38078786 Medical Surgical Nursing II

7/30/2019 38078786 Medical Surgical Nursing II

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RESPIRATORY SYSTEM

Normal Value of AtmosphericPressure (PA)

760 mm Hg

14.7 psi (pounds per square inch)Important Concepts!!!

Principle of air flow is from areasof higher pressure to areas of lower pressureFor exchange of gases to occur,NORMALLY (N), there must be apressure gradient of PLUS ANDMINUS SIX(+/-) 6 mm Hg

Pressure must be positive (+) (or greater outside) to enter the lung

RESPIRATORYMECHANISM

INSPIRATION EXPIRATION

RespiratoryMuscles

1. Diaphragm

2.PectoralMuscle

3. IntercostalMuscles

Lowers andcontracts

Contracts

Moves inwardand contracts

Rises andrelaxes

Relaxes

Moves outwardand contracts

Lung Size Increases DecreasesThorax Size Increases DecreasesIntrapulmonicPressure

Decreases(less thanatmosphericpressure)

Increases(greater thanatmosphericpressure)

IntrathoracicPressure

Decreases (lessthanatmosphericpressure)

Increases(greater thanatmosphericpressure)

Important Concepts!!!Upper Respiratory Tract

Composed of:NosePharynxAssociated Structures

Lower Respiratory Tract:Composed of:

LarynxTracheaBronchiLungs

Important Concepts!!!Hiluso Hilar Mass

Pleurisyo Pleural Effusion

Intrapulmonic Spaceo Space inside the lung

Intrathoracic Spaceo Space between the lungs

and the bony thoraxNormal Respiratory Rate

o

Twelve (12) cycles per minuteo Also known as Eupnea

Tachypneao Respiratory Rate above

the normal rateBradypnea

o Respiratory Rate belowthe normal rate

Apneao Absence of Respiration jor

absence of breathing

Types of RespirationReference is the cell

Internal or Cellular RespirationExternal Respiration

Important Concepts!!!Hyperpnea

o Deep BreathingHypopnea

o Shallow Breathing Kussmauls Breathing

o Deep, rapid breathsFactors Affecting the Rate and Depthof RespirationNeurological

MedullaCenter of Respiration


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PonsAffects the rhythmExpansion of the lungsHerring Brewer Prevents over distension of the

lungsClinicalArterial Blood Gas

Arteryo Complete presence of

oxygen and carbon dioxideParameters:

o pH7.35 to 7.45

o pHCO 3

22 to 26 meq / Liter o PCO 2 35 to 45 mm Hg

o PO 2 80 to 100 mm Hg(for adults)40 to 60 mm Hg (for infants)If increased or greater than 60% ininfants, it leads toRETROLENTALFIBROPLASIA

Important Concepts!!!Acidosis or alkalosis is detectedby the pH

Control:Respiratory / metabolic

Bicarbonateo Buffer / neutralizer o Must be > 26 meq / L to

counteract acidosisKidney

o Base factor Determination of Lung function

o PCO 2 Hypoxic Drive

o Stimulant is CO 2 Hyperventilation

o Prone to Alkalosiso Patient gets a lot of O 2 o Decreases amount of CO 2 o Therefore, breathe inside

a bago

Do paper bag breathingo Do cupped hand breathingRespiratory Acidosis

o Do pursed lip breathingo You want to retain positive

(+) pressure on the lungo Takes effect on CO 2

utilizationo To remove CO 2

Expiration is prolonged (longer than inspiration) by pursed lip

breathingASSESSMENT TO RULE OUTRESPIRATORY DISORDER

1. Cough

Important Concept!!!Three (3) types of cough medications:

Antitussiveso Suppresses the cough

reflexExpectorant

o Clears the airway

Mucolytico Lyses, breaks down,

liquefies the phlegm

Types of Cough

1.1) Non-productive CoughWith presence of phlegmWith copious amounts of phlegmPhlegm is retained and is notexpelled from the bodyMedication is a MUCOLYTIC

o It lyses, breaks down andliquefies the phlegm


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1.2) Productive CoughWith presence of phlegmWith copious amounts of phlegmPhlegm is being expelled fromthe body

