¦ Thyroid gland secretions (T3 and T4) are metabolic hormones
ú Thyroid hormones cause increased metabolism: CNS stimulation, increased vital signs, and increased GI motility (diarrhea)
HYPOTHYROIDISM | HYPERTHYROIDISM |
All body systems are DECREASED
except WEIGHT and MENSTRUATION! | All body systems are INCREASED
except WEIGHT and MENSTRUATION! |
ê decreased CNS: drowsiness, memory problems (forgetfulness) | é increased CNS: tremors, insomnia |
ê decreased v/s: hypotension, bradycardia, bradypnea, low body temp | é increased v/s: hypertension, tachycardia, tachypnea, fever |
ê decreased GI motility: constipation | é increased GI motility: diarrhea |
ê decreased appetite (anorexia) but with WEIGHT GAIN
[low metabolism causes decreased burning of fats and carbs] ú This leads to increased serum cholesterol à atherosclerosis (hardening of arteries due to cholesterol deposits) ú Because of increased cholesterol, hypothyroid patients are prone to hypertension, myocardial infarction, CHF and stroke | é increased appetite (hyperphagia) but with WEIGHT LOSS [high metabolism causes increased burning of fats and carbs] |
ê decreased metabolism causes decreased perspiration à
DRY SKIN and COLD INTOLERANCE | é increased metabolism causes increased perspiration à
MOIST SKIN and HEAT INTOLERANCE |
é Menorrhagia (excessive bleeding during menstruation) | ê Amenorrhea (absence of menstruation) |
| Pathognomic sign: EXOPHTHALMOS (bulging eyeballs) |
¦ Nursing Management for hypothyroidism: ú Low calorie diet ú Warm environment | ¦ Nursing Management for hyperthyroidism: ú High calorie diet ú Cool environment |
NERVOUS SYSTEM
¦ CNS: brain and spinal cord
¦ PNS: 12 cranial nerves + 31 spinal nerves
ú 8 cervical nerves (C1 to C8)
ú 12 thoracic nerves (T1 to T12)
ú 5 lumbar nerves (L1 to L5)
ú 5 sacral nerves (S1 to S5)
ú 1 coccygeal nerve (Co)
¦ The spinal cord terminates at L1 to L2, therefore a LUMBAR TAP is performed at L3 ,L4 or L5
(no risk of paralysis from spinal cord damage)
AUTONOMIC NERVOUS SYSTEM
Sympathetic Nervous System (SNS) | Parasympathetic Nervous System (PNS) |
¦ “Fight” or aggression response | ¦ “Flight” or withdrawal response |
¦ Also termed adrenergic or parasympatholytic response | ¦ Also termed cholinergic or sympatholytic response |
¦ The neurotransmitter for the SNS is norepinephrine | ¦ The neurotransmitter for the PNS is acetylcholine (Ach) |
All body activities are INCREASED except GIT! | All body activities are DECREASED except GIT! |
é increased blood flow to brain, heart and skeletal muscles: These are the most important organs during times of stress | ê normalized blood flow to vital organs |
é increased BP, increased heart rate:
To maintain perfusion to vital organs | ê decreased BP, decreased heart rate |
é bronchodilation and increased RR:
To increase oxygen intake | ê bronchoconstriction, decreased RR |
é urinary retention à FLUID VOLUME EXCESS Fluids are withheld by the body to maintain circulating volume | ê urinary frequency à FLUID VOLUME DEFICIT |
é pupillary dilation: MYDRIASIS:
To increase environmental awareness during aggression | ê pupillary constriction: MIOSIS
[this is the correct spelling, not meiosis J] |
ê decreased GIT activity: CONSTIPATION and DRY MOUTH:
Blood flow is decreased in the GIT because it is the least important area in times of stress | é Increased GIT: DIARRHEA and INCREASED SALIVATION
· |
DRUGS WITH SNS effects: | DRUGS WITH PNS effects: |
¦ Adrenergic/Parasympatholytic agents: ú Epinephrine [Adrenalin] ¦ Antipsychotics: ú Haloperidol [Haldol], Chlorpromazine [Thorazine], etc. § Side effect of Thorazine: Atopic Dermatitis (eczema) and foul-smelling odor [recall: patients in NCMH are smelly] § Side effect of all antipsychotics: Sx of PARKINSON’S DISEASE, therefore antipsychotics are given together with antiparkinson drugs ¦ Anti-parkinsonians: ú Cogentin, Artane, etc. ¦ Pre-operative drug: ú Atropine Sulfate (AtSO4) – given before surgery to decrease salivary and mucus secretions · | ¦ Anti-hypertensives: ú Methyldopa – for pregnancy induced hpn (PIH) ú b-blockers (-olol): § Propranolol [Inderal], atenolol, metoprolol ú ACE inhibitors (-pril): § Enalapril, Ramipril, Lisinopril, Benazepril, Captopril § Side effect of ACE inhibitors: AGRANULOCYTOSIS and NEUTROPENIA (blood dyscracias… always asked in board!) ú Calcium channel blockers (Calcium antagonists) § Nifedipine [Procardia], Verapamil [Isoptim],
Dialtiazem [Cardizem] ú NURSING ALERT: Anti-hypertensives are not given to patients with CHF or cardiogenic shock (Drug will cause a further decrease in heart rate à Death) ¦ Rx for Myasthenia Gravis: ú Pyridostigmine [Mestinon] ú Neostigmine [Prostigmin] |
NEURONS
3 characteristics of neurons:
1. Excitability – Neurons are affected by changes in the environment
2. Conductivity – Neurons transmit wave of excitations
3. Permanent cells – Once neurons are destroyed, they are not capable of regeneration.
2 3 types of cells according to regenerative capacity: |
Labile capable of regeneration | epidermis (skin), gastrointestinal tract (GIT), genito-urinary tract (GUT), respiratory tract (stab wounds to the lungs are survivable) |
Stable once destroyed, capable of regeneration but with limited survival time period | kidneys, liver, pancreas, salivary glands
|
Permanent once destroyed, not capable of regeneration | heart, neurons, osteocytes, retinal cells |
NEUROGLIA
¦ Function: support and protection of neurons
¦ Clinical significance: Majority of brain tumors arise from neuroglia
¦ Types:
ú Astrocytes
ú Microglia
ú Oligodendrocytes
ú Ependymal cells
¦ Note: Astrocytoma is the #1 type of brain tumor
ASTROCYTES – maintain the integrity of the BLOOD-BRAIN BARRIER
2 Toxic substances that can cross the BLOOD-BRAIN BARRIER: 1. Ammonia 2. Bilirubin 3. Carbon monoxide and Lead 4. Ketones |
| AMMONIA |
| ¦ Ammonia is a by-product of protein metabolism ¦ Ammonia is a toxic substance metabolized by the liver into a non-toxic substance (urea), which is then excreted by the kidneys ¦ Increase in serum ammonia can cause HEPATIC ENCEPHALOPATHY (Liver cirrhosis) ¦ Normal liver is scarlet brown; liver with cirrhosis is covered by fat deposits (“fatty liver”) ¦ The primary cause of hepatic encephalopathy is MALNUTRITION ¦ The major cause of hepatic encephalopathy is ALCOHOLISM ú Alcoholism causes Thiamine (B1) deficiency (Alcoholic beriberi) ¦ Ammonia is a cerebral toxin.
