Compilation of MS Notes
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MEDICAL-SURGICAL NURSING
NERVOUS SYSTEM
Overview of structures and functions:
Central Nervous System
Brain
Spinal Cord
Peripheral Nervous System
Cranial Nerves
Spinal Nerves
Autonomic Nervous System
Sympathetic nervous system
Parasympathetic nervous system
AUTONOMIC NERVOUS SYSTEM
Sympathetic Nervous System
(ADRENERGIC)
Parasympathetic Nervous
System(CHOLINERGIC, VAGAL,
SYMPATHOLYTIC)
- Involved in fight or aggressionresponse.- Release of Norepinephrine(cathecolamines)
from adrenal glands and causesvasoconstriction.
- Increase all bodily activity except GIT
EFFECTS OF SNS- Dilation of pupils(mydriasis) in orderto be aware.- Dry mouth (thickened saliva).- Increase BP and Heart Rate.- Bronchodilation, Increase RR- Constipation.- Urinary Retention.
- Increase blood supply to brain, heartand skeletal
muscles.- SNS
I. Adrenergic Agents- Give Epinephrine.Signs and Symptoms:- SNS
- Involved in fight or withdrawalresponse.- Release of Acetylcholine.
- Decreases all bodily activities
except GIT.
EFFECTS OF PNS- Constriction of pupils (meiosis).- Increase salivation.- Decrease BP and Heart Rate.- Bronchoconstriction, DecreaseRR.- Diarrhea- Urinary frequency.
I. Cholinergic Agents- Mestinon, Neostigmine.Side Effects- PNS
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Contraindication:- Contraindicated to patients sufferingfrom COPD (Broncholitis,Bronchoectasis, Emphysema, Asthma).
II. Beta-adrenergic Blocking Agents- Also called Beta-blockers.- All ending with lol- Propranolol, Atenelol, Metoprolol. Effects of Beta-blockersB roncho spasmE licits a decrease in myocardialcontraction.T reats hypertension.
A V conduction slows down. Should be given to patients withAngina Pectoris, MyocardialInfarction, Hypertension.
ANTI- HYPERTENSIVE AGENTS1. Beta-blockers lol2. Ace Inhibitors Angiotensin, pril(Captopril, Enalapril)
3. Calcium Antagonist Nifedipine(Calcibloc) In chronic cases of arrhythmia give
Lidocaine(Xylocaine)
II. Anti-cholinergic Agents
- To counter cholinergic agents.- Atropine SulfateSide Effects- SNS
CENTRAL NERVOUS SYSTEM
Brain and Spinal Cord.
I. CELLS
A. NEURONS Basic cells for nerve impulse and conduction.
PROPERTIES
Excitability ability of neuron to be affected by changes in external
environment.
Conductivity ability of neuron to transmit a wave of excitation from one
cell to another.
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Permanent Cell once destroyed not capable of regeneration.
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY
1. Labile
Capable of regeneration.
Epidermal cells, GIT cells, GUT cells, cells of lungs.
2. Stable
Capable of regeneration with limited time, survival period.
Kidney cells, Liver cells, Salivary cells, pancreas.
3. Permanent
Not capable of regeneration.
Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
B. NEUROGLIA
Support and protection of neurons.
TYPES
1. Astrocytes maintains blood brain barrier semi-permeable.
Majority of brain tumors (90%) arises from called
astrocytoma.
2. Oligodendria
3. Microglia
4. Epindymal
SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER
1. Ammonia
Cerebral toxin
Hepatic Encephalopathy (Liver Cirrhosis)
Ascites
Esophageal VaricesEarly Signs of Hepatic Encephalopathy
asterixis (flapping hand tremors).
Late Signs of Hepatic Encephalopathy
Headache
Dizziness
Confusion
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Fetor hepaticus (ammonia like breath)
Decrease LOC
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PATHOGNOMONIC SIGNS
1. PTB low-grade afternoon fever.
2. PNEUMONIA rusty sputum.
3. ASTHMA wheezing on expiration.
4. EMPHYSEMA barrel chest.
5. KAWASAKI SYNDROME strawberry tongue.
6. PERNICIOUS ANEMIA red beefy tongue.
7. DOWN SYNDROME protruding tongue.
8. CHOLERA rice watery stool.9. MALARIA stepladder like fever with chills.
10. TYPHOID rose spots in abdomen.
11. DIPTHERIA pseudo membrane formation
12. MEASLES kopliks spots.
13. SLE butterfly rashes.
14. LIVER CIRRHOSIS spider like varices.
15. LEPROSY lioning face.
16. BULIMIA chipmunk face.
17. APPENDICITIS rebound tenderness.
18. DENGUE petechiae or (+) Hermans sign.
19. MENINGITIS Kernigs sign (leg pain), Brudzinski sign (neck pain).
20. TETANY HYPOCALCEMIA (+) Trousseaus sign/carpopedal
spasm; Chvostek sign (facial spasm).
21. TETANUS risus sardonicus.
22. PANCREATITIS Cullens sign (ecchymosis of umbilicus); (+) Grey
turners spots.
23. PYLORIC STENOSIS olive like mass.
24. PDA machine like murmur.
25. ADDISONS DISEASE bronze like skin pigmentation.26. CUSHINGS SYNDROME moon face appearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVES DISEASE exopthalmus.
28. INTUSSUSCEPTION sausage shaped mass
2. Carbon Monoxide and Lead Poisoning
Can lead to Parkinsons Disease.
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Epilepsy
Treat with ANTIDOTE: Calcium EDTA.
3. Type 1 DM (IDDM)
Causes diabetic ketoacidosis.
And increases breakdown of fats.
And free fatty acids
Resulting to cholesterol and (+) to Ketones (CNS depressant).
Resulting to acetone breath odor/fruity odor.
KUSSMAULS respiration, a rapid shallow respiration.
Which may lead to diabetic coma.
4. Hepatitis
Signs of jaundice (icteric sclerae).
Caused by bilirubin (yellow pigment)
5. Bilirubin
Increase bilirubin in brain (Kernicterus).
Causing irreversible brain damage.
DEMYELINATING DISORDERS
1. ALZHEIMERS DISEASE
Atrophy of brain tissues.
Sign and Symptoms
4 As of Alzheimer
a. Amnesia loss of memory.
b. Agnosia no recognition of inanimate objects.
c. Apraxia no recognition of objects function.
d. Aphasia no speech (nodding).*Expressive aphasia
motor speech center
Brocas Aphasia
*Receptive aphasia
inability to understand spoken words.
Wernickes Aphasia
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Astrocites
Maintains integrity of blood brain barrier.
Oligodendria
Produces myelin sheath in CNS
Act as insulator and facilitates rapid nerve impulse transmission.
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General Knowing Gnostic Area or General Interpretative Area.
DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX.
2. MULTIPLE SCLEROSIS
Chronic intermittent disorder of CNS characterized by white patches of
demyelination in brain and spinal cord.
Characterized by remission and exacerbation.
Women ages 15-35 are prone
Unknown Cause
Slow growing virus
Autoimmune disorders
Pernicious anemia
Myasthenia gravis
Lupus
Hypothyroidism
GBS
Ig G only antibody that pass placental circulation causing passive
immunity.
- short term protection.
- Immediate action.
Ig A present in all bodily secretions (tears, saliva, colostrums).
Ig M acute in inflammation.
Ig E for allergic reaction.
Ig D for chronic inflammation.
* Give palliative or supportive care.
Signs and Symptoms
1. Visual disturbances
blurring of vision (primary) diplopia (double vision)
scotomas (blind spots)
2. Impaired sensation
to touch, pain, pressure, heat and cold.
tingling sensation
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paresthesia
numbness
3. Mood swings
euphoria (sense of well being)
4. Impaired motor function
weakness
spasticity
paralysis
5. Impaired cerebral function
scanning speech
TRIAD SIGNS OF MS
Ataxia
(Unsteady gait, (+) Rombergs test)
Intentional tremors Nystagmus
6. Urinary retention/incontinence
7. Constipation
8. Decrease sexual capacity
DIAGNOSTIC PROCEDURE
CSF analysis (increase in IgG and Protein).
MRI (reveals site and extent of demyelination). (+) Lhermittes sign a continuous and increase contraction of spinal
column.
NURSING MANAGEMENT
1. Administer medications as ordered
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CHARCOTSTRIAD
IAN
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a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute
exacerbation to reduce edema at site
of demyelination to prevent paralysis.
b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) muscle
relaxants.
c. Interferons alter immune response.
d. Immunosupresants
2. Maintain side rails to prevent injury related to falls.
3. Institute stress management techniques.
a. Deep breathing exercises
b.Yoga
4. Increase fluid intake and increase fiber to prevent constipation.
5. Catheterization to prevent retention.
a. Diuretics
b. Bethanicol Chloride (Urecholine)
Nursing Management
Only given subcutaneous.
Monitor side effects bronchospasm and wheezing.