Medication is anEXPECTORANTo To clear airway

1.3) Dry CoughNo phlegmCough needs to be suppressedMedication is an ANTITUSSIVE

o With sedating effect Important Concept!

o No antitussive is given

when there is phlegmo Suppression of cough willnot allow the phlegm to beexpelled from the body

2. Sputum and Phlegm

2.1 Color Important Concepts!!!

Salivao Normal color is clear

Phlegmo Red

With bloodHemoptysis

Spitting of blood

HematamesisUpper GIbleedingVomiting of bright red

bloodo Yellow GreenSignifies infection

o GreenishDepends on type of infecting microbe

o RustyBrown

Blood is brownishdue toextravasationPneumoniaDue to blood (old

blood)Viral or bacterialWith consolidation(hardening or naninigas)

o Two Types of Consolidation

Lobar Occurs at thelobes

Bronchial

Occurs in thebronchiOccurs inbronchopneu-monia

More common

Interjected Concept!Pulmonary Tuberculosis

o Bacterialo Mode of Transmission

Droplet nucleio RouteAirborne

o It is appropriate to wear MASK

o It is inappropriate to wear GOWN

o With CAVITIES

Other Interjected Concepts!Black and tarry stool

o

Indicates dead bloodMelena indicates upper GIbleeding

2.2) Viscosity and TenacityMucin

o Makes saliva slipperyPhlegm


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o Irritated salivao Thick and tenacious saliva

Hypermucous Productiono Leads to phlegm

Important Interjected Concepts!!!Rhinitiso Nasal cavity inflammation

Coldso Viral in nature

Coryzao Viral in nature

Glossitiso Inflammation of the tongue

Glottitiso Inflammation of the glottis

Tracheitiso Inflammation of thetrachea

Bronchiolitiso Inflammation of the

bronchiolesPneumonitis

o Inflammation of the alveoliGastritis

o Inflammation of thestomach

Stomatitiso Inflammation of the oral

cavity

Important Interjected Concepts!Signs of Inflammation

Rubor o Redness

Calor o Heat

Tumor o Swelling

Dolor o Pain

Functiolaesao Loss of Function

Viscosity and Tenacity of Sputum (continued. . .)

2.2.1) Frothy SputumAir is present but is due toPULMONARY EDEMAPneumothorax

o

Air at intrapleural space2.2.2) Stringy and Thready (thinner)Sputum

Due to BRONCHIAL ASTHMA Masyadong malagkit

Caused by allergeno Dusto Polleno All dust particles

Interjected ConceptClear and stretchy vaginal mucusor discharge indicates fertility

3. Assess for CyanosisBluish color due to lack of oxygen

3.1) Central CyanosisBluish coloration of the:FaceChest

3.2) Peripheral CyanosisBluish coloration of theextremities

3.3) Differential CyanosisAcrocyanosisUse Apgar scoring

o Within one (1) minuteo After five (5) minutes

APGAR also stands for:o A for Appearanceo P for Pulse

Heart Ratedetermines if thebaby is alive

o G for GrimaceTo rule outneurological


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problems or problems with thenervous systemImportant Concept!!

In newborns,

eyeblinking beforecrying is Normal

If there is NOBLINKING, thisindicates A SIGNOF MYASTHENIAGRAVIS of thenewbornThis indicates thatthere is NO

INNERVA-TIONo A for Activity

Muscle Tonicityo R for Respiration

Changes inrespiration requiresimmediateintervention andactionFirst thing to do tonewborn:

Suction

4. Abnormal Breath SoundsAlso called Adventitious BreathSounds

4.1) RalesTwo (2) types:

Fine RalesCoarse Rales

4.1.1) Fine RalesSound similar to when you rubyour hair Also called Friction Rub

4.1.2) Coarse RalesSound similar to crumpling of paper

4.2) RonchiSound similar to bubbling water

4.3) Wheezing

Musical soundWhistling soundOccurs more on or duringexpiratory phase

Important Concept!Abnormal breath sounds are dueto:

o Obstructiono Phlegm

5. Abnormal RespirationPattern of breathing or sequenceof breathing

5.1) Biots Respiration Initially NORMALFollowed by APNEAThen NORMALThen APNEAPattern is NANA normal,apnea, normal, apnea, etc.

