine SE confusion = VTach
b.) Bretyllium
c.) Quinines/Quinidine anti malarial agent. Give with meals.
- Toxic effect cinchonism
Quinidine toxicity
S/E anorexia, n/v, headache, vertigo, visual disturbances
8.
Assist in plasmaparesis (MG. GBS)
9.
Prevent comp arrhythmias, respiratory arrest
Prepare tracheostomy set at bedside.
INFL CONDITONS OF BRAIN
Meninges 3-fold membrane cover brain & spinal cord
Fx:
Protection & support
Nourishment
Blood supply
3 layers
1. Duramater
sub dural space
2. Arachmoid matter
3. Pia matter
sub arachnoid space
where CSF flows L3 & L4. Site for lumbar
puncture.
G. MENINGITIS
inflammation of meningitis & spinal cord
Etiology Meningococcus
Pneumococcus
Hemophilous influenza child
Streptococcus adult meningitis
MOT direct transmission via droplet nuclei
S&Sx
-
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Sx
neck pain
Dx:
1. Lumbar puncture lumbar/ spinal tap use of hallow spinal needle sub arachnoid space L3 & L4 or
L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture invasive
1. Consent / explain procedure to pt
- RN dx procedure (lab)
- MD operation procedure
2. Empty bladder, bowel promote comfort
3. Arch back to clearly visualize L3, L4
Nsg Ngt post lumbar
1. Flat on bed 12 24 h to prevent spinal headache & leak of CSF
2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue
4. Assess for movement & sensation of extremeties
Result
1. CSF analysis:
wbc, glucose
b. Decrease glucose
Confirms meningitis
c. increase CSF opening pressure
N 50 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
1. GIT irritation take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection alteration in normal bacterial flora
- N flora throat streptococcus
- N flora intestine e coli
Sx of superinfection of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapy
A Cushings synd reverse isolation - due to increased corticosteroid in body.
B Aplastic anemia reverse isolation - due to bone marrow depression.
C Cancer anytype reverse isolation immunocompromised.
D Post liver transplant reverse isolation takes steroids lifetime.
E Prolonged use steroids reverse isolation
F Meningitis strict respiratory isolation safe after 24h of antibiotic therapy
G Asthma not to be isolated
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3.
4.
5.
6.
7.
1.
2.
3.
4.
5.
6.
7.
8.
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S & Sx
1. TIA- warning signs of impending stroke attacks
- Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis
or plegia (monoplegia 1 extreme)
Increase ICP
2. Stroke in evolution progression of S & Sx of stroke
3. Complete stroke resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp
c.) Anorexia, n/v
d.) Dysphagia
e.) Increase BP
f.) (+) Kernigs & Brudzinski sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria inability to vocalize, articulate words
3. Aphasia
4. Agraphia diff writing
5. Alesia diff reading
6. Homoninous hemianopsia loss of half of field of vision
Left sided hemianopsia approach Right side of pt the unaffected side
Dx
1. CT Scan reveals brain lesion
2. Cerebral arteriography site & extent of mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All graphy invasive due to iodine dye
Post
1.) Force fluid to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal
Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
- To prevent decubitus ulcer
- To prevent hypostatic pneumonia after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding if pt cant swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia approach on unaffected side
9. Meds
Osmotic diuretics Mannitol
Loop diuretics Lasix/ Furosemide
Corticosteroids dextamethazone
Mild analgesic
Thrombolytic/ fibrolitic agents tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase
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Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants Heparin & Coumadin sabay
Coumadin will take effect after 3 days
Heparin monitor PTT partial thromboplastin time if prolonged bleeding give Protamine
SO4- antidote.
Coumadin Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K
Aquamephyton- antidote.
Antiplatelet PASA aspirin paraanemo aspirin, dont give to dengue, ulcer, and unknown
headache.
Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking
2. Dietary modification
- Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit physical therapy
1. Mental retardation
2. Delay in psychomotor development
Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide
Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus drug of choice: Diazepam & glucose
S & Sx
I. Generalized Seizure
a.) Grand mal / tonic clonic seizures
With or without aura warning symptoms of impending seizure attack- Epigastric painassociated with olfactory, tactile, visual, auditory sensory experience
- Epileptic cry fall
- Loss of consciousness 3 5 min
- Tonic clonic contractions
- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
- Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching of mouth
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of consciousness (LOC)
Conscious (conscious) awake levels of wakefulness
Lethargy (lethargic) drowsy, sleepy, obtunded
Stupor (stuporous) awakened by vigorous stimulation
Pt has gen body weakness, decrease body reflex
4. Coma (Comatose) light (+) all forms of painful stimulations
Deep (-) to painful stimulation
Question: Describe a conscious pt ?
a. Alert not all pt are alert & oriented to time & place
b. Coherent
c. Awake- answer
d. Aware
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CN assessment:
I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
Olfactory
Optic
Oculomotor
Trocheal
Trigeminal
Abducens
Facial
Acustic/auditory
Glassopharyngeal
Vagus
Spinal accessory
Hypoglossal
s
s
m
m
b
m
b
b
b
m
smallest CN
largest CN
s
longest CN
m
I. Olfactory dont use ammonia, alcohol, cologne irritating to mucosa use coffee, bar soap, vinegar,
cigarette tar
- Hyposmia decrease sensitivity to smell
- Diposmia distorted sense of smell
- Anosmia absence of sense of smell
Either of 3 might indicate head injury damage to cribriform plate of ethmoid bone where
olfactory cells are located or indicate inflammation condition sinusitis
II optic- test of visual acuity Snellens chart central or distance vision
Snellens E chart used for illiterate chart
N 20/20 vision distance by w/c person can see letters- 20 ft
Numerator distance to snellens chart
Denominator distance the person can see the letters
OD Rt eye
20/20 20/200 blindness cant read E biggest
OS left eye
20/20
OU both eye
20/20
2.
a.
b.
c.
d.
Common Disorders see page 85-87 for more info on glaucoma, etc.
1. Glaucoma Normal 12 21 mmHg pressure
- Increase IOP - Loss of peripheral vision tunnel vision
2. Cataract opacity of lens - Loss of central vision, Blurring or hazy vision
3. Retinal detachment curtain veil like vision & floaters
4. Macular degeneration black spots
III, IV, VI tested simultaneously
- Innervates the movementt of extrinsic ocular muscle
6 cardinal gaze EOM
Rt eye
IO
SO
N
O
left eye
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LR
SR
MR
S
E
3 4 EOM
IV sup oblique
VI lateral rectus
Normal response PERRLA (isocoria equal pupil)
Anisocoria unequal pupil
Oculomotor
1. Raising of eyelid Ptosis
2. Controls pupil size 2 -3 cm or 1.5 2 mm
V Trigeminal Largest consists of - ophthalmic, maxillary, mandibular
Sensory controls sensation of the face, mucus membrane; teeth & cornea reflex
Unconscious instill drop of saline solution
Motor controls muscles of chewing/ muscles of mastication
Trigeminal neuralgia diff chewing & swallowing extreme food temp is not recommended
Question: Trigeminal neuralgia, RN should give
a. Hot milk, butter, raisins
b. Cereals
c. Gelatin, toast, potato all correct but
d. Potato, salad, gelatin salad easier to chew
VI Facial: Sensory controls taste ant 2/3 of tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group 40 yrs old
Motor- controls muscles of facial expression, smile frown, raise eyebrow
Damage Bells palsy facial paralysis
Cause bells palsy pedia R/T forcep delivery
Temporary only
Most evident clinical sign of facial symmetry: Nasolabial folds
VIII Acoustic/ vestibule cochlear (controls hearing) controls balance (kenesthesia or position sense)
- Movement & orientation of body in space
- Organ of Corti for hearing true sense organ of hearing
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ENDOCRINE
Fx of endocrine ductless gland
Main gland Pituitary gland located at base of brain of Stella Turcica
Master gland of body
Master clock of body
Anterior pituitary gland adenohypophysis
Posterior pituitary gland neurohypophysis
Posterior pituitary:
1.) Oxytocin a.) Promotes uterine contraction preventing bleeding/ hemorrhage.
- Give after placental delivery to prevent uterine atony.
b.) Milk letdown reflex with help of prolactin.