¦ Early sign of Hepatic Encephalopathy: ú ASTERIXIS – flapping hand tremors. This is the EARLIEST SIGN OF HEPATIC ENCEPHALOPATHY.
¦ Late Signs of Hepatic Encephalopathy: ú Headache ú Restlessness ú Fetor hepaticus (ammonia-like breath) ú Decreased level of consciousness à HEPATIC COMA § Note: The primary Nursing Intervention in hepatic coma is AIRWAY [Assist in mechanical ventilation] |
| BILIRUBIN |
| ¦ Review: ú Bilirubin – yellow pigment ú Biliverdin – green pigment ú Hemosiderin – golden brown pigment ú Hemoglobin – red pigment ú Melanin – black pigment ¦ Icteric skin and sclerae is termed Jaundice = a sign of HEPATITIS ú Note: Icteric skin with normal sclerae is termed Carotinemia = a sign of PITUITARY GLAND TUMOR, not hepatitis ¦ Kernicterus (Hyperbilirubinemia) can lead to irreversible brain damage |
| CARBON MONOXIDE (CO) AND LEAD (Pb) |
| ¦ CO and Pb can cause PARKINSON’S DISEASE and SEIZURE ú Note: The initial sign of Parkinson’s disease: PILL-ROLLING TREMORS ¦ The antidote for Pb poisoning is Calcium EDTA ¦ The antidote for CO poisoning is Hyperbaric oxygenation (100% oxygen) |
| KETONES |
| ¦ Ketones are by-products of fat metabolism ¦ Ketones are CNS depressants ¦ Increased ketones can lead to diabetic ketoacidosis (DKA) seen in Type I diabetes mellitus (DM). ¦ DKA is due to increased fat metabolism: |
DIABETES MELLITUS
Type I DM | Type II DM |
¦ Insulin-dependent | ¦ Non Insulin-dependent |
¦ Juvenile onset type (common among children) | ¦ Adult/Maturity onset type (common among 40 y.o. & above) |
¦ Non-obese | ¦ Obese |
¦ “Brittle disease” | ¦ “Non-brittle disease” |
¦ Etiology: Hereditary | ¦ Etiology: Obesity |
¦ Symptomatic | ¦ Asymptomatic |
¦ Characterized by Weight Loss | ¦ Characterized by Weight Gain |
¦ Treatment: Insulin | ¦ Treatment: Oral Hypoglycemic Agents (OHA) |
¦ Complications: Diabetic Ketoacidosis (DKA) ú Sodium Bicarbonate (NaHCO3) administered to treat acidosis | ¦ Complications: Hyper-Osmolar Non-Ketotic Coma (HONCK) ú Non-ketotic, so no lipolysis |
ú Can lead to coma | ú Can also lead to coma |
| ú Can lead to seizure |
MICROGLIA
¦ Microglia are stationary cells that carry on phagocytosis
¦ Review:
ú Brain macrophage = Microglia
ú Blood macrophage = Monocyte
ú Kidney/Liver macrophage = Kupffer cell
ú Lung macrophage = Alveolar macrophage
ú Epithelial macrophage = Histiocytes
EPENDYMAL CELLS
¦ Ependymal cells secrete chemoattractants (glue) that concentrate bacteria
OLIGODENDROCYTES
¦ Produce myelin sheath
¦ Function: For insulation and to facilitate nerve impulse transmission
¦ The demyelinating disorders are MULTIPLE SCLEROSIS and ALZHEIMER’S DISEASE
ALZHEIMER’S DISEASE
¦ A type of dementia (degenerative disorder characterized by atrophy of the brain tissue)
¦ Caused by Acetylcholine (Ach) deficiency
¦ Irreversible
¦ Predisposing factors:
ú Aging
ú Aluminum toxicity
ú Hereditary
¦ SSx of Alzheimer’s (5 A’s):
ú Amnesia – partial or total loss of memory
§ The type of amnesia in Alzheimer’s is ANTEROGRADE AMNESIA.
§ 2 types of Amnesia:
ü Anterograde amnesia – loss of short-term memory
ü Retrograde amnesia – loss of long-term memory
ú Agnosia – inability to recognize familiar objects
ú Apraxia – inability to perform learned purposeful movements (using objects [toothbrush] for the wrong purpose)
ú Anomia – inability to name objects
ú Aphasia – inability to produce or comprehend language
§ The type of aphasia in Alzheimer’s is RECEPTIVE APHASIA.
§ 2 types of Aphasia:
ü Expressive aphasia (Broca’s aphasia)
þ inability to speak
þ positive nodding
þ nursing management is the use of a PICTURE BOARD
þ damage to Broca’s area (in frontal lobe), which is the motor speech center
ü Receptive aphasia (Wernicke’s aphasia)
þ inability to understand spoken words
þ positive illogical/irrational thoughts
þ can hear words but cannot put them into logical though
þ damage to Wernicke’s area (in temporal lobe), which is the language comprehension center
¦ The drugs of choice for Alzheimer’s are Donepezil [Aricept] or Tacrine [Cognex]
ú The drugs work by inhibiting cholinesterase (an enzyme that breaks down acetylcholine),
thereby increasing the levels of acetylcholine in the brain
ú Best given at bedtime
MULTIPLE SCLEROSIS (MS)
¦ Chronic intermittent disorder of the CNS characterized by white patches of demyelination in the brain and spinal cord
¦ Characterized by remission and exacerbation
¦ Common among women 15 to 35 y.o.
¦ Predisposing factors:
ú Idiopathic (unknown)
ú Slow-growing viruses
ú Autoimmune
ú Note: other autoimmune diseases: Systemic Lupus Erythematosus (SLE), hypo & hyperthyroidism, pernicious anemia, myasthenia gravis
¦ There is no treatment for autoimmune diseases, only palliative or supportive care (just treat S & Sx)
2 Review: ANTIBODIES IgG – can cross placenta; provides passive immunity IgA – found in body secretions (sweat, tears, saliva and colostrum) IgM – acute inflammations; the largest antibody IgE – allergic reactions IgD – chronic inflammations |
S & Sx of Multiple Sclerosis
¦ Visual disturbances
ú BLURRED VISION is the INITIAL SIGN of MULTIPLE SCLEROSIS
ú Diplopia (double vision)
ú Scotoma (blind spot in the visual field)
¦ Impaired sensation to touch, pain, pressure, heat and cold
ú Tingling sensations
ú Paresthesia (numbness)
§ Do not give hot packs to patients with MS. Because of decreased heat sensitivity, heat application can cause burns.
