Medical Surgical Nursing Review Notes 30pgs
Medical Surgical Nursing Review Notes 30pgs
Medical Surgical Nursing Review Notes 30pgs
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
PROPERTIES astrocytoma.
Conductivity – ability of neuron to transmit a wave of excitation from one cell to 3. Microglia
another. 4. Epindymal
Decrease LOC
1
PATHOGNOMONIC SIGNS
1. PTB – low-grade afternoon fever.
2. PNEUMONIA – rusty sputum.
3. ASTHMA – wheezing on expiration.
4. EMPHYSEMA – barrel chest.
5. KAWASAKI SYNDROME – strawberry tongue.
6. PERNICIOUS ANEMIA – red beefy tongue.
7. DOWN SYNDROME – protruding tongue.
8. CHOLERA – rice watery stool.
9. MALARIA – stepladder like fever with chills.
10. TYPHOID – rose spots in abdomen.
11. DIPTHERIA – pseudo membrane formation
12. MEASLES – koplik’s spots.
13. SLE – butterfly rashes.
14. LIVER CIRRHOSIS – spider like varices.
15. LEPROSY – lioning face.
16. BULIMIA – chipmunk face.
17. APPENDICITIS – rebound tenderness.
18. DENGUE – petechiae or (+) Herman’s sign.
19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain).
20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm).
21. TETANUS – risus sardonicus.
22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots.
23. PYLORIC STENOSIS – olive like mass.
24. PDA – machine like murmur.
25. ADDISON’S DISEASE – bronze like skin pigmentation.
26. CUSHING’S SYNDROME – moon face appearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus.
28. INTUSSUSCEPTION – sausage shaped mass
2
. Carbon Monoxide and Lead Poisoning Resulting to acetone breath odor/fruity odor.
Can lead to Parkinson’s Disease. KUSSMAUL’S respiration, a rapid shallow respiration.
Epilepsy Which may lead to diabetic coma.
Treat with ANTIDOTE: Calcium EDTA. 4. Hepatitis
3. Type 1 DM (IDDM) Signs of jaundice (icteric sclerae).
Causes diabetic ketoacidosis. Caused by bilirubin (yellow pigment)
And increases breakdown of fats. 5. Bilirubin
And free fatty acids Increase bilirubin in brain (Kernicterus).
Resulting to cholesterol and (+) to Ketones (CNS Causing irreversible brain damage.
depressant).
Astrocites
Maintains integrity of blood brain barrier.
Oligodendria DEMYELINATING DISORDERS
Produces
1. ALZHEIMER’S DISEASE myelin sheath in CNS
Atrophy of brain tissues.
Act as insulator and facilitates rapid nerve impulse transmission.
Sign and Symptoms
4 A’s of Alzheimer Hypothyroidism
a. Amnesia – loss of memory. GBS
b. Agnosia – no recognition of inanimate objects.
c. Apraxia – no recognition of objects function.
Ig G – only antibody that pass placental circulation causing passive immunity.
d. Aphasia – no speech (nodding).
- short term protection.
*Expressive aphasia
- Immediate action.
“motor speech center” Ig A – present in all bodily secretions (tears, saliva, colostrums).
Broca’s Aphasia Ig M – acute in inflammation.
*Receptive aphasia Ig E – for allergic reaction.
inability to understand spoken words. Ig D – for chronic inflammation.
Characterized by remission and exacerbation. to touch, pain, pressure, heat and cold.
2
paralysis 5. Impaired cerebral function
scanning speech
TRIAD SIGNS OF MS
Ataxia
(Unsteady gait, (+) Romberg’s test)
CHARCOTS
TRIAD
Intentional tremors IAN Nystagmus
6. Urinary retention/incontinence Monitor side effects bronchospasm and wheezing.
7. Constipation Monitor breath sounds 1 hour after subcutaneous administration.
8. Decrease sexual capacity
c. For Urinary Incontinence
Anti spasmodic agent
DIAGNOSTIC PROCEDURE
a. Prophantheline Bromide (Promanthene)
CSF analysis (increase in IgG and Protein).
Acid ash diet like cranberry juice, plums, prunes,
MRI (reveals site and extent of demyelination). pineapple, vitamin C and orange.
(+) Lhermitte’s sign a continuous and increase contraction of spinal To acidify urine and prevent bacterial multiplication.
column.
EPINDYMAL CELLS
Secretes a glue called chemo attractants that concentrate 2. Temporal
the bacteria. hearing
COMPOSITION OF BRAIN short term memory
80% brain mass 3. Parietal
10% blood for appreciation
10% CSF discrimination of sensory impulses to pain, touch, pressure,
I. Brain Mass heat, cold, numbness.
PARTS OF THE BRAIN 4. Occipital
1. CEREBRUM for vision
largest part Insula (Island of Reil)
composed of the Right Cerebral Hemisphere and Left visceral function activities of internal organ like gastric
Cerebral Hemisphere enclosed in the Corpus Callosum. motility.
Functions of Cerebrum Limbic System (Rhinencephalon)
integrative controls smell and if damaged results to Anosmia (absence
sensory of smell).
1. Frontal
higher cortical thinking 2. BASAL GAGLIA
controls personality areas of grey matter located deep within each cerebral
hemisphere.
controls motor activity
release dopamine (controls gross voluntary movement.
Broca’s Area (motor speech area) when damaged results to
garbled speech.
3
Dopamine Parkinson’s Disease Schizophrenia
size of pupil is 2 – 3 mm. early sign for males are testicular and penile enlargement
unequal size of pupil is anisocoria. early sign for females telarche and late sign is menarche.
appetite/satiety
controls some emotional responses like fear, anxiety and smallest part of the brain.
excitement. lesser brain.
controls pituitary functions controls balance, equilibrium, posture and gait.
Medulla Oblongata
Brain Herniation
hemorrhage
Signs and Symptoms (Early)
decrease LOC lethargy/stupor
restlessness/agitation coma
irritability
Signs and Symptoms (Late) abnormal posturing
changes in vital signs decorticate posturing (damage to cortex and spinal cord).
blood pressure (systolic blood pressure increases but decerebrate posturing (damage to upper brain stem that
diastolic remains the same). includes pons, cerebellum and midbrain).
widening of pulse pressure is neurologic in nature (if unilateral dilation of pupils called uncal herniation
narrow cardiac in nature).
bilateral dilation of pupils called tentorial herniation
heart rate decrease
resulting to mild headache
respiratory rate decrease
possible seizure activity
temperature increase directly proportional to blood
pressure.