2.) ADH antidiuretic hormone (vasopressin) -Prevents urination conserve H2O
A. DIABETIS INSIPIDUS
(DI- dalas ihi) hyposecretion of ADH
Cause: idiopathic/ unknown
Predisposing factor:
1. Pituitary surgery
2. Trauma/ head injury
3. Tumor
4. Inflammation
* alcohol inhibits release of ADH
S & Sx:
1. Polyuria
2. Sx of dehydration
- Excessive thirst (adult)
- Agitation
- Poor skin turgor
- Dry mucus membrane
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Fluid retention
Increase BP HPN
Edema
Wt gain
Danger of H2O intoxication Complications: 1. cerebral edema increase ICP 2. seizure
Dx Proc:
1. Urine specific gravity increase diluted urine
2. Hyponatremia Decreased Na
Nsg Mgt:
1. Restrict fluid
2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
3. Monitorstrictly V/S, I&O, neuro check increase ICP
4. Weigh daily
5. Assess for presence edema
6. Provide meticulous skin care
7. Prevent complications increase ICP & seizures activity
Anterior Pituitary Gland adeno
1. Growth hormone (GH) (Somatotropic hormone)
Fx: Elongation of long bones
Decrease GH dwarfism children
Increase GH gigantism
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PINEAL GLAND
1. Secretes Melatonin inhibits lutenizing hormone (LH) secretion
THYROID GLAND (TG)
Question: Normal physical finding on TG:
a. With tenderness thyroid never tender
b. With nodular consistency- answer
c. Marked asymmetry only 1 TG
d. Palpable upon swallowing - Normal TG never palpable unless with goiter
TG hormones:
T3
- Triodothyronine
effects of parathormone
- 3 molecules of iodine
T4
Thyrocalcitonin
-Tetraiodothyronine/ Tyroxine
FX antagonizes
- 4 molecules of iodine
Metabolic hormone
Increase metabolism brain inc cerebration, inc v/s
constipation
C. SIMPLE GOITER
- enlarged thyroid gland - iodine deficiency
Predisposing factors
1. Goiter belt area - Place far from sea no iodine. Seafoods rich in iodine
2. Mountainous area increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake)
Cabbage has progoitrin an anti thyroid agent with no iodine
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Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root
crops), all nuts.
3.
Goitrogenic drugs:
Anti thyroid agents :(PTU) prephyl thiupil
Lithium carbonate, Aspirin PASA
Cobalt, Phenyl butasone
Endemic goiter cause # 1
Sporadic goiter caused by #2 & 3
S & Sx enlarged TG
Mild restlessness
Mild dysphagia
Dx Proc.
1. Thyroid scan reveals enlarged TG
2. Serum TSH increase (confirmatory)
3. Serum T3, T4 N or below N
Nsg Mgt:
1. Administer meds
a.) Iodine solution Logols solution or saturated sol of K iodide SSKI
Nsg Mgt Lugols sol violet color
1. use straw prevent staining teeth
2. Prophylaxis 2 -3 drops Treatment 5 to 6 drops
Use straw to prevernt staining of teeth
1. Lugols sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron
solution.
B. Thyroid h / Agents
1. Levothyroxine (Synthroid)
2. Liothyronine (cytomel)
3. Thyroid extract
Nsg Mgt: for TH/agents
1. Monitor vs. HR due tachycardia & palpitation
2. Take it early AM SE insomnia
3. Monitor s/e
Tachycardia, palpitations
Signs of insomnia
Hyperthyroidism
restlessness agitation
Heat intolerance
HPN
3. Encourage increase intake iodine iodine is extracted from seaweeds (!)
Seafood- highest iodine content oysters, clams, crabs, lobster
Lowest iodine shrimps
Iodized salt easily destroyed by heat take it raw not cooked
4. Assist surgery- Sub total thyroidectomyComplication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at
incision site.Check nape for wet blood. 4.Laryngeal spasm DOB, SOB trache set ready at
bedside.
D. HYPOTHYROIDISM
decrease secretion of T3, T4 can lead to MI / Atherosclerosis
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Adult myxedema
Child- cretinism only endocrine dis lead to mental retardation
Predisposing factor:
1. `Iatrogenic causes caused by surgery
2. Atrophy of TG due to:
a. Irradiation
b. Trauma
c. Tumor, inflammation
3. Iodine def
4. Autoimmune Hashimoto disease
S&Sx everything decreased except wt gain & mens increase)
Early signs weakness and fatigue
Loss of appetite increased lypolysis breakdown of fats causing atherosclerosis = MI
Wt gain
Cold intolerance myxedema - coma
Constipation
Late Sx brittle hair/ nails
Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue
-Myxedema
Horseness voice
Decrease libido
Decrease VS hypotension bradycardia, bradypnea, and hypothermia
Lethargy
Memory impairment leading to psychosis-forgetfulness
Menorrhagia
Dx:
1. Serum T3 T4 decrease
2. Serum cholesterol increase can lead to MI
3. RA IU radio iodine uptake decrease
Nsg Mgt:
1. Monitor strictly V/S. I&O to determine presence of myxedema coma!
Myxedema Coma - Severe form of hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia,
hypothermia
Might lead to progressive stupor & coma
Impt mgt for Myxedema coma
1. Assist mech vent priority a/w
2. Adm thyroid hormone
3. Adm IVF replacement force fluid
Mgt myxedema coma
1. Monitor VS, I&O
2. Provide dietary intake low in calories due to wt gain
3. Skin care due to dry skin
4. Comfortable & warm environment due to cold intolerance
5. Administer IVF replacements
6. Force fluid
7. Administer meds take AM SE insomia. Monitor HR.
Thyroid hormones
Levothyroxine(Synthroid), Liothyronine (cytomel)
Thyroid extracts
8. Health teaching & discharge plan
a. Avoidance precipitating factors leading to myxedema coma:
27
Mark Darren Z. Praxides, RN
E. HYPERTHYROIDISM
Graves dse or thyrotoxicosis ( everything up except wt and mens)
-Increased T3 & T4
Predisposing factors:
1. Autoimmune disease release of long acting thyroid stimulator (LATS)
Exopthalmos
Enopthalmos severe dehydration depressed eye
2. Excessive iodine intake
3. Hyperplasia of TG
S&Sx:
1.
2.
3.
4.
5.
6.
8.
7.
8.
9.
Dx:
Nsg Mgt:
1. Monitor VS & I & O determine presence of thyroid storm or most feared complication:
Thyrotoxicosis
2. Administer meds
a. Antithyroid agents
1. Prophylthiuracil (PTU)
2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and
throat swab culture
Most feared complication : Thrombosis stroke CVS
3.
4.
5.
6.
7.
8.
28
Mark Darren Z. Praxides, RN
29
Mark Darren Z. Praxides, RN
F. HYPOPARATHYROIDISM
decreased parathormone
Hypocalcemia
(Or tetany)
Hyperphosphatemia
tetany
Tingling sensation
Paresthesia
Dysphagia
Laryngospasm
Bronchospasm
Pathognomonic Sign of tetany:
a. (+) Trousseaus or carpopedial spasm
b. (+) Chvostecks sign
f. Seizure
g. Arrhythmia
2. Chronic tetany
a. Loss of tooth enamel
b. Photophobia & cataract formation
c. GIT changes anorexia, n/v, general body malaise
d. CNS changes memory impairment, irritability
Dx:
1.
2.
3.
4.
Nsg Mgt:
1. Administration of meds:
a.) Acute tetany
Ca gluconate IV, slowly
b.) Chronic tetany
1. Oral Ca supplements
Ex. Ca gluconate
Ca carbonate
Ca lactate
Vit D (Cholecalceferol)
30
Mark Darren Z. Praxides, RN
Drug
Cholecalceferol
diet
calcidiol
sunlight
calcitriol
7am 9am
2. Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC
MAD
Aluminum containing acids
Mg containing antacids
Ex. Milk or magnesia
Aluminum OH gel
Diarrhea
Constipation
Maalox magnesium & aluminum - Less s/e
2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure
3. Diet increase Ca & decrease phosphorus
- Dont give milk due to increase phosphorus
Good = anchovies increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.
4. Bedside tracheostomy set due to laryngospasm
5. Encourage to breath with paper bag in order to produce mild respiratory acidosis to promote increase
ionized Ca levels
6. Most feared complication : Seizure & arrhythmia
7. Hormonal replacement therapy - lifetime
8. Important fallow up care
G. HYPERPARATHYROIDISM
- increase parathormone. Complication: Renal failure
Hypercalcemia can lead to Hypophosphatemia
Bone dse Mineralization
kidney stones
31
Mark Darren Z. Praxides, RN
a. Renal colic
b. Cool moist skin
3. GIT changes anorexia, n/v, ulcerations
4. CNS involvement irritability, memory impairment
Dx Proc:
1. Serum Ca increase
2. Serum phosphorus decreases
3. X-ray long bones reveals bone demineralization
Nsg Mgt: Kidney Stone
1.
2.
3.
4.
5.
6.
ADRENAL GLAND
12. Atop of @ kidney
13. 2 parts
Adrenal cortex outermost layer
Adrenal medulla - innermost layer
14. Secrets cathecolamines
a.) Epinephrine / Norephinephrine potent vasoconstrictor adrenaline=Increase BP
Adrenal Medullas only disease:
Adrenal Cortex
1.
2.
