Obstetrical Nursing

MATERNAL/OB NOTES

Human Sexuality
A. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes emotions and preferences that are related to sexual self and eroticism.
2. Sex – basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human sexuality.
B. Definitions related to sexuality:

Gender identity – sense of femininity or masculinity
2-4 yrs/3 yrs gender identity develops.
Role identity – attitudes, behaviors and attributes that differentiate roles

Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse.

Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change.
- developed at the moment of conception.

II. Sexual Anatomy and Physiology
A. Female Reproductive System
1. External value or pretender
a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis.

Stages of Pubic Hair Development
Tannerscale tool - used to determine sexual maturity rating.
Stage 1 – Pre-adolescence. No pubic hair. Fine body hair only
Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly hair at pubis symphysis
Stage 3 occurs between ages 12 and 13 – darker & curlier at labia
Stage 4 – occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh.
Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh .
b. Labia Majora - large lips longitudinal fold, extends symphisis pubis to perineum
c. Labia Minora – 2 sensitive structures
clitoris- anterior, pea shaped erectile tissue with lots sensitive nerve endings sight of sexual arousal (Greek-key)

fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn during delivery.
Site – episiotomy.

d. Vestibule – an almond shaped area that contains the hymen, vaginal orifice and bartholene’s glands.

1. Urinary Meatus – small opening of urethra, serves for urination
2. Skenes glands/or paraurethral gland – mucus secreting subs for lubrication
3. hymen – covers vaginal orifice, membranous tissue
4. vaginal orifice – external opening of vagina
5. bartholene’s glands- paravaginal gland or vulvo vaginal gland -2 small mucus secreting subs – secrets alkaline subs.
Alkaline – neutralizes acidity of vagina
Ph of vagina - acidic
Doderleins bacillus – responsible for acidity of vagina
Carumculae mystiformes-healing of torn hymen
e. Perineum – muscular structure – loc – lower vagina & anus
Internal:
A. vagina – female organ of copulation, passageway of mens & fetus, 3 – 4inches or 8 – 10 cm long, dilated canal
Rugae – permits stretching without tearing

B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and weights.
Size- 1x2x3
Shape: nonpregnant pear shaped / pregnant - ovoid
Weight - nonpregnant – 50 -60 kg- pregnant – 1,000g
Pregnant/ Involution of uterus:
4th stage of labor - 1000g
2 weeks after delivery - 500g
3 weeks after delivery - 300 g
5-6 weeks after delivery - returns to original, state 50 – 60

Three parts of the uterus
1. fundus - upper cylindrical layer
2. corpus/body - upper triangular layer
3. cervix - lower cylindrical layer
* Isthmus lower uterine segment during pregnancy
Cornua-junction between fundus & interstitial
Muscular compositions: there are three main muscle layers which make expansion possible in every direction.
1. Endometrium- inside uterus, lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs during menstruation.
Decidua- thick layer.
Endometriosis-proliferation of endometrial lining outside uterus. Common site: ovary.
S/sx: dysmennorhea, low back pain.
Dx: biopsy, laparoscopy
Meds: 1. Danazole (Danocrene) a. to stop mens b. inhibit ovulation
2. Lupreulide (Lupron) –inhibit FSH/LH production
2. Myometrium – largest part of the uterus, muscle layer for delivery process
• Its smooth muscles are considered to be the living ligature of the body.
- Power of labor, resp- contraction of the uterus
3. Perimetrium – protects entire uterus

C. ovaries – 2 female sex glands, almond shaped. Ext- vestibule int – ovaries
Function: 1. ovulation
2. Production of hormones

d. Fallopian tubes – 2-3 inches long that serves as a passageway of the sperm from the uterus to the ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the uterus.

4 significant segments
1. Infundibulum – distal part of FT, trumpet or funnel shaped, swollen at ovulation
2. Ampulla – outer 3rd or 2nd half, site of fertilization
3. Isthmus – site of sterilization – bilateral tubal ligation
4. Interstitial – site of ectopic pregnancy – most dangerous

B. Male Reproductive System
1. External
penis – the male organ of copulation and urination. It contains of a body of a shaft consisting of 3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female – the glands penis.

3 Cylindrical Layers
2 corpora cavernosa
1 corpus spongiosum

Scrotum – a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of which contains a testes.
- cooling mechanism of testes
- < 2 degrees C than body temp.
- Leydig cell – release testosterone









2. Internal

The Process of Spermatogenesis – maturation of sperm







Male and Female homologues

Male Female
Penile glans Clitoral glans
Penile shaft Clitorial shaft
Testes ovaries
Prostate Skene’s gands
Cowper’s Glands Bartholin's glands
Scrotum Labia Majora




III. Basic Knowledge on Genetics and Obstetrics
1. DNA – carries genetic code
2. Chromosomes – threadlike strands composed of hereditary material – DNA
3. Normal amount of ejaculated sperm 3 – 5 cc., 1 tsp
4. Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation
5. Sperm is viable within 48 – 72 hrs, 2-3 days
6. Reproductive cells divides by the process of meiosis (haploid)
Spermatogenesis – maturation of sperm
Oogenesis – process - maturation of ovum
Gematogenesis – formation of 2 haploid into diploid 23 + 23 = 46 or diploid
7. Age of Reproductivity – 15 – 44yo
8. Menstruation-
Menstrual Cycle – beginning of mens to beginning of next mens
Average Menstrual Cycle – 28 days
Average Menstrual Period - 3 – 5 days
Normal Blood loss – 50cc or ¼ cup
Related terminologies:
Menarche – 1st mens
Dysmenorrhea – painful mens
Metrorrhagia – bleeding between mens
Menorhagia – excessive during mens
Amenorrhea – absence of mens
Menopause – cessation of mens/ average : 51 years old
9. Functions of Estrogen and Progestin

* Estrogen “Hormone of the Woman” –
Primary function: development secondary sexual characteristic female.
Others:
1. inhibit production of FSH ( maturation of ovum)
2. hypertrophy of myometrium
3. Spinnbarkeit & Ferning ( billings method/ cervical)
4. development ductile structure of breast
5. increase osteoblast activities of long bones
6. increase in height in female
7. causes early closure of epiphysis of long bones
8. causes sodium retention
9. increase sexual desire

*Progestin “ Hormone of the Mother”
Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortous (twisted)
Secondary Function: uterine contractility (favors pregnancy)
Others: 1.inhibit prod of LH (hormone for ovulation)
2.inhibit motility of GIT
3. mammary gland development
4. increase permeability of kidney to lactose & dextrose causing (+) sugar
5. causes mood swings in moms
6. increase BBT

10. Menstrual Cycle
4 phases of Menstrual Cycle
1. Phases of Menstrual Cycle:
1. Proliferative
2. Secretory
3. Ischemic
4. Menses

Parts of body responsible for mens:
1. hypothalamus
2. anterior pituitary gland – master clock of body
3. ovaries
4. uterus
Initial phase – 3rd day – decreased estrogen
13th day – peak estrogen, decrease progesterone
14th day – Increase estrogen, increase progesterone
15th day – Decrease estrogen, increase progesterone
I. On the initial 3rd phase of menstruation , the estrogen level is decreased, this level stimulates the hypothalamus to release GnRH or FSHRF
II. GnRH/FSHRF – stimulates the anterior pituitary gland to release FSH
Functions of FSH:
1. Stimulate ovaries to release estrogen
2. Facilitate growth primary follicle to become graffian follicle (secrets large amt estrogen & contains mature ovum.)
III. Proliferative Phase – proliferation of tissue or follicular phase, post mens phase. Pre-ovularoty.
-phase of increase estrogen.

Follicular Phase – causing irregularities of mens
Postmenstrual Phase
Preovulatory Phase – phase increase estrogen

IV. 13th day of menstruation, estrogen level is peak while the progesterone level is down, these stimulates the hypothalamus to release GnRF on LHRF
1.) Mittelschmerz – slight abdominal pain on L or RQ of abdomen, marks ovulation day.
2.) Change in BBT, mood swing

V. GnRF/LHRF stimulates the ant pit gland to release LH.
Functions of LH:
1. (13th day-decreased progesterone) LH stimulates ovaries to release progesterone
2. hormone for ovulation
VI. 14th day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of ovulation.

VII. 15th day, after ovulation day, graafian follicle starts to degenerate yellowish known as corpus luteum (secrets large amount of progesterone)

VIII. Secretory phase-
Lutheal Phase
Postovulatory PhaseIncreased progesterone
Premenstrual Phase

IX. 24th day if no fertilization, corpus luteum degenerate ( whitish – corpus albicans)

X. 28th day – if no sperm in ovum – endometrium begins to slough off to begin mens

Cornix- where sperm is deposited
Sperm- small head, long tail, pearly white
Phonones-vibration of head of sperm to determine location of ovum
Sperm should penetrate corona radiata and zona pellocida.
Capacitation- ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona pellocida.

11. Stages of Sexual Responses (EPOR)
Initial responses:
Vasocongestion – congestion of blood vessels
Myotonia – increase muscle tension

1. Excitement Phase – (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) – erotic stimuli cause increase sexual tension, lasts minutes to hours.

2. Plateau Phase – (accelerated V/S) – increasing & sustained tension nearing orgasm. Lasts 30 seconds – 3 minutes.
3. Orgasm – (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension with physiologic or psychologic release, immeasurable peak of sexual experience. May last 2 – 10 sec- most affected are is pelvic area.

4. Resolution – (v/s return to normal, genitals return to pre-excitement phase)
Refractory Period – the only period present in males, wherein he cannot be restimulated for about 10-15 minutes

A. Fertilization
B. Stages of Fetal Growth and Development
3-4 days travel of zygote – mitotic cell division begins

*Pre-embryonic Stage
a. Zygote- fertilized ovum. Lifespan of zygote – from fertilization to 2 months
b. Morula – mulberry-like ball with 16 – 50 cells, 4 days free floating & multiplication
c. Blastocyst – enlarging cells that forms a cavity that later becomes the embryo. Blastocyst – covering of blastocys that later becomes placenta & trophoblast
d. Implantation/ Nidation- occurs after fertilization 7 – 10 days.
Fetus- 2 months to birth.
placenta previa – implantation at low side of uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization – corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed.

3 processes of Implantation
1. Apposition
2. Adhesion
3. Invasion

C. Dicidua – thickened endometrium ( Latin – falling off)
* Basalis (base) part of endometrium located under fetus where placenta is delivered
* Capsularies – encapsulate the fetus
* Vera – remaining portion of endometrium.

C. Chorionic Villi- 10 – 11th day, finger life projections
3 vessels=
A – unoxygenated blood
V – O2 blood
A – unoxygenated blood

Wharton’s jelly – protects cord

Chorionic villi sampling (CVS) – removal of tissue sample from the fetal portion of the developing placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex missing digits/toes.

E. Cytotrophoblast – inner layer or langhans layer – protects fetus against syphilis 24 wks/6 months – life span of langhans layer increase. Before 24 weeks critical, might get infected syphilis

F. Synsitiotrophoblast – synsitial layer – responsible production of hormone

1. Amnion – inner most layer
a. Umbilical Cord- FUNIS, whitish grey, 15 – 55cm, 20 – 21”. Short cord: abruptio placenta or inverted uterus.
Long cord:cord coil or cord prolapse
b. Amniotic Fluid – bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline.
*Function of Amniotic Fluid:
1. cushions fetus against sudden blows or trauma
2. facilitates musculo-skeletal development
3. maintains temp
4. prevent cord compression
5. help in delivery process

normal amt of amniotic fluid – 500 to 1000cc

polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of fluid
oligohydramnios- decrease amt of fluid – kidney disease

Diagnostic Tests for Amniotic Fluid

A. Amniocentesis empty bladder before performing the procedure.
Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac; fluid is tested for:
1. Genetic screening- maternal serum alpha feto-protein test (MSAFP) – 1st trimester
2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity – 3rd trimester
Testing time – 36 weeks
decreased MSAFP= down syndrome
increase MSAFP = spina bifida or open neural tube defect
Common complication of amniocenthesis – infection
Dangerous complications – spontaneous abortion
3rd trimester- pre term labor
Important factor to consider for amniocentesis- needle insertion site
Aspiration of yellowish amniotic fluid – jaundice baby
Greenish – meconium

A. Amnioscopy – direct visualization or exam to an intact fetal membrane.
B. Fern Test- determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic fluid)
C. Nitrazine Paper Test – diff amniotic fluid & urine.
Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid.

1. Chorion – where placenta is developed

Lecithin Sphingomyelin L/S
Ratio- 2:1 signifies fetal lung maturity not capable for RDS

Shake test – amniotic + saline & shake
Foam test
Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity


a. Placenta – (Secundines) Greek – pancake, combination of chorionic villi + deciduas basalis. Size: 500g or ½ kg
-1 inch thick & 8” diameter
Functions of Placenta:

1. Respiratory System – beginning of lung function after birth of baby. Simple diffusion

2. GIT – transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If mom hypoglycemic, fetus hypoglycemic

3. Excretory System- artery - carries waste products. Liver of mom detoxifies fetus.

4. Circulating system – achieved by selective osmosis
5. Endocrine System – produces hormones

• Human Chorionic Gonadrophin – maintains corpus luteum alive.
• Human placental Lactogen or sommamommamotropin Hormone – for mammary gland development. Has a diabetogenic effect – serves as insulin antagonist
• Relaxin Hormone- causes softening joints & bones
• estrogen
• progestin

6. It serves as a protective barrier against some microorganisms – HIV,HBV

Fetal Stage “ Fetal Growth and Development”
Entire pregnancy days – 266 – 280 days 37 – 42 weeks

Differentiation of Primary Germ layers
* Endoderm
1st week endoderm – primary germ layer
Thyroid – for basal metabolism
Parathyroid - for calcium
Thymus – development of immunity
Liver – lining of upper RT & GIT

* Mesoderm – development of heart, musculoskeletal system, kidneys and repro organ

* Ectoderm – development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth
First trimester:
1st month - Brain & heart development
GIT& resp Tract – remains as single tube
1. Fetal heart tone begins – heart is the oldest part of the body
2. CNS develops – dizziness of mom due to hypoglycemic effect
Food of brain – glucose complex CHO – pregnant womans food (potato)

Second Month
1. All vital organs formed, placenta developed
2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month
3. Sex organ formed
4. Meconium is formed

Third Month
1. Kidneys functional
2. Buds of milk teeth appear
3. Fetal heart tone heard – Doppler – 10 – 12 weeks
4. Sex is distinguishable

Second Trimester: FOCUS – length of fetus

Fourth Month
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, 18 – 20 weeks
3. buds of permanent teeth appear

Fifth Month
1. lanugo covers body
2. actively swallows amniotic fluid
3. 19 – 25 cm fetus,
4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks – multi
5. fetal heart tone heard with or without instrument

Sixth Month
1. eyelids open
2. wrinkled skin
3. vernix caseosa present

Third trimester: Period of most rapid growth. FOCUS: weight of fetus
Seventh Month – development of surfactant – lecithin

Eighth Month
1. lanugo begin to disappear
2. sub Q fats deposit
3. Nails extend to fingers

Ninth Month
1. lanugo & vernix caseosa completely disappear
2. Amniotic fluid decreases

Tenth Month – bone ossification of fetal skull


Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus

A. Drugs:
Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor hearing & deafness
Tetracycline – staining tooth enamel, inhibit growth of long bone
Vitamin K – hemolysis (destr of RBC), hyperbilirubenia or jaundice
Iodides – enlargement of thyroid or goiter
Thalidomides – Amelia or pocomelia, absence of extremities

Steroids – cleft lip or palate
Lithium – congenital malformation
B. Alcohol – lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by microcephaly
C. Smoking – low birth rate
D. Caffeine – low birth rate
E. Cocaine – low birth rate, abruption placenta

TORCH (Terratogenic) Infections – viruses
CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus.


T – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat
O – others. Hepa A or infectious heap – oral/ fecal (hand washing)
Hepa B, HIV – blood & body fluids
Syphilis
R – rubella – German measles – congenital heart disease (1st month) normal rubella titer 1:10
<1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Don’t get pregnant for 3 months. Vaccine is terratogenic
C – cytomegalo virus
H – herpes simplex virus

VI. Physiological Adaptation of the Mother to Pregnancy

A. Systemic Changes
1. Cardiovascular System – increase blood volume of mom (plasma blood) 30 – 50% = 1500 cc of blood
- easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis – due to hyperemia of nasal membrane palpitation,

Physiologic Anemia – pseudo anemia of pregnant women


Normal Values
Hct 32 – 42%
Hgb 10.5 – 14g/dL

Criteria
1st and 3rd trimester.- pathologic anemia if lower
HCT should not be 33%, Hgb should not be < 11g/dL

2nd trimester – Hct should not <32%
Hgb Shdn't < 10.5% pathologic anemia if lower

Pathogenic Anemia
- iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women.

- Assessment reveals:
• Pallor, constipation
• Slowed capillary refill
• Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia

Nursing Care:
• Nutritional instruction – kangkong, liver due to ferridin content, green leafy vegetable-alugbati,saluyot, malunggay, horseradish, ampalaya
• Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly administered, hematoma.
• Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs after, black stool, constipation
• Monitor for hemorrhage

Alert:
• Iron from red meats is better absorbed iron form other sources
• Iron is better absorbed when taken with foods high in Vit C such as orange juice
• Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs

Edema – lower extremities due venous return is constricted due to large belly, elevate legs above hip level.

Varicosities – pressure of uterus
- use support stockings, avoid wearing knee high socks
- use elastic bandage – lower to upper
-
Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position – side lying with pillow under hips or modified knee chest position

Thrombophlebitis – presence of thrombus at inflamed blood vessel
- pregnant mom hyperfibrinogenemia
- increase fibrinogen
- increase clotting factor
- thrombus formation candidate

outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion
milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens

Mgt:
1.) Bed rest
2.) Never massage
3.) Assess + Homan sign once only might dislodge thrombus
4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute)
5.) Monitor APTT antidote for Heparin toxicity, protamine sulfate
6.) Avoid aspirin! Might aggravate bleeding.

2. Respiratory system – common problem SOB due to enlarged uterus & increase O2 demand
Position- lateral expansion of lungs or side lying position.

3. Gastrointestinal – 1st trimester change

• Morning Sickness – nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon - small freq feeding. Vomiting in preg – emesisgravida.
Metabolic alkalosis, F&E imbalance – primary med mgt – replace fluids.
Monitor I&O


constipation – progesterone resp for constipation. Increase fluid intake, increase fiber diet
- fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.
Except guava – has pectin that’s constipating – veg – petchy, malungay.
- exercise
-mineral oil – excretion of fat soluble vitamins
* Flatulence – avoid gas forming food – cabbage

* Heartburn – or pyrosis – reflux of stomach content to esophagus
- small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanical

increase salivation – ptyalsim – mgt mouthwash

*Hemorrhoids – pressure of gravid uterus. Mgt; hot sitz bath for comfort

4. Urinary System – frequency during 1st & 3rd trimester lateral expansion of lungs or side lying pos – mgt for nocturia
Acetyace test – albumin in urine
Benedicts test – sugar in urine

5. Musculoskeletal

Lordosis – pride of pregnancy

Waddling Gait – awkward walking due to relaxation – causes softening of joints & bones
Prone to accidental falls – wear low heeled shoes
Leg Cramps – causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 cause while pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus
Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish,
Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab.
Vit D for increased Ca absorption
dorsiflexion

B. Local Changes
Local change: Vagina:
V – Chadwick’s sign – blue violet discoloration of vagina
C – Goodel's sign – change of consistency of cervix
I – Hegar's – change of consistency of isthmus (lower uterine segment)

LEUKORRHEA – whitish gray, mousy odor discharge
ESTROGEN – hormone, resp for leucorrhea
OPERCULUM – mucus plug to seal out bacteria.
PROGESTERONE – hormone responsible for operculum
PREGNANT – acidic to alkaline change to protect bacterial growth (vaginitis)


Problems Related to the Change of Vaginal Environment:
a. Vaginitits – trichomonas vaginalis due to alkaline environment of vagina of pregnant mom
Flagellated protozoa – wants alkaline

S&Sx:
Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema
Mgt:
FLAGYL – (metronidazole – antiprotozoa). Carcinogenic drug so don’t give at 1st trimester
1. treat dad also to prevent reinfection
2. no alcohol – has antibuse effect
VAGINAL DOUCHE – IQ H2O : 1 tbsp white vinegar

b. Moniliasis or candidiasis due to candida albecans, fungal infection.
Color – white cheese like patches adheres to walls of vagina.

Signs & Symptoms:
Management – antifungal – Nistatin, genshan violet, cotrimaxole, canesten
Gonorrhea -Thick purulent discharge
Vaginal warts- condifoma acuminata due to papilloma virus
Mgt: cauterization

2. Abdominal Changes – striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue – avoid scratching, use coconut oil, umbilicus is protruding


3. Skin Changes – brown pigmentation nose chin, cheeks – chloasma melasma due to increased melanocytes.
Brown pinkish line- linea nigra- symphisis pubis to umbilicus

4. Breast Changes – increase hormones, color of areola & nipple
pre colostrums present by 6 weeks, colostrums at 3rd trimester

Breast self exam- 7 days after mens –– supine with pillow at back
quadrant B – upper outer – common site of cancer

Test to determine breast cancer:
1. mammography – 35 to 49 yrs once every 1 to 2 yrs
50 yrs and above – 1 x a yr

6. Ovaries – rested during pregnancy

7. Signs & symptoms of Pregnancy
A. Presumptive – s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy . Subjective
B. Probable – signs observed by the members of health team. Objective
C. Positive Signs – undeniable signs confirmed by the use of instrument.

Ballotment sign of myoma
* + HCG – sign of H mole
- trans vaginal ultrasound. Empty bladder
- ultrasound – full bladder

placental grading – rating/grade
o – immature
1 – slightly mature
2 – moderately mature
3 – placental maturity
What is deposited in placenta which signify maturity - there is calcium
Presumptive Probable Positive
Breast changes
Urinary freq
Fatigue
Amenorrhea
Morning sickness
Enlarged uterus

Cloasma
Linea negra
Increased skin pigmentation
Striae gravidarium
Quickening Goodel's- change of consistency of cervix
Chadwick’s- blue violet discoloration of vagina
Hegar's- change of consistency of isthmus
Elevated BBT – due to increased progesterone
Positive HCG or (+)preg test

Ballottement – bouncing of fetus when lower uterine is tapped sharply
Enlarged abdomen
Braxton Hicks contractions – painless irregular contractions
Ultrasound evidence (sonogram) full bladder

Fetal heart tone
Fetal movement
Fetal outline
Fetal parts palpable

VII. Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory)
First Trimester: No tanginal signs & sx, surprise, ambivalence, denial – sign of maladaptation to pregnancy. Developmental task is to accept biological facts of pregnancy
Focus: bodily changes of preg, nutrition

Second Trimester – tangible S&Sx. mom identifies fetus as a separate entity – due to presence of quickening, fantasy. Developmental task – accept growing fetus as baby to be nurtured.
Health teaching: growth & development of fetus.

Third Trimester: - mom has personal identification on appearance of baby
Development task: prepare of birth & parenting of child. HT: responsible parenthood ‘baby’s Layette” – best time to do shopping.
Most common fear – let mom listen to FHT to allay fear
Lamaze classes


VII. Pre-Natal Visit:
1. Frequency of Visit: 1st 7 months – 1x a month
8 – 9 months – 2 x a month
10 – once a week
post term 2 x a week
2. Personal data – name, age (high risk < 18 & >35 yrs old) record to determine high risk – HBMR. Home base mom’s record. Sex ( pseudocyesis or false pregnancy on men & women)
Couvade syndrome – dad experiences what mom goes through – lihi)
Address, civil status, religion, culture & beliefs with respect, non judgmental
Occupation – financial condition or occupational hazards, education background – level knowledge

3. Diagnosis of Pregnancy
1.) urine exam to detect HCG at 40 – 100th day. 60 – 70 day peak HCG. 6 weeks after LMP- best to get urine exam.
2.) Elisa test – test for preg detects beta subunit of HCG as early as 7 – 10days
3.) Home preg kit – do it yourself
4. Baseline Data: V/S esp. BP, monitor wt. (increase wt – 1st sign preeclampsia)

Weight Monitoring
First Trimester: Normal Weight gain 1.5 – 3 lbs (.5 – 1lb/month)
Second trimester: normal weight gain 10 – 12 lbs (4 lbs/month) (1 lb/wk)
Third trimester: normal weight gain 10 – 12 lbs (4 lbs/ month) ( 1lb/wk)
Minimum wt gain – 20 – 25 lbs
Optimal wt gain – 25 – 35 lbs

5. Obstetrical Data:
nullipara – no pregnancy
a. Gravida- # of pregnancy
b. Para - # of viable pregnancy
Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age.
age of viability - 20 – 24 wks
Term 37 – 42 wks,
Preterm -20 – 37 weeks
abortion <20 weeks
Sample Cases:
1 – abortion GTPAL
1 – 2nd mo 2 0 01 0
G – 2
P – 0

1 – 40th AOG GT P A L
1 – 36th AOG 6 1 2 2 4
2 – misc
1 – twins 35 AOG
1 – 4th month G6 P3

1 – 39th week
1 – miscarriage GP GTPAL
1 – stillbirth 33 AOG (considered as para) 4 2 4 11 1 1
1 – preg 3rd wk

1 – 33 P
1 41st L
1 – abort A
1 – still 39 GP GTPAL
1 triplet 32 6 4 6 2 2 15
1 4th mon
c. Important Estimates:

1. Nagele’s Rule – use to determine expected date of delivery
Get LMP -3+ 7 +1 Apr-Dec LMP – Jan Feb Mar
M D Y +9 +7 no year

LMP Jan 25, 04
+9 +7
10 / 32 / 04
- 1
add 1 month to month
11/31/04 EDD

2. McDonald’s Rule – to determine age of gestation IN WEEKS
FUNDIC HT X 7/8=AOG in WK

Fundic Ht X 7 = AOG in weeks
8
Fr sypmhisis pubis to fundus 24 X 7 =21 wks
8
3. Bartholomew’s Rule – to determine age of gestation by proper location of fundus at abdominal cavity.

3 months – above sym pub
5 months – level of umbilicus
9 months – below zyphoid
10 months – level of 8 months due to lightening

4. Haases rule – to determine length of the fetus in cm.
Formula: 1st ½ of preg , square @ month
2nd ½ of preg, x @ month by 5
3mos x 3 = 9cm
4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st ½ of preg
5 x 5 = 25 cm

6 x 5 = 30 cm
7 x 5 = 35 cm 2nd ½ of preg
8 x 5 = 40 cm
9 x 5 = 45 cm

d. tetanus immunizations – prevents tetanus neonatum
-mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3

TT1 – any time during pregnancy
TT2 – 4 wks after TT1 – 3 yrs protection
TT3 – 6 months after TT2 – 5 yrs protection
TT4 – 1 yr after TT3 – 10 yrs protection
TT5 – yr after TT4 – lifetime protection

5. Physical Examination:
A. Examine teeth: sign of infection
Danger signs of Pregnancy
C - chills/ fever - infection
Cerebral disturbances ( headache – preeclampsia)

A – abdominal pain ( epigastric pain – aura of impending convulsions

B – boardlike abdomen – abruption placenta
Increase BP – HPN
Blurred vision – preeclampsia
Bleeding – 1st trimester, abortion, ectopic pre/2nd – H mole, incompetent cervix
3rd – placental anomalies

S – sudden gush of fluid – PROM (premature rupture of membrane) prone to inf.

