vom meonen MEDICAL-SURGICAL NURSING Prof. Ferdinand B. Valdez Members of the BOARD OF NURSING and their SPECIALIZATIONS: yChairman Carmencita Abequin, UP eMS ~ neuro, sensory, endocrine, BURNS, ONCOLOGY, elderly care, RESEARCH sHon. Marco Sto. Tomas, St. Joseph College of Nursing Funda, MCN, IMC Hon. Leonila Faire, UP renal transplant, RENAL DISORDERS, ENT, ophthal (cataract), OR sHon. Betty Meritt, UP Psych: Child psychology, stress management Hon. Peria Po, UP *Psych: Therapeutic comm., psych drugs, nursing theories yHon, Amelia Rosales, Ortafiez College of Nursing MS, Hon. Yolanda Arugay, PWU oCHN What is the nursing priority for a patient with epiglottitis? A. administer steroids B. assist in endotracheal intubation C. assist in tracheostomy D. apply warm moist pack The correct answer is C. Epiglottitis is an emergency situation requiring immediate intervention: the inflamed epiglottis is blocking the entrance to the trachea, therefore clearing the patient’s AIRWAY is the priority nursing action (eliminate options A and D). Option C is better than Option 8; endotracheal intubation will be difficult because the inflamed epiglottis will nat permit the insertion of a laryngoscope. The following are clinical manifestations of nontoxic goiter (hypothyroidism), EXCEPT: A. dry skin B. lethargy . insomnia D. sensitivity to cold The correct answer is C. Hypothyroidism causes a decrease in thyroid hormones, which in turn causes decreased metabolism. Options A, B and D are all consistent with decreased metabolism. Option C is a symptom of increased metabolism found in hyperthyroidism. s Thyroid gland secretions (T; and T;) are metabolic hormones Thyroid hormones cause increased metabolism: CNS stimulation, increased vital signs, and increased GI matility (diarrhea)Phare W decreased CNS: drowsiness, memory problems (forgetfulness) ¥ decreased v/s: hypotension, bradycardia, bradypnea, low body temp ¥ decreased GI motility: constipation ¥ decreased appetite (anorexia) but with WEIGHT GAIN {low metabolism causes decreased buming of fats and carbs] This leads to increased serum cholesterol > athorosclorosis (hardening of arteries due to cholesterol deposits) Because of increased cholesterol, hypothyroid patients are prone to hypertension, myocardial infarction, CHF and stroke ¥ decreased metabolism causes decreased perspiration > DRY SKIN and COLD INTOLERANCE % Menorrhagia (excessive bleeding during menstruation) 7 Nursing Management for hypothyroidism: Low calorie diet Warm environment Elaine % increased CNS: tremors, insomnia ‘# increased v/s: hypertension, tachycardia, tachypnea, fever increased Gi motility: diarrhea “* increased appetite (hyperphagia) but with WEIGHT LOSS [high metabolism causes increased burning of fats and carbs} ® increased metabolism causes increased perspiration > MOIST SKIN and HEAT INTOLERANCE v Amenorrhea (absence of menstruation) Pathognomic sign: EXOPHTHALMOS eyeballs Nursing Management for hyperthyroidism High calorie diet sCool environment What is the best way to prevent the spread of STDs? ‘A. Use condoms Monogamous relationship Abstinence B. c D. Practice Safe Sex The correct answer is B. TEST-TAKING TIP: Pick the conservative answer. Remember the Board of Nursing is composed of older women with traditional values who do nat approve of promiscuity (implied in options A and D). Telling the patient to abstain from sex (Option C) is not an acceptable response from the nurse. ‘What Is the nursing priority if the client \s suffering from 1*, 2™, 3% or 4" degree burns? A, fluid and electrolyte balance B. infection c. pain D. airway The correct answer is B. Infection is a priority for all types of burns. Airway is a priority only for burns to the face and neck. Pain is a second priority for 1" and 2" degree burns. Fluid and electrolyte balance is a second priority for 3 and 4" degree burs [no pain because nerve endings are damaged).What is a normal physical finding of the thyroid gland? A. nodular consistency B. asymmetry C. tendemess D. palpable upon swallowing ‘The correct answer is A. The thyroid gland is symmetrical, non-tender, and palpable only if the patient has goiter. The palpable mass on the neck is the thyroid cartilage. It is present in both males and females but is larger in males; it develops during puberty What food is most appropriate for a toddler? A. hotdog B. grapes Cc. milk D. spaghetti ‘The correct answer is D. Toddlers need a high-carb diet to sustain their active play lifestyle. Toddlers are also at risk for aspiration, therefore eliminate foods that are choking hazards (options A and B). Milk is not the best food for toddiers because of its low IRON content; Milk is the primary cause of Iron-deficiency Anemia in children. TEST-TAKING TIP: "Di ba may hotdog ang spaghetti? No, no, no... DO NOT ADD DETAILS TO THE QUESTION. Do not justify a wrong answer. What would the nurse include in the teaching plan for a paraplegic client? A. self-catheterization B. assisted coughing C. adapted feeding techniques D. compensatory swallowing ‘The correct answer is A. A paraplegic patient has lower extremity paralysis (paralyzed bladder and bowel). Therefore the nursing priority is ELIMINATION. Review: Monoplegia -- 1 limb paralysis, Hemiplegia ~ Right or Left side paralysis Paraplegia — Lower extremity paralysis (note: there is no such thing as upper extremity paralysis) Quadriplegia/Tetraplegia - Paralysis from the neck down. The priority for a quadriplegic patient is AIRWAY. NERVOUS SYSTEM CNS: brain and spinal cord /PNS: 12 cranial nerves + 31 spinal nerves 88 cervical nerves (C; to Cs) ®12 thoracic nerves (T; to Ti.) °5 lumbar nerves (L: to Ls) ®85 sacral nerves (S; to Ss) ®1 coccygeal nerve (Co) s The spinal cord terminates at L: to Lo, therefore a LUMBAR TAP is performed at Ls .Ls or Ls (no risk of paralysis from spinal cord damage)AUTONOMIC NERVOUS SYSTEM Sympathetic Nervous System (SNS) “{"Fight” or aggression response Also termed adrenergic or pi response ~_/"Flight” or withdrawal response sympatholytic Parasympathetic Nervous System (PNS) fAlso terme sympatholytic 1 response jolineraic yThe neurotransmitter for the SNS is sThe neurotransmitter for the PNS Is norepinephrine acetyicholine (Ach) All body activities are INCREASED _— All body activities are DECREASED except GIT! except GIT! % increased blood flow to brain, heart and skeletal muscles: these are the most important organs. during times of stress ¥ normalized blood flow to vital organs % increased BP, increased heart rate: ‘To maintain perfusion to vital organs ¥ decreased BP, decreased heart rate * bronchodilation and increased RR: “To increase oxygen intake 4 urinary retention > FLUID VOLUME EXCESS Fluids are withheld by the body to maintain circulating volume: W bronchoconstriction, decreased