32
Mark Darren Z. Praxides, RN
I. ADDISONS DISEASE
Steroids-lifetime
Decreased adrenocortical hormones leading to:
a.) Metabolic disturbances (sugar)
b.) F&E imbalances- Na, H2O, K
c.) Deficiency of neuromuscular function (salt & sex)
Predisposing Factors:
1. Atrophy of adrenal gland
2. Fungal infections
3. Tubercular infections
S/Sx:
1. Decrease sugar Hypoglycemia Decreased glucocorticoids - cortisol
T tremors, tachycardia
I - irritability
R - restlessness
E extreme fatigue
D diaphoresis, depression
2. Decrease plasma cortisol
Decrease tolerance to stress lead to Addisonians crisis
3. Decrease salt Hyponatermia Decreased mineralocorticoids - Aldosterone
Hypovolemia
a.) Hypotension
b.) Signs of dehydration extreme thirst, agitation
c.) Wt loss
4. Hyperkalemia
a.) Irritability
b.) Diarrhea
c.) Arrhythmia
5. Decrease sexual urge or libido- Decreased Androgen
6. Loss of pubic and axillary hair
To Prevent STD
Local practice monogamous relationship
CGFNS/NCLEX condom
7. Pathognomonic sign bronze like skin pigmentation due to decrease cortisol will stimulate pituitary
gland to release melanocyte stimulating hormone.
Dx Proc:
1. FBS decrease FBS (N 80 120 mg/dL)
2. Plasma cortisol decreased
Serum Na decreased (N 135 145 meg/L)
3. Serum K increased (N 3.5 5.5 meg/L)
Nsg Mgt:
1.
33
Mark Darren Z. Praxides, RN
2.
Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone
Nsg Mgt with Steroids
1. Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm.
2. Taper the dose (w/draw, gradually from drug) sudden withdrawal can lead to addisonian
crisis
3. Monitor S/E (Cushings syndrome S/Sx)
a.) HPN
b.) Hirsutism
c.) Edema
d.) Moon face & buffalo hump
e.) Increase susceptibility to infection sue to steroids- reverse isolation
b.) Mineralocorticoids ex. Flourocortisone
3.
4.
5.
6.
7.
8.
9.
J. CUSHINGS SYNDROME
increase secretion of adrenocortical hormone
Predisposing Factors:
1. Hyperplasia of adrenal gland
2. Tubercular infection milliary TB
S/Sx
1. Increase sugar Hyperglycemia
3 Ps
1. Polyuria
2. Polydipsia increase thirst
3. Polyphagia increase appetite
Classic Sx of DM 3 Ps & glycosuria + wt loss
34
Mark Darren Z. Praxides, RN
1.
2.
3.
4.
Nsg Mgt:
1. Monitor VS, I&O
2. Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone
- promotes excretion of NA while conserving potassium
Not lasix due to S/E hypoK & Hyperglycemia!
3. Restrict Na
4. Provide Dietary intake low in CHO, low in Na & fats
High in CHON & K
5. Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc.
6. Reverse isolation
7. Skin care due acne & striae
8. Prevent complication
- Most feared arrhythmia & DM
(Endocrine disorder lead to MI Hypothyroidism & DM)
9. Surgical bilateral Adrenolectomy
10.Hormonal replacement therapy lifetime due to adrenal gland removal- no more corticosteroid!
PANCREAS behind the stomach, mixed gland both endocrine and exocrine gland
Acinar cells (exocrine gland)
cells
secrets glucagon
35
Mark Darren Z. Praxides, RN
Secrets insulin
Fxn: hypoglycemia
Delta Cells
Secrets somatostatin
Fxn: antagonizes growth hormone
3 disorders of
1.
2.
3.
the Pancreas
DM
Pancreatic Cancer
Pancreatitis
Overview only:
K. PANCREATITIS
acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion self-digestion
Cause: unknown/idiopathic
18. Or alcoholism
Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turners sign ecchymosis of flank area
Both sx means hemorrhage
M. DIABETES MELLITUS
- metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism
Classification:
I.
36
Mark Darren Z. Praxides, RN
37
Mark Darren Z. Praxides, RN
1.
2.
S/Sx :
Same
1.
2.
Unknown/ idiopathic
Influence of maternal hormones
as type II
Asymptomatic
3 Ps & 1G
Catabolism
glycogen
nitrogen
free fatty acids (FFA) Cholesterol & Ketones
ketones
DKA
coma
38
Mark Darren Z. Praxides, RN
HPN
MI
death
stroke
Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma.
Ketones- a CNS depressant
Predisposing factor:
1. Stress between stress and infection, stress causes DKA more.
2. Hyperglycemia
3. Infection
S/Sx:
3 Ps & 1G
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glycosuria
5. Wt loss
6. Anorexia, N/V
7. (+) Acetone breath odor- fruity odor
8. Kussmaul's resp-rapid shallow
9. CNS depression
10. Coma
respiration
pathognomonic DKA
Dx Proc:
1. FBS increase, Hct increase (compensate due to dehydration)
N =BUN 10 -20
mg/100ml
--increased due to severe dehydration
Crea - .8 1
mg/100ml
Hct 42% (should be 3x high)-nto hgb
Nsg Mgt:
1. Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3. Monitor VS, I&O, blood sugar levels
4. Administer meds as ordered:
a.) Insulin therapy IV push
Regular Acting Insulin clear (2-4hrs, peak action)
b.) To counteract acidosis Na HCO3
c.) Antibiotic to prevent infection
Insulin
A.
1.
2.
Therapy
Sources:
Animal source beef/ pork-rarely used. Causes severe allergic reaction.
Human has less antigenecity property
Cause less allergic reaction. Humulin
If kid is allergic to chicken dont give measles vaccine due it comes from chicken embryo.
3. Artificially compound
B. Types of Insulin
1. Rapid Acting Insulin - Ex. Regular acting I
39
Mark Darren Z. Praxides, RN
- - 1 cc = 100 units
- - .5cc = 50 units
- - .1 cc = 10 units
6 units RA
Most Feared Complication of Type II DM
Hyper
osmolarity = severe dehydration
Osmolar
Non
- absence of lipolysis
Ketotic
- no ketone formation
Coma S/Sx: headache, restlessness, seizure, decrease LOC = coma
Nsg Mgt; - same as DKA except dont give NaHCO3!
1.Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
40
Mark Darren Z. Praxides, RN
Tx:
times
=confirms DM!!
Nsg Mgt;
1. Monitor for PEAK action of OHA & insulin
Notify Doc
2. Monitor VS, I&O, neurocheck, blood sugar levels.
3. Administer insulin & OHA therapy as ordered.
4. Monitor signs of hyper & hypoglycemia.
Pt DM hinimatay
20. You dont know if hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain cant tolerate low sugar!)
Cold, clammy skin hypo Orange Juice or simple sugar / warm to touch hyper adm insulin
5. Provide nutritional intake of diabetic diet:
CHO 50%
CHON 30%
Fats 20%
-Or offer alternative food products or beverage.
-Glass of orange juice.
6. Exercise after meals when blood glucose is rising.
7. Monitor complications of DM
a. Atherosclerosis HPN, MI, CVA
b. Microangiopathy small blood vessels
Eyes diabetic retinopathy , premature cataract & blindness
Kidneys recurrent pyelonephritis & Renal Failure
41
Mark Darren Z. Praxides, RN
bleeding
Formed Elements:
1. RBC (erythrocytes)
Spleen life span = 120 days
(N) 3 6 M/mm3
- Anucleated
- Biconcave discs
- Has molecules of Hgb (red cell pigment)
Transports & carries O2
42
Mark Darren Z. Praxides, RN
NON-GRANULOCYTES
1. Monocytes (macrophage) - largest WBC
- involved in long term phagocytes
- For chronic inflammation
- Other name macrophage
Macrophage
Macrophage
Macrophage
Macrophage
in
in
in
in
CNS- microglia
skin Histiocytes
lungs alveolar macrophage
Kidneys Kupffer cells
2. Lymphocytes
B Cell L bone marrow or bursa dependent
T cell devt of immunity- target site for HIV
NK cell natural killer cell
Have both antiviral & anti-tumor properties
3.Platelets (thrombocytes)
N- 150,000 450, 000/ mm3
it promotes hemostasis prevention of blood loss by activating
clotting
43
Mark Darren Z. Praxides, RN
B. ANEMIA
Iron deficiency Anemia chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate
absorption of iron leading to hypoxemic injury.
Incidence rate:
1. Common developed country due to high cereal intake
Due to accidents common on adults
2. Common tropical countries blood sucking parasites
3. Women 15 35yo reproductive yrs
4. Common among the poor poor nutritional intake
Suicide - common in teenager
Poisoning common in children (aspirin)
Aspiration common in infant
Accidents common in adults
Choking common in toddler
SIDS common in infant in US
22. Common in tropical zone Phil due blood sucks
Predisposing factor:
1. Chronic blood loss
a. Trauma
b. Mens
c. GIT bleeding:
i. Hematemesisii. Melena upper GIT duodenal cancer
iii. Hematochezia lower GIT large intestine fresh blood from rectum
2.
Inadequate intake of food rich in iron
3.
Inadequate absorption of iron due to :
a. Chronic diarrhea
b. Malabsorption syndrome celiac disease-gluten free diet. Food for celiac pts- sardines
c. High cereal intake with low animal CHON ingestion
d. Subtotal gastrectomy
4. Improper cooking of food
S/Sx:
1.
2.
3.
4.
5.
Asymptomatic
Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells
Atropic glossitis, dysphagia, stomatitis
Pica abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic
behavior)
44
Mark Darren Z. Praxides, RN
Lugols
Tetracycline
Oral iron
Macrodantine
3.
4.
a.
b.
c.
d.
e.