Monitor breath sounds 1 hour after subcutaneous administration.
c. For Urinary Incontinence
Anti spasmodic agent
a. Prophantheline Bromide (Promanthene)
Acid ash diet like cranberry juice, plums, prunes, pineapple,
vitamin C and orange.
To acidify urine and prevent bacterial multiplication.
COMMON CAUSE OF UTI
Female
short urethra (3-5 cm, 1-1 inches) poor perineal hygiene
vaginal environment is moist
Nursing Management
avoid bubble bath (can alter Ph of vagina).
avoid use of tissue papers
avoid using talcum powder and perfume.
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Male
Urethra (20 cm, 8 inches)
urinate after intercourse
MICROGLIA
stationary cells that carry on phagocytosis (engulfing of bacteria
or cellular debris, eating), pinocytosis (cell drinking).
MACROPHAGE ORGAN
Microglia
Monocytes
Kupffers cells
Histiocytes
Alveolar
Macrophage
Brain
Blood
Kidney
Skin
Lung
EPINDYMAL CELLS
Secretes a glue called chemo attractants that concentrate the
bacteria.
COMPOSITION OF BRAIN
80% brain mass
10% blood
10% CSF
I. Brain Mass
PARTS OF THE BRAIN
1. CEREBRUM
largest part
composed of the Right Cerebral Hemisphere and Left Cerebral
Hemisphere enclosed in the Corpus Callosum.
Functions of Cerebrum
integrative sensory
motor
Lobes of Cerebrum
1. Frontal
higher cortical thinking
controls personality
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controls motor activity
Brocas Area (motor speech area) when damaged results to
garbled speech.
2. Temporal
hearing
short term memory
3. Parietal
for appreciation
discrimination of sensory impulses to pain, touch, pressure, heat,
cold, numbness.
4. Occipital
for vision
Insula (Island of Reil)
visceral function activities of internal organ like gastric motility.
Limbic System (Rhinencephalon)
controls smell and if damaged results to Anosmia (absence of
smell).
controls libido
controls long term memory
2. BASAL GAGLIA
areas of grey matter located deep within each cerebral
hemisphere.
release dopamine (controls gross voluntary movement.
NEURO
TRANSMITTER
DECREASE INCREASE
Acethylcholine Myasthenia Gravis Bi-polar Disorder
Dopamine Parkinsons Disease Schizophrenia
3. MIDBRAIN/ MESENCEPHALON
acts as relay station for sight and hearing.
size of pupil is 2 3 mm.
equal size of pupil is isocoria.
unequal size of pupil is anisocoria.
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hearing acuity is 30 40 dB.
positive PERRLA
4. INTERBRAIN/ DIENCEPHALON
Parts of Diencephalon
A. Thalamus
acts as relay station for sensation.
B. Hypothalamus
controls temperature (thermoregulatory center).
controls blood pressure
controls thirst
appetite/satiety
sleep and wakefulness
controls some emotional responses like fear, anxiety and
excitement.
controls pituitary functions
androgenic hormones promotes secondary sex characteristics.
early sign for males are testicular and penile enlargement
late sign is deepening of voice.
early sign for females telarche and late sign is menarche.
5. BRAIN STEM
located at lowest part of brain
Parts of Brain Stem
1. Pons
pneumotaxic center controls the rate, rhythm and depth of
respiration.
2. Medulla Oblongata
controls respiration, heart rate, swallowing, vomiting, hiccup,vasomotor center (dilation and constriction of bronchioles).
3. Cerebellum
smallest part of the brain.
lesser brain.
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controls balance, equilibrium, posture and gait.
INTRA CRANIAL PRESSURE
Monroe Kellie Hypothesis
Skull is a closed container
Any alteration or increase in one of the intracranial components
Increase intra-cranial pressure
(normal ICP is 0 15 mmHg)
Cervical 1 also known as ATLAS.
Cervical 2 also known as AXIS.
Foramen Magnum
Medulla Oblongata
Brain Herniation
Increase intra cranial pressure
* Alternate hot and cold compress to prevent HEMATOMA
CSF cushions brain (shock absorber)
Obstruction of flow of CSF will lead to enlargement of skull posteriorly called
hydrocephalus.
Early closure of posterior fontanels causes posterior enlargement of skull in
hydrocephalus.
NEUROLOGIC DISORDERS
INCREASE INTRACRANIAL PRESSURE increase in intra-cranial bulk
brought about by an increase in one of the 3 major intra cranial components.
Causes:
head trauma/injury localized abscess
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cerebral edema
hemorrhage
inflammatory condition (stroke)
hydrocephalus
tumor (rarely)
Signs and Symptoms (Early)
decrease LOC
restlessness/agitation
irritability
lethargy/stupor
coma
Signs and Symptoms (Late)
changes in vital signs
blood pressure (systolic blood pressure increases but diastolic
remains the same).
widening of pulse pressure is neurologic in nature (if narrow
cardiac in nature).
heart rate decrease
respiratory rate decrease
temperature increase directly proportional to blood pressure.
projective vomiting
headache
papilledema (edema of optic disc)
abnormal posturing
decorticate posturing (damage to cortex and spinal cord).
decerebrate posturing (damage to upper brain stem that includes
pons, cerebellum and midbrain).
unilateral dilation of pupils called uncal herniation
bilateral dilation of pupils called tentorial herniation
resulting to mild headache
possible seizure activity
Nursing Management1. Maintain patent and adequate ventilation by:
a. Prevention of hypoxia and hypercarbia
Early signs of hypoxia
restlessness
agitation
tachycardia
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monitor strictly input and output every 1 hour notify physician if output is less
30 cc/hr.
administered via side drip
regulated fast drip to prevent crystal formation.
b. Loop diuretic (Lasix, Furosemide)
Drug of choice for CHF (pulmonary edema)
Loop of Henle in kidneys.
Nursing Management
Monitor vital signs especially BP (hypotension).
monitor strictly input and output every 1 hour notify physician if
output is less 30 cc/hr.
administered IV push or oral.
given early morning
immediate effect of 10 15 minutes.
maximum effect of 6 hours.
c. Corticosteroids
Dexamethasone (Decadron)
Hydrocortisone
Prednisone (to reduce edema that may lead to increase ICP)
Mild Analgesics (Codeine Sulfate for respiratory depression)
Anti Convulsants (Dilantin, Phenytoin)
*CONGESTIVE HEART FAILURE
Signs and Symptoms
dyspnea
orthopnea
paroxysmal nocturnal dyspnea
productive cough
frothy salivation cyanosis
rales/crackles
bronchial wheezing
pulsus alternans
anorexia and general body malaise
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PMI (point of maximum impulse/apical pulse rate) is displaced
laterally
S3 (ventricular gallop)
Predisposing Factors/Mitral Valve
RHD
Aging
TREATMENT
Morphine Sulfate
Aminophelline
DigoxinDiuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (Venous congestion)
Signs and Symptoms
jugular vein distention (neck)
ascites
pitting edema
weight gain
hepatosplenomegaly
jaundice
pruritus
esophageal varices
anorexia and general body malaise
Signs and Symptoms of Lasix in terms of electrolyte imbalances1. Hypokalemia
decrease potassium level
normal value is 3.4 5.5 meq/L
Sign and Symptoms
weakness and fatigue
constipation
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positive U wave on ECG tracing
Nursing Management
administer potassium supplements as ordered (Kalium Durule, Oral
Potassium Chloride)
increase intake of foods rich in potassium
FRUITS VEGETABLES
Apple
Banana
Cantalope
Oranges
Asparagus
Brocolli
Carrots
Spinach
2. Hypocalcemia/ Tetany
decrease calcium level
normal value is 8.5 11 mg/100 ml
Signs and Symptoms
tingling sensation
paresthesia
numbness
(+) Trousseaus sign/ Carpopedal spasm
(+) Chvosteks sign
Complications
Arrhythmia
Seizures
Nursing Management
Calcium Gluconate per IV slowly as ordered
* Calcium Gluconate toxicity results to SEIZURE
Magnesium Sulfate
Magnesium Sulfate toxicity
S/S
BP
Urine output DECREASE
Respiratory rate
Patellar relfex absent
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a. Allopurinol (Zyloprim)
Drug of choice for gout.
Mechanism of action : inhibits synthesis of uric acid.
b. Colchecine
Acute gout
Mechanism of action: promotes excretion of uric acid.
* KIDNEY STONES
Signs and Symptoms
renal colic
Cool moist skin
Nursing Management
force fluids
administer medications as ordered
a. Narcotic Analgesic
Morphine Sulfate
ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors.
b. Allopurinol (Zyloprim)
Side Effects
Respiratory depression (check for RR)
PARKINSONS DISEASE/ PARKINSONISM
Chronic progressive disorder of CNS characterized by
degeneration ofdopamine producing cells in the SUBSTANCIA
NIGRA of the midbrain and basal ganglia.