E – edema to upper ext. (preeclampsia)

6. Pelvic Examination – internal exam
1. empty bladder
2. universal precaution
EXT OS of cervix – site for getting specimen
Site for cervical cancer

Pap Smear – cervical cancer
- composed of squamous columnar tissue

Result:
Class I - normal
Class IIA – acytology but no evidence of malignancy
B – suggestive of infl.
Class III – cytology suggestive of malignancy
Class IV – cytology strongly suggestive of malignancy
Class V – cytology conclusive of malignancy

Stages of Cervical Cancer
Stage 0 – carcinoma insitu
1 – cancer confined to cervix
2 - cancer extends to vagina
3 – pelvis metastasis
4 – affection to bladder & rectum

7. Leopold’s Maneuver
Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone
- use palm! Warm palm.

Prep mom:
1. Empty bladder
2. Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles)
Procedure:
1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part to determine presentation

2nd Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart sound) where the ball of the stethoscope is placed to determine FHT. Get V/S(before 2nd maneuver) PR to diff fundic soufflé (FHR) & uterine soufflé.
Uterine soufflé – maternal H rate

3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers.
To determine degree of engagement.

Assess whether the presenting part is engaged in the pelvis )Alert : if the head is engaged it will not be movable).

4th Maneuver: the Examiner changes the position by facing the patient’s feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. To determine attitude – relationship of fetus to 1 another.

When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head will be flexed and vertex presenting.

Attitude – relationship of fetus to a part – or degree of flexion
Full flexion – when the chin touches the chest








8.Assessment of Fetal Well-Being-
A. Daily Fetal Movement Counting (DFMC) –begin 27 weeks
Mom- begin after meal - breakfast

a. Cardiff count to 10 method – one method currently available
(1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs)
(2) Expected findings – 10 movements in 1 hour or less
3) Warning signs
a.) more then 1 hour to reach 10 movements
b.) less then 10 movements in 12 hours(non-reactive- fetal distress)
c.) longer time to reach 10 FMs than on previous days
d.) movement are becoming weaker, less vigorous
Movement alarm signals - < 3 FMs in 12 hours
4.) warning signs should be reported to healthcare provider immediately; often require further testing. Examples: nonstress test (NST), biographical profile (BPP)

B. Nonstress test – to determine the response of the fetal heart rate to activity
Indication – pregnancies at risk for placental insufficiency
Postmaturity
a.) pregnancy induced hypertension (PIH), diabetes
b.) warning signs noted during DFMC
c.) maternal history of smoking, inadequate nutrition

Procedure:
Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor); external monitor is applied to document fetal activity; mother activates the “mark button” on the electronic monitor when she feels fetal movement.

Attach external noninvasive fetal monitors
1. tocotransducer over fundus to detect uterine contractions and fetal movements (FMs)
2. ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected
3. monitor until at least 2 FMs are detected in 20 minutes
• if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen
• if no FM after 1 hour further testing may be indicated, such as a CST

Result:
Noncreative
Nonstress
Not Good
Reactive
Responsive is
Real Good

Interpretation of results
i. reactive result
1. Baseline FHR between 120 and 160 beats per minute
2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15 seconds in a 10 to 20 minute period as a result of FM
3. Good variability – normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip.
4. result indicates a healthy fetus with an intact nervous system

ii. Nonreactive result
1. Stated criteria for a reactive result are not met
2. Could be indicative of a compromised fetus.
Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST)

9. Health teachings
a. Nutrition – do nutritional assessment – daily food intake
High risk moms:
1. Pregnant teenagers – low compliance to heath regimen.
2. Extremes in wt – underweight, over wt – candidate for HPN, DM
3. Low socio – economic status
4. Vegetarian mom – decrease CHON – needs Vit B12 – cyanocobalamin – formation of folic acid – needed for cell DNA & RBC formation. (Decrease folic acid – spina bifida/open neural tube defect)
How many Kcal CHO x4,CHON x4, fats x 9


Recommended Nutrient Requirement that increases During Pregnancy
Nutrients Requirements Food Source
Calories
Essential to supply energy for
- increased metabolic rate
- utilization of nutrients
- protein sparing so it can be used for
- Growth of fetus
- Development of structures required for pregnancy including placenta, amniotic fluid, and tissue growth. 300 calories/day above the prepregnancy daily requirement to maintain ideal body weight and meet energy requirement to activity level
- Begin increase in second trimester
- Use weight – gain pattern as an indication of adequacy of calorie intake.
- Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy; ketosis has been associated with fetal damage.

Caloric increase should reflect
- Foods of high nutrient value such as protein, complex carbohydrates (whole grains, vegetables, fruits)
- Variety of foods representing foods sources for the nutrients requiring during pregnancy
- No more than 30% fat
Protein
Essential for:
- Fetal tissue growth
- Maternal tissue growth including uterus and breasts
- Development of essential pregnancy structures
- Formation of red blood cells and plasma proteins
* Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH) 60 mg/day or an increase of 10% above daily requirements for age group

Adolescents have a higher protein requirement than mature women since adolescents must supply protein for their own growth as well as protein t meet the pregnancy requirement

Protein increase should reflect
- Lean meat, poultry, fish
- Eggs, cheese, milk
- Dried beans, lentils, nuts
- Whole grains
* vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids
Calcium-Phosphorous
Essential for
- Growth and development of fetal skeleton and tooth buds
- Maintenance of mineralization of maternal bones and teeth
- Current research is :
Demonstrating an association between adequate calcium intake and the prevention of pregnancy induce hypertension
Calcium increases of
- 1200 mg/day representing an increase of 50% above prepregnancy daily requirement.
- 1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous Calcium increases should reflect:
- dairy products : milk, yogurt, ice cream, cheese, egg yolk
- whole grains, tofu
- green leafy vegetables
- canned salmon & sardines w/ bones
- Ca fortified foods such as orange juice
- Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood
Iron
Essential for
- Expansion of blood volume and red blood cells formation
- Establishment of fetal iron stores for first few months of life 30 mg/day representing a doubling of the pregnant daily requirement
- Begin supplementation at 30- mg/day in second trimester, since diet alone is unable to meet pregnancy requirement
- 60 – 120 mg/day along with copper and zinc supplementation for women who have low hemoglobin values prior to pregnancy or who have iron deficiency anemia.
- 70 mg/day of vitamin C which enhances iron absorption
- inadequate iron intake results in maternal effects – anemia depletion of iron stores, decreased energy and appetite, cardiac stress especially labor and birth
- fetal effects decreased availability of oxygen thereby affecting fetal growth
* iron deficiency anemia is the most common nutritional disorder of pregnancy. Iron increases should reflect
- liver, red meat, fish, poultry, eggs
- enriched, whole grain cereals and breads
- dark green leafy vegetables, legumes
- nuts, dried fruits
- vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, broccoli or cabbage, potatoes
- iron from food sources is more readily absorbed when served with foods high in vit C

Zinc
Essential for
* the formation of enzymes
* maybe important in the prevention of congenital malformation of the fetus. 15mcg/day representing an increase of 3 mg/day over prepreganant daily requirements. Zinc increases should reflect
- liver, meats
- shell fish
- eggs, milk, cheese
- whole grains, legumes, nuts
Folic Acid, Folacin, Folate
Essential for
- formation of red blood cells and prevention of anemia
- DNA synthesis and cell formation; may play a role in the prevention of neutral tube defects (spina bifida), abortion, abruption placenta 400 mcg/day representing an increase of more then 2 times the daily prepregnant requirement. 300mcg/day supplement for women with low folate levels or dietary deficiency
4 servings of grains/day Increases should reflect
- liver, kidney, lean beef, veal
- dark green leafy vegetables, broccoli, legumes.
- Whole grains, peanuts
Additional Requirements
Minerals
- iodine
- Magnesium
- Selenium

175 mcg/day
320 mg/day
65 mcg/day Increased requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy.
Vitamins
E
Thiamine
Riborlavin
Pyridoxine ( B6)
B12
Niacin
10 mg/day
1.5 mg/day
1.6 mg/day
2.2 mg/day
2.2 mg day
17 mg/day Vit stored in body. Taking it not needed – fat soluble vitamins. Hard to excrete.

2.Sexual Activity
a.) should be done in moderation
b.) should be done in private place
c.) mom placed in comfy pos, sidelying or mom on top
d.) avoided 6 weeks prior to EDD
e.) avoid blowing or air during cunnilingus
f.) changes in sexual desire of mom during preg- air embolism
Changes in sexual desire:
a.) 1st tri – decrease desire – due to bodily changes
b.) 2nd trimester – increased desire due to increase estrogen that enhances lubrication
c.) 3rd trimester – decreased desire

Contraindication in sex:
1. vaginal spotting
1st trimester – threatened abortion
2nd trimester– placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane

3. Exercise – to strengthen muscles used during delivery process
- principles of exercise
1.) Done in moderation. 2.) Must be individualized
Walking – best exercise

Squatting – strengthen muscles of perineum. Increase circulation to perineum. Squat – feet flat on floor

Tailor Sitting – 1 leg in front of other leg ( Indian seat)

Raise buttocks 1st before head to prevent postural hypotension – dizziness when changing position


- shoulder circling exercise- strengthen chest muscles
- pelvic rocking/pelvic tilt- exercise – relieves low back pain & maintain good posture
- * arch back – standing or kneeling. Four extremities on floor

Kegel Exercise – strengthen pulococcygeal muscles
- as if hold urine, release 10x or muscle contraction

Abdominal Exercise – strengthens muscles of abdominal – done as if blowing candle

4. Childbirth Preparation:
Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience.

a. Psychophysical
1. Bradley Method – Dr. Robert Bradley – advocated active participation of husband at delivery process. Based on imitation of nature.

Features:
1.) darkened rm
2.) quiet environment
3.) relaxation tech
4.) closed eye & appearance of sleep

2. Grantly Dick Read Method – fear leads to tension while tension leads to pain

b. Psychosexual
1. Kitzinger method – preg, labor & birth & care of newborn is an impt turning pt in woman’s life cycle
- flow with contraction than struggle with contraction

c. Psychoprophylaxis – prevention of pain
1. Lamaze: Dr. Ferdinand Lamaze
req. disciple, conditioning & concentration. Husband is coach
Features:
1. Conscious relaxation
2. Cleansing breathe – inhale nose, exhale mouth
3. Effleurage – gentle circular massage over abdominal to relieve pain
4. imaging – sensate focus


5. Different Methods of delivery:
1.) birthing chair – bed convertible to chair – semifowlers
2.) birthing bed – dorsal recumbent pos
3.) squatting – relives low back pain during labor pain
4.) leboyers – warm, quiet, dark, comfy room. After delivery, baby gets warm bath.
5.) Birth under H20 – bathtub – labor & delivery – warm water, soft music.

IX. Intrapartal Notes – inside ER
A. Admitting the laboring Mother:
Personal Data: name, age, address, etc
Baseline Data: v/s esppecially BP, weight
Obstetrical Data: gravida # preg, para- viable preg, – 22 – 24 wks
Physical Exams,Pelvic Exams

B. Basic knowledge in Intrapartum.

b. 1 Theories of the Onset of Labor
1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) – contraction action
2.) oxytocin theory – post pit gland releases oxytocin. Hypothalamus produces oxytocin
3.) prostaglandin theory – stimulation of arachidonic acid – prostaglandin- contraction
4.) progesterone theory – before labor, decrease progesterone will stimulate contractions & labor
5.) theory of aging placenta – life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).

b.2. The 4 P’s of labor

1. Passenger
a. Fetal head – is the largest presenting part – common presenting part – ¼ of its length.
Bones – 6 bones S – sphenoid F – frontal - sinciput
E – ethmoid O – occuputal - occiput
T – temporal P – parietal 2 x
Measurement fetal head:
1. transverse diameter – 9.25cm
- biparietal – largest transverse
- bitemporal 8 cm
2. bimastoid 7cm smallest transverse

Sutures – intermembranous spaces that allow molding.
1.) sagittal suture – connects 2 parietal bones ( sagitna)
2.) coronal suture – connect parietal & frontal bone (crown)
3.) lambdoidal suture – connects occipital & parietal bone

Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis

Fontanels:
1.) Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close
2.) Posterior fontanel or lambda – triangular shape, 1 x 1 cm. Closes – 2 – 3 months.
4.) Anteroposterior diameter -
suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
occipitofrontal 12cm partial flexion
occipitomental – 13.5 cm hyper extension submentobragmatic-face presentation

2. Passageway
Mom 1.) < 4’9” tall
2.) < 18 years old
3.) Underwent pelvic dislocation
Pelvis
4 main pelvic types
1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy
2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow
3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
4. Platypelloid – flat AP diameter – narrow, transverse – wider

b. Pelvis
2 hip bones – 2 innominate bones
3 Parts of 2 Innominate Bones
Ileum – lateral side of hips
- iliac crest – flaring superior border forming prominence of hips
Ischium – inferior portion
- ischial tuberosity where we sit – landmark to get external measurement of pelvis
Pubes – ant portion – symphisis pubis junction between 2 pubis
1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis
1 coccyx – 5 small bones compresses during vaginal delivery


Important Measurements

1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the symphysis pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm=true conjugate)

2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm

3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more.

Tuberoischi Diameter – transverse diameter of the pelvic outlet. Ischial tuberosity – approximated with use of fist – 8 cm & above.

3. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. Psyche/Person – psychological stress when the mother is fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System

Pre-eminent Signs of Labor
S&Sx:
- shooting pain radiating to the legs
- urinary freq.
1. Lightening – setting of presenting part into pelvic brim - 2 weeks prior to EDD
* Engagement- setting of presenting part into pelvic inlet
2. Braxton Hicks Contractions – painless irregular contractions
3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase epinephrine
4. Ripening of the Cervix – butter soft
5. decreased body wt – 1.5 – 3 lbs
6. Bloody Show – pinkish vaginal discharge – blood & leukorrhea
7. Rupture of Membranes – rupture of water. Check FHT

Premature Rupture of Membrane ( PROM) - do IE to check for cord prolapse
Contraction drop in intensity even though very painful
Contraction drop in frequently
Uterus tense and/or contracting between contractions
Abdominal palpations

Nursing Care;
Administer Analgesics (Morphine)
Attempt manual rotation for ROP or LOP – most common malposition
Bear down with contractions
Adequate hydration – prepare for CS
Sedation as ordered
Cesarean delivery may be required, especially if fetal distress is noted

Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix into the vagina.

Danger signs:
PROM
Presenting part has not yet engaged
Fetal distress
Protruding cord form vagina



Nursing care:
1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy.
2. Slip cord away from presenting part
3. Count pulsation of cord for FHT
4. Prep mom for CS

Positioning – trendelenberg or knee chest position
Emotional support
Prepare for Cesarean Section

Difference Between True Labor and False Labor
False Labor True Labor
Irregular contractions
No increase in intensity
Pain – confined to abdomen
Pain – relived by walking
No cervical changes Contractions are regular
Increased intensity
Pain – begins lower back radiates to abdomen
Pain – intensified by walking
Cervical effacement & dilatation * major sx
of true labor.
Duration of Labor
Primipara – 14 hrs & not more than 20 hrs
Multipara – 8 hrs & not > 14 hrs

Effacement – softening & thinning of cervix. Use % in unit of measurement
Dilation – widening of cervix. Unit used is cm.

Nursing Interventions in Each Stage of Labor

2 segments of the uterus
1. upper uterine - fundus
2. lower uterine – isthmus

1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase:
Assessment: Dilations: 0 – 3 cm mom – excited, apprehensive, can communicate
Frequency: every 5 – 10 min
Intensity mild
Nursing Care:
1. Encourage walking - shorten 1st stage of labor
2. Encourage to void q 2 – 3 hrs – full bladder inhibit contractions
3. Breathing – chest breathing

Active Phase:
Assessment: Dilations 4 -8 cm Intensity: moderate Mom- fears losing control of self
Frequency q 3-5 min lasting for 30 – 60 seconds

Nursing Care:
M – edications – have meds ready
A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.
D – dry lips – oral care (ointment)
dry linens
B – abdominal breathing

Transitional Phase: intensity: strong Mom – mood changes with hyperesthesia
Assessment: Dilations 8 – 10 cm
Frequency q 2-3 min contractions
Durations 45 – 90 seconds

Hyperesthesia – increase sensitivity to touch, pain all over
Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain
keep informed of progress
controlled chest breathing
Nursing Care:
T – ires
I – nform of progress
R – estless support her breathing technique
E – ncourage and praise
D – iscomfort

Pelvic Exams
Effacement
Dilation
a. Station – landmark used: ischial spine
- 1 station = presenting part 1cm above ischial spine if (-) floating
- 2 station = presenting part 2 cm above ischial spine if (-) floating
0 station = level at ischial spine – engagement
+ 1 station = below 1 cm ischial spine
+3 to +5 = crowning – occurs at 2nd stage of labor

b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother
-spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
cephalic - Vertex – complete flexion
Face
Brow Poor Flexion
Chin
Breech - Complete Breech – thigh breast on abdomen, breast lie on thigh
Incomplete Breech – thigh rest on abdominal
Frank – legs extend to head
Footling – single, double
Kneeling

b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation.

c. Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.

Variety:
Occipito – LOA left occipito ant (most common and favorable position)– side of maternal pelvis
LOP – left occipito posterior
LOP – most common mal position, most painful
ROP – squatting pos on mom
ROT
ROA

Breech- use sacrum LSA – left sacro anterior
- put stet above umbilicus LST, LSP, RSA, RST, RSP
Shoulder/acromniodorso
LADA, LADT, LADP, RADA

Chin / Mento
LMA, LMT, LMP, RMP, RMA, RMT, RMP

Monitoring the Contractions and Fetal heart Tone
Spread fingers lightly over fundus – to monitor contractions

Parts of contractions:
Increment or crescendo – beginning of contractions until it increases
Acme or apex – height of contraction
Decrement or decrescendo – from height of contractions until it decreases
Duration – beginning of contractions to end of same contraction
Interval – end of 1 contraction to beginning of next contraction
Frequency – beginning of 1 contraction to beginning of next contraction
Intensity - strength of contraction

Contraction – vasoconstriction
Increase BP, decrease FHT
Best time to get BP & FHT just after a contraction or midway of contractions

Placental reserve – 60 sec o2 for fetus during contractions
Duration of contractions shouldn’t >60 sec
Notify MD

Mom has headache – check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia
Health teachings
1.) Ok to shower
2.)NPO – GIT stops function during labor if with food- will cause aspiration
3.)Enema administer during labor
a.)To cleanse bowel
b.)Prevent infection
c.)Sims position/side lying
12 – 18 inch – ht enema tubing

Check FHT after adm enema
Normal FHT= 120-160

Signs of fetal distress-
1.) <120 & >160
2.) mecomium stain amnion fluid
3.) fetal thrushing – hyperactive fetus due to lack O2

2. Second Stage: fetal stage, complete dilation and effacement to birth.

7 – 8 multi – bring to delivery room
10cm primi – bring to delivery room
Lithotomy pos – put legs same time up
Bulging of perineum – sure to come out
Breathing – panting ( teach mom)
Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2nd stage of labor.
Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula)
Mediolateral – more bleeding & pain, hard to repair, slow to heal
-use local or pudendal anesthesia.

Ironing the perineum – to prevent laceration
Modified Ritgens maneuver – place towel at perineum
1.)To prevent laceration
2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby.

Mechanisms of labor
1. Engagement -
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion

Three parts of Pelvis – 1. Inlet – AP diameter narrow, transverse diameter wider
2. Cavity
Two Major Divisions of Pelvis
1. True pelvis – below the pelvic inlet
2. False pelvis – above the pelvic inlet; supports uterus during pregnancy


Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis.
Nursing Care:
To prevent puerperal sepsis - < 48 hours only – vaginal pack

Bolus of Ptocin can lead to hypotension.


3. Third Stage: birth to expulsion of Placenta -placental stage placenta has 15 – 28 cotyledons
Placenta delivered from 3-10 minutes
Signs of placental separation
1. Fundus rises – becomes firm & globular “ Calkins sign”
2. Lengthening of the cord
3. Sudden gush of blood

Types of placental delivery
Shultz “shiny” – begins to separate from center to edges presenting the fetal side shiny
Dunkan “dirty” – begin to separate form edges to center presenting natural side – beefy red or dirty

Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER
Hurrying of placental delivery will lead to inversion of uterus.

Nsg care for placenta:
4. Check completeness of placenta.
5. Check fundus (if relaxed, massage uterus)
6. Check bp
7. Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives
8. Monitor hpn (or give oxytocin IV)
9. Check perineum for lacerations
10. Assist MD for episiorapy
11. Flat on bed
12. Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.

4. Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
Check placement of fundus at level of umbilicus.

If fundus above umbilicus, deviation of fundus
1.) Empty bladder to prevent uterine atony
2.) Check lochia
a. Maternal Observations – body system stabilizes
b. Placement of the Fundus
c. Lochia

d. Perineum –
R - edness
E- dema
E - cchemosis
D – ischarges
A – approximation of blood loss. Count pad & saturation

Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc

e. Bonding – interaction between mother and newborn – rooming in types
1.) Straight rooming in baby: 24hrs with mom.
2.) Partial rooming in: baby in morning , at night nursery




Complications of Labor
Dystocia – difficult labor related to:
Mechanical factor – due to uterine inertia – sluggishness of contraction
1.) hypertonic or primary uterine inertia
- intense excessive contractions resulting to ineffective pushing
- MD administer sedative valium,/diazepam – muscle relaxant
2.) hypotonic – secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin.

Prolonged labor – normal length of labor in primi 14 – 20 hrs
Multi 10 -14 hrs
> 14 hrs in multi & > 20 hrs in primi
- maternal effect – exhaustion. Fetal effect – fetal distress, caput succedaneum or cephal hematoma
- nsg care: monitor contractions and FHR

Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.
Earliest sign: tachycardia & restlessness
Late sign: hypotension
Outstanding Nursing dx: fluid volume deficit
Post of mom – modified trendelenberg
IV – fast drip due fluid volume def

Signs of Hypovolemic Shock:
Hypotension
Tachycardia
Tachypnea
Cold clammy skin

Inversion of the uterus – situation uterus is inside out.
MD will push uterus back inside or not hysterectomy.

Factors leading to inversion of uterus
1.) short cord
2.) hurrying of placental delivery
3.) ineffective fundal pressure

Uterine Rupture
Causes: 1.)
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
Sx:
a.) sudden pain
b.) profuse bleeding
c.) hypovolemic shock
d.) TAHBSO
Physiologic retraction ring
- Boundary bet upper/lower uterine segment
BANDL’S pathologic ring – suprapubic depression
a.) sign of impending uterine rupture

Amniotic Fluid Embolism or placental embolism – amniotic fluid or fragments of placenta enters natural circulation resulting to embolism
Sx:
dyspnea, chest pain & frothy sputum
prepare: suctioning
end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body – eyes, nose, etc.

Trial Labor – measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor
Multi: 8 – 14, primi 14 – 20

Preterm Labor – labor after 20 – 37 weeks) ( abortion <20 weeks)
Sx:
1. premature contractions q 10 min
2. effacement of 60 – 80%
3. dilation 2-3 cm

Home Mgt:
1. complete bed rest
2. avoid sex
3. empty bladder
4. drink 3 -4 glasses of water – full bladder inhibits contractions
5. consult MD if symptoms persist

Hosp:
1. If cervix is closed 2 – 3 cm, dilation saved by administer Tocolytic agents- halts preterm contractions.YUTOPAR- Yutopar Hcl)
150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IV
Tocolytic (Phil)
Terbuthaline (Bricanyl or Brethine) – sustained tachycardia
Antidote – propranolol or inderal - beta-blocker

If cervix is open – MD – steroid dextamethzone (betamethazone) to facilitate surfactant maturation preventing RDS

Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.


X. Postpartal Period 5th stage of labor
after 24hrs :Normal increase WBC up to 30,000 cumm

Puerperium – covers 1st 6 wks post partum
Involution – return of repro organ to its non pregnant state.
Hyperfibrinogenia
- prone to thrombus formation
- early ambulation

Principles underlying puerperium
1. To return to Normal and Facilitate healing

A. Physiologic Changes
a.1. Systemic Changes

1. Cardiovascular System
- the first few minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal state and thus adding to the workload of the heart. This is critical especially to gravidocardiac mothers.

2. Genital tract
a. Cervix – cervical opening
b. Vaginal and Pelvic Floor
c. Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10th day – no longer palpable due behind symphisis pubis
3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood- a medium for bacterial growth- (puerperal sepsis)- D&C
after, birth pain:
1. position prone
2. cold compress – to prevent bleeding
3. mefenamic acid

d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.
1. Ruba – red 1st 3 days present, musty/mousy, moderate amt
2. Serosa – pink to brown 4 – 9th day, limited amt
3. Alba – créme white 10 – 21 days very decreased amt
dysuria
- urine collection
- alternate warm & cold compress
- stimulate bladder

3. Urinary tract: Bladder – freq in urination after delivery- urinary retention with overflow
4. Colon: Constipation – due NPO, fear of bearing down
5. Perineal area – painful – episiotomy site – sims pos, cold compress for immediate pain after 24 hrs, hot sitz bath, not compress
sex- when perineum has healed

II. Provide Emotional Support – Reva Rubia
Psychological Responses:
a. Taking in phase – dependent phase (1st three days) mom – passive, cant make decisions, activity is to tell child birth experiences.
Nursing Care: - proper hygiene
b. Taking hold phase – dependent to independent phase (4 to 7 days). Mom is active, can make decisions
HT:
1.) Care of newborn
2.) Insert family planting method
common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming feeling of depression characterized by crying, despondence- inability to sleep & lack of appetite. – let mom cry – therapeutic.

c. Letting go – interdependent phase – 7 days & above. Mom - redefines new roles may extend until child grows.

III. Prevent complications

1. Hemorrhage – bleeding of > 500cc
CS – 600 – 800 cc normal
NSD 500 cc

I. Early postpartum hemorrhage– bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding – uterine atony. Complications: hypovolemic shock.
Mgt:
1.) massage uterus until contracted
2.) cold compress
3.) modified trendelenberg
4.) IV fast drip/ oxytocin IV drip

1st degree laceration – affects vaginal skin & mucus membrane.
2nd degree – 1st degree + muscles of vagina
3rd degree – 2nd degree + external sphincter of rectum
4th degree – 3rd degree + mucus membrane of rectum




Breast feeding – post pit gland will release oxytocin so uterus will contract.
Well contracted uterus + bleeding = laceration
- assess perineum for laceration
- degree of laceration
- mgt episiorapy

DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate.
- bleeding to any part of body
- hysterectomy if with abruption placenta
mgt: BT- cryoprecipitate or fresh frozen plasma

II. Late Postpartum hemorrhage – bleeding after 24 hrs – retained placental fragments
Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta, percreta,

Acreta – attached placenta to myometrium.
Increta – deeper attachment of placenta to myometrium hysterectomy
Percreta – invasion of placenta to perimetrium

Hematoma – bluish or purple discoloration of SQ tissue of vagina or perineum.
- too much manipulation
- large baby
- pudendal anesthesia
Mgt:
1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs
2.) shave
3.) incision on site, scraping & suturing

Infection- sources of infection
1.)endogenous – from within body
2.) exogenous – from outside
1.) anaerobic streptococci – most common - from members health team
2.) unhealthy sexual practices
General signs of inflammation:
1. Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)
2. purulent discharges
3. fever

Gen mgt:
1.) supportive care – CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity – for antibiotic

prolonged use of antibiotic lead to fungal infection
inflammation of perineum – see general signs of inflammation
2 to 3 stitches dislocated with purulent discharge
Mgt:
Removal of sutures & drainage, saline, between & resulting.
Endometriosis – inflammation of endometrial lining
Sx:
Abdominal tenderness, pos.
Fowlers – to facilitate drainage & localize infection oxytocin & antibiotic

IV. Motivate the use of Family Planning
1.) determine one’s own beliefs 1st
2.) never advice a permanent method of planning
3.) method of choice is an individuals choice.