¦ Mood Swings
ú Patients with MS are in a state of euphoria
S & Sx of Multiple Sclerosis (continued)
¦ Impaired motor activity
ú Weakness à spasticity à paralysis
¦ Impaired cerebellar function
ú ATAXIA (unsteady gait)
¦ Scanning speech
¦ Urinary retention and incontinence
¦ Constipation
¦ Decrease in sexual capacity
2 CHARCOT’S TRIAD Sx of MULTIPLE SCLEROSIS ¦ Ataxia ¦ Nystagmus ¦ Intentional Tremors |
Diagnostic Procedures for Multiple Sclerosis
¦ Cerebral analysis through lumbar puncture reveals increased IgG and protein
¦ MRI reveals site and extent of demyelination
¦ LHERMITTE’s SIGN
ú continuous contraction and pain in spinal cord following laminotomy
ú confirms diagnosis of MS
Nursing Management for Multiple Sclerosis
¦ Rx:
ú ACTH (steroids) – to reduce swelling and edema à prevents paralysis resulting from spinal cord compression
§ Steroids are best administered AM to mimic the normal diurnal rhythm of the body
§ Give 2/3 of dose in AM, 1/3 of dose in PM
§ ACTH is also administered in Motor Vehicular Accidents leading to spinal injury à prevents inflammation that can lead to paralysis
ú Muscle relaxants: Baclofen [Liorisal] and Dantrolene Sodium [Dantrium]
§ Can be used to treat hiccups, which is caused by irritation of the phrenic nerve.
ú Interferons – to alter immune response
ú Immunosuppresants
ú Diuretics – to treat urinary retention
ú Bethanecol Chloride [Urecholine] – cholinergic drug used to treat urinary retention; given subQ
§ Side effects of Bethanecol: Bronchospasm and Wheezing, so always check breath sounds 1 hour after administration.
§ Normal breath sounds are bronchovesicular.
ú Propantheline Bromide [Pro-Banthine] – antispasmodic drug to treat urinary incontinence
¦ Provide relaxation techniques
ú Deep breathing, yoga, biofeedback
¦ Maintain siderails – to prevent injury secondary to falls
¦ Prevent complications of immobility
ú Turn to side q 2 h, q 1 h for elderly patients, q 30 minutes on the affected extremity
¦ Provide catheterization
¦ Avoid heat application
¦ To treat constipation: Provide high fiber diet
¦ To treat UTI: Provide ACID-ASH DIET (acidifies urine to prevent bacterial infection)
ú Acid-ash diet consists of Grape, Cranberry, Plums, Prune Juice, Pineapple
ú Women are more prone to UTI
§ Females have shorter urethra (3 to 5 cm or 1 to 1½ inches) than males (20 cm or 6 to 8 inches)
§ Poor perineal hygiene (wiping from front to back)
§ Vaginal environment is moist (more conducive to bacteria)
§ Nursing Intervention: Avoid scented tissue paper, bubble baths, and using perfume or talcum powder in the perineum, as these can irritate the vagina
ú Male UTI is often related to post-coitus
§ Male must urinate after coitus to prevent urine stagnation
BRAIN
Composition:
¦ 80% Brain mass
¦ 10% Blood
¦ 10% Cerebrospinal Fluid (CSF)
Cerebrum
¦ Largest part of the brain
¦ Composed of 2 hemispheres (Left and Right) joined by the copus callosum
¦ Functions: sensory, motor and integrative
¦ Cerebral Lobes
ú Frontal
§ controls higher cortical thinking
§ Personality development
§ Motor functions
§ Inhibits primitive reflexes
§ Broca’s area, the motor speech center, is located in the frontal lobe
ú Temporal
§ controls hearing
§ Short-term memory
§ Wernicke’s area, the general interpretative area, is located in the temporal lobe
ú Parietal
§ Appreciation and discrimination of sensory impulses (touch, pain, pressure, heat, cold)
ú Occipital
§ Controls vision
ú Central (Insula or “Island of Reil”)
§ Controls visceral functions
ú Limbic system (rhinencephalon)
§ Controls smell
§ Anosmia is the absence of the sense of smell
§ Controls libido
§ Long-Term memory
ú Basal Ganglia
§ areas of gray matter located deep within each cerebral hemisphere
§ produce DOPAMINE, which controls gross voluntary movement
Remember: ü Dopamine deficit = PARKINSON’S DISEASE (Rx antiparkinsonian drugs to increase dopamine) ü Dopamine excess = SCHIZOPHRENIA (Rx antipsychotic drugs to decrease dopamine) ü Acetylcholine deficit = MYASTHENIA GRAVIS (Rx Mestinon to increase Ach) ü Acetylcholine excess = BIPOLAR DISORDER (Rx Lithium to decrease Ach)
Notice that… ü Neurotransmitter deficit = MedSurg illnesses ü Neurotransmitter excess = Psych illnesses |
Diencephalon – interbrain or “between brain”
¦ Hypothalamus
ú Temperature regulation
ú Controls BP
ú Reticular activating system: controls sleep and wakefulness
ú Controls thirst
ú Satiety center: controls appetite
ú Emotional responses: fear (from known cause) , anxiety (from unknown cause) and excitement
ú Controls pituitary functions
§ Pituitary gland relies on stimulation from hypothalamus
¦ Thalamus
ú Relay station for sensation
Mesencephalon (midbrain)
¦ Relay station for sight and hearing:
ú Controls size and response of pupil
§ Normal pupil size is 2 to 3 mm
§ Isocoria is equal pupil size
§ Anisocoria is unequal pupil size
§ Normal pupil response if PERRLA [Pupils equal, round, reactive to light and accomodation]
§ Accomodation is pupillary constriction for near vision, and pupillary dilation for far vision.
ú Controls hearing acuity
Brainstem
¦ Pons – pneumotaxic center ( controls depth and rhythm of respiration)
¦ Medulla Oblongata – lowest part of the brain
ú Damage to medulla is the most life-threatening
ú Controls respiration, heart rate, vomiting, swallowing, hiccups
ú Vasomotor center (controls vessel constriction and dilation)
ú The medulla oblongata is the termination point of spinal decussation
Cerebellum
¦ Smallest part of the brain; cerebellum is also known as the “lesser brain”
¦ For balance, posture, equilibrium and gait
¦ Cerebellar tests:
ú Romberg’s test
§ two nurses positioned to the left and right of the patient
§ patient assumes normal position, with both eyes closed
§ tests for ATAXIA (unsteady gait)
ú Finger-to-nose test
§ Tests for DYMETRIA (inability of the body to stop a movement at a desired point)
ú Alternate pronation and supination
§ Also tests for dymetria
MONRO-KELLIE HYPOTHESIS
¦ The Monro-Kellie hypothesis states the relationship between ICP and cranial components (blood, CSF and brain tissue):
ú The skull is a closed container, therefore any alteration in one of the intrathecal components can lead to increased intracranial pressure
ú The normal ICP is 0 to 15 mmHg.
Cerebrospinal Fluid (CSF)
¦ 125 to 150 mL produced per day by the choroid plexus
¦ CSF is clear, colorless, odorless
¦ contains glucose, protein and WBCs
¦ does not contain RBCs
¦ Function: cushions the brain (shock absorption)
¦ Hydrocephalus – obstruction of the flow of CSF leading to enlargement of the skull posteriorly
ú Enlargement due to early closure of posterior fontanel
Blood
CEREBROVASCULAR ACCIDENT (STROKE)
¦ Partial or complete obstruction in the brain’s blood supply.
