VELEZ COLLEGE COLLEGE OF NURSING

F. RAMOS STREET, CEBU CITY

A CASE STUDY ON PATIENT D.E., 74 YEARS OLD, MALE, DIAGNOSED WITH CHRONIC KIDNEY DISEASE STAGE V, HYPERTENSIVE
ARTERIOSCLEROTIC CARDIOVASCULAR DISEASE, CEREBROVASCULAR DISEASE AND BENIGN PROSTATIC HYPERPLASIA

Submitted by:

BSN III A BSN III B

Alo, Demi Mary Angel Bacalso, Andra Rivi
Aringay, Chrislly Denise Capoy, Neal Abram
Cavalida, Krystle Janine S. Gabisan, Gloria Leonisa B.
Gabaca, Patricia Mae Halog, Felix Alfred B.
Janer, Kenna Monique D. Lumongsod, Elizah Marie
Mann, Ma. Caitlin T. Migallen, Imee
Solon, Mary Nicole Moog, Jessah Mae A.
Tejada, Heartie Joy

Submitted to:
Mrs. Kachiri Salibio-Mercadal, RN, MSN
CLINICAL INSTRUCTOR

December 8, 2016
 INTRODUCTION

CHRONIC KIDNEY DISEASE

Chronic Kidney Disease, also known as chronic renal failure, chronic renal disease, or chronic kidney failure, is a progressive loss in kidney function
over a period of months or years. The symptoms of worsening kidney function are not specific, and might include feeling generally unwell and experiencing a
reduced appetite. Chronic kidney disease is much more common than people realize, and often goes undetected and undiagnosed until the disease is well
advanced and kidney failure is fairly imminent. It is not unusual for people to realize they have chronic kidney failure only when their kidney function is down to
25% of normal. As kidney failure advances and the organ's function is seriously impaired, dangerous levels of waste, fluid and toxic substances normally excreted
by the kidneys can rapidly build up in the body.

Stages of Renal Failure:

o Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2)
o Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m 2)
o Stage 3: Moderate reduction in GFR (30-59 mL/min/1.73 m 2)
o Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m 2)
o Stage 5: Kidney failure (GFR <15 mL/min/1.73 m 2 or dialysis)

Causes

In the majority of the cases, progressive kidney damage is the result of a chronic disease (a long-term disease), such as:

Diabetes - chronic kidney disease is linked to both Diabetes Types I and II. If the patient's diabetes is not well controlled, excess sugar (glucose) can
accumulate in the blood. Glucose can damage the glomeruli. Kidney disease is not common during the first ten years of diabetes; it more commonly
occurs between years 15 to 25 after diagnosis (of diabetes). However, as treatment methods improve, experts say that the number of diabetes patients
developing kidney disease is falling.
Hypertension (high blood pressure) - high blood pressure can damage the glomeruli.
Obstructed urine flow - if urine flow is obstructed it can back up into the kidney from the bladder (vesicoureteral reflux). Blocked urine flow increases
pressure on the kidneys, and undermines their function. Possible causes include an enlarged prostate, kidney stones, or a tumor.
Kidney diseases - including polycystic kidney disease, pyelonephritis, or glomerulonephritis.
Kidney artery stenosis - the renal artery narrows or is blocked before it enters the kidney.
Certain toxins - including fuels, solvents (such as carbon tetrachloride), and lead (and lead-based paint, pipes, and soldering materials). Even some types
of jewelry have toxins which can lead to chronic kidney failure.
 Fetal developmental problem - if the kidneys do not develop properly in the unborn baby while it is developing in the womb.
Systemic lupus erythematosis - an autoimmune disease. The body's own immune system attacks the kidneys as though they were foreign tissue.
Malaria and yellow fever
Some medications - overuse of, for example, NSAIDs (non-steroidal anti-inflammatory drugs), such as aspirin or ibuprofen.
Illegal drug abuse - such as heroin or cocaine.
Injury - a sharp blow or physical injury to the kidney(s)

Risk Factors

Systemic hypertension
Nephrotoxins
Obesity
Hyperlipidemia
Abnormal kidney structure
Being African-American, Native American or Asian-American
Family history of CKD
Smoking
Uncontrolled diabetes

Signs & Symptoms

Patients with chronic kidney disease stages 1-3 (glomerular filtration rate >30 ml/min/1.73 m 2) are frequently asymptomatic; in terms of possible negative
symptoms related simply to the reduction in GFR, they do not experience clinically evident disturbances in water or electrolyte balance or endocrine/metabolic
derangements.

Itching.
Muscle cramps.
Nausea and vomiting.
Not feeling hungry.
Swelling in your feet and ankles.
Too much urine (pee) or not enough urine.
Trouble catching your breath.
Trouble sleeping.
Hypertension due to water and sodium retention
 Heart failure and pulmonary edema due to fluid overload

Diagnosis
24-hour urinalysis for creatinine clearance
BUN level
Sodium and Water retention
ABG for acidosis
Blood tests for anemia
Calcium and Phosphate imbalance

Complications

Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake
Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis
Hypertension
Anemia
Bone disease and metastatic calcification

Medical Management

Medications such as antacids, antihypertensives and cardiovascular agents, antiseizure agents, erythropoeitin.
Diet therapy that include careful regulation of protein intake, fluid intake to balance fluid losses, sodium intake to balance sodium losses and some
restriction of potassium
Kidney dialysis.This is the removal of waste products and excessive fluids from blood when the kidneys cannot properly do the job any more. Dialysis has
some serious risks, including infection. However, it can also help the patient survive for considerably longer (than without it).
There are two main types of kidney dialysis. Each type also has subtypes. The two main types are:

Hemodialysis - blood is pumped out of the patient's body and goes through a dialyzer (an artificial kidney). The blood is pumped out
through two routes: 1. A catheter is placed in one of the main blood veins, or 2. A surgically created junction between a vein and artery in the
patient's arm. The blood moves across membranes in the dialyzer that filter out waste. The blood is then returned to the patient's body. At
any one time, just 237 milliliters (one cup) of blood is outside the body. The patient undergoes hemodialysis about three times per week.
Each session lasts for at least three hours. Experts now recognize that more frequent sessions result in a better quality of life for the patient,
as well as a better control of complications and lower risk of death. Modern home-use dialysis machines are making this more regular use of
hemodialysis more feasible today.
 Peritoneal dialysis - the blood is filtered in the patient's own abdomen; in the peritoneal cavity which contains a vast network of tiny blood
vessels. A catheter is implanted into the abdomen, into which a dialysis solution is infused and drained out for as long as is necessary to
remove waste and excess fluid.
Continuous ambulatory peritoneal dialysis - the dialysis solution is exchanged in the abdomen four times a day, every day.
Sessions are equally spaced throughout the day. The patient carries out the procedure himself/herself.
Continuous cycling peritoneal dialysis - a cycler machine automatically infuses daily solution into the peritoneal cavity and
takes it out while the patient is sleeping.
Nursing management

Astute nursing care to avoid the complications of renal function

Avoidance of stresses and anxieties of dealing with a life threatening illness
Assessment of fluid status and identifying potential imbalance
Implementing a dietary program to ensure proper nutritional intake within the limits of the treatment regimen
Provide explanations and information about chronic renal failure
Emotion support for the patient and the patients family

HYPERTENSIVE ARTERIOSCLEROTIC CARDIOVASCULAR DISEASE

Hypertensive heart disease refers to a more serious and dangerous type of heart problems that occur because of uncontrolled and prolonged elevation of blood
pressure due to thickening and hardening of the arteries. This could lead to a variety of changes in the myocardial structure, coronary vasculature, and conduction
system of the heart.

Causes

High blood pressure

High blood cholesterol level
High triglycerides concentrations in your blood
Smoking and other sources of tobacco
Elevated blood glucose concentration

Signs and Symptoms

Fatigue
Shortness of breath
 General weakness
Chest pain or pressure (angina).
Swelling in the feet, ankles, or abdomen
Irregular pulse
Elevated blood pressure
Enlarged heart and irregular heartbeat
Fluid in the lungs or lower extremities
Unusual heart sounds

Diagnosis

Blood tests it detect increased levels of cholesterol and blood sugar.

Electrocardiogram (EKG or ECG) - This test measures the electrical activity, rate, and rhythm of your heartbeat and will show any episodes of heart attack,
strain, or thickening of the heart muscle.
Exercise stress test - This test is often performed with imaging techniques, such as an echocardiogram or nuclear scans, to provide better detection
of heart disease
Cardiac catheterization -This directly locates and measure any blockages in the coronary arteries
Echocardiogram - it gives information about the wall thickness and chamber size and the blood flowing within.
Computed tomography (CT) scan - This provides information about the presence of calcium in heart arteries

Medical and Surgical Management

diuretics - diuretics lower blood pressure mainly by causing the kidneys to excrete more sodium and water, which reduces fluid volume throughout the body
and widens (dilates) blood vessels.
beta-blockers- beta blockers block some of the effects of the sympathetic nervous system, which increases the heart rate and raises blood pressure with
stress and/or activity. Beta blockers lower blood pressure in part by decreasing the rate and force at which the heart pumps blood.
ACE inhibitors- angiotensin-converting enzyme (ACE) inhibitors block production of the hormone, angiotensin II, a compound in the blood that causes
narrowing of blood vessels and increases blood pressure. By reducing production of angiotensin II, ACE inhibitors allow blood vessels to widen, which
lowers blood pressure and improves heart output.
calcium channel blockers- calcium channel blocker drugs reduce the amount of calcium that enters the smooth muscle in blood vessel walls and heart
muscle. Muscle cells require calcium to contract. Thus, by inhibiting the flow of calcium across muscle cell membranes, calcium channel blockers cause
muscle cells to relax and blood vessels to dilate, reducing blood pressure as well as reducing the force and rate of the heartbeat.
 angiotensin receptor blockers - angiotensin II receptor blockers (ARBs) block the effects of angiotensin II on cells in the heart and blood vessels. Similar to
ACE inhibitors, ARBs can widen blood vessels, lower blood pressure, and improve heart output.
alpha blockers- alpha blockers relax or reduce the tone of involuntary (ie, smooth) muscle in the walls of blood vessels (vascular smooth muscle), allowing
the vessels to widen, thereby lowering blood pressure. An increase in blood vessel diameter is known as "vasodilation."
vasodilators- direct vasodilators relax or reduce the tone of blood vessels. The two drugs in this class are hydralazine and minoxidil. Minoxidil is typically
used in only severe or resistant high blood pressure.
angioplasty and stenting for severe blockages.
open heart (bypass) surgery on severe cases may even be required.

Approach for Initiation and Titration of Antihypertensive Therapy: Drug Titration Strategy

1. Maximuze first medicine before adding second

2. Add second medication before reaching maximum dose of first medication
3. Start with 2 medication classes separtely or as fixed-dose combination

Lifestyle modifications:

DASH diet (Dietary Approach to Stop Hypertension)

- Grains: 6-8 servings/day naturally low in fat whole wheat products

- Vegtables: 4-5 servings/day high in fiber, vitamins, and minerals carrots, sweet potatoes, brocolli
- Fruits: 4-5 servings/day- packed with fiber, potassium, and magnesium, all typically low on fat
- Dairy: 2-3 servings/day- great source of calcium, Vit. D, and protein
- Lean meat, poultry, and fish: 6 servings or less/day- great source of protein B vitamins, iron, and zinc
- Nuts, seeds, and legumes: 4-5 servings/week- packed with great source of vitamins and fiber
- Fats and oils: 2-3 servings/day- fats help absorb essential vitamins and help the bodys immune system
Lower daily intake of sodium to 2,000 mg or 2 g or less per day
Eat foods high in fiber and potassium
Limit total daily calories to lose weight if necessary
Limit intake of foods that contain refined sugar, saturated fats, and cholesterol.
 Monitoring your weight
Increasing your activity level (as recommended by your doctor),
Avoiding tobacco products and alcohol
Regular medical checkups.

CEREBROVASCULAR DISEASE

Cerebrovascular disease is a vascular disease of the cerebral circulation, is the sudden death of some brain cells due to lack of oxygen when the blood
flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVD or CVA is also referred to as a stroke.

Types

There are two major types of stroke:

Ischemic stroke- occurs when a blood vessel that supplies blood to the brain is blocked by a blood clot or is dusrupted. This may happen due to:
A clot may form in an artery that is already very narrow. This is called a thrombotic stroke.
A clot may break off from another place in the blood vessels of the brain, or from some other part of the body, and travel up to the brain. This
is called cerebral embolism, or an embolic stroke.

Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)

Cerebral venous sinus thrombosis- the presence of acute thrombosis (a blood clot) in the dural venous sinuses, which drain blood from
the brain.