Natural Method – the only method accepted by the Catholic Church
Billings / Cervical mucus– test spinnbarkeit & ferning (estrogen)
- clear, watery, stretchable, elastic – long spinnbarkeit
Basal Body Temperature 13th day temp goes down before ovulation – no sex
- get before arising in bed

LAM – lactation amenorrheal method – hormone that inhibits ovulation is prolactin.
breast feeding- menstruation will come out 4 – 6 months
bottle fed 2 – 3 months
disadvantage of lam – might get pregnant

Symptothermal – combination of BBT & cervical. Best method

Social Method – 1.) coitus interuptus/ withdrawal - least effective method
2. coitus reservatus – sex without ejaculation –
3. coitus interfemora – “ipit”
4. calendar method

OVULATION –count minus 14 days before next mens (14 days before next mens)

Origoknause formula –
- monitor cycle for 1 year
- -get short test & longest cycle from Jan – Dec
- shortest – 18
- longest – 11

June 26 Dec 33
- 18 -11
8 - 22 unsafe days

21 day pill- start 5th day of mens
28day pill- start 1st day of mens
missed 1 pill – take 2 next day

Physiologic Method-

Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to become pregnant- 3 months. Consult OB-6mos.

Alerts on Oral Contraceptive:

-in case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she would wait for at least 3 months before attempting to conceive to provide time for the estrogen and progesterone levels to return to normal.
- if a new oral contraceptive is prescribed the mother should continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses.
- discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension associated with increase incidence of CVA and subarachnoid hemorrhage.

Signs of hypertension
Immediate Discontinuation
A – abdominal pain
C – chest pain
H - headache
E – eye problems
S – severe leg cramps
If mom HPN – stop pills STAT!
Adverse effect: breakthrough bleeding
Contraindicated:
1.) chain smoker
2.) extreme obesity
3.) HPN
4.) DM
5.) Thrombophlebitis or problems in clotting factors

- if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the start again.

DMPA – depoproveda – has progesterone inhibits LH – inhibits ovulation
Depomedroxy progesterone acetate – IM q 3 months
- never massage injected site, it will shorten duration

Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.
- 5 yrs – disadvantage if keloid skin
- as soon as removed – can become pregnant

Mechanism and Chemical Barriers


Intrauterine Device (IUD)
Action: prevents implantation – affects motility of sperm & ovum
- right time to insert is after delivery or during menstruation

primary indication for use of IUD
- parity or # of children, if 1 kid only don’t use IUD

HT:
1.) Check for string daily
2.) Monthly checkup
3.) Regular pap smear
Alerts;
- prevents implantation
- most common complications: excessive menstrual flow and expulsion of the device (common problem)
- others:
P eriod late (pregnancy suspected)
Abnormal spotting or bleeding
A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic pregnancy
Condom – latex inserted to erected penis or lubricated vagina
Adv; gives highest protection against STD – female condom

Alerts:
Disadvantage:
- it lessen sexual satisfaction
- it gives higher protection in the prevention of STDs

Diaphragm – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. REVERSABLE

Ht:
1.) proper hygiene
2.) check for holes before use
3.) must stay in place 6 – 8 hrs after sex
4.) must be refitted especially if without wt change 15 lbs
5.) spermicide – chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome

Alerts: Should be kept in place for about 6 – 8 hours

Cervical Cap – most durable than diaphragm no need to apply spermicide
C/I: abnormal pap smear

Foams, Jellies, Creams

Surgical Method – BTL , Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid lifting heavy objects
Vasectomy – cut vas deferense.
HT: >30 ejaculations before safe sex
O – zero sperm count, safe

XI. High Risk Pregnancy

1. Hemorrhagic Disorders

General Management
1.) CBR
2.) Avoid sex
3.) Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)
4.) Ultrasound to determine integrity of sac
5.) Signs of Hypovolemic shock
6.) Save discharges – for histopathology – to determine if product of conception has been expelled or not

First Trimester Bleeding – abortion or eptopic
A. Abortions – termination of pregnancy before age of viability (before 20 weeks)
Spontaneous Abortion- miscarriage
Cause: 1.) chromosomal alterations
2.) blighted ovum
3.) plasma germ defect

Classifications:

a. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed
b. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
Types:
1.) Complete – all products of conception are expelled. No mgt just emotional support!
2.) Incomplete – Placental and membranes retained. Mgt: D&C
Incompetent cervix – abortion
McDonalds procedure – temporary circlage on cervix
S/E; infection. During delivery, circlage is removed. NSD
Sheridan – permanent surgery cervix. CS

c. Habitual – 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. Present 2nd trimester
d. Missed – fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty dark brown bleeding
Mgt: induced labor with oxytocin or vacuum extraction

5.) Induced Abortion – therapeutic abortion to save life of mom. Double effect choose between lesser evil.

C. Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity. common site: tubal or ampular
Dangerous site - interstitial
Unruptured Tubal rupture
- missed period
- abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)
- scant, dark brown, vaginal bleeding

Nursing care:
Vital signs
Administer IV fluids
Monitor for vaginal bleeding
Monitor I & O - sudden , sharp, severe pain. Unilateral radiating to shoulder.
shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve)
+ Cullen’s Sign – bluish tinged umbilicus – signifies intra peritoneal bleeding
syncope (fainting)
Mgt:
Surgery depending on side
Ovary: oophrectomy
Uterus : hysterectomy


Second trimester bleeding

C. Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. – with fertilization. Progressive degeneration of chorionic villi. Recurs.
- gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.
Use: methotrexate to prevent choriocarcinoma
Assessment:
Early signs - vesicles passed thru the vagina
Hyperemesis gravidarium increase HCG
Fundal height
Vaginal bleeding( scant or profuse)
Early in pregnancy
High levels of HCG
Preeclampsia at about 12 weeks
Late signs hypertension before 20th week
Vesicles look like a “ snowstorm” on sonogram
Anemia
Abdominal cramping
Serious complications hyperthyroidism
Pulmonary embolus
Nursing care:
Prepare D&C
Do not give oxytoxic drugs
Teachings:
a. Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma
b. Avoid pregnancy for at least one year
Third Trimester Bleeding “Placenta Anomalies”

D. Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the cervical os. Abnormal lower implantation of placenta.
- candidate for CS
Sx: frank
Bright red
Painless bleeding
Dx:
Ultrasound
Avoid: sex, IE, enema – may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR

Assessment:
Engagement (usually has not occurred)
Fetal distress
Presentation ( usually abnormal)
Surgeon – in charge of sign consent, RN as witness
- MD explain to patient
complication: sudden fetal blood loss

Nursing Care
NPO
Bed rest
Prepare to induce labor if cervix is ripe
Administer IV

E. Abruptio Placenta – it is the premature separation of the placenta form the implantation site. It usually occurs after the twentieth week of pregnancy.
Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.

Assessment:
Concealed bleeding (retroplacental)
Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications:
Sudden fetal blood loss
-placenta previa & vasa previa
Nursing Care:
Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report s/sx of DIC
Monitor v/s for shock
Strict I&O
F. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained placental fragments if vessel is cut.
G. Placenta Circumvalata – fetal side of placenta covered by chorion
H. Placenta Marginata – fold side of chorion reaches just to the edge of placenta
I. Battledore Placenta – cord inserted marginally rather then centrally
J. Placenta Bipartita – placenta divides into 2 lobes
K. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
L. Vasa Previa – velamentous insertion of cord has implanted in cervical OS


2. Hypertensive Disorders

I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum.

1.) Gestational hypertension - HPN without edema & protenuria H without EP
2.) Pre-eclampsia – HPN with edema & protenuria or albuminuria HE P/A
3.) HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count

II. Transissional Hypertension – HPN between 20 – 24 weeks

III. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum.
Three types of pre-eclampsia
1.) Mild preeclampsia – earliest sign of preeclampsia
a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2


2.) Severe preeclampsia
Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending convulsion. BP 160/110 , protenuria +3 - +4

3.) Eclampsia – with seizure! Increase BUN – glomerular damage. Provide safety.

Cause of preeclampsia
1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi
2.) common in multiple pre (twins) increase exposure to chorionic villi
3.) common to mom with low socioeconomic status due to decrease intake of CHON

Nursing care:
P – romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to urinate.
P- prevent convulsions by nursing measures or seizure precaution
1.) dimly lit room . quiet calm environment
2.) minimal handling – planning procedure
3.) avoid jarring bed

P- prepare the following at bedside
- tongue depressor
- turning to side done AFTER seizure! Observe only! for safely.
E – ensure high protein intake ( 1g/kg/day)
- Na – in moderation

A – anti-hypertensive drug Hydralazine ( Apresoline)
C – convulsion, prevent – Mg So4 – CNS depressant
E – valuate physical parameters for Magnesium sulfate
Magnesium SO4 Toxicity:
1. BP decrease
2. Urine output decrease
3. Resp < 12
4. Patella reflex absent – 1st sigh Mg SO4 toxicity. antidote – Ca gluconate

3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas)
Function: of insulin – facilitates transport of glucose to cell
Dx: 1 hr 50gr glucose tolerance test GTT
Normal glucose – 80 – 120 mg/dl < 80 – hypoclycemic
( euglycemia) > 120 - hyperglycemia

3 degrees GTT of > 130 mg/dL
maternal effect DM
1.) Hypo or hyperglycemia – 1st trimester hypo, 2nd – 3rd trim – hyperglycemic
2.) Frequent infection- moniliasis
3.) Polyhydramnios
4.) Dystocia-difficult birth due to abnormalities in fetus or mom.
5.) Insulin requirement, decrease in insulin by 33% in 1st tri; 50% increase insulin at 2nd – 3rd trimester.
Post partum decrease 25% due placenta out.

Fetal effect
1.) hyper & hypoglycemia
2.) macrosomia – large gestational age – baby delivered > 400g or 4kg
3.) preterm birth to prevent stillbirth

Newborn Effect : DM
1.) hyperinsulinism
2.) hypoglycemia
normal glucose in newborn 45 – 55 mg/dL
hypoglycemic < 40 mg/dL
Heel stick test – get blood at heel
Sx:
Hypoglycemia high pitch shrill cry tremors, administer dextrose
3.) hypocalcemia - < 7mg%
Sx:
Calcemia tetany
Trousseau sign
Give calcium gluconate if decrease calcium

Recommendation
Therapeutic abortion
If push through with pregnancy
1.) antibiotic therapy- to prevent sub acute bacterial endocarditis
2.) anticoagulant – heparin doesn’t cross placenta

Class I & II- good progress for vaginal delivery
Class III & IV- poor prognosis, for vaginal delivery, not CS!
NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver
Regional anesthesia!
Low forcep delivery due to inability to push. It will shorten 2nd stage of labor.

Heart disease
Moms with RHD at childhood
Class I – no limit to physical activity
Class II – slight limitation of activity. Ordinary activity causes fatigue & discomfort.

Recommendation of class I & II
1.) sleep 10 hrs a day
2.) rest 30 minutes & after meal

Class III - moderate limitation of physical activity. Ordinary activity causes discomfort
Recommendation:
1.) early hospitalization by 7 months

Class IV. marked limitation of physical activity. Even at rest there is fatigue & discomfort.
Recommendation: Therapeutic abortion

XII. Intrapartal complications
1. Cesarean Delivery Indications:
a. Multiple gestation
b. Diabetes
c. Active herpes II
d. Severe toxemia
e. Placenta previa
f. Abruptio placenta
g. Prolapse of the cord
h. CPD primary indication
i. Breech presentation
j. Transverse lie

Procedure:
a. classical – vertical insertion. Once classical always classical
b. Low segment – bikini line type – aesthetic use

VBAC – vaginal birth after CS
INFERTILITY - inability to achieve pregnancy. Within a year of attempting it
- Manageable
STERILITY - irreversible
Impotency – inability to have an erection

2 types of infertility
1.) primary – no pregnancy at all
2.) Secondary – 1st pregnancy, no more next preg
test male 1st
- more practical & less complicated
- need: sperm only
- sterile bottle container ( not plastic has chem.)
- Sims Huhner test – or post coital test. Procedure: sex 2 hours before test
mom – remains supine 15 min after ejaculation
Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If >15 – low sperm count
Best criteria- sperm motility for impotency
Factors: low sperm count
1.) occupation- truck driver
2.) chain smoker
administer: clomid ( chomephine citrate) to induce spermatogenesis
Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm count
Implant sperm in ampula

1.) Mom: anovulation – no ovulation. Due to increase prolactin – hyperprolactinemia
Administer; parlodel ( Bromocryptice Mesylate)
Action; antihyper prolactineuria
Give mom clomid: action: to induce oogenesis or ovulation
S/E: multiple pregnancy

2.) Tubal Occlusion – tubal blockage – Hx of PID that has scarred tubes
- use of IUD
- appendicitis (burst) & scarring
= dx: hysterosalphingography – used to determine tubal patency with use of radiopaque material
Mgt: IVF – invitrofertilization (test tube baby)
England 1st test tube baby

To shorten 2nd stage of labor!
1.) fundal pressure
2.) episiotomy
3.) forcep delivery

Medical Surgical Nursing

MEDICAL SURGICAL
Reynaldo A. Donghit, Jr.

Overview of the Structures & Functions of Nervous System
Central NS PNS ANS
Brain & spinal cord 31 spinal & cranial sympathetic NS
Parasypathatic NS


Somatic NS
C- 8
T- 12
L- 5
S- 5
C- 1

ANS (or adrenergic of parasympatholitic response)

SNS involved in fight or aggression response Effects of SNS (anti-cholinergic/adrenergic)
1. Dilate pupil – to aware of surroundings
Release of norepinephrine (adrenaline – cathecolamine) - medriasis
Adrenal medulla (potent vasoconstrictor) 2. Dry mouth
Increases body activities VS = Increase 3. BP & HR= increased
Except GIT – decrease GITmotility bronchioles dilated to take more oxygen
4. RR increased
* Why GIT is not increased = GIT is not important! 5. Constipation & urinary retention
Increase blood flow to skeletal muscles, brain & heart.


I. Adrenergic Agents – Epinephrine (adrenaline)
SE: SNS effect
II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in –‘lol’)
- Blocks release of norepinephrine.
- Decrease body activities except GIT (diarrhea)
Ex. Propanolol, Metopanolol

SE:
B – broncho spasm (bronchoconstriction)
E – elicits a decrease in myocardial contraction
T – treats HPN
A – AV conduction slows down

Given to angina & MI – beta-blockers to rest heart
Anti HPN agents:
1. Beta blockers (-lol)
2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL
3. Calcium antagonist
ex CALCIBLOC or NEFEDIPINE

Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic)
- Involved in fly or withdrawal response 1. Meiosis – contraction of pupils
- Release of acetylcholine (ACTH) 2. Increase salivation
- Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased
4. RR decrease – broncho constriction
I Cholinergic agents 5. Diarrhea – increased GI motility
ex 1. Mestinon 6. Urinary frequency
Antidote – anti cholinergic agents Atropine Sulfate – S/E – SNS

S/E- of anti-hpn drugs:
1. orthostatic hpn
2. transient headache & dizziness.
-Mgt. Rise slowly. Assist in ambulation.

CNS (brain & spinal cord)
I. Cells – A. neurons
Properties and characteristics
a. Excitability – ability of neuron to be affected in external environment.
b. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another
c. Permanent cells – once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
Regenerative capacity
A. Labile – once destroyed cant regenerate
- Epidermal cells, GIT cells, resp (lung cells). GUT
B. Stable – capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cells
C. Permanent cells – retina, brain, heart, osteocytes can’t regenerate.

3.) Neuroglia – attached to neurons. Supports neurons. Where brain tumors are found.
Types:
1. Astrocyte
2. Oligodendria

Astrocytoma – 90 – 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.
Astrocyte – maintains integrity of blood brain barrier (BBB).
BBB – semi permeable / selective
-Toxic substance that destroys astrocyte & destroy BBB.
Toxins that can pass in BBB:
1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide – seizure & parkinsons.
3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. 4. Ketones –DM.

OLIGODENDRIA – Produces myelin sheath – wraps around a neuron – acts as insulator facilitates rapid nerve impulse transmission.
No myelin sheath – degenerates neurons

Damage to myelin sheath – demyellenating disorders


DEMYELLENATING DSE
1.)ALZHEIMER’S DISEASE– atrophy of brain tissue due to a deficiency of acetylcholine.

S&Sx:
A – amnesia – loss of memory
A – apraxia – unable to determine function & purpose of object
A – agnosia – unable to recognize familiar object
A – aphasia –
- Expressive – brocca’s aphasia – unable to speak
- Receptive – wernickes aphasia – unable to understand spoken words
Common to Alzheimer – receptive aphasia
Drug of choice – ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.



Microglia – stationary cells, engulfs bacteria, engulfs cellular debris.

II. Compositions of Cord & Spinal cord
80% - brain mass
10% - CSF
10% - blood
MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP.
Normal ICP: 0-15mmHg
Brain mass

1. Cerebrum – largest - Connects R & L cerebral hemisphere
- Corpus collusum
Rt cerebral hemisphere, Lt cerebral hemisphere
Function:
1. Sensory
2. Motor
3. Integrative
Lobes
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reflexes are inhibited
d. Site of development of sense of umor
e. Brocca’s area – speech center
Damage - expressive aphasia
2.) Temporal –
a. Hearing
b. Short term memory
c. Wernickes area – gen interpretative or knowing Gnostic area
Damage – receptive aphasia
3.) Parietal lobe – appreciation & discrimation of sensory imp
- Pain, touch, pressure, heat & cold
4.) Occipital - vision
5.) Insula/island of reil/ Central lobe- controls visceral fx
Function: - activities of internal organ
6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory

Basal Ganglia – areas of gray matte located deep within a cerebral hemisphere
- Extra pyramidal tract
- Releases dopamine-
- Controls gross voluntary unit

Decrease dopamine – (Parkinson’s) pin rolling of extremities & Huntington’s Dse.
Decrease acetylcholine – Myasthenia Gravis & Alzheimer’s
Increased neurotransmitter = psychiatric disorder Increase dopamine – schizo

MID BRAIN – relay station for sight & hearing
Controls size & reaction of pupil 2 – 3 mm
Controls hearing acuity
CN 3 – 4
Isocoria – normal size (equal)
Anisocoria – uneven size – damage to mid brain
PERRLA – normal reaction

DIENCEPHALON- between brain
Thalamus – acts as a relay station for sensation
Hypothalamus – (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional responses, controls pituitary function.

BRAIN STEM- a. Pons – or pneumotaxic center – controls respiration
Cranial 5 – 8 CNS

MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12

CEREBELLUM – lesser brain
- Controls posture, gait, balance, equilibrium


Cerebellar Tests:
a.) R – Romberg’s test- needs 2 RNs to assist
- Normal anatomical position 5 – 10 min
(+) Romberg’s test – (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test –
(+) To FTNT – dymetria – inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to cerebellum – dymentrium

Composition of brain - based on Monroe Kellie Hypothesis
- Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP

Normal ICP – 0 – 15 mmHg
Foramen Magnum
C1 – atlas
C2 – axis

(+) Projectile vomiting = increase ICP
Observe for 24 - 48 hrs
CSF – cushions the brain, shock absorber
Obstruction of flow of CSF = increase ICP
Hydrocephalus – posteriorly due to closure of posterior fontanel
CVA – partial/ total obstruction of blood supply

INCREASED ICP – increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis

B. S&Sx change in VS = always late symptoms
Earliest Sx:
a.) Change or decrease LOC – Restlessness to confusion Wide pulse pressure: Increased ICP
- Disorientation to lethargy Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign – change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 – 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 – 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)
4. Temp increase


Increased ICP: Increase BP Shock – decrease BP –
Decrease HR Increase HR CUSHINGS EFFECT
Decrease RR Increase RR
Increase Temp Decrease temp

b.) Headache
Projectile vomiting




Papilledima (edema of optic disk – outer surface of retina)
Decorticate (abnormal flexion) = Damage to cortico spinal tract /
Decerebrate (abnormal extension) = Damage to upper brain stem-pons/


c.) Uncal herniation – unilateral dilation of pupil. (Bilateral dilation of pupil – tentorial herniation.)
d.) Possible seizure.

Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).

Hypoxia – cerebral edema - increase ICP
Hypoxia – inadequate tissue oxygenation
Late symptoms of hypoxia –
B – bradycardia
E – extreme restlessness
D – dyspnea
C – cyanosis
Early symptoms – R – restlessness
A – agitation
T – tachycardia

Increase CO2 retention/ hypercarbia – cerebral vasodilatation = increase ICP
Most powerful respiratory stimulant increase in CO2
Hyperventilate decrease CO2 – excrete CO2

Respiratory Distress Syndrome (RDS) – decrease Oxygen
Suctioning – 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.
Ambu bag – pump upon inspiration

c. Assist in mechanical ventilation
1. Maintain patent a/w
2. Monitor VS & I&O
3. Elevate head of bed 30 – 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage
4. Limit fluid intake 1,200 – 1,500 ml/day
(FORCE FLUID means:Increase fluid intake/day – 2,000 – 3,000 ml/day)- not for inc ICP.
5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints – lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
-Valsalva maneuver or bearing down, avoid straining of stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
- Excessive cough – antitussive
Dextrometorpham
-Excessive vomiting – anti emetic (Plasil – Phil only)/ Phenergan
- Lifting of heavy objects
- Bending & stooping
e. Avoid clustering of nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic – Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue

Nursing considerations:
1.) Mannitol
1. Monitor BP – SE of hypotension
2. Monitor I&O every hr. report if < 30cc out put
3. Administer via side drip
4. Regulate fast drip – to prevent formation of crystals or precipitate

2.) Loop diuretic - Lasix (Furosemide)
Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt will urinate at 7:15
Immediate effect of Lasix within 15 minutes. Max effect – 6 hrs due (7am – 1pm)
S/E of Lasix
Hypokalemia (normal K-3.5 – 5.5 meg/L)
S&Sx
1. Weakness & fatigue
2. Constipation
3. (+) “U” wave in ECG tracing

Nursing Mgt:
1.) Administer K supplements – ex Kalium Durule, K chloride
Potassium Rich food:
ABC’s of K
Vegetables Fruits
A – asparagus A – apple
B – broccoli (highest) B – banana – green
C – carrots C – cantalope/ melon
O – orange (highest) –for digitalis toxicity also.
Vit A – squash, carrots yellow vegetables & fruits, spinach, chesa
Iron – raisins,
Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretions
Don’t give grapes – may choke

S/E of Lasix:
1.) Hypokalemia
2.) Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany:
S&Sx
weakness
Paresthesia
(+) Trousseau sign – pathognomonic – or carpopedal spasm. Put bp cuff on arm=hand spasm.
(+) Chevostek’s sign
Arrhythmia
Laryngospasm
Administer – Ca gluconate – IV slowly

Ca gluconate toxicity: Sx – seizure – administer Mg SO4
Mg SO4 toxcicity– administer Ca gluconate
B – BP decrease
U – urine output decrease
R – RR decrease
P – patellar reflexes absent

3.) Hyponatremia – Normal Na level = 135 – 145 meg/L
S/Sx – Hypotension
Signs of Dehydration: dry skin, poor skin turgor, gen body malaise.
Early signs – Adult: thirst and agitation / Child: tachycardia
Mgt: force fluid
Administer isotonic fluid sol

4.) Hyperglycemia – increase blood sugar level
P – polyuria
P – polyphagia
P – polydipsia

Nsg Mgt:
a. Monitor FBS (N=80 – 120 mg/dl)


5.) Hyperurecemia – increase serum uric acid. Tophi- urate crystals in joint.

Gouty arthritis kidney stones- renal colic (pain)
Cool moist skin
Sx joint pain & swelling usually at great toe.