RR “Y urinary frequency > FLUID VOLUME DEFICIT ® pupillary dilation: MYDRIASIS: ‘To increase environmental awareness during aggression ¥ pupillary constriction: MiosiS: isthe correct speling, nt miosis © ¥ decreased GIT activity: CONSTIPATION and DRY MOUTH: Bloed flow is docrossed inthe GIT bocauso it i the least impartant area times of stress Epinephrine [Adrenalin] Antipsychotics: sHaleperidol [Haldol], Chlorpromazine [Thorazine], etc. ‘Side effect of Thorazine: Atopic Dermatitis (eczema) and foul-smelling odor [recall patiants in NCMH are smelly} ‘Side effect of all antipsychotics: Sx of PARKINSON'S DISEASE, therefore antipsychotics are given together with aushareinsan orvas Death) Bx for Myasthenia Gravis: =Pyridostigmine [Mestinon] =Neostigmine [Prostigmin]The nurse admits a patient with COPD. For the management of hypertension, the doctor prescribes Inderal 40 mg P.O. What is the appropriate nursing action? ‘A. administer Inderal 1 hour before or 2 hours after meals 8. withhold Inderal if the pulse is less than 60 bpm €. question the physician regarding the order D. monitor BP prior to administration The correct answer is C. A patient with COPD has decreased respiration. Propranolol [Inderal] is contraindicated for patients with COPD because of its PNS effects (it will aggravate the patient's respiratory depression), NEURONS 3 characteristics of neurons: 1. Excitability ~ Neurons are affected by changes in the environment 2. Conductivity ~ Neurons transmit wave of excitations 3. er ECT 7 epidermis (skin), gastrointestinal tract (GIT), genito- Capable of regeneration urinary tract (GUT), respiratory tract (stab wounds to the lungs are survivable) Stable kidneys, liver, pancreas, salivary glands Once destroyed, capable of Fegenerstion but with limited survival time period Permanent heart, neurons, osteocytes, retinal cells once destroyed, not capable of regeneration NEUROGLIA s Function: support and protection of neurons Clinical significance: Majority of brain tumors arise from neuroglia sTypes: Astrocytes °Microglia Oligodendrocytes *Ependymal cells sNote: Astrocytoma is the #1 type of brain tumor ASTROCYTES - maintain the integrity of the BLOOD-BRAIN BARRIER Ce eee roe elo 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 sIncrease in serum ammonia can cause HEPATIC ENCEPHALOPATHY (Liver cirrhosis) Normal liver is scarlet brown: liver with cirrhosis is covered by fat deposits ("fatty liver") sThe primary cause of hepatic encephalopathy is MALNUTRITION. sThe major cause of hepatic encephalopathy is ALCOHOLISM Alcoholism causes Thiamine (B:) deficiency (Alcoholic beriberi) sAmmonia is a cerebral toxin.t J Early sian of Hepatic Encephalopathy: ®ASTERIXIS - flapping hand tremors. This is the EARLIEST SIGN OF HEPATIC ENCEPHALOPATHY. fl »Headache oRestlessness »Fetor hepaticus (ammonia-like breath) »Decreased level of consciousness > HEPATIC COMA *Note: The primary Nursing intervention in hepatic coma is AIRWAY [Assist in mechanical ventilation] BILIRUBIN Review: Bilirubin - yellow pigment sBiliverdin - green pigment eHemosiderin - golden brown pigment. »Hemoglobin - red pigment eMelanin - black pigment sicteric skin and sclerae is termed jaundice = a sign of HEPATITIS Note: Icteric skin with normal sclerae is termed Carotinemia = a sign of PITUITARY GLAND. TUMOR, not hepatitis Kemicterus |Hyperbilirubinemia) can lead to irreversible brain damage CARBON MONOXIDE (CO) AND LEAD (Pb) CO and Pb can cause PARKINSON’S DISEASE and SEIZURE ®Note: The initial sign of Parkinson's disease: PILL-ROLLING TREMORS sThe antidote for Pb paisoning is Calcium EDTA {The antidote for CO poisoning is Hyperbaric oxygenation (100% oxygen) KETONES sKetones are by-products of fat metabolism sKetones are CNS depressants sincreased ketones can lead to diabetic ketoacidosis (DKA) seen in Type | diabetes mellitus (DM). DKA is due to increased fat metabolism: ‘iw flood gar Tnereased Fat Metabolim (fatsareused aan alternate enesey ounce) TwereavedFreeFamty Aci ———_—— Incressed CHOLESTEROL Increased KETONES ally Siw seae em eee WEAKNESS WIGHT L055 Tate sion AceTONE oreart, USSU RESPRATTON DIABETES MELLITUS‘insulin-dependent {Non Insulin-dependent ‘Juvenile onset type (common among children) | s Adult/Maturity onset type (common among 40 y.0. & above) JNon-obese Js Obese ‘eee ease Fe ore alesse" Felogy Fereanay Felony obesty ‘symptomatic fama J Gharcterses b Weight Lose Fchoractraed 9y Weight Gan ‘j Treatment: Insulin J Treatment: Oral Hypoglycemic Agents (OHA) s Complications: Diabetic Ketoacidosis (DKA) joe Hyper-Osmolar Non-Ketotic Coma eee nee “Gniess'9 cma “Can ato endo coma ®Can lead to seizure MICROGLIA s Microglia are stationary cells that carry on phagocytosis y Review: Brain macrophage Microglia Blood macrophage Monocyte »kidney/Liver macrophage Kupffer cell »Lung macrophage Alveolar macrophage epithelial macrophage = — Histiocytes EPENDYMAL CELLS yEpendymal cells secrete chemoattractants (glue) that concentrate bacteria OLIGODENDROCYTES y Produce myelin sheath Function: For insulation and to facilitate nerve impulse transmission sThe demyelinating disorders are MULTIPLE SCLEROSIS and ALZHEIMER'S DISEASE ALZHEIMER'S DISEASE {A type of damentia (degenerative disorder characterized by atrophy of the brain tissue) Caused by Acetylcholine (Ach) deficiency slrreversible J Predisposing factors: Aging sAluminum toxicity sHereditary 4 SSx of Alzheimer's (5 A's): ofmnesia - partial or total loss of memory “The type of amnesia in Alzheimer's is ANTEROGRADE AMNESIA. +2 types of Amnesia YAnterograde amnesia — loss of short-term memory vRetrograde amnesia ~ loss of long-term memory °Agnosia - inability to recognize familiar objects »Apraxia - inability to perform learned purposeful movements (using objects [toothbrush] for the wrong purpose) °Anomia - inability to name objects °Aphasia - inability to produce or comprehend language "The type of aphasia in Alzheimer’s is RECEPTIVE APHASIA. #2 types of Aphasia: vExpressive aphasia (Broca’s aphasia)t e inability to speak positive nodding @Znursing management is the use of a PICTURE BOARD @Zidamage to Broca’s area (in frontal lobe), which is the motor speech center vReceptive aphasia (Wernicke’s aphasia) inability to understand spoken words Zpositive illogicavirrational thoughts ican hear words but cannot put them into logical though damage to Wernicke's area (in temporal lobe), which is the language comprehension center sThe drugs of choice for Alzheimer’s are Donepezil [Aricept] or Tacrine [Cognex] *The drugs work by inhibiting cholinesterase (an enzyme that breaks down acetylcholine), thereby increasing the levels of acetylcholine in the brain “Best given at bedtime Which is the characteristic of Alzheimer’s disease? .. transient ischemic attacks remissions and