Hemorrhagic stroke - occurs when a blood vessel in part of the brain becomes weak and bursts open. This causes blood to leak into the brain. Some
people have defects in the blood vessels of the brain that make this more likely. These defects may include:

Aneurysm
 Arteriovenous malformation (AVM)

Causes
There are three primary causes of cerebrovascular accidents:
cerebral thrombosis- CVA caused by cerebral thrombosis is the result of a build-up of plaque and inflammation in the arteries, called atherosclerosis. This
process narrows the brain arteries and lowers the amount of oxygen-rich blood that reaches the brain tissue. Arteries narrowed by atherosclerosis are more
likely to develop a blood clot that completely blocks bloodflow to an area of the brain.
cerebral embolism CVA caused by a cerebral embolism occurs when a clot forms in another part of the body and travels in the bloodstream to a
brain artery, blocking the flow of blood to the brain.
cerebral hemorrhage CVA caused by cerebral hemorrhage occurs when a brain artery breaks or leaks blood into the surrounding brain tissue.

Risk Factors

Nonmodifiable

Advanced age (older than 55 years)

Gender (Male)
Race (African American)

Modifiable

Hypertension
Atrial brillation
Hyperlipidemia
Obesity
Smoking
Diabetes
Asymptomatic carotid stenosis and valvular heart disease (eg, endocarditis, prosthetic heart valves)
Periodontal disease

Symptoms
Symptoms of a stroke depend on the area of the brain affected. The most common symptoms are:
Numbness or weakness of the face. Without adequate perfusion, oxygen is also low, and facial tissues could not function properly without them.
Change in mental status. Due to decreased oxygen, the patient experiences confusion.
Trouble speaking or understanding speech. Cells cease to function as a result of inadequate perfusion.
Visual disturbances. The eyes also need enough oxygen for optimal functioning.
Homonymous hemianopsia. There is loss of half of the visual field.
Loss of peripheral vision. The patient experiences difficulty seeing at night and is unaware of objects or the borders of objects.
Hemiparesis. There is a weakness of the face, arm, and leg on the same side due to a lesion in the opposite hemisphere.
Hemiplegia. Paralysis of the face, arm, and leg on the same side due to a lesion in the opposite hemisphere.
Ataxia. Staggering, unsteady gait and inability to keep feet together.
Dysarthria. This is the difficulty in forming words.
Dysphagia. There is difficulty in swallowing.
Paresthesia. There is numbness and tingling of extremities and difficulty with proprioception.
Expressive aphasia. The patient is unable to form words that is understandable yet can speak in single-word responses.
Receptive aphasia. The patient is unable to comprehend the spoken word and can speak but may not make any sense.
Global aphasia. This is a combination of both expressive and receptive aphasia.

Complications

Life-threatening complications include:

Increased pressure on the brain, which develops when the brainswells after a large stroke. Such swelling occurs quickly, becomes most severe within 3 to
5 days after the stroke, and can cause death. Pressure on the brain is more likely in people who have had a strokecaused by a bleeding blood vessel
(hemorrhagic stroke).
Blood pressure changes. People who have a stroke usually will have higher blood pressure for at least 1 to 3 days after the stroke. This may represent an
attempt by the body to increase blood flow to the part of the brain that is being affected by the stroke. Only very high blood pressure is treated. If it occurs,
very high blood pressureusually is brought down slowly. A rapid drop in blood pressure can lead to more brain damage.
Buildup of spinal fluid within the brain (hydrocephalus). Fluid on the brain is more likely to occur if the stroke was caused by bleeding (hemorrhagic stroke).
Spasms of blood vessels (vasospasm). Vasospasm may occur if the stroke was caused by a subarachnoid hemorrhage from an aneurysm.
A blood clot in the legs (deep vein thrombosis) that may travel to the lungs (pulmonary embolism).
Seizures.
Another stroke.
 Coma.

Diagnosis

Diagnosis of stroke involves a medical history and a physical examination. Tests are done to search for treatable causes of a stroke and help prevent further brain
damage.
CAT scan (a special X-ray study) of the brain is often done to show bleeding into the brain; this is treated differently than a stroke caused by lack of blood
supply. A CAT scan also can rule out some other conditions that may mimic a stroke.
Echocardiogram may be done to look for a source of blood clots in the heart. Narrowing of the carotid artery (the main artery that supplies blood to each
side of the brain) in the neck can be seen with a soundwave test called a carotid ultrasound.
Blood tests are done to look for signs of inflammation which can suggest inflamed arteries. Certain blood proteins are tested that can increase the chance
of stroke by thickening the blood.

Treatment

Stroke is a medical emergency. Quick treatment is needed. People who are having stroke symptoms need to get to a hospital as quickly as possible.

If the stroke is caused by a blood clot, a clot-busting drug may be given to dissolve the clot.
To be effective, this treatment must be started within 3 to 4 1/2 hours of when the symptoms first started. The sooner this treatment is started, the better the
chance of a good outcome.

Other treatments given in the hospital depend on the cause of the stroke. These may include:

Blood thinners such as heparin, warfarin (Coumadin), aspirin, or clopidogrel (Plavix)

Medicine to control risk factors, such as high blood pressure, diabetes, and high cholesterol
Special procedures or surgery to relieve symptoms or prevent more strokes
Nutrients and fluids

Physical therapy, occupational therapy, speech therapy, and swallowing therapy will all begin in the hospital. If the person has severe swallowing problems, a
feeding tube in the stomach (gastrostomy tube) will likely be needed. When a patient is no longer acutely ill after a stroke, the aim turns to maximizing the patient's
functional abilities. This can be done in an inpatient rehabilitation hospital or in a special area of a general hospital and in a nursing facility. The rehabilitation
process can involve speech therapy to relearn talking and swallowing, occupational therapy for regaining dexterity of the arms and hands, physical therapy for
improving strength and walking, etc. The goal is for the patient to resume as many of their pre-stroke activities as possible.

Nursing Interventions

Nursing care has a significant impact on the patients recovery. In summary, here are some nursing interventions for patients with stroke:

Positioning. Position to prevent contractures, relieve pressure, attain good body alignment, and prevent compressive neuropathies.
o Position to prevent contractures; use measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive
neuropathies.
o Elevate affected arm to prevent edema and brosis.
o Position ngers so that they are barely exed; place hand in slight supination. If upper extremity spasticity is noted, do not use a hand roll;
dorsal wrist splint may be used.
o Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a day.
o Prevent edema. Elevate affected arm to prevent edema and fibrosis.
Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.
o Provide full range of motion four or ve times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed
extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. If tightness occurs in any area, perform a
range of motion exercises more frequently.
Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.
Regain balance. Teach patient to maintain balance in a sitting position, then to balance while standing and begin walking as soon as standing balance is
achieved.
Personal hygiene. Encourage personal hygiene activities as soon as the patient can sit up.
Manage sensory difficulties. Approach patient with a decreased field of vision on the side where visual perception is intact.
Assess skin. Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.
Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (e.g., shortness of breath, chest pain, cyanosis, and
increasing pulse rate).
Supervise and support the patient during exercises; plan frequent short periods of exercise, not longer periods; encourage the patient to exercise
unaffected side at intervals throughout the day.

BENIGN PROSTATIC HYPERPLASIA

 Benign Prostatic Hyperplasia in many patients older than 50 years, the prostate gland enlarges, extending upward the bladder and obstructing the outflow
of the urine by encroaching on the vesical orifice.

Causes

The cause is uncertain, but evidence suggests that hormones initiate hyperplasia of the supporting stromal tissue and the glandular elements in the
prostate.

Risks Factors
Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than age 40. About one-third of men experience moderate to severe
symptoms by age 60, and about half do so by age 80.
Family history. Having a blood relative, such as a father or brother, with prostate problems means you're more likely to have problems.
Ethnic background. Prostate enlargement is less common in Asian men than in white and black men. Black men might experience symptoms at a younger
age than white men.
Diabetes and heart disease. Studies show that diabetes, as well as heart disease and use of beta blockers, might increase the risk of BPH.
Lifestyle. Obesity increases the risk of BPH, while exercise can lower your risk.

Signs & Symptoms

When the prostate enlarges, it may constrict the flow of urine. Nerves within the prostate and bladder may also play a role in causing the following common
symptoms:
Urinary frequency
Urinary urgency
Hesitancy-difficulty initiating the urinary stream; interrupted, weak stream
Incomplete bladder emptying
Straining
Decreased force of stream
Dribbling

Complications
Complications of enlarged prostate can include:
Sudden inability to urinate (urinary retention). You might need to have a tube (catheter) inserted into your bladder to drain the urine. Some men with an
enlarged prostate need surgery to relieve urinary retention.
 Urinary tract infections (UTIs). Inability to fully empty the bladder can increase the risk of infection in your urinary tract. If UTIs occur frequently, you might
need surgery to remove part of the prostate.

Bladder stones. These are generally caused by an inability to completely empty the bladder. Bladder stones can cause infection, bladder irritation, blood in
the urine and obstruction of urine flow.

Bladder damage. A bladder that hasn't emptied completely can stretch and weaken over time. As a result, the muscular wall of the bladder no longer
contracts properly, making it harder to fully empty your bladder.

Kidney damage. Pressure in the bladder from urinary retention can directly damage the kidneys or allow bladder infections to reach the kidneys.

Diagnosis

Digital rectal examination. The digital rectal examination (DRE) is an integral part of the evaluation in men with presumed BPH. During this portion of the
examination, prostate size and contour can be assessed, nodules can be evaluated, and areas suggestive of malignancy can be detected.

Laboratory studies

Urinalysis - Examine the urine using dipstick methods and/or via centrifuged sediment evaluation to assess for the presence of blood, leukocytes,
bacteria, protein, or glucose

Urine culture - This may be useful to exclude infectious causes of irritative voiding and is usually performed if the initial urinalysis findings indicate
an abnormality

Prostate-specific antigen - Although BPH does not cause prostate cancer, men at risk for BPH are also at risk for this disease and should be
screened accordingly (although screening for prostate cancer remains controversial)

Electrolytes, blood urea nitrogen (BUN), and creatinine - These evaluations are useful screening tools for chronic renal insufficiency in patients
who have high postvoid residual (PVR) urine volumes; however, a routine serum creatinine measurement is not indicated in the initial evaluation
of men with lower urinary tract symptoms (LUTS) secondary to BPH
 Ultrasonography. Ultrasonography (abdominal, renal, transrectal) is useful for helping to determine bladder and prostate size and the degree of
hydronephrosis (if any) in patients with urinary retention or signs of renal insufficiency. Generally, they are not indicated for the initial evaluation of
uncomplicated LUTS.

Endoscopy of the lower urinary tract. Cystoscopy may be indicated in patients scheduled for invasive treatment or in whom a foreign body or malignancy is
suspected. In addition, endoscopy may be indicated in patients with a history of sexually transmitted disease (eg, gonococcal urethritis), prolonged
catheterization, or trauma.

Medical Management
Medical treatment of BPH is usually reserved for men who have significant symptoms. The available drugs include:

o alpha blockers relax the smooth muscles of the prostate, and the bladder neck, which helps to relieve urinary obstruction caused by an enlarged
prostate in BPH.

o 5-alpha reductase inhibitors block the conversion of the male hormone testosterone into its active form in the prostate (DHT). The prostate
enlargement in BPH is directly dependent on DHT, so these drugs lead to an approximate 25% reduction in prostate size over six to 12 months. For
this reason, improvement in urinary symptoms most commonly takes this long to occur. Examples of 5-alpha reductase inhibitors
include Finasteride (Proscar) and dutasteride (Avodart). Side effects of finasteride may include declining interest in sex, problems getting an
erection, and problems with ejaculation.

o Behet's

Surgery or office procedures may also be used to treat BPH, most commonly in men who have not responded satisfactorily to medication or those who
have more severe problems, such as a complete inability to urinate.

o Transurethral resection of the prostate (TURP) has been used for the longest period of time. After the patient is given anesthesia, the doctor inserts
a special instrument into the urethra through the penis. With the instrument, the doctor then shaves away part of the inner prostate to relieve the
outflow of urine from the bladder.

o Laser procedures: A number of laser procedures are available, some of which can be performed in the doctor's office with minimal anesthesia.
These procedures also involve the removal of obstructing prostate tissue. They are generally associated with less bleeding and quicker recovery
than TURP.
 o Microwave therapy: This procedure is generally performed in the office and involves the use of microwave energy delivered to the prostate to kill
some of the cells leading eventually to shrinkage of the prostate.