Nsg Mgt of Gouty Arthritis
a.) Cheese (not sardines, anchovies, organ meat)
(Not good if pt taking MAO)
b.) Force fluid
c.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid – drug of choice for gout
Colchicene – excretes uric acid. Acute gout drug of choice.
Kidney stones – renal colic (pain). Cool moist skin
Mgt:
1.) Force fluid
2.) Meds – narcotic analgesic
Morphine SO4

SE of Morphine SO4 toxicity
Respiratory depression (check RR 1st)
Antidote for morphine SO4 toxicity –Narcan (NALOXONE)
Naloxone toxicity – tremors

Increase ICP meds:
3.) Corticosteroids - Dexamethsone – decrease cerebral edema (Decadrone)
4.) Mild analgesic – codeine SO4. For headache.
5.) Anti consultants – Dilantin (Phenytoin)

Question: Increase ICP what is the immediate nsg action?
a. Administer Mannitol as ordered
b. Elevate head 30 – 45 degrees
c. Restrict fluid
d. Avoid use of restraints

Nsg Priority – ABC & safety


Pt suffering from epiglotitis. What is nsg priority?
a. Administer steroids – least priority
b. Assist in ET – temp, a/w
c. Assist in tracheotomy – permanent (Answer)
d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET can’t pass. Need tracheostomy only-



Magic 2’s of drug monitoring

Drug N range Toxicity Classification Indication
D – digoxin .5 – 1.5 meq/L 2 cardiac glycosides CHF
L - lithium .6 – 1.2 meq/L 2 antimanic bipolar
A – aminophylline 10 – 19 mg/100ml 20 bronchodilator COPD
D – Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizures
A – acetaminophen 10 – 30 mg/100ml 200 narcotic analgesic osteoarthritis



Digitalis – increase cardiac contraction = increase CO
Nursing Mgt
1. Check PR, HR (if HR below 60bpm, don’t giveDigoxin)
Digitalis toxicity – antidote - Digivine
a. Anorexia -initial sx.
b. n/v GIT
c. Diarrhea
d. Confusion
e. Photophobia
f. Changes in color perception – yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)

L – lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine
Antimanic agent
Lithium toxicity
S/Sx -
a.) Anorexia
b.) n/s
c.) Diarrhea
d.) Dehydration – force fluid, maintain Na intake 4 – 10g daily
e.) Hypothyroidism
(CRETINISM– the only endocrine disorder that can lead to mental retardation)

A – aminophyline (theophylline) – dilates bronchioles.
Take bp before giving aminophylline.
S/Sx : Aminophylline toxicity:
1. Tachycardia
2. Hyperactivity – restlessness, agitation, tremors

Question: Avoid giving food with Aminophylline
a. Cheese/butter– food rich in tyramine, avoided only if pt is given MAOI
b. Beer/ wine -
c. Hot chocolate & tea – caffeine – CNS stimulant tachycardia
d. Organ meat/ box cereals – anti parkinsonian

MAOI – antidepressant
m AR plan
n AR dil can lead to CVA or hypertensive crisis
p AR nate
3 – 4 weeks - before MAOI will take effect
Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa

D – dilatin (Phenytoin) – anti convulsant/seizure
Nursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate
- Do sandwich method
- Give NSS then Dilantin, then NSS!
2. Instruct the pt to avoid alcohol – bec alcohol + dilantin can lead to severe CNS depression
Dilantin toxicity:
S/Sx:
G – gingival hyperplasia – swollen gums
i. Oral hygiene – soft toothbrush
ii. Massage gums
H – hairy tongue
A - ataxia
N – nystagmus – abnormal movement of eyeballs
A – acetaminophen/ Tylenol – non-opoid analgesic & antipyretic – febrile pts




Acetaminophen toxicity :
1. Hepato toxicity
2. Monitor liver enzymes
SGPT (ALT) – Serum Glutamic Piruvate Tyranase
SGOT- Serum Glutamic Acetate Tyranase
3. Monitor BUN (10 – 20)
Crea (.8-1)
Acetaminophen toxicity can lead to hypoglycemia
T – tremors, Tachycardia
I – irritability
R – restlessness
E – extreme fatigue
D – depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity – Acetylcesteine = causes outporing of secretions. Suction.
Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:
a. Nightmares
b. Extreme thirst – hyperglycemia symptoms
c. Weakness d. Diaphoresis

PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine producing cells in substancia nigra at mid brain & basal ganglia
- Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
2. Hypoxia
3. Arteriosclerosis
4. Encephalitis

High doses of the ff:
a. Reserpine (serpasil) anti HPN, SE – 1.) depression - suicidal 2.) breast cancer
b. Methyldopa (aldomet) - promote safety
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide - anti psychotic

SE of anti psychotic drugs – Extra Pyramidal Symptom
Over meds of anti psychotic drugs – neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism –
1. Pill rolling tremors of extremities – early sign
2. Bradykinesia – slow movement
3. Over fatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. Shuffling – most common
c. Propulsive gait
5. Mask like facial expression with decrease blinking eyes
6. Monotone speech
7. Difficulty rising from sitting position
8. Mood labilety – always depressed – suicide
Nsg priority: Promote safety
9. Increase salivation – drooling type
10. Autonomic signs:
- Increase sweating
- Increase lacrimation
- Seborrhea (increase sebaceous gland)
- Constipation
- Decrease sexual activity



Nsg Mgt
1.) Anti parkinsonian agents
- Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)
Mechanism of action
Increase levels of dopa – relieving tremors & bradykinesia
S/E of anti parkinsonian
- Anorexia
- n/v
- Confusion
- Orthostatic hypotension
- Hallucination
- Arrhythmia
Contraindication:
1. Narrow angled closure glaucoma
2. Pt taking MAOI (Parnate, Marplan, Nardil)

Nsg Mgt when giving anti-parkinsonian
1. Take with meals – to decrease GIT irritation
2. Inform pt – urine/ stool may be darkened
3. Instruct pt- don’t take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg
- Cause B6 reverses therapeutic effects of levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.
2.) Anti cholinergic agents – relieves tremors
Artane mech – inhibits acetylcholine
Cogentin action , S/E - SNS

3.) Antihistamine – Diphenhydramine Hcl (Benadryl) – take at bedtime
S/E: adult– drowsiness,– avoid driving & operating heavy equipt. Take at bedtime.
Child – hyperactivity CNS excitement for kids.
4.) Dopamine agonist
Bromotriptine Hcl (Parlodel) – respiratory depression. Monitor RR.


Nsg Mgt – Parkinson
1.) Maintain siderails
2.) Prevent complications of immobility
- Turn pt every 2h
Turn pt every 1 h – elderly
3.) Assist in passive ROM exercises to prevent contractures
4.) Maintain good nutrition
CHON – in am
CHON – in pm – to induce sleep – due Tryptopan – Amino Acid
5.) Increase fluid in take, high fiber diet to prevent constipation
6.) Assist in surgery – Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis

MULTIPLE SCLEROSIS (MS)
Chronic intermittent disorder of CNS – white patches of demyelenation in brain & spinal cord.
- Remission & exacerbation
- Common – women, 15 – 35 yo cause – unknown
Predisposing factor:
1. Slow growing virus
2. Autoimmune – (supportive & palliative treatment only)
Normal Resident Antibodies:
Ig G – can pass placenta – passive immunity. Short acting.
Ig A – body secretions – saliva, tears, colostrums, sweat
Ig M – acute inflammation
Ig E – allergic reactions
IgD – chronic inflammation


S & Sx of MS: (everything down)
1. Visual disturbances
a. Blurring of vision
b. Diplopia/ double vision
c. Scotomas (blind spots) – initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbness
b. Tingling
c. Paresthesia
3. Mood swings – euphoria (sense of elation )
4. Impaired motor function:
a. Weakness
b. Spasiticity –“ tigas”
c. Paralysis –major problem
5. Impaired cerebellar function
Triad Sx of MS
I – intentional tremors
N – nystagmus – abnormal rotation of eyes Charcots triad
A – Ataxia
& Scanning speech
6. Urinary retention or incontinence
7. Constipation
8. Decrease sexual ability
Dx – MS
1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG
2. MRI – reveals site & extent of demyelination
3. Lhermitte’s response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS
- Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH – adenocorticotopic
Steroids – to reduce edema at the site of demyelination to prevent paralysis
Spinal Cord Injury
Administer drug to prevent paralysis due to edema
a. Give ACTH – steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)
To decrease muscle spasticity
c. Interferone – to alter immune response
d. Immunosuppresants
2. Maintain siderails
3. Assist passive ROMexercises – promote proper body alignment
4. Prevent complications of immobility
5. Encourage fluid intake & increase fiber diet – to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence – give Prophantheline bromide (probanthene)

Antispasmodic anti cholinergic
8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.
9. Provide acid-ash diet – to acidify urine & prevent bacteria multiplication
Grape, Cranberry, Orange juice, Vit C

MYASTHENIA GRAVIS (MG) – disturbance in transmission of impulses from nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 – 40 yo, unknown cause or idiopathic
Autoimmune – release of cholenesterase – enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness
(Ascending muscle weakness – Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
1.) Ptosis – drooping of upper lid ( initial sign)
Check Palpebral fissure – opening of upper & lower lids = to know if (+) of MG.
2.) Diplopia – double vision
3.) Mask like facial expression
4.) Dysphagia – risk for aspiration!
5.) Weakening of laryngeal muscles – hoarseness of voice
6.) Resp muscle weakness – lead respiratory arrest. Prepare at bedside tracheostomy set
7.) Extreme muscle weakness during activity especially in the morning.
Dx test
1. Tensilon test (Edrophonium Hcl) – temporarily strengthens muscles for 5 – 10 mins. Short term- cholinergic. PNS effect.
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent – attach to ventilator
b.) Monitor pulmonary function test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr.
5. NGT feeding
Administer meds –
a.) Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) – Long term
- Increase acetylcholine
s/e – PNS
b.) Corticosteroids – to suppress immune resp
Decadron (dexamethasone)

Monitor for 2 types of Crisis:
Myastinic crisis Cholinergic crisis
A cause – 1. Under medication
2. Stress
3. Infection
B S&Sx 1. Unable to see – Ptosis & diplopia
2. Dysphagia- unable to swallow.
3. Unable to breath
C Mgt – adm cholinergic agents Cause: 1 over meds
S/Sx - PNS




Mgt. adm anti-cholinergic
- Atropine SO4
- SNS – dry mouth
7. Assist in surgical proc – thymectomy. Removal of thymus gland. Thymus secretes auto immune antibody.
8. Assist in plasmaparesis – filter blood
9. Prevent complication – respiratory arrest
Prepare tracheostomy set at bedside.

GBS – Guillain Barre Syndrome
- Disorder of CNS
- Bilateral symmetrical polyneuritis
- Ascending paralysis
Cause – unknown, idiopathic
- Auto immune
- r/t antecedent viral infection
- Immunizations




S&Sx
Initial :
1. Clumsiness
2. Ascending muscle weakness – lead to paralysis
3. Dysphagia
4. Decrease or diminished DTR (deep tendon reflexes)
- Paralysis
5. Alternate HPN to hypotension – lead to arrhythmia - complication
6. Autonomic changes – increase sweating, increase salivation.
Increase lacrimation
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)

Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl – immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding – due dysphagia

7. Adm meds (GBS) as ordered: – 1. Anti cholinergic – atropine SO4
2. Corticosteroids – to suppress immune response
3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine –SE confusion = VTach
b.) Bretyllium
c.) Quinines/Quinidine – anti malarial agent. Give with meals.
- Toxic effect – cinchonism
Quinidine toxicity
S/E – anorexia, n/v, headache, vertigo, visual disturbances
8. Assist in plasmaparesis (MG. GBS)
9. Prevent comp – arrhythmias, respiratory arrest
Prepare tracheostomy set at bedside.


INFL CONDITONS OF BRAIN
Meninges – 3-fold membrane – cover brain & spinal cord
Fx:
Protection & support
Nourishment
Blood supply
3 layers
1. Duramater sub dural space
2. Arachmoid matter
3. Pia matter sub arachnoid space where CSF flows L3 & L4. Site for lumbar puncture.

MENINGITIS – inflammation of meningitis & spinal cord

Etiology – Meningococcus
Pneumococcus
Hemophilous influenza – child
Streptococcus – adult meningitis
MOT – direct transmission via droplet nuclei

S&Sx
- Stiff neck or nuchal rigidity (initial sign)
- Headache
- Projectile vomiting – due to increase ICP
- Photophobia
- Fever chills, anorexia
- Gen body malaise
- Wt loss
- Decorticate/decerebration – abnormal posturing
- Possible seizure
Sx of meningeal irritation – nuchal rigidity or stiffness
Opisthotonus- rigid arching of back

Pathognomonic sign – (+) Kernig’s & Brudzinski sign

Leg pain neck pain

Dx:
1. Lumbar puncture – lumbar/ spinal tap – use of hallow spinal needle – sub arachnoid space L3 & L4 or L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture – invasive
1. Consent / explain procedure to pt
- RN – dx procedure (lab)
- MD – operation procedure
2. Empty bladder, bowel – promote comfort
3. Arch back – to clearly visualize L3, L4

Nsg Ngt post lumbar
1. Flat on bed – 12 – 24 h to prevent spinal headache & leak of CSF
2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue
4. Assess for movement & sensation of extremeties

Result
1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose
b. Decrease glucose
Confirms meningitis c. increase CSF opening pressure
N 50 – 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC – reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
1. GIT irritation – take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection – alteration in normal bacterial flora
- N flora throat – streptococcus
- N flora intestine – e coli
Sx of superinfxn of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapy
A – Cushing’s synd – reverse isolation - due to increased corticosteroid in body.
B – Aplastic anemia – reverse isolation - due to bone marrow depression.
C – Cancer anytype – reverse isolation – immunocompromised.
D – Post liver transplant – reverse isolation – takes steroids lifetime.
E – Prolonged use steroids – reverse isolation
F – Meningitis – strict respiratory isolation – safe after 24h of antibiotic therapy
G – Asthma – not to be isolated

3. Comfy & dark room – due to photophobia & seizure
4. Prevent complications of immobility
5. Maintain F & E balance
6. Monitor vs, I&O , neuro check
7. Provide client health teaching & discharge plan
a. Nutrition – increase cal & CHO, CHON-for tissue repair. Small freq feeding
b. Prevent complication hydrocephalus, hearing loss or nerve deafness.
8. Prevent seizure.
Where to bring 2 yo post meningitis
- Audiologist due to damage to hearing- post repair myelomeningocele
- Urologist -Damage to sacral area – spina bifida – controls urination
9. Rehab for neurological deficit. Can lead to mental retardation or a delay in psychomotor development.


CEREBRO VASCULAR ACCIDENT – stroke, brain attack or cerebral thrombosis, apoplexy
- Partial or complete disruption in the brains blood supply
- 2 largest & common artery in stroke
Middle cerebral artery
Internal carotid artery
- Common to male – 2 – 3x high risk

Predisposing factor:
1. Thrombosis – clot (attached)
2. Embolism – dislodged clot – pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness

S/Sx: cerebral embolism
Headache, disorientation, confusion & decrease in LOC

Femur fracture – complications: fat embolism – most feared complication w/in 24hrs
Yellow bone marrow – produces fat cells at meduallary cavity of long bone
Red bone marrow – provides WBC, platelets, RBC found at epiphisis
2.) Hemorrhage
3.) Compartment syndrome – compression of nerves/ arteries

Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery – mitral valve replacement

Lifestyle: 1. Smoking – nicotine – potent vasoconstrictor
2. Sedentary lifestyle
3. Hyperlipidemia – genetic
4. Prolonged use of oral contraceptives
- Macro pill – has large amt estrogen
- Mini pill – has large amt of progestin
- Promote lipolysis (breakdown of lipids/fats) – artherosclerosis – HPN - stroke
5. Type A personality
a. Deadline driven person
b. 2 – 5 things at the same time
c. Guilty when not dong anything
6. Diet – increase saturated fats
7. Emotional & physical stress
8. Obesity
S & Sx
1. TIA- warning signs of impending stroke attacks
- Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia (monoplegia – 1 extreme)
Increase ICP
2. Stroke in evolution – progression of S & Sx of stroke
3. Complete stroke – resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp
c.) Anorexia, n/v
d.) Dysphagia
e.) Increase BP
f.) (+) Kernig’s & Brudzinski – sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria – inability to vocalize, articulate words
3. Aphasia
4. Agraphia diff writing
5. Alesia – diff reading
6. Homoninous hemianopsia – loss of half of field of vision
Left sided hemianopsia – approach Right side of pt – the unaffected side

Dx
1. CT Scan – reveals brain lesion
2. Cerebral arteriography – site & extent of mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All – graphy – invasive due to iodine dye
Post
1.) Force fluid – to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal

Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids – prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
- To prevent decubitus ulcer
- To prevent hypostatic pneumonia – after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding – if pt can’t swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia – approach on unaffected side
9. Meds
Osmotic diuretics – Mannitol
Loop diuretics – Lasix/ Furosemide
Corticosteroids – dextamethazone
Mild analgesic
Thrombolytic/ fibrolitic agents – tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants – Heparin & Coumadin” sabay”
Coumadin will take effect after 3 days
Heparin – monitor PTT partial thromboplastin time if prolonged – bleeding give Protamine SO4- antidote.
Coumadin –Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K – Aquamephyton- antidote.
Antiplatelet – PASA – aspirin paraanemo aspirin, don’t give to dengue, ulcer, and unknown headache.

Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking
2. Dietary modification
- Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit – physical therapy
1. Mental retardation
2. Delay in psychomotor development


CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior.

Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attack
Febrile seizure Normal if < 5 yo Epilepsy – 2nd and with history of seizure
Pathologic if > 5 yo



Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide
Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus – drug of choice: Diazepam & glucose

S & Sx
I. Generalized Seizure –
a.) Grand mal / tonic clonic seizures
With or without aura – warning symptoms of impending seizure attack- Epigastric pain- associated with olfactory, tactile, visual, auditory sensory experience
- Epileptic cry – fall
- Loss of consciousness 3 – 5 min
- Tonic clonic contractions
- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
- Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure – (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching of mouth
- Loss of consciousness – 5 – 10 secs (quick & short)

II. Localized/partial seizure
a.) Jacksonian seizure or focal seizure – tingling/jerky movement of index finger/thumb & spreads to shoulder & 1 sideof the body with janksonian march
b.) Psychomotor/ focal motor - seizure
-Automatism – stereotype repetitive & non-purposive behavior
- Clouding of consciousness – not in control with environment
- Mild hallucinatory sensory experience

HALLUCINATIONS
1. Auditory – schitzo – paranoid type
2. Visual – korsakoffs psychosis – chronic alcoholism
3. Tactile – addict – substance abuse

III. Status epilecticus – continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia – coma – death
Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2.
Tx:Diazepam (drug of choice), glucose
Dx-Convulsion- get health history!
1. CT scan – brain lesion
2. EEG electroencephalography
- Hyperactivity brain waves
Nsg Mgt
Priority – Airway & safety
1. Maintain patent a/w & promote safety
Before seizure:
1. Remove blunt/sharp objects
2. Loosen clothing
3. Avoid restraints
4. Maintain siderails
5. Turn head to side to prevent aspiration
6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at home.
7. Avoid precipitating stimulus – bright glaring lights & noises
8. Administer meds
a. Dilantin (Phenytoin) –( toxicity level – 20 )


SE Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Don’t give alcohol – lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations

2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration
- Type of seizure
- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status epilepticus!
4. Assist in surgical procedure. Cortical resection
5. Complications: Subarachnoid hemorrhage and encephalitis

Question: 1 yo grand mal – immediate nursing action = a/w & safety
a. Mouthpiece – 1 yr old – little teeth only
b. Adm o2 inhalation – post!
c. Give pillow – safety (answer)
d. Prepare suction

Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale – obj measurement of LOC or quick neuro check
3 components of ECS
M – motor 6
V – verbal resp 5
E – eye opening 4
15

15 – 14 – conscious
13 – 11 – lethargy
10 – 8 – stupor
7 – coma
3 – deep coma – lowest score

Survey of mental status & speech (Comprehensice Neuro Exam)
1.) LOC & test of memory
2.) Levels of orientation
3.) CN assessment
4.) Motor assessment
5.) Sensory assessment
6.) Cerebral test – Romhberg, finger to nose
7.) DTR
8.) Autonomics

Levels of consciousness (LOC) –
1. Conscious (conscious) – awake – levels of wakefulness
2. Lethargy (lethargic) – drowsy, sleepy, obtunded
3. Stupor (stuporous) – awakened by vigorous stimulation
Pt has gen body weakness, decrease body reflex
4. Coma (Comatose) light – (+) all forms of painful stimulations
Deep – (-) to painful stimulation
Question: Describe a conscious pt ?
a. Alert – not all pt are alert & oriented to time & place
b. Coherent
c. Awake- answer
d. Aware

Different types of pain stimulation
- Don’t prick
1. Deep sternal stimulation/ pressure 3x– fist knuckle
With response – light coma
Without response – deep coma
2. Pressure on great toe – 3x
3. Orbital pressure – pressure on orbits only – below eye
4. Corneal reflex/ blinking reflex
Wisp of cotton – used to illicit blinking reflex among conscious patients
Instill 1-drop saline solution – unconscious pt if (-) response pt is in deep coma
5. Test of memory – considered educational background
a.) Short term memory –
- What did you eat for breakfast?
Damage to temporal lobe – (+) antero grade amnesia
b.) Long term memory
(+) Retrograde amnesia – damage to limbic system
6. Levels of orientation
Time Place Person

Graphesthesia- can identify numbers or letters written on palm with a blunt object.
Agraphesthesia – cant identify numbers or letters written on palm with a blunt object.

CN assessment:
I – Olfactory s
II – Optic s
III – Oculomotor m
IV – Trocheal m smallest CN
V – Trigeminal b largest CN
VI – Abducens m
VII – Facial b
VIII – Acustic/auditory s
IX – Glassopharyngeal b
X – Vagus b longest CN
XI– Spinal accessory m
XII – Hypoglossal m

I. Olfactory – don’t use ammonia, alcohol, cologne irritating to mucosa – use coffee, bar soap, vinegar, cigarette tar
- Hyposmia – decrease sensitivity to smell
- Diposmia – distorted sense of smell
- Anosmia – absence of sense of smell
Either of 3 might indicate head injury – damage to cribriform plate of ethmoid bone where olfactory cells are located or indicate inflammation condition – sinusitis

II optic- test of visual acuity – Snellens chart – central or distance vision
Snellens E chart – used for illiterate chart
N 20/20 vision distance by w/c person can see letters- 20 ft
Numerator – distance to snellens chart
Denominator – distance the person can see the letters
OD – Rt eye 20/20 20/200 – blindness – cant read E – biggest
OS – left eye 20/20
OU – both eye 20/20

2. Test of peripheral vision/ visual field
a. Superiority
b. Bitemporally
c. Inferiorly
d. Nasally


Common Disorders – see page 85-87 for more info on glaucoma, etc.
1. Glaucoma – Normal 12 – 21 mmHg pressure
- Increase IOP - Loss of peripheral vision – “tunnel vision”
2. Cataract – opacity of lens - Loss of central vision, “Blurring or hazy vision”
3. Retinal detachment – curtain veil – like vision & floaters
4. Macular degeneration – black spots

III, IV, VI – tested simultaneously
- Innervates the movementt of extrinsic ocular muscle
6 cardinal gaze EOM

Rt eye N left eye
IO SO O
S
LR MR E
SR

3 – 4 EOM
IV – sup oblique
VI – lateral rectus
Normal response – PERRLA (isocoria – equal pupil)
Anisocoria – unequal pupil

Oculomotor
1. Raising of eyelid – Ptosis
2. Controls pupil size 2 -3 cm or 1.5 – 2 mm

V – Trigeminal – Largest – consists of - ophthalmic, maxillary, mandibular
Sensory – controls sensation of the face, mucus membrane; teeth & cornea reflex

Unconscious – instill drop of saline solution
Motor – controls muscles of chewing/ muscles of mastication
Trigeminal neuralgia – diff chewing & swallowing – extreme food temp is not recommended



Question: Trigeminal neuralgia, RN should give
a. Hot milk, butter, raisins
b. Cereals
c. Gelatin, toast, potato – all correct but
d. Potato, salad, gelatin – salad easier to chew

VI Facial: Sensory – controls taste – ant 2/3 of tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group – 40 yrs old
Motor- controls muscles of facial expression, smile frown, raise eyebrow
Damage – Bells palsy – facial paralysis
Cause – bells palsy pedia – R/T forcep delivery
Temporary only
Most evident clinical sign of facial symmetry: Nasolabial folds

VIII Acoustic/ vestibule cochlear (controls hearing) – controls balance (kenesthesia or position sense)
- Movement & orientation of body in space
- Organ of Corti – for hearing – true sense organ of hearing

Outer – tympanic membrane, pinna, oricle (impacted cerumen), cerumen
Middle – hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media
- Eustachean ear
Inner ear- meniere dse, sensory hearing loss (research parts! & dse)
Remove vestibule – meniere’s dse – disease inner ear

Archimedes law – buoyancy (pregnancy – fetus)
Daltons law – partial pressure of gases
Inertia – law of motion (dizziness, vertigo)

1.) Pt with multiple stab wound - chest
- Movement of air in & out of lungs is carried by what principle?
- Diffusion – Dalton’s law
2.) Pregnant – check up – ultrasound reveals fetus is carried by amniotic fluid
- Archimedes
3.) Severe vertigo due- Inertia

Test for acoustic nerve:
- Repeat words uttered

IX – Glossopharyngeal – controls taste – posterior 1/3 of tongue
X – Vagus – controls gag reflex

Test 9 – 10
Pt say ah – check uvula – should be midline
Damage cerebral hemisphere is L or R
Gag reflex – place tongue depression post part of tongue
 Don’t touch uvula

XI – Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)
- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia
XII – Hypoglossal – controls movement of tongue – say “ah”. Assess tongue position=midline
L or R deviation
- Push tongue against cheek
- Short frenulum lingue –
Tongue tied – “bulol”





ENDOCRINE


Fx of endocrine – ductless gland
Main gland – Pituitary gland – located at base of brain of Stella Turcica
Master gland of body
Master clock of body

Anterior pituitary gland – adenohypophysis
Posterior pituitary gland – neurohypophysis

Posterior pituitary:
1.) Oxytocin – a.) Promotes uterine contraction preventing bleeding/ hemorrhage.
- Give after placental delivery to prevent uterine atony.
b.) Milk letdown reflex with help of prolactin.
2.) ADH – antidiuretic hormone – (vasopressin) -Prevents urination – conserve H2O


A. DIABETIS INSIPIDUS (DI- dalas ihi) – hyposecretion of ADH
Cause: idiopathic/ unknown
Predisposing factor:
1. Pituitary surgery
2. Trauma/ head injury
3. Tumor
4. Inflammation

* alcohol inhibits release of ADH

S & Sx:
1. Polyuria
2. Sx of dehydration (1st sx of dehydration in children-tachycardia)
- Excessive thirst (adult)
- Agitation
- Poor skin turgor
- Dry mucus membrane
3. Weakness & fatigue
4. Hypotension – if left untreated -
5. Hypovolemic shock
Anuria – late sign hypovolemic shock

Dx Proc:
1. Decrease urine specific gravity- concentrated urine
N= 1.015 – 1.035
2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia

Mgt:
1. Force fluid 2,000 – 3,000ml/day
2. Administer IV fluid replacement as ordered
3. Monitor VS, I&O
4. Administer meds as ordered
a.) Pitresin (vasopressin) IM
5. Prevent complications
Most feared complication – Hypovolemic shock

B.) SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone
- Increase ADH
- Idiopathic/ unknown


Predisposing factor
1. Head injury
2. Related to Bronchogenic cancer or lung caner-
Early Sign of Lung Ca - Cough –1. non productive 2. productive
3. Hyperplasia of Pit gland
Increase size of organ

S&Sx
1. Fluid retention
2. Increase BP – HPN
3. Edema
4. Wt gain
5. Danger of H2O intoxication –Complications: 1. cerebral edema – increase ICP – 2. seizure

Dx Proc:
1. Urine specific gravity increase – diluted urine
2. Hyponatremia – Decreased Na

Nsg Mgt:
1. Restrict fluid
2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
3. Monitorstrictly V/S, I&O, neuro check – increase ICP
4. Weigh daily
5. Assess for presence edema
6. Provide meticulous skin care
7. Prevent complications – increase ICP & seizures activity

Anterior Pituitary Gland – adeno
1. Growth hormone (GH) (Somatotropic hormone)
Fx: Elongation of long bones
Decrease GH – dwarfism children
Increase GH – gigantism
Increase GH – acromegaly – adult
Puberty 9 yo – 21 yo
Epiphyseal plate closes at 21 yo

Square face
Square jaw

Drug of choice in acromegaly: Ocreotide (Sandostatin) SE dizziness
- Somatostatin Hormone – antagonizes the release of of GH
2. Melanocytes stimulating hormone - MSH
- Skin pigmentation
3. Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland
(Oxytocin-Initiates milk letdown reflex)
4. Adrenocorticotropic hormone – ACTH - Development & maturation of adrenal cortex
5. Luteinizing hormone – produces progesterone.
6. FSH- produces estrogen

PINEAL GLAND
1. Secretes Melatonin – inhibits lutenizing hormone (LH) secretion

THYROID GLAND (TG)
Question: Normal physical finding on TG:
a. With tenderness – thyroid never tender
b. With nodular consistency- answer
c. Marked asymmetry – only 1 TG
d. Palpable upon swallowing - Normal TG never palpable unless with goiter




TG hormones:
T3 T4 Thyrocalcitonin
- Triodothyronine -Tetraiodothyronine/ Tyroxine FX – antagonizes effects of parathormone

- 3 molecules of iodine - 4 molecules of iodine



Metabolic hormone

Increase metabolism brain –inc cerebration, inc v/s all v/s down, constipation

Hypo T3 T4 - lethargy & memory impairment –
Hyper T3 T4 - agitation, restlessness, and hallucination
7. Increase VS, increase motility


HYPOTHYROIDISM – all decreased except wt & menstruation, loss of appetite but with wt gain menorrhagia – increase in mens
HYPERTHYROIDISM - Increase appetite – wt loss, amenorrhea


SIMPLE GOITER – enlarged thyroid gland - iodine deficiency
Predisposing factors
1. Goiter belt area - Place far from sea – no iodine. Seafood’s rich in iodine
2. Mountainous area – increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake)
Cabbage – has progoitrin – an anti thyroid agent with no iodine
Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops), all nuts.
3. Goitrogenic drugs:
Anti thyroid agents :(PTU) prephyl thiupil
Lithium carbonate, Aspirin PASA
Cobalt, Phenyl butasone
Endemic goiter – cause # 1
Sporadic goiter – caused by #2 & 3

S & Sx – enlarged TG
Mild restlessness
Mild dysphagia

Dx Proc.
1. Thyroid scan – reveals enlarged TG
2. Serum TSH – increase (confirmatory)
3. Serum T3, T4 – N or below N

Nsg Mgt:
1. Administer meds
a.) Iodine solution – Logol’s solution or saturated sol of K iodide SSKI
Nsg Mgt Lugol’s sol – violet color
1. use straw – prevent staining teeth
2. Prophylaxis 2 -3 drops Treatment – 5 to 6 drops
Use straw – to prevernt staining of teeth
1. Lugol’s sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron solution.