Nursing Management
projective vomiting 1. Maintain patent and adequate ventilation by:
headache a. Prevention of hypoxia and hypercarbia
Dyspnea Hydrocortisone
Increase CO2 (most powerful respiratory stimulant) Mild Analgesics (Codeine Sulfate for respiratory
retention. depression)
constipation
2. Hypocalcemia/ Tetany
decrease calcium level
5
tingling sensation
paresthesia
numbness
Magnesium Sulfate
3. Hyponatremia
decrease sodium level
agitation
Nursing Management
force fluids
foods high in uric acid (sardines, organ meats and force fluids
anchovies) administer medications as ordered
*Increase in tophi deposit leads to Gouty arthritis. a. Narcotic Analgesic
Signs and Symptoms Morphine Sulfate
joint pain (great toes) ANTIDOTE: Naloxone (Narcan) toxicity
swelling leads to tremors.
Nursing Management b. Allopurinol (Zyloprim)
6
PARKINSON’S DISEASE/ PARKINSONISM
Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia.
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
2. Arteriosclerosis
3. Hypoxia
4. Encephalitis
5. Increase dosage of the following drugs:
a. Reserpine(Serpasil)
b. Methyldopa(Aldomet) AntihypertensiveS
c. Haloperidol(Haldol)
d. Phenothiazine AntipsychoticS
Aloneness
Multiple loss
Loss of spouse
causes suicide Loss of Job
mask like facial expression with decrease blinking of the effects of Levodopa
eyes.
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide
difficulty rising from sitting position.
Nursing Management
1. Digitalis Toxicity only mixed with plain NSS or 0.9 NaCl to prevent
Signs and Symptoms development of crystals or precipitate.
nausea and vomiting administered sandwich method
diarrhea avoid taking alcohol because it can lead to severe CNS
confusion depression
diarrhea nystagmus
hypothyroidism
provide oral care
force fluids
5. Acetaminophen Toxicity
increase sodium intake to 4 – 10 g% daily
Signs and Symptoms
hepatotoxicity (monitor for liver enzymes)
3. Aminophylline Toxicity
Signs and Symptoms SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
restlessness) hypoglycemia
Tremors, tachycardia
Irritability initial sign is ptosis a clinical parameter to determine
Restlessness ptosis is palpebral fissure.
Extreme fatigue diplipia
Diaphoresis, depression
mask like facial expression
Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.
dysphagia
MYASTHENIA GRAVIS
neuromuscular disorder characterized by a disturbance in
hoarseness of voice
the transmission of impulses from nerve to muscle cells at respiratory muscle weakness that may lead to respiratory
autoimmune: it involves release of cholinesterase an temporary relief of signs and symptoms for about 5 – 10
7. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.G.
8. Assist in plasma paresis and removing auto immune anti bodies
9. Prevent complications
INFLAMMATORY CONDITIONS OF THE BRAIN fever, chills, anorexia, general body malaise and weight
MENINGITIS loss
Meninges Possible increase in ICP and seizure activity
3 fold membrane that covers brain and spinal
Abnormal posturing (decorticate and decerebrate)
cord.
Signs of meningeal irritation
for support and protection
a. Nuchal rigidity or stiff neck
for nourishment b. Opisthotonus (arching of back)
blood supply c. (+) Kernig’s sign (leg pain)
LAYERS OF THE MENINGES d. (+) Brudzinski sign (neck pain)
1. Dura matter – outer layer
2. Arachnoid – middle layer D. Diagnostic Procedures
3. Pia matter – inner layer Lumbar puncture: a hollow spinal needle is inserted in the
subdural space between the dura and subarachnoid space between the L3 – L4 to L5.
arachnoid Nursing Management for LP
subarachnoid space between the arachnoid Before Lumbar Puncture
1. Secure informed consent and explain procedure.
and pia, CSF aspiration is done. 2. Empty bladder and bowel to promote comfort.
3. Encourage to arch back to clearly visualize L3-L4.
Post Lumbar Puncture
A. Etiology 1. Place flat on bed 12 – 24 o
1. Meningococcus – most dangerous 2. Force fluids
3. Check punctured site for any discoloration, drainage and leakage to tissues.
2. Pneumococcus 4. Assess for movement and sensation of extremities.
3. Streptococcus - causes adult meningitis CSF analysis reveals
1. Increase CHON and WBC
4. Hemophilus Influenzae – causes pediatric meningitis 2. Decrease glucose
3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)
4. (+) cultured microorganism (confirms meningitis)
B. Mode of transmission
airborne transmission (droplet nuclei) CBC reveals
1. Increase wbc
C. Signs and Symptoms
headache E. Nursing Management
9. Provide client health care and discharge planning concerning: Cheyne Stokes Respiration
a. Maintain good diet of increase CHO, CHON, calories with small anorexia, nausea and vomiting
frequent feedings.
dysphagia
b. Prevent complications
(+) Kernig’s sign and Brudzinski sign which may lead to
most feared is hydrocephalus
hemorrhagic stroke
hearing loss/nerve deafness is second complication
focal neurological deficits
consult audiologist
a. phlegia
c. Rehabilitation for neurological deficit b. aphasia
mental retardation c. dysarthria (inability to articulate words)
delayed psychomotor development d. alexia (difficulty reading)
e. agraphia (difficulty writing)
CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) f. homonymous hemianopsia (loss of half of
7. Administer medications as ordered 2. EEG – reveals hyper activity of electrical brain waves
Conscious 15 – 14
Lethargy 13 – 11
Stupor 10 – 8
Coma 7
Survey of mentalDeep
status andComa
speech 3
CRANIAL NERVES
I. OLFACTORY S
II. OPTIC S
III OCCULOMOTOR M
IV. TROCHLEAR M (Smallest)
V. TRIGEMINAL B (Largest)
VI. ABDUCENSE M
VII. FACIAL B
VIII. ACOUSTIC S
IX. GLOSSOPHARYNGEAL B
X. VAGUS B (Longest)
XI. SPINAL ACCESSORY M
XII. HYPOGLOSSAL M
CRANIAL NERVE I: OLFACTORY Snellen’s Alphabet chart: for literate clients
sensory function for smell Snellen’s E chart: for illiterate clients
Material Used Snellen’s Animal chart: for pediatric clients
don’t use alcohol, ammonia, perfume because it is irritating
normal visual acuity 20/20
and highly diffusible.
numerator is constant, it is the distance of person from the
use coffee granules, vinegar, bar of soap, cigarette
chart (6 – 7 m, 20 feet)
Procedure
denominator changes, indicates distance by which the
test each nostril by occluding each nostril
person normally can see letter in the chart.