Nursing management

Health history. The health history focuses on the urinary tract, previous surgical procedures, general health issues, family history of prostate diseases, and
fitness for possible surgery.
Physical assessment. Physical assessment includes digital rectal examination.
Reduce anxiety.
Relieve discomfort. Bed rest and analgesics are prescribed if a patient experiences discomfort.
Provide instruction. Before the surgery, the nurse reviews with the patient the anatomy of the affected structures and their function in relation to the urinary
and reproductive systems.
Maintain fluid balance. Fluid balance should be restored to normal.

ANATOMY AND PHYSIOLOGY

THE CARDIOVASCULAR SYSTEM

The Heart

The heart is a muscular pumping organ located medial to the lungs along the bodys midline in the
thoracic region. The bottom tip of the heart, known as its apex, is turned to the left, so that about 2/3 of
the heart is located on the bodys left side with the other 1/3 on right. The top of the heart, known as the
hearts base, connects to the great blood vessels of the body: the aorta, vena cava, pulmonary trunk,
and pulmonary veins.

Blood Vessels

Blood vessels are the bodys highways that allow blood to flow quickly and efficiently from the heart to every
region of the body and back again. The size of blood vessels corresponds with the amount of blood that passes through the vessel. All blood vessels contain a
hollow area called the lumen through which blood is able to flow. Around the lumen is the wall of the vessel, which may be thin in the case of capillaries or very
thick in the case of arteries.
There are three major types of blood vessels: arteries, capillaries and veins. Blood vessels are often named after either the region of the body through which they
carry blood or for nearby structures. For example, the brachiocephalic artery carries blood into the brachial (arm) and cephalic (head) regions. One of its
branches, the subclavian artery, runs under the clavicle; hence the name subclavian. The subclavian artery runs into the axillary region where it becomes known
as the axillary artery.

Arteries and Arterioles: Arteries are blood vessels that carry blood away from the heart. Blood carried by arteries is usually highly oxygenated, having just left the
lungs on its way to the bodys tissues. The pulmonary trunk and arteries of the pulmonary circulation loop provide an exception to this rule these arteries carry
deoxygenated blood from the heart to the lungs to be oxygenated.

Arteries face high levels of blood pressure as they carry blood being pushed from the heart under great force. To withstand this pressure, the walls of the
arteries are thicker, more elastic, and more muscular than those of other vessels. The largest arteries of the body contain a high percentage of elastic
tissue that allows them to stretch and accommodate the pressure of the heart.

Smaller arteries are more muscular in the structure of their walls. The smooth muscles of the arterial walls of these smaller arteries contract or expand to
regulate the flow of blood through their lumen. In this way, the body controls how much blood flows to different parts of the body under varying
circumstances. The regulation of blood flow also affects blood pressure, as smaller arteries give blood less area to flow through and therefore increases the
pressure of the blood on arterial walls.

Arterioles are narrower arteries that branch off from the ends of arteries and carry blood to capillaries. They face much lower blood pressures than arteries due
to their greater number, decreased blood volume, and distance from the direct pressure of the heart. Thus arteriole walls are much thinner than those of arteries.
Arterioles, like arteries, are able to use smooth muscle to control their aperture and regulate blood flow and blood pressure.

Capillaries: Capillaries are the smallest and thinnest of the blood vessels in the body and also the most common. They can be found running throughout
almost every tissue of the body and border the edges of the bodys avascular tissues. Capillaries connect to
arterioles on one end and venules on the other.

Capillaries carry blood very close to the cells of the tissues of the body in order to exchange gases,
nutrients, and waste products. The walls of capillaries consist of only a thin layer of endothelium so that there is
the minimum amount of structure possible between the blood and the tissues. The endothelium acts as a filter to keep blood cells inside
of the vessels while allowing liquids, dissolved gases, and other chemicals to diffuse along their concentration gradients into or out of tissues.

Precapillary sphincters are bands of smooth muscle found at the arteriole ends of capillaries. These sphincters regulate blood flow into the capillaries.
Since there is a limited supply of blood, and not all tissues have the same energy and oxygen requirements, the precapillary sphincters reduce blood flow
to inactive tissues and allow free flow into active tissues.
Veins and Venules: Veins are the large return vessels of the body and act as the blood return counterparts of arteries. Because the arteries, arterioles, and
capillaries absorb most of the force of the hearts contractions, veins and venules are subjected to very low blood pressures. This lack of pressure allows the walls
of veins to be much thinner, less elastic, and less muscular than the walls of arteries.

Veins rely on gravity, inertia, and the force of skeletal muscle contractions to help push blood back to the heart. To facilitate the movement of blood, some
veins contain many one-way valves that prevent blood from flowing away from the heart. As skeletal muscles in the body contract, they squeeze nearby
veins and push blood through valves closer to the heart.

When the muscle relaxes, the valve traps the blood until another contraction pushes the blood closer to the heart. Venules are similar to arterioles as they
are small vessels that connect capillaries, but unlike arterioles, venules connect to veins instead of arteries. Venules pick up blood from many capillaries
and deposit it into larger veins for transport back to the heart.

Blood

The average human body contains about 4 to 5 liters of blood. As a liquid connective tissue, it transports many substances through the body and helps to maintain
homeostasis of nutrients, wastes, and gases. Blood is made up of red blood cells, white blood cells, platelets, and liquid plasma.

Red Blood Cells: Red blood cells, also known as erythrocytes, are by far the most common type of blood cell and make up about 45% of blood volume.
Erythrocytes are produced inside of red bone marrow from stem cells at the astonishing rate of about 2 million cells every second. The shape of erythrocytes is
biconcavedisks with a concave curve on both sides of the disk so that the center of an erythrocyte is its thinnest part. The unique shape of erythrocytes gives
these cells a high surface area to volume ratio and allows them to fold to fit into thin capillaries. Immature erythrocytes have a nucleus that is ejected from the cell
when it reaches maturity to provide it with its unique shape and flexibility. The lack of a nucleus means that red blood cells contain no DNA and are not able to
repair themselves once damaged.

Erythrocytes transport oxygen in the blood through the red pigment hemoglobin. Hemoglobin contains iron and proteins joined to greatly increase the
oxygen carrying capacity of erythrocytes. The high surface area to volume ratio of erythrocytes allows oxygen to be easily transferred into the cell in the
lungs and out of the cell in the capillaries of the systemic tissues.

White Blood Cells: White blood cells, also known as leukocytes, make up a very small percentage of the total number of cells in the bloodstream, but have
important functions in the bodys immune system. There are two major classes of white blood cells: granular leukocytes and agranular leukocytes.

1 Granular Leukocytes: The three types of granular leukocytes are neutrophils, eosinophils, and basophils. Each type of granular leukocyte is
classified by the presence of chemical-filled vesicles in their cytoplasm that give them their function. Neutrophils contain digestive enzymes that
neutralize bacteria that invade the body. Eosinophils contain digestive enzymes specialized for digesting viruses that have been bound to by
antibodies in the blood. Basophils release histamine to intensify allergic reactions and help protect the body from parasites.
 2
3 Agranular Leukocytes: The two major classes of agranular leukocytes are lymphocytes and monocytes. Lymphocytes include T cells and natural
killer cells that fight off viral infections and B cells that produce antibodies against infections by pathogens. Monocytes develop into cells called
macrophages that engulf and ingest pathogens and the dead cells from wounds or infections.
4
Platelets : Also known as thrombocytes, platelets are small cell fragments responsible for the clotting of blood and the formation of scabs. Platelets form in the red
bone marrow from large megakaryocyte cells that periodically rupture and release thousands of pieces of membrane that become the platelets. Platelets do not
contain a nucleus and only survive in the body for up to a week before macrophages capture and digest them.

Plasma: Plasma is the non-cellular or liquid portion of the blood that makes up about 55% of the bloods volume. Plasma is a mixture of water, proteins, and
dissolved substances. Around 90% of plasma is made of water, although the exact percentage varies depending upon the hydration levels of the individual. The
proteins within plasma include antibodies and albumins. Antibodies are part of the immune system and bind to antigens on the surface of pathogens that infect the
body. Albumins help maintain the bodys osmotic balance by providing an isotonic solution for the cells of the body. Many different substances can be found
dissolved in the plasma, including glucose, oxygen, carbon dioxide, electrolytes, nutrients, and cellular waste products. The plasma functions as a transportation
medium for these substances as they move throughout the body.

Physiology

Functions of the Cardiovascular System

The cardiovascular system has three major functions: transportation of materials, protection from pathogens, and regulation of the bodys homeostasis.

Transportation: The cardiovascular system transports blood to almost all of the bodys tissues. The blood delivers essential nutrients and oxygen and
removes wastes and carbon dioxide to be processed or removed from the body. Hormones are transported throughout the body via the bloods liquid
plasma.

Protection: The cardiovascular system protects the body through its white blood cells. White blood cells clean up cellular debris and fight pathogens that
have entered the body. Platelets and red blood cells form scabs to seal wounds and prevent pathogens from entering the body and liquids from leaking out.
Blood also carries antibodies that provide specific immunity to pathogens that the body has previously been exposed to or has been vaccinated against.

Regulation: The cardiovascular system is instrumental in the bodys ability to maintain homeostatic control of several internal conditions. Blood vessels help
maintain a stable body temperature by controlling the blood flow to the surface of the skin. Blood vessels near the skins surface open during times of
overheating to allow hot blood to dump its heat into the bodys surroundings. In the case of hypothermia, these blood vessels constrict to keep blood
flowing only to vital organs in the bodys core. Blood also helps balance the bodys pH due to the presence of bicarbonate ions, which act as a buffer
solution. Finally, the albumins in blood plasma help to balance the osmotic concentration of the bodys cells by maintaining an isotonic environment.
The Circulatory Pump

The heart is a four-chambered double pump, where each side (left and right) operates as a separate pump. The left and right sides of the heart are separated by
a muscular wall of tissue known as the septum of the heart. The right side of the heart receives deoxygenated blood from the systemic veins and pumps it to the
lungs for oxygenation. The left side of the heart receives oxygenated blood from the lungs and pumps it through the systemic arteries to the tissues of the body.
Each heartbeat results in the simultaneous pumping of both sides of the heart, making the heart a very efficient pump.

Regulation of Blood Pressure

Several functions of the cardiovascular system can control blood pressure. Certain hormones along with autonomic nerve signals from the brain affect the rate and
strength of heart contractions. Greater contractile force and heart rate lead to an increase in blood pressure. Blood vessels can also affect blood pressure.
Vasoconstriction decreases the diameter of an artery by contracting the smooth muscle in the arterial wall. The sympathetic (fight or flight) division of the
autonomic nervous system causes vasoconstriction, which leads to increases in blood pressure and decreases in blood flow in the constricted region. Vasodilation
is the expansion of an artery as the smooth muscle in the arterial wall relaxes after the fight-or-flight response wears off or under the effect of certain hormones or
chemicals in the blood. The volume of blood in the body also affects blood pressure. A higher volume of blood in the body raises blood pressure by increasing the
amount of blood pumped by each heartbeat. Thicker, more viscous blood from clotting disorders can also raise blood pressure.

Hemostasis

Hemostasis, or the clotting of blood and formation of scabs, is managed by the platelets of the blood. Platelets normally remain inactive in the blood until they
reach damaged tissue or leak out of the blood vessels through a wound. Once active, platelets change into a spiny ball shape and become very sticky in order to
latch on to damaged tissues. Platelets next release chemical clotting factors and begin to produce the protein fibrin to act as structure for the blood clot. Platelets
also begin sticking together to form a platelet plug. The platelet plug will serve as a temporary seal to keep blood in the vessel and foreign material out of the
vessel until the cells of the blood vessel can repair the damage to the vessel wall.

THE URINARY SYSTEM

Urinary system
Also known as the renal system.
It eliminates waste products such as nitrogenous wastes, toxins and drugs from the body and maintains fluid/salt balance.
Consists of paired kidneys with ureters, a urinary bladder, and urethra.
Kidneys

Bean-shaped organs found along the posterior wall of the abdominal cavity.
The left kidney is located slightly higher than the right kidney because the right side of the liver is much larger than the left
side.
They remove liquid waste from the blood in the form of urine; keep a stable balance of salts and other substances in the blood
They produce erythropoietin, a hormone that aids the formation of red blood cells. The kidneys remove urea from the blood
through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a
glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the
urine as it passes through the nephrons and down the renal tubules of the kidney.

