FLUID AND ELECTROLYTES

Albumin – protein that causes blood to stay inside the vessel. (Osmotic Pressure)

Solutions:1. Isotonic

a. zero pressure solutionb. for dehydrated patientsc. Examples:

i. Plain NSS / .9 NSSii. Plain LRiii. Plain IMBiv. Plain solution

2. Hypertonica. increased pressured (shrink/crenation)b. increased solute, decreased solventc. Examples:

i. D5

ii. D10

iii. D50

3. Hypotonica. Decreased pressured (swelling)b. Decreased solute, increased solventc. Examples:

i. .30ii. .35iii. .45iv. .80

Edema Formation – hypertonic Hypertonic and diuretic go hand in hand!

***Electrolyte***

Sodium - sodium attracts water - water retention- Outside- Normal Value: 135-145 mmol/L or meq/L

Potassium- Inside- Important for contraction- Normal Value: 3.5-5.0 meq/L

Mineralocorticoid - sodium secretion- Example: aldosterone

Glucocorticoid - glucose- Example: cortisol

Fluid Disturbances:1. Fluid Volume

a. Deficit – Decreased ECFi. Causes:

1. Inadequate intake/absorption of water

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2. Increased renal losses (diurectic, Diabetes)3. Increased skins losses4. Increased gastrointestinal losses (vomiting, diarrhea)5. Third-spacing – movement of fluid in the body where

normally no fluid accumulates (ascitis)ii. Signs and Symptoms:

1. Thirst – early manifestation2. Weight loss – acute; 2.2 lbs/day3. Rough, dry tongue and it will shrink4. Poor skin turgor – ability of the skin to return to its normal

appearance (abdominal area – best site)5. Oliguria – urine output of >400 ml/24h6. Hemoconcentration – Test: Increased hematocrit7. Fever (late manifestation)8. Restlessness9. Weakness10. Decreased Level of Consciousness – Lethargy: early

manifestation in decreased LOC11. Decreased CVP – Normal: 4-6 mmHg (CVP is the pressure

that monitors the Right Atrium)12. Increased BUN – due to hemoconcentration

iii. Management:1. Fluid replacement2. Establish a patent line and start with isotonic solution3. Treat the underlying cause

b. Excess – increased ECFi. Signs and Symptoms:

ii. Signs and Symptoms: (Systemic)1. Acute weight gain2. Hypertension (due to fluid overload)3. Hepatosplenomegaly4. Engorge tongue5. Decreased hematocrit6. Increased CVP (hypervolemia)7. Distended neck vein/ neck vein engorgement – elevate head

of bed at 20 degrees angle; < 4cm – distended neck vein fluid volume excess

iii. Signs and Symptoms (Pulmonary)1. Cough (cardinal sign of Respiratory Problem)2. Dyspnea

a. Exertional Dyspneab. Orthopnea dyspneac. Paroxysmal nocturnal dyspnea

3. Rales or cracklesiv. Management:

2

Edema Formation

Systemic

Pulmonary

Systemic Congestio

n

Fluid migrates to pulmonary area

1. Dietary modification (low sodium diet)2. Fluid restrictions (1000 to 1300 ml/day)3. Diuretic Therapy (most effective)

v. Nursing Alerts1. Diuretics

a. Given in the morningb. Closely monitor for K and Nac. Not allowed to take food or beverages that increase

diuretics2. Fluid Volume Imbalances

a. Daily weighing – best way to assess fluid volume imbalances

2. Sodium Alterationsa. Hyponatremia

i. Decrease intake absorption of Naii. Increase intake (fluid volume excess)iii. Signs and Symptoms

1. Nausea and vomiting2. Headache3. Muscle cramps4. Restlessness5. Weakness6. Irritable7. Decrease LOC

iv. Management1. Increase Na diet2. Limit water intake

v. Drugs1. PNSS – replace sodium2. For severe – Diuretic/Hypertonic

b. Hypernatremiai. Life threatening condition – cause intracranial bleedingii. Signs and Symptoms

1. Thirst2. Dry, sticky mucus membrance3. Rough, dry tongue4. Fever5. Weakness6. Cramps7. Decrease LOC – due to intracranial bleeding8. Water retention

iii. Management1. Diet: Decrease Na 2. Fluid replacement

3. Potassium Alterationsa. Potassium and Hydrogen are bestfriendsb. Increase Potassium = Increase Hydrogen retention (decrease pH –

acidosis)c. Decrease Potassium = Hydrogen elimination (Increase pH – alkalosis)d. Hypokalemia and Hyperkalemia will give weaknesse. Hypokalemia potentiates the effect of digoxin

i. A decrease in Potassium = Increase the effect of digoxin (leading to digitalis toxicity)

f. Hyperkalemia increases the risk for cardiac arrestg. Potassium chloride must not be given in bolus or in high concentration. KCl

will be incorporated with PNSS. KCl = 20 mg/dL (maximum that you can give)

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h. Increase Potassium/hyperkalemia will increase sensitivity of insulin and glucose.

i. HYPOKALEMIAi. Decrease potassium levelii. Causes:

1. Decrease intake/inadequate absorption of K2. Increase renal losses3. Increase gastrointestinal losses4. Frequent gastric suctioning5. Disorders (Cushing’s Syndrome)

iii. Signs and Symptoms1. Generalized weakness2. Constipation3. Paralytic Ileus4. Fecal Impaction – passing of a liquid stool5. Dysrrhythmia/arrhythmia – drug: Lidocaine, xylocaine6. ECG changes – prominent U wave7. Muscle Cramps

iv. Diet1. Banana, dried food, meat, raisins, fruit juice (orange juice),

green leafy vegetables (malunggay – iron, Vitamin C, potassium)

2. 1 banana = 300 mg3. Potassium supplement – oral or parenteral

j. HYPERKALEMIAi. Causes:

1. Increase intake/absorption of potassium2. Renal failure Decrease potassium elimination

Potassium retention Hyperkalemia3. Release from intracellular to extracellular (e.g. burns,

Frequent BT)ii. Signs and Symptoms

1. Weakness2. Diarrhea3. Irritability4. Increased risk for cardiac arrest5. Muscle cramps6. Dysrrhythmia/arrhythmia 7. ECG changes – Peaked T wave

iii. Management:1. Diet: Low potassium diet2. Drugs: Diuretics/↑ OFI3. Insulin and D50 water4. Sodium polystyrene Sulfonate (kayexalate) – PO or enema

iv. Alert: Watch for hypernatremia4. Calcium Alterations

a. Calcium: Normal = 8.5 to 10.5 mg/dLi. Bone formationii. Strengthen boneiii. Contractioniv. Clot formation

b. HYPOCALCEMIAi. Decrease in calcium levelii. Causes:

1. Decrease intake/absorption of calcium2. Increase renal losses3. Decrease bone resorption

iii. Signs and Symptoms1. Neuromuscular Irritability

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a. Chvostek’s Signi. Tap 2 to 3 cm anterior to the ear lobe, patient

develops muscle twitchingb. Trousseau sign/Carpapedal Spasm

i. Get a BP cuff, inflate at the arms of the patient @ 100 mmHg. After 30 minutes, the patient fingers have spasms.

c. Hyperreflexiai. Hyperactive reflexes

2. Weakness3. Cramps4. Dysrrhythmia/arrhythmia5. Hypertension6. Irritability

iv. Management:1. Diet: High calcium

a. Diary products – milk (1 glass of milk = 300 mg of Ca)

b. Green leafy vegetablesc. Vitamin D (Calciferon) – enhances calciumd. Calcium-containing solutions

i. Calcium gluconateii. Calcium chlorideiii. Calcium gluceptate

c. HYPERCALCEMIAi. Too much calciumii. Causes:

1. Increase intake/absorption of calcium2. Increase bone resorption3. Decrease renal losses

iii. Signs and Symptoms1. Hyporeflexia2. Hypoactive bowel sound3. Hypotension4. Increase bone pain – due to bone resorption5. Flank pain – due to kidney stone formation

a. Most common form of kidney stone: Calcium Stonesiv. Management:

1. Diet: Low calcium2. Drugs: Diuretics, ↑ OFI, Calcitonin

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↓ Ca

Hypocalcemia

Parathyroid gland is stimulated

Parathormone:↑ Ca absorption

Promotes osteoclast activity (bone destroying)

↑ Calcium

3. Other Drugs: Biphosphonate, Plicamycin, Gallium Nitrate

5. Phosphate and Magnesium Alterationsa. Phosphate For: b. Magnesium Electrical Transmission/Neuronal Transmissionc. Normal Phosphate = 3.5 to 4.5 mg/dLd. Normal Magnesium = 2.7 mg/dLe. HYPOPHOPHATEMIA

i. Causes:1. Impaired renal function – most common2. Alcoholism - malnutrition

ii. Signs and Symptoms1. Seizures/convulsions2. Disorientation3. Weakness4. Lethargy5. Impaired WBC function6. Platelet dysfunction7. Anemia – G6PD deficiencies (hemolytic anemia) Glucose-6

Phosphate Dehydrogenase Deficiency anemiaiii. Management:

1. Diet:a. High phosphate dietb. Drink milk

i. 1 glass = 250 mgc. Fish – head d. Phosphate supplements: PO, Parenterale. Phosphate is contraindicated in:

i. Renal failureii. Hypocalcemia

(Why?)

f. HYPERPHOSPHATEMIA

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↑ Ca

Hypercalcemia

Thyroid gland stimulated

Calcitonin:Effects:

Decrease Ca absorptionCalcium deposition

↓ Calcium

Renal Failure ↓ Phosphate Elimination Phosphate retention

↓ Ca absorptionHypocalcemia Hyperphosphatemia

i. Increase phosphate in the bloodii. Causes:

1. Acute phosphate overload2. Renal failure3. Release from intracellular to extracellular

iii. Signs and Symptoms:1. Hyperphosphatemia will decrease Ca absorption leading to

hypocalcemia2. Signs and symptoms of hyperphosphatemia = hypocalcemia

a. Neuromuscular Irritabilityi. Chvostek’s Sign

1. Tap 2 to 3 cm anterior to the ear lobe, patient develops muscle twitching

ii. Trousseau sign/Carpapedal Spasm1. Get a BP cuff, inflate at the arms of the

patient @ 100 mmHg. After 30 minutes, the patient fingers have spasms.

iii. Hyperreflexia1. Hyperactive reflexes

b. Weaknessc. Crampsd. Dysrrhythmia/arrhythmiae. Hypertensionf. Irritability

iv. Management: 1. Diet: Low phosphate diet, High Ca diet2. Drugs:

a. Diuretics/Increase Ob. Ca supplements

3. Severe: Dialysisg. HYPOMAGNESEMIA

i. Causes1. Elimination of magnesium (ex. Diarrhea)2. Decrease intake/absorption of magnesium

ii. Signs and Symptoms1. Hypertension2. Seizures3. Neuromuscular irritability4. Weakness5. Cramps/Paresthesia (numbness or tingling sensation)

iii. Management:1. Give Magnesium Sulfate

a. Check DTRb. Check BP Magnesiumc. Check RR Toxicityd. Check UOe. Magnesium sulfate toxicity/Hypermagnesemia

h. HYPERMAGNESEMIAi. Causes

1. Decrease elimination2. Acute magnesium overload

ii. Signs and Symptoms1. Diminished or absent reflexes (earliest manifestation)2. Hypotension3. Respiratory Depression4. Oliguria5. Patient develops irritability6. Facial flushing

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7. Risk for cardiac arrestiii. Management

1. Stop giving magnesium2. Give calcium containing solution3. Severe: Dialysis

ACID-BASE BALANCES

Normal ABG ResultspH 7.35 to 7.45PO2 80 to 100 mmHgPCO2 35 to 45 mmHgHCO3 22 to 26 mEq/L

**HCO3 – neutralizes acidity

Interpretation of

Results↑ pH Alkalosis↓ pH Acidosis

↑ HCO3 Alkalosis↓ HCO3 Acidosis

↓ PO2 Hypoxia↓ O2 Hypoxia

↑ CO2 Hypercapnia

↓ CO2 Hypocapnia

Nursing Alerts1. Respiratory and urinary systems are systems that will regulate acid-base.2. Vasodilation is the common effect of acidosis.3. Vasoconstriction is the common effect of alkalosis.