¦ Common sites of thrombotic stroke:
ú Middle cerebral artery
ú Internal carotid artery
¦ The leading cause of CVA is THROMBUS formation (attached clot)
ú A dislodged thrombus becomes an EMBOLUS (free-floating clot) à very dangerous if it goes to the BRAIN, HEART or LUNGS
¦ CVA causes increased ICP.
INCREASED INTRACRANIAL PRESSURE (ICP)
¦ Increased intracranial bulk brought about by an increase in one of the intracranial components
¦ Predisposing factors:
ú Head injury
ú Tumor
ú Localized abscess (pus)
ú Hydrocephalus
ú Meningitis
ú Cerebral edema
ú Hemorrhage (stroke)
¦ Note: For all causes of increased ICP, the patient should be positioned 30º to 45º (Semi-Fowler’s)
¦ Early Signs of Increased ICP
ú Change or decreased level of consciousness (restlessness to confusion)
ú Irritability and agitation
ú Disorientation to lethargy to stupor to coma
ú Remember: The 4 levels of consciousness: Conscious à Lethargy à Stupor à Coma
¦ Late Signs of Increased ICP
ú Changes in v/s
§ é Increased BP:
ü WIDENING PULSE PRESSURE – increased systolic pressure while diastolic pressure remains the same
ü Note: narrowing pulse pressure is seen in SHOCK (inadequate tissue perfusion).
§ ê Decreased Heart rate (bradycardia)
§ ê Decreased Respiratory rate (bradypnea)
ü Cheyne-Stokes respiration – hyperpnea followed by periods of apnea
§ Increased Temp
ü Note: Temp as a vital sign usually parallels BP
Vital signs | Increased ICP | Shock |
BP | é increased | ê decreased |
Heart Rate | ê decreased | é increased |
Resp Rate | ê decreased | é increased |
Temp | é high | ê low |
Pulse Pressure | é widening | ê narrowing |
§ Notes:
ü Increased heart rate in shock compensates for blood loss
ü Decreased temp in shock is due to decreased blood causing a decrease in warmth.
ü Hypertension, Bradycardia and irregular RR = CUSHING’S TRIAD of increased ICP
ü Increased BP as a response to increased ICP is termed as CUSHING REFLEX
þ Increased BP is an attempt by the body to maintain cerebral perfusion during increased ICP
ú Headache, papilledema, PROJECTILE VOMITTING
§ Papilledema is edema of the optic disc in the retina, leading to irreversible blindness
§ Projectile vomiting due to compression of the medulla, which is the center for vomiting.
ú Abnormal Posturing:
§ Decorticate posture – abnormal flexion, due to damage to the corticospinal tract (spinal cord & cerebral cortex)
§ Decerebrate posture– abnormal extension, due to damage to upper brain
§ Note: Flaccid posture is lost muscle tone, not found in increased ICP (found in poliomyelitis).
ú Unilateral dilation of pupils
§ Uncal herniation – herniation of uncus (in temporal lobe) puts pressure on Cranial Nerve III which controls parasympathetic input to the eye, causing unequal pupillary dilation (ANISOCORIA)
ú Possible seizure
¦ Nursing Management for increased ICP
ú Maintain patent airway and adequate ventilation
§ To prevent hypoxia (inadequate O2 in tissues) and hypercarbia (increased CO2 in blood)
ü Note: Hypoxemia is inadequate O2 in the blood
Early Signs of Hypoxia | Late Signs of Hypoxia |
¦ Restlessness ¦ Agitation ¦ Tachycardia | ¦ Bradycardia ¦ Cyanosis ¦ Dyspnea ¦ Extreme Restlessness |
Hypercarbia – CO2 retention
Remember: increased CO2 is the most potent respiratory stimulant
High CO2 à stimulates medulla à increase RR (hyperventilation) à normalized O2 and CO2
(negative feedback mechanism to maintain homeostasis)
¦ Nursing Management for increased ICP (continued)
ú Assist in mechanical ventilation: Ambubag or Mechanical Ventilator
§ Note: Ambubag should only be pressed during inspiration
ú Hyperventilate or hyper-oxygenate client to 100% before and after suctioning
§ Note: Suctioning performed for only 10 to 15 seconds; apply suction only while removing the suction catheter
§ When suctioning an endotracheal tube, insert the suction cath all the way until resistance is felt, to ensure complete removal of secretions
ú Position Semi-Fowler’s
§ Elevate head of bed 30 to 45º with neck in neutral position unless contraindicated to promote venous drainage.
ú Limit fluid intake to 1.2 to 1.5 L per day
§ Note: Forced fluids is 2 to 3 L per day
ú Monitor v/s, I&O and neurocheck (neurovital signs)
ú Prevent complications of immobility (turn to side)
ú Prevent further increased ICP:
§ Provide comfortable, quiet environment
ü Stress increases ICP
§ Avoid use of restraints [Jacket, wrist or elbow restraints]
ü Anxiousness increases ICP
§ Maintain siderails
§ Avoid clustering of nursing activities together
§ Instruct client to avoid activities leading to Valsalva maneuver (bearing down)
ü Avoid straining of stool: administer laxatives/stool softeners: Bisacodyl [Dulcolax]
ü Avoid excessive coughing: administer antitussives (cough suppresant): Dextromethorphan [Robitussin]
þ Note: common side effect of antitussives is drowsiness, so avoid driving or operating heavy machinery
ü Avoid vomiting: administer anti-emetic: Phenergan [Plasil]
ü Avoid bending, stooping, lifting heavy objects
ú Administer meds:
§ Osmotic diuretics – Mannitol [Osmitrol]
ü Check BP before administering; mannitol can lead to low fluid volume à hypotension
ü Monitor strictly I & O and inform physician if output is less than 30 cc per hour
ü Mannitol is given as side-drip (piggy-back)
þ Regulate at FAST-DRIP to prevent crystallization [formation of precipitates in tubing] à clogged IV line
þ Note: KVO rate is 10 to 15 gtts per minute
ü Inform client that he will feel a flushing sensation as the drug is introduced.
§ Loop Diuretics – Furosemide [Lasix]
ü Nursing management for loop diuretics is the same as for Osmotic diuretics
ü Lasix is given IV Push (from ampule)
ü Best given AM to prevent sleep disturbances. Lasix given PM will prevent restful sleep due to frequent urination.