If pt cant tolerate oral iron prep administer parenteral iron prep example:
1. Iron dextran (IV, IM)
2. Sorbitex (IM)
Nsg Mgt parenteral iron prep
1. Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues.
2. Dont massage injection site. Ambulate to facilitate absorption.
3. Monitor S/E:
a.) Pain at injury site
b.) Localized abscess (nana)
c.) Lymphadenopathy
d.) Fever/ chills
45
Mark Darren Z. Praxides, RN
C. PERNICIOUS ANEMIA
- megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to
Hypochlorhydria
decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement.
Predisposing factor
1. Subtotal gastrectomy removal stomach
2. Hereditary
3. Infl dse of ileum
4. Autoimmune
5. Strict vegetable diet
STOMACH
Parietal or ergentaffen Oxyntic cells
Fxn produce intrinsic factor
Fx aids in digestion
D. APLASTIC ANEMIA
stem cell disorder due to bone marrow depression leading to pancytopenia all RBC are decreased
46
Mark Darren Z. Praxides, RN
Decrease RBC
decrease WBC
decrease platelets
Anemia
thrombocytopenia
Increase WBC leukocytocys
Increase RBC polycythemia vera complication stroke, CVA, thrombosis
leukopenia
1. CBC pancytopenia
2. Bone marrow biopsy/ aspiration at post iliac crest reveals fatty streaks in bone marrow
Nsg Mgt:
1. Removal of underlying cause
2. Blood transfusion as ordered
3. Complete bed rest
4. O2 inhalation
5. Reverse isolation due leukopenia
6. Monitor signs of infection
7. Avoid SQ, IM or any venipuncture site = HEPLOCK
8. Use electric razor when shaving to prevent bleeding
9. Administer meds
Immunosuppresants
Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days 3 weeks to achieve max
therapeutic effect of drug.
BLOOD TRANSFUSION:
Objectives:
1. To replace circulating blood volume
2. To increase O2 carrying capacity of blood
3. To combat infection if theres decrease WBC
4. To prevent bleeding if theres platelet deficiency
Nsg Mgt & principles in Blood Transfusion
1. Proper refrigeration
2. Proper typing & crossmatching
Type O universal donor
AB universal recipient
47
Mark Darren Z. Praxides, RN
BT reactions
S/Sx Hemolytic reaction:
H hemolytic Reaction
1. Headache, dizziness, dyspnea, palpitation,
lumbar/ sterna/ flank pain,
A allergic Reaction
hypotension, flushed skin , (red) port wine urine.
P pyrogenic Reaction
C circulatory overload
A air embolism
T - thrombocytopenia
C citrate intoxication expired blood =hyperkalemia
H hyperkalemia
Nsg Mgt: Hemolytic Reaction:
1. Stop BT
2. Notify Doc
3. Flush with plain NSS
4. Administer isotonic fluid sol to prevent acute tubular necrosis & conteract shock
5. Send blood unit to blood bank for reexamination
6. Obtain urine & blood samples of pt & send to lab for reexamination
7. Monitor VS & Allergic Rxn
Allergic Reaction:
S/Sx
1.
2.
3.
4.
5.
Fever/ chills
Urticaria/ pruritus
Dyspnea
Laryngospasm/ bronchospasm
Bronchial wheezing
Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
48
Mark Darren Z. Praxides, RN
Pyrogenic Reaction:
S/Sx
a.) Fever/ chills
b.) Headache
c.) Dyspnea
d. tachycardia
e. palpitations
f. diaphoresis
Nsg Mgt:
1.
2.
3.
4.
5.
6.
7.
8.
Stop BT
Notify Doc
Flush with PNSS
Administer antipyretics, antibiotics
Send blood unit to blood bank
Obtain urine & blood samples send to lab
Monitor VS & IO
Tepid sponge bath offer hypothermic blanket
Circulatory Overload:
Sx
a.
b.
c.
d.
Dyspnea
Orthopnea
Rales or crackles
Exertional discomfort
Nsg Mgt:
1. Stop BT
2. Notify Doc. Dont flush due pt has circulatory overload.
3. Administer diuretics
Priority cases:
Hemolytic Rxn 1st due to hypotension 1st priority attend to destruction of Hgb O2 brain damage
Allergic
3rd
th
Pyrogenic
4
Circulatory
2nd
Hemolytic
Anaphylitic
2nd
1st priority
49
Mark Darren Z. Praxides, RN
6. Anaphylaxis
7. Neoplasia growth of new tissue
8. Pregnancy
S/Sx
1.
2.
3.
4.
5.
6.
Dx Proc
1. CBC reveals decrease platelets
2. Stool for occult blood (+)
Specimen stool
3. Opthalmoscopic exam sub retinal hemorrhage
4. ABG analysis metabolic acidosis
pH
pH
HCO3
PCO2
respiratory alkalosis
ph
PCO2
respiratory acidosis
ph
HCO3
metabolic alkalosis
ph
HCO3
metabolic acidosis
Oncologic Nsg
Oncology study of neoplasia new growth
Benign (tumor)
Diff
- well differentiated
Malignancy (cancer)
poorly or undifferentiated
50
Mark Darren Z. Praxides, RN
Encapulation (+)
Metastasis (-)
Prognosis good
Therapeutic modality surgery
(-)
(+)
poor
1. Chemotherapy
plenty S/E
2. Radiation
3. Surgery
most preferred treatment
4. Bone marrow transplant - Leukemia only
Predisposing factors: (carcinogenesis)
G genetic factors
I immunologic factors
V viral factors
a. Human papiloma virus causing warts
b. Epstein barr virus
E environmental Factors 90%
a. Physical irradiation, UV rays, nuclear explosion, chronic irritation, direct trauma
b. Chemical factors
- Food additives (nitrates
- Hydrocarbon vesicants, alkalies
- Drugs (stillbestrol)
- Uraehane
- Hormones
- Smoking
Male
3.) Prostate cancer - common 40 & above (middle age & above)
BPH 50 & above
1.) Lung cancer
2.) Liver cancer
Female
1. Breast cancer 40 yrs old & up mammography 15 20 mins (SBE 7 days after mens)
2. Cervical cancer 90% multi sexual partners
5% early pregnancy
3. Ovarian cancer
Classes of cancer
Tissue typing
1.
2.
3.
Warning / Danger Sx of CA
C change in bowel /bladder habits
A a sore that doesnt heal
U unusual bleeding/ Discharge
T thickening of lump breast or elsewhere
I indigestion? Dysphagia
O obvious change in wart/ mole
N nagging cough/ hoarseness
U unexplained anemia
A - anemia
S sudden wt loss
L loss of wt
Therapeutic Modality:
1. Chemotherapy use various chemotherapeutic agents that kills cancer cells & kills normal
rapidly producing cells GIT, bone marrow, and hair follicle.
Classification:
51
Mark Darren Z. Praxides, RN
a.)
b.)
c.)
d.)
Alkylating agents
Plant alkaloids vincristine
Anti metabolites nitrogen mustard
Hormones DES
Steroids
e.) Antineoplastic antibiotics
S/E & mgt
GIT - -Nausea & vomiting
Nsg Mgt:
1.
Administer anti emetic 4 6h before start of chemo
Plasil
2. Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
25. Non irritating / non spicy
- Diarrhea
1. Administer anti diarrheal 4 6h before start of chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care offer ice chips/ popsickles
2. Inform pt hair loss temporary alopecia
Hair will grow back after 4 6 months post chemo.
-Bone marrow depression anemia
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding
Repro organ sterility
1. Do sperm banking before start of chemo
Renal system increase uric acid
1. Administer allopurinol/ xyloprin (gout)
26. Inhibits uric acid
27. Acute gout colchicines
28. Increase secretion of uric acid
Neurological changes peristalsis paralytic ileus
Most feared complication ff any abdominal surgery
Vincristine plant alkaloid causes peripheral neuropathy
2. Radiation therapy involves use of ionizing radiation that kills cancer cells & inhibit their growth &
kill N rapidly producing cells.
Types
1.
2.
3.
of energy emitted
Alpha rays rarely used doesnt penetrate skin tissues
Beta rays internal radiation more penetration
Gamma ray external radiation penetrates deeper underlying tissues
Methods of delivery
1. External radiation- involves electro magnetic waves
Ex. cobalt therapy
2. Internal radiation injection/ implantation of radioisotopes proximal to CA site for a specific period
of time.
2 types:
a.) Sealed implant radioisotope with a container & doesnt contaminate body fluid.
b.) Unsealed implant radioisotope without a container & contaminates body fluid.
Ex. Phosphorus 32
3 Factors affecting exposure:
A.) Half life time period required for half of radioisotopes to decay.