4. Hyperventilation leads to respiratory alkalosis.Hyperventilation ↑ CO2 loss Hypocapnia ↑ pH (alkalosis) Respiratory

5. Hypoventilation leads to respiratory acidosisHopoventilation ↓ CO2 loss Hypercapnia ↓ pH (acidosis) Respiratory

6. Vomiting and frequent gastric suctioning leads to metabolic alkalosisVomiting and frequent gastric suctioning ↑ gastric acid loss ↑ pH (alkalosis) Metabolic

7. Diarrhea leads to metabolic acidosisDiarrhea ↑ fluid loss ↑ Hydrogen concentration ↓ pH (acidosis) Metabolic

8. Severe vomiting leads to metabolic acidosisSevere vomiting profound ↑ gastric acid loss Stimulates: Parietal cells to produce more HCl acid (compensation) ↓ pH (acidosis) Metabolic

RESPIRATORY ALKALOSIS

pH PaCO2

HCO3

Uncompensated ↑ ↓ NPartially compensated

↑ ↓ ↓

Fully compensated

N ↓ ↓

Causes:1. Hyperventilation

a. Factors:i. Anxietyii. Too much laughingiii. Feveriv. CNS infectionsv. Ingestion of toxic substances/agent (Alkaseltzer)

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2. Hypokalemia3. Metabolic Acidosis

Signs and Symptoms1. Seizures2. Deep, rapid breathing3. Hyperventilation4. Confusion5. Hypokalemia6. Light headedness7. Tingling of extremities

Management1. Breath in a cuphand or paper bag regardless of the color2. Drugs:

a. Sedative (to correct anxiety)b. Anxiolyticc. Narcoticsd. Antipyretic

3. Treat infections

RESPIRATORY ACIDOSIS

pH PaCO2

HCO3

Uncompensated ↓ ↑ NPartially compensated

↓ ↑ ↑

Fully compensated

N ↑ ↑

Causes:1. Hypoventilation

a. Factors: Damage: Medulla Oblongata (Center for Respiratory, BP, HR) Respiratory Disorders Chest trauma Neurologic problem (CVA, Seizures, Alzheimers) Neuromuscular problem (MS, MG)

2. Hyperkalemia3. Suffocation4. Metablic Alkalosis

Signs and Symptoms1. Hypoventilation2. Rapid, shallow breathing3. Increase BP4. Dyspnea5. Hyperkalemia6. Disorganization7. Increase cardiac output8. Muscle weakness9. Hypoxemia

Management1. Acute

a. IV Sodium Barcarbonate (NaHCO3) – less than 7.15 pHb. Check for patent line because it can cause 3rd degree chemical burn

2. Chronic

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a. PO Sodium Bicarbonate (NaHCO3)3. Hook patient to a mechanical ventilator to aide the patient to breath

3 Alarms in the mechanical ventilator:a. High Alarm – obstruction Suction Auscultate if suctioning is effectiveb. Low Pressure Alarm – leakage/loose connections correct the tubingc. Apnea Alarm – Nobody is hooked at the ventilatord. If you cannot figure out what cause the alarm, do bagging manually. Give

the patient oxygen vial bagging (Ambubag)

METABOLIC ACIDOSIS

pH PaCO2

HCO3

Uncompensated ↓ N ↓Partially compensated

↓ ↓ ↓

Fully compensated

N ↓ ↓

Causes:1. Diarrhea2. Severe vomiting3. Renal Failure – Decrease hydrogen elimination Metabolic Acidosis4. Increase fat metabolism (DM)

↑ Fats Fatty Acids Yields kenones DKA (form of metabolic acidosis) Penetrate blood brain barrier Diabetic Coma

5. Hyperkalemia6. Respiratory Alkalosis

Signs and Symptoms1. Headache2. Disorientation3. Hyperkalemia4. Muscle twitching5. Changes in LOC6. Kussmaul Respiration

Management1. Acute: IV NaHCO32. Severe: PO NaHCO33. Same management with Respiratory Acidosis

METABOLIC ALKALOSIS

pH PaCO2

HCO3

Uncompensated ↑ N ↑Partially compensated

↑ ↑ ↑

Fully compensated

N ↑ ↑

Causes:1. Vomiting2. Frequent gastric suctioning3. Acute HCO2 overload4. Hypokalemia5. Respiratory Acidosis (Decrease pH)

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Signs and Symptoms1. Restlessness followed by lethargy2. Dysrrhythmia3. Compensatory hypoventilation4. Diarrhea5. Confusion (decrease LOC)6. Nausea and vomiting

Management:1. Mild: Na treatment2. Vomiting

a. Give antiemetic as orderedb. Give KCl + PNSS (to replace gastric losses)

3. Severe: Give IV ammonium chlorideNursing Alerta. Contraindicated to hepatic or renal disordersb. Must not be given I liter in 4 hours

4. Drugs: Acetazolamide (Diuretic) – promote excretion/elimination of HCO3 and potassium

BURNS- Refers to cell death or tissue death due to an extreme heat caused by chemical,

geothermal, radiation, fire and electricity

Classification:1. First Degree Partial thickness burn2. Second Degree3. Third Degree Full thickness burn4. Fourth Degree

Classification

LAYER COMMON PRESENTATION

First Epidermis Redness/ErythmaSecond Epidemis + Dermis Blisters/most painfulThird Skin + Subcutaenous Charcoal/Edema and

EscharFourth Skin + Subcutaneous +

Muscles + BonesPainless

HealingClassific

ationHealing

First 3 to 7 daysSecond Average 21 daysThird Skin grafting – 3 types:

*Autograft – self *Xenograft/Heterograft – animal cow/pig *Allograft – cadaver

Fourth Skin grafting and amputationEschar – tough coagulum of necrotic tissue (“kugang”)Compartment Syndrome – 3rd degree burnSigns and Symptoms of Compartment Syndrome

1. Pain2. Pallor3. Paralysis4. Pulselessness5. Paresthesia (numbness and tingling sensation)6. Poikilothermia (coolness of the skin surface)

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1st Nursing Action:1. Elevate extremity – for venous return2. Report to doctor

TBSA (Total Body Surface Area)- area of injury- Rule of Nines

o Head (includes neck) – 9%o Anterior Trunk – 18%o Posterior Trunk – 18%o Each arm – 9%o Each leg – 18%o Perineum – 1%

- Major Burn: More than 25%o Systemic complications arise if the patient sustained major burnso Systemic Complications of Burns:

Hemodynamic instability (starts immediately) Talks about blood Begins almost immediately with injury to capillaries Problem with blood circulation; poor perfusion (secondary to

fluid shifting secondary to increased permeability) Because of the burn, there is increased permeability.

Leading to shifting of plasma to interstitial fluid. Respiratory dysfunction

Common cause of death (carbon monoxide poisoning) Carbon monoxide has greater affinity to hemoglobin

Carboxy hemoglobin – hemoglobin filled with carbon; decreased oxygen carrying ability hypoxemia hypoxia

Hemoglobino Heme – where oxygen bindso Globin – where carbon dioxide binds

Hypermetabolic Response Due to the injury sustained by the patient As a nurse, what is the implication if patient has

hypermetabolic response:o Increased metabolism – would lead to increased

metabolic acid production metabolic acidosiso Increased calorie requirement – 6,000 to 8,000

cal/day (Normal: 1200 to 2000 cal/day), therefore TPN is important. Diet of patient should be high calorie, high protein, high carbohydrates.

Organ Dysfunction Due to shock, hemodynamic instability

Sepsis and Immune dysfunction A small break in skin would lead to infection Patient is immunocompromised – therefore put the patient in

reverse isolation Doctors would prescribe antibiotic – common drug given:

Silvadene Not topical, IM but IVTT route

Pain – give analgesic (Morphine Sulfate 2 mg/hr until pain goes away)

Morphine – narcotic analgesic; can cause addiction. Watch for respiratory depression and drug addiction. Antidote: Naloxone (Narcan)

Emotional trauma – intervention: therapeutic communication (let the patient verbalize fear) Do not start the question with why

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In General, if patient got BURN ( more than 25% ), it would give 4 major problem:

Cell lysiso Can cause release of potassium from intracellular to

extracellular can cause hyperkalemia Increased heart rate decreased cardiac output decreased tissue perfusion organ dysfunctions

Possible inhalation injuryo Would lead to Carboxy hemoglobin decreased

oxygen carrying ability Hypoxemia decreased tissue perfusion

Break in the physical barriero Lead to Increased infection and altered

thermoregulation Increased permeability

o Lead to fluid shifting (Effects) Hemoconcentration (increased in Hct) Hyponatremia

o Burn Shock (An example of hypovolemic shock)o Burn shock requires massive stress responseo MSR stimulates adrenal gland/ Release of

Catecholamineso Simulation of adrenal gland would lead to following

problems: Hyperglycemia Increased metabolism

Would lead to metabolic acidosis Would increase calorie requirements

Increased hydrochloric acid Curling’s Ulcer Tissue Injury (due to catecholamines released;

infection also would lead to tissue injury) Increased heart rate decreased cardiac

output- Stages of BURNS

o Emergent Phase Occurs when? Actual exposure to extreme heat

o Shock Phase Occurs on the first 24-48 hours post burn (movement of fluid is

from plasma to interstitial)o Diuresis / Fluid Remobilization Phase

Occurs 2 to 5 days post burn During this phase, movement of fluid is interstitial to plasma (there

will be hemodilution), therefore, cge ihi (diuresis) to prevent congestion

Priority: Prevention of congestiono Rehabilitation Phase / Convalescent Phase / Recovery Phase

Will only start if diuresis is completedo Resuscitative Phase – a combination of emergent and shock phase

- Fluid and Electrolyte Changes During Burnso Emergent Phase/Shock/Resuscitative Phase

Generalized dehydration (plasma to interstitial) Reduction of blood volume Decreased urine output Hyperkalemia (due to cell lysis) Hyponatremia (due to fluid shifting) Metabolic acidosis Hemoconcentration (elevated Hct)

o Diuresis Phase

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Hemodilution (decreased Hct) Increased urine output compensation (because of hemodilution) Hyponatremia (due to dilution) Hypokalemia (early stage: Hyperkalemia, hyponatremia.. Later on:

Hypokalemia, hyponatremia) Metabolic acidosis (due to the injury sustained by the patient)

o Rehabilitation Phase No more imbalances

- Phases of Burn Care Prioritieso Emergent/Shock Phase

First aid – safety; prevent added injury Rescue the patient/Remove the patient to a safe place Activate the alarm Confine or contain the fire – How: close the door, lower the

curtain, close the windows Extinguish the fire

o Pull the safety pino Aim the nozzle o Squeeze

Evacuateo Who to evacuate first? Well patient

Prevention of shock/respiratory distress Detection and treatment of injuries Wound assessment and care – evaluate the degree of damage;

reassess the patient from time to timeo Diuretic Phase or Fluid Remobilization Phase

Wound care and closure Prevention and treatment of complications Nutritional Support

o Rehabilitation Phase Prevention of scars and contractures

How to prevent scars?o Let patient wear anti-scar stocking

Best time to wear: must be worn a week after healing has completed

For how long: 16 to 18 months, maximum of 2 years

How often: wear 23 hours/day How to prevent contractures (happens because you fail to

position the patient properly)o Position: Anatomical position (Extremities extended,

digits abducted) Physical, occupational and vocational rehabilitation

Start rehab upon admission When do rehab phase begin: when diuresis is completed

Functional and cosmetic reconstruction Psychosocial counseling

- Treatment:o Soak burned area in cool water not more than 10 minutes. If more than 10

minutes, it would cause severe vasoconstriction and would impede normal flow of blood.

o Prevent causal agent from producing further tissue damage – FIRST ACTION

o Emergency care includes: Resuscitation Stabilization with IV while maintaining cardiac and respiratory

functiono Hospital setting

Fluid replacement

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Maintenance of nutritional demands (TPN)o Antibiotic Therapyo Maintenance of cardiac and respiratory functiono Pain managemento Emotional supporto Prevention of complicationso Skin graftingo Rehabilitation

- Common Complicationso Respiratory Dysfunctiono Infectiono Fluids and electrolyte imbalanceso Paino DBT (Deep Vein Thrombosis)o DIC (Disseminated Intravascular Coagulation) or Blood coagulopathyo Body image disturbanceo Compartment syndrome

(Escharotomy; Escharectomy) – can be performed on bedside without anesthesia

Fasciotomy – OR under general anesthesia

OXYGENATION- refers to perfusion of gases- not only oxygen, but also involves carbon dioxide- 3 systems involved:

o Respiratoryo Hemotopoesiso Cardiovascular

RESPIRATORY SYSTEMSneeze – reflex that clears upper respiratory tractVibriscae – hair of the nose; filter the air coming inEpiglottis – division of upper and lower respiratory systemCough – reflex that clears lower respiratory tractVocal cords

- one injury: hoarseness of voice- both are injured: loss of voice- paralysis:

Airway obstruction – noisy breathingComplete airway obstruction – loss of voiceGlobet cells – produce mucusCarina – anatomical landmark for the tip of endotracheal tubeHering-Breuer Reflex – reflex that govern inflation or deflation process of alveoliIntrathoracic – negative pressure

Nursing Diagnosis:1. Altered tissue perfusion

a. Used if there is circulatory obstructionb. Dili pwede sa respiratory problemsc. Example: MI, DVT, Pulmonary Embolism, Angina Pectoris

2. Impaired Gas Exchangea. Used if the patient is having alveolar problem or lung problemb. Example: Patient having emphysema - there is loss of lung elasticity;

patient having or too much mucus production; 3. Ineffective Breathing Pattern

a. Used if the patient has hypoventilation or hyperventilation4. Ineffective Airway Clearance

a. Used if patient has airway obstruction

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b. Example: Bronchitis, Asthma

RESPIRATORY DISORDERS1. Restrictive Lung Disease

a. Are any process that limits lung expansionb. Limits movement of air into the lungsc. Inspiratory problemd. Example: Atelectasis, Infections (PTB, Pneumonia), Chest Trauma

(Hemothorax, Tension Pneumothorax, Pneumothorax)2. COPD/CAL (Chronic Airway Limitation)

a. Any process that limits movement of air out from the lungsb. Expiratory problemc. Safest oxygen flow rate: 1 to 2 L/min ONLYd. 6 L/min – the more it causes dyspnea; If oxygen increases, carbon dioxide

decreases, so there is hypocapnea; kung walay carbon dioxide, walay stimulator, so it would lead to respiratory depression

e. Most appropriate oxygen device: Venturi Mask (Because venturi mask is the only device that would give you the accurate oxygen concentration) Next: Nasal Cannula

f. Croup Tent – important nursing intervention: tuck the sides g. Most common cardiovascular for COPD: Cardiomegaly (right ventricular

hypertrophy or cor pulmonale) h. Example: Emphysema, Bronchitis, Bronchiectasis, Asthma

3. Pulmonary Vascular Disordera. Any problem affecting the vascular compartment of the pulmonary areab. Example: Cor Pulmonale, Pulmonary Embolism

Restrictive Lung Disorders1. Atelectasis

a. Definition: Collapse of a previously inflated lung tissueb. 2 Major Types:

i. Primary – a type of atelectasis brought about by surfactant1. common among premature babies (SIDS/ARDS) –

betamethasone promotes lung maturityii. Secondary – brought about by compression or obstruction

1. compression: hemothorax and pneumothorax2. obstruction: aspiration

c. Signs and Symptomsi. Dyspneaii. Cough iii. Hypoxia iv. Chest painv. Asymmetrical lung expansionvi. Decreased breath sound on the affected lung fieldvii. Restlessness viii. Cold, clammy skin

d. Appropriate Nursing Diagnosis:i. Impaired Gas Exchange

e. Diagnostic Testi. Chest X-ray – confirms collapsed Lungii. ABG

1. decreased PH2. increased PCO23. decreased PO24. Reading: Respiratory acidosis, hypoxia

f. Managementi. Drugs:

1. Bronchodilator

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a. Ventolin, Aminophyline (given parenteral), Theophylline (given PO)

2. Anticholinergic Drug – decreases spasm, decreases mucus production

3. Antibiotic4. Anticholinergic

ii. Specific Nursing Management:1. Position: High Fowler’s Position – to promote lung expansion2. Give oxygen supplement – to correct hypoxia3. Hook the patient in respiratory support 4. Treat the underlying cause/problem5. Decrease environment and physical stimuli – to decrease

oxygen demand; limit visitors2. Chest Trauma

a. Common cause: accidentb. Types:

i. Blunt/Non-Penetrating Chest Trauma1. Common problem is FLAIL CHEST – arise from three or more

fractured ribs adjacent to each other / multiple rib fracture. These fractured ribs become loose ribs, piercing own lung tissue during inspiration (Paradoxical Respiration).