Parts of the Kidney:

o Renal Capsule outer membrane that surrounds the kidney; it is thin but tough and fibrous
o Renal Pelvis basin-like area that collects urine from the nephrons, it narrows into the upper end of
the ureter
o Calyx extension of the renal pelvis; they channel urine from the pyramids to the renal pelvis
o Cortex the outer region of the kidney; extensions of the cortical tissue, contains about one million
blood filtering nephrons
o Nephron these are the filtration units in the kidneys
o Medulla inner region of the kidney contains 8-12 renal pyramids. The pyramids empty into the calyx.
o Medullary pyramids formed by the collecting ducts, inner part of the kidney
o Ureter collects filtrate and urine from renal pelvis and takes it to the bladder for urination
o Renal Artery branches off of the aorta bringing waste-filled blood into the kidney for filtering in the
nephrons; the renal artery is further subdivided into several branches inside the kidney. Each minute,
the kidneys receive 20% of the blood pumped by the heart. Some arteries nourish the kidney cells
themselves.
o Renal Vein removes the filtered blood from the kidneys to the inferior vena cava

Function of the kidney:

 Every minute 1300 mL of blood enter the kidneys, 1299 mL leave the kidney. and 1 mL leaves as urine. The kidneys have many functions. The kidneys are
the major organs that maintain homeostasis (balance of the various body functions) in the body and help control blood pressure. They maintain balance in
electrolytes, acid-base, and fluid in the blood. The kidneys remove nitrogenous waste from the body (creatinine, urea, ammonia) and keep essential substances
the body needs to function as it should. The kidneys produce the hormone erythropoietin that stimulates the production of red blood cells and enzymes.

When the kidneys arent working as they should, there is a failure of homeostasis which can cause death if not corrected. A panel of blood tests, called
a Kidney Function Profile, is used to monitor the kidneys, detect kidney problems or make a diagnosis.

Parts of a Nephron:

o Renal Artery - brings waste-filled blood from the aorta to the kidney for filtering in the nephron.
o Glomerulus - each glomerulus is a cluster of blood capillaries surrounded by a Bowmans capsule. It looks
similar to
a ball of tangled yarn.
o Proximal convoluted tubule (PCT)- nearest the glomerulus; have permeable cell membranes that reabsorb
glucose, amino acids, metabolites and electrolytes into nearby capillaries and allow for circulation of water
o Loop of Henle has an ascending and descending limb, these loops along with their blood vessels and
collecting tubes for the pyramids in the medulla. When the filtrate reaches the descending limb of the loop,
water content has been reduced by 70%. The filtrate contains high levels of salts (mostly sodium). As the
filtrate moves further through the loop, more water is removed which further concentrates the filtrate.
Thin descending limb of the loop of Henle
Thick Ascending limb of the loop of Henle
o Distal convoluted tubule- farthest from the glomerulus; helps regular potassium excretion.
o Renal Vein when filtration is complete, blood leaves the nephron to join the renal vein, which removes
the filtered blood from the kidney
o Arterioles blood is brought to and carried away from the glomerular capillaries by two very small blood vesselsthe afferent and efferent arterioles.
o Collecting Duct collects the filtrate
Flow of blood in the kidneys:

The blood enters the kidney and goes to the glomerulus. Pressure forces fluid out of the blood through membrane filtration slits creating a cell-free fluid
(plasma) of water and small molecules that enters into the renal tubule. Large cells and proteins stay in the blood. This plasma is taken to the nearest
(proximal) convoluted tubule. This runs down into the medulla into the loop of Henle and then back to the farthest (distal) convoluted tubule to join with
other tubules. In the distal tubule most of the salts are reabsorbed. What is left is further modified until it becomes concentrated urine which contains urea
and other waste products at the end of the collecting duct. (See Anatomy Terms to understand proximal and distal.)
Glomerular filtration Filtrate is made as the blood is filtered through a collection of capillaries in the nephron called glomeruli.
Tubular reabsorption The tubules in the nephrons reabsorb the filtered blood in nearby blood vessels.
 Tubular secretion The filtrate passes through the tubules to the collecting ducts and then taken to the bladder.
Ureters

Pair of tubes that carry urine from the kidneys to the urinary bladder.
About 10 to 12 inches long and run on the left and right sides of the body parallel to the vertebral column. Gravity and peristalsis of smooth muscle tissue in
the walls of the ureters move urine toward the urinary bladder.
The ends of the ureters extend slightly into the urinary bladder and are sealed at the point of entry to the bladder by the ureterovesical valves. These valves
prevent urine from flowing back towards the kidneys.
Urinary Bladder

A sac-like hollow organ used for the storage of urine. The walls of the bladder allow it to stretch to hold about 600-800 mL of urine.
Urethra

The tube through which urine passes from the bladder to the exterior of the body.
The female urethra is around 2 inches long and ends inferior to the clitoris and superior to the vaginal opening. In males, the urethra is around 8 to 10
inches long and ends at the tip of the penis.
2 urethral sphincters control the flow of urine through the urethra (the internal and external urethral sphincter muscles). The internal urethral sphincter an
involuntarily controlled, when the bladder reaches a certain set level of distention. The opening of the internal sphincter results in the sensation of needing
to urinate. The External urethral sphincter is voluntarily controlled and is made of skeletal muscle and may be opened to allow urine to pass through the
urethra or may be held closed to delay urination.
Functions of the Kidneys

A. Filtration
The nephron is the functional unit of the kidney that filters blood to produce urine. Arterioles in the kidneys deliver blood to a bundle of capillaries
surrounded by a capsule called a glomerulus. As blood flows through the glomerulus, much of the bloods plasma is pushed out of the capillaries
and into the capsule, leaving the blood cells and a small amount of plasma to continue flowing through the capillaries. The liquid filtrate in the
capsule flows through a series of tubules lined with filtering cells and surrounded by capillaries. The cells surrounding the tubules selectively absorb
water and substances from the filtrate in the tubule and return it to the blood in the capillaries.
At the same time, waste products present in the blood are secreted into the filtrate. By the end of this process, the filtrate in the tubule has become
urine containing only water, waste products, and excess ions. The blood exiting the capillaries has reabsorbed all of the nutrients along with most of
the water and ions that the body needs to function.

B. Storage and Excretion of Wastes

 Urination is the process of releasing urine from the urinary bladder through the urethra and out of the body. The process of urination begins when
the muscles of the urethral sphincters relax, allowing urine to pass through the urethra. At the same time that the sphincters relax, the smooth
muscle in the walls of the urinary bladder contract to expel urine from the bladder.
After urine has been produced by the kidneys, it is transported through the ureters to the urinary bladder. The urinary bladder fills with urine and
stores it until the body is ready for its excretion. When the volume of the urinary bladder reaches anywhere from 150 to 400 mL, its walls begin to
stretch and stretch receptors in its walls send signals to the brain and spinal cord. These signals result in the relaxation of the involuntary internal
urethral sphincter and the sensation of needing to urinate. Urination may be delayed as long as the bladder does not exceed its maximum volume
(600-800 mL), but increasing nerve signals lead to greater discomfort and desire to urinate.

C. Maintenance of Homeostasis
The kidneys maintain the homeostasis of several important internal conditions by controlling the excretion of substances out of the body.

Ions. The kidney can control the excretion of potassium, sodium, calcium, magnesium, phosphate, and chloride ions into urine. In cases where
these ions reach a higher than normal concentration, the kidneys can increase their excretion out of the body to return them to a normal level.
Conversely, the kidneys can conserve these ions when they are present in lower than normal levels by allowing the ions to be reabsorbed into the
blood during filtration.
pH. The kidneys monitor and regulate the levels of hydrogen ions (H+) and bicarbonate ions in the blood to control blood pH. H+ ions are produced
as a natural byproduct of the metabolism of dietary proteins and accumulate in the blood over time. The kidneys excrete excess H+ ions into urine
for elimination from the body. The kidneys also conserve bicarbonate ions, which act as important pH buffers in the blood.
Osmolarity. The cells of the body need to grow in an isotonic environment in order to maintain their fluid and electrolyte balance. The kidneys
maintain the bodys osmotic balance by controlling the amount of water that is filtered out of the blood and excreted into urine. When a person
consumes a large amount of water, the kidneys reduce their reabsorption of water to allow the excess water to be excreted in urine. This results in
the production of dilute, watery urine. In the case of the body being dehydrated, the kidneys reabsorb as much water as possible back into the
blood to produce highly concentrated urine full of excreted ions and wastes. The changes in excretion of water are controlled by antidiuretic
hormone (ADH). ADH is produced in the hypothalamus and released by the posterior pituitary gland to help the body retain water.
Blood Pressure. The kidneys monitor the bodys blood pressure to help maintain homeostasis. When blood pressure is elevated, the kidneys can
help to reduce blood pressure by reducing the volume of blood in the body. The kidneys are able to reduce blood volume by reducing the
reabsorption of water into the blood and producing watery, dilute urine. When blood pressure becomes too low, the kidneys can produce the
enzyme renin to constrict blood vessels and produce concentrated urine, which allows more water to remain in the blood.

D. Production of Hormones
The kidneys produce and interact with several hormones that are involved in the control of systems outside of the urinary system.
 Renin. Renin is not a hormone itself, but an enzyme that the kidneys produce to start the renin-angiotensin system (RAS). The RAS increases
blood volume and blood pressure in response to low blood pressure, blood loss, or dehydration. Renin is released into the blood where it catalyzes
angiotensinogen from the liver into angiotensin I. Angiotensin I is further catalyzed by another enzyme into Angiotensin II.
Angiotensin II stimulates several processes, including stimulating the adrenal cortex to produce the hormone aldosterone. Aldosterone then
changes the function of the kidneys to increase the reabsorption of water and sodium ions into the blood, increasing blood volume and raising
blood pressure. Negative feedback from increased blood pressure finally turns off the RAS to maintain healthy blood pressure levels.
Erythropoietin. Erythropoietin, also known as EPO, is a hormone that is produced by the kidneys to stimulate the production of red blood cells. The
kidneys monitor the condition of the blood that passes through their capillaries, including the oxygen-carrying capacity of the blood. When the blood
becomes hypoxic, meaning that it is carrying deficient levels of oxygen, cells lining the capillaries begin producing EPO and release it into the
bloodstream. EPO travels through the blood to the red bone marrow, where it stimulates hematopoietic cells to increase their rate of red blood cell
production. Red blood cells contain hemoglobin, which greatly increases thebloods oxygen-carrying capacity and effectively ends the hypoxic
conditions.

THE NERVOUS SYSTEM

The nervous system is the part of an animal's body that coordinates its actions and transmits signals to and
from different parts of its body. Nervous tissue first arose in wormlike organisms about 550 to 600 million years ago.
In vertebrate species it consists of two main parts, the central nervous system (CNS) and the peripheral nervous
system (PNS). The CNS contains the brain and spinal cord. The PNS consists mainly of nerves, which are enclosed
bundles of the long fibers or axons that connect the CNS to every other part of the body. Nerves that transmit signals
from the brain are called motor or efferent nerves, while those nerves that transmit information from the body to the
CNS are called sensory or afferent. Most nerves serve both functions and are called mixed nerves. The PNS is
divided into a) somatic and b) autonomic nervous system, and c) the enteric nervous system. Somatic nerves
mediate voluntary movement. The autonomic nervous system is further subdivided into the sympathetic and the
parasympathetic nervous systems. The sympathetic nervous system is activated in cases of emergencies to mobilize
energy, while the parasympathetic nervous system is activated when organisms are in a relaxed state. The enteric
nervous system functions to control the gastrointestinal system. Both autonomic and enteric nervous systems
function involuntarily. Nerves that exit from the cranium are called cranial nerves while those exiting from the spinal
cord are called spinal nerves.

At the cellular level, the nervous system is defined by the presence of a special type of cell, called the neuron,
also known as a "nerve cell". Neurons have special structures that allow them to send signals rapidly and precisely to other cells. They send these signals in the
form of electrochemical waves traveling along thin fibers called axons, which cause chemicals called neurotransmitters to be released at junctions called
synapses. A cell that receives a synaptic signal from a neuron may be excited, inhibited, or otherwise modulated. The connections between neurons can form
neural circuits and also neural networks that generate an organism's perception of the world and determine its behavior. Along with neurons, the nervous system
contains other specialized cells called glial cells (or simply glia), which provide structural and metabolic support.
 The central nervous system functions to send signals from one cell to others or from one part of the body to others and to receive feedback. Malfunction of
the nervous system can occur as a result of genetic defects, physical damage due to trauma or toxicity, infection or simply of ageing. The medical specialty of
neurology studies disorders of the nervous system and looks for interventions that can prevent or treat them. In the peripheral nervous system, the most common
problem is the failure of nerve conduction, which can be due to different causes including diabetic neuropathy and demyelinating disorders such as multiple
sclerosis and amyotrophic lateral sclerosis.