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Multiple losscausessuicide
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
2. Arteriosclerosis
3. Hypoxia
4. Encephalitis
5. Increase dosage of the following drugs:
a. Reserpine(Serpasil)
b. Methyldopa(Aldomet) AntihypertensiveS
c. Haloperidol(Haldol)
d. Phenothiazine AntipsychoticS
SIDE EFFECTS RESERPINE Major depression leading to suicide
Aloneness
Loss of spouse Loss of Job
direct approach towards the client
close surveillance is a nursing priority
time to commit suicide is on weekends early morning
Signs and Symptoms for Parkinsons
pill rolling tremors of extremities especially the hands.
bradykinesia (slowness of movement) rigidity (cogwheel type)
stooped posture
shuffling and propulsive gait
over fatigue
mask like facial expression with decrease blinking of the eyes.
difficulty rising from sitting position.
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Monotone type speech
mood lability (in state of depression)
increase salivation (drooling type)
autonomic changes
a. increase sweating
b. increase lacrimation
c. seborrhea
d. constipation
e. decrease sexual capacity
Nursing Management
1. Administer medications as ordered
Anti Parkinsonian agents
Levodopa (L-dopa) short acting
Amantadine Hydrochloride (Symmetrel)
Carbidopa (Sinemet)
Mechanism of Action
increase level of dopamine
Side Effects
GIT irritation (should be taken with meals
orthostatic hypotension
arrhythmia
hallucinations
Contraindications
clients with narrow angle closure glaucoma
clients taking MAOIs (no foods with triptophan and thiamine)
urine and stool may be darkened
no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of
Levodopa
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid
Hydrazide
Anti Cholinergic Agents (ARTANE and COGENTIN) - to relieve tremors
Mechanism of Action
inhibits action of acethylcholine
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Side Effects
SNS
Anti Histamine (Dipenhydramine Hydrochloride)
Side Effects
Adult: drowsiness
Children: CNS excitement (hyperactivity) because blood brain barrier is not yet
fully developed.
Dopamine Agonist - relieves tremor rigidity
Bromocriptene Hydrochloride (Parlodel)
Side Effects
Respiratory depression
2. Maintain side rails to prevent injury
3. Prevent complications of immobility
4. Decrease protein in morning and increase protein in afternoon to
induce sleep
5. Encourage increase fluid intake and fiber.
6. Assist/supervise in ambulation
7. Assist in Stereotaxic Thalamotomy
MAGIC 2s IN DRUG MONITORING
DRUG NORMAL
RANGE
TOXICI
TYLEVEL
INDICATI
ON
CLASSIFICATI
ON
Digoxin/ Lanoxin(Increase force of
cardiac output)
.5 1.5 meq/L 2 CHF CardiacGlycoside
Lithium/ Lithane (Decrease levelof
Ach/NE/Serotonin)
.6 1.2 meq/L 2 Bipolar Anti-ManicAgents
Aminophylline(Dilates bronchialtree)
10 19mg/100 ml
20 COPD Bronchodilators
Dilantin/Phenytoin
10 19mg/100 ml
20 Seizures Anti-Convulsant
Acetaminophen/Tylenol
10 30mg/100 ml
200 OsteoArthritis
Non-narcoticAnalgesic
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1. Digitalis Toxicity
Signs and Symptoms
nausea and vomiting
diarrhea
confusion
photophobia
changes in color perception (yellowish spots)
Antidote: Digibind
2. Lithium Toxicity
Signs and Symptoms
anorexia
nausea and vomiting
diarrhea
dehydration causing fine tremors
hypothyroidism
Nursing Management
force fluids
increase sodium intake to 4 10 g% daily
3. Aminophylline Toxicity
Signs and Symptoms
tachycardia
palpitations
CNS excitement (tremors, irritability, agitation and restlessness)Nursing Management
only mixed with plain NSS or 0.9 NaCl to prevent development of
crystals or precipitate.
administered sandwich method
avoid taking alcohol because it can lead to severe CNS depression
avoid caffeine
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4. Dilantin Toxicity
Signs and Symptoms
gingival hyperplasia (swollen gums)
hairy tongue
ataxia
nystagmus
Nursing Management
provide oral care
massage gums
5. Acetaminophen Toxicity
Signs and Symptoms
hepatotoxicity (monitor for liver enzymes)
SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
nephrotoxicity monitor BUN (10 20) and Creatinine (.8 1)
hypoglycemia
Tremors, tachycardia
Irritability
Restlessness
Extreme fatigue
Diaphoresis, depression
Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.
MYASTHENIA GRAVIS
neuromuscular disorder characterized by a disturbance in the
transmission of impulses from nerve to muscle cells at the
neuromuscular junction leading to descending muscle weakness.
Incidence rate: women 20 40 years oldPredisposing factors
unknown
autoimmune: it involves release of cholinesterase an enzyme that
destroys Ach.
Signs and Symptoms
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initial sign is ptosis a clinical parameter to determine ptosis is
palpebral fissure.
diplipia
mask like facial expression
dysphagia
hoarseness of voice
respiratory muscle weakness that may lead to respiratory arrest
extreme muscle weakness especially during exertion and morning
Diagnostic Procedure
Tensilon test (Edrophonium Hydrochloride) provides temporary
relief of signs and symptoms for about 5 10 minutes and a
maximum of15 minutes.
if there is no effect there is damage to occipital lobe and
midbrain and is negative for M.G.
Nursing Management
1. airway
2. aspiration maintain patent airway and adequate ventilation
3. mmobility
* assist in mechanical ventilation and monitor pulmonary function test
* monitor strictly vital signs, input and output and neuro check
* monitor strength or motor grading scale
4. maintain side rails to prevent injury related to falls
5. institute NGT feeding
6. administer medications as ordered
a. Cholinergic (Mestinon)
b. Anti Cholenisterase (Neostegmin)
Mechanism of Action
increase level of Ach
Side Effects PNS
Cortocosteroids suppress immune response
monitor for 2 types of crisis:
MYASTHENIC CRISIS CHOLINERGIC CRISIS
Causes:- under medication- stress
Cause:- over medication
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- infectionSigns and Symptoms- The client is unable to see,swallow, speak, breathe
Treatment- administer cholinergic agents asordered
Signs and Symptoms- PNS
Treatment- Administer anti cholinergic agents(Atropine Sulfate)
7. Assist in surgical procedure known as thymectomy because it is believed
that the thymus gland is responsible for M.G.
8. Assist in plasma paresis and removing auto immune anti bodies
9. Prevent complications
INFLAMMATORY CONDITIONS OF THE BRAIN
MENINGITIS
Meninges
3 fold membrane that covers brain and spinal cord.
for support and protection
for nourishment
blood supply
LAYERS OF THE MENINGES
1. Dura matter outer layer2. Arachnoid middle layer
3. Pia matter inner layer
subdural space between the dura and arachnoid
subarachnoid space between the arachnoid and pia, CSF
aspiration is done.
A. Etiology
1. Meningococcus most dangerous
2. Pneumococcus
3. Streptococcus - causes adult meningitis
4. Hemophilus Influenzae causes pediatric meningitis
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B. Mode of transmission
airborne transmission (droplet nuclei)
C. Signs and Symptoms
headache
photophobia
projectile vomiting
fever, chills, anorexia, general body malaise and weight loss
Possible increase in ICP and seizure activity
Abnormal posturing (decorticate and decerebrate)
Signs of meningeal irritation
a. Nuchal rigidity or stiff neck
b. Opisthotonus (arching of back)
c. (+) Kernigs sign (leg pain)
d. (+) Brudzinski sign (neck pain)
D. Diagnostic Procedures
Lumbar puncture: a hollow spinal needle is inserted in the
subarachnoid space between the L3 L4 to L5.
Nursing Management for LP
Before Lumbar Puncture1. Secure informed consent and explain procedure.2. Empty bladder and bowel to promote comfort.
3. Encourage to arch back to clearly visualize L3-L4.Post Lumbar Puncture1. Place flat on bed 12 24 o
2. Force fluids3. Check punctured site for any discoloration, drainage and leakage to tissues.4. Assess for movement and sensation of extremities.CSF analysis reveals1. Increase CHON and WBC2. Decrease glucose
3. Increase CSF opening pressure (normal pressure is 50 100 mmHg)4. (+) cultured microorganism (confirms meningitis)
CBC reveals
1. Increase wbc
E. Nursing Management
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1. Enforce complete bed rest
2. Administer medications as ordered
a. Broad spectrum antibiotics (Penicillin, Tetracycline)
b. Mild analgesics
c. Anti pyretics
3. Institute strict respiratory isolation 24 hours after initiation of anti biotic
therapy
4. Elevate head 30-45o
5. Monitor strictly V/S, input and output and neuro check
6. Institute measures to prevent increase ICP and seizure.
7. Provide a comfortable and darkened environment.
8. Maintain fluid and electrolyte balance.
9. Provide client health care and discharge planning concerning:
a. Maintain good diet of increase CHO, CHON, calories with small
frequent feedings.
b. Prevent complications
most feared is hydrocephalus
hearing loss/nerve deafness is second complication
consult audiologist
c. Rehabilitation for neurological deficit
mental retardation
delayed psychomotor development
CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)
a partial or complete disruption in the brains blood supply.