52
Mark Darren Z. Praxides, RN
CARDIOVASCULAR SYSTEM
Overview of function & structure of the heart
HEART
- Muscular, pumping organ of the body
- Left mediastinum
- Weigh 300 400 grams
- Resembles a closed fist
- Covered by serous membrane pericardium
Pericardium
Parietal layer
Pericardial
Fluid prevent
Friction rub
Visceral layer
Layer
1. Epicardium outermost
2. Myocardium inner responsible for pumping action/ most dangerous layer - cardiogenic shock
3. Endocardium innermost layer
Chambers
1. Upper collecting/ receiving chamber - Atria
2. Lower pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
Closure of AV valves gives rise to 1st heart sound or S1 or lub
2. Semi lunar valve
a.) Pulmonic
b.) Aortic
Closure of semilunar valve gives rise to 2nd heart sound or S2 or dub
Extra heart Sound
53
Mark Darren Z. Praxides, RN
AV
Purkenjie Fibers
Bundle of His
T wave inversion MI
widening QRS arrhythmia
ARTEROSCLEROSIS
- Narrowing or artery due to calcium & CHON deposits
at tunica media.
54
Mark Darren Z. Praxides, RN
A. ANGINA PECTORIS
- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT
nitroglycerin, resulting fr temp myocardial ischemia.
Predisposing Factor:
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10.hypothyroidism
Precipitating factors
4 Es
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake of food saturated fats.
Signs & Symptoms
1. Initial symptoms Levines sign hand clutching of chest
2. Chest pain sharp, stabbing excruciating pain. Location substernal
55
Mark Darren Z. Praxides, RN
3.)
4.)
5.)
6.)
7.)
B. MI MYOCARDIAL INFARCTION
hear attack terminal stage of CAD
56
Mark Darren Z. Praxides, RN
Types:
1. Trasmural MI most dangerous MI Mal-occlusion of both R&L coronary artery
2. Sub-endocardial MI mal-occlusion of either R & L coronary artery
Most critical period upon dx of MI 48 to 72h
- Majority of pt suffers from PVC premature ventricular contraction.
Predisposing factors
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral
contrac
eptive
prolong
ed
8. sedentary
lifestyle
9. obesity
10. hypothyroidism
Diagnostic Exam
1. cardiac enzymes
a.) CPK MB Creatinine
Phosphokinase
b.) LDH lactic acid
dehydrogenase
c.) SGPT (ALT) Serum Glutanic
Pyruvate Transaminase- increased
d.) SGOT (AST) Serum Glutamic
Oxalo-acetic - increased
2. Troponin test increase
3. ECG tracing ST segment
increase,
widening or QRS complexes
means arrhythmia in MI indicating
PVC
4. serum cholesterol & uric acid increase
5. CBC increase WBC
Nursing Management
1. Narcotic analgesics Morphine SO4 to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias PVC
2. Shock cardiogenic shock. Late signs of cardiogenic shock in MI oliguria
3. thrombophlebitis - deep vein
4. CHF left sided
5. Dresslers syndrome post MI syndrome
-Resistant to medications
-Administer 150,000 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
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Mark Darren Z. Praxides, RN
2. Isordil
- Antiarrythmic
1. Lydocaine blocks release of norepenephrine
2. Brithylium
- Beta-blockers lol
1. Propanolol (inderal)
- ACE inhibitors - pril
1. Captopril (enalapril)
- Ca antagonist
1. Nifedipine
- Thrombolitics or fibrinolytics to dissolve clots/ thrombus
S/E allergic reactions/ uticaria
1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting factor
PTT
PT
If prolonged bleeding
prolonged bleeding
Antidote
antidote Vit K
Protamine sulfate
- Anti platelet PASA (aspirin)
d.) Resume ADL sex/ activity 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert
Before meals not after, due after meals increase metabolism heart is pumping hard after
meals.
2.) Position non-weight bearing position.
When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet decrease Na, Saturated fats, and caffeine
f.) Follow up care.
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Mark Darren Z. Praxides, RN
1. CXR cardiomegaly
2. PAP Pulmonary Arterial Pressure
PCWP Pulmonary CapillaryWedge Pressure
PAP measures pressure of R ventricle. Indicates cardiac status.
PCWP measures end systolic/ diastolic pressure
PAP & PCWP:
Swan ganz catheterization cardiac catheterization is done at bedside at ICU
(Trachesostomy bedside) - Done 5 20 mins scalpel & trachesostomy set
CVP indicates fluid or hydration status
Increase CVP decrease flow rate of IV
Decrease CVP increase flow rate of IV
3. Echocardiography reveals enlarged heart chamber or cardiomayopathy
4. ABG PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis
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Mark Darren Z. Praxides, RN
1. CXR cardiomegaly
2. CVP measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 hypervolemia
Decrease CVP < 4 hypovolemia
Flat on bed post of pt when giving CVP
Position during CVP insertion Trendelenburg to prevent pulmonary embolism &
promote ventricular filling.
3. Echocardiography enlarged heart chamber / cardiomyopathy
4.Liver enzyme
SGPT ( ALT)
SGOT AST
Nsg mgt: Increase force of myocardial contraction = increase CO
3 6L of CO
1. Administer meds:
Tx for LSHF: M morphine SO4 to induce vasodilatation
A aminophylline & decrease anxiety
D digitalis (digoxin)
D - diuretics
O - oxygen
G - gases
a.) Cardiac glycosides
Increase myocardial = increase CO
Digoxin (Lanoxin). Antidote: digivine
Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure.
b.) Loop diuretics: Lasix effect with in 10-15 min. Max = 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety
e.) Vasodilators NTG
f.) Anti-arrythmics Lidocaine
2.
3.
4.
5.
6.
Arterial ulcers
1. Thromboangiitis Obliterans male/ feet
2. Reynauds female/ hands
venous ulcer
1. Varicose veins
2. Thrombophlebitis
S/Sx
1. Intermittent claudication leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes
3.
4.
5.
6.
White
bluish
Pallor
cyanosis
red
rubor
Dx:
1. Oscillometry decrease peripheral pulse volume.
2. Doppler UTZ decrease blood flow to affected extremities.
3. Angiography reveals site & extent of mal-occulsion.
5.
Nsg Mgt:
1. Encourage a slow progression of physical activity
a.) Walk 3 -4 x / day
b.) Out of bed 2 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM
a.) Avoid walking barefoot
b.) Cut toe nails straight
c.) Apply lanolin lotion prevent skin breakdown
d.) Avoid wearing constrictive garments
4. Avoid smoking & exposure to cold environment
5. Surgery: BKA (Below the knee amputation)
2.)REYNAUDS
fingers
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Mark Darren Z. Praxides, RN
Predisposing factors:
1. Female, 40 yrs
2. Smoking
3. Collagen dse
a.) SLE pathognomonic sign butterfly rash on
Chipmunk face bulimia
Cherry red skin carbon
Spider angioma liver cirrhosis
Caput medusae leg & trunk
Lion face leprosy
face
nervosa
monoxide poisoning
umbilicus- Liver cirrhosis
VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return
Predisposing factors:
a. Hereditary
b. Congenital weakness of veins
c. Thrombophlebitis
d. Heart dse
e. Pregnancy
f. Obesity
g. Prolonged immobility - Prolonged standing
S/Sx:
1. Pain especially after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs
Dx:
1. Venography
2. Trendelenbergs test vein distend quickly < 35 secs
Nsg Mgt:
1. Elevate legs above heart level to promote venous return 1 to 2 pillows
2. Measure circumference of leg muscles to determine if swollen.
3. Wear anti embolic or knee high stockings. Women panty hose
4. Meds: Analgesics
5. Surgery: vein sweeping & ligation
Sclerotherapy spider web varicosities
S/E thrombosis
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Mark Darren Z. Praxides, RN
B. THROMBOPHLEBITIS
(deep vein thrombosis) - Inflammation of veins with thrombus formation
Predisposing factors:
1. Smoking
2. Obesity
2. Hyperlipedemia
4. Prolonged use of oral contraceptives
5. Chronic anemia
6. DM
7. MI
8. CHF
9. Postop complications
10. Post cannulation insertion of various cardiac catheters
S/Sx:
1. Pain at affected extremities
2. Cyanosis
3. (+) Homans sign - Pain at leg muscles upon dorsiflexion of foot.
Dx:
1.
Angiography
2.
Doppler UTZ
Nsg Mgt:
1. Elevate legs above heart level.
2. Apply warm, moist packs to decrease lymphatic congestion.
3. Measure circumference of leg muscles to detect if swollen.
4. Use anti embolic stockings.
5. Meds: Analgesics.
Anticoagulant: Heparin
6. Complication:
Pulmonary Embolism:
-
RESPIRATORY SYSTEM
OVERVIEW OF RESPIRATORY SYSTEM:
I. Upper respiratory tract:
Fx:
1. Filtering of air
2. Warming & moistening
3. Humidification
a. Nose cartilage
- Parts:
Rt nostril
separated by septum
Lt nostril
b.