B. Thyroid h / Agents
1. Levothyroxine (Synthroid)
2. Liothyronine (cytomel)
3. Thyroid extract


Nsg Mgt: for TH/agents
1. Monitor vs. – HR due tachycardia & palpitation
2. Take it early AM – SE insomnia
3. Monitor s/e
Tachycardia, palpitations
Signs of insomnia
Hyperthyroidism restlessness agitation
Heat intolerance
HPN

3. Encourage increase intake iodine – iodine is extracted from seaweeds (!)
Seafood- highest iodine content oysters, clams, crabs, lobster
Lowest iodine – shrimps
Iodized salt –easily destroyed by heat take it raw not cooked

4. Assist surgery- Sub total thyroidectomy-
Complication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at incision site.Check nape for wet blood. 4.Laryngeal spasm – DOB, SOB – trache set ready at bedside.


2.) HYPOTHYROIDISM – decrease secretion of T3, T4 – can lead to MI / Atherosclerosis
Adult – myxedema
Child- cretinism – only endocrine dis lead to mental retardation
Predisposing factor:
1. `Iatrogenic causes – caused by surgery
2. Atrophy of TG due to:
a. Irradiation
b. Trauma
c. Tumor, inflammation
3. Iodine def
4. Autoimmune – Hashimoto disease

S&Sx everything decreased except wt gain & mens increase)
Early signs – weakness and fatigue
Loss of appetite – increased lypolysis – breakdown of fats causing atherosclerosis = MI
Wt gain
Cold intolerance – myxedema - coma
Constipation
Late Sx – brittle hair/ nails
Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Myxedema
Horseness voice
Decrease libido
Decrease VS – hypotension bradycardia, bradypnea, and hypothermia
Lethargy
Memory impairment leading to psychosis-forgetfulness
Menorrhagia

Dx:
1. Serum T3 T4 decrease
2. Serum cholesterol increase – can lead to MI
3. RA IU – radio iodine uptake – decrease


Nsg Mgt:
1. Monitor strictly V/S. I&O – to determine presence of myxedema coma!
Myxedema Coma - Severe form of hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia
Might lead to progressive stupor & coma
Impt mgt for Myxedema coma
1. Assist mech vent – priority a/w
2. Adm thyroid hormone
3. Adm IVF replacement – force fluid

Mgt myxedema coma
1. Monitor VS, I&O
2. Provide dietary intake low in calories – due to wt gain
3. Skin care due to dry skin
4. Comfortable & warm environment due to cold intolerance
5. Administer IVF replacements
6. Force fluid
7. Administer meds – take AM – SE insomia. Monitor HR.
Thyroid hormones
Levothyroxine(Synthroid), Liothyronine (cytomel)
Thyroid extracts
8. Health teaching & discharge plan
a. Avoidance precipitating factors leading to myxedema coma:
1. Exposure to cold environment
2. Stress 3. Infection
4. Use of sedative, narcotics, anesthetics not allowed – CNS depressants V/S already down
Complications:
9. Hypovolemic shock, myxedema coma
10. Hormonal replacement therapy - lifetime
11. Importance of follow up care

HYPERTHYROIDISM - Graves dse or thyrotoxicosis ( everything up except wt and mens)
-Increased T3 & T4
Predisposing factors:
1. Autoimmune disease – release of long acting thyroid stimulator (LATS)
Exopthalmos
Enopthalmos – severe dehydration depressed eye
2. Excessive iodine intake
3. Hyperplasia of TG

S&Sx:
1. Increase in appetite – hyperphagia – wt loss due to increase metabolism
2. Skin is moist - perspiration
3. Heat intolerance
4. Diarrhea – increase motility
5. All VS increase = HPN, tachycardia, tachypnea, hyperthermia
6. CNS changes
8. Irritability & agitation, restlessness, tremors, insomnia, hallucinations
7. Goiter
8. Exopthalmos – pathognomonic sx
9. Amenorrhea

Dx:
1. Serum T3 & T4 - increased
2. Radio iodine uptake – increase
3. Thyroid scan – reveals enlarged TG

Nsg Mgt:
1. Monitor VS & I & O – determine presence of thyroid storm or most feared complication: Thyrotoxicosis
2. Administer meds
a. Antithyroid agents
1. Prophylthiuracil (PTU)
2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture
Most feared complication : Thrombosis – stroke CVS

3. Diet – increase calorie – to correct wt loss
4. Skin care –
5. Comfy & cool environment
6. Maintain siderails- due agitation/restlessness
7. Provide bilateral eye patch – to prevent drying of eyes- exopthalmos
8. Assist in surgery – subtotal thyroidectomy

Nsg Mgt: pre-op
Adm Lugol’s solution (SSKI) K iodide
9. To decrease vascularity of TG
10. To prevent bleeding & hemorrhage
Mgt post op:
Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis
Triad signs of thyroidstorm;
a. Tachycardia /palpitation
b. Hyperthermia
c. Agitation

Nsg Mgt Thyroid Storm:
1. Monitor VS & neuro check
Agitated might decrease LOC
2. Antipyretic – fever
Tachycardia -  blockers (-lol)
3. Siderails – agitated

Comp 2. Watch for inadvertent (accidental) removal of parathyroid gland

Secretes Para hormone
If removed, hypocalcemia - classic sign tetany – 1. .(+) Trousseau sign/ 2. Chvosteck’s sign
Nsg Mgt:
Adm calcium gluconate slowly – to prevent arrhythmia
Ca gluconate toxicity – antidote – MgSO4
3.Laryngeal (voice box) nerve damage (accidental)
Sx: hoarseness of voice
***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage
Notify physician!

4. Signs of bleeding post subtotal thyroidectomy
- “Feeling of fullness” at incision site
Nsg mgt:
Check soiled dressing at nape area

5. Signs of laryngeal spasm
a. DOB
b. SOB
Prepare at bedside tracheostomy

6. Hormonal replacement therapy - lifetime
7. Importance of follow up care
(Liver cirrhosis – bedside scissor – if pt complaints of DOB)


(Cut cystachean tube to deflate balloon)


Parathyroid gland – pair of small nodules located behind the TG
11. Secrets parathyroid hormone – promotes Ca reabsorption

Thyrocalcitonin – antagonises secretion of parathyroid hormone

1. Hypoparthroidism – decrease of parathyroid hormone
2. Hyperparathroidsm


HYPOPARATHYROIDISM – decreased parathormone


Hypocalcemia Hyperphosphatemia
(Or tetany)

[If Ca decreases, phosphate increases]

A. Predisposing, factors:
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to
a. Irradiation
b. Trauma
S&Sx:
1. Acute tetany
a. Tingling sensation
b. Paresthesia
c. Dysphagia
d. Laryngospasm
e. Bronchospasm

Pathognomonic Sign of tetany:
a. (+) Trousseau’s or carpopedial spasm
b. (+) Chvosteck’s sign

f. Seizure most feared complication
g. Arrhythmia

2. Chronic tetany
a. Loss of tooth enamel
b. Photophobia & cataract formation
c. GIT changes – anorexia, n/v, general body malaise
d. CNS changes – memory impairment, irritability

Dx:
1. Serum calcium – decrease (N 8.5 – 11 mg/100ml)
2. Serum phosphate increase (N 2.5 – 4.5 mg/100ml)
3. X-ray of long bone – decrease bone density
4. CT Scan – reveals degeneration of basal ganglia

Nsg Mgt:
1. Administration of meds:
a.) Acute tetany –
Ca gluconate – IV, slowly
b.) Chronic tetany
1. Oral Ca supplements
Ex. Ca gluconate
Ca carbonate
Ca lactate

Vit D (Cholecalceferol)

Drug diet sunlight


Cholecalceferol calcidiol calcitriol 7am – 9am


2. Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC MAD
Aluminum containing acids Mg containing antacids
Ex. Milk or magnesia
Aluminum OH gel Diarrhea

Constipation Maalox – magnesium & aluminum - Less s/e
2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure
3. Diet – increase Ca & decrease phosphorus
- Don’t give milk – due to increase phosphorus
Good = anchovies – increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.
4. Bedside – tracheostomy set –due to laryngospasm
5. Encourage to breath with paper bag in order to produce mild respiratory acidosis – to promote increase ionized Ca levels
6. Most feared complication : Seizure & arrhythmia
7. Hormonal replacement therapy - lifetime
8. Important fallow up care

HYPERPARATHYROIDISM - increase parathormone. Complication: Renal failure
Hypercalcemia can lead to Hypophosphatemia


Bone dse - kidney stones
Mineralization


Leading to bone fracture

Ca – 99% bones
1% serum blood

Predisposing Factors:
1. Hyperplasia parathyroid gland (PTG)
2. Over compensation of PTG due to Vit D deficiency
Children – Rickets Vit D
Adults – Osteomalacia deficiency

Sippy’s diet – Vit D diet – not good for pt with ulcer
2 -4 cups of milk & butter
Karrel’s diet – Vit D diet – not good for pt with ulcer
6 cups of milk & whole cream

Food rich in CHON – eggnog – combination of egg & milk

S/Sx:
Bone fracture
1. Bone pain (especially at back), bone fracture
2. Kidney stone –
a. Renal colic
b. Cool moist skin
3. GIT changes – anorexia, n/v, ulcerations
4. CNS involvement– irritability, memory impairment

Dx Proc:
1. Serum Ca increase
2. Serum phosphorus decreases
3. X-ray long bones – reveals bone demineralization


Nsg Mgt: Kidney Stone

1. Force fluids – 2,000 – 3,000/day or 2-3L/day
2. Isotonic solution
3. Warm sitz bath – for comfort
4. Strain all urine with gauze pad
5. Acid ash diet – cranberry, plum, grapefruit, vit C, calamansi – to acidify urine
6. Adm meds
a. Narcotic analgesic – Morphine SO4, Demerol (Meperidine Hcl)
S/E – resp depression. Monitor RR)
Narcan/ Naloxone – antidote
Naloxone toxicity – tremors
7. Siderails
8. Assist in ambulation
9. Diet – low in Ca, increase phosphorus lean meat
10. Prevent complication
Most feared – renal failure
11. Assist surgical procedure – parathyroidectomy
12. Impt ff up care
13. Hormonal replacement- lifetime

ADRENAL GLAND
12. Atop of @ kidney
13. 2 parts
Adrenal cortex – outermost layer
Adrenal medulla - innermost layer
14. Secrets cathecolamines
a.) Epinephrine / Norephinephrine – potent vasoconstrictor – adrenaline=Increase BP


Adrenal Medulla’s only disease:
PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla
-increase nor/epinephrine
-with HPN and resistant to drugs
-drug of choice: beta blockers
-complication: HPN crisis = lead to stroke
-no valsalva maneuver

Adrenal Cortex –
1. Zona fasiculata – secrets glucocorticoids
Ex. Cortisol - Controls glucose metabolism (SUGAR)
2. Zona reticularis – secrets traces of glucocorticoids & androgenic hormones
M – testosterone
F – estrogen & progesterone
Fx – promotes development of secondary sexual characteristics
3. Zona glomerulosa - secretes mineralcortisone
Ex. Aldosterone
Fx: promotes Na & H2O reabsorption & excretion of potassium (SALT)

ADDISON’S DISEASE – Steroids-lifetime
Decreased adrenocortical hormones leading to:
a.) Metabolic disturbances (sugar)
b.) F&E imbalances- Na, H2O, K
c.) Deficiency of neuromuscular function (salt & sex)

Predisposing Factors:
1. Atrophy of adrenal gland
2. Fungal infections
3. Tubercular infections


S/Sx:
1. Decrease sugar – Hypoglycemia – Decreased glucocorticoids - cortisol

T – tremors, tachycardia
I - irritability
R - restlessness
E – extreme fatigue
D – diaphoresis, depression

2. Decrease plasma cortisol
Decrease tolerance to stress – lead to Addisonian’s crisis

3. Decrease salt – Hyponatermia – Decreased mineralocorticoids - Aldosterone
Hypovolemia
a.) Hypotension
b.) Signs of dehydration – extreme thirst, agitation
c.) Wt loss
4. Hyperkalemia
a.) Irritability
b.) Diarrhea
c.) Arrhythmia
5. Decrease sexual urge or libido- Decreased Androgen
6. Loss of pubic and axillary hair

To Prevent STD Local – practice monogamous relationship
CGFNS/NCLEX – condom
7. Pathognomonic sign– bronze like skin pigmentation due to decrease cortisol will stimulate pituitary gland to release melanocyte stimulating hormone.

Dx Proc:
1. FBS – decrease FBS (N 80 – 120 mg/dL)
2. Plasma cortisol – decreased
Serum Na – decreased (N 135 – 145 meg/L)
3. Serum K – increased (N 3.5 – 5.5 meg/L)

Nsg Mgt:
1. Monitor VS, I&O – to determine presence of Addisonian crisis
15. Complication of Addison’s dse : Addisonian crisis
16. Results the acute exacerbation of Addison’s dse characterized by :
Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia
17. Lead to progressive stupor & coma

Nsg Mgt Addisonian Crisis (Coma)
1. Assist in mechanical ventilation
2. Adm steroids
3. Force fluids

2. Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone

Nsg Mgt with Steroids
1. Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm.
2. Taper the dose (w/draw, gradually from drug) – sudden withdrawal can lead to addisonian crisis
3. Monitor S/E (Cushing’s syndrome S/Sx)
a.) HPN
b.) Hirsutism
c.) Edema
d.) Moon face & buffalo hump
e.) Increase susceptibility to infection sue to steroids- reverse isolation

b.) Mineralocorticoids ex. Flourocortisone

3. Diet – increase calorie or CHO
Increase Na, Increase CHON, Decrease K
4. Force fluid
5. Administer isotonic fluid as ordered
6. Meticulous skin care – due to bronze like
7. HT & discharge planning
a) Avoid precipitating factors leading to Addisonian crisis
1. Sudden withdrawal crisis
2. Stress
3. Infection
b) Prevent complications
Addisonian crisis & Hypovolemic shock
8. Hormonal replacement therapy – lifetime
9. Important: follow up care

CUSHING’S SYNDROME – increase secretion of adrenocortical hormone
Predisposing Factors:
1. Hyperplasia of adrenal gland
2. Tubercular infection – milliary TB
S/Sx
1. Increase sugar – Hyperglycemia
3 P’s
1. Polyuria
2. Polydipsia – increase thirst
3. Polyphagia – increase appetite
Classic Sx of DM – 3 P’s & glycosuria + wt loss
2. Increase susceptibility to infection – due to increased corticosteroid
3. Hypernatrermia
a. HPN
b. Edema
c. Wt gain
d. Moon face
Buffalo hump
Obese trunk classic signs
Pendulous abdomen
Thin extremities

4. Hypokalemia
a. Weakness & fatigue
b. Constipation
c. ECG – (+) “U” wave
5. Hirsutism – increase sex
6. Acne & striae
7. Increase muscularity of female
Dx:
1. FBS – increase↑ (N: 80-120mg/dL)
2. Plasma cortisol increase
3. Na – increase (135-145 meq/L)
4. K- decrease (3.5-5.5 meq/L)

Nsg Mgt:
1. Monitor VS, I&O
2. Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone
- promotes excretion of NA while conserving potassium

Not lasix due to S/E hypoK & Hyperglycemia!

3. Restrict Na
4. Provide Dietary intake – low in CHO, low in Na & fats
High in CHON & K
5. Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc.
6. Reverse isolation
7. Skin care – due acne & striae
8. Prevent complication
- Most feared – arrhythmia & DM
(Endocrine disorder lead to MI – Hypothyroidism & DM)
9. Surgical bilateral Adrenolectomy
10. Hormonal replacement therapy – lifetime due to adrenal gland removal- no more corticosteroid!


PANCREAS – behind the stomach, mixed gland – both endocrine and exocrine gland

Acinar cells (exocrine gland) Islets of Langerhans (endocrine gland ductless)

Secrete pancreatic juices at pancreatic ducts.  cells

Aids in digestion (in stomach) secrets glucagon

Fxn: hyperglycemia (high glucose)

 Cells

Secrets insulin


Fxn: hypoglycemia

Delta Cells

Secrets somatostatin

Fxn: antagonizes growth hormone


3 disorders of the Pancreas
1. DM
2. Pancreatic Cancer
3. Pancreatitis


Overview only:
PANCREATITIS (check page 72)– acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion – self-digestion
Cause: unknown/idiopathic
18. Or alcoholism

Pathognomonic sign- (+) Cullen’s sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turner’s sign – ecchymosis of flank area


Both sx means hemorrhage



CHRONIC HEMORRHAGIC PANCREATITIS- “bangugot”
Predisposing factors - unknown
Risk factor:
1. History of hepatobiliary disorder
2. Alcohol
3. Drugs – thiazide diuretics, oral contraceptives, aspirin, penthan
4. Obesity
5. Hyperlipidemia
6. Hyperthyroidism
7. High intake of fatty food – saturated fats


DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism

Classification:
I. Type I DM (IDDM) – “Juvenile “ onset, common in children, non-obese “brittle dse”
-Insulin dependent diabetes mellitus
Incidence rate
1.) 10% of population with DM have Type I
Predisposing Factor:
1. 90% hereditary – total destruction of pancreatic dells
2. Virus
3. Toxicity to carbon tetrachloride
4. Drugs – Steroids both cause hyperglycemia
Lasix - loop diuretics

S/Sx:
3 P’S + G
1.) Polyuria
2.) Poydipsia
3.) Polyphagia
4.) Glycosuria
5.) Weight loss
6.) Anorexia
7.) N/V
8.) Blurring of vision
9.) Increase susceptibility to infection
10.) Delayed/ poor wound healing

Mgt:
1. Insulin Therapy
Diet
Exercise

Complications – Diabetic Ketoacidosis (DKA)
Diabetic Ketoacidosis (DKA) – due to increase fat catabolism or breakdown of fats

DKA –(+) fruity or acetone breath odor
Kassmaul’s respiration – rapid, shallow breathing

Diabetic coma (needs oxygen)


II. Type II DM – (NIDDM)
Adult/ maturity onset type – age 40 & above, obese
Incidence Rate
1. 90% of pop with DM have Type II
Mid 1980’s marked increase in type II because of increase proliferation of fast food chains!

Predisposing Factor:
1. Obesity – obese people lack insulin receptors binding site
2. Hereditary

S/Sx:
1. Asymptomatic
2. 3 P’s and 1G

Tx:
1. Oral Hypoglycemic Agents (OHA)
2. Diet
3. Exercise


Complication: HONKC
H – hyper
O – osmolar
N – non
K – ketotic
C – coma

III. GESTATIONAL DM – occurs during pregnancy & terminates upon delivery of child

Predisposing Factors:
1. Unknown/ idiopathic
2. Influence of maternal hormones
S/Sx :
Same as type II –
1. Asymptomatic
2. 3 P’s & 1G

Type of delivery – CS – due to large baby
Sx of hypoglycemia on infant
1. High pitched shrill cry
2. Poor sucking reflex
IV. DM ASSOCIATED WITH OTHER DISORDER
a.) Pancreatic tumor
b.) Cancer
c.) Cushing’s syndrome

3 MAIN FOOD GROUPS
Anabolism Catabolism
1. CHON glucose glycogen
2. CHON amino acids nitrogen
3. Fats fatty acids free fatty acids (FFA) – Cholesterol & Ketones

Pancreas → glucose → ATP (Main fuel/energy of cell )
Reserve glucose – glycogen
Liver will undergo – glucogenesis – synthesis of glucagons
& Glycogenolysis – breakdown of glucagons
& Gluconeogenesis – formation of glucose form CHO sources – CHON & fats












Hyperglycemia – pancreas will not release insulin. Glucose can’t go to cell, stays at circulation causing hyperglycemia.
increase osmotic diuresis – glycosuria
Lead to cellular starvation


Lead to wt loss stimulates the appetite/ satiety center polyuria
(Hypothalamus)
Cellular dehydration
Polyphagia
Stimulates thirst center (hypothalamus)

Polydipsia

Increased CHON catabolism

Lead to (-) nitrogen balance

Tissue wasting (cachexia)



Increase fat catabolism

Free fatty acids

Cholesterol ketones DKA

Atherosclerosis coma

HPN death


MI stroke


DIABETIC KETOACIDOSIS (DKA)
- Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma.
- Ketones- a CNS depressant

Predisposing factor:
1. Stress – between stress and infection, stress causes DKA more.
2. Hyperglycemia
3. Infection

S/Sx: 3 P’s & 1G
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glycosuria
5. Wt loss
6. Anorexia, N/V
7. (+) Acetone breath odor- fruity odor pathognomonic DKA
8. Kussmaul's resp-rapid shallow respiration
9. CNS depression
10. Coma

Dx Proc:
1. FBS increase, Hct – increase (compensate due to dehydration)
N =BUN – 10 -20 mg/100ml --increased due to severe dehydration
Crea - .8 – 1 mg/100ml

Hct 42% (should be 3x high)-nto hgb

Nsg Mgt:
1. Can lead to coma – assist mechanical ventilation
2. Administer .9NaCl – isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3. Monitor VS, I&O, blood sugar levels
4. Administer meds as ordered:
a.) Insulin therapy – IV push
Regular Acting Insulin – clear (2-4hrs, peak action)
b.) To counteract acidosis – Na HCO3
c.) Antibiotic to prevent infection

Insulin Therapy
A. Sources:
1. Animal source – beef/ pork-rarely used. Causes severe allergic reaction.
2. Human – has less antigenecity property
Cause less allergic reaction. Humulin

If kid is allergic to chicken – don’t give measles vaccine due it comes from chicken embryo.
3. Artificially compound

B. Types of Insulin
1. Rapid Acting Insulin - Ex. Regular acting I
2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)
3. Long acting I - Ex. Ultra lente

Types of Insulin color & consistency onset peak duration
1. Rapid clear - 2-4h -
2. Intermediate cloudy - 6-12h -
3. Long acting cloudy - 12-24h -

Ex. 5am Hemoglucose test (HGT)

250 mg/dl
Adm 5 units of RA I
Peak 7-9am – monitor hypoglycemic reaction at this time- TIRED

Nsg Mgt: upon injection of insulin:
1.Administer insulin at room temp! – To prevent lipodystrophy = atrophy/ hypertrophy of SQ tissues
2. Insulin is only refrigerated once opened!
3. Gently roll vial bet palms. Avoid shaking to prevent formation of bubbles.
4. Use gauge 25 – 26needle – tuberculin syringe
5. Administer insulin at either 45(for skinny pt) or 90 (taba pt)depending on the client tissue deposit.
6. Don’t aspirate after injection
7. Rotate injection site to prevent lipodystrophy
8. Most accessible site – abdomen
9. When mixing 2 types of insulin, aspirate
1st regular/ clear – before cloudy to prevent contaminating clear insulin & to promote accurate calibration.
10. Monitor signs of complications:
a. Allergic reactions – lipodystrophy
b. Somogyi’s phenomenon – hypoglycemia followed by periods of hyperglycemia or rebound effect of insulin.






11. 1ml or cc of tuberculin = 100 units of insulin


- - 1 cc = 100 units

- - .5cc = 50 units

- - .1 cc = 10 units


6 units RA


Most Feared Complication of Type II DM
Hyper ↑ osmolarity = severe dehydration
Osmolar
Non - absence of lipolysis
Ketotic - no ketone formation
Coma – S/Sx: headache, restlessness, seizure, decrease LOC = coma

Nsg Mgt; - same as DKA except don’t give NaHCO3!

1.Can lead to coma – assist mechanical ventilation
2. Administer .9NaCl – isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3.Monitor VS, I&O, blood sugar levels
4.Administer meds
a.) Insulin therapy – IV
b.) Antibiotic to prevent infection
Tx:
O ral
H ypoglycemic
A gents
19. Stimulates pancreas to secrete insulin

Classifications of OHA
1. First generation Sulfonylurear
a. Chlorpropamide (diabenase)
b. Tolbutamide (orinase)
c. Tolazamide (tolinase)

2. 2nd generation sulfonylurear
a. Diabeta (Micronase)
b. Glipside (Glucotrol)


Nsg Mgt or OHA
1. Administer with meals – to lessen GIT irritation & prevent hypoglycemia
2. Avoid alcohol (alcohol + OHA = severe hypoglycemic reaction=CNS depression=coma) Antabuse-Disufram

Dx for DM
1. FBS – N 80 – 120 mg/dl = Increased for 3 consecutive times =confirms DM!!
+ 3 P’s & 1G
2. Oral glucose tolerance (OGTT) - Most sensitive test
3. Random blood sugar – increased
4. Alpha Glucosylated Hgb – elevated



Nsg Mgt;
1. Monitor for PEAK action of OHA & insulin
Notify Doc
2. Monitor VS, I&O, neurocheck, blood sugar levels.
3. Administer insulin & OHA therapy as ordered.
4. Monitor signs of hyper & hypoglycemia.