2 most common cerebral artery affected by stroke
a. Mid Cerebral Artery
b. Internal Cerebral Artery the 2 largest artery
A. Incidence Rate men are 2-3 times high risk
B. Predisposing Factors
thrombus (attached)
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embolus (detached and most dangerous because it can go to the
lungs and cause pulmonary embolism or the brain and cause
cerebral embolism.
Signs and Symptoms of Pulmonary Embolism
Sudden sharp chest pain
Unexplained dyspnea
Tachycardia
Palpitations
Diaphoresis
Mild restlessness
Signs and Symptoms of Cerebral Embolism
Headache and dizziness
Confusion
Restlessness
Decrease LOC
Fat embolism is the most feared complications after femur fracture.
Yellow bone marrow are produced from the medullary cavity of the long bones
and produces fat cells.
If there is bone fracture there is hemorrhage and there would be escape of the
fat cells in the circulation.
Compartment syndrome (compression of arteries and nerves)
C. Risk Factors
1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis,
Valvular Heart Disease, Post Cardiac Surgery (mitral valve replacement)
2. Lifestyle (smoking), sedentary lifestyle
3. Obesity (increase 20% ideal body weight)
4. Hyperlipidemia more on genetics/genes that binds to cholesterol
5. Type A personality
a. deadline driven
b. can do multiple tasks
c. usually fells guilty when not doing anything
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6. Related to diet: increase intake of saturated fats like whole milk
7. Related stress physical and emotional
8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids)
leading to atherosclerosis that will lead to hypertension and eventually CVA.
D. Signs and Symptoms
dependent on stages of development
1. TIA
Initial sign of stroke or warning sign
Signs and Symptoms
headache and dizziness
tinnitus
visual and speech disturbances
paresis (plegia)
possible increase ICP
2. Stroke in evolution
progression of signs and symptoms of stroke
3. Complete stroke
resolution phase characterized by:
Signs and Symptoms
headache and dizziness
Cheyne Stokes Respiration
anorexia, nausea and vomiting
dysphagia
(+) Kernigs sign and Brudzinski sign which may lead to
hemorrhagic stroke
focal neurological deficits
a. phlegia
b. aphasiac. dysarthria (inability to articulate words)
d. alexia (difficulty reading)
e. agraphia (difficulty writing)
f. homonymous hemianopsia (loss of half of visual field)
E. Diagnostic Procedure
1. CT Scan reveals brain lesions
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Side Effect: Allergic Reaction
Urokinase
Tissue Plasminogen Activating Factor
Side Effect: Chest Pain
f. Anti Coagulants
Heparin (short acting)
check for partial thromboplastin time if prolonged there is a risk for bleeding.
give Protamine Sulfate
Comadin/ Warfarin (long acting)
give simultaneously because Coumadin will take effect after 3 days
check for prothrombin time if prolonged there is a risk for bleeding
give Vit. K (Aqua Mephyton)
g. Anti Platelet
PASA (Aspirin)
Contraindicated for dengue, ulcer and unknown cause of
headache because it may potentiate bleeding11. Provide client health teachings and discharge planning concerning
a. avoidance of modifiable risk factors (diet, exercise, smoking)
b. prevent complication (subarachnoid hemorrhage is the most feared
complication)
c. dietary modification (decrease salt, saturated fats and caffeine)
d. importance of follow up care
GUILLAIN BARRE SYNDROME
a disorder of the CNS characterized by bilateral symmetrical polyneuritis
leading to ascending muscle paralysis.
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A. Predisposing Factors
1. Autoimmune
2. Antecedent viral infections such as LRT infections
B. Signs and Symptoms
1. Clumsiness (initial sign)
2. Dysphagia
3. Ascending muscle weakness leading to paralysis
4. Decreased of diminished deep tendon reflex
5. Alternate hypotension to hypertension
** ARRYTHMIA (most feared complication)
6. Autonomic symptoms that includes
a. increase salivation
b. increase sweating
c. constipation
C. Diagnostic Procedures
1. CSF analysis reveals increase in IgG and protein
D. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. monitor pulmonary function test
2. Monitor strictly the following
a. vital signs
b. intake and output
c. neuro check
d. ECG
3. Maintain side rails to prevent injury related to fall
4. Prevent complications of immobility by turning the client every 2 hours5. Institute NGT feeding to prevent aspiration
6. Assist in passive ROM exercise
7. Administer medications as ordered
a. Corticosteroids suppress immune response
b. Anti Cholinergic Agents Atrophine Sulfate
c. Anti Arrythmic Agents
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Lidocaine, Zylocaine
Bretylium blocks release of norepinephrine to prevent increase
of BP
8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-
bodies)
9. Prevent complications
a. Arrythmia
b. Paralysis or respiratory muscles/Respiratory arrest
* Sengstaken Blakemore Tube
for liver cirrhosis
to decompress bleeding esophageal verices (prepare scissor to cut
tube incase of difficulty in breathing to release air in the balloon
for hemodialysis prepare bulldog clips to prevent air embolism.
CONVULSIVE DISORDER/ CONVULSION
disorder of CNS characterized by paroxysmal seizure with or
without loss of consciousness abnormal motor activity alternation in
sensation and perception and changes in behavior.
Seizure first convulsive attack
Epilepsy second or series of attacks
Febrile seizure normal in children age below 5 years
A. Predisposing Factors
1. Head injury due to birth trauma
2. Genetics
3. Presence of brain tumor
4. Toxicity froma. lead
b carbon monoxide
5. Nutritional and Metabolic deficiencies
6. Physical and emotional stress
7. Sudden withdrawal to anti convulsant drug is predisposing factor for status
epilepticus (drug of choice is Diazepam, Valium)
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B. Signs and Symptoms
Dependent on stages of development or types of seizure
I. Generalized Seizure
1. Grand mal Seizure (tonic-clonic seizure)
a. Signs or aura with auditory, olfactory, visual, tactile, sensory
experience
b. Epileptic cry is characterized by fall and loss of consciousness for 3
5 minutes
c. Tonic contractions - direct symmetrical extension of extremities
Clonic contractions - contraction of extremities
d. Post ictal sleep unresponsive sleep
2. Petit mal Seizure absence of seizure common among pediatric clients
characterized by
a. blank stare
b. decrease blinking of eyes
c. twitching of mouth
d. loss of consciousness (5 10 seconds)
II. Partial or Localized Seizure
1. Jacksonian Seizure (focal seizure)
Characterized by tingling and jerky movement of index finger and
thumb that spreads to the shoulder and other side of the body.
2. Psychomotor Seizure (focal motor seizure)
a. automatism stereotype repetitive and non propulsive behavior
b. clouding of consciousness not in contact with environment
c. mild hallucinatory sensory experience
III. Status Epilepticus A continuous uninterrupted seizure activity, if left untreated can
lead to hyperpyrexia and lead to coma and eventually death.
Drug of choice: Diazepam, Valium and Glucose
C. Diagnostic Procedures
1. CT Scan reveals brain lesions
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Survey of mental status and speech
a. LOC
b. Test of memory
Levels of orientation
Cranial nerve assessment
Sensory nerve assessment
Motor nerve assessment
Deep tendon reflex
Autonimics
Cerebellar test
a, Rombergs test 2 nurses, positive for ataxia
b. Finger to nose test positive result mean dimetria
(inability of body to stop movement at
desired point)
c. Alternate supination and pronation positive result mean
dimetria
I. LEVEL OF CONSCIOUSNESS
1. Conscious - awake
2. Lethargy lethargic (drowsy, sleepy, obtunded)
3. Stupor
stuporous (awakened by vigorous stimulation) generalized body weakness
decrease body reflex
4. Coma
comatose
light coma (positive to all forms of painful stimulus)
deep coma (negative to all forms of painful stimulus)
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DIFFERENT PAINFUL STIMULATION
1. Deep sternal stimulation/ deep sternal pressure
2. Orbital pressure
3. Pressure on great toes
4. Corneal or blinking reflex
Conscious client use a wisp of cotton
Unconscious client place 1 drop of saline solution
II. TEST OF MEMORY1. Short term memory
ask most recent activity
positive result mean anterograde amnesia and damage to temporal
lobe
2. Long term memory
ask for birthday and validate on profile sheet
positive result mean retrograde amnesia and damage to limbic
system
consider educational background
III. LEVELS OF ORIENTATION
1. Time first asked
2. Person second asked
3. Place third asked
CRANIAL NERVES
CRANIAL NERVES FUNCTION
I. OLFACTORY SII. OPTIC SIII OCCULOMOTOR MIV. TROCHLEAR M
(Smallest)V. TRIGEMINAL B
(Largest)VI. ABDUCENSE M
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VII. FACIAL BVIII. ACOUSTIC SIX.