Abnormal Findings
- 20/200 indicates blindness
1. Hyposnia – decrease sensitivity to smell
20/20 visual acuity if client is able to read letters above the
2. Dysosmia – distorted sense of smell
red line.
3. Anosmia – absence of smell
2. Test of visual field or peripheral vision
Indicative of
a. Superiorly
1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells
b. Bitemporaly
are located
c. Nasally
2. may indicate inflammatory conditions (sinusitis)
d. Inferiorly
Common among 40 years old and above 1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor
Hereditary
Hypertension
2. Cataract
Obesity Decrease opacity of lens
B. Signs and Symptoms A. Predisposing Factor
1. Loss of peripheral vision 1. Aging 65 years and above
pathognomonic sign is tunnel vision 2. Related to congenital
2. Headache, nausea, vomiting, eye pain (halos around light) 3. Diabetes Mellitus
steamy cornea 4. Prolonged exposure to UV rays
C. Diagnostic Procedures
C. Pathognomonic Signs
1. Tonometry
1. Blurring or hazy vision
2. Perimetry
2. Milky white appearance at center of pupils
3. Gonioscopy
3. Decrease perception to colors
4. Macular Degeneration
Degeneration of the macula lutea (yellowish spot at the
3. Retinal Detachment center of retina)
6 muscles
Oculomotor
controls the size and response of pupil
DIABETES INSIPIDUS
CRANIAL NERVE VII: FACIAL o Decrease production of anti diuretic hormone
Sensory: controls taste, anterior 2/3 of tongue
there is facial paralysis or Bell’s Palsy and the primary o Presence of tumor
cause is forcep delivery. B. Signs and Symptoms
1. Polyuria
CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR 2. Signs of dehydration
Controls balance particularly kinesthesia or position sense, a. Adult: thirst
refers to movement and orientation of the body in space. b. Agitation
Parts of the Ear c. Poor Skin turgor
1. Outer Ear d. Dry mucous membrane
C. Diagnostic Procedure
1. Urine specific gravity is increased
ENDOCRINE SYSTEM
2. Serum Sodium is decreased
Overview of the structures and functions
1. Pituitary Gland (Hypophysis Cerebri)
D. Nursing Management
o Located at base of brain particularly at sella turcica
1. Restrict fluid
o Master gland or master clock
2. Administer medications as ordered
o Controls all metabolic function of body
a. Loop diuretics (Lasix)
PARTS OF THE PITUITARY GLAND b. Osmotic diuretics (Mannitol)
1. Anterior Pituitary Gland 3. Monitor strictly vital signs, intake and output and neuro check
o called as adenohypophysis 4. Weigh patient daily and assess for pitting edema
2. Posterior Pituitary Gland 5. Provide meticulous skin care
o called as neurohypophysis 6. Prevent complications
o secretes hormones oxytocin -promotes
uterine contractions preventing bleeding/ hemorrhage ANTERIOR PITUITARY GLAND
o administrate oxytocin immediately after o also called ADENOHYPOPHYSIS secretes
delivery to prevent uterine atony. 1. Growth hormones (somatotropic hormone)
o Promotes elongation of long bones
o Hyposecretion of GH among children results to Dwarfism
o Hypersecretion of GH results to Gigantism B. Signs and Symptoms
o Hypersecretion of GH among adults results to 1. Enlarged thyroid gland
HYPOTHYROIDISM
HYPOTHYROIDISM
o all are decrease except weight and menstruation
o hyposecretion of thyroid hormone
o memory impairment
o adults: MYXEDEMA non pitting edema
Signs and Symptoms
o children: CRETINISM the only endocrine disorder that
o there is loss of appetite but there is weight gain
can lead to mental retardation
o menorrhagia
o cold intolerance
A. Predisposing Factors
o constipation 1. Iatrogenic Cause – disease caused by medical intervention such as
surgery
HYPERTHYROIDISM 2. Related to atrophy of thyroid gland due to trauma, presence of
o all are increase except weight and menstruation tumor, inflammation
Signs and Symptoms 3. Iodine deficiency
o increase appetite but there is weight loss 4. Autoimmune (Hashimotos Disease)
o amenorrhea
o exophthalmos
B. Signs and Symptoms
THYROID DISORDERS (Early Signs)
SIMPLE GOITER 1. Weakness and fatigue
o enlargement of thyroid gland due to iodine deficiency 2. Loss of appetite but with weight gain which promotes lipolysis
leading to atherosclerosis and MI
o contains pro-goitrin an anti thyroid agent that has no 2. Non pitting edema (Myxedema)
broccoli, all nuts 5. Decrease in all vital signs – hypotension, bradycardia, bradypnea,
d. Cobalt
e. Phenylbutazones (NSAIDs) C. Diagnostic Procedures
- if goiter is caused by 1. Serum T3 and T4 is decreased
2. Serum Cholesterol is increased o infection
3. RAIU (Radio Active Iodine Uptake) is decreased o cold intolerance
o use of anesthetics, narcotics, and sedatives
D. Nursing Management o prevent complications (myxedema coma, hypovolemic
1. Monitor strictly vital signs and intake and output to determine shock
presence of o hormonal replacement therapy for lifetime
o Myxedema coma is a complication of hypothyroidism and
o importance of follow up care
an emergency case
HYPERTHYROIDISM
o a severe form of hypothyroidism is characterized by severe
o increase in T3 and T4
hypotension, bradycardia, bradypnea, hypoventilation,
o Grave’s Disease or Thyrotoxicosis
hyponatremia, hypoglycemia, hypothermia leading to
o developed by Robert Grave
pregressive stupor and coma.