exacerbations \id deterioration of mental functioning because of arteri slowly progressive deficits in the intellect, which may not be noted for a long time. ‘The correct answer is D. Option Ais a characteristic of stroke. Option Bis a characteristic of Myasthenia Gravis or Multiple Sclerosis. Option C is a characteristic of Dementia (?) What type of environment is appropriate for a client with Alzheimer's? A. familiar B. variable C. challenging D. non-stimulating ‘The correct answer is A. To promote the patient's safety and security, the patient needs to be in a familiar environment. What is the best nursing action if a client with Alzheimer’s begins to speak about the 1930's? ‘A. orient the client to time and place B. distract the client by inviting him to watch TV C. encourage the client to talk about recent events D. listen to the client's anecdotes The correct answer is D. A client with Alzheimer’s disease has short-term memory loss, but has intact long-term memories. Therefore allowing the client to reminisce about the past reinforces the client’s self-esteem. Options A is incorrect because the client is not disoriented. Option B is incorract because it dismisses the client’s concerns. Option Cis incorrect because with short-term memory loss, the client cannot talk about recent events, MULTIPLE SCLEROSIS (MS) r Chronic intermittent disorder of the CNS characterized by white patches of demyelination in the brain and spinal cords Characterized by remission and exacerbation yCommon among women 15 to 35 yo. s Predisposing factors: idiopathic (unknown) »Slow-growing viruses Autoimmune ®Note: other autoimmune diseases: Systemic Lupus Erythematosus (SLE), hypo & hyperthyroidism, pernicious anemia, myasthenia gravis sThere is no treatment for autoimmune diseases, only palliative or supportive care (just treat S & Sx) PRC ne Ig¢ ‘an cross placenta; provides passive immunity IgA — found in body secretions (sweat, tears, saliva and colostrum) IgM — acute inflammations; the largest antibody IgE -allergic reactions gD __— chronic inflammations S & Sx of Multiple Sclerosis s Visual disturbances BLURRED VISION is the INITIAL SIGN of MULTIPLE SCLEROSIS eDiplopia (double vision) »Scotoma (blind spot in the visual field) J Impaired sensation to touch, pain, pressure, heat and cold sTingling sensations »Paresthesia (numbness) "Do not give hot packs to patients with MS. Because of decreased heat sensiti application can cause burns. Mood Swings, Patients with MS are in a state of euphoria S & Sx of Multiple Sclerosis (continued) slmpaired motor activity Weakness > spasticity > paralysis s impaired cerebellar function PATAXIA (unsteady gait) s Scanning speech s Urinary retention and incontinence y Constipation y Decrease in sexual capacity ity, heat CHARCOT'S TRIAD Sx 6} Cte aearlta ey Ataxia sNystagmus L {Intentional Tremors Diagnostic Procedures for Multiple Sclerosis 4 Cerebral analysis through lumbar puncture reveals increased IgG and protein sNIRI reveals site and extent of demyelination s LHERMITTE’s SIGN continuous contraction and pain in spinal cord following laminotomy. sconfirms diagnosis of MS Nursing Management for Multiple Sclerosis FRX:PACTH (steroids) - to reduce swelling and edema > prevents paralysis resulting from spinal cord compression "Steroids are best administered AM to mimic the normal diurnal rhythm of the body "Give */; of dose in AM, "/s of dose in PM "ACTH is also administered in Motor Vehicular Accidents leading to spinal injury > prevents infiammation that can lead to paralysis »Muscle relaxants: Baclofen [Liorisal] and Dantrolene Sodium [Dantrium] *Can be used to treat hiccups, which is caused by irritation of the phrenic nerve. interferons ~ to alter immune response simmunosuppresants Diuretics -to treat urinary retention »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. ’Propantheline Bromide [Pro-Banthine] — antispasmodic drug to treat urinary incontinence Provide relaxation techniques Deep breathing, yoga, biofeedback s Maintain siderails - to prevent injury secondary to falls 4 Prevent complications of immobility Tum to side q 2h, q 1 h for elderly patients, q 30 minutes on the affected extremity J Provide catheterization Avoid heat application 17 treat constipation: Provide high fiber diet so treat UTI: Provide ACID-ASH DIET (acidifies urine to prevent bacterial infection) °Acid-ash diet consists of Grape, Cranberry, Plums, Prune Juice, Pineapple sWomen are more prone to UTI sFemales have shorter urethra (3 to 5 cm or 1 to 1% 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 eMale UTI is often related to post-coitus Male must urinate after coitus to prevent urine stagnation What is the action of Baclofen [Liorisal]? induces sleep stimulates appetite muscle relaxant reduce bacterial urine count The correct answer is C. Baclofen is a muscle relaxant used to treat spastic movement in multiple sclerosis, spinal cord injury, amyotrophic lateral sclerosis (Lou Gehrig's Disease) and trigeminal neuralgia. BRAIN Composition: 80% Brain mass 410% Blood 4 10% Cerebrospinal Fluid (CSF) Cerebrum/ Largest part of the brain ‘Composed of 2 hemispheres (Left and Right) joined by the copus callosum s Functions: sensory, motor and integrative Cerebral Lobes 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 ®Temporal *controls hearing *Short-term memory *Wernicke's area, the general interpretative area, is located in the temporal lobe Parietal "Appreciation and discrimination of sensory impulses (touch, pain, pressure, heat, cold) Occipital *Controls vision Central (Insula or “Island of Rei Controls visceral functions *Limbic system (rhinencephalon) -Controls smell "anosmia is the absence of the sense of smell "Controls libido *Long-Term memory Basal Ganglia sareas of gray matter located deep within each cerebral hemisphere "produce DOPAMINE, which controls gross voluntary movement PARKINSON'S DISEASE —_(Rx antiparkinsonian drugs toincrease dopamine) “Dopamine excess = SCHIZOPHRENIA (Rx antipsychotic drugs to decrease dopamine) vAcetylcholine deficit = MYASTHENIA GRAVIS (Rx Mestinon to increase Ach) v Acetylcholine excess = BIPOLAR DISORDER —_(Rx Lithium to decrease Ach) Notice that... “Neurotransmitter deficit = MedSurg iinesses ¥ Neurotransmitter excess = Psych ilinesses Diencephaton - interbrain or “between brain” s Hypothalamus sTemperature regulation Controls BP »Reticular activating system: controls sleep and wakefulness Controls thirst Satiety center: controls appetite °Emotional responses: fear (from known cause) . anxiety (from unknown cause) and excitement Controls pituitary functions *Pituitary gland relies on stimulation from hypothalamus sThalamus Relay station for sensation Mesencephalon (midbrain)Relay station for sight and hearing: Controls size and response of