5.2) Cheyne StokesInitially NORMALFollowed by HYPERPNEA (deepbreathing)Then APNEAPattern is NHA normal,hyperpnea, apnea

5.3) Kussmauls Respiration Hyperpnic with tachypnea

Malalim na, mabilis pa Asthmatic and labored breathing

Common Signs and Symptoms of Respiratory Diseases

1. DyspneaAlso called Difficulty of Breathing


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o ManagementPositioning

High-Fowlers

Interjected Concept!!In reverse trendelenberg, only thehead part is elevatedThis is indicated for arterialocclusion

2. Cough3. Anorexia

o Loss of appetiteo Management

Provide small

frequent feedingsPatient chooses hisown foodNurse assists in theselection of the foodGood oral hygienetriggers appetite

4. Weight Loss5. Malaise

o Weakness6. Easy Fatigability

o

Managemento Provide bed rest7. General Debilitation

o Loss of functiono Patient wants to move but

is unable to do soo Debilitation

Apathetic(schizophrenic)

8. Irritability

Interjected Concept!!!Correct technique in cleaning thepatient is from A CLEANER

AREA to a DIRTIER AREA toavoid conveying infection

Chronic Signs and Symptoms of Respiratory Diseases

Overdeveloped strap musclesElevated sternum and shoulder Barrel chest or Pigeon Breast

o No elastic recoilo

Common in emphysemaStridor o Noisy Respiration

Clubbing of Fingerso Caused by hypoxia of the

jointsChest Retraction

Interjected Concept!The urinary bladder is consideredfull when it contains a volume of

about 450 to 500 mlYou cannot stop the urge to voidat this level of fullness of theurinary bladder

General Management Techniques:To minimize weakness

o Provide bed restFor dyspnea

o Proper positioningProvide good nutrition

o Proper and balancednutrition

Environmental SanitationOxygenation

o If patient is dyspneic andnot relieved by positioning

o Nasal Cannula or nasalprongs

o Nasal flowLow flowOne (1) to three (3)liters per minuteAverage of two (2)liters per minuteHigh flow is at six(6) liters per minute

Coupetteo A plastic bubble

Isolette


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o An incubator Nasal Catheter Tip should be placed posterior tothe uvula

Important Concepts!!!If the respiratory disease in an infectiousdisorder, management would includethe following:

Isolationo Reverse Isolation

Patient is beingisolated because hecould easily beinfected bydiseases

The patient himself is being protectedExample:Burn patients aresubjected toreverse isolationbecause they areprone to infectionAIDS patients areon reverse isolationbecause they areimmunocompro-mised

o Strict IsolationPatient is beingisolated because hecan readily spreadthe diseaseThe people aroundthe patient arebeing protectedExample:PTB patients aresubjected to strictisolationMycobacteriumtuberculosis is

transmitted throughdroplet and isairborne

Medicationo A dependent functiono

Antibiotics areadministeredo For allergens

Antihistamines aregiven

o BronchospasmBronchodilators

o CoughCough medication

RESPIRATORY DISORDERS

PULMONARY TUBERCULOSIS Causative agent isMycobacterium tuberculosisAcid-fast bacillusTemperature

o Coated with waxo Melt this with temperature

(an additional factor)Mode of transmission is droplet /airborne

Stages of Pulmonary Tuberculosis

Stage No. 1 MINIMALINFILTRATION

No cavitaries but with lesionPrimary complex in childrenWith chemotherapy or multi-drugtherapyUrine becomes BRICK ORANGE

o Due to Rifampicino A normal and expected

side effect of Rifampicinuse

Interjected Concepts!!!In cancer, chemotherapy causesthe following:

o Alopecia


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Loss of hair o Keratin

Protein in the hair o Collagen

Protein in the

internal organso DNA and RNA proliferationis blocked

Stage No. 2 MODERATELYADVANCED

With cavitaryOne-half of lung is affectedLobectomy or removal of onelobe is performedInitially, position the patient at the