GLOSSOPHARYNGEAL
B
X. VAGUS B
(Longest)XI. SPINAL
ACCESSORY
M
XII. HYPOGLOSSAL M
CRANIAL NERVE I: OLFACTORY
sensory function for smell
Material Used dont use alcohol, ammonia, perfume because it is irritating and
highly diffusible.
use coffee granules, vinegar, bar of soap, cigarette
Procedure
test each nostril by occluding each nostril
Abnormal Findings
1. Hyposnia decrease sensitivity to smell
2. Dysosmia distorted sense of smell
3. Anosmia absence of smell
Indicative of
1. head injury damaging the cribriform plate of ethmoid bone where olfactory
cells are located
2. may indicate inflammatory conditions (sinusitis)
CRANIAL NERVE II: OPTIC
sensory function for vision or sight
Functions
1. Test visual acuity or central vision or distance
use Snellens Chart Snellens Alphabet chart: for literate clients
Snellens E chart: for illiterate clients
Snellens Animal chart: for pediatric clients
normal visual acuity 20/20
numerator is constant, it is the distance of person from the chart (6
7 m, 20 feet)
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denominator changes, indicates distance by which the person
normally can see letter in the chart.
- 20/200 indicates blindness
20/20 visual acuity if client is able to read letters above the red line.
2. Test of visual field or peripheral vision
a. Superiorly
b. Bitemporaly
c. Nasally
d. Inferiorly
COMMON VISUAL DISORDERS
1. Glaucoma
increase IOP
normal IOP is 12 21 mmHg
preventable but not curable
A. Predisposing Factors
Common among 40 years old and above
Hereditary
Hypertension
Obesity
B. Signs and Symptoms
1. Loss of peripheral vision
pathognomonic sign is tunnel vision
2. Headache, nausea, vomiting, eye pain (halos around light)
steamy cornea
may lead to blindness
C. Diagnostic Procedures1. Tonometry
2. Perimetry
3. Gonioscopy
D. Treatment
1. Miotics constricts pupil
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a. Pilocarpine Sodium, Carbachol
2. Epinephrine eyedrops decrease formation of aqueous humor
3. Carbonic Anhydrase Inhibitors
a. Acetazolamide (Diamox) promotes increase outflow of aqueous
humor or drainage
4. Timoptics (Timolol Maleate)
E. Surgical Procedures
1. TRABECULECTOMY (Peripheral Indectomy) drain aqueous humor
2. Cataract
Decrease opacity of lens
A. Predisposing Factor
1. Aging 65 years and above
2. Related to congenital
3. Diabetes Mellitus
4. Prolonged exposure to UV rays
B. Signs and Symptoms
1. Loss of central vision
C. Pathognomonic Signs
1. Blurring or hazy vision
2. Milky white appearance at center of pupils
3. Decrease perception to colors
Complication is blindness
D. Diagnostic Procedure1. Opthalmoscopic exam
E. Treatment
1. Mydriatics (Mydriacyl) constricts pupils
2. Cyclopegics (Cyclogyl) paralyses cilliary muscle
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F. Surgical Procedure
Extra Intra
Capsular Capsular
Cataract Cataract
Lens Lens
Extraction Extraction
- Partial removal - Total removal of cataract with its surrounding
capsules
Most feared complication post op is RETINAL DETACHMENT
3. Retinal Detachment
Separation of epithelial surface of retina
A. Predisposing Factors
1. Post Lens Extraction
2. Myopia (near sightedness)
B. Signs and Symptoms
1. Curtain veil like vision
2. Floaters
C. Surgical Procedures
1. Scleral Buckling
2. Cryosurgery cold application
3. Diathermy heat application
4. Macular Degeneration
Degeneration of the macula lutea (yellowish spot at the center of
retina)
A. Signs and Symptoms
1. Black Spots
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CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS
Controls or innervates the movement of extrinsic ocular muscle
(EOM)
6 muscles
Superior Rectus Superior Oblique
Lateral Rectus Medial Rectus
Inferior Oblique Inferior Rectus
trochlear controls superior oblique
abducens controls lateral rectus
oculomotor controls the 4 remaining EOM
Oculomotor
controls the size and response of pupil
normal pupil size is 2 3 mm
equal size of pupil: Isocoria
Unequal size of pupil: Anisocoria Normal response: positive PERRLA
CRANIAL NERVE V: TRIGEMINAL
largest cranial nerve
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consists of ophthalmic, maxillary, mandibular
sensory: controls sensation of face, mucous membrane, teeth, soft
palate and corneal reflex)
motor: controls the muscle of mastication or chewing
damage to CN V leads to trigeminal neuralgia/thickdolorum
medication: Carbamezapine(Tegretol)
CRANIAL NERVE VII: FACIAL
Sensory: controls taste, anterior 2/3 of tongue
pinch of sugar and cotton applicator placed on tip of tongue
Motor: controls muscle of facial expression
instruct client to smile, frown and if results are negative there is
facial paralysis or Bells Palsy and the primary cause is forcep
delivery.
CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR
Controls balance particularly kinesthesia or position sense, refers
to movement and orientation of the body in space.
Parts of the Ear
1. Outer Ear
Pinna
Eardrum
2. Middle Ear
Hammer Malleus
Anvil Incus
Stirrup Stapes
3. Inner Ear
Vestibule: Meineres Disease
Cochlea Mastoid Cells
Endolymph and Perilymph
COCHLEA: controls hearing, contains the Organ of Corti (the true organ of
hearing)
Let client repeat words uttered
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CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE
Glosopharyngeal: controls taste, posterior 1/3 of tongue
Vagus: controls gag reflex
Uvula should be midline and if not indicative of damage to cerebral
hemisphere
Effects of vagal stimulation is PNS
CRANIAL NERVE XI: SPINAL ACCESSORY
Innervates with sternocleidomastoid (neck) and trapezius
(shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL
Controls the movement of tongue
Let client protrude tongue and it should be midline and if unable to
do indicative of damage to cerebral hemisphere and/or has short
frenulum.
ENDOCRINE SYSTEM
Overview of the structures and functions
1. Pituitary Gland (Hypophysis Cerebri)
o Located at base of brain particularly at sella turcica
o Master gland or master clock
o Controls all metabolic function of body
PARTS OF THE PITUITARY GLAND1. Anterior Pituitary Gland
o called as adenohypophysis
2. Posterior Pituitary Gland
o called as neurohypophysis
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o secretes hormones oxytocin -promotes uterine contractions
preventing bleeding/ hemorrhage
o administrate oxytocin immediately after delivery to prevent
uterine atony.
o initiates milk let down reflex with help of hormone prolactin
2. Antidiuretic Hormone
o Pitressin (Vasopressin)
o Function: prevents urination thereby conserving water
o Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic
Hormone
DIABETES INSIPIDUS
o Decrease production of anti diuretic hormone
A. Predisposing Factoro Related to pituitary surgery
o Trauma
o Inflammation
o Presence of tumor
B. Signs and Symptoms
1. Polyuria2. Signs of dehydration
a. Adult: thirst
b. Agitation
c. Poor Skin turgor
d. Dry mucous membrane
3. Weakness and fatigue
4. Hypotension
5. Weight loss
6. If left untreated results to hypovolemic shock (sign is anuria)
C. Diagnostic Procedures
1. Urine Specific Gravity
o Normal value: 1.015 1.030
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D. Nursing Management
1. Restrict fluid
2. Administer medications as ordered
a. Loop diuretics (Lasix)
b. Osmotic diuretics (Mannitol)
3. Monitor strictly vital signs, intake and output and neuro check
4. Weigh patient daily and assess for pitting edema
5. Provide meticulous skin care
6. Prevent complications
ANTERIOR PITUITARY GLAND
o also called ADENOHYPOPHYSIS secretes
1. Growth hormones (somatotropic hormone)
o Promotes elongation of long bones
o Hyposecretion of GH among children results to Dwarfism
o Hypersecretion of GH results to Gigantism
o Hypersecretion of GH among adults results to Acromegaly
(square face)
o Drug of choice: Ocreotide (Sandostatin)
2. Melanocyte Stimulating hormone
o for skin pigmentation
o Hyposecretion of MSH results to Albinism
o Most feared complications of albinism
a. Lead to blindness due to severe photophobia
b. Prone to skin cancer
o Hypersecretion of MSH results to Vitiligo
3. Adrenochorticotropic hormone (ACTH)
o promotes development of adrenal cortex
4. Lactogenic homone (Prolactin)
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o promotes development of mammary gland
o with help of oxytocin it initiates milk let down reflex
5. Leutinizing hormone
o secretes estrogen
6. Follicle stimulating hormone
o secretes progesterone
PINEAL GLAND
o secretes melatonin
o inhibits LH secretion
o it controls/regulates circadian rhythm (body clock)
THYROID GLAND
o located anterior to the neck
3 Hormones secreted
1. T3 (Tri iodothyronine)- 3 molecules of iodine (more potent)2. T4 (tetra iodothyronine, Thyroxine)
o T3 and T4 are metabolic or calorigenic hormone
o promotes cerebration (thinking)
3. Thyrocalcitonin antagonizes the effects of parathormone to
promote calcium resorption.