Pt DM –“ hinimatay”
20. You don’t know if hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain can’t tolerate low sugar!)
Cold, clammy skin – hypo – Orange Juice or simple sugar / warm to touch – hyper – adm insulin
5. Provide nutritional intake of diabetic diet:
CHO – 50%
CHON – 30%
Fats – 20%
-Or offer alternative food products or beverage.
-Glass of orange juice.
6. Exercise – after meals when blood glucose is rising.
7. Monitor complications of DM
a. Atherosclerosis – HPN, MI, CVA
b. Microangiopathy – small blood vessels
Eyes – diabetic retinopathy , premature cataract & blindness
Kidneys – recurrent pyelonephritis & Renal Failure
(2 common causes of Renal Failure : DM & HPN)
c. Gangrene formation
d. Peripheral neuropathy
1. Diarrhea/ constipation
2. Sexual impotence
e. Shock due to cellular dehydration
8. Foot care mgt
a. Avoid waking barefooted
b. Cut toe nails straight
c. Apply lanolin lotion – prevent skin breakdown
d. Avoid wearing constrictive garments

9. Annual eye & kidney exam
10. Monitor urinalysis for presence of ketones
Blood or serum – more accurate
11. Assist in surgical wound debridement
12. Monitor signs or DKA & HONKC
13. Assist surgical procedure
BKA or above knee amputation

Overview: HEMATOLOGICAL SYSTEMS
I Blood
II Blood vessels
III Blood forming organs
1. Thymus – removed myasthenia gravis
2. Liver – largest gland
3. Lymph nodes
4. Lymphoid organs – payers patch
5. Bone marrow
6. Spleen – destroys RBC
Blood vessels
1. Veins –SVC, IVC, Jugular vein – blood towards the heart
2. Artery – carries blood away from the
21. Aorta, carotid
3. Capillaries



Blood 45% formed elements – 55% plasma – fluid portion of vlood. Yellow color.

Serum Plasma CHON’s (Produced in Liver)
1. Albumin- largest, most abundant plasma
Maintains osmotic pressure preventing edema
FXN: promotes skin integrity
2. Globulins – alpha – transports steroids Hormones & bilirubin
 - Transports iron & copper
Gamma – transport immunoglobulins or antibodies
3. Prothrombin – fibrinogen – clotting factor to prevent bleeding
Formed Elements:
1. RBC (erythrocytes) Spleen life span = 120 days
(N) 3 – 6 M/mm3
- Anucleated
- Biconcave discs
- Has molecules of Hgb (red cell pigment)
Transports & carries O2

SICKLE CELL ANEMIA –sickle shaped RBC. Should be round. Impaired circulation of RBC.
-immature cells=hemolysis of RBC=decreased hgb
3 Nsg priority
1. a/w – avoid deoxygenating activities
- High altitude is bad
2. Fluid deficit – promote hydration
3. Pain & comfort


Hgb ( hemoglobin)

F= 12 – 14 gms %
M = 14-16 gms %


Hct – 3x hgb 12 x 3 = 36
(hamatocrit) F 36 – 42% 14 x 3 = 42
M 42 – 48%
Average 42%
- Red cell percentage in whole red


Substances needed for maturation of RBC
a.) Folic acid
b.) Iron
c.) Vit C
d.) Vit B12 (cyanocobalamin)
e.) Vit B6 (Pyridoxine)
f.) Intrinsic factor

Pregnant: 1st trimester- Folic acid – prevent neural tube deficit
3rd tri – iron
Life span of rbc – 80 – 120 days. Destroyed at spleen.









WBC – leucocytes 5,000 – 10,000/mm3
GRANULOCYTES
1. Polymorphonuclearneutrophils
Most abundant 60-70% WBC
- fx – short term phagocytosis
For acute inflammation

2. PM Basophils

-Involved in Parasitic infection
- Release of chem. Mediator for inflammation
Serotonin, histamine, prostaglandin, bradykinins

3. PM eosinophils
- Allergic reactions NON-GRANULOCYTES
1. Monocytes (macrophage) - largest WBC
- involved in long term phagocytes
- For chronic inflammation
- Other name macrophage

Macrophage in CNS- microglia
Macrophage in skin – Histiocytes
Macrophage in lungs – alveolar macrophage
Macrophage in Kidneys – Kupffer cells

2. Lymphocytes
B Cell – L – bone marrow or bursa dependent
T cell – dev’t of immunity- target site for HIV
NK cell – natural killer cell
Have both antiviral & anti-tumor properties

3.Platelets (thrombocytes)
N- 150,000 – 450, 000/ mm3
it promotes hemostasis – prevention of blood loss by activating clotting
- Consists of immature or baby platelets known as megakaryocytes – target of virus – dengue
- Normal lifespan 9 – 12 days

Drug of choice for HIV Zidovudine (AZT or Retrovir)
Standard precaution for HIV gloves, gown, goggles & mask

Malaria – night biting mosquito
Dengue – day biting mosquito

Signs of platelet dis function:
a.) Petecchiae
b.) Ecchemosis/ bruises
c.) Oozing or blood from venipuncture site

ANEMIA
Iron deficiency Anemia – chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption of iron leading to hypoxemic injury.

Incidence rate:
1. Common – developed country – due to high cereal intake
Due to accidents – common on adults
2. Common – tropical countries – blood sucking parasites
3. Women – 15 – 35yo – reproductive yrs
4. Common among the poor – poor nutritional intake


Suicide - common in teenager
Poisoning – common in children (aspirin)
Aspiration – common in infant
Accidents – common in adults
Choking – common in toddler
SIDS – common in infant in US
22. Common in tropical zone – Phil due blood sucks

Predisposing factor:
1. Chronic blood loss
a. Trauma
b. Mens
c. GIT bleeding:
i. Hematemesis-
ii. Melena – upper GIT – duodenal cancer
iii. Hematochezia – lower GIT – large intestine – fresh blood from rectum
2. Inadequate intake of food rich in iron
3. Inadequate absorption of iron – due to :
a. Chronic diarrhea
b. Malabsorption syndrome –celiac disease-gluten free diet. Food for celiac pts- sardines
c. High cereal intake with low animal CHON ingestion
d. Subtotal gastrectomy
4. Improper cooking of food

S/Sx:
1. Asymptomatic
2. Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
3. Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells
4. Atropic glossitis, dysphagia, stomatitis
5. Pica – abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior)

Brittle hair, spoon shaped nail – atrophy of epidermal cells
N = capillary refill time < 2 secs
N = shape nails – biconcave shape, 180
Atrophy of cells “Plummer Vinsons Syndrome” due to cerebral hypoxia
1. Atropic glossiti – inflammation of tongue due to atrophy of pharyngeal and tongue cells
2. Stomatitis – mouth sores
3. Dysphagia


Dx Proc:
1. RBC
2. Hgb
3. Reticulocyte
4. Hct
5. Iron
6. Ferritin

Nsg Mgt
1. Monitor signs of bleeding of all hema test including urine & stool
2. Complete bed rest – don’t overtire pt =weakness and fatigue=activity intolerance
3. Encourage – iron rich food
23. Raisins, legumes, egg yolk
4. Instruct the pt to avoid taking tea - impairs iron absorption
5. Administer meds
a.) Oral iron preparation
Ferrous SO4
Fe gluconate
Fe Fumarate
Nsg Mgt oral iron meds:
1. Administer with meals – to lessen GIT irritation
2. If diluting in iron liquid prep –adm with straw

Straw
1. Lugol’s
2. Tetracycline
3. Oral iron
4. Macrodantine

3. Give Orange juice – for iron absorption
4. Monitor & inform pts S/E
a. Anorexia
b. n/v
c. Abdominal pain
d. Diarrhea or constipation
e. Melena

If pt can’t tolerate oral iron prep – administer parenteral iron prep example:
1. Iron dextran (IV, IM)
2. Sorbitex (IM)

Nsg Mgt parenteral iron prep
1. Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues.
2. Don’t massage injection site. Ambulate to facilitate absorption.
3. Monitor S/E:
a.) Pain at injury site
b.) Localized abscess (“nana”)
c.) Lymphadenopathy
d.) Fever/ chills
e.) Urticaria – itchiness
f.) Hypotension – anaphylactic shock

Anaphylactic shock – give epinephrine


PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to
Hypochlorhydria – decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement.

Predisposing factor
1. Subtotal gastrectomy – removal stomach
2. Hereditary
3. Infl dse of ileum
4. Autoimmune
5. Strict vegetable diet

STOMACH

Parietal or ergentaffen Oxyntic cells

Fxn – produce intrinsic factor Fxn – secrets Hcl acid

For reabsorption of B12 Fx aids in digestion

For maturation of RBC


Diet high caloric or CHO to correct wt loss

S/Sx:
1. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
2. GIT changes
a. Red – beefy tongue – PATHOGNOMONIC – mouth sores
b. Dyspepsia – indigestion
c. Wt loss
d. Jaundice
3. CNS –
Most dangerous anemia: pernicious due to neuroglogic involvement.
a. Tingling sensation
b. Paresthesia
c. (+) Romberg’s test
Ataxia
d. Psychosis
Dx:- Shilling’s test


Nsg Mgt – Pernicious anemia
1. Enforce CBR
2. Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or ventrogluteal. Not given oral – due pt might have tolerance to drug
3. Diet – high calorie or CHO. Increase CHON, iron & Vit C
4. Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged.
5. Avoid applying electric heating pads – can lead to burns

APLASTIC ANEMIA – stem cell disorder due to bone marrow depression leading to pancytopenia – all RBC are decreased


Decrease RBC decrease WBC decrease platelets
Anemia leukopenia thrombocytopenia
Increase WBC leukocytocys
Increase RBC polycythemia vera – complication stroke, CVA, thrombosis

Predisposing factors leading to Aplastic Anemia
1. Chemicals – Banzene & its derivatives
2. radiation
3. Immunologic injury
4. Drugs – cause bone marrow depression
a. Broad spectrum antibiotic - Chlorampenicol
- Sulfonamides – bactrim
b. Chemo therapeutic agents
Methotrexate – alkylating agents
Nitrogen mustard – anti metabolic
Vincristine – plant alkaloid

S/Sx:
1. Anemia:
a. Weakness & fatigue
b. Headache, dizziness, dyspnea
c. cold sensitivity, pallor
d. palpitations
2. Leucopenia – increase susceptibility to infection
3. Thrombocytopenia –
a. Peticchiae
b. Oozing ofblood from venipuncture site
c. ecchymosis
Dx:
1. CBC – pancytopenia
2. Bone marrow biopsy/ aspiration at post iliac crest – reveals fatty streaks in bone marrow
Nsg Mgt:
1. Removal of underlying cause
2. Blood transfusion as ordered
3. Complete bed rest
4. O2 inhalation
5. Reverse isolation due leukopenia
6. Monitor signs of infection
7. Avoid SQ, IM or any venipuncture site = HEPLOCK
8. Use electric razor when shaving to prevent bleeding
9. Administer meds
Immunosuppresants
Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days – 3 weeks to achieve max therapeutic effect of drug.



BLOOD TRANSFUSION:
Objectives:
1. To replace circulating blood volume
2. To increase O2 carrying capacity of blood
3. To combat infection if there’s decrease WBC
4. To prevent bleeding if there’s platelet deficiency

Nsg Mgt & principles in Blood Transfusion
1. Proper refrigeration
2. Proper typing & crossmatching
Type O – universal donor
AB – universal recipient
85% of people is RH (+)
3. Asceptically assemble all materials needed:
a.) Filter set
b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis

Hypotonic sol – swell or burst
Hypertonic sol – will shrink or crenate
c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis.
d.) Instruct another RN to recheck the following .
Pts name, blood typing & cross typing expiration date, serial number.
e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments – indicates bacterial contamination. Don’t dispose. Return to blood bank.
f.) Never warm blood products – may destroy vital factors in blood.
- Warming is done if with warming device – only in EMERGENCY! For multiple BT.
- Within 30 mins room temp only!
g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for > 2h causes blood deterioration.
h.) Avoid mixing or administering drug at BT line – leads to hemolysis
i.) Regulate BT 10 – 15 gtts/min KVO or 100cc/hr to prevent circulatory overload
j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min for 1st 15min.
- Majority of BT reaction occurs within 1h.


BT reactions S/Sx Hemolytic reaction:
H – hemolytic Reaction 1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ flank pain,
A – allergic Reaction hypotension, flushed skin , (red) port wine urine.
P – pyrogenic Reaction
C – circulatory overload
A – air embolism
T - thrombocytopenia
C – citrate intoxication – expired blood =hyperkalemia
H – hyperkalemia

Nsg Mgt: Hemolytic Reaction:
1. Stop BT
2. Notify Doc
3. Flush with plain NSS
4. Administer isotonic fluid sol – to prevent acute tubular necrosis & conteract shock
5. Send blood unit to blood bank for reexamination
6. Obtain urine & blood samples of pt & send to lab for reexamination
7. Monitor VS & Allergic Rxn
Allergic Reaction:
S/Sx
1. Fever/ chills
2. Urticaria/ pruritus
3. Dyspnea
4. Laryngospasm/ bronchospasm
5. Bronchial wheezing

Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antihistamine – diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive
If (+) Hypotension – anaphylactic shock administer – epinephrine
5. Send blood unit to blood bank
6. Obtain urine & blood samples – send to lab
7. Monitor VS & IO
8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension – indicates anaphylactic shock
24. administer epinephrine
9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB

Pyrogenic Reaction:

S/Sx
a.) Fever/ chills d. tachycardia
b.) Headache e. palpitations
c.) Dyspnea f. diaphoresis

Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antipyretics, antibiotics
5. Send blood unit to blood bank
6. Obtain urine & blood samples – send to lab
7. Monitor VS & IO
8. Tepid sponge bath – offer hypothermic blanket

Circulatory Overload:
Sx
a. Dyspnea
b. Orthopnea
c. Rales or crackles
d. Exertional discomfort

Nsg Mgt:
1. Stop BT
2. Notify Doc. Don’t flush due pt has circulatory overload.
3. Administer diuretics
Priority cases:
Hemolytic Rxn – 1st due to hypotension – 1st priority – attend to destruction of Hgb – O2 brain damage
Allergic 3rd
Pyrogenic 4th
Circulatory 2nd

Hemolytic 2nd
Anaphylitic 1st priority


DIC – DISSEMINATED INTRAVASCULAR COAGULATION
25. Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting factors (Prothrombin & Fibrinogen).

Predisposing factor:
1. Rapid BT
2. Massive trauma
3. Massive burns
4. Septicemia
5. Hemolytic reaction
6. Anaphylaxis
7. Neoplasia – growth of new tissue
8. Pregnancy

S/Sx
1. Petechiae – widespread & systemic (lungs, lower & upper trunk)
2. Ecchymosis – widespread
3. Oozing of blood from venipunctured site
4. Hemoptysis – cough blood
5. Hemorrhage
6. Oliguria – late sx

Dx Proc–
1. CBC – reveals decrease platelets
2. Stool for occult blood (+)
Specimen – stool
3. Opthalmoscopic exam – sub retinal hemorrhage
4. ABG analysis – metabolic acidosis


pH HCO3
R pH PCO2 respiratory alkalosis

O ph PCO2 respiratory acidosis

M ph HCO3 metabolic alkalosis

E ph HCO3 metabolic acidosis

Diarrhea – met acidosis
Vomitting – met alk
Pyloric stenosis – met alkalosis – vomiting
Ileostomy or intestinal tubing – met acidosis
Cushing’s – met alk
DM met acid
Chronic bronchitis – resp acid – with hypoxemia, cyanosis

Nsg Mgt DIC
1. Monitor signs of bleeding – hema test + urine, stool, GIT
2. Administer isotonic fluid solution to prevent shock.
3. Administer O2 inhalation
4. Administer meds
a. Vit K aquamephyton
b. Pitressin or vasopressin – to conserve water.
5. NGT – lavage
- Use iced saline lavage
6. Monitor NGT output
7. Provide heplock
8. Prevent complication: hypovolemic shock
Late signs of hypovolemic shock : anuria
Oncologic Nsg:
Oncology – study of neoplasia –new growth


Benign (tumor) Malignancy (cancer)

Diff - well differentiated poorly or undifferentiated
Encapulation – (+) (-)
Metastasis – (-) (+)
Prognosis – good poor
Therapeutic modality surgery 1. Chemotherapy plenty S/E
2. Radiation
3. Surgery most preferred treatment
4. Bone marrow transplant - Leukemia only
Predisposing factors: (carcinogenesis)
G – genetic factors
I – immunologic factors
V – viral factors
a. Human papiloma virus – causing warts
b. Epstein barr virus
E – environmental Factors 90%
a. Physical – irradiation, UV rays, nuclear explosion, chronic irritation, direct trauma
b. Chemical factors –
- Food additives (nitrates
- Hydrocarbon vesicants, alkalies
- Drugs (stillbestrol)
- Uraehane
- Hormones
- Smoking
Male
3.) Prostate cancer - common 40 & above (middle age & above)
BPH – 50 & above
1.) Lung cancer
2.) Liver cancer

Female
1. Breast cancer – 40 yrs old & up – mammography 15 – 20 mins (SBE – 7 days after mens)
2. Cervical cancer – 90% multi sexual partners
5% early pregnancy
3. Ovarian cancer

Classes of cancer
Tissue typing
1. Carcinoma – arises from surface epithelium & glandular tissues
2. Sarcoma- from connective tissue or bones
3. Multiple myeloma – from bone marrow
Pathological fracture of ribs & back pain
4. Lymphoma – from lymph glands
5. Leukemia – from blood

Warning / Danger Sx of CA
C – change in bowel /bladder habits
A – a sore that doesn’t heal
U – unusual bleeding/ Discharge
T – thickening of lump – breast or elsewhere
I – indigestion? Dysphagia
O – obvious change in wart/ mole
N – nagging cough/ hoarseness
U – unexplained anemia A - anemia
S – sudden wt loss L – loss of wt

Therapeutic Modality:
1. Chemotherapy – use various chemotherapeutic agents that kills cancer cells & kills normal rapidly producing cells – GIT, bone marrow, and hair follicle.

Classification:
a.) Alkylating agents –
b.) Plant alkaloids – vincristine
c.) Anti metabolites – nitrogen mustard
d.) Hormones – DES
Steroids
e.) Antineoplastic antibiotics

S/E & mgt
GIT - -Nausea & vomiting
Nsg Mgt:
1. Administer anti emetic 4 – 6h before start of chemo
Plasil
2. Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
26. Non irritating / non spicy

- Diarrhea
1. Administer anti diarrheal 4 – 6h before start of chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care – offer ice chips/ popsickles
2. Inform pt – hair loss – temporary alopecia
Hair will grow back after 4 – 6 months post chemo.
-Bone marrow depression – anemia
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding
Repro organ – sterility
1. Do sperm banking before start of chemo
Renal system – increase uric acid
1. Administer allopurinol/ xyloprin (gout)
27. Inhibits uric acid
28. Acute gout – colchicines
29. Increase secretion of uric acid
Neurological changes – peristalsis – paralytic ileus
Most feared complication ff any abdominal surgery
Vincristine – plant alkaloid causes peripheral neuropathy

2. Radiation therapy – involves use of ionizing radiation that kills cancer cells & inhibit their growth & kill N rapidly producing cells.

Types of energy emitted
1. Alpha rays – rarely used – doesn’t penetrate skin tissues
2. Beta rays – internal radiation – more penetration
3. Gamma ray – external radiation – penetrates deeper underlying tissues

Methods of delivery
1. External radiation- involves electro magnetic waves
Ex. cobalt therapy
2. Internal radiation – injection/ implantation of radioisotopes proximal to CA site for a specific period of time.
2 types:
a.) Sealed implant – radioisotope with a container & doesn’t contaminate body fluid.
b.) Unsealed implant – radioisotope without a container & contaminates body fluid.
Ex. Phosphorus 32

3 Factors affecting exposure:
A.) Half life – time period required for half of radioisotopes to decay.
- At end of half life – less exposure
B.) Distance – the farther the distance – lesser exposure
C. ) Time – the shorter the time, the lesser exposure
D.) Shielding – rays can be shielded or blocked by using rubber gloves –  &  gamma – use thick lead on concrete.


S/E & Mgt:
a.) Skin errythema, redness, sloughing
1. Assist in battling pt
2. Force fluid – 2,000 – 3,000 ml/day
3. Avoid lotion or talcum powder – skin irritation
4. Apply cornstarch or olive oil
b.) GIT –nausea / vomiting -
1. Administer antiemetic 4 – 6h before start of chemo - Plasil
2 Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
Non irritating / non spicy
Dysglusia – decrease taste sensitivity
-When atrophy papilla (taste buds) – 40 yo
Stomatitis
c.) Bone marrow depression
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding

Overview of function & structure of the heart
HEART
- Muscular, pumping organ of the body
- Left mediastinum
- Weigh 300 – 400 grams
- Resembles a closed fist
- Covered by serous membrane – pericardium
Pericardium


Parietal layer Pericardial Visceral layer
Fluid – prevent
Friction rub

Layer
1. Epicardium – outermost
2. Myocardium – inner – responsible for pumping action/ most dangerous layer - cardiogenic shock
3. Endocardium – innermost layer
Chambers
1. Upper – collecting/ receiving chamber - Atria
2. Lower – pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
Closure of AV valves – gives rise to 1st heart sound or S1 or “lub”
2. Semi lunar valve
a.) Pulmonic
b.) Aortic
Closure of semilunar valve – gives rise to 2nd heart sound or S2 or “dub”
Extra heart Sound
S3 – ventricular Gallop – CHF
S4 – atrial gallop – MI, HPN

Heart conduction system
1. Sino atrial node (SA node) (or Keith-Flock node)
Loc – junction of SVC & Rt atrium
Fx- primary pace maker of heart
-Initiates electric impulse of 60 – 100 bpm
2. Atrioventicular node (AV node or Tawara node)
Loc – inter atrial septum
Delay of electric impulse to allow ventricular filling
3. Bundle of His – location interventricular septum
Rt main Bundle Branch
Lt main Bundle Branch
4. Purkenjie Fiber
Loc- walls of ventricles-- Ventricular contractions

SA node





Purkenjie Fibers
Bundle of His

Complete heart block – insertion of pacemaker at Bundle Branch
Metal – Pace Maker – change q3 – 5 yo


Prolonged PR – atrial fib T wave inversion – MI
ST segment depression – angina widening QRS – arrhythmia
ST – elev – MI


CAD – coronary artery dse or Ischemic Heart Dse (IHD)
Atherosclerosis – Myocrdial injury
Angina Pectoris – Myocardial ischemia
MI- myocardial necrosis


ATHEROSCLEROSIS ARTEROSCLEROSIS
- Hardening or artery due to fat/ lipid deposits at tunica intima. - Narrowing or artery due to calcium & CHON deposits at tunica media.

Artery – tunica adventitia – outer
- Tunica intima – innermost
- Tunica media – middle

ATHEROSCLEROSIS
Predisposing Factor
1. Sex – male
2. Black race
3. Hyperlipidemia
4. Smoking
5. HPN
6. DM
7. Oral contraceptive- prolonged use
8. Sedentary lifestyle
9. Obesity
10. Hypothyroidism
Signs & Symptoms
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P – percutaneous
T – tansluminar
C – coronary
A – angioplasty

Obj:
1. To revascularize the myocardium
2. To prevent angina
3. Increase survival rate

PTCA – done to pt with single occluded vessel .
Multiple occluded vessels
C – coronary
A – arterial
B – bypass
A –and
G – graft surgery

Nsg Mgt Before CABAG
1. Deep breathing cough exercises
2. Use of incentive spirometer
3. Leg exercises

ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT nitroglycerin, resulting fr temp myocardial ischemia.
Predisposing Factor:
1. sex – male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10.hypothyroidism
Precipitating factors
4 E’s
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake of food – saturated fats.
Signs & Symptoms
1. Initial symptoms – Levine’s sign – hand clutching of chest
2. Chest pain – sharp, stabbing excruciating pain. Location – substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT
3. Dyspnea
4. Tachycardia
5. Palpitation
6.diaphoresis
Diagnosis
1.History taking & PE
2. ECG – ST segment depression
3. Stress test – treadmill = abnormal ECG
4. Serum cholesterol & uric acid - increase.
Nursing Management
1.) Enforce CBR
2.) Administer meds
NTG – small doses – venodilator
Large dose – vasodilator
1st dose NTG – give 3 – 5 min
2nd dose NTG – 3 – 5 min
3rd & last dose – 3 – 5 min
Still painful after 3rd dose – notify doc. MI!

55 yrs old with chest pain:
1st question to ask pt: what did you do before you had chest pain.
2nd question: does pain radiate? If radiate – heart in nature. If not radiate – pulmonary origin

Venodilator – veins of lower ext – increase venous pooling lead to decrease venous return.

Meds:
A. NTG- Nsg Mgt:
1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug.
2. Monitor S/E:
orthostatic hypotension – dec bp
transient headache
dizziness
3. Rise slowly from sitting position
4. Assist in ambulation.
5. If giving NTG via patch:
i. avoid placing it near hairy areas-will dec drug absorption
ii. avoid rotating transdermal patches- will dec drug absorption
iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch
B. Beta blockers – propanolol
C. ACE inhibitors – captopril
D. Ca antagonist - nefedipine
3.) Administer O2 inhalation
4.) Semi-fowler
5.) Diet- Decrease Na and saturated fats
6.) Monitor VS, I&O, ECG
7.) HT: Discharge planning:
a. Avoid precipitating factors – 4 E’s
b. Prevent complications – MI
c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug
d. Importance of follow-up care.

MI – MYOCARDIAL INFARCTION – hear attack – terminal stage of CAD
- Characterized by necrosis & scarring due to permanent mal-occlusion

Types:

1. Trasmural MI – most dangerous MI – Mal-occlusion of both R&L coronary artery
2. Sub-endocardial MI – mal-occlusion of either R & L coronary artery

Most critical period upon dx of MI – 48 to 72h
- Majority of pt suffers from PVC premature ventricular contraction.

Predisposing factors Signs & symptoms Diagnostic Exam
1. sex – male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10. hypothyroidism 1. chest pain – excruciating, vice like, visceral pain located substernal or precodial area (rare)
- radiates back, arm, shoulders, axilla, jaw & abd muscles.
- not usually relived by rest r NTG
2. dyspnea
3. erthermia
4. initial increase in BP
5. mild restlessness & apprehensions
6. occasional findings
a.) split S1 & S2
b.) pericardial friction rub
c.) rales /crackles
d.) S4 (atrial gallop) 1. cardiac enzymes
a.) CPK – MB – Creatinine Phosphokinase
b.) LDH – lactic acid dehydrogenase
c.) SGPT – (ALT) – Serum Glutanic Pyruvate Transaminase- increased
d.) SGOT (AST) – Serum Glutamic Oxalo-acetic - increased
2. Troponin test – increase
3. ECG tracing – ST segment increase,
widening or QRS complexes – means arrhythmia in MI indicating PVC
4. serum cholesterol & uric acid - increase
5. CBC – increase WBC


Nursing Management
1. Narcotic analgesics – Morphine SO4 – to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation – low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet – decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 – 30 ml/week – wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias – PVC
2. Shock – cardiogenic shock. Late signs of cardiogenic shock in MI – oliguria
3. thrombophlebitis - deep vein
4. CHF – left sided
5. Dressler’s syndrome – post MI syndrome
-Resistant to medications
-Administer 150,000 – 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. Isordil
- Antiarrythmic
1. Lydocaine blocks release of norepenephrine
2. Brithylium
- Beta-blockers – “lol”
1. Propanolol (inderal)
- ACE inhibitors - pril
1. Captopril – (enalapril)
- Ca – antagonist
1. Nifedipine
- Thrombolitics or fibrinolytics– to dissolve clots/ thrombus


S/E allergic reactions/ uticaria
1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting factor



Monitor for bleeding:
- Anticoagulants
1. Heparin 2. Caumadin – delayed reaction 2 – 3 days

PTT PT

If prolonged bleeding prolonged bleeding

Antidote antidote Vit K
Protamine sulfate
- Anti platelet PASA (aspirin)
d.) Resume ADL – sex/ activity – 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert –
Before meals not after, due after meals increase metabolism – heart is pumping hard after meals.
2.) Position – non-weight bearing position.