Functions of the Nervous System

1. Sensory Function

2. Integration

3. Motor Function

Types of Cells in Nervous Tissue

1. Neurons - functional unit of the nervous system. Neurons can also be

classified by the direction that they send information:

a. Sensory (or afferent) neurons: send information from sensory receptors

(e.g., in skin, eyes, nose, tongue, ears) TOWARD the central nervous system.
b. Motor (or efferent) neurons: send information AWAY from the central
nervous system to muscles or glands.
c. Interneurons: send information between sensory neurons and motor
neurons. Most interneurons are located in the central nervous system.

*PARTS OF A NEURON:

2. Neuroglia support, protect and nourish neurons

*TYPES:

a. Schwann Cells
: are located in the peripheral nervous system (PNS). They play a supporting role in the nervous system by wrapping around nerve tissue and cells to form a
protective myelin sheath (which is comprised of 80 percent lipid and approximately 20 percent protein). Schwann cells are involved in nerve regeneration, repair
and development, the conduction of nerve impulses and the provision of antigens to T-lymphocytes (a type of WBC, or white blood cells, that play a role in cell
immunity).

b. Satellite Cells
: or satellite glial cells (SGCs), surround neurons in the parasympathetic, sympathetic and sensory ganglia. The parasympathetic ganglia are a group of nerve cells
that lie outside the central nervous system, and arise from the spinal cord. They are located in or around affected tissues and organs. Sympathetic ganglia form
part of the sympathetic nervous system and are comprised of nerves that arise from the lumbar and thoracic regions of the spinal cord. They inform the body about
impending danger and stress and prepare it for an appropriate fight-or-flight response. Sensory ganglia lie in the PNS and detect sensory receptors. Satellite cells
are involved in muscular repair and regeneration.

c. Oligodendrocyte
: Is part of the central nervous system (CNS) that function to provide support to nerves and axons. They produce an insulating myelin sheath that surrounds axons
and allows them to function efficiently.

d. Astrocytes
: are cells that are common to the spinal cord and brain. They function to supply nutrients to cells of the nervous tissue, maintain ion balance in extracellular cells,
repair and regenerate damaged spinal cord and brain cells and support cells of the blood-brain barrier (endothelial cells).

e. Ependymal Cells
: make up the ependyma, which are found in regions of the brain and spinal cord. They facilitate the unidirectional flow of the cerebral spinal fluid (CSF), which
transports nutrients to the cells of the brain and removes toxic metabolites (by-products of metabolism).

f. Microglia
: is a type of neuroglia that resides in the spinal cord and brain. They function to provide immunity to nervous cells, engulf harmful foreign particles; repair
damaged neural tissue and is involved in extracellular signaling. Microglia is the first stage of defense in the central nervous system.

A. CENTRAL NERVOUS SYSTEM

Part 1: Spinal cord

The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the medulla oblongata in the brainstem to the lumbar
region of the vertebral column. The brain and spinal cord together make up the central nervous system (CNS). The spinal cord begins at the occipital bone and
extends down to the space between the first and second lumbar vertebrae; it does not extend the entire length of the vertebral column. It is around 45 cm (18 in) in
men and around 43 cm (17 in) long in women. Also, the spinal cord has a varying width, ranging from 13 mm (12 in) thick in the cervical and lumbar regions to 6.4
mm (14 in) thick in the thoracic area. The enclosing bony vertebral column protects the relatively shorter spinal cord. The spinal cord functions primarily in the
transmission of neural signals between the brain and the rest of the body but also contains neural circuits that can independently control numerous reflexes and
central pattern generators.

The spinal cord has three major functions:

1.) as a conduit for motor information, which travels down the spinal cord,
2.) as a conduit for sensory information in the reverse direction,
3.) and finally as a center for coordinating certain reflexes.

Grey matter
Grey matter (or gray matter) is a major component of the central nervous system, consisting of neuronal cell bodies, neuropil (dendrites and myelinated as
well as unmyelinated axons), glial cells (astroglia and oligodendrocytes), synapses, and capillaries. Grey matter is distinguished from white matter, in that it
contains numerous cell bodies and relatively few myelinated axons, while white matter contains relatively very few cell bodies and is composed chiefly of long-
range myelinated axon tracts. The colour difference arises mainly from the whiteness of myelin. In living tissue, grey matter actually has a very light grey colour
with yellowish or pinkish hues, which come from capillary blood vessels and neuronal cell bodies.

Structure:
Grey matter refers to unmyelinated neurons and other cells of the central nervous system. It is present in the brain, brainstem and cerebellum, and present
throughout the spinal cord.

Grey matter is distributed at the surface of the cerebral hemispheres (cerebral cortex) and of the cerebellum (cerebellar cortex), as well as in the depths of
the cerebrum (thalamus; hypothalamus; subthalamus, basal ganglia putamen, globus pallidus, nucleus accumbens; septal nuclei), cerebellar (deep cerebellar
nuclei dentate nucleus, globose nucleus, emboliform nucleus, fastigial nucleus), brainstem (substantia nigra, red nucleus, olivary nuclei, cranial nerve nuclei).

Grey matter in the spinal cord is known as the grey column which travels down the spinal cord distributed in three grey columns that are presented in an
"H" shape. The forward-facing column is the anterior grey column, the rear-facing one is the posterior grey column and the interlinking one is the lateral grey
column. The grey matter on the left and right side is connected by the gray commissure. The grey matter in the spinal cord consists of interneurons, as well as cell
bodies.

Function
Grey matter contains most of the brain's neuronal cell bodies. The grey matter includes regions of the brain involved in muscle control, and sensory
perception such as seeing and hearing, memory, emotions, speech, decision making, and self-control.
The grey matter in the spinal cord is split into three grey columns:
1.) The anterior grey column contains motor neurons. These synapse with interneurons and the axons of cells that have travelled down the pyramidal tract.
These cells are responsible for the movement of muscles.
2.) The posterior grey column contains the points where sensory neurons synapse. This receives sensory information from the body, including fine touch,
proprioception, and vibration. This information is sent from receptors of the skin, bones, and joints through sensory neurons whose cell bodies lie in the
 dorsal root ganglion. This information is then transmitted in axons up the spinal cord in spinal tracts, including the dorsal column-medial lemniscus tract and
the spinothalamic tract.
3.) The lateral grey column is the third column of the spinal cord.

The grey matter of the spinal cord can be divided into different layers, called Rexed laminae. These describe, in general, the purpose of the cells within the
grey matter of the spinal cord at a particular location.

White matter

White matter refers to areas of the central nervous system that are mainly made up of myelinated axons also called tracts. Long thought to be passive
tissue, white matter actively affects learning and brain functions, modulating the distribution of action potentials, acting as a relay and coordinating communication
between different brain regions.

White matter is named for its relatively light appearance resulting from the lipid content of myelin. However, the tissue of the freshly cut brain appears
pinkish white to the naked eye because myelin is composed largely of lipid tissue veined with capillaries. Its white color in prepared specimens is due to its usual
preservation in formaldehyde.

Location
White matter forms the bulk of the deep parts of the brain and the superficial parts of the spinal cord. Aggregates of gray matter such as the basal ganglia
(caudate nucleus, putamen, globus pallidus, subthalamic nucleus, nucleus accumbens) and brain stem nuclei (red nucleus, substantia nigra, cranial nerve nuclei)
are spread within the cerebral white matter.

The cerebellum is structured in a similar manner as the cerebrum, with a superficial mantle of cerebellar cortex, deep cerebellar white matter (called the
"arbor vitae") and aggregates of grey matter surrounded by deep cerebellar white matter (dentate nucleus, globose nucleus, emboliform nucleus, and fastigial
nucleus). The fluid-filled cerebral ventricles (lateral ventricles, third ventricle, cerebral aqueduct, fourth ventricle) are also located deep within the cerebral white
matter.

Function
White matter is the tissue through which messages pass between different areas of gray matter within the central nervous system. The white matter is
white because of the fatty substance (myelin) that surrounds the nerve fibers (axons). This myelin is found in almost all long nerve fibers, and acts as an electrical
insulation. This is important because it allows the messages to pass quickly from place to place. Unlike gray matter, which a peak in development in a persons
twenties, the white matter continues to develop, and peaks in middle age.
 Part 2: Brain

I. BRAIN STEM

- is the part of the brain between the spinal cord and the diencephalon

MAJOR REGIONS OF THE BRAIN STEM

1. Medulla Oblongata
: a continuation of the spinal cord and within its white matter are all ascending & descending extending between
the spinal cord and other parts of the brain.
: Its grey matter contains several nuclei namely:
a. Cardiac centre- adjust the force and rate of the heart beat
b. Vasomotor centre- regulates the blood pressure by adjusting the blood vessels
c. Medullary Respiratory Centre- adjust the basic rhythm and rate of breathing
d. Reflex Centre- controls reflexes for swallowing, vomiting, coughing, hiccupping and sneezing.
e. Nuclei of cranial nerves- pairs or cranial nerve VIII and XI
2. Pons
: Located superior to the medulla and inferior to the cerebellum
: A bridge whose white mater contains tracts which connects brain from one another and its grey matter contains several nuclei which are sites of signals
for voluntary movements that originates from the cerebrum then relayed to the cerebellum.
: It also a respiratory center that controls breathing and contains pairs for cranial nerve V and VIII
3. Midbrain
: connects the pons and the diencephalon
: Its white matter contains tracts which conduct nerve impulses from the cerebrum to the spinal cord.
: Its grey matter contains nuclei which are reflex centers for startle/auditory reflex and visual/blinking reflex
: It contains pairs for cranial nerves III and IV which coordinates eye movements
II. RETICULAR FORMATION

- It is group of nuclei scattered throughout the brain. It is a major component of the reticular activating system which maintains the arousal and regulates sleep
wake pattern.

III. DIENCEPHALON

- is the part of the brain superior to the brain stem

IV. CEREBRUM

Is the largest part of the brain that is divided into left and right hemispheres. It is also called seat of intelligence
The hemispheres are separated by a groove called the great longitudinal fissure and are joined at the bottom of this fissure by a structure called the
corpus callosum which allows communication between the two sides of the brain.
The surface of the cerebrum contains billions of neurons and glia that together form a region of gray matter called the cerebral cortex also known as the
home of the conscious mind.
The surface of the cerebral cortex appears wrinkled with small grooves that are called sulci and bulges between the grooves that are called gyri. Beneath
the cerebral cortex are connecting fibers that interconnect the neurons and form a white-colored area called the white matter.
The basal ganglia or basal nuclei is a collective term of nuclei that lies deep within the cerebral hemisphere that regulates initiation and termination of
action, muscle tone and subconscious contractions of skeletal muscles
In the inner border of the cerebrum and the floor diencephalon a ring of structures called limbic system or emotional brain is located. It plays a primary
function in the range of emotions.

LOBES OF THE BRAIN:

a. Frontal lobe

The frontal lobe is located at the front of each cerebral hemisphere and positioned in front of the parietal lobe and
above and in front of the temporal lobe. It is separated from the parietal lobe by a space between tissues called
the central sulcus, and from the temporal lobe by a deep fold called the lateral sulcus also called the Sylvian fissure.
The precentral gyrus, forming the posterior border of the frontal lobe, contains the primary motor cortex, which
controls voluntary movements of specific body parts.

The frontal lobe contains most of the dopamine-delicate neurons in the cerebral cortex. The dopamine system is
associated with reward, attention, short-term memory tasks, planning, and motivation. Dopamine tends to limit and
select sensory information arriving from the thalamus to the forebrain. A report from the National Institute of Mental
Health says a genevariant that reduces dopamine activity in the prefrontal cortex is related to poorer performance and
inefficient functioning of that brain region during working memory tasks, and to a slightly increased risk
for schizophrenia.

b. Parietal lobe
 The parietal lobe is positioned above the occipital lobe and behind the frontal lobe and central sulcus.The parietal lobe integrates sensory information among
various modalities, including spatial sense and navigation (proprioception), the main sensory receptive area for the sense of touch (mechanoreception) in
the somatosensory cortex which is just posterior to the central sulcus in the postcentral gyrus, and the dorsal stream of the visual system. The major sensory
inputs from the skin (touch, temperature, and pain receptors), relay through the thalamus to the parietal lobe.