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Mark Darren Z. Praxides, RN
Branches:
1. Oropharynx
2. Nasopharynx
3. Layngopharynx
Fx:
Glottis opening
Opens to allow passage of air
Closes to allow passage of food
II. Lower Rt Fx for gas exchange
a. Trachea windpipe
- has cartillagenous rings
- site for permanent/ artificial a/w tracheostomy
b. Bronchus R & L main bronchus
c. Lungs R 3 lobes = 10 segments
L 2 lobes 8 segments
Post pneumonectomy - position affected side to promote expansion of lungs
Post segmental lobectomy position unaffected side to promote drainage
Lungs covered by pleural cavity, parietal lobe & visceral lobe
Alveoli acinar cells
- site of gas exchange (O2 & CO2)
- diffusion: Daltons law of partial pressure of gases
Ventilation movement of air in & out of lungs
Respiration movement of air into cells
Type II cells of alveoli secrets surfactant
Surfactant - decrease surface tension of alveoli
Lecithin & spinogometer
L/S ratio 2:1 indicator of lung maturity
If 1:2 adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.
A. PNEUMONIA
inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.
Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Hemophilus pneumoniae(Bronchopneumonia)
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.
High risk elderly & children below 5 yo
Predisposing factors:
1. Smoking
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Mark Darren Z. Praxides, RN
2. Air pollution
3. Immuno-compromised
a. AIDS PLP
b. Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue
S/Sx:
1.
2.
3.
4.
5.
6.
7.
8.
1. Enforce CBR
2. Strict respiratory isolation
3. Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
4. Force fluids 2 to 3 L/day
5. Institute pulmonary toileta.) Deep breathing exercise
b.) Coughing exercise
c.) Chest physiotherapy cupping
d.) Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfy & humid environment
9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt for postural drainage:
a.) Best done before meals or 2 4 hrs after meals to prevent Gastroesophageal Reflux
b.) Monitor VS & breath sounds
Normal breath sound bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 30 min before procedure
e.) Stop if pt cant tolerate procedure
f.) Provide oral care it may alter taste sensation
g.) C/I pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)
Normal IOP 12 21 mmHg
11. HT:
a.) Avoidance of precipitating factors
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Mark Darren Z. Praxides, RN
Diagnosis:
1. Skin test mantoux test infection of Purified CHON Derivative PPD
DOH 8-10 mm induration
WHO 10-14 mm induration
Result within 48 72h
(+) Mantoux test previous exposure to tubercle bacilli
Mode of transmission droplet infection
2. Sputum AFB (+) to cultured microorganism
3. CXR pulmonary
infiltrate caseosis necrosis
4. CBC increase WBC
Nursing Mgt:
1. CBR
2. Strict resp isolation
3. O2 inhalation
4. Semi fowler
5. Force fluid to liquefy secretions
6. DBCE
7. Nebulize & suction
8. Comfy & humid environment
9. Diet increase CHO & calories, CHON, Vit, minerals
10. Short course chemotherapy
Intensive phase
INH isoniazide
Rifampicin
resistance
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Mark Darren Z. Praxides, RN
PZA Pyrazinamide given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity
HT:
Standard regimen
1. Injection of streptomycin aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
a.) Ototoxicity damage CN # 8 tinnitus hearing loss
b.) Nephrotoxicicity monitor BUN & Crea
a.) Avoid pred factors
b.) Complications:
1.) Atelectasis
2.) Miliary TB spread of Tb to other system
b.) Compliance to meds
- Religiously take meds
C. HISTOPLASMOSIS
- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum
transmitted to birds manure.
S/Sx: Same as pneumonia & PTB like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis
Dx:
1. Histoplasmin skin test = (+)
2. ABG pO2 decrease
Nsg Mgt:
1. CBR
2. Meds:
a.) Anti fungal agents
Amphotericin B (Fungizone)
S/E :
a.) Nephrotoxcicity check BUN
b.) Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.
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Mark Darren Z. Praxides, RN
2. Bronchial asthma
3. Bronchiectasis
4. Pulmonary emphysema terminal stage
D. CHRONIC BRONCHITIS
- called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet mucus
producing cells leading to narrowing of smaller airways.
Predisposing factors:
1. Smoking all COPD types
2. Air pollution
S/Sx:
1. Prod cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmo HPN a.)Leading to peripheral edema
b.) Cor pulmonary respiratory in origin
7. Anorexia, gen body malaise
Dx:
1. ABG
PO2
PCO2
Resp acidosis
E. BRONCHIAL ASTHMA
- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller airway.
Predisposing factor:
1. Extrinsic Asthma called Atropic/ allergic asthma
a.) Pallor
b.) Dust
c.) Gases
d.) Smoke
e.) Dander
f.) Lints
2. Intrinsic AsthmaCause:
Herediatary
Drugs aspirin, penicillin, blockers
Food additives nitrites
Foods seafood, chicken, eggs, chocolates, milk
Physical/ emotional stress
Sudden change of temp, humidity &air pressure
3. mixed type: combi of both ext & intr. Asthma
90% cause of asthma
S/Sx:
1.
2.
3.
4.
5.
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Mark Darren Z. Praxides, RN
Dx:
Nsg Mgt:
1. CBR all COPD
2. Medsa.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before
corticosteroids
b.) Corticosteroids due inflammatory. Given 10 min after adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist at bedside put suction machine.
e.) Antihistamine
2. Force fluid
3. O2 all COPD low inflow to prevent resp distress
4. Nebulize & suction
5. Semifowler all COPD except emphysema due late stage
6. HT
a.) Avoid pred factors
b.) Complications:
- Status astmaticus- give epinephrine & bronchodilators
- Emphysema
c.) Adherence to med
F. BRONCHIECTASIS
abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.
Predisposing factors:
1. Recurrent upper & lower RI
2. Congenital anomalies
3. Tumors
4. Trauma
S/Sx:
1. Productive cough
2. Dyspnea
3. Anorexia, gen body malaise- all energy are used to increase respiration.
4. Cyanosis
5. Hemoptisis
Dx:
1. ABG PO2 decrease
2. Bronchoscopy direct visualization of bronchus using fiberscope.
Nsg Mgt: before bronchoscopy
1. Consent, explain procedure MD/ lab explain RN
2. NPO
3. Monitor VS
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Mark Darren Z. Praxides, RN
G. PULMONARY EMPHYSEMA
irreversible terminal stage of COPD
Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of
gases.
- Body will compensate over distension of thoracic cavity
- Barrel chest
Predisposing factor:
1. Smoking
2. Allergy
3. Air pollution
4. High risk elderly
5. Hereditary - 1 anti trypsin to release elastase for recoil of alveoli.
-
S/Sx:
1. Productive cough
2. Dyspnea at rest due terminal
3. Anorexia & gen body malaise
4. Rales/ rhonchi
5. Bronchial wheezing
6. Decrease tactile fremitus (should have vibration) palpation 99. Decreased - with air or fluid
7. Resonance to hyperresonance percussion
8. Decreased or diminished breath sounds
9. Pathognomonic: barrel chest increase post/ anterior diameter of chest
10. Purse lip breathing to eliminated PCO2
11. Flaring of alai nares
Diagnosis:
1. Pulmonary function test decrease vital lung capacity
2. ABG
a.) Panlobular / centrolobular emphysema
pCO2 increase
pO2 decrease hypoxema
resp acidosis
b.) Panacinar/ Centracinar
pCO2 decrease
pO2 increase hyperaxemia
resp alkalosis
Nursing Mgt:
1. CBR
2. Meds
a.) Bronchodilators
b.) Corticosteroids
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
3. O2 Low inflow
4. Force fluids
5. High fowlers
6. Neb & suction
7. Institute
P posture
E end
E expiratory to prevent collapse of alveoli
P pressure
8. HT
a.) Avoid smoking
b.) Prevent complications
Blue bloaters
Pink puffers
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Mark Darren Z. Praxides, RN
H. PNEUMOTHORAX
partial / or complete collapse of lungs due to entry or air in pleural space.
Types:
1. Spontaneous pneumothorax entry of air in pleural space without obvious cause.
Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
Eg. open pneumothorax air enters pleural space through an opening in chest wall
-Stab/ gun shot wound
2. Tension Pneumothorax air enters plural space with @ inspiration & cant escape leading to over
distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side.
Eg. flail chest paradoxical breathing
Predisposing factors:
1.Chest trauma
2.Inflammatory lung conditions
3.Tumor
S/Sx:
1. Sudden sharp chest pain
2. Dyspnea
3. Cyanosis
4. Diminished breath sound of affected lung
5. Cool moist skin
6. Mild restlessness/ apprehension
7. Resonance to hyper resonance
Diagnosis:
1. ABG pO2 decrease
2. CXR confirms pneumothorax
Nursing Mgt:
1. Endotracheal intubation
2. Thoracenthesis
3. Meds Morphine SO4
- Anti microbial agents
4. Assist in test tube thoracotomy
Nursing Mgt if pt is on CPT attached to H2O drainage
1. Maintain strict aseptic technique
2. DBE
3. At bedside
a.) Petroleum gauze pad if dislodged Hemostan
b.) If with air leakage clamp
c.) Extra bottle
4. Meds Morphine SO4
Antimicrobial
5. Monitor & assess for oscillation fluctuations or bubbling
a.) If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
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Mark Darren Z. Praxides, RN
When
1.
2.
3.