pupil "Normal pupil size is 2 to 3mm. *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. Controls hearing acuity Brainstem Pons ~ pneumotaxic center ( controls depth and rhythm of respiration) sMedulla Oblongata - lowest part of the brain »Damage to medulla is the most life-threatening Controls respiration, heart rate, vomiting, swallowing, hiccups »Vasomotor center (controls vessel constriction and dilation) »The medulla oblongata is the termination point of spinal decussation Cerebellum Smallest part of the brain; cerebellum is also Known as the “lesser brain” J For balance, posture, equilibrium and gait s Cerebellar tests: »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) oFinger-to-nose test “Tests for DYMETRIA (inability of the body to stop a movement at a desired point) °Alternate pronation and supination *A\so tests for dymetria MONRO-KELLIE HYPOTHESIS {J The Monro-kellie hypothesis states the relationship between ICP and cranial components (blood, CSF and brain tissue) ®=The skull is a closed container, therefore any alteration in one of the intrathecal components can lead to Increased intracranial pressure »The normal ICP is 0 to 15 mmHg. =. | es = 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) s Hydrocephalus - obstruction of the flow of CSF leading to enlargement of the skull posteriorly ®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:Middle cerebral artery internal carotid artery sThe leading cause of CVA is THROMBUS formation (attached clot) ®A dislodged thrombus becomes an EMBOLUS (free-floating clot) > very dangerous if it goes to the BRAIN, HEART or LUNGS J CVA causes increased ICP. INCREASED INTRACRANIAL PRESSURE (ICP) s Increased intracranial bulk brought about by an increase in one of the intracranial components Predisposing factors: Head injury sTumor sLocalized abscess (pus) Hydrocephalus, Meningitis Cerebral edema sHemorrhage (stroke) s Note: For all causes of increased ICP, the patient should be positioned 302 to 452 (Semi-Fowler's) What is the EARLIEST SIGN of increased ICP? A. headache 8. widening pulse pressure C. tachycardia D. agitation ‘The correct answer is D. A change in the level of consciousness is the earliest sign of increased ICP. Options A and B are both LATE SIGNS. Option C is incorrect; increased ICP causes bradycardia, not tachycardia Describe a conscious client: A. Aware 8. Coherent C. Awake’ D. Alert ‘The correct answer is C. Consciousness describes a patient's level of wakefulness. The terms aware, coherent and alert (Options A, B and D) are used when describing a patient's orientation to person, place and time. / Early Signs of Increased ICP ’Change or decreased level of consciousness (restlessness to confusion) sirritability and agitation "Disorientation to lethargy to stupor to coma "Remember: The 4 levels of consciousness: Conscious > Lethargy > Stupor > Coma slate Signs of Increased ICP »Changes in v/s "A Increased BP: vWIDENING PULSE PRESSURE - increased systolic pressure while diastolic pressure remains the same“Note: narrowing pulse pressure is seen in SHOCK (inadequate tissue perfusion). *W Decreased Heart rate (bradycardia) «¥ Decreased Respiratory rate (bradypnea) ~Cheyne-Stokes respiration ~ hyperpnea followed by periods of apnea "Increased Temp ~/Note: Temp as a vital sign usually parallels BP BP 4 increased W decreased Heart Rate | Yosceg | increases Resp Rate | Soveaces | Bincenred Temp ‘high Viow prise |p widening | ¥ narrowing *Notes: vincreased heart rate in shock compensates for blood loss Decreased temp in shock is due to decreased blood causing a decrease in warmth. “Hypertension, Bradycardia and irregular RR = CUSHING’S TRIAD of increased ICP vincreased BP as a response to increased ICP is termed as CUSHING REFLEX increased BP is an attempt by the body to maintain cerebral perfusion during increased ICP *Headache, papilledema, PROJECTILE VOMITTING *Papiliedema is edema of the optic cisc in the retina, leading to irreversible blindness "Projectile vomiting due to compression of the medulla, which is the center for vorniting. *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 poliomy Unilateral dilation of pupils *Uncal herniation ~ herniation of uncus (in temporal lobe) puts pressure on Cranial Nerve Ill which controls parasympathetic input to the eye, causing unequal pupillary dilation (ANISOCORIA) Possible seizure is). Nursing Management for increased ICP Maintain patent airway and adequate ventilation "To prevent hypoxia (inadequate 0, in tissues) and hypercartia (increased CO; in blood) stimulates medulla > increase RR (hyperventilation) > normalized 02 and CO: (negative feedback mechanam to maintain homeosteds) y Nursing Management for increased ICP (continued) Assist in mechanical ventilation: Ambubag or Mechanical Ventilator Note: Ambubag should only be pressed during inspiration *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 Position Semi-Fowler’s "Elevate head of bed 30 to 452 with neck in neutral position unless contraindicated to promote venous drainage. Limit fluid intake to 1.2 to 1.5 L per day *Note: Forced fluids is 2 to 3 L per day Monitor vis, 1&0 and neurocheck (neurovital signs) »Prevent complications of immobility (turn to side) Prevent further increased ICP: *Provide comfortable, quiet environment vStress increases ICP "Avoid use of restraints (Jacket. wrist or elbow restraints] vAnxiousness increases ICP *Maintain siderails “Avoid clustering of nursing activities together Instruct client to avoid activities leading to Valsalva maneuver (bearing down) Avoid straining of stool: administer laxatives/stool softeners: Bisacodyl [Dulcolax] vAvoid excessive coughing: administer antitussives (cough suppresant): Dextromethorphan [Robitussin] Note: common side effect of antitussives is drowsiness, so avoid driving or operating heavy machinery vAvoid vomiting: administer anti-emetic: Phenergan [Plasil] vAvoid bending, stooping, litting heavy objects eAdminister meds: "Osmotic diuretics - Mannitol [Osmitrol] Check BP before administering; mannitol can lead to low fluid volume > hypotension Monitor strictly | & O and inform physician if output is less than 30 cc per hour “Mannitol is given as side-drip (piggy-back) DRegulate at FAST-DRIP to prevent crystallization [formation of precipitates in tubing] > clogged IV line Note: KVO rate is 10 to 15 atts per minute vinform client that he will feel a flushing sensation as the drug is introduced. "Loop Diureties - Furosemide [Lasix] Nursing management for loop diuretics is the same as for Osmotic diuretics Lasix is given IV Push (from ampule) ¥ 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es. vSide-effect of steroids: respiratory depression "Mild analgesics: Codein Sulfate Anticonvulsants: Dilantin [Phenytoin] Lasix is