Several areas of the parietal lobe are important in language processing. The somatosensory cortex can be illustrated as a distorted figure
the homunculus (Latin: "little man"), in which the body parts are rendered according to how much of the somatosensory cortex is devoted to them. The superior
parietal lobule and inferior parietal lobule are the primary areas of body or spatial awareness. A lesion commonly in the right superior or inferior parietal lobule
leads to hemineglect.

c. Occipital lobe

The occipital lobe is the visual processing center of the mammalian brain containing most of the anatomical region of the visual cortex. The primary visual
cortex is Brodmann area 17, commonly called V1 (visual one). Human V1 is located on the medial side of the occipital lobe within the calcarine sulcus; the full
extent of V1 often continues onto the posterior pole of the occipital lobe. V1 is often also called striate cortex because it can be identified by a large stripe of
myelin, the Stria of Gennari. Visually driven regions outside V1 are called extrastriate cortex. There are many extrastriate regions, and these are specialized for
different visual tasks, such as visuospatial processing, color differentiation, and motion perception.

d. Temporal lobe

The temporal lobe is located beneath the lateral fissure on both cerebral hemispheres of the mammalian brain. The temporal lobe is involved in processing
sensory input into derived meanings for the appropriate retention of visual memories, language comprehension, and emotion association.

e. Limbic lobe

The limbic lobe is an arc-shaped region of cortex on the medial surface of each cerebral hemisphere of the mammalian brain, consisting of parts of the frontal,
parietal and temporal lobes. The term is ambiguous, with some authors including the paraterminal gyrus, the subcallosal area, the cingulate gyrus,
the parahippocampal gyrus, the dentate gyrus, the hippocampus and the subiculum;]while the Terminologia Anatomica includes the cingulate sulcus, the cingulate
gyrus, the isthmus of cingulate gyrus, the fasciolar gyrus, the parahippocampal gyrus, the parahippocampal sulcus, the dentate gyrus, the fimbrodentate sulcus,
the fimbria of hippocampus, the collateral sulcus, and therhinal sulcus, and omits the hippocampus.

f. Insular cortex

The insular cortex is a portion of the cerebral cortex folded deep within the lateral sulcus (the fissure separating the temporal lobe from the parietal and frontal
lobes).
The insulae are believed to be involved in consciousness and play a role in diverse functions usually linked to emotion or the regulation of the body's homeostasis.
These functions include perception, motor control, self-awareness, cognitive functioning, and interpersonal experience. In relation to these, it is involved
in psychopathology.

The insular cortex is divided into two parts: the larger anterior insula and the smaller posterior insula in which more than a dozen field areas have been identified.
The cortical area overlying the insula toward the lateral surface of the brain is the operculum (meaning lid). The opercula are formed from parts of the enclosing
frontal, temporal, and parietal lobes.

V. CEREBELLUM

Located posterior to the medulla and pons

It is the part of the brain responsible for the coordination of movements of the skeletal muscles and maintaining posture and balance.

CEREBRAL CIRCULATION
- Is the movement of blood through the network of blood vessels supplying the brain.
- There are 2 main parts: Arterial Cerebral Circulation and Cerebral Venous Circulation.
- (in the adult) normal rate is 750 milliliters per minute, representing 15% of the cardiac output.

1. Arterial cerebral circulation- is normally divided into anterior cerebral circulation and posterior cerebral circulation. There are two main pairs of arteries that
supply the cerebral arteries and the cerebrum: Internal carotid arteries and vertebral arteries. The anterior and posterior cerebral circulations are interconnected
via bilateral posterior communicating arteries. They are part of the Circle of Willis, which provides backup circulation to the brain.

1A. Anterior cerebral circulation -is the blood supply to the anterior portion of the brain. It is supplied by the following arteries:
Internal carotid arteries these large arteries are the left and right branches of the common carotid arteries in the neck which enter the skull, as
opposed to the external carotid branches which supply the facial tissues. The internal carotid artery branches into the anterior cerebral artery and
continues to form the middle cerebral artery.

1B. Posterior Cerebral Circulation - is the blood supply to the posterior portion of the brain, including the occipital lobes, cerebellum and brainstem. It is
supplied by the following arteries:
Vertebral arteries: These smaller arteries branch from the subclavian arteries which primarily supply the shoulders, lateral chest and arms. Within the
cranium the two vertebral arteries fuse into the basilar artery.

2. Cerebral Venous Drainage/Circulation- The venous drainage of the cerebrum can be separated into two subdivisions: superficial and deep.
 Superficial system - is composed of dural venous sinuses that are located on the surface of the cerebrum. The most prominent of these sinuses is the
superior sagittal sinus which flows in the sagittal plane under the midline of the cerebral vault, posteriorly and inferiorly to the torcula, forming the
confluence of sinuses, where the superficial drainage joins with the sinus that primarily drains the deep venous system. From here, two transverse
sinuses bifurcate and travel laterally and inferiorly in an S-shaped curve that form the sigmoid sinuses which go on to form the two jugular veins. In the
neck, the jugular veins parallel the upward course of the carotid arteries and drain blood into the superior vena cava.

Deep venous drainage is primarily composed of traditional veins inside the deep structures of the brain, which join behind the midbrain to form the
vein of Galen. This vein merges with the inferior sagittal sinus to form the straight sinus which then joins the superficial venous system mentioned
above at the confluence of sinuses.

Protection of the brain

The brain and spinal cord are covered by the meninges, the three protective membranes of the tough dura mater, the arachnoid materand the pia mater.
The cerebrospinal fluid (CSF) within the skull and spine provides further protection and also buoyancy, and is found between the pia mater and the
arachnoid mater.

The CSF that is produced in the ventricular system is also necessary for chemical stability, and the provision of nutrients needed by the brain. The CSF helps to
protect the brain from jolts and knocks to the head and also provides buoyancy and support to the brain against gravity. (Since the brain and CSF are similar in
density, the brain floats in neutral buoyancy, suspended in the CSF.) This allows the brain to grow in size and weight without resting on the floor of the cranium,
which would destroy nervous tissue.

1. LAYERS OF THE MENINGES:

 2. VENTRICULAR SYSTEM

The ventricular system is a set of four
fluid (CSF) is produced. Within each ventricle
production of CSF. The ventricular system is
allowing for the flow of CSF to circulate. All of
with ependyma, a specialised form
interconnected cavities (ventricles) in the brain, where the cerebrospinal
is a region of choroid plexus, a network of ependymal cells involved in the
continuous with the central canal of the spinal cord (from the fourth ventricle)
the ventricular system and the central canal of the spinal cord is lined
ofepithelium.

The system comprises four ventricles:

lateral ventricles right and left (one for each hemisphere)
third ventricle
fourth ventricle

There are several foramina, openings acting as channels, that connect the ventricles. The interventricular foramina (also called the foramina of Monro) connect the
lateral ventricles to the third ventricle through which the cerebrospinal fluid can flow.
Name From To

interventricular lateral
third ventricle
foramina (Monro) ventricles

cerebral aqueduct (Sylvius) third ventricle fourth ventricle

fourth subarachnoid space via the cisterna

median aperture (Magendie)
ventricle magna

right and left lateral fourth subarachnoid space via the cistern of
aperture (Luschka) ventricle great cerebral vein

3. CSF BLOOD FLOW

The ventricles are filled with cerebrospinal fluid (CSF) which bathes and cushions the brain andspinal cord within their
bony confines. CSF is produced by modified ependymal cells of the choroid plexus found in all components of the ventricular system
except for the cerebral aqueduct and theposterior and anterior horns of the lateral ventricles. CSF flows from the lateral ventricles via theforamina
of Monro into the third ventricle, and then the fourth ventricle via the cerebral aqueduct in the brainstem. From the fourth
ventricle it can pass into the central canal of the spinal cord or into the cisterns of the subarachnoid space via three small
foramina: the central foramen of Magendieand the two lateral foramina of Luschka.

The fluid then flows around the superior sagittal sinus to be reabsorbed via the arachnoid villi (or granulation villi) into
the venous sinuses, after which it passes through the jugular vein and majorvenous system. CSF within the spinal cord can flow
all the way down to the lumbar cistern at the end of the cord around the cauda equina where lumbar punctures are performed.

The cerebral aqueduct between the third and fourth ventricles is very small, as are the foramina, which means that they can be easily blocked.

4. BLOOD BRAIN BARRIER

The bloodbrain barrier (BBB) is a highly selective permeability barrier that separates the circulating blood from the brainextracellular fluid in the central
nervous system (CNS). The bloodbrain barrier is formed by brain endothelial cells, which are connected by tight junctions with an extremely high electrical
resistivity of at least 0.1 m. The bloodbrain barrier allows the passage of water, some gases, and lipid-soluble molecules by passive diffusion, as well as the
selective transport of molecules such as glucose and amino acids that are crucial to neural function. On the other hand, the bloodbrain barrier may prevent the
entry of lipophilic, potential neurotoxins by way of an active transport mechanism mediated by P-glycoprotein. Astrocytes are necessary to create the bloodbrain
barrier. A small number of regions in the brain, including the circumventricular organs (CVOs), do not have a bloodbrain barrier.

The bloodbrain barrier occurs along all capillaries and consists of tight junctions around the capillaries that do not exist in normal circulation. Endothelial
cells restrict the diffusion of microscopic objects (e.g., bacteria) and large or hydrophilic molecules into thecerebrospinal fluid (CSF), while allowing the diffusion of
small or hydrophobic molecules (O2, CO2, hormones). Cells of the barrier actively transport metabolic products such as glucose across the barrier with specific
proteins. This barrier also includes a thick basement membrane and astrocytic endfeet.

Structure

This "barrier" results from the selectivity of the tight junctions between endothelial cells in CNS vessels that
restricts the passage of solutes. At the interface between blood and the brain, endothelial cells are stitched
together by these tight junctions, which are composed of smaller subunits, frequently biochemical dimers, that
are transmembrane proteins such as occludin, claudins, junctional adhesion molecule (JAM), or ESAM, for
example. Each of these transmembrane proteins is anchored into the endothelial cells by another protein
complex that includes zo-1 and associated proteins.

The bloodbrain barrier is composed of high-density cells restricting passage of substances from the
bloodstream much more than does the endothelial cells in capillaries elsewhere in the body. Astrocyte cell
projections called astrocytic feet (also known as "glia limitans") surround the endothelial cells of the BBB,
providing biochemical support to those cells. The BBB is distinct from the quite similar bloodcerebrospinal fluid
barrier, which is a function of the choroidal cells of the choroid plexus, and from the bloodretinal barrier, which
can be considered a part of the whole realm of such barriers.

Several areas of the human brain are not on the brain side of the BBB. Some examples of this include the circumventricular organs, the roof of the third and
fourth ventricles, capillaries in the pineal gland on the roof of the diencephalon and the pineal gland. The pineal gland secretes the hormone melatonin "directly into
the systemic circulation", thus melatonin is not affected by the bloodbrain barrier.

MONRO-KELLIE HYPOTHESIS
The pressure-volume relationship between ICP,
volume of CSF, blood, and brain tissue, and cerebral
perfusion pressure (CPP) is known as the Monro-
Kellie doctrine or the Monro-Kellie hypothesis.

The Monro-Kellie hypothesis states that the cranial

compartment is incompressible, and the volume
inside the cranium is a fixed volume. The cranium
and its constituents (blood, CSF, and brain tissue)
create a state of volume equilibrium, such that any
increase in volume of one of the cranial constituents
must be compensated by a decrease in volume of
another.

The principal buffers for increased volumes include

CSF and, to a lesser extent, blood volume. These
buffers respond to increases in volume of the
remaining intracranial constituents. For example, an
increase in lesion volume (e.g. epidural hematoma)
will be compensated by the downward displacement
of CSF and venous blood.These compensatory
mechanisms are able to maintain a normal ICP for
any change in volume less than approximately 100
120 mL.

The Monro-Kellie hypothesis is named

after Edinburgh doctors Alexander
Monro and George Kellie.

CRANIAL NERVES

B. PERIPHERAL NERVOUS SYSTEM

 The peripheral nervous system (PNS) is the part of the nervous system that consists of the nerves and ganglia
outside of the brain and spinal cord. The main function of the PNS is to connect the central nervous system (CNS) to the
limbs and organs, essentially serving as a communication relay going back and forth between the brain and spinal cord with
the rest of the body. Unlike the CNS, the PNS is not protected by the bone of spine and skull, or by the bloodbrain barrier,
which leaves it exposed to toxins and mechanical injuries. The peripheral nervous system is mainly divided into the somatic
nervous system and the autonomic nervous system. In the somatic nervous system, the cranial nerves are part of the PNS
with the exception of cranial nerve II, the optic nerve, along with the retina. The second cranial nerve is not a true peripheral
nerve but a tract of the diencephalon. Cranial nerve ganglia originate in the CNS. However, the remaining ten cranial nerve
axons extend beyond the brain and are therefore considered part of the PNS. The Autonomic nervous system is an
involuntary control of smooth muscle. The connection between CNS and organs allows the system to be in two different
functional states: sympathetic and parasympathetic.