HYPOTHYROIDISM
o all are decrease except weight and menstruation
o memory impairment
Signs and Symptoms
o there is loss of appetite but there is weight gain
o menorrhagia
o cold intolerance
o constipation
HYPERTHYROIDISM
o all are increase except weight and menstruation
Signs and Symptoms
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o increase appetite but there is weight loss
o amenorrhea
o exophthalmos
THYROID DISORDERS
SIMPLE GOITER
o enlargement of thyroid gland due to iodine deficiency
A. Predisposing Factors
1. Goiter belt area
a. places far from sea
b. Mountainous regions
2. Increase intake of goitrogenic foods
o contains pro-goitrin an anti thyroid agent that has no iodine.
o cabbage, turnips, radish, strawberry, carrots, sweet potato,
broccoli, all nutso soil erosion washes away iodine
o goitrogenic drugs
a. Anti Thyroid Agent Prophylthiuracil (PTU)
b. Lithium Carbonate
c. PASA (Aspirin)
d. Cobalt
e. Phenylbutazones (NSAIDs)
- if goiter is caused by
B. Signs and Symptoms
1. Enlarged thyroid gland
2. Mild dysphagia
3. Mild restlessness
C. Diagnostic Procedures
1. Serum T3 and T4 reveals normal or below normal
2. Thyroid Scan reveals enlarged thyroid gland.
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3. Serum Thyroid Stimulating Hormone (TSH) is increased (confirmatory
diagnostic test)
D. Nursing Management
1. Enforce complete bed rest
2. Administer medications as ordered
a. Lugols Solution/SSKI ( Saturated Solution of Potassium Iodine)
o color purple or violet and administered via straw to prevent staining
of teeth.
o
4 Medications to be taken via straw: Lugols, Iron, Tetracycline,Nitrofurantoin (drug of choice for pyelonephritis)
b. Thyroid Hormones
o Levothyroxine (Synthroid)
o Liothyronine (Cytomel)
o Thyroid Extracts
Nursing Management when giving Thyroid Hormones
1. Instruct client to take in the morning to prevent insomnia
2. Monitor vital signs especially heart rate because drug causes
tachycardia and palpitations
3. Monitor side effects
o insomnia
o tachycardia and palpitations
o hypertension
o heat intolerance
4. Increase dietary intake of foods rich in iodine
o seaweeds
o seafoods like oyster, crabs, clams and lobster but not shrimps
because it contains lesser amount of iodine.
o iodized salt, best taken raw because it it is easily destroyed by heat
5. Assist in surgical procedure ofsubtotal thyroidectomy
HYPOTHYROIDISM
o hyposecretion of thyroid hormone
o adults: MYXEDEMA non pitting edema
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o children: CRETINISMthe only endocrine disorder that can lead
to mental retardation
A. Predisposing Factors
1. Iatrogenic Cause disease caused by medical intervention such as
surgery
2. Related to atrophy of thyroid gland due to trauma, presence of
tumor, inflammation
3. Iodine deficiency
4. Autoimmune (Hashimotos Disease)
B. Signs and Symptoms
(Early Signs)
1. Weakness and fatigue
2. Loss of appetite but with weight gain which promotes lipolysis leading
to atherosclerosis and MI
3. Dry skin
4. Cold intolerance
5. Constipation
(Late Signs)
1. Brittleness of hair and nails
2. Non pitting edema (Myxedema)
3. Hoarseness of voice
4. Decrease libido
5. Decrease in all vital signs hypotension, bradycardia, bradypnea,
hypothermia
6. CNS changes
o
lethargyo memory impairment
o psychosis
o menorrhagia
C. Diagnostic Procedures
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1. Serum T3 and T4 is decreased
2. Serum Cholesterol is increased
3. RAIU (Radio Active Iodine Uptake) is decreased
D. Nursing Management
1. Monitor strictly vital signs and intake and output to determine presence
of
o Myxedema coma is a complication of hypothyroidism and an
emergency case
o
a severe form of hypothyroidism is characterized by severehypotension, bradycardia, bradypnea, hypoventilation,
hyponatremia, hypoglycemia, hypothermia leading to pregressive
stupor and coma.
Nursing Management for Myxedema Coma
Assist in mechanical ventilation
Administer thyroid hormones as ordered
Force fluids
2. Force fluids
3. Administer isotonic fluid solution as ordered
4. Administer medications as ordered
Thyroid Hormones
a. Levothyroxine
b. Leothyronine
c. Thyroid Extracts
5. Provide dietary intake that is low in calories
6. Provide comfortable and warm environment
7. Provide meticulous skin care
8. Provide client health teaching and discharge planning concerning
a. Avoid precipitating factors leading to myxedema coma
o stress
o infection
o cold intolerance
o use of anesthetics, narcotics, and sedatives
o prevent complications (myxedema coma, hypovolemic shock
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o hormonal replacement therapy for lifetime
o importance of follow up care
HYPERTHYROIDISM
o increase in T3 and T4
o Graves Disease orThyrotoxicosis
o developed by Robert Grave
A. Predisposing Factors
1. Autoimmune it involves release of long acting thyroid stimulator
causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign ofdehydration among infants)
2. Excessive iodine intake
3. Related to hyperplasia (increase size)
B. Signs and Symptoms
1. Increase appetite (hyperphagia) but there is weight loss
2. Moist skin
3. Heat intolerance
4. Diarrhea
5. All vital signs are increased
6. CNS involvement
a. Irritability and agitation
b. Restlessness
c. Tremors
d. Insomnia
e. Hallucinations
7. Goiter
8. Exopthalmus
9. Amenorrhea
C. Diagnostic Procedures
1. Serum T3 and T4 is increased
2. RAIU (Radio Active Iodine Uptake) is increased
3. Thyroid Scan- reveals an enlarged thyroid gland
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TRIAD SIGNS
D. Nursing Management
1. Monitor strictly vital signs and intake and output
2. Administer medications as ordered
Anti Thyroid Agent
a. Prophythioracill (PTU)
b. Methymazole (Tapazole)
Side Effects of Agranulocytosis
o increase lymphocytes and monocytes
o
fever and chillso sore throat (throat swab/culture)
o leukocytosis (CBC)
3. Provide dietary intake that is increased in calories.
4. Provide meticulous skin care
5. Comfortable and cold environment
6. Maintain side rails
7. Provide bilateral eye patch to prevent drying of the eyes.
8. Assist in surgical procedures known as subtotal thyroidectomy
** Before thyroidectomy administer Lugols Solution (SSKI) to
decrease vascularity of the thyroid
gland to prevent bleeding and hemorrhage.
POST OPERATIVELY,
1. Watch out for signs of thyroid storm/ thyrotoxicosis
Agitation
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Hyperthermia Tachycardia
o administer medications as ordered
a. Anti Pyretics
b. Beta-blockers
o monitor strictly vital signs, input and output and neuro check.
o maintain side rails
o offer TSB
2. Watch out for accidental removal of parathyroid gland that may
lead to
Hypocalcemia (tetany)
Signs and Symptoms
o (+) trousseaus sign
o (+) chvostek sign
o Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as
ordered
3. Watch out for accidental Laryngeal damage which may lead to
hoarseness of voice
Nursing Management
o encourage client to talk/speak immediately after operation and notify
physician
4. Signs of bleeding (feeling of fullness at incisional site)
Nursing Management
o Check the soiled dressings at the back or nape area.
5. Hormonal replacement therapy for lifetime
6. Importance of follow up care
PARATHYROID GLAND
o A pair of small nodules behind the thyroid gland
o Secretes parathormone
o Promotes calcium reabsorption
o Hypoparathyroidism
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o Hyperparathyroidism
HYPOPARATHYROIDISM
o Decrease secretion of parathormone leading to hypocalcemia
o Resulting to hyperphospatemia
A. Predisposing Factors
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to:
a. inflammationb. tumor
c. trauma
B. Signs and Symptoms
1. Acute tetany
a. tingling sensation
b. paresthesia
c. numbness
d. dysphagia
e. positive trousseus sign/carpopedal spasm
f. positive chvostek sign
g. laryngospasm/broncospasm
h. seizure feared complications
i. arrhythmia
2. Chronic tetany
a. photophobia and cataract formation
b. loss of tooth enamel
c. anorexia, nausea and vomiting
d. agitation and memory impairment
C. Diagnostic Procedures
1. Serum Calcium is decreased (normal value: 8.5 11 mg/100 ml)
2. Serum Phosphate is decreased (normal value: 2.5 4.5 mg/100 ml)
3. X-ray of long bones reveals a decrease in bone density
4. CT Scan reveals degeneration of basal ganglia
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D. Nursing Management
1. Administer medications as ordered such as:
a. Acute Tetany
Calcium Gluconate IV slowly
b. Chronic Tetany
Oral Calcium supplements
Calcium Gluconate
Calcium Lactate
Calcium Carbonate
c. Vitamin D (Cholecalciferol) for absorption of calcium
CHOLECALCIFEROL ARE DERIVED FROM
Drug Diet (Calcidiol) Sunlight
(Calcitriol)
d. Phosphate binder
Aluminum Hydroxide Gel (Ampogel)
Side effect: constipation
ANTACID
A.A.C MAD
Aluminum Containing Magnesium ContainingAntacids Antacids
AluminumHydroxide
Gel Side Effect: Constipation Side Effect:
Diarrhea
2. Avoid precipitating stimulus such as glaring lights and noise
3. Encourage increase intake of foods rich in calcium
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a. anchovies
b. salmon
c. green turnips
4. Institute seizure and safety precaution
5. Encourage client to breathe using paper bag to produce mild
respiratory acidosis result.