§ Corticosteroids: Dexamethasone [Decadron] to decrease cerebral edema
ü Side-effect of steroids: respiratory depression
§ Mild analgesics: Codein Sulfate
§ Anticonvulsants: Dilantin [Phenytoin]
2 SIDE EFFECTS OF LASIX Normal Values ú ê K: HYPOKALEMIA 3.5 to 5.5 mEq/L ú ê Ca HYPOCALCEMIA 8.5 to 11 mg/dL ú ê Na: HYPONATREMIA 135 to 145 mEq/L
ú é Glucose: HYPERGLYCEMIA 80 to 100 mg/dL ú é Uric Acid: HYPERURICEMIA 3 to 7 mg/dL |
| HYPOKALEMIA |
|
HYPOKALEMIA | HYPERKALEMIA |
¦ Potassium less than 3.5 mEq/L ¦ SSx of hypokalemia: ú Weakness, fatigue ú Decreased GI motility: constipation ú Positive U Wave on ECG à can lead to arrhythmias ú Metabolic alkalosis ú Bradycardia (HR 60 to 100 bpm) ¦ Rx for hypokalemia ú K supplements: Oral KCl, Kalium durule ¦ Foods rich in K: ú Fruits: Apple, Banana, Cantaloupe § Note: Green bananas have more K ú Vegetables: Asparagus, Broccoli, Carrots ú Also rich in K: orange, spinach, apricot | ¦ Potassium greater than 5.5 mEq/L ¦ SSx of hyperkalemia: ú Irritability, excitement ú Increased GI motility: diarrhea, abdominal cramps ú Peaked T wave à can also lead to arrhythmia ú Metabolic acidosis
|
|
| HYPOCALCEMIA |
| ¦ Tetany – involuntary muscle contraction ¦ SSx of hypocalcemia: ú Trousseau sign – carpal spasm when BP cuff is inflated 150 to 160 mmHg ú Chvostek sign – facial twitch when facial nerve is tapped at the angle of the jaw ¦ Complications of hypocalcemia: Arrhythmia and Seizure (Calcium deficiency is life-threatening!) ¦ Nursing management for hypocalcemia: ú Administer Ca Gluconate IV § Must be administered slowly to prevent cardiac arrest § Excess Ca Gluconate à Ca Gluconate toxicity à seizure § Antidote for Ca excess: Magnesium Sulfate ü Monitor for signs of MgSO4 toxicity (BURP): þ BP low þ Urine output low þ RR low þ PATELLAR REFLEX ABSENT – important! earliest sign of MgSO4 toxicity |
| HYPONATREMIA |
| ¦ Low sodium à Fluid Volume Deficit àHypotension ¦ The initial sign of dehydration is THIRST (adults) or TACHYCARDIA (infants) ¦ Nursing Management: Force fluids (2 to 3 L/day), administer isotonic IV |
| HYPERGLYCEMIA |
| ¦ SSx: 3P’s (Polyuria, Polydipsia, Polyphagia) ¦ Nursing Management: Monitor Fasting Blood Sugar (Normal FBS is 80 to 100 mg/dL) |
| HYPERURICEMIA |
| ¦ Uric acid is a by-product of purine metabolism ¦ Foods high in uric acid: ú Organ meats, sardines, anchovies, legumes, nuts ¦ Tophi – uric acid crystals ¦ Gout – uric acid deposit in joints leading to joint pain & swelling, particularly affecting the great toes. ¦ Nursing Management for Gout: ú Force fluids (2 to 3 L/day) ú Rx: Allopurinol [Zyloprim] – drug of choice for gout § Most common side effect: allergic reaction (maculopapular rash) ú Rx: Colchicine – drug of choice for acute gout ¦ KIDNEY STONES – tophi accumulation in kidneys ú The pain associated with kidney stones is termed RENAL COLIC ú Nursing Management for Kidney Stones: § Force fluids § Rx: Morphine Sulfate – narcotic analgesics are the drug of choice to relieve renal colic ü Side-effect of narcotic analgesics: Respiratory depression, so always check RR before administering ü Antidote for Morphine overdose: Naloxone [Narcan] þ SSx of Naloxone toxicity: tremors § Strain the urine using gauze |
¦ A pathognomonic sign is a definitive diagnostic sign of a disease.
PATHOGNOMONIC SIGNS |
Disease | Sign |
Tetany | Trousseau and Chvostek signs |
Tetanus | Risus sardonicus (abnormal sustained spasm of the facial muscles) |
Liver cirrhosis | Spider angioma, due to esophageal varices |
SLE | Butterfly rash |
Bulimia Nervosa | Chipmunk facies (parotid gland swelling) |
Leprosy | Leonine facies (thickened lion-like facial skin) |
Cushing syndrome | Moon face |
Measles | Koplik spots |
Diphtheria | Pseudomembrane on tonsils, pharynx and nasal cavity |
Down Syndrome | Protrusion of tongue, Simian crease on palm |
Kawasaki’s Disease | Strawberry tongue |
Pernicious anemia | Red beefy tongue |
Hyperthyroidism | Exophthalmos |
Asthma | Wheezing on expiration |
Emphysema | Barrel chest |
Pneumonia | Rusty sputum |
Addison’s disease | Bronze-like skin |
Appendicitis | Rebound tenderness |
Pancreatitis | Cullen’s sign (bluish discoloration of umbilicus) |
Chronic hemorrhagic pancreatitis | Gray-turner’s spot (ecchymosis in flank area) |
Cholera | Rice-watery stool |
Malaria | Chills |
Typhoid fever | Rose spots in abdomen |
Thrombophlebitis | Homan’s sign |
Meningitis | Kernig’s and Brudzinski’s sign |
Pyloric stenosis | Olive-shaped mass |
Hyperpituitarianism | Carotinemia |
Hepatitis | Jaundice |
Dengue | Petechiae |
Tetralogy of Fallot | Clubbing of fingers |
Cataract | Hazy vision (loss of central vision) |
Glaucoma | Tunnel vision (loss of peripheral vision) |
Retinal Detachment | Curtain veil-like vision (right or left side of vision is blocked) |
PTB | Low-grade afternoon fever |
Cholecystitis | Murphy’s sign (pain on deep inspiration when inflamed gallbladder is palpated) |
Angina Pectoris | Levine’s sign (hand clutching of chest) |
Patent Ductus Arteriosus | Machine-like murmur |
Myasthenia Gravis | Ptosis (drooping of eyelids) |
Parkinson’s Disease | Pill-Rolling Tremors |
Digoxin
¦ Indicated for Congestive Heart Failure
¦ Mechanism of digoxin: increases force of myocardial contractions, thereby increasing cardiac output
ú The normal cardiac output is 3 to 6 L/min.
¦ Nursing Management when administering Digoxin:
ú Check apical pulse rate: if below 60, withhold drug and notify the physician.