When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet – decrease Na, Saturated fats, and caffeine
f.) Follow up care.

CHF – CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.
- Backflow
1.) Left sided heart failure:

Predisposing factors:
1.) 90% mitral valve stenosis – due RHD, aging
RHD affects mitral valve – streptococcal infection
Dx: - Aso titer – anti streptolysine O > 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging – degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis

S/Sx
Pulmonary congestion/ Edema
1. Dyspnea
2. Orthopnea (Diff of breathing sitting pos – platypnea)
3. Paroxysmal nocturnal dysnea – PNO- nalulunod
4. Productive cough with blood tinged sputum
5. Frothy salivation (from lungs)
6. Cyanosis
7. Rales/ crackles – due to fluid
8. Bronchial wheezing
9. PMI – displaced lateral – due cardiomegaly
10. Pulsus alternons – weak-strong pulse
11. Anorexia & general body malaise
12. S3 – ventricular gallop

Dx
1. CXR – cardiomegaly
2. PAP – Pulmonary Arterial Pressure
PCWP – Pulmonary CapillaryWedge Pressure

PAP – measures pressure of R ventricle. Indicates cardiac status.
PCWP – measures end systolic/ diastolic pressure
PAP & PCWP:
Swan – ganz catheterization – cardiac catheterization is done at bedside at ICU
(Trachesostomy – bedside) - Done 5 – 20 mins – scalpel & trachesostomy set

CVP – indicates fluid or hydration status
Increase CVP – decrease flow rate of IV
Decrease CVP – increase flow rate of IV
3. Echocardiography – reveals enlarged heart chamber or cardiomayopathy

4. ABG – PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

2.) Right sided HF

Predisposing factor
1. 90% - tricuspid stenosis
2. COPD
3. Pulmonary embolism
4. Pulmonic stenosis
5. Left sided heart failure

S/Sx
Venous congestion
- Neck or jugular vein distension
- Pitting edema
- Ascites
- Wt gain
- Hepatomegalo/ splenomegaly
- Jaundice
- Pruritus
- Esophageal varies
- Anorexia, gen body malaise

Diagnosis:
1. CXR – cardiomegaly
2. CVP – measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 – hypervolemia
Decrease CVP < 4 – hypovolemia
Flat on bed – post of pt when giving CVP
Position during CVP insertion – Trendelenburg to prevent pulmonary embolism & promote ventricular filling.

3. Echocardiography – enlarged heart chamber / cardiomyopathy
4.Liver enzyme
SGPT ( ALT)
SGOT AST

Nsg mgt: Increase force of myocardial contraction = increase CO
3 – 6L of CO

1. Administer meds:
Tx for LSHF: M – morphine SO4 to induce vasodilatation
A – aminophylline & decrease anxiety
D – digitalis (digoxin)
D - diuretics
O - oxygen
G - gases

a.) Cardiac glycosides
Increase myocardial = increase CO
Digoxin (Lanoxin). Antidote: digivine
Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure.
b.) Loop diuretics: Lasix – effect with in 10-15 min. Max = 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety
e.) Vasodilators – NTG
f.) Anti-arrythmics – Lidocaine

2. Administer O2 inhalation – high! @ 3 -4L/min via nasal cannula
3. High fowlers
4. Restrict Na!
5. Provide meticulous skin care
6. Weigh pt daily. Assess for pitting edema.
Measure abdominal girth daily & notify MD
7. Monitor V/S, I&O, breath sounds
8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote decrease venous return
9. Diet – decrease salt, fats & caffeine
10. HT:
a) Complications :shock
Arrhythmia
Thrombophlebitis
MI
Cor Pulmonale – RT ventricular hypertrophy
b.) Dietary modifications
c.) Adherence to meds

PERIPHERAL MUSCULAR DISEASE

Arterial ulcers venous ulcer
1. Thromboangiitis Obliterans – male/ feet 1. Varicose veins
2. Reynauds – female/ hands 2. Thrombophlebitis



1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small to medium sized arteries & veins of lower extremities. Male/ feet

Predisposing factors:
- Male
- Smokers

S/Sx
1. Intermittent claudication – leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes

White bluish red

Pallor cyanosis rubor

3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis
4. Tropic changes
5. Ulcerations
6. Gangrene formation


Dx:
1. Oscillometry – decrease peripheral pulse volume.
2. Doppler UTZ – decrease blood flow to affected extremities.
3. Angiography – reveals site & extent of mal-occulsion.

Nsg Mgt:
1. Encourage a slow progression of physical activity
a.) Walk 3 -4 x / day
b.) Out of bed 2 – 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM –
a.) Avoid walking barefoot
b.) Cut toe nails straight
c.) Apply lanolin lotion – prevent skin breakdown
d.) Avoid wearing constrictive garments
4. Avoid smoking & exposure to cold environment
5. Surgery: BKA (Below the knee amputation)




2.)REYNAUD’S PHENOMENON – acute episodes of arterial spasm affecting digits of hands & fingers

Predisposing factors:

1. Female, 40 yrs
2. Smoking
3. Collagen dse
a.) SLE – pathognomonic sign – butterfly rash on face
Chipmunk face – bulimia nervosa
Cherry red skin – carbon monoxide poisoning
Spider angioma – liver cirrhosis
Caput medusae – leg & trunk umbilicus- Liver cirrhosis
Lion face – leprosy

b.) Rheumatoid arthritis –
4. Direct hand trauma – piano playing, excessive typing, operating chainsaw
S/Sx:
1. Intermittent claudication - leg pain upon walking - Relieved by rest
2. Cold sensitivity

Nsg Mgt:
a. Analgesics
b. Vasodilators
c. Encourage to wear gloves especially when opening a refrigerator.
d. Avoid smoking & exposure to cold environment


VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins – lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return

Predisposing factors:
a. Hereditary
b. Congenital weakness of veins
c. Thrombophlebitis
d. Heart dse
e. Pregnancy
f. Obesity
g. Prolonged immobility - Prolonged standing
S/Sx:
1. Pain especially after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs

Dx:
1. Venography
2. Trendelenberg’s test – vein distend quickly < 35 secs

Nsg Mgt:
1. Elevate legs above heart level – to promote venous return – 1 to 2 pillows
2. Measure circumference of leg muscles to determine if swollen.
3. Wear anti embolic or knee high stockings. Women – panty hose
4. Meds: Analgesics
5. Surgery: vein sweeping & ligation
Sclerotherapy – spider web varicosities
S/E thrombosis

THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation
Predisposing factors:
1. Smoking
2. Obesity
3. Hyperlipedemia
4. Prolonged use of oral contraceptives
5. Chronic anemia
6. DM
7. MI
8. CHF
9. Postop complications
10. Post cannulation – insertion of various cardiac catheters

S/Sx:
1. Pain at affected extremities
2. Cyanosis
3. (+) Homan’s sign - Pain at leg muscles upon dorsiflexion of foot.
Dx:
1. Angiography
2. Doppler UTZ
Nsg Mgt:
1. Elevate legs above heart level.
2. Apply warm, moist packs to decrease lymphatic congestion.
3. Measure circumference of leg muscles to detect if swollen.
4. Use anti embolic stockings.
5. Meds: Analgesics.
Anticoagulant: Heparin
6. Complication:
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
- Mild restlessness

OVERVIEW OF RESPIRATORY SYSTEM:
I. Upper respiratory tract:
Fx:
1. Filtering of air
2. Warming & moistening
3. Humidification
a. Nose – cartilage
- Parts: Rt nostril separated by septum
Lt nostril

- Consists of anastomosis of capillaries –
Kessel – Bach Plexus – site of epistaxis
b. Pharynx (throat) – muscular passageway for air& food
Branches:
1. Oropharynx
2. Nasopharynx
3. Layngopharynx

c. Larynx – voice box
Fx:
1. For phonation
2. Cough reflex

Glottis – opening
Opens to allow passage of air
Closes to allow passage of food

II. Lower Rt – Fx for gas exchange
a. Trachea – windpipe
- has cartillagenous rings
- site for permanent/ artificial a/w – tracheostomy
b. Bronchus – R & L main bronchus
c. Lungs – R – 3 lobes = 10 segments
L – 2 lobes – 8 segments

Post pneumonectomy - position affected side to promote expansion of lungs
Post segmental lobectomy – position unaffected side to promote drainage

Lungs – covered by pleural cavity, parietal lobe & visceral lobe
Alveoli – acinar cells
- site of gas exchange (O2 & CO2)
- diffusion: Daltons law of partial pressure of gases

Ventilation – movement of air in & out of lungs
Respiration – movement of air into cells

Type II cells of alveoli – secrets surfactant
Surfactant - decrease surface tension of alveoli

Lecithin & spinogometer
L/S ratio 2:1 – indicator of lung maturity

If 1:2 – adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.


I. PNEUMONIA – inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.

Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Hemophilus pneumoniae(Bronchopneumonia)
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.

High risk elderly & children below 5 yo


Predisposing factors:
1. Smoking
2. Air pollution
3. Immuno-compromised
a. AIDS – PLP
b. Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility – CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue

S/Sx:
1. Productive cough – pathognomonic: greenish to rusty sputum
2. Dyspnea with prolonged respiratory grunt
3. Fever, chills, anorexia, gen body malaise
4. Wt loss
5. Pleuritic friction rub
6. Rales/ crackles
7. Cyanosis
8. Abdominal distension leading to paralytic ileus

Sputum exam – could confirm presence of TB & pneumonia

Dx:
1. Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism.
2. CXR – pulmo consolidation
3. CBC – increase WBC
Erythrocyte sedimentation rate
4. ABG – PO2 decrease

Nsg Mgt:
1. Enforce CBR
2. Strict respiratory isolation
3. Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides – ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
4. Force fluids – 2 to 3 L/day
5. Institute pulmonary toilet-
a.) Deep breathing exercise
b.) Coughing exercise
c.) Chest physiotherapy – cupping
d.) Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfy & humid environment
9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt for postural drainage:
a.) Best done before meals or 2 – 4 hrs after meals to prevent Gastroesophageal Reflux
b.) Monitor VS & breath sounds
Normal breath sound – bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 – 30 min before procedure
e.) Stop if pt can’t tolerate procedure
f.) Provide oral care – it may alter taste sensation
g.) C/I – pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)
Normal IOP – 12 – 21 mmHg
11. HT:
a.) Avoidance of precipitating factors
b.) Complication: Atelectacies & meningitis
c.) Compliance to meds

PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB or tubercle bacilli or acid fast bacilli – gram (+) aerobic, motile & easily destroyed by heat or sunlight.

Predisposing factors:
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle (mycobacterium BOVIS)
5. Virulence
6. Over fatigue

S/Sx:
1. Productive cough – yellowish
2. Low fever
3. Night sweats
4. Dyspnea
5. Anorexia, general body malaise, wt loss
6. Chest/ back pain
7. Hempotysis

Diagnosis:
1. Skin test – mantoux test – infection of Purified CHON Derivative PPD
DOH – 8-10 mm induration
WHO – 10-14 mm induration
Result within 48 – 72h
(+) Mantoux test – previous exposure to tubercle bacilli

Mode of transmission – droplet infection
2. Sputum AFB – (+) to cultured microorganism
3. CXR – pulmonary infiltrate caseosis necrosis
4. CBC – increase WBC

Nursing Mgt:
1. CBR
2. Strict resp isolation
3. O2 inhalation
4. Semi fowler
5. Force fluid to liquefy secretions
6. DBCE
7. Nebulize & suction
8. Comfy & humid environment
9. Diet – increase CHO & calories, CHON, Vit, minerals
10. Short course chemotherapy



- Intensive phase

INH – isoniazide - give before meals for absorption
Rifampicin - given within 4 months, given simultaneously to prevent resistance
-S/E: peripheral neutitis – vit B6
Rifampicin -All body secretions turn to red orange color urine, stool, saliva, sweat & tears.

PZA – Pyrazinamide – given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity

Standard regimen
1. Injection of streptomycin – aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
a.) Ototoxicity – damage CN # 8 – tinnitus – hearing loss
b.) Nephrotoxicicity – monitor BUN & Crea
HT:
a.) Avoid pred factors
b.) Complications:
1.) Atelectasis
2.) Miliary TB – spread of Tb to other system
c.) Compliance to meds
- Religiously take meds

HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted to birds manure.
S/Sx: Same as pneumonia & PTB – like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis

Dx:
1. Histoplasmin skin test = (+)
2. ABG – pO2 decrease

Nsg Mgt:
1. CBR
2. Meds:
a.) Anti fungal agents
Amphotericin B (Fungizone)
S/E :
a.) Nephrotoxcicity check BUN
b.) Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 – force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.

COPD – Chronic Obstructive Pulmonary Disease
1. Chronic bronchitis
2. Bronchial asthma
3. Bronchiectasis
4. Pulmonary emphysema – terminal stage

CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet mucus producing cells leading to narrowing of smaller airways.

Predisposing factors:
1. Smoking – all COPD types
2. Air pollution
S/Sx:
1. Prod cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmo HPN – a.)Leading to peripheral edema
b.) Cor pulmonary – respiratory in origin
7. Anorexia, gen body malaise

Dx:
1. ABG
PO2 PCO2 Resp acidosis

Hypoxemia – causing cyanosis
Nsg Mgt:
(Same as emphysema)

2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller airway.
Predisposing factor:
1. Extrinsic Asthma – called Atropic/ allergic asthma
a.) Pallor
b.) Dust
c.) Gases
d.) Smoke
e.) Dander
f.) Lints

2. Intrinsic Asthma-
Cause:
Herediatary
Drugs – aspirin, penicillin, b blockers
Food additives – nitrites
Foods – seafood, chicken, eggs, chocolates, milk
Physical/ emotional stress
Sudden change of temp, humidity &air pressure
3. mixed type: combi of both ext & intr. Asthma
90% cause of asthma

S/Sx:
1. C – cough – non productive to productive
2. D – dyspnea
3. W – wheezing on expiration
4. Cyanosis
5. Mild apprehension & restlessness
6. Tachycardia & palpitation
7. Diaphoresis
Dx:
1. Pulmo function test – decrease lung capacity
2. ABG – PO2 decrease

Nsg Mgt:
1. CBR – all COPD
2. Meds-
a.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids
b.) Corticosteroids – due inflammatory. Given 10 min after adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist – at bedside put suction machine.
e.) Antihistamine
3. Force fluid
4. O2 – all COPD low inflow to prevent resp distress
5. Nebulize & suction
6. Semifowler – all COPD except emphysema due late stage
7. HT
a.) Avoid pred factors
b.) Complications:
- Status astmaticus- give epinephrine & bronchodilators
- Emphysema
c.) Adherence to med

BRONCHIECTASIS – abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.

Predisposing factors:
1. Recurrent upper & lower RI
2. Congenital anomalies
3. Tumors
4. Trauma
S/Sx:
1. Productive cough
2. Dyspnea
3. Anorexia, gen body malaise- all energy are used to increase respiration.
4. Cyanosis
5. Hemoptisis


Dx:
1. ABG – PO2 decrease
2. Bronchoscopy – direct visualization of bronchus using fiberscope.
Nsg Mgt: before bronchoscopy
1. Consent, explain procedure – MD/ lab explain RN
2. NPO
3. Monitor VS
Nsg Mgt after bronchoscopy
1. Feeding after return of gag reflex
2. Instruct client to avoid talking, smoking or coughing
3. Monitor signs of frank or gross bleeding
4. Monitor of laryngeal spasm
- DOB
- Prepare at bedside tracheostomy set

Mgt: same as emphysema except Surgery
Pneumonectomy – removal of affected lung
Segmental lobectomy – position of pt – unaffected side

PULMONARY EMPHYSEMA – irreversible terminal stage of COPD
- Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases.
- Body will compensate over distension of thoracic cavity
- Barrel chest
Predisposing factor:
1. Smoking
2. Allergy
3. Air pollution
4. High risk – elderly
5. Hereditary - a 1 anti trypsin to release elastase for recoil of alveoli.

S/Sx:
1. Productive cough
2. Dyspnea at rest – due terminal
3. Anorexia & gen body malaise
4. Rales/ rhonchi
5. Bronchial wheezing
6. Decrease tactile fremitus (should have vibration)– palpation – “99”. Decreased - with air or fluid
7. Resonance to hyperresonance – percussion
8. Decreased or diminished breath sounds
9. Pathognomonic: barrel chest – increase post/ anterior diameter of chest
10. Purse lip breathing – to eliminated PCO2
11. Flaring of alai nares

Diagnosis:
1. Pulmonary function test – decrease vital lung capacity
2. ABG –
a.) Panlobular / centrolobular emphysema
pCO2 increase
pO2 decrease – hypoxema resp acidosis Blue bloaters
b.) Panacinar/ Centracinar
pCO2 decrease
pO2 increase – hyperaxemia resp alkalosis Pink puffers
Nursing Mgt:
1. CBR
2. Meds –
a.) Bronchodilators
b.) Corticosteroids
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
3. O2 – Low inflow
4. Force fluids
5. High fowlers
6. Neb & suction
7. Institute
P – posture
E – end
E – expiratory to prevent collapse of alveoli
P – pressure
8. HT
a.) Avoid smoking
b.) Prevent complications
1.) Cor pulmonary – R ventricular hypertrophy
2.) CO2 narcosis – lead to coma
3.) Atelectasis
4.) Pneumothorax – air in pleural space
9. Adherence to meds

RESTRICTIVE LUNG DISORDER
PNEUMOTHORAX – partial / or complete collapse of lungs due to entry or air in pleural space.
Types:
1. Spontaneous pneumothorax – entry of air in pleural space without obvious cause.
Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
Eg. open pneumothorax – air enters pleural space through an opening in chest wall
-Stab/ gun shot wound
2. Tension Pneumothorax – air enters plural space with @ inspiration & can’t escape leading to over distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side.
Eg. flail chest – “paradoxical breathing”

Predisposing factors:
1.Chest trauma
2.Inflammatory lung conditions
3.Tumor
S/Sx:
1. Sudden sharp chest pain
2. Dyspnea
3. Cyanosis
4. Diminished breath sound of affected lung
5. Cool moist skin
6. Mild restlessness/ apprehension
7. Resonance to hyper resonance
Diagnosis:
1. ABG – pO2 decrease –
2. CXR – confirms pneumothorax
Nursing Mgt:
1. Endotracheal intubation
2. Thoracenthesis
3. Meds – Morphine SO4
- Anti microbial agents
4. Assist in test tube thoracotomy
Nursing Mgt if pt is on CPT attached to H2O drainage
1. Maintain strict aseptic technique
2. DBE
3. At bedside
a.) Petroleum gauze pad if dislodged Hemostan
b.) If with air leakage – clamp
c.) Extra bottle
4. Meds – Morphine SO4
Antimicrobial
5. Monitor & assess for oscillation fluctuations or bubbling
a.) If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
1. Check for loop, clots, and kink
2. Milk towards H2O seal
3. Indicates re-expansion of lungs
When will MD remove chest tube:
1. If (-) fluctuations
2. (+) Breath sounds
3. CXR – full expansion of lungs

Nursing Mgt of removal of chest tube
1. DBE
2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space.
3. Apply vaselinated air occlusive dressing
- Maintain dressing dry & intact
GIT
I. Upper alimentary canal - function for digestion
a. Mouth
b. Pharynx (throat)
c. Esophagus
d. Stomach
e. 1st half of duodenum
II. Middle Alimentary canal – Function: for absorption
- Complete absorption – large intestine
a. 2nd half of duodenum
b. Jejunum
c. Ileum
d. 1st half of ascending colon
III. Lower Alimentary Canal – Function: elimination
a. 2nd half of ascending colon
b. Transverse
c. Descending colon
d. Sigmoid
e. Rectum
IV. Accessory Organ
a. Salivary gland
b. Verniform appendix
c. Liver
d. Pancreas – auto digestion
e. Gallbladder – storage of bile

I. Salivary Glands
1. Parotid – below & front of ear
2. Sublingual
3. Submaxillary

- Produces saliva – for mechanical digestion
- 1200 -1500 ml/day - saliva produced

PAROTITIS – “mumps” – inflammation of parotid gland
-Paramyxo virus

S/Sx:
1. Fever, chills anorexia, gen body malaise
2. Swelling of parotid gland
3. Dysphagia
4. Ear ache – otalgia

Mode of transmission: Direct transmission & droplet nuclei
Incubation period: 14 – 21 days
Period of communicability – 1 week before swelling & immediately when swelling begins.

Nursing Mgt:
1. CBR
2. Strict isolation
3. Meds: analgesic
Antipyretic
Antibiotics – to prevent 2° complications
4. Alternate warm & cold compress at affected part
5. Gen liquid to soft diet
6. Complications
Women – cervicitis, vaginitis, oophoritis
Both sexes – meningitis & encephalitis/ reason why antibiotics is needed
Men – orchitis might lead to sterility if it occur during / after puberty.

VERNIFORM APPENDIX – Rt iliac or Rt inguinal area
- Function – lymphatic organ – produces WBC during fetal life - ceases to function upon birth of baby

APENDICITIS – inflamation of verniform appendix
Predisposing factor:
1. Microbial infection
2. Feacalith – undigested food particles – tomato seeds, guava seeds
3. Intestinal obstruction

S/Sx:
1. Pathognomonic sign: (+) rebound tenderness
2. Low grade fever, anorexia, n/v
3. Diarrhea / & or constipation
4. Pain at Rt iliac region
5. Late sign due pain – tachycardia

Diagnosis:
1. CBC – mild leukocytosis – increase WBC
2. PE – (+) rebound tenderness (flex Rt leg, palpate Rt iliac area – rebound)
3. Urinalysis

Treatment: - appendectomy 24 – 45°
Nursing Mgt:
1. Consent
2. Routinary nursing measures:
a.) Skin prep
b.) NPO
c.) Avoid enema – lead to rupture of appendix
3. Meds:
Antipyretic
Antibiotics
*Don’t give analgesic – will mask pain
- Presence of pain means appendix has not ruptured.
4. Avoid heat application – will rupture appendix.
5. Monitor VS, I&O bowel sound

Nursing Mgt: post op
1. If (+) to Pendrose drain – indicates rupture of appendix
Position- affected side to drain
2. Meds: analgesic due post op pain
Antibiotics, Antipyretics PRN
3. Monitor VS, I&O, bowel sound
4. Maintain patent IV line
5. Complications- peritonitis, septicemia

Liver – largest gland
- Occupies most of right hypochondriac region
- Color: scarlet red
- Covered by a fibrous capsule – Glisson’s capsule
- Functional unit – liver lobules

Function:
1. Produces bile
Bile – emulsifies fats
- Composed of H2O & bile salts
-Gives color to urine – urobilin
Stool – stircobilin
2. Detoxifies drugs
3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins
Hypevitaminosis – vit D & K
Vit A – retinol
Def Vit A – night blindness
Vit D – cholecalciferon
- Helps calcium
- Rickets, osteoarthritis

4. It destroys excess estrogen hormone
5. For metabolism
A. CHO –
1. Glycogenesis – synthesis of glycogens
2. Glycogenolysis – breakdown of glycogen
3. Gluconeogenesis – formation of glucose from CHO sources
B. CHON-
1. Promotes synthesis of albumin & globulin
Cirrhosis – decrease albumin
Albumin – maintains osmotic pressure, prevents edema
2. Promotes synthesis of prothrombin & fibrinogen
3. Promotes conversion of ammonia to urea.
Ammonia like breath – fetor hepaticus
C. FATS – promotes synthesis of cholesterol to neutral fats – called triglycerides

LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring

Early sign – hepatic encephalopathy
1. Asterixis – flapping hand tremors
Late signs – headache, restlessness, disorientation, decrease LOC – hepatic coma.
Nursing priority – assist in mechanical ventilation


Predisposing factor:
Decrease Laennac’s cirrhosis – caused by alcoholism
1. Chronic alcoholism
2. Malnutrition – decreaseVit B, thiamin - main cause
3. Virus –
4. Toxicity- eg. Carbon tetrachloride
5. Use of hepatotoxic agents
S/Sx:
Early signs:
a.) Weakness, fatigue
b.) Anorexia, n/v
c.) Stomatitis
d.) Urine – tea color
Stool – clay color
e.) Amenorrhea
f.) Decrease sexual urge
g.) Loss of pubic, axilla hair
h.) Hepatomegaly
i.) Jaundice
j.) Pruritus or urticaria

2. Late signs
a.) Hematological changes – all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- decrease
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusate, Palmar errythema

c.) GIT changes
Ascitis, bleeding esophageal varices – due to portal HPN
d.) Neurological changes:

Hepatic encephalopathy - ammonia (cerebral toxin)
Late signs: Early signs:
Headache asterexis
Fetor hepaticus (flapping hand tremors)
Confusion
Restlessness
Decrease LOC

Hepatic coma

Diagnosis:
1. Liver enzymes- increase

SGPT (ALT)
SGOT (AST)
2. Serum cholesterol & ammonia increase
3. Indirect bilirubin increase
4. CBC - pancytopenia
5. PTT – prolonged
6. Hepatic ultrasonogram – fat necrosis of liver lobules

Nursing Mgt
1. CBR
2. Restrict Na!
3. Monitor VS, I&O
4. With pt daily & assess pitting edema
5. Measure abdominal girth daily – notify MD
6. Meticulous skin care
7. Diet – increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
8. Complications:
a.) Ascites – fluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics – 10 – 15 min effect
2. Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted

b.) Bleeding esophageal varices
- Dilation of esophageal veins
1. Meds: Vit K
Pitrisin or Vasopresin (IM)
2. NGT decompression- lavage
- Give before lavage – ice or cold saline solution
- Monitor NGT output
3. Assist in mechanical decompression
- Insertion of sengstaken-blackemore tube
- 3 lumen typed catheter
- Scissors at bedside to deflate balloon.
c.) Hepatic encephalopathy –
1. Assist in mechanical ventilation – due coma
2. Monitor VS, neuro check
3. Siderails – due restless
4. Meds – Laxatives – to excrete ammonia


HEPATITIS- jaundice (icteric sclera)

Bilirubin

Kernicterus/ hyperbilirubinia

Irreversible brain damage

Pancreas – mixed gland (exocrine & endocrine gland)

PANCREATITIS – acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion.
Bleeding of pancreas - Cullen’s sign at umbilicus

Predisposing factors:
1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs – Thiazide diuretics, pills Pentamidine HCL (Pentam)
7. Diet – increase saturated fats
S/Sx:
1. Severe Lt epigastric pain – radiates from back &flank area
- Aggravated by eating, with DOB
2. N/V
3. Tachycardia
4. Palpitation due to pain
5. Dyspepsia – indigestion
6. Decrease bowel sounds
7. (+) Cullen’s sign - ecchymosis of umbilicus hemorrhage
8. (+) Grey Turner’s spots – ecchymosis of flank area
9. Hypocalcemia
Diagnosis:
1. Serum amylase & lipase – increase
2. Urine lipase – increase
3. Serum Ca – decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine Hcl (Demerol)
Don’t give Morphine SO4 –will cause spasm of sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- Ex. Papavarine Hcl
Prophantheline Bromide (Profanthene)
c.) Vasodilator – NTG
d.) Antacid – Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation
f.) Ca – gluconate

2. Withold food & fluid – aggravates pain
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
Complications of TPN
1. Infection
2. Embolism
3. Hyperglycemia
4. Institute stress mgt tech
a.) DBE
b.) Biofeedback
5. Comfy position - Knee chest or fetal like position
6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON
7. Complications: Chronic hemorrhagic pancreatitis

GALLBLADDER – storage of bile – made up of cholesterol.
CHOLECYSTITIS/ CHOLELITHIASIS – inflammation of gallbladder with gallstone formation.
Predisposing factor:
1. High risk – women 40 years old
2. Post menopausal women – undergoing estrogen therapy
3. Obesity
4. Sedentary lifestyle
5. Hyperlipidemia
6. Neoplasm
S/Sx:
1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night
2. Fatty intolerance
3. Anorexia, n/v
4. Jaundice
5. Pruritus
6. Easy bruising
7. Tea colored urine
8. Steatorrhea

Diagnosis:
1. Oral cholecystogram (or gallbladder series)- confirms presence of stones

Nursing Mgt:
1. Meds – a.) Narcotic analgesic - Meperdipine Hcl – Demerol
b.) Anti cholinergic - Atropine SO4
c.) Anti emetic
Phenergan – Phenothiazide with anti emetic properties
2. Diet – increase CHO, moderate CHON, decrease fats
3. Meticulous skin care
4. Surgery: Cholecystectomy
Nursing Mgt post cholecystectomy
-Maintain patency of T-tube intact & prevent infection

Stomach – widest section of alimentary canal
- J shaped structures
1. Anthrum
2. Pylorus
3. Fundus
Valves
1. 1.cardiac sphincter
2. Pyloric sphincter

Cells
1. Chief/ Zymogenic cells – secrets
a.) Gastric amylase - digest CHO
b.) Gastric lipase – digest fats
c.) Pepsin – CHON
d.) Rennin – digests milk products
2. Parietal / Argentaffin / oxyntic cells
Function:
a.) Produces intrinsic factor – promotes reabsorption of vit B12 cyanocobalamin – promotes maturation of RBC
b.) Secrets Hcl acid – aids in digestion
3. Endocrine cells - Secrets gastrin – increase Hcl acid secretion

Function of the stomach
1.Mechanical
2.Chem. Digestion
3.Storage of food
-CHO, CHON- stored 1 -2 hrs. Fats – stored 2 – 3 hrs

PEPTIC ULCER DISEASE – (PUD) – excoriation / erosion of submucosa & mucosal lining due to:
a.) Hypercecretion of acid – pepsin
b.) Decrease resistance to mucosal barrier

Incidence Rate:
1. Men – 40 – 55 yrs old
2. Aggressive persons

Predisposing factors:
1. Hereditary
2. Emotional
3. Smoking – vasoconstriction – GIT ischemia
4. Alcoholism – stimulates release of histamine = Parietal cell release Hcl acid = ulceration
5. Caffeine – tea, soda, chocolate
6. Irregular diet
7. Rapid eating
8. Ulcerogenic drugs – NSAIDS, aspirin, steroids, indomethacin, ibuprofen
Indomethacin - S/E corneal cloudiness. Needs annual eye check up.