2. Management: Hook the patient in mechanical ventilator, to facilitate healing of the fractured rib.

ii. Penetrating Chest Trauma1. Common problems:

a. Hemothorax – refers to blood in pleural spacei. Accumulation of blood in the lower lobe

b. Pneumothorax – airi. Upper lobe

c. HemoPneumothoraxi. 1 tube in the lower lobe

d. Tension Pneumothoraxi. During inspiration, the hole opens allowing air

to get inside. During expiration, it closes. So air is trapped inside the lungs.

ii. Mediastinal shift – common in pneumothorax, if not corrected would lead to cardiogenic shock or atelectasis

2. Thoracentesis3.

c. Thoracentesisi. A form of invasive procedure that involves insertion of needle in the

pleural space to drain air or fluid for the purpose of diagnosis or treatment

ii. Main Reason: to restore a negative pressured cavityiii. Nursing responsibilities before insertion:

1. Check Doctor’s order2. Witness signing of consent3. Check the vital signs of the patient – pay attention on RR4. Check chest x-ray result – 5. Teach deep breathing exercises

iv. Nursing responsibility during insertion1. Best position: sitting position or high-fowler’s position,

leaning forward, arms supported on a high-chair or arms elevated.

2. What to instruct during insertion: Exhale and close your glottis / valsalva’s maneuver higher intrathoracic pressure preventing entry of air into the lungs of the patient, prevents pneumothorax

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3. Exact site:a. Drain air: insertion is on the 2nd or 3rd intercostal

spacesb. Drain fluid: insertion is on 5th or 6th intercostal spaces

v. Nursing responsibility after insertion:1. Best position: Lying on the good side or unaffected side2. Check the site of insertion3. Check the vital signs of the patient – particularly the RR of

patient4. Check tidaling or oscillation (fluctuation or the rise and fall of

fluid in the tube during respiration) – this is normal. If walay tidaling, the needle is out or there is obstruction in the tube. During inspiration, fluid rises. During expiration, fluid falls.

vi. Nursing alerts:1. Keep collecting bottle below the level of insertion2. Do not clamp the tube for long period of time. Because it

can cause tension pneumothorax. Clamp the tube not more than 30 minutes.

3. Clamp the tube as close to the patient’s body.4. Do not milk the tube. Because it creates pressure inside, it

causes suction and cause damage on the pleural tissue.vii. Interpretation:

1. Intermittent Bubblinga. Indicates that the lung had reexpanded

2. Continuous Bubblinga. Indicates leakage

3. No drainage coming outa. Indicates resolution

viii. One-way bottle systemix. Two-way bottle systemx. Three-way bottle system

** Immersed 2cm below

COPD/CAL1. Emphysema

a. Loss of lung elasticityb. Irreversiblec. Causes:

i. Smokingii. Deficiency in antitrypsin – an enzyme that causes destruction of the

alveolar walliii. Chemical exposure – asbestos

d. Pathologic Changesi. Loss of lung elasticityii. Formation of Bulla/Bullaeiii. Hyperinflation of lung tissue - Common result of chest x-ray: Barrel

chest (increased AP Diameter) Hyperresonant soundiv. Small air trapping or collapse

e. Typesi. Panlobular – upper lobeii. Centrolobular – common in central aspect of lung tissueiii. Paraseptal Distal Acinar Emphysema – distal part of lung tissue

f. Diagnostic Testi. Chest x-ray – barrel chest; increased AP diameterii. Decreased PH, increased PCO2, decreased PO2iii. Pulmonary function test

1. Incentive Spirometer – Normal: increased in the residual volume and a decrease in the expiratory reserved volume

iv.

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g. Pink Pufferi. Increased CO2 retention (pink)ii. No cyanosisiii. Purse lip breathingiv. Dyspneav. Ineffective coughvi. Hyperresonance on percussionvii. Orthopneicviii. Barrel chestix. Exertional dyspneax. Prolonged expiratory timexi. Speaks in short jerky sentencesxii. Anxiousxiii. Use of accessory muscles to breathexiv. Thin appearance

h. Management:i. Drugs:

1. Bronchodilator2. Antibiotic 3. Anticholinergic drug4. Mucolytic expectorant

ii. Nursing Management:1. Cessation of smoking

a. How to convince? Tell the patient on the consequences of his action.

2. Oxygen supplement3. Diet of patient

a. High caloriesb. High proteinc. High fiber

4. Avoid pollutants or other irritating substances5. Assist or prepare the patient for surgery

a. Surgical procedures:i. Lobectomy – part of a lung

1. Best position post lobectomy: lying on good side

2. Chest tube inserted in patients lungii. Pneumonectomy – entire lung

1. Best position post pneumonectomy: lying on the affected or bad side. New answer: lying high fowler’s position

2. Bronchitisa. Refers to inflammation of the bronchial area due to inhalation of noxious

fumes or irritating substancesb. “Smoker’s cough”c. Common cause: Smoking (same with emphysema except decreased in

antitrypsin)d. The problem is inflammation, too much mucus production which leads to

obstructione. Reversible problemf. Termed as “blue bloaters”

i. Blue because there is cyanosisii. Bloaters due to edema formation and clubbing of fingers

(secondary to chronic hypoxia)iii. Edema Right ventricular hypertrophy CHFiv. Schamroth method – method used to determine clubbing of fingersv. Normal degree angle of nail: 160 degrees

1. If > 160 but < 180 = early clubbing

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2. IF > 180 = advanced clubbing/ digital clubbingvi.

g. Nursing Diagnosis: Ineffective Airway Clearanceh. Chronic Bronchitis “Blue Bloaters”

i. Color dusky to cyanoticii. Recurrent cough and increased sputum productioniii. Hypoxiaiv. Hypercapniav. Acidosisvi. Edematousvii. Increased respiratory rateviii. Exertional dyspneaix. Increased incidence in heavy cigarette smokersx. Digital clubbing

i. Diagnostic Testi. X-ray – constriction in the bronchial airway

1. increased mucus production2. ABG – same with emphysema, respiratory acidosis and

hypoxia3. Pulmonary function test – same with emphysema

j. Management:i. Most important management is cessation of smoking

1. Perception of own’s behavior – first question to be asked for patient’s under rehabilitation

ii. Common drugs1. Bronchodilator

a. Closely monitor normal theophylline and aminophylline level which is 10 to 20 unit gram/dL

b. If > 20: theophylline or aminophylline toxicityc. Indicators of aminophylline and theophylline toxicity

i. Patient develops nausea and vomitingii. Headacheiii. Chest painiv. Palpitations – unpleasant awareness of

heartbeatv. Tremors or shakiness

d. Meter Dosed Inhaleri. Instruction: Simultaneously squeeze and

inhale deeply to deliver the drug directly in the respiratory system

2. Corticosteroidsa. Anti-inflammatoryb. If patient is using corticosteroids, corticosteroids

must not be taken for long periods of time because it causes immune suppression. So watch out for signs and symptoms of infections.

c. It can also cause cushing’s syndrome or hypercorticolism.

d. Do not stop corticosteroid abruptly, it must be gradual.

e. Corticosteroids cause gynecomastia3. Anticholinergic drug

a. Decreases mucus productionb. Example: atrophine sulfatec. Are also anti spasmodic

4. Beta blockersa. Help dilate bronchial areab. What is the most life-threatening side effect:

BRONCHOSPASM. That is why it is contraindicated to

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asthmatic patient because the more it causes bronchospasm.

c. Beta blocker may mask the signs and symptoms of shock and hypoglycemia. So closely monitor blood sugar level.

d. What is the first drug given to patient? Bronchodilator.

e. Corticosteroid first before beta blocker to subside inflammation first, so that beta blocker can get inside.

5. Antibiotica. Prophylaxis against infection

6. Diureticiii. Nursing Management

1. Oxygen supplement is important2. Watch for water retention3. High fowler’s position to relieve dyspnea4. Limit visitors, decrease environment and physical stimuli5. Diet is similar with emphysema

3. Bronchiectasisa. Permanent dilation

Emphysema Smoking and Increased CO2

Pink puffers - no cyanosis- hypercapnia

Vasodilation

Blood congestion

Pulmonary Vascular Disease1. Cor Pulmonale

a. Refers to enlargement of the right ventricle due to constriction on the pulmonary vessels secondary to respiratory disorders

b. Management: treat respiratory disorder2. Pulmonary Embolism

a. Narrowing or occlusion in one or more pulmonary vesselb. Causes:

i. Clotii. Cholesterol or fat or lipidiii. Amniotic fluidiv. Air embolism

c. Common questioni. What is the best position to patient suspected of pulmonary

embolism? Trendelenberg position (because if head is higher, air will go to the head)

ii. What position, right or left side lying position? Left side-lying position (if right lung is on top, air bubbles will get inside the right lung, then it will be absorbed by the pulmonary arteries correcting pulmonary embolism)

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d. Signs and symptomsi. Acute chest painii. Dyspneaiii. Coughiv. Nausea and vomitingv. Cold, clammy skin

e. Signs and symptoms of shocki. Restlessnessii. Diaphoresisiii. Pleuritic pain – there is pain when you inhale deeply

f. Diagnostic testi. Confirmatory test: PULMONARY ANGIOGRAPHY

1. a procedure that will evaluate patency of blood vessel2. doctors will make use of femoral line3. In any form of angiography assess peripheral or distal pulses

before and after procedure4. If after angiography, no pulses, damaged ang artery.

Therefore, inform the doctor immediately.5. Post angriography, increase OFI to facilitate elimination of

dye or contrasts.ii.

g. Nursing Diagnosis: Altered Tissue Perfusion, Alteration in comfort h. Drugs:

i. Anticoagulant – prevents clot formation1. example: Aspirin, Heparin, Warfarin, Coumadin2. Best diagnostic test that would evaluate effectiveness of

Heparin: Partial Thromboplastin Time (PTT) or Clotting time Antidote: Protamine Sulfate

a. Can you give Heparin to pregnant mothers? YES because heparin cannot pass the placenta.

b. Protamine Sulfate is still anticoagulant. But kung mag meet sila sa Heparin, mahimo siya coagulant.

3. Best diagnostic test that would evaluate effectiveness of Warfarin: PT Antidote: Vitamin K

4. Watch for bleeding!ii. Thrombolytic Drug

1. Streptokinasea. Dissolves the bloodb. An enzyme that is from a bacteria. That’s why do not

give to immunosuppressed.c. Delivered through IV pumpd. *** Must be given within 6 hours. But better if given

within 3 hours.iii. Analgesic

1. Morphine Sulfateiv.

i. Nursing Managementi. Best position: High fowler’s position to promote lung expansion

except for air embolismii. Oxygen supplement is importantiii. If there’s a need to hook the patient in respiratory support, do so.iv. Decrease environment and physical stimuli.v. Prepare the patient for surgery. Removal of clot (Embolectomy)

BLOOD- important for the following reasons:

o transportationo protectiono regulation

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- Pluripotent – a cell that will subdivide into several types of cellso Myloid – RBC, WBC, Plateleto Lymphoid – B-Lymphocytes and T-Lymphocytes

- RBC – 4.8 to 5.4 m/mm3 - WBC – 5000 to 10,000/mm3- Platelet – 150,000 to 450,000/mm3

o Thrombocytopenia – less than normal plateleto Thrombocytosis – too much platelet

- Blood volumeo Male - 5 to 6 literso Female - 4 to 5 liters

- Blood coloro Oxygenated blood – bright redo Deoxygenated blood – dull red

- Ph of bloodo 7.35 to 7.45o Slightly alkaline in nature

- Normal Temperature = 38 degrees celsius- Taste: It has a metallic taste- Different Blood Types

o Type A Can transfuse type A and O

o Type B Type B and O

o Type O – Universal Donor Type O

o Type AB – Universal Recipient A, B, AB, O

- Rho Rh+

a blood with Rh antigeno Rh-

a blood without Rh antigen - O- - if you don’t know the blood type, type O can be given. Negative because the

safest blood is a blood that has no Rh antigen.o Ideally ang ihatag nimo nga blood for type O- nga patient, is blood type O.