Nursing Management for Myxedema Coma
A. Predisposing Factors
Assist in mechanical
1. Autoimmune – it involves release of long acting thyroid stimulator
ventilation
causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of
Administer thyroid hormones
dehydration among infants)
as ordered
2. Excessive iodine intake
Force fluids
3. Related to hyperplasia (increase size)
2. Force fluids
3. Administer isotonic fluid solution as ordered
B. Signs and Symptoms
4. Administer medications as ordered
1. Increase appetite (hyperphagia) but there is weight loss
Thyroid Hormones
2. Moist skin
a. Levothyroxine
3. Heat intolerance
b. Leothyronine
4. Diarrhea
c. Thyroid Extracts
5. All vital signs are increased
5. Provide dietary intake that is low in calories
6. CNS involvement
6. Provide comfortable and warm environment
a. Irritability and agitation
7. Provide meticulous skin care
b. Restlessness
8. Provide client health teaching and discharge planning concerning
c. Tremors
a. Avoid precipitating factors leading to myxedema coma
d. Insomnia
o stress
e. Hallucinations
7. Goiter
8. Exopthalmus
9. Amenorrhea
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
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 chills
o 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 Lugol’s Solution (SSKI) to decrease vascularity of the thyroid
gland to prevent bleeding and hemorrhage.
POST OPERATIVELY,
1. Watch out for signs of thyroid storm/ thyrotoxicosis
Agitation
TRIAD SIGNS
Hyperthermia Tachycardia
o administer medications as ordered
a. Anti Pyretics
b. Beta-blockers
o monitor strictly vital signs, input and output and neuro check.
o maintain side rails
o offer TSB
2. Watch out for accidental removal of parathyroid gland that may a. inflammation
lead to b. tumor
Hypocalcemia (tetany) c. trauma
Signs and Symptoms B. Signs and Symptoms
o (+) trousseau’s sign 1. Acute tetany
o (+) chvostek sign a. tingling sensation
o Watch out for arrhythmia, seizure give Calcium Gluconate IV b. paresthesia
3. Watch out for accidental Laryngeal damage which may lead to e. positive trousseu’s sign/carpopedal spasm
o encourage client to talk/speak immediately after operation and h. seizure feared complications
4. Signs of bleeding (feeling of fullness at incisional site) a. photophobia and cataract formation
o Check the soiled dressings at the back or nape area. c. anorexia, nausea and vomiting
d. agitation and memory impairment
5. Hormonal replacement therapy for lifetime
6. Importance of follow up care
C. Diagnostic Procedures
1. Serum Calcium is decreased (normal value: 8.5 – 11 mg/100 ml)
PARATHYROID GLAND
2. Serum Phosphate is decreased (normal value: 2.5 – 4.5 mg/100 ml)
o A pair of small nodules behind the thyroid gland
3. X-ray of long bones reveals a decrease in bone density
o Secretes parathormone
4. CT Scan – reveals degeneration of basal ganglia
o Promotes calcium reabsorption
o Hypoparathyroidism
D. Nursing Management
o Hyperparathyroidism
1. Administer medications as ordered such as:
a. Acute Tetany
HYPOPARATHYROIDISM
Calcium Gluconate IV slowly
o Decrease secretion of parathormone leading to hypocalcemia
b. Chronic Tetany
o Resulting to hyperphospatemia Oral Calcium supplements
Calcium Gluconate
A. Predisposing Factors Calcium Lactate
1. Following subtotal thyroidectomy Calcium Carbonate
2. Atrophy of parathyroid gland due to: c. Vitamin D (Cholecalciferol) for absorption of calcium
d. Phosphate binder
Aluminum Hydroxide Gel (Ampogel)
Side effect: constipation
ANTACID
A.A.C MAD
▼ ▼
Aluminum Containing Magnesium Containing
Antacids Antacids
▼ ▼
Aluminum
Hydroxide
Gel
▼
Side Effect: Constipation Side Effect: Diarrhea
2. Avoid precipitating stimulus such as glaring lights and noise B. Signs and Symptoms
3. Encourage increase intake of foods rich in calcium 1. Bone pain especially at back (bone fracture)
a. anchovies 2. Kidney stones
b. salmon a. renal cholic
c. green turnips b. cool moist skin
4. Institute seizure and safety precaution 3. Anorexia, nausea and vomiting
5. Encourage client to breathe using paper bag to produce mild respiratory 4. Agitation and memory impairment
acidosis result.
6. Prepare trache set at bedside for presence of laryngo spasm C. Diagnostic Procedures
7. Prevent complications 1. Serum Calcium is increased
8. Hormonal replacement therapy for lifetime 2. Serum Phosphate is decreased
9. Importance of follow up care. 3. X-ray of long bones reveals bone demineralization
D. Nursing Management
HYPERTHYROIDISM 1. Force fluids to prevent kidney stones
o Decrease parathormone 2. Strain all the urine using gauze pad for stone analysis
o Hypercalcemia: bone demineralization leading to bone fracture (calcium 3. Provide warm sitz bath
is stored 99% in bone and 1% blood) 4. Administer medications as ordered
o Kidney stones a. Morphine Sulfate (Demerol)
5. Encourage increase intake of foods rich in phosphate but decrease in calcium
A. Predisposing Factors 6. Provide acid ash in the diet to acidify urine and prevent bacterial growth
2. Over compensation of parathyroid gland due to vitamin D deficiency 8. Maintain side rails
ADDISON’S DISEASE
o Hyposecretion of adreno cortical hormone leading to
CUSHING SYNDROME
a. metabolic disturbance – Sugar
o Hypersecretion of adenocortical hormones
b. fluid and electrolyte imbalance – Salt
c. deficiency of neuromuscular function – Salt/Sex
A. Predisposing Factors
1 Related to hyperplasia of adrenal gland
A. Predisposing Factors
2. Increase susceptibility to infections
1. Related to atrophy of adrenal glands
3. Hypernatremia
2. Fungal infections
a. hypertension
b. edema
B. Signs and Symptoms
c. weight gain
1. Hypoglycemia – TIRED
d. moon face appearance and buffalo hump
2. Decrease tolerance to stress
e. obese trunk
3. Hyponatremia
f. pendulous abdomen
- hypotension
g. thin extremities
- signs of dehydration
4. Hypokalemia
- weight loss
a. weakness and fatigue
4. Hyperkalemia
b. constipation
- agitation
c. U wave upon ECG (T wave hyperkalemia)
- diarrhea
5. Hirsutism
- arrhythmia
6. Acne and striae