UNAFFECTED SIDEThen, turn patient on an hourlybasis

Stage No. 3 FAR ADVANCEDWith cavitaryWhole or entire lungs areaffectedPneumonectomy or removal of the entire lungs is performedPosition patient at the

AFFECTED SIDEMediastinal Shift is a commoncomplicationTurning on an hourly basis is alsoperformed

Diagnostic Tests for PulmonaryTuberculosis

Chest X-rayTo show where the lesion islocated

Sputum ExaminationCulture and SensitivityTo identify the bacteriaTo know what antibiotic will beused to combat the invadingmicroorganism

The doctor and the medicaltechnician would perform this

White Blood Cell (WBC) andErythrocyte Sedimentation Rate

(ESR) TestIncreased WBC levels indicate:o Bacterial infectiono Kochs infection

Mantoux Test or Tubercullin TestUtilizes PPD (Purified ProteinDerivative)Route is IntradermalResult is read after forty-eight(48) to seventy-two (72) hours

Positive Reading if:o 10 mm induration or diameter of the wheal(hardness or pantal butnot the erythema)

o 5 mm induration for HIVpositive patients

Important Concepts!A positive result or a positiveMantoux Test does not mean thata person has PTBIt only means that the person hadbeen exposed to the invadingbacteriaThen, it is advised that the other tests would be performedThe most credible test is theSPUTUM TEST (also for pneumonia)You will know the microorganismYou will know the drug to be used

Signs and Symptoms of PTB

Fever o Low grade fever (onset) in

the afternoono Patients resistance is low

at this time


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o Virulence also increaseso If PTB is advanced, fever

does not manifest as lowgrade

Excessive Sweatingo

HyperhidrosisDehydrationo Management is to

increase oral fluid intakeAnorexiaWeight LossEasy Fatigability

Management of PTB patientsBed RestPositioning

For patients with dyspnea, placein high- Fowlers position Provide good and proper nutritionIncrease Fluid IntakeMedication

o Triple Chemotherapyo Rifampicin

Brick orange urineo Isoniazid (INH)

Peripheral neuritisProvide Vitamin B 6 or pyridoxine

o Pyrazinamide (PZA)Gout formationUric acid crystals

Important Concepts!!!In PTB, there is an onset of low-grade fever In Pneumonia, there is an onsetof high-grade fever

Short-Course ChemotherapySix (6) monthsProlonged

o More than one year Use Ethambutol

o Side effect is OPTICALNEURITIS

Use Streptomycin

o Side effect is on the 8 th cranial nerve

o Therefore, this isOTOTOXIC

CHRONIC OBSTRUCTIVEPULMONARY DISEASESMnemonic is ABBE

AsthmaBronchitisBronchiectasis

o With scarring or nodulescalled SARCOID

o With numerous sarcoidscalled SARCOIDOSIS

May lead to:o

Lung cancer o Emphysema

Important Concept on COPDs!!! All COPDs are characterized by:

Presence of phlegmObstruction by phlegm

Signs and Symptoms of COPDProductive CoughExertional Dyspnea

o In asthmaticPink Cyanosis

o Due to compensatorymechanism

Blue bloaterso Cyanosiso Hyperventilateo Reddish during attack -

hyperemiao Increases altitude and

decreased PO 2 results intohyperemia

Wheezingo Expiratory

Barrel Chesto Common in emphysema

AnorexiaFollowed by weight loss, bodymalaise, etc.


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Respiratory infectionFatigueCor Pulmonale

o Right Ventricular Hypertrophy due to

increased vascular resistance or vasoconstriction

Results into a BOOT-SHAPEDHEART

Nursing Interventions for COPDpatients:

Assess the following:o Breathing patterno Breath soundso

SecretionsPromote mobilization of secretions through:

o Mucolytic agentso For productive cough, use

expectorantso Increased humidification of

moisteningo Fluid intake of 1.5 to 2.0

liters per daySaliva is not part of daily fluid loss

o Suctioningo Chest Physiotherapyo Positioning to allow

maximum breathingo Teach the patient to use

pursed lip breathingAdminister low flow oxygenMonitor therapeutic and sideeffects of the medications usedBed restEncourage Range of MotionexercisesAssist with activities of daily living(ADL) as neededAssess for signs of infectionProvide proper caloricrequirement: Increase proteinintake