GIT
I. Upper alimentary canal - function for digestion
a. Mouth
b. Pharynx (throat)
c. Esophagus
d. Stomach
e. 1st half of duodenum
II. Middle Alimentary canal Function: for absorption
- Complete absorption large intestine
a. 2nd half of duodenum
b. Jejunum
c. Ileum
d. 1st half of ascending colon
III. Lower Alimentary Canal Function: elimination
a. 2nd half of ascending colon
b. Transverse
c. Descending colon
d. Sigmoid
e. Rectum
IV. Accessory Organ
a. Salivary gland
b. Verniform appendix
c. Liver
d. Pancreas auto digestion
e. Gallbladder storage of bile
I. Salivary Glands
1. Parotid below & front of ear
2. Sublingual
3. Submaxillary
-
A. PAROTITIS
mumps inflammation of parotid gland
-Paramyxo virus
S/Sx:
1. Fever, chills anorexia, gen body malaise
2. Swelling of parotid gland
3. Dysphagia
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Mark Darren Z. Praxides, RN
B. APENDICITIS
inflamation of verniform appendix
Predisposing factor:
1. Microbial infection
2. Feacalith undigested food particles tomato seeds, guava seeds
3. Intestinal obstruction
S/Sx:
1.
2.
3.
4.
5.
Diagnosis:
1. CBC mild leukocytosis increase WBC
2. PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area rebound)
3. Urinalysis
Treatment: - appendectomy 24 45
Nursing Mgt:
1. Consent
2. Routinary nursing measures:
a.) Skin prep
b.) NPO
c.) Avoid enema lead to rupture of appendix
3. Meds:
Antipyretic
Antibiotics
*Dont give analgesic will mask pain
- Presence of pain means appendix has not ruptured.
4. Avoid heat application will rupture appendix.
5. Monitor VS, I&O bowel sound
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Mark Darren Z. Praxides, RN
1. Produces bile
Bile emulsifies fats
- Composed of H2O & bile salts
-Gives color to urine urobilin
Stool stircobilin
2. Detoxifies drugs
3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins
Hypevitaminosis vit D & K
Vit A retinol
Def Vit A night blindness
Vit D cholecalciferon
- Helps calcium
- Rickets, osteoarthritis
4. It destroys excess estrogen hormone
5. For metabolism
A. CHO
1. Glycogenesis synthesis of glycogens
2. Glycogenolysis breakdown of glycogen
3. Gluconeogenesis formation of glucose from CHO sources
B. CHON1. Promotes synthesis of albumin & globulin
Cirrhosis decrease albumin
Albumin maintains osmotic pressure, prevents edema
2. Promotes synthesis of prothrombin & fibrinogen
3. Promotes conversion of ammonia to urea.
Ammonia like breath fetor hepaticus
C. FATS promotes synthesis of cholesterol to neutral fats called triglycerides
C. LIVER CIRRHOSIS
- lost of architectural design of liver leading to fat necrosis & scarring
Early sign hepatic encephalopathy
1. Asterixis flapping hand tremors
Late signs headache, restlessness, disorientation, decrease LOC hepatic coma.
Nursing priority assist in mechanical ventilation
Predisposing factor:
Decrease Laennacs cirrhosis caused by alcoholism
1. Chronic alcoholism
2. Malnutrition decreaseVit B, thiamin - main cause
3. Virus
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Mark Darren Z. Praxides, RN
S/Sx:
Early signs:
a.) Weakness, fatigue
b.) Anorexia, n/v
c.) Stomatitis
d.) Urine tea color
Stool clay color
e.) Amenorrhea
f.) Decrease sexual urge
g.) Loss of pubic, axilla hair
h.) Hepatomegaly
i.) Jaundice
j.) Pruritus or urticaria
2. Late signs
2.
3.
4.
5.
6.
SGPT (ALT)
SGOT (AST)
Serum cholesterol & ammonia increase
Indirect bilirubin increase
CBC - pancytopenia
PTT prolonged
Hepatic ultrasonogram fat necrosis of liver lobules
Nursing Mgt
1. CBR
2. Restrict Na!
3. Monitor VS, I&O
4. With pt daily & assess pitting edema
5. Measure abdominal girth daily notify MD
6. Meticulous skin care
7. Diet increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
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Mark Darren Z. Praxides, RN
8. Complications:
a.) Ascites fluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics 10 15 min effect
2. Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental puncture of bladder as trochar is
inserted
b.) Bleeding esophageal varices
- Dilation of esophageal veins
1. Meds: Vit K
Pitrisin or Vasopresin (IM)
2. NGT decompression- lavage
- Give before lavage ice or cold saline solution
- Monitor NGT output
3. Assist in mechanical decompression
- Insertion of sengstaken-blackemore tube
- 3 lumen typed catheter
- Scissors at bedside to deflate balloon.
c.) Hepatic encephalopathy
1. Assist in mechanical ventilation due coma
2. Monitor VS, neuro check
3. Siderails due restless
4. Meds Laxatives to excrete ammonia
D. HEPATITIS
- jaundice (icteric sclera)
Bilirubin
Kernicterus/ hyperbilirubinia
Irreversible brain damage
E. PANCREATITIS
acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
auto digestion.
Bleeding of pancreas - Cullens sign at umbilicus
Predisposing factors:
1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam)
7. Diet increase saturated fats
S/Sx:
1. Severe Lt epigastric pain radiates from back &flank area
- Aggravated by eating, with DOB
2. N/V
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Mark Darren Z. Praxides, RN
3. Tachycardia
4. Palpitation due to pain
5. Dyspepsia indigestion
6. Decrease bowel sounds
7. (+) Cullens sign - ecchymosis of umbilicus
hemorrhage
8. (+) Grey Turners spots ecchymosis of flank area
9. Hypocalcemia
Diagnosis:
1. Serum amylase & lipase increase
2. Urine lipase increase
3. Serum Ca decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine Hcl (Demerol)
Dont give Morphine SO4 will cause spasm of sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- Ex. Papavarine Hcl
Prophantheline Bromide (Profanthene)
c.) Vasodilator NTG
d.) Antacid Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac)
to decrease pancreatic stimulation
f.) Ca gluconate
2. Withold food & fluid aggravates pain
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
Complications of TPN
1. Infection
2. Embolism
3. Hyperglycemia
4. Institute stress mgt tech
a.) DBE
b.) Biofeedback
5. Comfy position - Knee chest or fetal like position
6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON
7. Complications:
Chronic hemorrhagic pancreatitis
GALLBLADDER storage of bile made up of cholesterol.
F. CHOLECYSTITIS/ CHOLELITHIASIS
inflammation of gallbladder with gallstone formation.
Predisposing factor:
1. High risk women 40 years old
2. Post menopausal women undergoing estrogen therapy
3. Obesity
4. Sedentary lifestyle
5. Hyperlipidemia
6. Neoplasm
S/Sx:
1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night
2. Fatty intolerance
3. Anorexia, n/v
4. Jaundice
5. Pruritus
6. Easy bruising
7. Tea colored urine
8. Steatorrhea
Diagnosis:
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Mark Darren Z. Praxides, RN
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Mark Darren Z. Praxides, RN
SITE
PAIN
HYPERSECRET
ION
VOMITING
HEMORRHAG
E
WT
COMPLICATIO
NS
GASTRIC ULCER
Intrum or lesser curvature
-30 min 1 hr after eating
- epigastrium
- gaseous & burning
- not usually relieved by food &
antacid
Normal gastric acid secretion
common
hematemeis
Wt loss
a. stomach cause
b. hemorrhage
DUODENAL ULCER
Duodenal bulb
-2-3 hrs after eating
- mid epigastrium
- cramping & burning
- usually relieved by food &
antacid
- 12 MN 3am pain
Increased gastric acid
secretion
Not common
Melena
Wt gain
a. perforation
79
Mark Darren Z. Praxides, RN
HIGH RISK
60 years old
20 years old
Diagnosis:
1. Endoscopic exam
2. Stool from occult blood
3. Gastric analysis N gastric
Increase duodenal
4. GI series confirms presence of ulceration
Nursing Mgt:
1. Diet bland, non irritating, non spicy
2. Avoid caffeine & milk/ milk products
Increase gastric acid secretion
3. Administer meds
a.) Antacids
AAC
Aluminum containing antacids
Ex. aluminum OH gel
(Ampho-gel)
S/E constipation
80
Mark Darren Z. Praxides, RN
2. Administer meds:
a.) Analgesic
b.) Antibiotic
c.) Antiemetics
3. Maintain patent IV line
4. VS, I&O & bowel sounds
5. Complications:
a.) Hemorrhage hypovolemic shock
Late signs anuria
b.) Peritonitis
c.) Paralytic ileus most feared
d.) Hypokalemia
e.) Thromobphlebitis
f.) Pernicious anemia
7.)Dumping syndrome common complication rapid gastric emptying of hypertonic food solutions
CHYME leading to hypovolemia.
Sx of Dumping syndrome:
1. Dizziness
2. Diaphoresis
3. Diarrhea
4. Palpitations
Nursing mgt:
1. Avoid fluids in chilled solutions
2. Small frequent feeding s-6 equally divided feedings
3. Diet decrease CHO, moderate fats & CHON
4. Flat on bed 15 -30 minutes after q feeding
INTEGUMENTARY
A. BURNS
direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority infection (all kinds of burns)
Head burn-priority- a/w
2nd priority for 1st & 2nd - pain
2nd priority for 3rd - F&E
Thermal- direct contact flames, hot grease, sunburn.