5. Decrease libido
7. Easy bruising
6. Loss of pubic and axillary hair
8. Increase masculinity among females
7. Bronze like skin pigmentation
B. Diagnostic Procedures
C. Diagnostic Procedures
1. FBS is increased
1. FBS is decreased (normal value: 80 – 100 mg/dl)
2. Plasma Cortisol is increased
2. Plasma Cortisol is decreased
3. Serum Sodium is increased
3. Serum Sodium is decrease (normal value: 135 – 145 meq/L)
4. Serum Potassium is decreased
4. Serum Potassium is increased (normal value: 3.5 – 4.5 meq/L)
C. Nursing Management
D. Nursing Management
1. Monitor strictly vital signs and intake and output
1. Monitor strictly vital signs, input and output to determine presence of Addisonian
2. Weigh patient daily and assess for pitting edema
crisis (complication of addison’s disease)
3. Measure abdominal girth daily and notify physician
o Addisonian crisis results from acute exacerbation of addison’s disease
4. Restrict sodium intake
characterized by
5. Provide meticulous skin care
a. severe hypotension
6. Administer medications as ordered
b. hypovolemic shock
a. Spinarolactone – potassium sparring diuretics
c. hyponatremia leading to progressive stupor and coma
7. Prevent complications (DM)
Nursing Management for Addisonian Crisis
8. Assist in surgical procedure (bilateral adrenoraphy)
1. Assist in mechanical ventilation,
9. Hormonal replacement for lifetime
- administer steroids as ordered
10. Importance of follow up care
- force fluids
CLASSIFICATION OF DM
Type 1 (IDDM) Type 2 (NIDDM)
- Juvenile onset type - Adult onset
- Brittle disease - Maturity onset type
- Obese over 40 years old
A. Incidence Rate A. Incidence Rate
- 10% general population has type 1 DM - 90% of general population has type 2 DM
B. Predisposing Factors B. Predisposing Factors
1. Hereditary (total destruction of pancreatic cells) 1. Obesity – because obese persons lack insulin receptor binding sites
2. Related to viruses
3. Drugs
a. Lasix
b. Steroids
4. Related to carbon tetrachloride toxicity
C. Signs and Symptoms
C. Signs and Symptoms 1. Usually asymptomatic
1. Polyuria 2. Polyuria
2. Polydypsia 3. Polydypsia
3. Polyphagia 4. Polyphagia
4. Glucosuria 5. Glucosuria
5. Weight loss 6. Weight gain
6. Anorexia, nausea and vomiting
7. Blurring of vision
8. Increase susceptibility to infection
9. Delayed/poor wound healing D. Treatment
D. Treatment 1. Oral Hypoglycemic agents
1. Insulin therapy 2. Diet
2. Diet 3. Exercise
3. Exercise
E. Complications
E. Complication 1. Hyper
1. Diabetic Ketoacidosis 2. Osmolar
3. Non
4. Ketotic
5. Coma
HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria Polyuria
GLUCONEOGENESIS
Formation of glucose from non-CHO sources
Increase protein formation
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Negative Nitrogen balance
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Tissue wasting (Cachexia)
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INCREASE FAT CATABOLISM
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Free fatty acids
Cholesterol Ketones
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Atherosclerosis Diabetic Keto Acidosis
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Hypertension
Acetone Breath Kussmaul’s Respiration
odor
MI CVA
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
EYES KIDNEY
-PREMATURE CATARACT -RECURRENT PYELONEPHRITIS
- Blindness - Renal failure
b. instruct client to cut toenails straight
c. HPN and DM major cause of renal failure c. instruct client to avoid wearing constrictive garments
d. Gangrene formation d. encourage client to apply lanolin lotion to prevent skin breakdown
e. Shock due to dehydration e. assist in surgical wound debriment (give analgesics 15 – 30 mins
- peripheral neuropathy prior)
- diarrhea/constipation 9. Instruct client to have an annual eye and kidney exam
- sexual impotence 10. Monitor for signs of DKA and HONKC
8. Institute foot care management 11. Assist in surgical procedure
a. instruct client to avoid walking barefooted
HEMATOLOGICAL SYSTEM
1. Arteries 1. Liver
55% Plasma 45% Formed 2. Veins 3. Spleen
4. Lymphoid Organ
Serum Plasma CHON 5. Lymph Nodes
(formed in liver) 6. Bone Marrow
1. Albumin
2. Globulins
3. Prothrombin and Fibrinogen
ALBUMIN b. iron
- Largest and numerous plasma CHON c. vitamin c
- Maintains osmotic pressure preventing edema d. vitamin b12 (cyanocobalamin)
e. vitamin b6 (pyridoxine)
GLOBULINS f. intrinsic factor
- Alpha globulins - transport steroids, bilirubin and hormones - Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen
- Beta globulins – iron and copper
- Gamma globulins 2. WBC (LEUKOCYTES)
a. anti-bodies and immunoglobulins - normal value: 5000 – 10000/mm3
b. prothrombin and fibrinogen clotting factors A. Granulocytes
1. Polymorpho Neutrophils
FORMED ELEMENTS - 60 – 70% of WBC
1. RBC (ERYTHROCYTES) - involved in short term phagocytosis for acute inflammation
- normal value: 4 – 6 million/mm3 2. Polymorphonuclear Basophils
- only unnucleated cell - for parasite infections
- biconcave discs - responsible for the release of chemical mediation for inflammation
- consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin 3. Polymorphonuclear Eosinophils
(green pigment) hemosiderin (golden brown pigment) - for allergic reaction
- transports and carries oxygen to tissues B. Non Granulocytes
- hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% 1. Monocytes
- hematocrit red cell percentage in wholeblood - macrophage in blood
- normal value: female 36 – 42% male 42 – 48% - largest WBC
- substances needed for maturation of RBC - involved in long term phagocytosis for chronic inflammation
a. folic acid 2. Lymphocytes
HIV 2. Echhymosis
- 6 months – 5 years incubation period 3. Oozing of blood from venipunctured site
- 6 months window period
- western blot opportunistic BLOOD DISORDERS
- ELISA Iron Deficiency Anemia
- drug of choice AZT (Zidon Retrovir) - A chronic microcytic anemia resulting from inadequate absorption of iron leading to
hypoxemic tissue injury
2 Common fungal opportunistic infection in AIDS A. Incidence Rate