9. Gastrin producing tumor or gastrinoma – Zollinger Ellisons sign
10. Microbial invasion – helicobacter pylori. Metromidazole (Flagyl)

Types of ulcers
Ascending to severity
1. Acute – affects submucosal lining
2. Chronic – affects underlying tissue – heals & forms a scar

According to location
1. Stress ulcer
2. Gastric ulcer
3. Duodenal ulcer – most common

Stress ulcers – common among eritically ill clients

2 types
1.Curing’s ulcer – cause: trauma & birth

hypovolemia

GIT schemia

Decrease resistance of mucosal barriers to Hcl acid

Ulcerations

2.Cushing’s ulcer – cause – stroke/CVA/ head injury

Increase vagal stimulation

Hyperacidity

Ulcerations


GASTRIC ULCER DUODENAL ULCER
SITE Intrum or lesser curvature Duodenal bulb
PAIN -30 min – 1 hr after eating
- epigastrium
- gaseous & burning
- not usually relieved by food & antacid -2-3 hrs after eating
- mid epigastrium
- cramping & burning
- usually relieved by food & antacid
- 12 MN – 3am pain
HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion
VOMITING Common Not common
HEMORRHAGE Hematemeis Melena
WT Wt loss Wt gain
COMPLICATIONS a. stomach cause
b. hemorrhage a. perforation
HIGH RISK 60 years old 20 years old
Diagnosis:
1. Endoscopic exam
2. Stool from occult blood
3. Gastric analysis – N – gastric
Increase – duodenal
4. GI series – confirms presence of ulceration

Nursing Mgt:
1. Diet – bland, non irritating, non spicy
2. Avoid caffeine & milk/ milk products

Increase gastric acid secretion
3. Administer meds
a.) Antacids

AAC
Aluminum containing antacids Magnesium containing antacids
Ex. aluminum OH gel ex. milk of magnesia
(Ampho-gel) S/E diarrhea
S/E constipation


Maalox (fever S/E)

b.) H2 receptor antagonist
Ex
1. Ranitidine (Zantac)
2. Cimetidine (Tagamet)
3. Tamotidine (Pepcid)
- Avoid smoking – decrease effectiveness of drug

Nursing Mgt:
1. Administer antacid & H2 receptor antagonist – 1hr apart
-Cemetidine decrease antacid absorption & vise versa
c.) Cytoprotective agents
Ex
1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
2. Cytotec
d.) Sedatives/ Tranquilizers - Valium, lithium
e.)Anticholinergics
1. Atropine SO4
2. Prophantheline Bromide (Profanthene)

(Pt has history of hpn crisis With peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na.

4. Surgery: subtotal gastrectomy - Partial removal of stomach
Billroth I (Gastroduodenostomy)
-Removal of ½ of stomach & anastomoses of gastric stump to the duodenum. Billroth II (Gastrojejunostomy)
- removal of ½ -3/4 of stomach & duodenal bulb & anastomostoses of gastric stump to jejunum.

Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.

Nursing Mgt:
1. Monitor NGT output
a.) Immediately post op should be bright red
b.) Within 36- 42h – output is yellow green
c.) After 42h – output is dark red
2. Administer meds:
a.) Analgesic
b.) Antibiotic
c.) Antiemetics
3. Maintain patent IV line
4. VS, I&O & bowel sounds
5. Complications:
a.) Hemorrhage – hypovolemic shock
Late signs – anuria
b.) Peritonitis
c.) Paralytic ileus – most feared
d.) Hypokalemia
e.) Thromobphlebitis
f.) Pernicious anemia

7.)Dumping syndrome – common complication – rapid gastric emptying of hypertonic food solutions – CHYME leading to hypovolemia.
Sx of Dumping syndrome:
1. Dizziness
2. Diaphoresis
3. Diarrhea
4. Palpitations

Nursing mgt:
1. Avoid fluids in chilled solutions
2. Small frequent feeding s-6 equally divided feedings
3. Diet – decrease CHO, moderate fats & CHON
4. Flat on bed 15 -30 minutes after q feeding

BURNS – direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority – infection (all kinds of burns)
Head burn-priority- a/w
2nd priority for 1st & 2nd ° - pain
2nd priority for 3rd ° - F&E

Thermal- direct contact – flames, hot grease, sunburn.
Electric, – wires
Chem. – direct contact – corrosive materials acids
Smoke – gas / fume inhalation

Stages:
1. Emergent phase – Removal of pt from cause of burn. Determine source or loc or burn
2. Shock phase – 48 - 72°. Characterized by shifting of fluids from intravascular to interstitial space
S/Sx:
- BP decrease
- Urine output
- HR increase
- Hct increase
- Serum Na decrease
- Serum K increase
- Met acidosis

3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
4. Recovery/ convalescent phase – complete diuresis. Wound healing starts immediately after tissue injury.

Class:
I. Partial Burn
1. 1st degree – superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure with no fluid filled vesicles
2. 2nd degree – deep burns
- Affects epidermis & dermis
- Cause –chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
1. Third & 4th degrees burn
- Affects all layers of skin, muscles, bones
- Cause – electrical
- Less painful
- Dry, thick, leathery wound surface – known as ESCHAR – devitalized or necrotic tissue.
Assessment findings
Rule of nines
Head & neck = 9%
Ant chest = 18%
Post chest = 18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum= 1%
Total 100%

Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth – Claustridium tetany

Tetany


Tetanolysin tetanospasmin

Hemolysis muscle spasm

b.) Morphine SO4
c.) Systemic antibiotics
1. Ampicillin
2. Cephalosporin
3. Tetracyclin
4. Topical antibiotic :
1. Silver Sulfadiazene (silvadene)
2. Sulfamylon
3. Silver nitrate
4. Povidone iodine (betadine)
2. Administer isotonic fluid sol & CHON replacements
3. Strict aseptic technique
4. Diet – increase CHO, increase CHON, increase Vit C, and increase K- orange
5. If (+) to burns on head, neck, face - Assist in intubation
6. Assist in hydrotherapy
7. Assist in surgical wound debridement. Administer analgesic 15 – 30 minutes before debridement
8. Complications:
a.) Infection
b.) Shock
c.) Paralytic ileus - due to hypovolemia & hypokalemia
d.) Curling’s ulcer – H2 receptor antagonist
e.) Septicemia blood poisoning
f.) Surgery: skin grafting
GUT – genito-urinary tract
Function:
1. Promote excretion of nitrogenous waste products
2. Maintain F&E & acid base balance
1. Kidneys – pair of bean shaped organ
- Retro peritonially (back of peritoneum) on either side of vertebral column. Encased in Bowmans’s capsule.

Parts:
1. Renal pelvis – pyenophritis – infl
2. Cortex
3. Medulla
Nephrones – basic living unit
Glomerulus – filters blood going to kidneys

Function of kidneys:
1. Urine formation
2. Regulation of BP

Urine formation – 25% of total CO (Cardiac Output) is received by kidneys
1. Filtration
2. Tubular Reabsorption
3. Tubular Secretion

Filtration – Normal GFR/ min is 125 ml of blood
Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption)
Tubular secretion – 1 ml is excreted in urine

Regulation of BP:

Predisposing factor:
Ex CS – hypovolemia – decrease BP going to kidneys
Activation of RAAS

Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus

Angiotensin I mild vasoconstrictor

Angiotensin II vasoconstrictor


Adrenal cortex increase CO increase PR

Aldosterone
Increase BP
Increase Na &
H2O reabsorption

Hypervolemia

Ureters – 25 – 35 cm long, passageway of urine to bladder
Bladder – loc behind symphisis pubis. Muscular & elastic tissue that is distensible
- Function – reservoir or urine
1200 – 1800 ml – Normal adult can hold
200 – 500 ml – needed to initiate micturition reflex

Color – amber
Odor – aromatic
Consistency – clear or slightly turbid
pH – 4.5 – 8
Specific gravity – 1.015 – 1.030
WBC/ RBC – (-)
Albumin – (-)
E coli – (-)
Mucus thread – few
Amorphous urate (-)

Urethra – extends to external surface of body. Passage of urine, seminal & vaginal fluids.
- Women 3 – 5 cm or 1 to 1 ½ “
- Male – 20cm or 8”

UTI
CYSTITIS – inflammation of bladder
Predisposing factors:
1. Microbial invasion – E. coli
2. High risk – women
3. Obstruction
4. Urinary retention
5. Increase estrogen levels
6. Sexual intercourse
S/Sx:
1. Pain – flank area
2. Urinary frequency & urgency
3. Burning upon urination
4. Dysuria & hematuria
5. Fever, chills, anorexia, gen body malaise
Diagnosis:
1. Urine culture & sensitivity - (+) to E. coli
Nursing Mgt:
1. Force fluid – 2000 ml
2. Warm sitz bath – to promote comfort
3. Monitor & assess for gross hematuria
4. Acid ash diet – cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
5. Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides – cotrimaxazole (Bactrim)
- Gantrism (ganthanol)
Urinary antiseptics – Mitropurantoin (Macrodantin)
Urinary analgesic- Pyridum
6. Ht
a.) Importance of Hydration
b.) Void after sex
c.) Female – avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications:
Pyelonephritis



PYELONEPHRITIS – acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, interstitial abscess formation.
- Lead to Renal Failure

Predisposing factor:
1. Microbial invasion
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary frequency, urgency
d.) Nocturia, dsyuria, hematuria
e.) Burning on urination

Chronic Pyelonephritis
a.) Fatigue, wt loss
b.) Polyuuria, polydypsia
c.) HPN

Diagnosis:
1. Urine culture & sensitivity – (+) E. coli & streptococcus
2. Urinalysis
Increase WBC, CHON & pus cells
3. Cystoscopic exam – urinary obstruction

Nursing Mgt:
1. Provide CBR – acute phase
2. Force fluid
3. Acid ash diet
4. Meds:
a.) Urinary antiseptic – nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
b.) Urinary analgesic – Peridium
5. Complication- Renal Failure

NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract
- calcium , oxalate, uric acid

milk cabbage anchovies
cranberries organ meat
nuts tea nuts
chocolates sardines

Predisposing factors:
1. Diet – increase Ca & oxalate
2. Hereditary – gout
3. Obesity
4. Sedentary lifestyle
5. Hyperparathyroidism



S/Sx:
1. Renal colic
2. Cool moist skin (shock)
3. Burning upon urination
4. Hematuria
5. Anorexia, n/v
Diagnosis:
1. IVP – intravenous pyelography. Reveals location of stone
2. KUB – reveals location of stone
3. Cytoscopic exam- urinary obstruction
4. Stone analysis – composition & type of stone
5. Urinalysis – increase EBC, increase CHON
Nursing Mgt:
1.Force fluid
2.Strain urine using gauze pad
3.Warm sitz bath – for comfort
4.Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent IV line
d.) Diet – if + Ca stones – acid ash diet
If + oxalate stone – alkaline ash diet - (Ex milk/ milk products)
If + uric acid stones – decrease organ meat / anchovies sardines
6. Surgery
a.) Nephectomy – removal of affected kidney
Litholapoxy – removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones
b.) Extracorporeal shock wave lithotripsy
- Non - invasive
- Dissolve stones by shock wave
7. Complications: Renal Failure

BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to
a.) Hydro ureters – dilation of ureters
b.) Hydronephrosis – dilation of renal pelvis
c.) Kidney stones
d.) Renal failure

Predisposing factor:
1. High risk – 50 years old & above
60 – 70 – (3 to 4 x at risk)
2. Influence of male hormone
S/Sx:
1.Decrease force of urinary stream
2.Dysuria
3.Hematuria
4.Burning upon urination
5.Terminal bubbling
6.Backache
7.Sciatica
Diagnosis:
1. Digital rectal exam – enlarged prostate gland
2. KUB – urinary obstruction
3. Cystoscopic exam – obstruction
4. Urinalysis – increase WBC, CHON

Nursing Mgt:
1. Prostatic message – promotes evacuation of prostatic fluid
2. Limit fluid intake
3. Provide catheterization
4. Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter
b. Fenasteride (Proscar) - Atrophy of Prostate Gland
5. Surgery: Prostatectomy – TURP- Transurethral resection of Prostate- No incision
-Assist in cystoclysis or continuous bladder irrigation.
Nursing mgt:
c. Monitor symptoms of infection
d. Monitor symptoms gross/ flank bleeding. Normal bleeding within 24h.
3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention

ACUTE RENAL FAILURE – sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E balance due to a decrease in GFR. (N 125 ml/min)

Predisposing factor:
Pre renal cause- decrease blood flow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension decrease flow to kidneys
4. CHF
5. Hemorrhage
6. Dehydration

Intra-renal cause – involves renal pathology= kidney problem
1. Acute tubular necrosis-
2. Pyelonephritis
3. HPN
4. Acute GN

Post renal cause – involves mechanical obstruction
1. Stricture
2. Urolithiasis
3. BPH

CHRONIC RF – irreversible loss of kidney function
Predisposing factors:
1. DM
2. HPN
3. Recurrent UTI/ nephritis
4. Exposure to renal toxins

Stages of CRF
1. Diminished Reserve Volume – asymptomatic
Normal BUN & Crea, GFR < 10 – 30%
2. Renal Insufficiency
3. End Stage Renal disease

S/Sx:
1.) Urinary System
a.) polyuria
b.) nocturia
c.) hematuria
d.) Dysuria
e.) oliguria 2.) Metabolic disturbances
a.) azotemia (increase BUN & Crea)
b.) hyperglycemia
c.) hyperinulinemia
3.) CNS
a.) headache
b.) lethargy
c.) disorientation
d.) restlessness
e.) memory impairment 4.) GIT
a.) n/v
b.) stomatitis
c.) uremic breath
d.) diarrhea/ constipation
5.) Respiratory
a.) Kassmaul’s resp
b.) decrease cough reflex 6.) hematological
a.) Normocytic anemia
bleeding tendencies

7.) Fluid & Electrolytes
a.) hyperkalemia
b.) hypernatermia
c.) hypermagnesemia
d.) hyperposphatemia
e.) hypocalcemia
f.) met acidosis 8.) Integumentary
a.) itchiness/ pruritus
b.) uremic frost
Nursing Mgt:
1. Enforce CBR
2. Monitor VS, I&O
3. Meticulous skin care. Uremic frost – assist in bathing pt
4. Meds:
a.) Na HCO3 – due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN – hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca – Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
2.) Obtain baseline data & monitor VS, I&O, wt, blood exam
3.) Strict aseptic technique
4.) Monitor for signs of complications:
B – bleeding
E – embolism
D – disequilibrium syndrome
S – septicemia
S – shock – decrease in tissue perfusion
Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste prod leading to:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) Paresthesia

5. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
6. Maintain patency of shunt by:
i. Palpate for thrills & auscultate for bruits if (+) patent shunt!
ii. Bedside- bulldog clip
- If with accidental removal of fistula to prevent embolism.
- Infersole (diastole) – common dialisate used
7. Complication
- Peritonitis
- Shock

8. Assist in surgery:
Renal transplantation : Complication – rejection. Reverse isolation

EYES
External parts
1. Orbital cavity – made up of connective tissue protects eye form trauma.
2. EOM – extrinsic ocular muscles – involuntary muscles of eye needed for gazing movement.
3. Eyelashes/ eyebrows – esthetic purposes
4. Eyelids – palpebral fissure – opening upper & lower lid. Protects eye from direct sunlight

Meibomean gland – secrets a lubricating fluid inside eyelid
b.) Stye/ sty or Hordeolum- inflamed Meibomean gland
5. Conjunctiva
6. Lacrimal apparatus – tears

Process of grieving
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
2. Intrinsic coat
I. sclerotic coat – outer most
a.) Sclera – white. Occupies ¾ post of eye. Refracts light rays
b.) Canal of schlera – site of aqueous humor drainage
c.) Cornea – transparent structure of eye

II/ Uveal tract – nutritive care
Uveitis – infl of uveal tract
Consist of:
a.) Iris – colored muscular ring of eye
2 muscles of iris:
1. Circular smooth muscle fiber - Constricts the pupil
2.radial smooth muscle fiber - Dilates the pupil

2 chambers of the eye
1. Anterior
a.) Vitereous Humor – maintains spherical shape of the eye
b.) Aqueous Humor – maintains intrinsic ocular pressure
Normal IOP= 12-21 mmHg

II. Retina (innermost layer)
i. Optic discs or blind spot – nerve fibers only

No auto receptors

cones (daylight/ colored vision) rods – night twilight vision

phototopic vision “scotopic vision” = vit A deficiency – rods insufficient

ii. Maculla lutea – yellow spot center of retina
iii. Fovea centralis – area with highest visual acuity oracute vision

Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays – bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes

Unit of measurements of refraction – diopters
Normal eye refraction – emmetropia

ERROR of refraction
1. Myopia – near sightedness – Treatment: biconcave lens
2. Hyperopia/ or farsightedness – Treatment: biconvex lens
3. Astigmatisim – distorted vision – Treatment: cylindrical
4. Prebyopia – “old slight” – inelasticity of lens due to aging – Treatment: bifocal lens or double vista
Accommodation of lenses – based on thelmholtz theory of accommodation

Near vision = far vision=
Ciliary muscle contracts= ciliary muscle dilates / relaxes=
Lens bulges lens is flat

Convergence of the eye:
Error:
1. Exotropia – 1 eye normal
2. Esophoria – corrected by corrective eye surgery
3. Strabismus- squint eye
4. Amblyopia – prolong squinting



GLAUCOMA – increase IOP – if untreated, atrophy of optic nerve disc – blindness
Predisposing factors:
1. High risk group – 40 & above
2. HPN
3. DM
4. Hereditary
5. Obesity
6. Recent eye trauma, infl, surgery

Type:
1. Chronic – (open angle G.) – most common type
Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema
2. Acute (close angle G.) – Most dangerous type
Forward displacement of iris to cornea leading to blindness.
3. Chronic (closed – angle) - Precipitated by acute attack

S/Sx:
1. Loss of peripheral vision – tunnel vision
2. Halos around lights
3. Headache
4. n/v
5. Steamy cornea
6. Eye discomfort
7. If untreated – gradual loss of central vision – blindness

Diagnosis:
1. Tonometry – increase IOP >12- 21 mmHg
2. Perimetry – decrease peripheral vision
3. Gonioscopy – abstruction in anterior chamber

Nursing mgt:
1. Enforce CBR
2. Maintain siderails
3. Administer meds
a.) Miotics – lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)
b.) Epinephrine eye drops – decrease secretion of aqueous humor
c.) Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
4. Surgery:
Invasive:
a.) Trabeculectomy – eyetrephining – removal of trabelar meshwork of canal or schlera to drain aqueous humor
b.) Peripheral Iridectomy – portion of iris is excised to drain aqueous humor

Non-invasive:
Trabeculoctomy (eye laser surgery)

Nursing Mgt pre op- all types surgery
1. Apply eye patch on unaffected eye to force weaker eye to become stronger.

Nursing Mgt post op – all types of surgery
1. Position unaffected/ unoperated side - to prevent tension on suture line.
2. Avoid valsalva maneuver
3. Monitor symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
4. Eye patch – both eyes - post op


CATARACT – partial/ complete opacity of lens
Predisposing factor:
1. 90-95% - aging (degenerative/ senile cataract)
2. Congenital
3. Prolonged exposure to UV rays
4. DM-

S/Sx:
1. Loss of central vision - “Hazy or blurring of vision”
2. Painless
3. Milky white appearance at center of pupil
4. Decrease perception of colors

Diagnosis: Opthalmoscopic exam – (+) opacity of lens
Nsg Mgt:
1. Reorient pt to environment – due opacity
2. Siderails
3. Meds – a.) Mydriatics – dilate pupil – not lifetime
Ex. Mydriacyl
c.) Cyslopegics – paralyzes ciliary muscle. Ex. Cyclogye
4. Surgery





E – extra
C - capsular
C – cataract partial removal of lens
L - lens
E – extraction

I - intra
C - capsular
C – cataract total removal of lens &
L – lens surrounding capsules
E – extraction

Nursing Mgt:

1.Position unaffected/ unoperated side - to prevent tension on suture line.
2.Avoid valsalva maneuver

3.Monitor symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
4.Eye patch – both eyes - post op


RETINAL DETACHMENT- separation of 2 layers of retina

Predisposing factors:
1. Severe myopia – nearsightedness
2. Diabetic Retinopathy
3. Trauma
4. Following lens extraction
5. HPN

S/Sx:
1. “Curtain –veil” like vision
2. Flashes of lights
3. Floaters
4. Gradual decrease in central vision
5. Headache

Diagnosis- opthaloscopic exam
Nursing Mgt:
1. Siderails (all visual disease)
2. Surgery:
a.) Cryosurgery
b.) Scleral buckling

EAR –
1. Hearing
2. Balance (Kinesthesia or position sense)

Parts:
1. Outer-
a.) Pinna/ auricle – protects ear from direct trauma
b.) Ext. auditory meatus – has ceruminous gland. Cerumen
c.) Tympanic membrane – transmits sound waves to middle ear

Disorders of outer ear
Entry of insects – put flashlight to give route of exit
Foreign objects – beans (bring to MD)
H2O - drain
2. Middle ear

a.) Ear osssicle

1. Hammer -malleus
2. Anvil -Incus for bone conduction disorder conductive hearing loss
3. Stirrups -stapes



b. Eustachian tube - Opens to allow equalization of pressure on both ears
- Yawn, chew, and swallow
Children – straight, wide, short
c.) Otitis media
Adult – long, narrow & slanted

c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth – for balance, vestibule

Utricle & succule

Otolithe or ear stone – has Ca carbonate

Movement of head = Righting reflex = Kinesthesia
b. Membranous Labyrinth
1. Cochlea – ( function for hearing) has organ of corti
2. Endolymph & perilymph – for static equilibrium
3. Mastoid air cells – air filled spaces in temporal bone in skull

Complications of Mastoditis – meningitis

Types of hearing loss:
1. Conductive hearing loss – transmission hearing loss
Causes:
a.) Impacted cerumen – tinnitus & conduction hearing loss- assist in ear irrigaton
b.) Immobility of stapes – OTOSCLEROSIS
d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes
e.) Stapes can’t transmit sound waves

Surgery
Stapedectomy – removal of stapes, spongy bone & implantation of graft/ ear prosthesis

Predisposing factor:
1. Familiar tendency
2. Ear trauma & surgery

S/Sx:
1. Tinnitus
2. Conductive hearing loss

Diagnosis:
1. Audiometry – various sound stimulates (+) conductive hearing loss
2. Weber’s test – Normal AC> BC
result BC > AC

Stapedectomy
Nursing Mgt post op
1. Position pt unaffected side
2. DBE
No coughing & blowing of nose
- Night lead to removal of graft
3. Meds:
a.) Analgesic
b.) Antiemetic
c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)
4. Assess – motor function – facial nerve - (Smile, frown, raise eyebrow)
5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap

SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS
Cause:
1. Tumor on cocheal
2. Loud noises (gun shot)
3. Presbycusis – bilateral progressive hearing loss especially at high frequencies – elderly
Face elderly to promote lip reading
4. Meniere’s disease – endolymphatic hydrops
f.) Inner ear disease char by dilation of endo – lympathic system leading to increase volume of endolin


Predisposing factor of MENIERE’S DISEASE
Smoking
Hyperlipidemia
30 years old
Obesity – (+) chosesteatoma
Allergy
Ear trauma & infection

S/Sx:
1. TRIAD symptoms of Meniere’s disease
a.) Tinnitus
b.) Vertigo
c.) Sensory neural hearing loss
2. Nystagmus
3. n/v
4. Mild apprehension, anxiety
5. Tachycardia
6. Palpitations
7. Diaphoresis

Diagnosis:
1. Audiometry – (+) sensory hearing loss

Nursing mgt:
1. Comfy & darkened environment
2. Siderails
3. Emetic basin
4. Meds:
a.) Diuretics –to remove endolymph
b.) Vasodilator
c.) Antihistamine
d.) Antiemetic
e.) Antimotion sickness agent
f.) Sedatives/ tranquilizers

5. Restrict Na
6. Limit fluid intake
7. Avoid smoking
8. Surgery – endolymphatic sac decompression- Shunt