Provide health teachings:o Avoidance of smoking,

irritants, infectiono Avoidance of extreme

temperatureso

Proper nutrition andhydrationo Use measures to conserve

energy

Important Concepts!!!For Orthopnea

o Do the Orthopnic positiono Fowlers Position and lean

forwardo Lung is most expanded in

this positiono Lung is most open in thisposition

o Lungs expand but they donot thicken

Atelectasiso Lung collapseo Overdistended lung

collapseEmphysema

o Bursting of alveolio Bleeding occurso If there is pus, it is called

EMPYEMAPyothorax

o Presence of pus in thepleural space

Important Concepts!!!The heart is located at the center of the chestThe apex of the heart ispositioned to the left of the chestRight Atrium is larger than theother chambersThe Left Ventricle has the highestpressure among the four chambers of the heartThis serves as the main pump of the heart


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Cardiac Outputo Five (5) to seven (7) literso Average is six (6) liters

Stroke Volumeo Amount or volume of blood

released through the heartin one beato Equivalent to about fifty

(50) to seventy (70) mlTidal Volume is about 500 to 700ml per respirationCardiac Output

o 5 7 liters per minuteStroke Volume

o 50 70 ml per beatTidal Volume

o

500 700 ml per respiration

Important Concepts!!!Approximate Distribution of Oxygenin the BodyBrain 15% of oxygen in

the circulatingblood

Heart 5% of oxygen inthe circulating

bloodGI and Liver 25% of oxygen inthe circulatingblood

Renal System 25% of oxygen inthe circulatingblood

Extremities(upper andlower)

30% of oxygen inthe circulatingblood

Important Concepts!!!Decreased level of consciousnessCaused by peripheral hypoxiaSyncope

o FaintingTachycardia

o Early sign of decreasedlevel of consciousness

Bradycardiao Late sign of decreased

level of consciousness

Interjected Concepts!!!

Angina Pectoriso Stabbing paino Unifocal pain

Myocardial Infarctiono Crushing paino Excruciating paino Radiating to the left

Due to the fact thatthe output is at theleftCoarctation of the

aortaOther Important Concepts!!!

Pulse Deficito The difference between

the APICAL and theBRACHIAL PULSE

o Normally, the differencebetween these values isZERO

o Difference signifies thepresence of anOCCLUSION

Pulse Rate resembles the HeartRatePulse Pressure

o Systolic-Diastolico Normal is 40 mm Hgo Artery is 40 mm Hgo Vein is 10 mm Hgo Artery has pulse

Tricuspid Valve is locatedbetween the Right Atrium and theRight Ventricle

Important Concept!!!Cor Pulmonale

Also called Right Ventricular Hypertropy


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Pulmonary artery constrictionleads to decreased blood flow tothe lungs for oxygenationBlood is, therefore, retained atthe Right Ventricle

A sphincter can be opened byincreased pressureA valve cannot be opened byincreased pressureTherefore, there is an INCREASEIN THE SIZE OF THE RIGHTVENTRICLECor Pulmonale results into aBOOT-SHAPED HEART

Suctioning

OB-gyneo The first thing to do to thenewborn in the Philippinesetting is to SUCTIONTHE BABY

CGFNSo The first thing to do to the

newborn is to WRAP THEBABY to preventhypothermia

Situation:Newborn has mucus on mouthand nose.

Question:Which do you suction first?

Answer The mouth!

Rationale:There is more mucus in themouth from the GI tract.This gives rise to greater risk for aspirationThen place the patient on lateraltrendelenberg

Important Concept!!Infants are obligate nose breathers

Important Concepts!!!After a month, if the infant has arespiratory disorder

o Suction the NOSE FIRSTIn adults, the nose is cleaner

Therefore, the proper sequenceof suctioning is from cleaner todirtier (nose then mouth)