But in cases of emergency, pwede maghatag ug type 0+ provided that it is his FIRST transfusion. Ang succeeding na daun niya nga transfusion should be O- throughout his life. If maghatag ka ug 0+ the 2nd time around, i-destroy na pud to niya ang daan nga antigen, resulting to hemolysis.

Blood Disorders1. ANEMIA – it is not a disease but a condition where there is a decrease in RBC #

and a decrease in hemoglobin massa. Common denominator among Anemias: Decreased oxygen carrying abilityb. Common Signs and Symptoms

i. Pallor ii. Weaknessiii. Headacheiv. Dizzinessv. **Easy fatigability or easy exhaustion – is very common among

Iron-Deficiency anemia.vi. Patient develops pica – cause of pica is unknown; common among

iron-deficiency anemiavii. Neurologic Deficits – common among patients with pernicious

anemia; priority is safety of patientviii. Beefy red tongue or sore in the tongue – common to patients with

pernicious anemia

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1. **Strawberry tongue – Kawasaki2. **Red or white strawberry tongue – Scarlet fever

c. Chronic manifestations of late anemiai. Koilonychia – spoon-like nail because of hypoxiaii. Angular Chelliosis – ulcer formation on the side of the mouth; an

indication of chronic anemiaiii. Hyperthyroidism – common to patient with iron-deficiency anemia

because iron is important to the synthesis of T3 and T4iv. Chronic infectionv. Cardiomegalyvi. Heart failurevii. Generalized edema

d. Classifications of Anemiai. Anemia secondary to blood loss – anemia results from bleeding

1. Acute Anemiaa. Suddenb. Conditions: Hemorrhage

2. Chronic Anemiaa. Occurs graduallyb. Conditions: Peptic Ulcer Disease, Ulcerative Colitis,

Bleeding hemorrhoidsc. Management:

i. Blood Transfusionii. Correct underlying cause

ii. Anemia secondary to nutritional deficiencies – most common anemia in the Philippines due to poverty

1. Iron-Deficiency Anemiaa. Patient must have iron supplementb. Food rich in iron:

i. Green leafy vegetablesii.

c. Nursing Alerts for Ironi. Iron is best absorbed in an empty stomachii. Iron is gastric irritant iii. Iron must be taken 30 minutes before meal or

an hour after mealiv. Iron must be taken together with vitamin C –

vitamin c enhances iron absorption. 70 cc is enough to enhance iron absorption.

v. Pediatric with Iron Deficiency Anemia. The best indicator that iron supplement is effective: A change in the stool characteristics. What is that change? It becomes a black tarry stool or green stool.

d. Drug of choice against iron toxicity: 1gm DEFEROXAMINE (Destferal) 1gm can neutralize 75 mg of iron

e. Antidote of iron hypersensitivity: EPINEPHRINEf. Iron preparations

i. Tabletii. Liquid** - if taken in liquid form, do not forget

to use straw or medicine dropper because it can cause permanent discoloration of the teeth, which is brown to black in color.

1. The most important nursing action after giving iron in liquid form is Oral Care.

iii. Parenteral1. Example: Dextran Forte

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2. Do not forget, you have to give deep IM Z-track technique.

2. Megaloblastic Anemiaa. Folate/Folic Acid Anemia

i. Folic Acid is important for DNA and RNA synthesis of RBC. Also important to prevent neural tube defects.

ii. As a result, the bone marrow of the patient will compensate. That compensation is that the bone marrow produces large cells.

iii. Implication: iv. Folic Acid dosage: 1mg/day

b. Pernicious Anemiai. The problem is that you have a deficiency in

Vitamin B12ii. Either there is no parietal cells or no intrinsic

factor.iii. Without intrinsic factor, you cannot absorb

vitamin B12iv. B12 is absorbed in the Ileum part of the small

intestine. So maski naay intrinsic factor, but wala na ang Ileum, naa japun ka pernicious anemia.

v. HALLMARK: Beefy red tongue or red beefy tongue or sore in the tongue

vi. Confirmatory Test: Schilling’s Test1. Hatagan ug 2 ka klase nga B12 ang

patient, that is Radioactive B12 (PO) and Non-radioactive (IM)

2. 6 to 9% of the radioactive substances will be eliminated through urine within 24 hours. Therefore the most important nursing action during Schilling’s test, is 24-hour urine collection.

3. If may radioactive substances ang urine, negative for pernicious anemia.

4. If there is no radioactive substance, there is pernicious anemia.

5. Ang non-radioactive pang buffer lang.vii. Lifelong administration of B12

1. Dosage: 1000 units of Vitamin B122. Frequency: every month3. Route: IM, vastus lateralis

3. G6PD Deficiency Anemiaa. Glucose 6 Phosphate Dehydrogenase Deficiencyb. G6PD is important for glucose metabolism.c. There is hemolysis because of too much glucose,

because there is no metabolism of glucose due to the deficiency in G6PD

d. Added Manifestations i. Weaknessii. Petichaeiii. Hepatosplenomegalyiv. Hemoglobinuriav. Bloody urinevi. Renal shut down

e. Management:i. Diet: high phosphate diet

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ii. Blood transfusioniii. BMT – Bone Marrow Transplant (3 types)

1. Antologousa. The donor will be the patient

himselfb. When do doctors harvest bone

marrow of the patient? During period of Remission. Remission is a time when no laboratory tests can identify presence of cancer cells or abnormal cells.

2. Allogeneica. The donors are the siblings or

brothers or sisters. It must be compatible.

3. Syngeneica. Donor is the identical twin.

iii. Anemia secondary to Impaired RBC Production – the problem here is the bone marrow of the patient. It is not producing sufficient or mature blood cells.

1. Aplastic Anemiaa. A rare blood disorder characterized by a decrease in

the bone marrow elements of unknown reason.b. A precursor for leukemia.c. Decreased bone marrow elements, so decreased

RBC, WBC (pancytopenia) and platelet.d. Aplastic anemia and pancytopenia are the same.e. Patients are immunocompromised so important ang

reverse isolation. Observe strict aseptic technique.f. Platelet is decreased so bleeding is common. So no

invasive procedures and no aspirin.g. Drug of choice: Bone Marrow Suppressant –

METHOTREXATE or Cytosani. I-suppress ang bone marrow para magstop

siya ug produce ug immature blood cells.ii. Antibioticiii. BTiv. BMT

2. Sickle Cell Anemiaa. A blood disorder characterized by production of a

defective hemoglobin Sb. Hemoglobin S – sicklingc. Sickle Cell Crisis or vaso occlusive crisis – common

cause: hypoxiad. ***Oxygen supplement – to prevent hypoxiae. ***Hydrate, hydrate, hydrate the patient – to prevent

clot formationf. Infarctiong. Effects of Sickling

i. Spleen – primary site of sickling1. So there is infarction decreased

spleen activity increased risk for infection

ii. CNS infarction neurologic deficits (CVA)iii. Lungs infarction increased pulmonary

pressure pulmonary hypertensioniv. Liver

jaundice/biliribinemia/pruritus/bleeding tendencies

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v. Kidneys infarction glomerular damage vi. Bones hypoxia increase bone marrow

activity bone painvii. Skin/Vascular obstruction ulcer formation

painviii. Penis obstruction priapism necrosis

painh. Management:

i. Drugs1. methotrexate2. antibiotics3. thrombolitics4. anticoagulant5. analgesic

ii. nursing Management: 1. oxygen supplement2. hydration3. bone marrow transplant

iv. Anemia secondary to Renal Failure1. Kidneys will produce or release erythropoietin (a hormone

that stimulates bone marrow activity. Leading to increased RBC production.

2. Management:a. Drugs

i. Iron supplementii. Erythropoietin (Eprex)iii. Blood transfusion iv. Kidney transplant

2. Polycythema Veraa. A chronic myeloproliferative disorder, involving all bone marrow elements.

There is proliferation in myeloid cell. Increased RBC, WBC and platelet.b. Common among women compared to men.c. Cause is unknownd. Signs and Symptoms:

i. Increased RBC, WBC, plateletii. Plethoric appearance (rody appearance)iii. Hypertension (because of increase in blood volume)iv. Hemoconcentrationv. Pain on the digits – because of increase in blood volumevi. Hepatsplenomegalyvii. Cardiomegaly viii. Increased clot formation * - the most common cause of death

amont polycythema verae. **Avoid high altitude places – because a high altitude area has a decrease

oxygen concentration. In the environment, the normal oxygen saturation is >21%. In the body, oxygen saturation is 95 to 100%. Once there is less oxygen saturation, it would stimulate the kidneys of the patient, releasing erythropoietin, causing an increase in RBC production.

f. Management:i. Medication:

1. Immune bone marrow suppressant – METHOTREXATE2. Vasodilators3. Anticoagulant4. Antihypertensive drugs

ii. Nursing Management:Nursing Diagnosis: Risk for altered tissue perfusion – because of circulatory obstruction1. Deliver oxygen2. Hydrate patient – to prevent clot formation

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3. Bone marrow transplant4. Phlebotomy – about 500 to 2000 ml / week

a. Cannot be transfused, because the blood is considered to be defective.

3. Thrombocytopeniaa. A decrease in platelet countb. Causes:

i. Drugs – Alcohol, Aspirin, Chloramphenicol (drug of choice for typhoid fever), chemotherapy drug, radiation exposure, anticoagulants, thrombolytics, quinolones, Phenobarbital

ii. Infection – viral infection (tanan naay thrombocytopenia), Ebola Viral Infection (most feared viral infection). Ebola and dengue viral infection pareho naay fever and thrombocytopenia. But Ebola liquefaction of internal organ.

iii. Disorder – leukemia c. Management:

i. Platelet concentrate transfusiond. Nursing Alerts

i. No invasive proceduresii. No dark-colored foodsiii. No strenuous activitiesiv. Avoid aspirinv. Patient with bleeding tendencies, best exercise: Swimming (less

physical contact)vi. For pediatric patients, common presentation of bleeding:

hemarthrosis (bleeding in the joints). Early indication of hemarthrosis is reluctance to move a body part.

**Nursing Actions: Pad the joint or extremitiesvii. Ensure safe administration of blood product

CARDIOVASCULAR SYSTEM2 Valves

1. AV Valvea. Tricuspid Valveb. Mitral Valve

2. Semilunar Valvea. Pulmonaryb. Aortic

Heart sound is due to the closure of the valve.S1 closure of AV valve.S2 closure of the Semilunar valve.Abnormal heart sounds – murmurs; S3 and S4S3 – heard after S2; common cause is heart failureS4 – heard before S1; common cause is hypertension

ECG = EKG1. P wave – atrial depolarization (depolarization is contraction/stimulation)2. QRS complex

a. Atrial repolarization (repolarization is resting/relaxation)b. Ventricular depolarization

3. T wave – ventricular repolarization

12 Leads of ECG- are the different angles or view of the heart

1. Chest Leadsa. V1 – right sideb. V2 – right side

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c. V3 – septum d. V4 – septum e. V5 – left side f. V6 – left side

2. Limb Leadsa. Ib. IIc. IIId. IVe. AVRf. AVLg. AVF

Normal Rate: 60 to 100 bpmNormal P-R: 0.12 to 0.20 secondsNormal QRS: 0.08 to 0.12 seconds1 small box = 0.04 seconds1 big box (5X5) = 0.20 seconds350, 150, 100, 75, 60, 50

ECG INTERPRETATION1. Ischemia – Inverted T wave2. Injury – ST segment elevated3. Infarction

a. Old – pathological Q waveb. New – ST segment elevation

4. Hypokalemia – prominent U wave5. Hyperkalemia – peak T wave

CORONARY ARTERY DISORDERS- refers to perfusion alteration- coronary arteries is not allowing blood to flow freely in the heart, most probably

because of obstruction- the goal is to improve perfusion by all means1. Atherosclerosis

a. An abnormal accumulation of lipid, or fatty, substances and fibrous tissues in the vessel wall

b. Cholesteroli. LDL – bad

1. as early as 7 years old, there is already fat deposition2. WBC and macrophages modify the LDL3. during modification, there is injury in the vessel

ii. HDL – goodiii. Triglycerides – increased risk for CAD

c.2. Arteriosclerosis

a. Refers to hardening of the vessel wallsb. Ischemia – disrupted blood flow

Risk Factors:1. Modifiable

a. High Blood Pressureb. Cigarette Smokingc. High Blood Cholesterol Levelsd. Diabetes Mellitus – accelerates atherosclerosise. Lack of estrogen in womenf. Physical inactivityg. Obesity – paired with hypertension

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2. Non Modifiablea. Family History of CADb. Increasing age (55 years old and above)c. Gender – common among Males, type A personalityd. Race – African-American

Normal Total Serum Cholesterol = 150 to 240 mg/dlHDL = 29 to 77 mg/dlLDL – 60 to 160 mg/dlTriglycerides = 10 to 190 mg/dl

Desired LD levels:1. 1 risk factor or no risk factor = < 1602. 2 or more risk factors = < 1303. Diagnosed with CAD = < 100

ANGINA PECTORIS- refers to chest pain or chest discomfort- “choked chest”- Angina is due to myocardial ischemia (inability of the coronary arteries to supply

blood adequately)- Specific causes:

o Atherosclerosiso Arteriosclerosiso Vasospasm – common early in morningo Vasocompression – brought about by inflammatory processeso Drugs –

Decongestants – all lead to myocardial ischemia Adrenergic drugs

- Types:o Stable

A type of angina pectoris if patient is under stress or physical exertion. You know when the attack will occur.