6. Prepare trache set at bedside for presence of laryngo spasm
7. Prevent complications
8. Hormonal replacement therapy for lifetime
9. Importance of follow up care.
HYPERTHYROIDISM
o Decrease parathormone
o Hypercalcemia: bone demineralization leading to bone fracture (calcium
is stored 99% in bone and 1% blood)
o Kidney stones
A. Predisposing Factors
1. Hyperplasia of parathyroid gland
2. Over compensation of parathyroid gland due to vitamin D deficiency
a. Children: Ricketts
b. Adults: Osteomalacia
B. Signs and Symptoms
1. Bone pain especially at back (bone fracture)
2. Kidney stones
a. renal cholic
b. cool moist skin
3. Anorexia, nausea and vomiting
4. Agitation and memory impairment
C. Diagnostic Procedures
1. Serum Calcium is increased
2. Serum Phosphate is decreased
3. X-ray of long bones reveals bone demineralization
D. Nursing Management
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1. Force fluids to prevent kidney stones
2. Strain all the urine using gauze pad for stone analysis
3. Provide warm sitz bath
4. Administer medications as ordered
a. Morphine Sulfate (Demerol)
5. Encourage increase intake of foods rich in phosphate but decrease in
calcium
6. Provide acid ash in the diet to acidify urine and prevent bacterial growth
7. Assist/supervise in ambulation
8. Maintain side rails
9. Prevent complications (seizure and arrhythmia)
10. Assist in surgical procedure known as parathyroidectomy
11. Hormonal replacement therapy for lifetime
12. Importance of follow up care
ADRENAL GLAND
o Located atop of each kidney
o 2 layers of adrenal gland
a. Adrenal Cortex outermost
b. Adrenal Medulla innermost (secretes catecholamines a power
hormone)
2 Types of Catecholamines
o Epinephrine and Norepinephrine (vasoconstrictor)
o Pheochromocytoma (adrenal medulla)
o Increase secretion of norepinephrine
o Leading to hypertension which is resistant to pharmacological agents
leading to CVA
o Use beta-blockers
ADRENAL CORTEX
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3 Zones/Layers
1. Zona Fasciculata
- secretes glucocortocoids (cortisol)
- function: controls glucose metabolism
- Sugar
2. Zona Reticularis
- secretes traces of glucocorticoids and androgenic hormones
- function: promotes secondary sex characteristics
- Sex
3. Zona Glumerulosa
- secretes mineralocorticoids (aldosterone)
- function: promotes sodium and water reabsorption and excretion of
potassium
- Salt
ADDISONS DISEASE
o Hyposecretion of adreno cortical hormone leading to
a. metabolic disturbance Sugar
b. fluid and electrolyte imbalance Salt
c. deficiency of neuromuscular function Salt/Sex
A. Predisposing Factors
1. Related to atrophy of adrenal glands
2. Fungal infections
B. Signs and Symptoms
1. Hypoglycemia TIRED
2. Decrease tolerance to stress
3. Hyponatremia- hypotension
- signs of dehydration
- weight loss
4. Hyperkalemia
- agitation
- diarrhea
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- arrhythmia
5. Decrease libido
6. Loss of pubic and axillary hair
7. Bronze like skin pigmentation
C. Diagnostic Procedures
1. FBS is decreased (normal value: 80 100 mg/dl)
2. Plasma Cortisol is decreased
3. Serum Sodium is decrease (normal value: 135 145 meq/L)
4. Serum Potassium is increased (normal value: 3.5 4.5 meq/L)
D. Nursing Management
1. Monitor strictly vital signs, input and output to determine presence of
Addisonian crisis (complication of addisons disease)
o Addisonian crisis results from acute exacerbation of addisons disease
characterized by
a. severe hypotension
b. hypovolemic shock
c. hyponatremia leading to progressive stupor and coma
Nursing Management for Addisonian Crisis
1. Assist in mechanical ventilation,
- administer steroids as ordered
- force fluids
2. Administerisotonic fluid solution as ordered
3. Force fluids
4. Administer medications as ordered
Corticosteroids
a. Dexamethasone (Decadrone)
b. Prednisonec. Hydrocortisone (Cortison)
Nursing Management when giving steroids
1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon
to mimic the normal diurnal rhythm
2. Taper dose (withdraw gradually from drug)
3. Monitor side effects
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a. hypertension
b. edema
c. hirsutism
d. increase susceptibility to infection
e. moon face appearance
4. Mineralocorticoids (Flourocortisone)
5. Provide dietary intake, increase calories, carbohydrates, protein but
decrease in potassium
6. Provide meticulous skin care
7. Provide client health teaching and discharge planning
a. avoid precipitating factor leading to addisonian crisis leading to
- stress
- infection
- sudden withdrawal to steroids
b. prevent complications
- addisonian crisis
- hypovolemic shock
c. hormonal replacement for lifetime
d. importance of follow up care
CUSHING SYNDROME
o Hypersecretion of adenocortical hormones
A. Predisposing Factors1 Related to hyperplasia of adrenal gland
2. Increase susceptibility to infections
3. Hypernatremia
a. hypertension
b. edema
c. weight gain
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d. moon face appearance and buffalo hump
e. obese trunk
f. pendulous abdomen
g. thin extremities
4. Hypokalemia
a. weakness and fatigue
b. constipation
c. U wave upon ECG (T wave hyperkalemia)
5. Hirsutism
6. Acne and striae
7. Easy bruising
8. Increase masculinity among females
B. Diagnostic Procedures
1. FBS is increased
2. Plasma Cortisol is increased
3. Serum Sodium is increased
4. Serum Potassium is decreased
C. Nursing Management
1. Monitor strictly vital signs and intake and output
2. Weigh patient daily and assess for pitting edema
3. Measure abdominal girth daily and notify physician
4. Restrict sodium intake
5. Provide meticulous skin care
6. Administer medications as ordered
a. Spinarolactone potassium sparring diuretics
7. Prevent complications (DM)
8. Assist in surgical procedure (bilateral adrenoraphy)9. Hormonal replacement for lifetime
10. Importance of follow up care
PANCREAS
- Located behind the stomach
- Mixed gland (exocrine and endocrine)
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- Consist ofacinar cells which secretes pancreatic juices that aids in digestion
thus it is an exocrine gland
- Consist ofislets of langerhans
- Has alpha cells that secretes glucagons (function: hyperglycemia)
- Beta cells secretes insulin (function: hypoglycemia)
- Delta cells secretes somatostatin (function: antagonizes the effects of growth
hormones)
3 Main Disorders of Pancreas
1. Pancreatic Tumor/Cancer
2. Diabetes Mellitus
3. Pancreatitis
DIABETES MELLITUS
- metabolic disorder characterized by non utilization of carbohydrates, protein
and fat metabolism
CLASSIFICATION OF DM
Type 1 (IDDM)
- Juvenile onset type
- Brittle disease
A. Incidence Rate
- 10% general population has type 1
DM
B. Predisposing Factors
1. Hereditary (total destruction ofpancreatic cells)
2. Related to viruses
3. Drugs
a. Lasix
b. Steroids
4. Related to carbon tetrachloride
Type 2 (NIDDM)
- Adult onset
- Maturity onset type
- Obese over 40 years old
A. Incidence Rate
- 90% of general population has type 2
DM
B. Predisposing Factors
1. Obesity because obese personslack insulin receptor binding sites
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toxicity
C. Signs and Symptoms
1. Polyuria
2. Polydypsia
3. Polyphagia
4. Glucosuria
5. Weight loss
6. Anorexia, nausea and vomiting
7. Blurring of vision8. Increase susceptibility to infection
9. Delayed/poor wound healing
D. Treatment
1. Insulin therapy
2. Diet
3. Exercise
E. Complication
1. Diabetic Ketoacidosis
C. Signs and Symptoms
1. Usually asymptomatic
2. Polyuria
3. Polydypsia
4. Polyphagia
5. Glucosuria
6. Weight gain
D. Treatment
1. Oral Hypoglycemic agents
2. Diet
3. Exercise
E. Complications
1. Hyper
2. Osmolar
3. Non
4. Ketotic
5. Coma
MAIN
FOODSTUFF
ANABOLISM CATABOLISM
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1.