1. Kaposi’s Sarcoma 1. Common among developed countries
2. Pneumocystis Carinii Pneumonia 2. Common among tropical zones
3. Common among women 15 – 35 years old
3. Platelets (THROMBOCYTES) 4. Related to poor nutrition
- Normal value: 150,000 – 450,000/mm3 B. Predisposing Factors
- Promotes hemostasis (prevention of blood loss) 1. Chronic blood loss due to trauma
- Consist of immature or baby platelets or megakaryocytes which is the target of a. Heavy menstruation
dengue virus b. Related to GIT bleeding resulting to hematemesis and melena (sign
- Normal life span of platelet is 9 – 12 days for upper GIT bleeding)
c. fresh blood per rectum is called hematochezia
Signs of Platelet Dysfunction 2. Inadequate intake of iron due to
1. Petechiae a. Chronic diarrhea
b. Related to malabsorption syndrome 2. Weakness and fatigue (initial signs)
c. High cereal intake with low animal protein digestion 3. Headache and dizziness
d. Subtotal gastrectomy 4. Pallor and cold sensitivity
4. Related to improper cooking of foods 5. Dyspnea
C. Signs and Symptoms 6. Palpitations
1. Usually asymptomatic 7. Brittleness of hair and spoon shape nails (koilonychias)
8. Atropic Glossitis (inflammation of tongue)
- Stomatitis PLUMBER VINSON’S SYNDROME
- Dysphagia
9. PICA (abnormal appetite or craving for non edible foods
D. Diagnostic Procedures a. Anorexia
1. RBC is decreased b. Nausea and vomiting
2. Hgb is decreased c. Abdominal pain
3. Hct is deceased d. Diarrhea/constipation
4. Iron is decreased e. Melena
5. Reticulocyte is decreased 5. If client cant tolerate/no compliance administer parenteral iron
6. Ferritin is decreased preparation
E. Nursing Management a. Iron Dextran (IM, IV)
1. Monitor for signs of bleeding of all hema test including urinw, stool and GIT b. Sorbitex (IM)
2. Enforce CBR so as not to over tire client Nursing Management when giving parenteral iron preparations
3. Instruct client to take foods rich in iron 1. Administer Z tract technique to prevent discomfort, discoloration and
a. Organ meat leakage to tissues
b. Egg (yolk)
2. Avoid massaging the injection site instead encourage to ambulate to
c. Raisin
d. Sweet potatoes facilitate absorption
e. Dried fruits
3. Monitor side effects
f. Legumes
g. Nuts a. Pain at injection site
4. Instruct the client to avoid taking tea and coffee because it contains tannates which
b. Localized abscess
impairs iron absorption
c. Lymphadenopathy
5. Administer medications as ordered
d. Fever and chills
Oral Iron Preparations
e. Skin rashes
a. Ferrous Sulfate
f. Pruritus/orticaria
b. Ferrous Fumarate
g. Hypotension (anaphylactic shock)
c. Ferrous Gluconate
- 300 mg/day
Nursing Management when taking oral iron preparations
PERNICIOUS ANEMIA
1. Instruct client to take with meals to lessen GIT irritation
- Chronic anemia characterized by a deficiency of intrinsic factor leading to
2. When diluting it in liquid iron preparations administer with straw to
hypochlorhydria (decrease hydrochloric acid secretion)
prevent staining of teeth
Medications administered via straw
A. Predisposing Factors
- Lugol’s solution
1. Subtotal gastrectomy
- Iron
2. Hereditary factors
- Tetracycline
3. Inflammatory disorders of the ileum
- Nitrofurantoin (Macrodentin)
4. Autoimmune
3. Administer with Vitamin C or orange juice for absorption
5. Strictly vegetarian diet
4. Monitor and inform client of side effects
STOMACH
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Pareital cells/ Argentaffin or Oxyntic cells
PANCYTOPENIA
SA NODE
AV NODE
BUNDLE OF HIS
PURKINJE FIBERS
ATHEROSCLEROSIS
ATHEROSCLEROSIS ARTERIOSCLEROSIS
- narrowing of artery - hardening of artery
- lipid or fat deposits - calcium and protein deposits
- tunica intima - tunica media
- Instruct the client to rise slowly from sitting position 6. Mild restlessness and apprehension
7. Occasional findings
- Assist or supervise in ambulation
a. Pericardial friction rub
- When giving nitrol or transdermal patch
b. Split S1 and S2
o Avoid placing near hairy areas as it may decrease drug
c. Rales/Crackles upon auscultation
absorption
d. S4 or atrial gallop
o Avoid rotating transdermal patches as it may decrease drug
absorption
E. Diagnostic Procedure
o Avoid placing near microwave ovens or duting defibrillation
1. Cardiac Enzymes
as it may lead to burns (most important thing to remember)
a. CPK – MB
- Creatinine phosphokinase is increased
b. Beta-blockers
- Heart only, 12 – 24 hours
- Propanolol - side effects PNS
b. LDH – Lactic acid dehydroginase is increased
- Not given to COPD cases because it causes bronchospasm
c. SGPT – Serum glutamic pyruvate transaminase is increased
d. SGOT – Serum glutamic oxal-acetic transaminase is increased
c. ACE Inhibitors
2. Troponin Test – is increased
- Enalapril
3. ECG tracing reveals
a. ST segment elevation
d. Calcium Antagonist
b. T wave inversion
- NIfedipine
c. Widening of QRS complexes indicates that there is arrhythmia in MI
4. Serum Cholesterol and uric acid are both increased
3. Administer oxygen inhalation
5. CBC – increased WBC
4. Place client on semi fowlers position
5. Monitor strictly vital signs, intake and output and ECG tracing
F. Nursing Management
6. Provide decrease saturated fats sodium and caffeine
Goal: Decrease myocardial oxygen demand
7. Provide client health teachings and discharge planning
a. Avoidance of 4 E’s
1. Decrease myocardial workload (rest heart)
b. Prevent complication (myocardial infarction)
- Administer narcotic analgesic/morphine sulfate
c. Instruct client to take medication before indulging into physical exertion to
- Side Effects: respiratory depression
achieve the maximum therapeutic effect of drug
- Antidote: Narcan/Naloxone
d. The importance of follow up care
- Side Effects of Naloxone Toxicity is tremors
2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min
MYOCARDIAL INFARCTION
3. Enforce CBR without bathroom privileges
Heart attack
a. Using bedside commode
Terminal stage of coronary artery disease characterized by malocclusion, necrosis and scarring.