Arteriosclerosiso Unstable

Even at rest may occur You need to closely monitor patient, because may progress to

myocardial infarction Also known as Preinfarction Angina Most common cause: Atherosclerosis

o Silent No signs and symptoms (asymptomatic)

o Variant Nocturnal angina pectoris Pwede mugawas early in the morning AKA Prinzmetal Angina Most common cause: Vasospasm

o Intractable/Refractory The patient will not respond to common medications, that is why

patient complains of severe pain.o Ludwig’s Angina

Brought about by drugs. Drug-induced angina

- Signs and Symptomso Chest pain (precipitated by the following)

Emotion Eating Environment (cold) Exertion

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Exercise ** can be relieved by rest and or nitroglycerin ** chest pain is usually less than 20 minutes ** (+) Levine sign – grasping anterior chest because of pain ** The major difference of chest pain experienced by patient with

angina and MI: Characteristic of paino Chest discomforto Chest tightness

- Common Diagnostic Testo ECG – inverted T waveo Blood analysis

Lipid profile Cardiac enzymes (CPK-MB, Trop-T, LDH)

o Thalium Scan – an invasive procedure Identify what part of the heart with hypoxia

o Coronary Angiography All assess for distal and peripheral pulses

- Managemento Drugs

Vasodilator – Nitroglycerin Nursing Alerts: Nitroglycerin is a vasodilator Nitroglycerin comes in different preparations

o tablet, spray – take sublingually; store in a dark dry tightly capped container because it is photosensitive.

Burning or tingling sensation when taking the drug – best indicator that nitroglycerin is effective or still fresh

Lightheadedness is a normal side effect of nitroglycerin

Discard nitroglycerin after 6 months – nitroglycerin starts to decline its potency on the 4th month

Nitroglycerin must be taken 1 tab at a time or one spray at a time, 5 minutes interval, maximum of 3 tablets or 3 sprays

After 3 days, if pain is still present, consult doctor.

o Patch do not touch the medicated surface place on anterior chest do not place on a hairy site – shave site along

the direction of hair growth to decrease the risk for skin breakdown

To prevent nitroglycerin tolerance, the nursing action is to establish a 12-bour no nitroglycerin per day

Anticoagulant Analgesic if severe pain occurs Beta blockers to decrease myocardial oxygen demand

o Nursing Management: First nursing action if patient in your unit complains of chest pain:

Give oxygen supplement 1 to 2 L/minute Position the patient in a Semi-Fowler’s position to promote good

lung expansion Modify the diet of the patient: Low sodium, low fat, high protein,

high potassium, high fiber diet (to prevent constipation) Decrease environment and physical stimuli to decrease the

workload of the heart

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Prepare the patient for surgery PTCA (Percutaneous Transluminal Coronary Angioplasty)

o Before and after, assess for peripheral and distal pulses

CABG (Coronary Artery Bypass Grafting) – ultimate choice If not corrected, angina may progress to MI

MYOCARDIAL INFARCTION- caused by coronary occlusion- causes are same with angina- Patient may present with the following:

o Dyspneao Anxiety – dyspnea, diaphoresis and nausea and vomiting are related to

anxietyo Nausea and vomitingo Chest pain / crushing substernal pain – not all patients with MI have chest

pain, not common among women. Not also common to patient with diabetes mellitus, because they have diabetic neuropathy, so sira ang nerve, so walay pain.

Chest pain is more than 20 minutes Cannot be relived by rest or nitroglycerin (+) for Levine sign Chest pain may radiate back, down the neck, shoulder and on the

left arm. Pwede sa right but most common sa left arm. Why it radiates on the left arm? Because the nerve that supplies the heart and the nerve that supplies the left arm originated in the same branch.

Aura - Epigastric Pain. Ngano naa epigastric pain? Patient thought it was an epigastric pain, but instead, it is part of chest pain.

o Elevated temperature Why elevated? Pag may occlusion, there is no oxygen supply on

the cells, so they will pursue an anaerobic circulation. Anaerobic circulation increases the release of lactic acid, these acid causes injury to the vessels. Due to injury. Injury triggers release of cardiac enzymes, and these enzymes activate pyrogens which causes and elevated temperature.

CPK-MB Normal CPK

o Male – 5 to 35o Female – 5 to 25

CPK rises 4 to 8 hours Peak of CPK is ½ to 1 ½ days CPK normalizes 3 to 4 days after the attack

LDH Normal: 100 to 190 IU/L Rises 12 to 24 hours after the attack Peak is 2 to 6 days after

Trop-T Normal: Negative Kelan lumalabas: immediately Peak is 4 to 24 hours Trop-T normalizes 1 to 3 weeks after the attack Most reliable enzyme

o Palor Due to a decrease in cardiac output decrease tissue perfusion

o Arrhythmia Or dysrrhythmia – a life-threatening complication of MI. If not

correct, not prevented, it will lead to cardiac arrest. (Lidocaine) **Watch for PVC (characteristics)

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Widening of QRS complex 6 PVC in 1 minute is considered life threatening

** Watch out for Ventricular Tachycardia – a life threatening arrhythmia or dysrrhythmia

First drug given to patient – Vasopressin Next is give Lidocaine After Lidocaine, defibrillation (Max Joules: 300 J) Next, cardiac compression

o Diaphoresis- When is MI attack common? In the morning during when taking a bath because

ga startle man.- Diagnostic Test

o Ischemia – inverted T waveo Old infarction – pathological Q waveo New infarction – inverted ST segmento Blood analysis

Lipid profile Cardiac enzymes Liver enzymes BUN and Creatinine

o Thalium scan and coronary angiography- Management:

o Morphine Sulfate – narcotic analgesic, may cause respiratory depressiono Oxygen o Aspirino Nitrates – a vasodilatoro Streptokinase – a thrombolytic drugo Surgery – PTCA and CABG

- Nursing Diagnosis: Alteration in Comfort: Pain- Nursing Alerts:

o Diet: low sodium, low fat, high protein, high fibero Position: Semi Fowler’s o Avoid constipationo Decrease environment and physical stimulio Resumption of physical activity – 4 to 6 weeks after the attack or if not,

patient can resume sexual activity if patient can climb stairs more than 10 steps without chest pain

o When is the best time to do sexual activity??? Early in the morning because the heart has well rested

o Approach: Use passive approacho Where is the best place to do sexual activity?? In a familiar environment

to decrease anxiety

CONGESTIVE HEART FAILURE- inability of the heart to pump properly- Two types

o Right-Sided CHF Systemic manifestation

Fatigue Increased peripheral venous pressure Ascites Enlarged liver and spleen Distended jugular vein Anorexia and complaints of GI distress Swelling in hands and finger Dependent edema

o Left-Sided CHF

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Pulmonary manifestation Paroxysmal nocturnal dyspnea Elevated pulmonary capillary wedge pressure Cough Crackles Wheezes Blood tinged sputum Restlessness Confusion Orthopnea Tachycardia Exertional dyspnea Cyanosis

- Goal in management: increase the force of contraction without increasing heart rate

- Approach in managing CHF:o Upright position – to prevent pulmonary congestiono Nitrates – nitrates are vasodilator, to promote blood flowo Lasix – a form of diuretic; to get rid of too much fluid inside the body; best

given in morning and watch out for hypokalemia. Hypokalemia increases the risk of digitalis toxicity.

o Oxygeno Aminophylline – a bronchodilator; dilates the bronchial area to relieve

dyspneao Digoxin – drug of choice for CHF. Why? Because the action of digoxin is the

goal of the digoxin and that is to increase the force of contraction. Before giving digoxin : check heart rate and blood pressure,

because these are indications of digitalis toxicity or overdosage of digoxin

What is the normal digoxin level? 0.5 to 2.0 microgram/dL If more than 2, digitalis toxicity. (signs)

Bradycardia Hypotension Tremors Diarrhea Nausea and vomiting Yellow to yellow-green halos around the light Risk for cardiac arrest

Antidote: Digibind or Digoxin Immune Fab or DigiFabo Fluid restriction – 1000 to 1300 ml/day or 1 to 1.3 L/dayo After load decrease

How to decrease afterload? Bed rest Giving drugs

o Beta blockerso ACE inhibitor – drugs ending in pril; common side

effect is COUGH Rotating tourniquet – do not remove all tourniquets at the

same timeo Sodium restriction – because sodium attracts watero Test for potassium and ABG – because hypokalemia potentiates the effect

of ABG

RHEUMATIC HEART DISEASE- is a sequalae or a complication of frequent or untreated GABS (Group A

Betahemolytic Streptococcus) infection- Major Manifestations:

o Pancarditis – inflammation on the three layers of the heart

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o Valvular defect/s – must be prevented or corrected because this is irreversible. Mitral Valve – commonly affected valve

o Subcutaneous nodules ** Would resolve even without medication It does not require treatment

o Chorea – St. Vitus Dance; abnormal jerky movement; common in upper extremities and jaw of patient; it is self-limiting lasting for 3 months; aggravated by loud music

- Minor Manifestations:o Chest paino Frequent sore throato Fevero Weaknesso Myalgia – muscle paino Elevated ASO titer – Anti Streptolysin O (an antibody specific for

Streptolysin O)- Diagnostic Test

o No specific testo Diagnosing is based on assessment by Jone’s Criteria

2 major manifestations, 1 minor manifestation 1 major manifestation, 2 minor manifestations

o Other tests Throat culture X-ray Blood analysis

- Management:o Drug

Penicillin – drug of choice Given 6 to 8 years during active infection – stress the

importance of compliance or Erythromycin Aspirin Corticosteroids

- Nursing Alerts:o Stress the importance of good oral hygieneo Inform the doctor or dentist prior to dental work-up or any invasive

procedureso Stress the importance of complianceo Have yearly or annual physical examination, specially 2D-echo – to

evaluate cardiac abnormalitiesALTERATION IN HORMONAL REGULATION

Hormonal Regulation:

Hypothalamus

Pituitary Gland (hypophysis)

Hormone

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Target Cell/Organ

Effect

Pituitary Gland1. Anterior

a. Growth Hormoneb. Prolactinc. Melanocyte Stimulating Hormoned. Follicle Stimulating Hormonee. Leutinizing Hormonef. ACTHg. Thyroid Stimulating Hormone

2. Posteriora. Anti Diuretic Hormone / Vasopressinb. Oxytocin

ADRENOCORTICOTROPIC HORMONE- target cell or organ: Adrenal Gland (located above the kidney) or Supra Renal

Gland- Effect:

o Stimulate the adrenal gland to produce it’s own hormoneo Adrenal Cortex (4 hormones)

Cortisol (most abundant hormone produced) Glucocorticoid - because it has a direct effect on glucose anti-inflammatory

Aldosterone Mineralocorticoid - because it has a direct effect on mineral Promotes water retention

Androgen Development of secondary male characteristics

Adrenal Estrogen Insignificant

o Adrenal Medulla (2 hormones) Epinephrine (Adrenalin)

For sympathetic reactions Norepinephrine

-same-

THYROID STIMULATING HORMONE- Stimulates thyroid gland to produce it’s own hormone- 3 hormones produced:

o T3 Triiodothyronine Derived from iodine Important to increase the basal metabolic rate

o T4 Tetraiodothyronine or Thyroxine Derived from iodine Important to increase the basal metabolic rate

o Calcitonin Decreases calcium level

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ANTIDIURETIC HORMONE (Vasopressin)- target cell or organ: KIDNEY- Prevents formation of large volume of urine

Anterior Pituitary Gland (7 hormones)1. Growth Hormone

a. Hypersecretioni. Pedia – giantism/gigantismii. Adult - Acromegaly

b. Hyposecretioni. Dwarfism

2. Melanocyte Stimulating Hormonea. Hypersecretion – darkens the skinb. Hyposecretion - Albino

3. Prolactina. Hypersecretion – lactation or milk productionb. Hyposecretion – no lactation

4. FSHa. Menstrual Disorders

5. LHa. Menstrual Disorders

6. ACTHa. Hypersecretion – Cushing’s Syndromeb. Hyposecretion – Addison’s Disease

7. TSHa. Hypersecretion – Hyperthyroidism/Thyrotoxicosis (Example: Grave’s

Disease)b. Hyposecretion – Hypothyroidism

i. Pedia – Cretinismii. Adult - Myxedema

Posterior Pituitary Gland1. ADH

a. Hyper – SIADHb. Hypo – Diabetes Insipidus

2. Oxytocina. Hyper – contraction or Let-down reflex or Milk Ejectionb. Hypo – muscle atony

Tumor – the most common causeManagement: Surgery – removal of the tumorHypophysectomy – removal of pituitary gland; a form of craniotomyCommon Problem post-op: Increased ICP – elevate head of bed (30 to 45 degrees) to promote venous return.Midline position – neutral position to prevent compression

Craniotomy- 3 approaches

o Supratentorial Above the hair line Best position: Elevate head of bed / High Fowler’s Position / Lying

on his back with head of bed elevated / Head of bed elevated, lying on the side of the unaffected side

o Infratentorial Below Best position: Side lying position, head of bed elevated depending

on patient’s preference kung left or righto Transsphenoidal

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Most common approach for hypophysectomy Incision: beneath the upper lip of the patient to gain access on the

nasal cavity Best position post-op: High Fowler’s position / Lying on his back

- Nursing Alertso Avoid blowing the noseo Maintain nasal packingo Avoid brushing the teeth and do not gargle – because the more it increases

ICP and bleeding episodes. Use padded tongue depressor 6 to 10 days post-operatively.

o Watch for Rhinorrhea – CSF leakage sa nose. First nursing action if you suspect Rhinorrhea: Check for the glucose

content – because CSF contains glucose 50 to 80 mg/dL. How? Get a specimen and send to lab for analysis. Or get a white clean clothe or gauze, wipe the fluid and let it dry. If

it leaves a yellow mark, then it is CSF.