¦ SSx of Dig toxicity:
ú GI DISTURBANCES (Early Sign): Anorexia (loss of appetite is the most evident sign), nausea and vomiting, diarrhea
ú Visual disturbances: photophobia, XANTOPSIA (seeing yellow spots), diplopia
ú Confusion
¦ The antidote for dig toxicity is DIGIBIND
| Congestive Heart Failure (CHF) |
| ¦ CHF can be Left-sided or Right-sided ¦ Left-sided CHF can lead to Right-sided CHF, but Right cannot lead to Left ¦ Lasix is given to both types of CHF ¦ CHF is the inability of the heart to pump blood towards systemic circulation ¦ RIGHT-SIDED CHF – the #1 cause is TRICUSPID VALVE STENOSIS ¦ LEFT-SIDED CHF – the #1 cause is MITRAL VALVE STENOSIS
RIGHT SIDED CHF Tricuspid valve stenosis ¯ Fluid goes back to circulation ¯ VENOUS CONGESTION |
LEFT SIDED CHF Mitral valve stenosis
¯ Fluid goes back to the lungs ¯ PULMONARY EDEMA |
|
| Left-Sided Heart Failure (LSHF) |
| ¦ Can be caused by Rheumatic Heart Disease: ú Tonsillitis à strep bacteria migrate to mitral valve à RHEUMATIC HEART DISEASE à mitral stenosis à LSHF ¦ SSx of LSHF: ú Most of the symptoms of LSHF are RESPIRATORY: § Pulmonary edema and congestion § Dyspnea: ü Paroxysmal nocturnal dyspnea – difficulty of breathing at nighttime þ Nursing intervention: give patient 2 to 3 pillows ü Orthopnea – difficulty of breathing while lying down þ Nursing intervention: Position patient High-Fowlers or Orthopneic position § Productive cough, blood-tinged sputum § Frothy salivation – alveolar fluid in the mouth § Abnormal breath sounds: Rales (crackles) and bronchial wheezing ú Cardiovascular symptoms: § Pulsus alternans – weak pulse followed by strong bounding pulse ü Can lead to arrhythmia § Point of Maximal Impulse (PMI) is displaced laterally ü Fluid in the lungs pushes heart to one side ü Check apical pulse to determine the location of PMI ü Normal PMI is at the left midclavicular line between the 4th and 5th intercostals space (below the nipple). þ Note: if the PMI is displaced vertically (lower than normal) then the patient has cardiomegaly. § S3 extra heart sound (Ventricular gallop) ü Note: S4 sound occurs in myocardial infarction ú Anorexia and body malaise ú Cyanosis |
| Right-Sided Heart Failure (RSHF) |
| ¦ SSx of RSHF: ú Venous congestion – blood goes back to superior & inferior vena cava ú Jugular vein distention ú Pitting edema ú Ascites – fluid in the peritoneal cavity ú Weight gain ú Hepatosplenomegaly ú Jaundice ú Pruritus and urticaria ú Esophageal varices ú Generalized body malaise and anorexia |
Lithium
¦ Antimanic agent – indicated for Bipolar Disorder
¦ Mechanism: decreases acetylcholine (Ach), norepinephrine and serotonin
¦ SSx of Lithium toxicity:
ú Anorexia
ú Diarrhea and Dehydration, therefore force fluids
ú Hypothyroidism
ú Fine tremors
¦ Nursing management for lithium:
ú Force fluids
ú Increase Sodium intake to 4 to 10 g daily
Aminophylline
¦ Indicated for Chronic Obstructive Pulmonary Disease (COPD)
¦ Bronchodilators dilate the bronchial tree, thereby allowing more air to enter the lungs
¦ SSx of aminophylline toxicity:
ú Tachycardia
ú Palpitations
ú CNS excitability: irritability, agitation, restlessness and tremors
¦ Nursing management for aminophylline:
ú AVOID COFFEE – will aggravate CNS excitability
4 Types of COPD
Bronchitis | Asthma | Bronchiectasis | Emphysema |
“blue-bloater” – cyanosis with edema |
|
| “pink-puffer” – acyanotic with compensatory purse-lip breathing |
| Pathognomonic Sign: Wheezing on expiration | Hemoptysis – blood in cough | Pathognomonic Sign:
Barrel-chest |
| Reversible |
| Irreversible |
|
|
| Terminal stage |
|
|
| Can lead to pneumothorax (air in pleural space), |
|
|
| CO2 narcosis |
| Caused by allergic reaction |
| Caused by allergic reaction |
| Hereditary |
| Hereditary |
|
| Surgery: Pneumonectomy (removal of 1 lung) |
|
|
| Diagnosis: Bronchoscopy |
|
Can lead to Cor Pulmonale (enlarged right ventricle) |
|
| Can lead to Cor Pulmonale |
¦ For all types of COPD:
ú #1 cause is smoking
ú Expect doctor to prescribe bronchodilators
ú LOW-FLOW OXYGEN only so as not so suppress the respiratory drive
Dilantin
¦ Dilantin is an anticonvulsant – indicated for seizure disorders
¦ Seizure is the term for the first convulsive attack that an individual experiences
¦ Epilepsy is the term for the second or succeeding attacks
¦ Febrile seizures are normal for children below 5 y.o. (febrile seizures are outgrown)
¦ Nursing management when giving Dilantin:
ú Only mixed with plain NSS to prevent formation of crystals/precipitates
ú Given via “sandwich method” (give NSS à give dilantin à give NSS)
ú Instruct client to avoid taking alcohol (Dilantin + alcohol can lead to severe CNS depression)
¦ SSx of Dilantin toxicity:
ú GINGIVAL HYPERPLASIA (important!)
§ Remember to provide oral care to patient receiving Dilantin:
ü use soft bristle toothbrush
ü instruct client to massage gums
ú Hairy tongue
ú Ataxia – positive Romberg’s test
ú Nystagmus (abnormal movement of the eyes)
Acetaminophen [a.k.a Paracetamol]
¦ Acetaminophen is the treatment of choice for osteoarthritis
ú Pathognomonic sign of osteoarthritis: HEBERDEN’S NODES (knobs on finger joints)
ú Note: osteoarthritis is localized while rheumatoid arthritis is systemic.
¦ Sx of acetaminophen toxicity:
ú Hepatotoxicity – therefore monitor LIVER ENZYMES:
§ SGPT (serum glutamic pyruvate transaminase), also called ALT (alanine transaminase)
§ SGOT (serum glutamic oxaloacetic transaminase), also called AST (aspartate transaminase)
ú Nephrotoxicity – therefore monitor Blood Urea Nitrogen (BUN) and Creatinine
§ Normal BUN is 10 to 20 mg/dL
§ Normal Creatinine is 0.8 to 1.0 mg/dL
ü Creatinine is the most sensitive indicator of kidney function
ú Hypoglycemia
§ SSx of Hypoglycemia (Remember T-I-R-E-D):
ü Tremors, Tachycardia
ü Irritability
ü Restlessness
ü Extreme Fatigue
ü Diaphoresis, Depression
¦ The antidote for acetaminophen overdose is ACETYLCYSTEINE [Mucomyst]
ú Note: Acetylcysteine is a mucolytic used for respiratory conditions with excess and thick mucus production (emphysema, bronchitis, bronchiectasis)
ú Oral acetylcysteine comes in granule form and is orange-flavored (like powdered juice)
ú Acetylcysteine causes outpouring secretions.
§ N.Mgt. for administering acetylcysteine: prepare suction apparatus
Parkinson’s Disease
¦ A chronic progressive disorder of the CNS characterized by degeneration of DOPAMINE-producing cells in the substancia nigra of the midbrain and basal ganglia.
¦ Parkinson’s disease is irreversible
¦ Predisposing factors:
ú Lead and carbon monoxide poisoning
ú Arteriosclerosis – hardening of an artery
ú Hypoxia
ú Encephalitis
ú High doses of drugs:
§ Antihypertensives: Reserpine [Serpasil] and Methyldopa [Aldomet]
§ Anti-psychotic agents: Haloperidol [Haldol] and Phenothiazines
ü Recall: Anti-hypertensives have PNS effects, Anti-psychotics have SNS effects
§ Side effects of Reserpine: DEPRESSION and BREAST CANCER
§ Note: Reserpine is the only antihypertensive with a major side effect of depression à patient becomes SUICIDAL
§ Nursing management for suicidal patients: PROMOTE SAFETY (remove equipment that patient can use to harm himself)
2 Triad causes of suicide: 1. Loss of spouse 2. Loss of job 3. Aloneness |
§ Nursing management for suicidal patients: DIRECT APPROACH
ü Maintain patient on close supervision
§ Reserpine is also linked to the development of BREAST CANCER.