4. Instruct client to avoid forms of valsalva maneuver
5. Place client on semi fowlers position
A. Types
6. Monitor strictly vital signs, intake and output and ECG tracing
7. Provide a general liquid to soft diet that is low in saturated fats, sodium and caffeine 4. Hypertension
8. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy to induce 5. Aortic valve stenosis
vasodilation B. Signs and Symptoms
9. Administer medication as ordered 1. Dyspnea
a. Vasodilators 2. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing
- Nitroglycerine 3. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers
- ISD (Isosorbide Dinitrate, Isodil) sublingual 4. Productive cough with blood tinged sputum
5. Frothy salivation
b. Anti Arrythmic Agents 6. Cyanosis
- Lidocaine (Xylocane 7. Rales/Crackles
- Side Effects: confusion and dizziness 8. Bronchial wheezing
- Brutylium 9. Pulsus Alternans – weak pulse followed by strong bounding pulse
c. Beta-blockers 10. PMI is displaced laterally due to cardiomegaly
11. There is anorexia and generalized body malaise
d. ACE Inhibitors 12. S3 – ventricular gallop
C. Diagnostic Procedure
e. Calcium Antagonist 1. Chest x-ray – reveals cardiomegaly
2. PAP (pulmonary arterial pressure) – measures pressure in right ventricle or cardiac status
f. Thrombolytics/ Fibrinolytic Agents PCWP (pulmonary capillary wedge pressure) – measures end systolic and dyastolic pressure
- Streptokinase - both are increased
- Side Effects: allergic reaction, pruritus - done by cardiac catheterization (insertion of swan ganz catheter)
- Urokinase 3. Ecocardiography – enlarged heart chamber (cardiomyopathy), dependent on extent of heart
- TIPAF (tissue plasminogen activating factor) failure
- Side Effects: chest pain 4. ABG – reveals PO2 is decreased (hypoxemia), PCO2 is increased (respiratory acidosis)
- Monitor for bleeding time
2. RIGHT SIDED HEART FAILURE
g. Anti Coagulant A. Predisposing Factors
- Heparin (check for partial thrombin time) 1. Tricuspid valve stenosis
- Antidote: protamine sulfate 2. Pulmonary embolism
- Coumadin/ Warfarin Sodium (check for prothrombin time) 3. Related to COPD
- Antidote: Vitamin K 4. Pulmonic valve stenosis
5. Left sided heart failure
h. Anti Platelet
- PASA (Aspirin)
- Anti thrombotic effect B. Signs and Symptoms (venous congestion)
- Side Effects of Aspirin 1. Neck/jugular vein distension
Tinnitus 2. Pitting edema
Heartburn 3. Ascites
Indigestion/Dyspepsia 4. Weight gain
- Contraindication 5. Hepatosplenomegaly
Dengue 6. Jaundice
Peptic Ulcer Disease 7. Pruritus
Unknown cause of headache 8. Anorexia
9. Esophageal varices
10. Provide client health teaching and discharge planning concerning C. Diagnostic Procedures
a. Avoidance of modifiable risk factors 1. Chest x-ray – reveals cardiomegaly
- arrhythmia (caused by premature ventricular contraction) 2. Central venous pressure (CVP)
b. Cardiogenic shock - Measure pressure in right atrium (4 – 10 cm of water)
- late sign is oliguria - CVP fluid status measure
c. Left Congestive Heart Failure - If CVP is less than 4 cm of water hypovolemic shock
d. Thrombophlebitis - Do the fluid challenge (increase IV flow rate)
- homan’s sign - If CVP is more than 10 cm of water hypervolemic shock
e. Stroke/CVA - Administer loop diuretics as ordered
f. Post MI Syndrome/Dressler’s Syndrome - When reading CVP patient should be flat on bed
- client is resistant to pharmacological agents, administer 150,000 – - Upon insertion place client in trendelendberg position to promote ventricular
450,000 units of streptokinase as ordered filling and prevent pulmonary embolism
g. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac 3. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy
rehab, post CABG and instruct to 4. Liver enzymes – SGPT and SGOT is increased
- make sex as an appetizer rather than dessert
- instruct client to assume a non weight bearing position D. Nursing Management
- client can resume sexual intercourse if can climb staircase Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min)
- dietary modification 1. Enforce CBR
h. Strict compliance to mediation and importance of follow up care 2. Administer medications as ordered
a. Cardiac glycosides
CONGESTIVE HEART FAILURE - Digoxin (Lanoxin)
Inability of the heart to pump blood towards systemic circulation - Increase force of cardiac contraction
- If heart rate is decreased do not give
Types of Heart Failure b. Loop Diuretics
1. LEFT SIDED HEART FAILURE - Lasix (Furosemide)
c. Bronchodilators
A. Predisposing Factors d. Narcotic analgesics
1. 90% is mitral valve stenosis due to - Morphine Sulfate
a. RHD – inflammation of mitral valve due to invasion of Grp. A beta-hemolytic e. Vasodilators
streptococcus - Nitroglycerine
- Formation of aschoff bodies in the mitral valve f. Anti Arrhythmic
- Common among children - Lidocaine (Xylocane)
- ASO Titer (Anti streptolysin O titer)
- Penicillin 3. Administer oxygen inhalation with high inflow, 3 – 4 L/min, delivered via nasal cannula
- Aspirin 4. High fowlers position
b. Aging 5. Monitor strictly vital signs, intake and output and ECG tracing
2. Myocardial Infarction 6. Measure abdominal girth daily and notify physician
3. Ischemic heart disease 7. Provide a dietary intake of low sodium, cholesterol and caffeine
8. Provide meticulous skin care 2. Angiography – reveals site and extent of malocclusion
9. Assist in bloodless phlebotomy – rotating tourniquet, rotated clockwise every 15 minutes to
promote decrease venous return D. Nursing Management
10. Provide client health teaching and discharge planning 1. Administer medications as ordered
a. Prevent complications a. Analgesics
- Arrythmia b. Vasodilators
- Shock 2. Encourage to wear gloves
- Right ventricular hypertrophy 3. Instruct client on importance of cessation of smoking and exposure to cold environment
- MI
- Thrombophlebitis VARICOSITIES
b. Dietary modification Abnormal dilation of veins of lower extremities and trunks due to