DISTURBANCES AFFECTING ACTH1. Addison’s Disease

a. Decreased adrenal hormonesb. Manifestation:

i. Decreased glucocorticoid – hypoglycemia ii. Decreased mineralocorticoid – hyponatremia/hyperkalemiaiii. Decreased androgen – abnormal hair distribution

c. Pathognomonic Sign: Bronze pigmentation of the skin or tanning of the skin

d. Other signs and symptomsi. Weakness ii. Postural hypotension or orthostatic hypotension

1. *** Avoid sitting or standing quickly, it must be gradualiii. Abnormal distribution of body hair

e. Nursing Diagnosis: Fluid Volume Deficiti. **Dehydration is the most common cause of Adrenal Crisis or

Addisonian Crisisii. Adrenal Crisis or Addisonian Crisis – refers to critical deficiency of

the adrenal hormonesiii. Most common cause: Dehydrationiv. Nursing Implication: How to prevent adrenal crisis? Hydrate the

patientv. Signs and Symptoms of Adrenal Crisis

1. Dehydration2. Hyponatremia3. Hyperkalemia4. Vascular collapse

a. ***It is the most common cause of deathb. Vascular collapse is due to fluid volume deficit

5. Renal shut downvi. Drug of choice: Hydrocortisone

f. Diet of the patient: i. Before steroids

1. High carbohydrates2. High Na3. Low K4. High protein5. High calorie

ii. During steroids – steroids promote water retention1. Low Na2. High K

g. Drug that replaces glucocorticoid – Hydrocortisone

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h. Drug that replaces mineralocorticoid – Fludocortisonei. Wath for: Cushing’s Syndrome

2. Cushing’s Sydnromea. Refers to excessive adrenal hormone productionb. Increase in adrenal hormone (cortex – Cortisol)c. AKA Hypercorticolismd. Manifestation

i. Increased glucocorticoid – hyperglycemia ii. Increased mineralocorticoid – hypernatremia / hypokalemiaiii. Increased androgen – Hirsutism (applicable to females)

e. Nursing Diagnosis: Fluid Volume Excessf. Pathognomonic Sign:

i. Moon face – due to edemaii. Buffalo hump or fat deposition on the back – due to edema and fat

depositioniii. Truncal Obesity – due to fat depositioniv. Weight gain – classic sign ***

g. Other signs and symptomsi. Poor wound healingii. Infection or chronic infection – admit under reverse isolationiii. Fragile skiniv. Acne v. Amenorrheavi. Ecchymosis vii. Decreased libidoviii. Enlarged clitorisix. Hypertensionx. Mood swings – irritable

h. Diet:i. Low carbohydratesii. Low sodiumiii. High potassiumiv. High proteinv. Low calorie

i. Drugsi. Drug of choice: Metyrapone (adrenal suppressant) ii. Diuretic iii. Insulin – anti diabetic agentiv. K supplement

j. Surgeryi. Adrenalectomy – removal of adrenal gland

TSH DISTURBANCES1. Hyperthyroidism / Thyrotoxicosis

a. Example: Grave’s Disease – common if you failed to eat iodine-rich food (ex: seafoods)

b. 3 common features:i. Increased T3 and T4

1. Increased basal metabolic ratea. Tachycardiab. Palpitationc. Weight lossd. Diarrheae. Fine silky straight hairf. Diaphoresis g. Hypertensionh. Increased systolic blood pressurei. Hyperactivej. Amenorrhea

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k. Fine hand tremorsl. Muscle wastingm. Hyperactivity – provide restful environment

2. Increased heat productiona. Heat intolerance

3. Increased calorie requirementa. Polyphagia

4. Diet: Increased calorie, increase carbohydrates, increase protein

ii. Exopthalmia – bulging of eyeballs; Dalyrimple Sign or thyroid stareiii. Goiter – enlargement of thyroidism

1. May be present also in hypothyroidism2. Cause: hyperplasia3. Assess for bruit or thrill over the thyroid

c. Best Diagnostic Test: TSHd. Drugs:

i. Antithyroid agent1. PTU – Propylthiurazil; inhibits thyroid hormone synthesis2. Lugol’s Solution – also known as SSKI (Strong Saturated

Potassium Iodide) a. Action: Decrease vascularity of thyroid gland

Watch for: Hypothyroidism!ii. Corticosteroids – help inhibit thyroid hormone synthesisiii. Beta blockers (-olol drugs)iv. Digoxinv. Iodine preparation (Iodotope)

e. Surgery:i. Thyroidectomy ii. Nursing Alert:

1. Best position post-thyroidectomy – Fowler’s position2. Keep tracheostomy tray on the bed side, specially on the

first 24 hours post-op – because respiratory distress is common on the first 24 hours

a. Causes of respiratory distress:i. Tracheal collapse – due to surgeryii. Trachea mucus accumulationiii. Laryngeal edemaiv. Vocal cord paralysis – can cause airway

obstructionv. Hypocalcemia – accident removal of

parathyroid gland. Drug of choice: Calcium Gluconate

3. Hoarseness and a weak voice are normal and temporary conditions

4. How to assess for laryngeal nerve function: ability to swallow or ability to talk or speak

5. Watch for bleeding: Check for blood in the nape of the patient

6. Watch for thyroid storm – a sudden increase in the T3 and T4 due to stimulation upon surgery. Signs of thyroid storm:

a. Tachycardiab. Vomitingc. Feverd. Hypertension e. Hyperkinesis

2. Hypothyroidisma. There is a decrease in T3 and T4b. Common to women than in menc. Most common cause: Hashimoto’s Disease

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i. An autoimmune problem ii. Our immune system will destroy our own thyroid gland

d. 3 problemsi. Decreased BMR

1. Constipation2. Amenorrhea3. Hair loss4. Brittle nails and hair5. Coarse, Scaly, dry skin6. Lethargy7. Anorexia8. Fatigue

ii. Decreased heat production1. Cold intolerance

iii. Decreased calorie requirementsiv. Goiter – due to hypertrophy

e. For pedia – Cretinismi. Mentally retardedii. Dwarfism

f. Adult – Myxedemai. Edema formationii. Depression

g. Myxedema Comai. A critical deficiency in T3 and T4, leading to severe depressionii. Most common cause: STRESSiii. Signs and symptoms:

1. Hypothermia2. Bradycardia3. Lethargy progressing to Coma4. Cardiopulmonary arrest

iv. ***Priority: Airway of Patienth. DIET

i. Low calorieii. High proteiniii. High fiber

i. DRUGSi. Liothyronine (Cytomel) – replaces T3ii. Levothyroxine (Synthroid) – replaces T4

Nursing Alert:1. When is the best time to give Cytomel and Synthroid: In the

morning. Not at night because it can cause insomnia.2. Watch for over dosage or over medication. Signs of over

medication:a. Tachycardiab. Restlessnessc. Nervousnessd. Insomnia

iii. Stool Softeners: DOCUSATE SODIUM (Colace)j. Nursing Alert:

i. Avoid sedative, narcotics and other CNS depressants – the more it causes depression

ii. Assess fluid volume – because there is edemaiii. Provide a warm environment – because there is cold intoleranceiv. Provide frequent rest period

DISTURBANCES CAUSES ADH (ANTIDIURETIC HORMONE)1. Syndrome of Inappropriate AntiDiuretic Hormone

a. Increased ADH

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b. Fluid volume excess because there is retentionc. Signs and symptoms:

i. Decrease Hct (Hemodilution)ii. Increase Urine Specific Gravity – urine is concentrated; Normal:

1.010 to 1.0251. ***Best Test to evaluate ADH abnormalities

d. Drugsi. Diuretics

2. Diabetes Insipidusa. Decrease in ADHb. Cause: Ideopathic / Unknown c. Closely related to patient who underwent brain surgeryd. Nursing Diagnosis: Fluid Volume Deficite. Signs and Symptoms

i. Polydypsia – 4 to 40 L per dayii. Polyuria - > 5 L/dayiii. Dehydration iv. Increased Hctv. Decreased Urine specific gravity

f. Diet:i. Regular diet but avoid food that exert diuretic effect

g. Drugs:i. Vasopressin – route: nasal spray or parenteral

1. Desmopressin2. Desmoressin3. Pitressin4. Lypressin

3. Diabetes Mellitusa. Siphoning of the blood – because of too much sugarb. A form of a metabolic disorder characterized by an elevation in blood sugar

(hyperglycemia), resulting from a defect in insulin production, action or both action and production

c. The problem is the pancreasi. Alpha Cells – secrete glucagons (increase glucose in the blood)ii. Beta Cells – insulin (decrease glucose)

d. Test to evaluate function of Pancreas: Fasting Blood Sugare. Types

i. Type 11. Also called Juvenile Diabetes, Juvenile-onset Diabetes,

Ketosis-prone Diabetes, Brittle Diabetes2. approximately 5 to 10% of people with diabetes3. acute onset, usually before age 304. requires injection of insulin to control their blood glucose

level5. Normal glucose: 80 to 1206. Not enough production of insulin7. DKA

ii. Type 21. Adult-onset Diabetes, Maturity-onset Diabetes, Ketosis-

Resistant Diabetes, Stable Diabetes2. Hyperglycemic, Hyperosmolar, Non Ketosis (HHNK)3. 90 to 95% of people with diabetes4. onset is common to people older than 30 years and obese5. Not necessarily mag insulin6. the problem is the action of insulin7.

f. 5 Psi. Polydypsia – excessive thirstii. Polyuria – excessive urination

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iii. Polyphagia – excessive hungeriv. Poor wound healingv. Profound weight loss

g. Signs of hyperglycemiai. Polydipsiaii. Polyuriaiii. Polyphagia iv. Feverv. Warm skin to touchvi. Fruity breath

h. Signs of Hypoglycemiai. Shakiness or tremorsii. Headache iii. Nausea iv. Cold, clammy skinv. Diaphoresis vi. Irritability

i. ** If the skin is warm to touch, insulin is rushj. ** If the skin is cold and clammy, give candyk. Life-saving carbohydrates

i. Fruit juice ½ cup – mas okay sa hard candy because fruit juice is already in liquid form

ii. Hard candyiii. 4 tsp of sugariv. 1 tbsp honey or syrupv. 8 ounces low fat milk or skim milkvi. 3 graham crackers

l. Management:i. Nutritional Management

1. the basic foundation for diabetes control2. Factors:

a. Nutritionb. Dietc. Weight reduction

3. Caloric requirement: 1800 to 2400 per daya. Carbo – 50 to 60%b. Fats – 20 to 30%c. Protein – 10%d. *** Diabetic diet is a well-balanced diet

ii. Exercise1. Benefits:

a. Help decrease blood sugar level – How? By increasing sensitivity of insulin receptors

b. Helps decrease risk for cardiac abnormality2. General Precaution:

a. Use proper foot wear during exerciseb. Inspect feet daily after exercise c. Avoid exercise during extreme temperatured. Avoid exercise during periods of poor metabolic

controliii. Monitoring

1. essential to evaluate whether blood sugar is well regulated2. FBS (Things to remember)

a. Place the patient on NPO 8 to 12 hours3. HGT

a. Where to prick? Side – less nerve endings, so less pain

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4. Glycosylated Hemoglobin Test – the best to evaluate glucose in the blood for the past 2 to 3 months. That is the best test to evaluate effectiveness of treatment. Normal: < 7.5%

iv. Pharmacologic therapy1. Things to remember about insulin:

a. Insulin is a fat-soluble hormoneb. Insulin must be given subcutaneously – do not

massage site, do not apply warm compressc. Insulin must be stored in a cool environment – ref: 3

months, room temp: 1 monthd. Breastfeeding will decrease insulin dosage

requirement – breastfeeding has an antidiabegenic effect

e. Infection or illness will not affect insulin administration

f. When monitoring for hypoglycemia, check for the peak

g. When monitoring for the time, when you will see a decrease in the blood sugar, monitor for the onset or check for the onset

h. Regular insulin is short-acting insulin – regular insulin can be given subcu and IV

i. NPH (neutral protamine hagedorn) – intermediate acting insulin; cloudy insulin

j. NPH must be given at 10 pm to prevent dawn phenomenon

k. When mixing insulin, aspirate air first. Regular insulin should be aspirated first.

l. Watch for complications.i. Acute hypoglycemiaii. Somogyi effect – rebound hyperglycemiaiii. Lipodystrophy – hardening of the fats due to

frequent site of administration. 1. abdomen – pinaka mabilis mag absorb

nang insulin2. arms3. thigh

iv. Dawn phenomenon – a condition in which the patient requires high dose of insulin in the morning due to an effect of growth hormone and adrenal hormone

m. Types of Insulini. Rapid Acting

1. Agent – Lispro (Humalog); Aspart (Novolog)

2. Onset: 10 to 15 minutes3. Peak: 1 hour4. Duration: 3 hours

ii. Short-Acting1. Agent: Regular Insulin; Humalog R;

Novolin R; Iletin II Regular2. Onset: ½ to 1 hour3. Peak: 2 to 3 hours4. Duration: 4 to 6 hours

iii. Intermediate-acting1. Agent: NPH; Humulin N; Iletin II Lente;

Iletin II NPH; Novolin (Lente); Novolin N2. Onset: 2 to 4 hours3. Peak: 6 to 12 hours

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4. Duration: 16 to 20 hours5. Note: Given at 10 pm to prevent Dawn

Phenomenon . 3 am is the best time to check sugar level for Dawn Phenomenon.

iv. Long-Acting Insulin1. Agent: Ultralente (UL)2. Onset: 6 to 8 hours3. Peak: 12 to 16 hours4. Duration: 20 to 30 hours

v. Very Long-Acting1. Agent: Glargine (Lantus)2. Onset: 1 hour3. Peak: Continous4. Duration: 24 hours

v. Education 1. Proper feet care

Reminders:a. Keep your feet dry at all timesb. You may apply moisturizer on the feet, except on the

toes or between the toes. A moist area attracts microorganism.

c. Pat when drying the feet.d. Trim your own nails. – trim straight across; do not let

a Podiatrist or manicurist trim your nailse. Do not soak your feet on extreme temperaturef. Do not walk barefootedg. Regularly change your socks. Best sock – a cotton

fiber sock because it is absorbent.h. Use a well-fitted footwear. Not too tight, not too

loose. Best shoes walking on the beach: a canvass shoes.