given at 7 AM. What is the earliest time that the nurse would expect the client to urinate? ‘A. 7:10 AM B 7:30AM © 12 noon D. 1pm The correct answer is A. Lasix takes effect in 10 to 15 minutes. Option D (6 hours) is the maximum therapeutic effect of Lasix. ERLoocamoa rs HYPOKALEMIA 3.5 to 5.5 HYPOCALCEMIA 8.5 to 11 HYPONATREMIA, 135 to 145 >A Glucose HYPERGLYCEMIA 80 to 100 mg/dl. A) Uric Acid: HYPERURICEMIA 3 to 7 mo/dt HYPOKALEMIAPotassium less than 3.5 mEq/L Sx of hypokalemia: Weakness, fatigue »Decreased GI motility: constipation sPositive U Wave on ECG > can lead to arrhythmias =Metabolic alkalosis »Bradycardia (HR 60 to 100 bpm) (x for hypokalemia °K supplements: Oral KCI, Kalium durule # Foods rich in K: fruits: Apple, Banana, Cantaloupe *Note: Green bananas have more K Vegetables: Asparagus, Broccoli, Carrots eAlso rich in K: orange, spinach, apricot fPotassium greater than 5.5 mEq/L / $Sx of hyperkalemia: olrritability, excitement increased GI motility: diarrhea, abdominal cramps sPeaked T wave > can also lead to arrhythmia sMetabolic acidosis HYPOCALCEMIA sTetany - involuntary muscle contraction sSSx of hypocalcemia: sTrousseau sign — carpal spasm when BP cuff is inflated 150 to 160 mmHg »Chvostek sign - facial twitch when facial nerve is tapped at the angle of the jaw s Complications of hypocalcemia: Arrhythmia and Seizure (Calcium deficiency is life-threatening! sNursing management for hypocalcemia: sAdminister Ca Gluconate IV *Must be administered slowly to prevent cardiac arrest "Excess Ca Gluconate > Ca Gluconate toxicity > seizure "Antidote for Ca excess: Magnesium Sulfate “Monitor for signs of MgSO, toxicity (BURP): BP low urine output low GRR low RAPATELLAR REFLEX ABSENT — important! earliest sign of MgSO, toxicity HYPONATREMIA f Low sodium > Fluid Volume Deficit Hypotension / The initial sign of dehydration is THIRST (adults) or TACHYCARDIA (infants) j Nursing Management: Force fluids (2 to 3 L/day), administer isotonic IV HYPERGLYCEMIAJSSx: 3P’s (Polyuria, Polydipsia, Polyphagia) sNursing 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: Organ meats, sardines, anchovies, legumes, nuts sTophi ~ uric acid crystals sGout - uric acid deposit in joints leading to joint pain & swelling, particularly affecting the great toes, sNursing Management for Gout: Force fluids (2 to 3 Liday) Rx: Allopurinol [Zyloprim] - drug of choice for gout *Most common side effect: allergic reaction (maculopapular rash) Rx: Colchicine — drug of choice for acute gout SKIDNEY STONES - tophi accumulation in kidneys sThe pain associated with kidney stones is termed RENAL COLIC Nursing Management for Kidney Stones: *Force fluids *Rx: Morphine Sulfate — narcotic analgesics are the drug of choice to relieve renal colic “Side-effect of narcotic analgesics: Respiratory depression, so always check RR before administering Antidote for Morphine overdose: Naloxone [Narcan] MSSx of Naloxone toxicity: tremors Strain the urine using gauze sA pathognomonic sign is a defi ive diagnostic sign of a disease. PATHOGNOMONIC SIGNS cord Tiousseau and Chvostek signs cent Risus sardonicus (abnormal sustained spasm of the facial muscles) Pera Spider angioma, due to esophageal varices ad Butterfly rash eto) Chipmunk facies (parotid aland swelling) ad ‘Leonine facies (thickened lion-like facial skin) re accu) ‘Moon face eee Koplik spots ec) Pseudomembrane on tonsils, pharynx and nasal cavity Peary Protrusion of tongue, Simian crease on palm eed Strawberry tongue eee) Red beafy tongue raat Exophtnaimos: eo Wheezing on expiration Coser Barrel chest ote) Rusty sputum ree Bronzelike skin ere es Rebound tenderness ee Gullen’s sign (bluish discoloration of umbilicus) Cetus Gray-turner’s spot (ecchymosis in flank area) Peace Cholera Rice-watery stool Can hills Sed Rose spots in abdomen ee ‘Homan’s sign Cae Kermig’s and Brudzinski's sign Pyloric stenosis Olive-shaped mass,PATHOGNOMONIC SIGNS eon 2 as Jaundice Per) Petechiae Tetralogy of Fallot Clubbing of fingers rs Hazy vision (loss of central vision) ery “Tunnel vision (loss of peripheral vision) Pe ess Curtain veil-ke vision (right or left side of vision is blocked) PTB ‘Low-grade afternoon fever ord Murphy's sign (pain on deep inspiration when inflamed gallbladder is palpated) Roe een ‘Levine's sign (hand clutching of chest) Machine-lke murmur Arteriosus eens Prosis [drooping of eyelids) Seeman ees Pill-Roling Tremors < Questions about increased ICP > patient has increased ICP due to stroke, What is the immediate nursing action? ‘A. Administer Mannitol as ordered B. Elevate the head of the bed 30° - 452 CC. Restrict fluids D. Avoid the use of restraints The correct answer is A. Mannitol will produce the fastest response in decreasing the patient's intracranial pressure. Option 8, while correct, will not produce a fast response. Option Cis incorrect; a patient with increased ICP should have fluids limited, not restricted. Option D rervention for a patient at risk for developing increased ICP. but it will not help if the ICP is already elevated. Apatient is at risk for increased ICP. What would be the priority for the nurse to ‘monitor? ‘A. Unequal pupil size B. Decreased systolic BP . Tachycardia D. Decreased body temp The correct answer is A. Increased ICP causes anisocoria due to pressure on the oculomotor nerve. Options B, Cand D are incorrect: increased ICP produces increased BP, bradycardia and hyperthermiWhich nursing intervention is appropriate for a client with intracranial pressure of 20 mmig? A. Give the client a warming blanket B. Administer low-dose barbiturates . Encourage client to hyperventilate D. Restrict the patient's fluids ‘The correct answer is C. Increased ICP produces bradypnea, so hyperventilating will help maintain the client's oxygenation. Option A is incorrect; increased ICP produces hyperthermia, so a warming blanket will aggravate the client's temperature. Option B is incorrect; barbiturates are CNS depressants that will further decrease the client's respiratory rate. Option D is incorrect; a patient with increased ICP should have fluids limited, not restricted (Semantics? Really?! Nete: This can be a valid answer if there are no better options) Acclient who is regaining consciousness after a craniotomy attempts to pull out his IV line. Which action protects the client without increasing ICP? A. Jacket restraints 8. Wrap hands in a soft mitten restraint C. Tuck arms and hands under the draw sheet D. Apply wrist restraints to each arm. The correct answer is B. Mittens will protect the client while still allowing freedom of movement. Options A, C and D will limit the patient's movement, which will increase the patient's anxiety and consequently increase the patient's ICP. patient with a left frontal lobe tumor has a craniotomy. Four hours post