ONCOLOGIC NURSING ¦ The most frequent types of cancer in women (in order): 1. Breast 2. Cervical 3. Ovarian 4. Uterine ¦ The most frequent types of cancer in men (in order): 1. Bronchogenic (lung) 2. Hepatic (liver) 3. Prostate – for men 40 y.o. and above 4. Testicular – for men 30 y.o. and above § 3 L’s of testicular cancer: ü Large ü Lumped ü Loaded (heavy) |
Anyway, back to Parkinson’s…
¦ SSx of Parkinson’s disease:
ú Early sign: PILL-ROLLING TREMORS – pathognomonic sign of Parkinson’s
ú Second sign: BRADYKINESIA (slowness of movement)
§ “cogwheel” rigidity – intermittent jerking movement
§ Stooped posture
§ Shuffling Gait, Propulsive Gait
¦ SSx of Parkinson’s disease (continued):
ú Overfatigue
ú Mask-like facial expression
ú Decreased blinking of the eyes
ú Difficulty in arising from sitting position
ú Monotone speech
ú Mood: Lability (depressed) à prone to suicide, therefore PROMOTE SAFETY
ú Increased salivation (drooling)
§ Prepare suction app at bedside
ú Autonomic changes:
§ Increased sweating and lacrimation
§ Seborrhea (oversecretion of sebaceous gland)
§ Decreased sexual capacity
¦ Stages of Parkinson’s Disease
I. Unilateral flexion of upper extremities
II. Shuffling gait
III. Progressive difficulty in ambulating
IV. Progressive weakness
V. Disability = last stage
¦ Nursing management for Parkinson’s
ú
2 Anti-Parkinsonians 1. Larodopa 2. Sinemet 3. Symmetrel 4. Artane and Cogentin 5. Benadryl 6. Parlodel |
Rx Anti-Parkinson agents:
§ Levodopa (L-dopa) [Larodopa] – short-acting anti-parkinson
ü Mechanism: increases levels of dopamine
ü Side effects:
þ GIT irritation (nausea and vomiting)
þ ORTHOSTATIC HYPOTENSION – always asked in the board exam!
þ Arrhythmia
þ Hallucination
þ Confusion
ü Contraindications of L-dopa
þ Not given to clients with glaucoma
þ Not given to patients taking MAO inhibitors (tricyclic antidepressants)
§ The MAO inhibitors are Marplan, Nardil and Parnate
§ Patients taking MAO inhibitors should be instructed to avoid foods rich in Tyramine (cheese, beer, wine, avocado) because MAOIs + Tyramine = Hypertensive crisis (severe hpn causing organ damage)
ü Nursing management for L-dopa
þ Best given with meals to avoid GIT irritation
þ Inform client that his urine and stool may be darkened
þ Instruct client to avoid foods rich in Vit B6 (Pyridoxine): cereals, green leafy vegetables and organ meats
§ Pyridoxine reverses the therapeutic effect of levodopa
· Note: Vit B6 intake should be increased for patients taking Isoniazid (INH) to counter INH side-effect of peripheral neuritis
§ Carbidopa [Sinemet] – long-acting anti-parkinson
ü Mechanism: same as levodopa
ü Side effects:
þ Hypokinesia
þ Hyperkinesias
þ Psychiatric symptoms: EXTRA-PYRAMIDAL SYMPTOMS
§ Amantadine HCl [Symmetrel]
ü Mechanism: same as levodopa
ü Side effects:
þ Tremors
þ Rigidity
þ Bradykinesia
ú Rx for Parkinson’s (continued):
§ Anticholinergics: [Artane] and [Cogentin]
ü Anticholinergics are given to relieve tremors
ü Mechanism of action: inhibits acetylcholine
ü Side-effects: SNS effects
§ Antihistamines: Diphenhydramine [Benadryl]
ü Antihistamines also relieve tremors
ü Side effect for adults: drowsiness
þ Patient should avoid driving and operating machinery
ü Side effect for children: CNS excitability – hyperactivity (paradoxical effect for young children < 2 y.o.)
§ Dopamine agonists: Bromocriptine [Parlodel]
ü Relieves tremors, rigidity and bradykinesia
ü Side-effect: Respiratory depression, therefore CHECK RR
ú Maintain siderails, to prevent injury related to falls
ú Prevent complications of immobility: Turn to side q 2, q 1 if elderly
ú Diet should be low-protein in AM, high-protein in PM (give milk before bedtime)
§ High-protein diet induces sleep (Tryptophan is a precursor to melatonin, the sleep hormone)
ú Increase oral fluid intake and high-fiber diet to prevent constipation
§ Increase intake of bran and psyllium; use bulk-forming laxatives [Metamucil]
ú Assist in ambulation
ú Safety precautions: Patient should wear flat rubber shoes, and use grab bars
ú Assist in surgical procedure: STEREOTAXIC THALAMOTOMY
§ A portion of the thalamus is destroyed to reduce tremors
§ Complications of the procedure:
ü Subarachnoid hemorrhage
ü Encephalitis
ü Aneurysm
Meningitis
¦ Inflammation of the meninges
¦ The meninges is a three-fold membrane that covers the brain and spinal cord.
ú Function of the meninges: support and protection, nourishment and blood supply
ú 3 layers of the meninges:
§ Dura matter – outermost
ü Subdural space – between dura and arachnoid matter
§
2 SSx of Meningitis ¦ Headache, photophobia, fever and chills, anorexia, weight loss, generalized body malaise ¦ INCREASED ICP à projectile vomiting, decorticate & decerebrate posturing ¦ Signs of meningeal irritation: ú Nuchal rigidity (stiff neck) is the initial sign of meningitis. ú Opisthotonus (hyperextension of head and neck) is the second sign. ¦ Pathognomonic signs of meningitis: ú Kernig’s sign – leg pain (severe pain is felt upon straightening the leg when the thigh is flexed) ú Brudzinski’s sign – neck pain (severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed) |
Arachnoid matter – middle
ü Subarachnoid space – between arachnoid and pia matter
þ The subarachnoid space is where CSF circulates
þ The subarachnoid space between L3 and L4 is the site for lumbar puncture.
§ Pia matter – innermost
¦ Etiologic agents for meningitis:
ú Meningococcus – most dangerous cause of meningitis
ú Pneumococcus
ú Streptococcus – causes adult meningitis
ú Haemophilus influenzae – causes pediatric meningitis
¦ The mode of transmission of meningitis is AIRBORNE via droplet nuclei.