c. Strict compliance to medications Incompetent valve resulting to
Increased venous pooling resulting to
PERIPHERAL VASCULAR DISORDER Venous stasis causing
Arterial Ulcer Decrease venous return
I. Thrombo Angitis Obliterans
Burger’s Disease A. Predisposing Factors
Reynaud’s Disease 1. Hereditary
2. Congenital weakness of veins
Venous Ulcer 3. Thrombophlebitis
1. Varicose Veins 4. Cardiac disorder
2. Thrombophlebitis (deep vein thrombosis) 5. Pregnancy
6. Obesity
THROMBOANGITIS OBLITERANS 7. Prolonged standing or sitting
Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the
lower extremities B. Signs and Symptoms
1. Pain after prolonged standing
A. Predisposing Factors 2. Dilated tortuous skin veins
1. High risk groups – men 30 years old and above 3. Warm to touch
2. Smoking 4. Heaviness in legs
C. Diagnostic Procedure
B. Signs and Symptoms 1. Venography
1. Intermittent claudication – leg pain upon walking 2. Trendelenburg’s Test - veins distends quickly in less than 35 seconds
2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)
3. Decreased peripheral pulses D. Nursing Management
4. Trophic changes 1. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows
5. Ulceration under the legs
6. Gangrene formation 2. Measure the circumference of leg muscle to determine if swollen
3. Wear anti embolic stockings
C. Diagnostic Procedures 4. Administer medications as ordered
1. Oscillometry – decrease in peripheral pulses a. Analgesics
2. Doppler UTZ – decrease blood flow to the affected extremity 5. Assist in surgical procedure
3. Angiography – reveals site and extent of malocclusion a. Vein stripping and ligation (most effective)
b. Sclerotherapy – can recur and only done in spider web varicosities and danger
D. Nursing Management of thrombosis (2 – 3 years for embolism)
1. Encourage a slow progressive physical activity
a. walking 3 – 4 times a day
b. out of bed 3 – 4 times a day THROMBOPHLEBITIS
2. Administer medications as ordered Deep vein thrombosis
a. Analgesics Inflammation of the veins with thrombus formation
b. Vasodilators
c. Anti coagulants A. Predisposing Factors
3. Institute foot care management 1. Obesity
4. Instruct client to avoid smoking and exposure to cold environment 2. Smoking
5. Assist in surgical procedure – bellow knee amputation 3. Related to pregnancy
4. Chronic anemia
5. Prolong use of oral contraceptives – promotes lipolysis
6. Diabetes mellitus
REYNAUD’S DISEASE 7. Congestive heart failure
Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the 8. Myocardial infarction
hands 9. Post op complication
10. Post cannulation – insertion of various cardiac catheter
A. Predisposing Factors 11. Increase in saturated fats in the diet.
1. High risk group – female 40 years old and above
2. Smoking B. Signs and Symptoms
3. Collagen diseases 1. Pain at affected extremity
a. SLE (butterfly rash) 2. Warm to touch
b. Rheumatoid Arthritis 3. Dilated tortuous skin veins
4. Direct hand trauma 4. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot
a. Piano playing
b. Excessive typing C. Diagnostic Procedure
c. Operating chainsaw 1. Venography
2. Angiography
B. Signs and Symptoms
1. Intermittent claudication – leg pain upon walking
2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor) D. Nursing Management
3. Trophic changes 1. Elevate legs above heart level to promote increase venous return
4. Ulceration 2. Apply warm moist pack – to reduce lymphatic congestion
5. Gangrene formation 3. Measure circumference of leg muscle to determine if swollen
4. Encourage to wear anti embolic stockings or knee elastic stockings
C. Diagnostic Procedures 5. Administer medications as ordered
1. Doppler UTZ – decrease blood flow to the affected extremity a. Analgesics
b. Anti Coagulant Disorders of Respiratory System
- Heparin 1. PTB/Pulmonary Tuberculosis (Koch’s Disease)
6. Monitor for signs of complications - Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli
Embolism - An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight
a. Pulmonary
- Sudden sharp chest pain A. Precipitating Factors
- Unexplained dyspnea 1. Malnutrition
- Tachycardia 2. Overcrowded places
- Palpitations 3. Alcoholism
- Diaphoresis 4. Over fatigue
- Restlessness 5. Ingestion of an infected cattle with mycobacterium bovis
b. Cerebral 6. Virulence (degree of pathogenecity) of microorganism
- Headache
- Dizziness B. Mode of Transmission
- Decrease LOC 1. Airborne transmission via droplet nuclei
MURPHY’S SIGN is seen in clients with cholelithiasis, cholecystitis
characterized by pain at the right upper quadrant with tenderness C. Signs and Symptoms
1. Low grade afternoon fever, night sweats
RESPIRATORY SYSTEM 2. Productive cough (yellowish sputum)
OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY 3. Anorexia, generalized body malaise
SYSTEM 4. Weight loss
I. Upper Respiratory System 5. Dyspnea
1. Filtering of air 6. Chest pain
2. Warming and moistening of air 7. Hemoptysis (chronic)
3. Humidification
A. Nose
- Cartillage D. Diagnostic Procedure
- Right nostril 1. Mantoux Test (skin test)
- Left nostril - Purified protein derivative
- Separated by septum - DOH 8 – 10 mm induration, 48 – 72 hours
- Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) - WHO 10 – 14 mm induration, 48 – 72 hours
B. Pharynx/Throat - Positive Mantoux test (previous exposure to tubercle bacilli but without active TB)
- Serves as a muscular passageway for both food and air
C. Larynx 2. Sputum Acid Fast Bacillus
- For phonation (voice production) - Positive to cultured microorganism
- For cough reflex
Glottis 3. Chest X-ray
- Opening of larynx - Reveals pulmonary infiltrates
- Opens to allow passage of air
- Closes to allow passage of food going to the esophagus 4. CBC
- The initial sign of complete airway obstruction is the inability to cough - Reveals increase WBC
- Chest physiotherapy ABG analysis – reveals PO2 decrease (hypoxemia), PCO 2 increase, pH decrease