surgery, which data indicates increased ICP? ‘A. BP 160/90 B. Patients difficult to arouse C. Patient has a positive Babinski response D. Patient has urinary incontinence The correct answer is B. The earliest and most sensitive sign of increased ICP is a change in the level of consciousness. Options A and C are both late signs (elevated BP + positive Babinski reflex due to damage to the corticospinal tract). Option D is not diagnostic of increased ICP. Acclient with intracranial pressure of 20 mmHg due to multiple stroke is to be discharged while receiving oxygen at 2 Limin via cannula. What information should the nurse impart to the client regarding the use of oxygen at home? ‘A. The client should limit activity at home B. The use of exygen will eliminate the shortness of breath C. Oxygen spontaneously ignites and explodes D. The use of oxygen during activity will relieve the strain on the client's heart. The correct answer is D. Option Ais incorrect; it does not convey any information about the use of oxygen. Option B is incorrect; oxygen can relieve but not eliminate shortness of breath. Option Cis incorrect; oxygen can spontaneously ignite but not explode.Drug Monitoring sThe 5 most common drugs given in the board exam: D-L-A-D-A. aot Ts Uh POC coir joxin [Lanoxin ii Cn Congestive Heart Cersie ae y nail | 0.5 —1.5 ngimt Failure Lithium [Lithane, Eskalith] 2 mEq/L 0.6-1.2 mEq/L — Bipolar Disorder Anti-manic agent. Aminophylline 30 [Theophylline] mgjdt_ 10-19 mgidL ‘copp Bronchodlator , Dilantin [henytoinl mgjat 20-29 mgidl. Seizure disorders Acetaminophen 360 [Tylenol] moja 20-30 mg/dL Osteoarthritis Non-narcotic analgesic Digoxin s Indicated for Congestive Heart Failure s Mechanism of digoxin: increases force of myocardial contractions, thereby increasing cardiac output The normal cardiac output is 3 to 6 L/min. sNursing Management when administering Digoxin: Check apical pulse rate: if below 60, withhold drug and notify the physician. 4sSSx of Dig toxicity: °GI DISTURBANCES (Early Sign): Anorexia (loss of appetite is the most evident sign), nausea and vomiting, diarrhea Visual disturbances: photophobia, XANTOPSIA (seeing yellow spots), diplopia Confusion sThe antidote for dig toxicity is DIGIBIND Congestive Heart Failure (CHF) J CHF can be Left-sidad or Right-sided sLeft-sided CHF can lead to Right-sided CHF, but Right cannot lead to Left sf Lasix is given to both types of CHF CHF is the inability of the heart to pump blood towards systemic circulation sRIGHT-SIDED CHF - the #1 cause is TRICUSPID VALVE STENOSIS. {LEFT-SIDED CHF - the #1 cause is MITRAL VALVE STENOSIS.Low ae Pressure Pressure Highest Pressure Poa Mitral valve stenosis ‘Tricuspid valve : stenosis Fluid goas back to J the lungs Fluid goes back to circulation 4 PULMONARY EDEMA 1 VENOUS CONGESTION Left-Sided Heart Failure (LSHF) sCan be caused by Rheumatic Heart Disease: Tonsillitis > strep bacteria migrate to mitral valve > RHEUMATIC HEART DISEASE > mitral stenosis > LSHF J SSK of LSHF: Most of the symptoms of LSHF are RESPIRATORY: *Pulmonary edema and congestion Dyspnea: ~ Paroxysmal nocturnal dyspnea - difficulty of breathing at nighttime Nursing intervention: give patient 2 to 3 pillows vOrthopnea - difficulty of breathing while lying down 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 Cardiovascular symptoms: "Puisus alternans - weak pulse followed by strong bounding pulse #Can lead to arrhythmia *Point of Maximal Impulse (PMI) is displaced laterally “Fluid in the lungs pushes heart to one side“Check apical pulse to determine the location of PMI Normal PM| is at the left midclavicular line between the 4" and 5" intercostals space (below the nipple). Note: if the PMI is displaced vertically (lower than normal) then the patient has cardiomegaly. "5, extra heart sound (Ventricular gallop) “Note: S. sound occurs in myocardial infarction Anorexia and body malaise eCyanosis ht-Sided Heart Failure (RSHF) 18x of RSHF Venous congestion — blood goes back to superior & inferior vena cava ‘Jugular vein distention sPitting edema Ascites — fluid in the peritoneal cavity Weight gain sHepatosplenomegaly sJaundice Pruritus and urticaria Esophageal varices Generalized body malaise and anorexia Lithium sAntimanic agent - indicated for Bipolar Disorder sMechanism: decreases acetylcholine (Ach), norepinephrine and serotonin 4SSx of Lithium toxicity: Anorexia Diarrhea and Dehydration, therefore force fluids sHypothyroidism oFine tremors sNursing management for lithium oForce fluids increase Sodium intake to 4 to 10 g daily Aminophylline Indicated for Chronic Obstructive Pulmonary Disease (COPD) yBronchodilators dilate the bronchial tree, thereby allowing more air to enter the lungs 4 SSx of aminophylline toxicity: sTachycerdia "Palpitations ENS excitability: irritability, agitation, restlessness and tremors Nursing management for aminophylline: ®AVOID COFFEE - will aggravate CNS excitability 4 Types of COPD Ens “blue-bloater” — “pink-pulfer” — cyanosis with edema acyanotic with compensatory purse- lip breathing Pathoanomonic Sign: Hemoptysis - blood __Fathoanomonic Sign:Wheezing on in cough Barrel-chest expiration Reversible iireversibie Terminal stage Canlead to pneumothorax (air in pleural space), CO; narcosis ‘Caused by allergic Caused by allergic reaction reaction Hereditary Hereditary surgery Pneumonectomy (removal of 1 lung) Diagnosis: Bronchoscopy an lead to cor Can lead to Cor Pulmonale (enlarged Pulmonale right ventricle) For all types of COPD: 41 cause is smoking Expect doctor to prescribe bronchodilators ®LOW-FLOW OXYGEN only so as not so suppress the respiratory drive Dilanti s 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.0. (febrile seizures are outgrown) yNursing management when giving Dilantin: Only mixed with plain NSS to prevent formation of crystals/precipitates Given via “sandwich method” (give NSS > give dilantin > give NSS) sinstruct client to avoid taking alcohol (Dilantin + alcohol can lead to severe CNS depression) 4 SSx of Dilantin toxicity: °GINGIVAL HYPERPLASIA (important!) *Remember to provide oral care to patient receiving Dilantin: use soft bristle toothbrush vinstruct client to massage gums Hairy tongue eAtaxia - positive Romberg’s test »Nystaamus (abnormal movement of the eyes) Acetaminophen [a.k.a Paracetamol] y Acetaminophen is the treatment of choice for osteoarthritis pathognomonic sign of osteoarthritis: HEBERDEN’S NODES (knobs on finger joints) Note: osteoarthritis is localized while theurnatoid arthritis is systemic. Sx of acetaminophen toxicity sHepatotoxicity - therefore monitor LIVER ENZYMES: *SGPT (serum glutamic pyruvate transaminase), also called ALT (alanine transaminase) *SGOT (serum glutamic oxaloacetic transaminase, also called AST (aspartate transaminase] eNephrotoxicity - therefore monitor Blood Urea Nitrogen (BUN) and Creatinine *Normal BUN is 10 to 20 ma/dL. *Normal Creatinine is 0.8 to 1.0 mo/dLCreatinine is the most sensi sHypoglycemia "55x of Hypoglycemia (Remember T--R-E-D): Tremors, Tachycardia virritability yRestlessness vExtreme Fatigue yDiaphoresis, Depression sThe antidote for acetaminophen overdose is ACETYLCYSTEINE [Mucomyst] ’Note: Acetylcysteine is a mucolytic used for respiratory conditions with excess and thick mucus production (emphysema, bronchitis, bronchiectasis) »Oral acetyicysteine comes in granule form and is orange-flavored (like powdered juice) »Acetylcystaine causes outpouring secretions. "N.Mgt. for administering acetylcysteine: prepare suction apparatus indicator of kidney function The following are symptoms of hypoglycemia EXCEPT: A. extreme thirst B. nightmares C. weakness D. diaphoresis ‘The correct answer is A, Options B, C and D are all symptoms of hypoglycemia: nightmares due to depression, weakness (extreme fatigue) and diapnoresis. Option A Is one of the 3 P’s of hyperglycemia: Polydipsia [excessive thirst], Polyphagia [excessive hunger], and Polyuria [excess urine output). antl Lea nt LES tned wl LI tee Parkinson’s Disease yA chronic progressive disorder of the CNS characterized by degeneration of DOPAMINE-producing cells in the substancia nigra of the midbrain and basal ganglia. j Parkinson's disease is irreversible s Predisposing factors: *Lead and carbon monoxide poisoning *Arteriosclerosis — hardening of an artery Hypoxia Encephalitis sHigh doses of drugs: *Antihypertensives: Reserpine [Serpasil] and Methyldopa [Aldomet] *Anti-psychotic agents: Haloperido! [Haldol] and Phenothiazines 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 > patient becomes SUICIDAL Nursing management for suicidal patients: PROMOTE SAFETY (remove equipment that patient can use to harm himself) rere ss of spouse 2. Loss of job "Nursing management for suicidal patients: DIRECT APPROACH vMaintain patent on close supervisionIn the healthcare setting, suicide attempts most commonly occur: A. Monday 1-3 am’ B. Sunday 6- 9am C. Saturday 1-3 am D. Friday 6 - 9 am The correct answer is C. Suicide attempts most commonly occur on weekends and early mornings when the nursing staff is not around. "Reserpine is also linked to the development of BREAST CANCER. ONCOLOGIC NURSING \s The most frequent types of cancer in women, {in order): 1. Breast 2. Cervical 3. Ovarian 4. Uterine \r 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.0. and above "3 L's of testicular cancer: “Large ~Lumped vLoaded (heavy) ‘The most common preferred treatment for cancer is ‘A. chemotherapy B. radiation therapy C. surgery D. bone marrow transplant The correct answer is C. If the cancer is treatable by surgery, it is preferred over other treatments that have multiple side effects (Options A and 8). Option Dis a specific. treatment for leukemia that is not applicable to other types of cancer. Anyway, back to Parkinson’... /SSx of Parkinson's disease: Early sign: PILL-ROLLING TREMORS — pathognomonic sign of Parkinson's Second sign: BRADYKINESIA (slowness of movement) *'cogwheel” rigidity - intermittent jerking movement *Stooped posture "Shuffling Gait, Propulsive Gait / SSx of Parkinson's disease (continued): sOverfatigue eMask-like facial expression Decreased blinking of the eyes sDifficulty in arising from sitting position »Monotone speech. ’Mood: Lability (depressed) > prone to suicide, therefore PROMOTE SAFETYincreased salivation (drooling) *Prepare suction app at bedside Autonomic changes: “Increased sweating and lacrimation *Seborrhea (oversecretion of sebaceous gland) *Decreased sexual capacity J Stages of Parkinson's Disease |. Unilateral flexion of upper extremities Il. Shuffling gait Ill, Progressive difficulty in ambulating IV. Progressive weakness V. Disability = last stage y Nursing management for Parkinson’s ®Rx Anti-Parkinson agents: ees *Levodopa (L-dopa) [Larodopa] ~ short-acting anti-parkinson procera v Mechanism: increases levels of dopamine Symmetrel vside effects: Artane and Cogentin GIT irritation (nausea and vomiting) Benadryl SORTHOSTATIC HYPOTENSION - always asked in the Pariogel board exam! BArrhythmia Hallucination confusion ¥Contraindications of L-dopa Not given to clients with glaucoma 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) vNursing management for L-dopa Best given with meals to avoid GIT irritation inform client that his urine and stool may be darkened instruct client to avoid foods rich in Vit Be (Pyridoxine): cereals, green leafy vegetables and organ meats Pyridoxine reverses the therapeutic effect of levodopa Note: Vit Bs intake should be increased for patients taking Isoniazid (INH) to counter INH side-effect of peripheral neuritis *Carbidopa [Sinemet] - long-acting anti-parkinson Mechanism: same as levodopa vSide effects DHypokinesia @kyperkinesias Psychiatric symptoms: EXTRA-PYRAMIDAL SYMPTOMS *Amantadine HC! [Symmetrel] “Mechanism: same as levodopa vside effects @tremors Rigidity DBradykinesia ®Rx for Parkinson's (continued): ‘*Anticholineraics: [Artane] and [Cogentin] vAnticholineraics are given to relieve tremorsMechanism of action: inhibits acetylcholine vSide-effects: SNS effects "Antihistamines: Diphenhydramine [Benadryl] v Antihistamines also relieve tremors Side effect for adults: drowsiness @Patient should avoid driving and operating machinery vSide effect for children: CNS excitability - hyperactivity (paradoxical effect for young, children <2 yo.) "Dopamine agonists: Bromocriptine [Parlodel] “Relieves tremors, rigidity and bradykinesia vSide-effect: Respiratory depression, therefore CHECK RR »Maintain siderails, to prevent injury related to falls Prevent complications of immobility: Tum to side q 2, q 1 if elderly ®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] *Inctease oral fluid intake and high-fiber diet to prevent constipation Increase intake of bran and psyllium; use bulk-forming laxatives [Metamucil] Assist in ambulation °Safety precautions: Patient should wear flat rubber shoes, and use grab bars eAssist in surgical procedure: STEREOTAXIC THALAMOTOMY *A portion of the thalamus is destroyed to reduce tremors *Complications of the procedure: v Subarachnoid hemorrhage v Encephalitis “Aneurysm What is the goal collaboratively made by the nurse, physician, physical theray nutritionist for a patient with Parkinson's disease? A. Maintain joint flexibility B. Build muscle strength C. Improve muscle endurance D. Reduce ataxia The correct answer is A. Because of the degenerative nature of Parkinson's, it is not possible for the patient to perform exercises that build muscles or increase endurance {eliminate Options B and C). Op relevant; ataxia is a symptom of Multiple Sclerosis, not Parkinson's. The