ú Transmitted through coughing, talking, sneezing, kissing
ú Not transmitted through sexual contact
Diagnostic Tests for Meningitis:
¦ LUMBAR PUNCTURE (spinal tap) – diagnostic procedure for meningitis
ú A hollow needle is inserted into the subarachnoid space to obtain a sample of cerebrospinal fluid
ú Nursing management before LP:
§ Secure informed consent and explain the procedure to the patient:
ü Note: All surgeries should be explained by the doctor, but all diagnostic procedures should be explained by the nurse!!!
§ Empty bladder and bowel to promote comfort.
§ Encourage client to arch his back to enable the physician to clearly visualize L3 and L4.
ú Nursing management after LP:
§ Place client flat on bed for 12 to 24 hours after the procedure to prevent spinal headache and leakage of CSF.
ü Spinal headache is due to decreased CSF pressure (similar to orthostatic hypotension).
§ Force fluids to replace lost CSF
§ Check the puncture site for discomfort, discoloration and leakage to tissues
§ Assess for movement and sensation of extremities to determine if the procedure caused any nerve damage.
ú If the patient has meningitis:
§ CSF analysis would reveal elevated protein and WBC, decreased glucose, increased CSF opening pressure (normal CSF pressure is 50 – 160 mmHg), and (+) bacterial culture
¦ Complete blood count (CBC) reveals Leukocytosis (increased WBC)
Notes on Hematology:
| Increased | Decreased |
RBC | Polycythemia | Anemia |
WBC | Leukocytosis | Leukopenia |
Platelets | Thrombocytosis | Thrombocytopenia |
¦ NDx for patient with Anemia: Activity Intolerance; NMgt is to place the patient on complete bed rest and administer O2.
¦ Polycythemia à agglutination à thrombosis à HYPERTENSIVE STROKE
ú Initial sign of hpn stroke is headache.
ú Late sign is pruritus/itchiness due to abnormal histamine metabolism
¦ Thrombocytopenia: decreased platelets à bleeding à hemorrhage
ú Side-effects of platelet dysfunction:
§ Eccymosis
§ Petechiae/purpura
§ Oozing of blood from puncture site.
ú NMgt for thrombocytopenia: Avoid parenteral injections
ú Note: Platelets depletion happens in Disseminated Intravascular Coagulation à treated by heparin
¦ Leukocytosis leads to increased susceptibility to infections, so place the patient on REVERSE ISOLATION (to protect the patient).
¦ Patients with infectious diseases are places on STRICT ISOLATION (to protect other patients).
Nursing Management for Meningitis:
¦ Administer Rx:
ú Broad spectrum antibiotics (Penicillin)
ú Analgesics
ú Antipyretics
¦ Institute strict respiratory isolation 24 hours after initiation of antibiotic therapy.
¦ Comfortable and dark environment
¦ Monitor v/s, I&O and neurocheck
¦ Maintain fluid and electrolyte balance
¦ Prevent complications of immobility
¦ Institute measures to prevent inc ICP
Review: Adrenal Gland
Hormones of the Adrenal Cortex:
¦ Sugar: Glucocorticoids (e.g. cortisol) control glucose metabolism
¦ Salt: Mineralocorticoids (e.g. aldosterone) promote sodium and water reabsorption and potassium excretion
¦ Sex: Androgenic hormones (testosterone, estrogen, progesterone) promote development of secondary sexual char
Diseases of the Adrenal Gland:
Addison’s disease Hyposecretion of adrenal hormones | Cushing’s syndrome Hypersecretion of adrenal hormones |
¦ Sugar ê: hypoglycemia ¦ Salt ê: hyponatremia, with hyperkalemia ¦ Sex ê: decreased libido | ¦ Sugar é: hyperglycemia ¦ Salt é: hypernatremia, with hypokalemia ¦ Sex é: hirsutism, acne, striae |
Hypoglycemia (T-I-R-E-D) ¦ Tremors/Tachycardia ¦ Irritability ¦ Restlessness ¦ Extreme fatigue ¦ Diaphoresis/Depression | Hyperglycemia (P-P-P) ¦ Polyuria ¦ Polydypsia ¦ Polyphagia Note: DM is a complication of Cushing’s |
¦ Decreased tolerance to stress due to decreased steroids à can lead to ADDISIONIAN CRISIS | ¦ Increased steroids cause decreased WBC (Leukopenia) à IMMUNODEFICIENCY Note: Steroids takers (athletes,body builders) experience ssx of Cushing’s |
Hyponatremia ¦ Hypotension ¦ Dehydration ¦ Weight Loss | Hypernatremia with Fluid Volume Excess ¦ Hypertension ¦ Edema ¦ Weight Gain ¦ Pathognomonic Sx of Cushings: ú Moon-face ú Buffalo hump ú Obese trunks ú Pendulous Abdomen ú Thin extremeties |
Hyperkalemia ¦ Irritability, agitation ¦ Diarrhea, abdominal cramps ¦ Peak T waves à arrhythmia | Hypokalemia ¦ Weakness, fatigue ¦ Constipation ¦ Prominent U wave à can also lead to arrhythmia |
¦ Decreased sexual urge and loss of pubic and axillary hair | ¦ Hirsutism, acne and striae due to increased sex hormones |
¦ Pathognomonic sx: Bronze-like skin ú Decreased cortisol causes pituitary gland to secrete Melanocyte-stimulating hormone | ¦ Other signs: ¦ Depression ¦ Easy bruising ¦ Increased masculinity in women |
Management: ¦ Steroids (2/3 dose in AM and 1/3 dose in PM)
| Management: ¦ Potassium-sparing diuretics: Aldactone [Spironolactone] – promotes excretion of sodium while retaining potassium ¦ DO NOT GIVE LASIX ¦ Limit fluids ¦ Increase potassium in the diet |
Nursing Management for Meningitis (continued):
¦ Provide client Health teaching and discharge planning
¦ Diet: High carb, high protein, high cal with small freq feedings
¦ Prevent complications: HYDROCEPHALUS and NERVE DEAFNESS
ú Patient with meningitis should be referred to an audiologist for testing.
¦ Rehabilitation for residual deficits: mental retardation or delay in psychomotor development
Myasthenia Gravis
¦ A neurovascular disorder characterized by a disturbance in the transmission of impulse fro nerve to muscle cells at the neuromuscular junction leading to DESCENDING MUSCLE PARALYSIS.
¦ More common in women aged 20 to 40.
¦ Etiology: idiopathic, related to autoimmune
ú For unknown reasons, the body is producing cholinesterase which destroys acetylcholine, the neurotransmitter for muscle movement, leading to muscle weakness.
¦ SSx:
ú Initial Sign: PTOSIS (drooping of upper eyelid)
ú Diplopia
ú Masklike facial expression
ú Dysphagia
ú Hoarseness
ú Respiratory muscle weakness à respiratory arrest (Prepare tracheostomy set at bedside)
ú Extreme muscle weakness especially during activity or exertion
¦ Dx test:
ú TENSILON TEST
§ Tensilon (Edrophonium HCl) is a short acting anti-cholinesterase
§ Tensilon is administered via IV push
§ If patient has MG, symptoms will be temporarily relieved (for 5 to 10 minutes)
ú CSF analysis reveals elevated cholinesterase levels
ú