Structure

The peripheral nervous system is divided into somatic nervous system, sensory nervous systems, and autonomic
nervous system. The somatic nervous system is under voluntary control, and transmits signals from the brain to end organs
such as muscles. The sensory nervous system transmits signals from senses such as taste and touch (including fine touch
and gross touch) to the spinal cord and brain. The autonomic nervous system is a 'self-regulating' system which influences
the function of organs over which we have little or no voluntary control, such as the digestive system.

Sensory-somatic nervous system

The somatosensory nervous system consists of sensory nerves and somatic nerves, and many nerves which hold both functions.

In the head and neck, cranial nerves carry somatosensory data. There are twelve cranial nerves, ten of which originate from the brainstem, and mainly
control the functions of the anatomic structures of the head with some exceptions. The nuclei of the olfactory nerve and the optic nerves lie in the forebrain and
thalamus, respectively, and are thus not considered to be true cranial nerves. One unique cranial nerve is the vagus nerve, which receives sensory information
from organs in the thorax and abdomen. The accessory nerve is responsible for innervating the sternocleidomastoid and trapezius muscles, neither of which being
exclusively in the head.

For the rest of the body, Spinal nerves are responsible for somatosensory information. These arise the spinal cord. Usually these arise as a web ("plexus")
of interconnected nerves roots that arrange to form single nerves. These nerves control the functions of the rest of the body. In humans, there are 31 pairs of
spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. These nerve roots are called according to the spinal vertebrata which they are adjacent
to. In the cervical region, the spinal nerve roots come out above the corresponding vertebrae (i.e., nerve root between the skull and 1st cervical vertebrae is called
spinal nerve C1). From the thoracic region to the coccygeal region, the spinal nerve roots come out below the corresponding vertebrae. It is important to note that
this method creates a problem when naming the spinal nerve root between C7 and T1 (so it is called spinal nerve root C8). In the lumbar and sacral region, the
spinal nerve roots travel within the dural sac and they travel below the level of L2 as the cauda equina.
Cervical spinal nerves (C1C4)

The first 4 cervical spinal nerves, C1 through C4, split and recombine to produce a variety of nerves that serve the neck and back of head.

Spinal nerve C1 is called the suboccipital nerve, which provides motor innervation to muscles at the base of the skull. C2 and C3 form many of the nerves
of the neck, providing both sensory and motor control. These include the greater occipital nerve, which provides sensation to the back of the head, the lesser
occipital nerve, which provides sensation to the area behind the ears, the greater auricular nerve and the lesser auricular nerve.

The phrenic nerve is a nerve essential for our survival which arises from nerve roots C3, C4 and C5. It supplies the diaphragm, enabling breathing. If the
spinal cord is transected above C3, then spontaneous breathing is not possible.

Brachial plexus (C5T1)

The last four cervical spinal nerves, C5 through C8, and the first thoracic spinal nerve, T1, combine to form the brachial plexus, or plexus brachialis, a
tangled array of nerves, splitting, combining and recombining, to form the nerves that subserve the upper-limb and upper back. Although the brachial plexus may
appear tangled, it is highly organized and predictable, with little variation between people.

Lumbosacral plexus (L1L4)

The anterior divisions of the lumbar nerves, sacral nerves, and coccygeal nerve form the lumbosacral plexus, the first lumbar nerve being frequently joined by
a branch from the twelfth thoracic. For descriptive purposes this plexus is usually divided into three parts:

1. lumbar plexus
2. sacral plexus
3. pudendal plexus

Autonomic nervous system

The autonomic nervous system controls involuntary responses to regulate physiological functions. The brain and spinal cord from central nervous system
are connected with organs that have smooth muscle, such as the heart, bladder, and other cardiac, exocrine, and endocrine related organs, by ganglionic neurons.
The most notable physiological effects from autonomic activity are pupil constriction and dilation, and salivation of saliva. The autonomic nervous system is always
activated, but is either in the sympathetic or parasympathetic state. Depending on the situation, one state can overshadow the other, resulting in a release of
different kinds of neurotransmitters. There is a lesser known division of the autonomic nervous system known as the enteric nervous system. Located only around
the digestive tract, this system allows for local control without input from the sympathetic or the parasympathetic branches, though it can still receive and respond
to signals from the rest of the body. The enteric system is responsible for various functions related to gastrointestinal system.
Sympathetic nervous system

The sympathetic system is activated during a fight or flight situation in which great mental stress or physical danger is encountered. Neurotransmitters
such as noradrenaline and adrenaline are released, which increases heart rate and blood flow in certain areas like muscle, while simultaneously decreasing
activities of non-critical functions for survival, like digestion. The systems are independent to each other, which allow activation of certain parts of the body, while
others remain rested.

Parasympathetic nervous system

Primarily using the neurotransmitter acetylcholine (ACh) as a mediator, the parasympathetic system allows the body to function in a rest and digest state.
Consequently, when the parasympathetic system dominates the body, there are increases in salivation and activities in digestion, while heart rate and other
sympathetic response decrease. Unlike the sympathetic system, humans have some voluntary controls in the parasympathetic system. The most prominent
examples of this control are urination and defecation.

CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATIONS

Client in Context
Patient D.E., 74 years old, male, married, Filipino,
Roman Catholic born on February 2, 1942, currently
residing in Lawaan, Talisay Cebu City, was admitted for
the third time at CVGH on November 18,2016 at
around 3:08 pm, via ambulance per wheelchair
accompanied by his daughter and son for complaints
of cough and dyspnea noted 3 days PTA. Patient is
under the service of Dr. Martiniano C. Zanoria of
Department of Internal Medicine with a case number of
039260 and a hospital number of 1500076779.
History of Present Illness
3 days PTA, patient suddenly experienced
intermittent productive cough with yellowish-greenish
sputum amounting to 1-2 tbsp. per expectoration
associated with dyspnea and body malaise. No fever,
vomiting and headache were noted. Patient was
nebulized by son with Ventolin Salbutamol 5mg twice a
day which provided him with minimal relief.
2 days PTA, patients condition persisted and was
then accompanied with loss of appetite. Patients son
continued nebulising him with Ventolin Salbutamol 5mg
twice a day which, again, provided him with minimal
relief. Still no fever, vomiting, and headache noted and
no consultation was done.
1 day PTA, patient still experienced productive
cough with greenish sputum amounting to 1-2 tbsp per
expectoration associated with dyspnea, body malaise,
loss of appetite and fever with a temperature of
38.9C/axilla. Patients daughter decided to seek
PHYSICAL EXAMINATION
Day 1 (November 23 , 2016; 4:00pm)
General Appearance: Seen patient lying on bed on bed,
oriented, lethargic, responsive, afebrile and coherent, with
O2 at 6L/min on via nasal cannula, with ISA on right hand,
with FBC- CDU attached and with the following vital signs:
BP: 130/80 mmHg
PR: 86 bpm
RR: 20 cpm
Temp: 36.0 C/ axilla
Oxygen Saturation: 97%
Skin: Skin is brown and is evenly pigmented. It is slightly
moist, smooth, and warm with calluses noted on plantar
surface of both feet. Presence of senile turgor- skin wrinkles
or tents when pinched. Multiple senile lentigines noted on
both upper extremities and face. Grade 1 pressure ulcers
were noted on the back of the patient. Uneven color of both
legs noted, thighs have lighter skin color than the legs.
Scales on both legs were noted.
Scalp and Hair: Hair is straight, smooth, mixed black, gray,
and white colored and is evenly distributed with no patchy
hair loss noted. Scalp is clean and dry with no lesions and
lice infestation.
Nails: Upper and lower extremities has transparent nails
with slightly pale nail beds. Nails are round with 160 nail
base. Nails are dirty but well-
3/5 1/5 trimmed, hard, smooth and firm.
3/5 1/5
 MEDICATIONS
1. Ciprofloxacin (Ciprolam) 250 mg BID PO AC

Classification:
- Anti-bacterial/Fluoroquionolone

Action:
- Bactericidal; Interferes with the cell replication in susceptible bacteria preventing cell reproduction.

Indications:
- Treatment of infections caused by gram (-) bacterias, pneumonia, UTIs and lower respiratory tract infections

Contraindications:
- Allergies to Ciprofloxacin or norfloxacin or other fluoroquionolones, pregnancy and lactation
- Use cautiously on patients with renal impairment , seizure, tendinitis or tendon rupture

Adverse effects:
- Headache, dizziness, insomnia, fatigue, somnolence, depression, blurred vision, arrhythmias, hypotension, angina
- Nausea, vomiting, dry mouth, abdominal pain, diarrhea, fever, rash
- Elevated BUN, AST, ALT and decreased WBC count, hematocrit and neutrophil

Nursing Considerations:

- If antacid is needed, take it at least 2 hours before or after dose

- Do not crush tablet or chew them upon swallowing
- Drink plenty of fluid upon taking this medication
- Eat frequent small meals
- Avoid driving or any strenuous activities

2. Amlodipinie 10 mg/tab OD PO

Classification:
- Anti angina/ Anti-hypertensive/ Calcium channel blocker

Action:
 - Inhibits the movements of calcium ions across the membranes of cardiac and arterial muscles which results in the depression of impulse formation in
specialized cardiac pacemaker cells and these effects lead to decreased cardiac work and oxygen consumption and increase delivery of oxygen in patients
with vasopastic angina
Indication:
- Angina pectoris , chronic stable angina, essential hypertension

Contraindication:
- Allergies to amlodipine, impaired hepatic or renal function, sick sinus syndrome. 2nd or 3rd degree heart block
- Use cautiously with heart failure

Adverse effects:
- Dizziness, light headedness, headache, lethargy, fatigue, peripheral edemas, arrhythmias
- Flushing, rash, nausea, abdominal discomfort

Nursing Considerations:
- Monitor BP carefully
- Monitor cardiac rhythm regularly
- Administer drug without regards to meal, but take with meals of stomach upset occurs
- Eat small frequent meals
- Adjust lightning, noise and temperature
- Report irregular heartbeat, shortness of breath, swelling of the hands, pronounced dizziness, constipation

3. Folic Acid 5mg OD PO

Classification:
- Vitamin Supplement

Action:
- Required for nucleoprotein synthesis and maintenance of normal erythropoiesis

Indication:
- Treatment for megobalstic anemias due to nutritional deficiency

Contraindication:
- Allergies to folic acid
- Use cautiously in lactation
 Adverse effects:
- Allergic reactions

Nursing Considerations:
- Administer orally if possible, but if with severe GI malabsorption occurs give IM, IV or subcutaneously
- Report rash, difficulty in breathing, pain or discomfort on injection site

4. Simvastatin 20mg/tab OD qHS

Classification:
- Anti-hyperlipidimic/ HMG CoA reductase inhibitor

Actions:
- Inhibits the HMG CoA reductase, the enzyme that catalyzes the the first step in the cholesterol synthesis pathway, resolution a decrease in serum
cholesterol, serum LDLs and either an increase or no change in serum HDLs

Indications:
- Treatment of elevated total cholesterol and LDLs with primary hypercholesterolemia and of patients with isolated hypertriglyceridemia
- Reduce risk of coronary heart disease

Contraindications:
- Allergy with simvastatin, active liver disease
- Use cautiously with impaired renal and hepatic function, cataracts

Adverse Effects:
- Headache, sleep disturbances, flatulence, diarrhea, abdominal pain, cramps, dyspepsia
- Sinusitis, pharyngitis, athralgia, myalgia, sensitive to light

Nursing Considerations:
- Give in the evening, highest rates of cholesterol synthesis are between midnight and 5 am
- Do not drink grape fruit while using drug
- Eat small frequent meals
- Use a sunscreen and wear protective clothing
- Report adverse effects if noted

5. Esomeprazole (Nexium) 40mg OD AC BF

Classification:
 - Proton pump inhibitor

Action:
- Suppresses gastric acid secretion by specific inhibition of the hydrogen potassium enzyme system at the secretory surface of the gastric parietal cells, blocks
the final acid production
Indication:
- GERD, duodenal ulcers
- Reduction in occurrence of gastric ulcers associated with continuous NSAID use

Contraindications:
- Hypersensitivity to esomeprazole, hepatic impairment, pregnancy and lactation

Adverse effects:
- Headache, dizziness, vertigo, insomnia, rash, inflammation, urticaria, pruritis, alopecia
- Diarrhea, abdominal pain, sinusitis, cough, epistaxis

Nursing Considerations:
- Take drug at least 1 hour before meals
- Swallow capsules whole, do not crush or chew
- Avoid driving or any hazardous acts
- Report if any adverse effects is noted