client with Parkinson's disease is being switched from levodopa to carbidopa. What complication would arise from the prescription change and dosage adjustment? A. euphoria B. jaundice CC. vis fiuctuation D. symptoms of diabetes The correct answer is C. Recall that a side-effect of levodopa is orthostatic hypotension, which is a sudden decrease in blood pressure that occurs when changing from lying position to standingA nursing aid is assisting a Parkinson’s patient during meal time. Which of the following actions by the nursing aid is inappropriate? A. Allowing the patient to cut his own food B. Placing the patient upright C. filling the coffee cup half-full D. Setting limits on the length of mealtime The correct answer is D. A patient with Parkinson's has bradykinesia (slowness of movement), thus it is inappropriate to rush the patient with meals. Note: Allowing the patient to cut his own food (Option A) does net necessarily require the use of a metal knife (remember: do not add details to the question). The patient should be allowed to perform activities that he can do independently to maintain his self-esteem, Meningi J Inflammation of the meninges The meninges is a three-fold membrane that covers the brain and spinal cord. Function of the meninges: support and protection, nourishment and blood supply ©3 layers of the meninges: Dura matter - outermost vSubdural space ~ between dura and arachnoid matter '& SSx of Mening “Arachnoid matter - middle \; Headache, photophobia, fever and chills, Subarachnoid space ~ between arachnoid and anorexia. weight loss. generalized body pia matter FINCREASED ICP > project rojectile vomiting, BThe subarachnoid space is where CSF rate 9 decorticate & decerebrate posturing i; Signs of meningeal irritation: ®Nuchal rigidity (stiff neck) is the Initial sign of meningitis, circulates Zhe subarachnoid space between 13 and Lis the site for lumbar puncture. *Pia matter - innermost eopisthotonus (hyperextension oF J Etiologic agents for meningitis: head and neck) is the second sign. eMeningococcus - most dangerous cause of meningitis //Pathegnomonic signs of meningitis: ’Pneumoceccus agglutination > thrombosis > HYPERTENSIVE STROKE sinitial sign of hpn stroke is headache. Late sign is pruritusjitchiness due to abnormal histamine metabolism. s Thrombocytopenia: decreased platelets > bleeding > hemorrhage sSide-effects of platelet dysfunction: *Eccymosis *Petechiae/purpura *Oozing of blood from puncture site. °NMgt for thrombocytopenia: Avoid parenteral injections "Note: Platelets depletion happens in Disseminated Intravascular Coagulation > treated by heparin sLeukocytosis leads to increased susceptibility to infections, so place the patient on REVERSE ISOLATION (to protect the patient), y Patients with infectious diseases are places on STRICT ISOLATION (to protect other patients)Identify the type of isolation for clients with the following conditions: . Cushing's Syndrome Aplastic anemia . Cancer (any type) Prolonged use of steroids AIDS Post liver transplant . Typhoid fever Hepatitis A Measles Mumps Pneumonia PTB Diphtheria . Meningitis Asthma REVERSE ISOLATION, because the patient has an illness that depresses the immune system, or is receiving immunosuppressive drugs, G to H: ENTERIC ISOLATION, because these illnesses are transmitted via a feco-oral route. | to M: STRICT ISOLATION, because these illnesses are transmitted airborne or droplet O: none, a patient with asthma does not need to be isolated. Nursing Management for Mening! s Administer Rx: Broad spectrum antibiotics (Penicillin) Analgesics antipyretics sInstitute strict respiratory isolation 24 hours after initiation of antibiotic therapy. Comfortable and dark environment Monitor vis, 1&0 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: y Sugar: Glucocorticoids (e.g. cortisol) contro! glucose metabolism r 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 Cree acaeus Pee een sSugar ¥: hypoglycemia ySugar *: hyperglycemia sSalt ¥: hyponatremia, with hyperkalemia {Salt #: hypernatremia, with hypokalemia Sex ¥: decreased libido ‘Sex : hirsutism, acne, striae Hypoglycemia (T-I-R-E-D) Hyperglycemia (P-P-P) sTremors/Tachycardia sPolyuria slrritability /Polydypsia Restlessness sPolyphagia yExtreme fatigue Note: DM is a complication of Cushing's sDiaphoresis/Depression | Decreased tolerance to stress due to " Jinereased steroids cause decreased WBCdecreased steroids (Leukopenia) > can lead to ADDISIONIAN CRISIS. > IMMUNODEFICIENCY Note: Stercids takers (athletes,body builders) experience 88x of Cushing's Hyponatremia Hypernatremia with Fluid Volume Excess s Hypotension sHypertension y Dehydration yEdema s Weight Loss Weight Gain '/Pathognomonic Sx of Cushings: *Moon-face “Buffalo hump Obese trunks *Pendulous Abdomen “Thin extremeties Hyperkalemi Hypokalemia irritability, agitation s Weakness, fatigue sDiarthea, abdominal cramps Constipation sPeak T waves > arrhythmia Prominent U wave > can also lead to arrhythmia yDecreased sexual urge and loss of pubic and | s Hirsutism, acne and striae due to increased sex axillary hair hormones yPathognomonic 5x: Bronze-like skin Other signs: Decreased cortisol couses pituitary gland to secretes Depression Melanocyte-stimulating hormone Teeny Bruising iincreased masculinity in women Management Management: sSteroids ("/s dose in AM and %/ dose in PM) | Potassium-sparing diuretics: Aldactone [Spironolactone] — promotes excretion of sodium while retaining potassium £00 NOT GIVE LASIX Limit fluids flncrease 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 Patient with meningitis should be referred to an audiologist for testing. Rehabilitation for residual deficits: mental retardation or delay in psychomotor development During the acute stage of meningitis, a 3-year old patient is restless and irritable. Which nursing intervention is most appropriate? ‘A. Limit conversations with the child B. Keep extraneous noise to a minimum C. Allow child to play in the bathtub D. Perform treatments quickly The correct answer is Option 8, which will minimize the danger of increased ICP. Myasthenia Gravis yA 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. rEtiology: idiopathic, related to autoimmune»For unknown reasons, the body is producing cholinesterase which destroys acetylcholine, the neurotransmitter for muscle movement, leading to muscle weakness. 1SSx sinitial Sign: PTOSIS (drooping of upper eyelid) sDiplopia »Maskiike facial expression =Dysphagia cHoarseness: Respiratory muscle weakness > respiratory arrest (Prepare tracheostomy set at bedside) extreme muscle weakness especially during activity or exertion Dx test: sTENSILON TEST “Tensilon (Ecrophonium 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) CSF analysis reveals elevated cholinesterase levels