Electric, wires
Chem. direct contact corrosive materials acids
Smoke gas / fume inhalation
Stages:
1. Emergent phase Removal of pt from cause of burn. Determine source or loc or burn
2. Shock phase 48 - 72. Characterized by shifting of fluids from intravascular to interstitial space
=Hypovolemia
S/Sx:
-
BP
decrease
Urine output
HR
increase
Hct
increase
Serum Na
decrease
Serum K
increase
Met acidosis
81
Mark Darren Z. Praxides, RN
3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
4. Recovery/ convalescent phase complete diuresis. Wound healing starts immediately after tissue injury.
Class:
I. Partial Burn
1. 1st degree superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure with no fluid filled vesicles
2. 2nd degree deep burns
- Affects epidermis & dermis
- Cause chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
1. Third & 4th degrees burn
- Affects all layers of skin, muscles, bones
- Cause electrical
- Less painful
- Dry, thick, leathery wound surface known as ESCHAR devitalized or necrotic tissue.
Assessment findings
Rule of nines
Head & neck = 9%
Ant chest =
18%
Post chest =
18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum= 1%
Total
100%
Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth Claustridium tetany
Tetany
Tetanolysin
tetanospasmin
Hemolysis
muscle spasm
82
Mark Darren Z. Praxides, RN
8. Complications:
a.) Infection
b.) Shock
c.) Paralytic ileus - due to hypovolemia & hypokalemia
d.) Curlings ulcer H2 receptor antagonist
e.) Septicemia blood poisoning
f.) Surgery: skin grafting
increase CO
increase PR
Aldosterone
Increase Na &
H2O reabsorption
Increase BP
83
Mark Darren Z. Praxides, RN
Hypervolemia
Ureters 25 35 cm long, passageway of urine to bladder
Bladder loc behind symphisis pubis. Muscular & elastic tissue that is distensible
- Function reservoir or urine
1200 1800 ml Normal adult can hold
200 500 ml needed to initiate micturition reflex
Color
amber
Odor
aromatic
Consistency clear or slightly turbid
pH
4.5 8
Specific gravity 1.015 1.030
WBC/ RBC (-)
Albumin
(-)
E coli
(-)
Mucus thread
few
Amorphous urate (-)
Urethra extends to external surface of body. Passage of urine, seminal & vaginal fluids.
- Women 3 5 cm or 1 to 1
- Male 20cm or 8
UTI
A. CYSTITIS
inflammation of bladder
Predisposing factors:
1. Microbial invasion E. coli
2. High risk women
3. Obstruction
4. Urinary retention
5. Increase estrogen levels
6. Sexual intercourse
S/Sx:
1. Pain flank area
2. Urinary frequency & urgency
3. Burning upon urination
4. Dysuria & hematuria
5. Fever, chills, anorexia, gen body malaise
Diagnosis:
1. Urine culture & sensitivity - (+) to E. coli
Nursing Mgt:
1. Force fluid 2000 ml
2. Warm sitz bath to promote comfort
3. Monitor & assess for gross hematuria
4. Acid ash diet cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
5. Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides cotrimaxazole (Bactrim)
- Gantrism (ganthanol)
Urinary antiseptics Mitropurantoin (Macrodantin)
Urinary analgesic- Pyridum
6. Ht
a.) Importance of Hydration
b.) Void after sex
c.) Female avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
84
Mark Darren Z. Praxides, RN
d.) Complications:
Pyelonephritis
B. PYELONEPHRITIS
acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, interstitial abscess
formation.
- Lead to Renal Failure
Predisposing factor:
1. Microbial invasion
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary frequency, urgency
d.) Nocturia, dsyuria, hematuria
e.) Burning on urination
Chronic Pyelonephritis
a.) Fatigue, wt loss
b.) Polyuuria, polydypsia
c.) HPN
Diagnosis:
1. Urine culture & sensitivity (+) E. coli & streptococcus
2. Urinalysis
Increase WBC, CHON & pus cells
3. Cystoscopic exam urinary obstruction
Nursing Mgt:
1. Provide CBR acute phase
2. Force fluid
3. Acid ash diet
4. Meds:
a.) Urinary antiseptic nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
b.) Urinary analgesic Peridium
2. Complication- Renal Failure
B. NEPHROLITHIASIS/ UROLITHIASIS
- formation of stones at urinary tract
- calcium ,
oxalate,
milk
cabbage
cranberries
nuts tea
chocolates
uric acid
anchovies
organ meat
nuts
sardines
85
Mark Darren Z. Praxides, RN
Predisposing factors:
1. Diet increase Ca & oxalate
2. Hereditary gout
3. Obesity
4. Sedentary lifestyle
5. Hyperparathyroidism
S/Sx:
1. Renal colic
2. Cool moist skin (shock)
3. Burning upon urination
4. Hematuria
5. Anorexia, n/v
Diagnosis:
1. IVP intravenous pyelography. Reveals location of stone
2. KUB reveals location of stone
3. Cytoscopic exam- urinary obstruction
4. Stone analysis composition & type of stone
5. Urinalysis increase EBC, increase CHON
Nursing Mgt:
1.Force fluid
2.Strain urine using gauze pad
3.Warm sitz bath for comfort
4.Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent IV line
d.) Diet if + Ca stones acid ash diet
If + oxalate stone alkaline ash diet - (Ex milk/ milk products)
If + uric acid stones decrease organ meat / anchovies sardines
6. Surgery
a.) Nephectomy removal of affected kidney
Litholapoxy removal of 1/3 of stones- Stones will recur. Not advised for pt with big
stones
b.) Extracorporeal shock wave lithotripsy
- Non - invasive
- Dissolve stones by shock wave
7. Complications: Renal Failure
86
Mark Darren Z. Praxides, RN
7.Sciatica
Diagnosis:
1. Digital rectal exam enlarged prostate gland
2. KUB urinary obstruction
3. Cystoscopic exam obstruction
4. Urinalysis increase WBC, CHON
Nursing Mgt:
1. Prostatic message promotes evacuation of prostatic fluid
2. Limit fluid intake
3. Provide catheterization
4. Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter
b. Fenasteride (Proscar) - Atrophy of Prostate Gland
5. Surgery: Prostatectomy TURP- Transurethral resection of Prostate- No incision
-Assist in cystoclysis or continuous bladder irrigation.
Nursing mgt:
c. Monitor symptoms of infection
d. Monitor symptoms gross/ flank bleeding. Normal bleeding within 24h.
3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention
sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E balance due to a
decrease in GFR. (N 125 ml/min)
Predisposing factor:
Pre renal cause- decrease blood flow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension decrease flow to kidneys
4. CHF
5. Hemorrhage
6. Dehydration
Intra-renal cause involves renal pathology= kidney problem
1. Acute tubular necrosis2. Pyelonephritis
3. HPN
4. Acute GN
Post renal cause involves mechanical obstruction
1. Stricture
2. Urolithiasis
3. BPH
E. CHRONIC RF
irreversible loss of kidney function
Predisposing factors:
1. DM
2. HPN
3. Recurrent UTI/ nephritis
4. Exposure to renal toxins
87
Mark Darren Z. Praxides, RN
Stages of CRF
1. Diminished Reserve Volume asymptomatic
Normal BUN & Crea, GFR < 10 30%
2. Renal Insufficiency
3. End Stage Renal disease
S/Sx:
1.) Urinary System
2.) Metabolic disturbances
a.) polyuria
a.) azotemia (increase BUN
b.) nocturia
& Crea)
c.) hematuria
b.) hyperglycemia
d.) Dysuria
c.) hyperinulinemia
e.) oliguria
3.) CNS
4.) GIT
a.) headache
a.) n/v
b.) lethargy
b.) stomatitis
c.) disorientation
c.) uremic breath
d.) restlessness
d.) diarrhea/ constipation
e.) memory
impairment
5.) Respiratory
6.) hematological
a.) Kassmauls resp
a.) Normocytic anemia
b.) decrease cough
bleeding tendencies
reflex
7.) Fluid &
8.) Integumentary
Electrolytes
a.) itchiness/ pruritus
a.) hyperkalemia
b.) uremic frost
b.) hypernatermia
c.)
hypermagnesemia
d.)
hyperposphatemia
e.) hypocalcemia
f.) met acidosis
Nursing Mgt:
1. Enforce CBR
2. Monitor VS, I&O
3. Meticulous skin care. Uremic frost assist in bathing pt
4. Meds:
a.) Na HCO3 due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
2.) Obtain baseline data & monitor VS, I&O, wt, blood exam
3.) Strict aseptic technique
4.) Monitor for signs of complications:
B bleeding
E embolism
D disequilibrium syndrome
S septicemia
S shock decrease in tissue perfusion
Disequilibrium syndrome from rapid removal of urea & nitrogenous waste prod leading to:
a.) n/v
b.) HPN
88
Mark Darren Z. Praxides, RN
89
Mark Darren Z. Praxides, RN