Carbohydrates
2. Protein
3. Fats
Glucose
Amino
Acids
Fatty Acids
Glycogen
Nitrogen
Free Fatty
Acids
- Cholesterol
- Ketones
HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria Polyuria
Cellular starvation weight loss Cellular dehydration
Stimulates the appetite/satiety center Stimulates the thirst
center
(Hypothalamus) (Hypothalamus)
Polyphagia Polydypsia
* Liver has glycogen that undergo glycogenesis/ glycogenolysis
GLUCONEOGENESIS
Formation of glucose from non-CHO sourcesIncrease protein formation
Negative Nitrogen balance
Tissue wasting (Cachexia)
INCREASE FAT CATABOLISM
Free fatty acids
Cholesterol Ketones
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Atherosclerosis Diabetic Keto Acidosis Hypertension
Acetone Breath KussmaulsRespiration
odorMI CVA
Death Diabetic Coma
DIABETIC KETOACIDOSIS
- Acute complication of type 1 DM due to severe hyperglycemia leading to
severe CNS depression
A. Predisposing Factors
1. Hyperglycemia
2. Stress number one precipitating factor
3. Infection
B. Signs and Symptoms
1. Polyuria
2. Polydypsia
3. Polyphagia
4. Glucosuria
5. Weight loss
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6. Anorexia, nausea and vomiting
7. Blurring of vision
8. Acetone breath odor
9. Kussmauls Respiration (rapid shallow breathing)
10 CNS depression leading to coma
C. Diagnostic Procedures
1. FBS is increased
2. BUN (normal value: 10 20)
3. Creatinine (normal value: .8 1)
4. Hct (normal value: female 36 42, male 42 48) due to severe dehydration
D. Nursing Management
1. Assist in mechanical ventilation
2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract
dehydration and shock
3. Monitor strictly vital signs, intake and output and blood sugar levels
4. Administer medications as ordered
a. Insulin therapy (regular acting insulin/rapid acting insulin peak action
of 2 4 hours)
b. Sodium Bicarbonate to counteract acidosis
c. Antibiotics to prevent infection
HYPER OSMOLAR NON KETOTIC COMA
- Hyperosmolar: increase osmolarity (severe dehydration)
- Non ketotic: absence of lypolysis (no ketones)
A. Signs and Symptoms
1. Headache and dizziness2. Restlessness
3. Seizure activity
4. Decrease LOC diabetic coma
B. Nursing Management
1. Assist in mechanical ventilation
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2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract
dehydration and shock
3. Monitor strictly vital signs, intake and output and blood sugar levels
4. Administer medications as ordered
a. Insulin therapy (regular acting insulin peak action of 2 4 hours)
- for DKA use rapid acting insulin
b. Antibiotics to prevent infection
INSULIN THERAPY
A. Sources of Insulin
1. Animal sources
- Rarely used because it can cause severe allergic reaction
- Derived from beef and pork
2. Human Sources
- Frequently used type because it has less antigenicity property thus less
allergic reaction
3. Artificially Compound Insulin
B. Types of Insulin
1. Rapid Acting Insulin (clear)
- Regular acting insulin (IV only)
- Peak action is 2 4 hours
2. Intermediate Acting Insulin (cloudy)
- Non Protamine Hagedorn Insulin (NPH)
- Peak action is 8 16 hours
3. Long Acting Insulin (cloudy)
- Ultra Lente
- Peak action is 16 24 hours
C. Nursing Management for Insulin Injections
1. Administer at room temperature to prevent development of lipodystrophy
(atrophy, hypertrophy of subcutaneous tissues)
2. Place in refrigerator once opened
3. Avoid shaking insulin vial vigorously instead gently roll vial between palm to
prevent formation of bubbles
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4. Use gauge 25 26 needle
5. Administer insulin either 45o 90o depending on amount of clients tissue
deposit
6. No need to aspirate upon injection
7. Rotate insulin injection sites to prevent development of lipodystrophy
8. Most accessible route is abdomen
9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to
prevent contaminating the clear insulin and promote proper calibration.
10. Monitor for signs of local complications such as
a. Allergic reactions
b. Lipodystrophy
c. Somogyis Phenomenon rebound effect of insulin characterized by
hypoglycemia to hyperglycemia
ORAL HYPOGLYCEMIC AGENTS
- Stimulates the pancreas to secrete insulin
A. Classsification
1. First Generation Sulfonylureas
a. Chlorpropamide (Diabenase)
b. Tolbutamide (Orinase)
c. Tolamazide (Tolinase)
2. Second Generation Sulfonylureas
a. Glipzide (Glucotrol)
b. Diabeta (Micronase)
Nursing Management when giving OHA
1. Instruct the client to take it with meals to lessen GIT irritation and prevent
hypoglycemia
2. Instruct the client to avoid taking alcohol because it can lead to severe
hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms
B. Diagnostic Procedures
1. FBS is increased (3 consecutive times with signs or polyuria, polydypsia,
polyphagia and glucosuria confirmatory for DM)
2. Random Blood Sugar is increased
3. Oral glucose tolerance test is increased most sensitive test
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4. Alpha Glycosylated Hemoglobin is increased
C. Nursing Management
1. Monitor for peak action of insulin and OHA and notify physician
2. Administer insulin and OHA therapy as ordered
3. Monitor strictly vital signs, intake and output and blood sugar levels
4. Monitor for signs of hypoglycemia and hyperglycemia
- administer simple sugars
- for hypoglycemia (cold and clammy skin) give simple sugars
- for hyperglycemia (dry and warm skin)
5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%,
protein 30% and fats 20% or offer alternative food substitutes
6. Instruct client to exercise best after meals when blood glucose is rising
7. Monitor signs for complications
a. Atherosclerosis (HPN, MI, CVA)
b. Microangiopathy (affects small minute blood vessels of eyes and
kidneys)
EYES KIDNEY
-PREMATURE
CATARACT
- Blindness
-RECURRENT
PYELONEPHRITIS
- Renal failure
c. HPN and DM major cause of renal failure
d. Gangrene formation
e. Shock due to dehydration
- peripheral neuropathy
- diarrhea/constipation
- sexual impotence
8. Institute foot care management
a. instruct client to avoid walking barefooted
b. instruct client to cut toenails straight
c. instruct client to avoid wearing constrictive garments
d. encourage client to apply lanolin lotion to prevent skin breakdown
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e. assist in surgical wound debriment (give analgesics 15 30 mins
prior)
9. Instruct client to have an annual eye and kidney exam
10. Monitor for signs of DKA and HONKC
11. Assist in surgical procedure
HEMATOLOGICAL SYSTEM
I. Blood II. Blood Vessels III. Blood FormingOrgans
1. Arteries 1. Liver 55% Plasma 45% Formed 2. Veins 3. Spleen
4. Lymphoid OrganSerum Plasma CHON 5. Lymph
Nodes(formed in liver) 6. Bone Marrow
1. Albumin2. Globulins
3. Prothrombin and Fibrinogen
ALBUMIN
- Largest and numerous plasma CHON
- Maintains osmotic pressure preventing edema
GLOBULINS- Alpha globulins - transport steroids, bilirubin and hormones
- Beta globulins iron and copper
- Gamma globulins
a. anti-bodies and immunoglobulins
b. prothrombin and fibrinogen clotting factors
FORMED ELEMENTS
1. RBC (ERYTHROCYTES)
- normal value: 4 6 million/mm3
- only unnucleated cell
- biconcave discs
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- consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin
(green pigment) hemosiderin (golden brown pigment)
- transports and carries oxygen to tissues
- hemoglobin: normal value female 12 14 gms% male 14 16 gms%
- hematocrit red cell percentage in wholeblood
- normal value: female 36 42% male 42 48%
- substances needed for maturation of RBC
a. folic acid
b. iron
c. vitamin c
d. vitamin b12 (cyanocobalamin)
e. vitamin b6 (pyridoxine)
f. intrinsic factor
- Normal life span of RBC is 80 120 days and is killed in red pulp of
spleen
2. WBC (LEUKOCYTES)
- normal value: 5000 10000/mm3
A. Granulocytes
1. Polymorpho Neutrophils
- 60 70% of WBC
- involved in short term phagocytosis for acute inflammation
2. Polymorphonuclear Basophils
- for parasite infections
- responsible for the release of chemical mediation for inflammation
3. Polymorphonuclear Eosinophils
- for allergic reaction
B. Non Granulocytes
1. Monocytes- macrophage in blood
- largest WBC
- involved in long term phagocytosis for chronic inflammation
2. Lymphocytes
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B-cell T-cell Natural killer cell- bone marrow - thymus - anti viral and anti tumor property
for immunity
HIV
- 6 months 5 years incubation period
- 6 months window period
- western blot opportunistic
- ELISA
- drug of choice AZT (Zidon Retrovir)
2 Common fungal opportunistic infection in AIDS
1. Kaposis Sarcoma
2. Pneumocystis Carinii Pneumonia
3. Platelets (THROMBOCYTES)
- Normal value: 150,000 450,000/mm3
- Promotes hemostasis (prevention of blood loss)
- Consist of immature or baby platelets or megakaryocytes which is the target
of dengue virus
- Normal life span of platelet is 9 12 days
Signs of Platelet Dysfunction
1. Petechiae
2. Echhymosis
3. Oozing of blood from venipunctured