6. Eryhtropoietin (Recormon)

Classification:
- Recombinant Human Erythropoietin

Actions:
- A natural glycoprotein produced in the kidneys, which stimulates red blood cell production in the bone marrow

Indication:
- Treatment of anemia associated with chronic renal failure

Contraindication:
- Uncontrolled hypertension, hypersensitivity
- Cautious with pregnancy, lactation, sickle cell anemia, porphyria
 Adverse effects:
- Headache, athralgia, CVA, seizure, dizziness fatigue, hypertension, edema, chest pain, nausea, vomiting, diarrhea
- Clotting of access line, development of anti-erythropoietin anti-bodies with subsequent pure red cell aplasia and extreme anemia

Nursing Considerations:
- Gently mix medication, do not shake, shaking may denature the glycoprotein
- Use only one dose per vial
- Discard unused portions
- Monitor access lines for any signs of clotting
- Must be given only through IV or subcutaneously
- Ensure proper nutrition
- Report if any adverse effects occurred

7. NaHCO3 2 tabs TID 2H PC

Classification:
- Antacid/ Electrolyte/ Urinary Alkalinizer

Action:
- Increases plasma bicarbonate, buffers excess hydrogen ions concentration; raises blood pH; reverse the clinical manifestations of acidosis and reduces
gastric acidity

Indications:
- Metabolic acidosis, adjunctive treatment of severe diarrhea with accompanying loss of bicarbonate
- Minimation of uric acid crystalluria
- Prophylaxis of GI bleeding, ulcers and aspiration pneumonia

Contraindication:
- Allergies to components of preparations
- Used cautiously on patients with renal impairment, heart failure, pregnancy and lactation

Adverse effects:
- GI rupture following ingestion, systemic alkalosis, hypokalemia, hyponatremia
- Chemical cellulitis, tissue necrosis

Nursing considerations:
- Chew oral tablets thoroughly and follow with full glass of water
- Do not take within -2 hours of any other drugs to decrease risk of drug interactions
 - Monitor cardiac rhythm regularly

8. Febuxostat 40mg/tab OD PO (every other day)

Classification:
- Anti- gout/ Xanthine Oxidase Inhibitior

Action:
- Blocks xanthine oxidase; an enzyme in the process of uric acid formation

Indication:
- Long term management of hyperuricemia in patients with gout

Contraindications:
- Hypersensitivity to drug components, concurrent treatment with azathioprine, theophyllines

Adverse effects:
- Dizziness, thromboembolic events, MI, stroke
- Nausea, liver function abnormalities, athralgia, gout flares, rash

Nursing Considerations:
- Administer without regard to food, maybe taken with antacids
- Obtain baseline and periodic serum uric acid levels
- Take medication once a day
- If dose is miss, take next dose as soon as possible
- Store drug in room temperature, protected by light

9. Meropenem (Meromax) 500mg IV infusion OD

Classification:
- Antibiotic (Carbapenem)

Action:
- Bactericidal; inhibits of bacterial cell wall and causes cell death in susceptible cells

Indications:
- Intra-abdominal infections caused by viridians group streptococci, community-acquired pneumonia, bacterial meningitis
 Contraindications:
- Allergies to cephalosporins, penicillins, beta lactams
- Use cautiously with renal impairment, pregnancy, lactation, CNS disorders

Adverse effects:
- Headache, dizziness, lethargy, paresthesias, seizure, pneumonia
- Nausea, vomiting, diarrhea, pseudomembranous colitis, liver toxicity, superinfections, abscess

Nursing considerations:
- This drug can only be given IV
- Take drug with food
- Report if any adverse effects occurs

10. Cefuroxime (Zinnat) 500mg/tab BID PC

Classification:
- Antibiotic/ Second Generation Cephalosporin

Action:
- Bactericidal; inhibits synthesis of bacterial cell wall, causing cell death

Indication:
- Pharyngitis, tonsillitis, otitis media, UTIs, lower respiratory tract infections

Contraindication:
- Allergies to cephalosporins and penicillins
- Cautiously with renal failure, lactation, pregnancy

Adverse effects:
- Headache, dizziness, lethargy, paresthesia
- Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembtanous colitis

Nursing considerations:
- Take full course of therapy even if symptoms already subsided
- This drug is specific for a certain infection and should not be used to self treat other problems
- Swallow tablets whole, do not crush them
- Take drug with food
 DISCHARGE PLAN
Medication

Instructed the patient to take the prescribed medications religiously, at the right time and at the right dose.
Instructed not to stop any medications abruptly without the doctors order.
Instructed to take the full course of medication regimen with good compliance
o Maintenance medications:
Amlodipine 10 mg/tab OD PO
Folic Acid 5mg OD PO
Simvastatin 20mg/tab OD qHS
Eryhtropoietin
Febuxostat 40mg/tab OD PO

Environment

Encouraged to maintain calm and peaceful environment to promote adequate rest periods.
Instructed SO to clear away any obstructions/sharp objects during patients ambulation to decrease risk of injury.
Encouraged SO to provide soft pillow or cushion on the chair when patient sits, to promote relaxation.
Encouraged SO to prepare all necessary things nearer to the patient.
Advised SO to maintain cleanliness at home.

Treatment

Instructed to attend follow-up check-ups seriously if ordered by the doctor.

Instructed to maintain medication regimen or treatment with good compliance
Advised S.O. and patient to seek medical advice if any unusualities may arise..

Health Teachings

Instructed the SO to assist patient carefully in positioning and ambulation.

Instructed SO to maintain patients cleanliness through bed bath.
Encouraged SO and patient to use lotion to moisturize the skin especially on the lower legs.
Told the SO to position the patient into semi or high-fowlers, especially when patient feels dyspneic.
Encouraged SO and patient to wear loose and comfortable clothing to promote circulation.
Instructed the SO to monitor the patient at all times, and stay beside the patient.
 Encouraged SO to do passive range of motion to the patient especially on the left upper and lower part of the body.

Observable Signs and Symptoms

Informed patient and SO to report to the doctor immediately if any unusualities may occur such as headache, fever, dyspnea, restlessness, decreased urine
output, dizziness, and diminished peripheral pulses.

Diet

Instructed SO and patient not to eat high-purine foods such as meat, beans, and dried fish.
Instructed to limit sodium intake to decrease edema, and prevent increase in blood pressure.
Instructed to prevent eating foods high in cholesterol, such as meat, fried foods etc.

Safety, Security, & Spirituality

Encouraged to put pillow or soft cushion on the chair to promote relaxation when sitting.
Advised to put pillows beside the patient to prevent risk of falling from the bed.
Instructed to clear any obstructions or sharp objects on the patients pathway.
Advised patient to continually pray to God for his fast recovery and guidance.
 Appendix A

24 Hour Diet Recall

Meal of the Day 24-hour diet recall Usual/Typical Diet

Breakfast 1 slice Francis, 1 cup Coffee 1 cup coffee with 1 slice Francis bread
Lunch 1 slice Banana, 1 glass Water Utan bisaya, 1 cup rice, 1 glass Water
Dinner Fish tinola, cup Rice, Lemon-C 1 cup rice, Chicken soup, 8oz. Coca-Cola
Am Snack NONE NONE
Pm Snack Fudge Bar, cup Water 1 cup coffee with 1 slice Francis

Appendix C

Attachments Client Ecomap

Strongly Attached-

Moderately Attached

Slightly Attached-
Family CLIENT
Negatively Attached - God

Friends
 Appendix B

Family Genogram

Paternal Side Maternal Side

Legend:
Grandfather Grandmother Grandfather Grandmother
= Deceased Male
(BP) (HPN) (Old Age) (?)

= Deceased Female

= Living Male

Father Mother
(HPN) (Old Age)
= Living Female

= Patient

A& W= Alive and Well

CKD Stage 5, HACVD, CVD, BPH
BP= Bronchopneumonia

(?)= Unknown
Appendix D Appendix E
Appendix F
 Appendix G

PITTSBURGH SLEEP QUALITY INDEX (PSQ) Not during the Less than once Once or twice Three of more
past month a week a week times a week
1. During the past month, when have you usually gone to bed at night?
Usual Bed Time : 8pm

2. During the past month, how long in (minutes) has it usually take you
to fall asleep each night ?
A
Number of Minutes: 10 minutes

3. During the past month, when have you usually gotten up in the B
morning?
Usual getting up time: 4am
C
4. During the past month, how many hours of actual sleep did you get
D
at night?(This may be different than the number of hours you spend in
bed.)
E
Hours of sleep per night: 8 hours F
5. During the past month have you had trouble sleeping because you
a. cannot get to sleep within 30 minutes
G
b. wake up in the middle of the night or early morning
c. have to get up to use the bathroom H
d. cannot breathe comfortably
e. cough or snore loudly I
f. feel too cold
g. feel too hot
h. had bad dreams
J
i. have pain
j. other reasons, please describe
Answers Number 5
 6. During the past month, how would you rate your sleep quality
overall?

7. During the past month, how often have

You taken medicine(prescribed or over the counter) to help you
sleep?

8. During the past month, how often have you had trouble staying
awake while driving,
eating meals, or engaging in social activity?

9. During the past month, how much of a problem has it been for you
to keep up enough enthusiasm to get things done?

10. During the past month, how much of a problem has it been for you
Very Good Fairly Good Fairly Bad Very bad to keep up

6 enough enthusiasm to get things done?

Not during the Less than Once or Three or more Scoring

past month once a week twice a times a week
week Component 1: Subjective sleep quality
Examine question #6, and assign scores as follows
7 Response Component 1 score
Very Good 0

8 Fairly Good
Fairly Bad
1
2
Very Bad 3
Score: 1
No problem at Only s very Somewhat A very big
all slight of a problem problme
Component 2: Sleep Latency
problem
1. Examine question #2, and assign scores as follows:
9 Response : 15minutes 0
No bed partner Partner/ Partner in Partner in same 16-30 minutes 1
or roommate roommate in same room, bed 31-60 minutes 2
other room but not
same bed

10
>60 minutes 3 >85% 0
Question # 2 score: 0 75-84% 1
2. Examine question #5a, and assign scores as follows: 65-74% 2
Response Score <65% 3
Not during the past month 0 Score: 0
Less than once a week 1
Once or twice a week 2 Component 5: Sleep Disturbances
Three or more times a week 3 1. Examine questions #5b-5j, and assign scores for each questions
Question #5a score: 0 Response Score
3. Add #2 score and #5a score Not during the past month 0
Sum of #2 and #5 : 0 Less than once a week 1
4. Assign component 2 score as follows Once or twice a week 2
Sum of # 2 and #5a Component 2 score Three or more times a week 3
0 0 5b : 3
1-2 1 5c: 1
3-4 2 5d: 3
5-6 3 5e: 0
Score : 0 5f: 0
Component 3: Sleep duration 5g: 1
Examine question #4, and assign scores as follows 5h: 1
Response Component 3 score 5i: 0
>7 hours 0 5h: -
6-7 hours 1 2. Add the scores for questions #5b-5j:
5-6 hours 2 Sum of #5b-5j: 9
<5 hours 3 3. Assign component 5 score as follows:
Score: 0 Sum of #5b-5j Component 5 score
0 0
Component 4: Habitual sleep efficiency 1-9 1
1. Write the number of hours of slept (question#4) here: 8 hours 19-18 2
2. Calculate the number of hours spent in bed: 19-27 3
Getting up time (question#3): 4 am Score: 1
Bedtime (question#1): 8 pm
Number of hours spent in bed: 8.16 hours Component 6: Use of sleeping medication
3. Calculate habitual sleep efficiency as follows: Examine question #7 and assign scores as follows:
(number of hours sleep/ number of hours spent in bed) X 100 = Response Component 6 score
Habitual sleep efficiency Not during the past month 0
8 hours/ 8.16 hours X 100 = 98.03% Less than once a week 1
Habitual sleep efficiency % Component 4 score Once or twice a week 2
Three or more times a week 3 4. Assign component 7 score as follows:
Score: 3 Sum of #8 and #9 Component 7 score
0 0
Component 7: Daytime dysfunction 1-2 1
Examine question#8, and assign scores as follows: 3-4 2
Response score 5-6 3
Never 0 Score: 2
Once or twice 1 Global PSI Score (Add the seven component scores together) = 4 No
Once or twice each week 2 difficulty in Sleeping
Three or more times each week 3
Question #8 score: 1
2, Examine question #9, and assign scores as follows:
Response Score
No problem at all 0
Only a very slight problem 1
Somewhat of a problem 2
A very big problem 3
Question #9 score: 2
Add scores for each question #8 and #9
APPENDIX H
Sum of #8 and #9: 3