DKA HHNKCommon to Type 1 Common to Type 2There is slight elevation in the blood sugar level

Blood sugar is highly elevated (700mg/dL)

Acidosis No acidosisHyperventilation or Cosmos Respiration No hyperventilation or cosmos respirationThere is ketone breath No ketone breathNormal or slightly elevated blood osmolality (normal blood osmolality 260 to 290)

Hyper osmolar blood (333 osmolality)

Hypernatremia and hypokalemia Hypernatremia and hypokalemiaDue to increase fat metabolism Due to hyperglycemia and fluid loss,

leading to dehydration, hypernatremia and hypokalemia

Diagnostic Test: ABGManagement:

1. First anticipated action is fluid replacement. The first solution to be used is Isotonic Solution. To be followed by Hypotonic Solution. Never use Hypertonic.

2. Give insulin3. Give potassium supplement4. Give sodium bicarbonate

Management:1. Give potassium supplement2.

Sodium Hypochlorite - Active component of Dakin’s Solution

45

MUSCULOSKELETAL DISORDERS1. Arthritis

a. Inflammation of jointb. Joint refers to connection of two bones for mobilityc. 3 Major Types:

i. Rheumatoid Arthritisii. Osteoarthritisiii. Gouty Arthritis

ARTHRITIS RHEUMATOID OSTEOARTHRITIS GOUTYDescription Systemic (all joints)

* SynovialNon-systemic (specific for weight bearing joint and joint in the interphalangeal area)

Not systemic or not non-systemic, it is a purine metabolism disorder.Common joint affected: Big toe/ankles

Cause Idiopathic: But said to be auto-immune

Closely related to 3 factors:

- Infection- Hormonal- Lifestyle

changes

Most common form of arthritis.

Cause: Idiopathic, but said to be degenerative type

Related to 3 Factors:- Aging- Trauma- Obesity

Cause:- Familial

Increase uric acid level

Common Women (35 to 50 yo) Both sexes Men Common Signs and Symptoms

Inflammation *Nursing Action: Apply cold compressPain – aspirinStiffness in the joint *Nursing action: Take a warm shower bath

Sign and Symptoms

Increase synovial fluid

Leading to structural damage Leading to physical deformities

Node formation:- Heberden’s

Node – seen on distal joints (most common)

- Bouchard’s Node – seen on proximal joints

Urate crystal deposition, referred to as Tophi

Management: Arthrocentesis – removal of sinovial fluid

d. Diagnostic Testsi. Xrayii. CBC (anemia) - common to rheumatoid arthritis because it is an

autoimmune diseaseiii. Increased ESR – indicates chronic or systemic inflammationiv. (+) Rheumatoid Factor v. Increased serum uric acid levelvi. IF negative sa rheumatoid factor and normal uric acid level, tapos

naay inflammation – diagnosis: Osteoarthritise. Nursing Alerts:

i. If inflammation occurs, apply cold compress.ii. If stiffness occurs, apply warm compress or take warm shower bath.

46

iii. Supply light-weight cups, utensils, easy to open beverages or cartons.

1. type of utensil to offer: a plastic spoon and fork2. Fracture

a. Refers to a break in the continuity of the boneb. Most common cause: Traumac. 2 Major Types:

i. Open/Compound – a break in the bone and the bone is exposed to the environment

ii. Closed/Simple – A break in the bone, but the skin is intact1. Comminuted Fracture – fragmented2. Transverse – break is transversely done3. Oblique – slanted break4. Spiral – 5. Greenstick – common to pediatric; common site: ulna and

radius6. Depressed – common in skull7. Compressed – common in extremities

d. Signs and symptomsi. Pain aggravated by movement

1. First nursing action: immobilizeii. Develops inflammation*iii. Edema formation*

1. inflammation and edema increase the risk for compartment syndrome

iv. Asymmetryv. Hematoma or discolorationvi. Complaints of painvii. *Patient with long bone fracture or multiple fracture is at risk to

develop fat embolism. – fat embolism is common on the first 24 to 48 hours. And the most common presentation: Respiratory difficulty.

viii. *If the patient sustained anterior cranial fracture, patient develops rhinorrhea and raccoon’s eye (discoloration of the periorbital area or periorbital hematoma).

ix. If the patient sustained basilar fracture, common presentation is otorrhea and Battle’s sign.

e. Diagnostic Testi. X-ray

f. Management:i. The first nursing action is to immobilize the patient. Advantages:

1. Promote bone healing2. Decreases bleeding episodes3. Decreases paint4. Decreases risk for further injuryMethods of Immobilization:1. Splint application2. Cast application3. Traction application

ii. Surgery1. reduction – realignment of the bone

1. open2. closed

2. amputationiii. Using of assistive device for walking

1. crutches2. walker3. cane

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CASTS2 Types:

1. Plaster of ParisNursing Alerta. 24 to 72 hours to dryb. Avoid waterc. Dry the cast but turning the patient every 2 hours to promote drying of the

cast. Wrap the cast on a cotton fiber to promote dryness.d. Electric fan in drying Plaster of Paris.e. When caring for the cast, use your palm, not your fingertips.f. Signs of a dry cast – white, hard, shiny and resistantg. Support the cast on a plastic, protected by pillow or rubber underneath.h. Do not cover the cast until it is dry.

2. Synthetic Cast (Fiberglass)Nursing Alerta. Perform neurovascular status of the patient

i. Neuro – warm, hot, sharpii. Vascular – check the capillary refill time < 3 seconds

b. Watch out for Compartment Syndromei. Elevate the extremityii. Report to the physicianiii. Prepare the patient for removal of cast

c. It is normal for the patient to feel heat sensation. When it dries, heat must subside.

d. Maintain good skin integrity – instruct patient to do isometric exercisesi. Isotonic movement – contraction and degree of flexionii. Isometric movement – contraction

e. Check for hot spotsi. Hot spots indicate inflammation under the cast

f. Note any odor from the cast – infection g. Do not insert anything under the casth. If itchy

i. Scratch the opposite sideii. Get straw and blowiii. Pour alcoholiv. Apply cold compress on top of the castv. Tap the cast on topvi. Drink anti-histamine as orderedvii. Prepare to remove the cast

TRACTION

2 Types1. Skin traction

a. Pulling only the skinb. Short-term/Intermittent tractionc. Pediad. 5 to 8 pounds (2.5 to 3.5 kg)e. Types of Skin Traction

i. Bucks Traction1. Patient with fracture hip2. Exerts pull in the extremities3. Priority: Prevention of foot drop. Put some foot plate but

never allow to rest the foot on the board4. Shock block – will prevent the client from falling the bed and

provides counter traction5. How to Turn to side?

a. Client may turn towards the unaffected side

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b. Place pillow between the legs and client can turn towards the unaffected side

ii. Russell’s Traction1. Used to patient with fractured femoral shaft2. Knee bent, suspended in a sling, attach to rope and pulling

on a Balkan Frame3. Priority: Prevention of skin breakdown in the popliteal area.4. How to turn the patient?

a. Patient can turn slightly from side to side without turning the body below the waist

iii. Cervical Traction1. Used by patient who develops spinal cord injury, specifically

cervical injury2. First priority: Maintain head, neck, spin alignment3. Second priority: Pad the chin, protect the ears. 4. Do not turn the patient. If it is a must to turn the patient, use

log rolling technique.iv. Pelvic Traction

1. Used when the patient develops low back pain2. Best position: Semi-fowler’s position with knee bent3. Priority: To prevent skin breakdown on the lumbo-sacral

area4. Turn to side? NO, instead tell the patient to hold the trapeze,

then pull the bodyv. Bryant’s Traction

1. Common to pedia2. Used to patient with hip dislocation and fracture in the lower

extremities3. Both lower extremities are raise up/above the mattress 4. Priority: Maintain leg at 90 degree angle and elevate the

buttock above the mattress at 3 inches2. Skeletal Traction

a. Doctors insert tongs, pinb. Nursing Priority: Prevention of Infection

Infection Osteomyelitis CA: Staphylococcus Aureusc. Signs and Symptoms

i. Inflammationii. Rednessiii. Tendernessiv. Pain on the sitev. Foul smellingvi. Discharges coming from the sitevii. Fever

d. Nursing Actionsi. Observe for proper pin care – surgical asepsisii. How often is the pin care? Every 8 hours

e. Nursing Alerti. Perform neurovascular checkii. Watch out for compartment syndromeiii. Instruct the patient to wiggle toes or fingers to promote good

circulationiv. Instruct the patient to do plantar/dorsiflexionv. Ropes must be align and weights must be hang freelyvi. The line of traction must be alone the long axis of the bonevii. There should be no PAIN while on traction – pain means not in

proper position; best nursing action is to reposition the patient

NEURO

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Cerebral Cortex – decorticateBroca – motor speech formation; speech aphasiaWernicke – sensory speech understanding; receptive aphasiaHypothalamus – thirst, limbs

Covering/Protection of the Brain1. Scalp2. Skull3. Maninges

Signs of Meningeal Irritationa. Nuchal rigidity (stiff neck)b. Brudzinski’s Signc. Kernig’s Signd. Opisthotonos

4. CSFa. Produced by the choroids plexusb. Absorbed by arachnoid villic. Normal volume: 150 mLd. Normal characteristics:

i. Color: clear and colorless – cloudy CSF means infectionii. Protein in CSF – normal: 15 to 45 mg/dL

Increase protein in CSF – bacterial infection, demyelinationiii. Glucose in CSF – Normal: 50 to 80 mg/dL

Increase glucose – hyperglycemia; promotes infectionDecrease glucose - hypoglycemia

iv. Gama Globulin in CSF – 3 to 12 %1. Increased Gama Globulin – infection 2. Increased IgG – demyelination (MS, GBS)3. Increased IgG – MS4. Increased IgG, Increase CHON – GBS

v. WBC in the CSF – 0 to 5 mm31. Increased WBC – infection

vi. RBC in the CSF – negative e. Lumbar Tap

i. Side-lying, knee chest position, fetal position, shrimp position, C position – to widen vertebral disk

ii. L3 and L4iii. Void before procedure because distended bladder cause headacheiv. Post procedure

1. Flat on bed 8 to 12 hours – to prevent leakage2. Prone 2 to 3 hours3. Post procedure headache – increased OFI

v. Contraindication1. Increased ICP – sudden release of pressure cerebral

herniation; Normal pressure is 5 to 15 mmHgvi. 3 Factors

1. CSF Volume – 150 mL2. Blood Volume – 150 mL3. Brain Volume – 1,400 mL**IF increased, it can cause increased ICP

Signs and Symptoms of Increased ICP (Adult)1. Headache2. Vomiting3. Decrease sensory and motor function4. Impaired eye movement 5. Unequal size of pupils

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6. Cushing triad – increase systolic (widening pulse pressure); decrease diastolic; decrease pulse rate

7. Seizure8. Respiratory depression

Signs and Symptoms Increased ICP (Pedia)1. High pitch cry2. Increase head circumference3. Bulging of fontanels4. Cranial suture separation

Management:5. Drugs:

a. Mannitol - osmotic diureticb. Corticosteroid – decrease inflammationc. Anticonvulsant: Phenytoin (Dilantin) – cause gingival

hyperplasia provide oral care and use a soft bristle tooth bruth give in small amount because it can cause vasoconstriction and vascular collapse

d. Acetazolamide – decrease CSF6. Nursing Management

a. Position patient: head of the bed elevated and in neutral position

b. Diet: Low Na, Fluid restricted diet, High fiver to prevent constipation

c. Avoid coughing, sneezing, bending body below the waist, combing the hair, brushing the teeth vigorously

CEREBROVASCULAR ACCIDENT- a disruption in the normal flow of blood going to the brain- Type

o Ischemic/Thromboembolic Clot formation

Atrial flutter, atrial fibrillation will lead to clot formation Increased ICP Gradual TIA – abrupt neurologic deficit lasting less than 1 hour but

not exceeding 24 hourso Hemorrhagic

Bleeding 3 problems:

Bleeding Increase ICP Nasospasm

Sudden TIA

CM1. Visual Field

a. Homonymous hemii. Blindness or visual fluid deficit of either right or left visual field of

both eyesii. Horner’s Syndromeiii. Priority:

1. Safety of the patient2. Walk on the side of the patient that is blind3. Stay with the unaffected visual field

b. Loss of peripheral vision “Tunnel Vision”i. Nursing Implication: Scan the loss visual field

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c. Diplopiai. Double visionii. Nursing Implication

1. Cover each eye alternately each day2. Place things of the patient on its proper place and do not

forget to tell the quantity of the object2. Motor Deficits

a. Hemiparesis – weakness b. Hemiplagia – paralysis

i. Turn patient to side every 2 hoursii. Affected side – 20 minutesiii. Right side on the headboard – things will be placed if right

hemispheric strokeiv. Right hemispheric stroke – Ambulate? Left side approachv. Immobility? Passive ROM

c. Ataxia – raise side railsd. Dysarthria – difficulty in forming words; use other forms; Drug: Piracetame. Dysphagia – difficulty swallowing

i. Nursing alert: Avoid thin liquid – increase risk of aspiration elevate head of bed

3. Sensory Deficitsa. Paresthesia – tingling sensation, funny feeling

4. Visual Deficitsa. Expressive Aphasiab. Receptive Aphasiac. Global Aphasia

5. Cognitive Deficitsa. Memory lossb. Decrease attention spanc. Altered judgment

6. Emotional Deficitsa. Depression – motivation: Positive Reinforcement – let the patient feel little

successb. Withdrawal c. Decrease tolerance to stressful situation

i. Formulate short term goalii. Adhere to the plan, inform the patient of the plan of care

7. Diagnostic Testa. CT Scan – non contrast typeb. MRI – no metals allowedc. EKG/ECG – dysrhthmia/arrhythmiad. Cerebral Angiography – assess for peripheral distal

8. Management:a. Thromboembolic/Ischemic Stroke

i. Goal: Salvage brain functionii. Drugs:

1. Thrombolyic Drugs2. Anticoagulant3. Piracetam

iii. Measure to decrease ICPiv. Surgery v. Best indication for ambulation: Decrease in ICP

b. Hemorrhagic Strokei. Goal:

1. To control bleeding2. To prevent rebleeding – common on the 1st 2 weeks after

intial bleeding3. Correct or prevent complication

a. Re-bleeding (common)

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b. Cerebral vasospasm – anti cholinergic Atropine sulfate

c. Acute hydrocephalusd. Seizure/convulsions/epilepsy

4. Specific Management:a. Complete bed rest with sedationb. Drugs: Anti cholinergic dug Piracetamc. Measures to decrease ICPd. Surgery e. Best indication for ambulation: No signs of active

bleeding

SEIZURES- Abnormal sensory, motor, autonomic psychic functions due to excessive firing of

neurons- Causes:

o Idiopathic Genetic Developmental defect on the first trimester

o Acquired Allergic reaction Metatoxic, metabolic toxic conditions Hypertension Brain tumor/injury CNS infections Fever – Febrile seizure is 3 months to 7 years old

- 2 Typeso Partial – excessive firing of neurons is generated by part of the brain

Simple Partial – conscious, repetitive distal to proximal Complex Partial – unconscious, repetitive distal to proximal Secondary Generalized Partial – unconscious

o Generalized – excessive firing of the neurons is generated by the entire brain

Tonic Clonic (Grand-Mal) Combined with tonic and clonic seizure Tonic is a purposeful body movement/rigidity lasting for 10

to 20 seconds Clonic is a period of contraction, relaxation

Absence Seizure (Petit Mal) Characterized by blank stares Common to children Lasting for less than 20 seconds

Akinetic/Atonic (Drop Attack) Characterized by sudden loss of muscle tone

- Diagnostic Testo EEG

Test that records electrical activity of the brain Last for 45 to 60 minutes Nursing action: Increase chance of seizure While on EEG

Deprive patient if enough rest a night prior test- Management

o Drugs Anticonvulsant

Phenytoin (Dilantin) Clonazepam

Phenobarbital Lamotrigine Valproic Acid (Depakene)

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o Nursing Management: Nurses major role before and during seizure

Observe and record the event Duration of seizure Type of movement Circumstance just before the seizure The first thing the patient does before the seizure Epileptic cry – first sound heard just before the seizure Occurrence of aura – common aura: epigastric pain

Nursing care during seizure Provide privacy Priority: safety Ease the patient to the floor If in bed, raise the side rails, remove the pillows and remove

the blanket to prevent suffocation Protect the head with a pad Push aside any furniture Best time to insert oral airway: During aura Best position: Side lying position Do not attempt to restrain the patient during seizure

Nurses major role after seizure Best position: Side lying position with head flexed forward to

facilitate drainage of secretion Re-orient the patient Allow the patient to take the rest. Best approach if the

patient is agitated or anxious after seizure is to use a calm persuasion and a gentle restrain.

PARKINSON’S DISEASE- a slowly progressive neurologic movement disorder- decrease dopamine (inhibitory)- Triad Symptoms

o Resting tremors Head of the patient and hand of the patient Head – side to side Hand – pill rolling

o Bradykinesia Slow movement Decrease blinking reflex, loss of facial expression (muscle-face) Loss of normal arm swing while walking

o Muscle Rigidity Increase resistance to passive movement

- Other signs and symptomso Paroxysmal flushingo Gastric and urinary retentiono Shuffle gaito Stoop postureo Sexual dysfunction

- Diagnostic Testo No specific testo PET Scan (Position Emission Tomography)

Invasive procedure Structure and cellular activity

- Drugso Levodopa

Anti-Parkinsonian Precursor for dopamine Decrease vitamin B6 because it can inhibit absorption of Levodopa

o Anti-histamine

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o MAOIo Dopamin Agonisto Anti-Viral

- Surgeryo Sterotactic Surgery – it will limit the syndrome (triad)o Thalamotomy – incision of thalamuso Pallidotomy – incision of pallidum

- Nursing Alerto Safety is the primary concerno Best chair? Rocking chairo Hungry and wants to eat utensils? Provide steel spoon and forko Raise the bedside commode or chair of the patiento Install hand rails in the CR

SPINAL CORD INJURY

- Common sites: C5, C6, C7, T12 and L1- Signs and Symptoms

o C1 – C8 (atlas and axis) Develops quadriplegia Respiratory Failure Bladder, bowel dysfunction

o T1 – L4 Paraplegia Bladder and bowel dysfunction

o Spinal Cord Injury above T6, Increases the risk of Autonomic Dysreflexia (autonomic hyperreflexia)

Signs and Symptoms Motor deficits of the upper extremities UE Bowel/bladder dysfunction Loss of pain, touch, temperature sensation, + motor deficits LE Ipsilateral Paralysis

- Diagnostic Testo X-rayo CT Scano MRI – careful for patients with claustrophobia

- Drugo Corticosteroid – to decrease inflammation

- Specific Managemento Immobilize the patiento Priority? Maintain neck and spine alignmento Using of devices:

Traction and Halo vest – driving is contraindicatedo Surgery

- Nursing Alerto Maintain good skin integrityo Maintain urinary elimination

Urinary elimination distended urinary bladder autonomic dysreflexia o Promote adequate breathing and airway clearanceo Monitor for complications

Orthostatic hypotension/postural hypotension DVT

Causes Virchows Triad

o Venous Stasiso Hypercoagulopathy

Increase platelet Burns

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o Blood vessel wall injury brns

Signs and Symptoms Positive Homan’s Sign Pain or tenderness on the site – common: lower pelvis or calf Distention of superficial veins Warm skin to touch

Management Warfarin Bed rest minimum of 3 days Improve venous return

o Affected Limb – do not massage, no passive ROM, do not apply compression, no exercise, do not put pillow under the knee

o Unaffected limbs – promote passive ROMo Anti-emboli stocking – best time is early in the

morning before raising up from bedo Warm compress – warm compress site? Lower part of

the abdomen Autonomic Dysreflexia

Abnormal sympathetic reaction that arises after spinal shock Common to SCI above T6 Spinal Shock – an abrupt loss in spinal cord function

Causeso Distended visceral organ – urinary bladdero Physical stimuli – constipation

Signs and Symptomso Severe headacheo Severe hypertension

Most common cause of death Head of the bed elevated

o Facial flushingo Diaphoresis – forehead of the patiento Pallor below the lesion

Managemento First Nursing Action:

Promote urinary elimination If catheter is attached, check for obstruction

o Decrease physical stimuli

Drug of Choiceo Apressolin (Hydralazine)o Other hypertensive drugs

MYASTHENIA GRAVIS- Autoimmune problem affecting myoneural junction causing varying degree of

weakness of the face, throat and other voluntary muscles due to production of antibodies specific for acetylcholine

- Common: Women (20 to 40 years old) Men (60 to 70 years old)

- Idiopathic- Signs and Symptoms

o Ptosis and Diplopia – early manifestationo Generalized weakness

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Generalized weakness respiratory failure deatho Nasal Smile - Hallmark

- Diagnostic Testo Tensilon Test

Anti-cholinesterase test Tensilon – Edrophonium HCl; inhibits Ach breakdown 2 mg @ a time = 10 mg 30 seconds post administration Negative weakness/ptosis for 3 to 5 minutes positive tensilon

test 10 mg given @ chetine Cholinergic Crisis

Cholinergic Crisis Signs and Symptoms

Bradycardia Sweating Cramping and Weakness

Antidote: Atropine Sulfate 0.4 mg Management

Mestinon (Prydostimine Bromide) and Prostigmine (Neostigmine Bromide)

o Must be given before meal to improve motor activity Plasmapheresis

o Cleansing of the blood to remove circulatory antibodies

Surgeryo Removal of thymus – Thymectomyo 3 Common Problems

Myasthenia crisis Weakness – respiratory failure

Cholinergic Crisis – overdose Test to differentiate – Tensilon Test

Brittle crisis**Myasthenic – positive slight increase muscle strength**Cholinergic – exacerbate weakness

o Management: Myasthenia Crisis – give Tensilon Cholinergic Crisis – stop Tensilon and give

atropine sulfate Brittle crisis - plasmapheresis

MI – pain radiates @ left armSpleen – pain radiates @ left shoulderGallbladder – pain radiates @ right shoulderUrinary bladder – pain radiates on shoulders right and left

GENITO-URINARY

Renal Calculi1. Kidney stones, urolithiasis2. Most common cause of upper urinary tract infection3. Stones

a. Calcium Stones – due to hypercalcemiab. Urate Stones – due to increase uric acid level (Purine metabolism disorder)c. Cystine Stones – rare (Amino acid metabolism disorder)d. Magnessium Ammonium Phosphate Stone – staghorn/struvite (UTI)

4. Signs and Symptomsa. Pain – classic symptom of Renal Calculi (costovertebral angle)

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i. Renal colic – brought about by over stretching of the ureter or other collecting system; deep dull ache and exaggerated by drinking large volume of liquid

ii. Non colicky Pain – due to pressure on the renal pelvis; hydronephrosis – increase in pressure causes pain

5. Diagnostic Testa. Urinarlysis

i. Hematuria, UTI, crystals formationii. Most important nursing action: Strain the urine of the patient using

several layer of gauze.iii. Send to laboratory for analysis

b. Radiographi. Xrayii. Ultrasoundiii. Bladder is full prior to the test

c. Blood analysisi. Increase WBC – UTIii. Increase uric acidiii. Increase calcium

6. Managementa. Drugs

i. Analgesicii. Diureticiii. Antibioticiv. Anti-goutv. Anti-inflammatoryvi. Alpha-blockers – block alpha receptors to relax smooth musclevii. Doxazosin, Teraxosinviii. Calcitonin – for hypercalcemia

b. Dietary Modificationc. Surgery

i. Percutaneous Nephrolithotomyii. Lithotripsy

1. Nursing alert: Post lithotripsy – Increase OFI to flush stonesd. Specific Management

i. Calcium Stones1. Increase OFI2. Diuretics3. Low calcium diet4. Calcitonin

ii. Urate Stones1. Increase OFI (2 to 3 L/day)2. Decrease purine diet3. Drugs – Allopurinol, Colchicine4. Alkalanization of urine – alkaline-ash diet; drink milk and

citrus juiceiii. Cystine Stones

1. Increase OFI2. Diuretic3. Alkalinization of urine

iv. Magnesium Ammonium Phosphate Stone1. Increase OFI2. Drugs: Ciprofloxacin 500 mg TID x 7 days

Rocephin 1 gm IM single dose Doxycycline 1000mg BID x 7 days

3. Acidify the urine – acid-ash diet; drink cranberry juice

BENIGN PROSTATIC HYPERTROPHY/HYPERPLASIA- Enlargement of the prostate narrowing of ureter

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- Causeo Uknowno Related: Aging above 60 years old and Androgen hormone imbalance

- Signs and Symptomso Urinary frequencyo Dribbling urineo Hematuriao Urinary stasiso Obstructive voiding syndrome

Difficulty starting urination Urinary hesitancy Decrease urine stream force Feeling of incomplete voiding

- Diagnostic Testo Most definitive test: Cystouretheroscopyo Urinalysiso DRE (Digital Rectal Exam) – evaluate the size of the prostate

Prostate soft – BPH Prostate firm – prostate CA

o Blood analysis BUN/Creatinine (RF) PSA Level – Normal: 4 to 10 mg/mL)

- Management:o Drugs

Alpha blockers Diuretic Antibiotic Androgen hormone inhibitor

Example: Proscaro Catheterization o Surgery

Most effective: Prostatectomy – removal of the prostateApproaches Suprapubic/intravesical Retropubic Perineal

o Lead to impotence Transurethral (TURP)

o Post procedure – continuous bladder irrigation (cystoclysis/murphy’s drip/CBI)

o

o- Nursing Alert-

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