Interjected Concepts!!!Wash the breast of a woman withlukewarm water

Important Concepts!!!For patient with increasedIntracranial pressure and mucus

at both the nose and the mouth o Do suctioning only at themouth

o Do not suction at the noseo This would cause the

patient to sneezeSneezing further increasesintracranial pressure

Chest Physiotherapy (CPT)Done on the chest in a gentlemanner If the patient is female, do it atthe upper part of the chestComposed of:

o TappingUsing one handWith greater force

o ClappingUsing both hands

o CuppingUsing one hand

Positiono Semi- Fowlers Position

Important Concepts!Back tapping, back clapping andback cupping is not part of CPTLow-flow oxygenation is used inCOPDs to maintain hypoxic drive

o CO 2 stimulates breathing


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Use pursed lip breathing for acidosis to maintain positive (+)pressure as expiration is longer

Signs and Symptoms of Infection

Mnemonic is SHIRP S is for:o Swelling

H is for:o Heat

I is for:o Impaired Motor Function

R is for:o Redness

P is for:o Pain

Important Concepts!!!If infection is present, there is

ALWAYS INFLAMMATIONBut not all inflammation isaccompanied by infectionIncrease protein in diet for tissuerepair Increase protein in diet for repair of lung tissueExtreme temperature is atriggering factor for asthma but isnot an allergen

PNEUMONIAViral and bacterialWith consolidationWith fever High-grade at onsetDuring an attack of pain, positionthe patient ON THE AFFECTEDSIDEManagement

o Turn patientTurning promotescirculationWithout circulation,one cannot removethe consolidation of phlegm

o Cough-upPriority interventionFirst thing to doIncreasescirculation to

removeconsolidatedphlegm

o Deep Breathing

LUNG CANCERBiopsy is needed to confirm thisdiseaseReal cause is unknown,idiopathicSmoking only decreases cellular

resistancePredisposing Factors in Lung Cancer

Familialo Genetic / hereditary

Cigarette smokingo Second hand smokeo Filtered cigarettes lessens

contaminationExposure to occupationalcarcinogens

o AsbestosAsbestos in lungs inincreasingquantities causeslung cancer

o SilicosisSilicon oxide inlungs

o TalcosisCement in the lungs

o BronchiectasisNodules are sarcoidBenign or malignant

Diagnostic Tests for Lung Cancer

Chest X-rayTo know where the tumor is


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CT ScanCAT Scan

For axial skeleton

Sputum ExaminationCytologic examination of thesputum

BronchoscopyDirect visualization of the tracheaand the bronchusIf with biopsy, it is calledFIBEROPTIC BRONCHOSCOPYPre-procedure

o Anesthesia is giveno

Xylocaine appliedPost-procedureo NPO until gag reflex

returnsWithout the presence of the gagreflex, there is a risk for aspiration

Signs and Symptoms of Lung Cancer Persistent Coughing andExpectoration

o Phlegmo Irritation due to the

presence of tumor o This is the CLASSIC SIGN

and SYMPTOM of lungcancer

DyspneaDysphagiaHoarseness of voice

o Vocal cords arecompressed by the tumor

Anorexia

Important Interjected Concepts!!!Pediculosis

o Presence of licePTB is characterized by:

o Bacterial causationo Cavitaries in the lungs

o Low-grade fever (onset)with chills

Lighteningo Fetus if floating above

pelvis

Descento Also considered asSTATION

o Fetus is no longer floatingabove pelvis but is at thelevel of the ischial spine

Crowningo Fetus is at about +3 or +4

relative to level of theischial spine

Chest TubeThoracostomy TubePurposes:

o Primary PurposeFor re-expansion of the lung

o Secondary PurposeTo maintainnegative pressurein the lung throughdrainage

Important Concepts!All chest surgeries require chesttubesIn pneumonectomy, no lungs areleftAll bottles should be placedbelow the chest levelBubbling must be intermittentIf bubbling is continuous, there IS

A LEAKAGEFluctuations in water level isnormalUpon INSPIRATION

o The water at the tubeDESCENDS

o The water level at thebottle ASCENDS

Upon EXPIRATION


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o The water at the tube ASCENDS

o The water level at thebottle DESCENDS

Avoid milking and kinking the

tubeo These are not routinelydone

Negative pressure is suctionpressureClamping of the tube is NOTDONE

Indicators for Chest Tube RemovalAbsence of distressAbsence of fluctuation

o

This means that the lung isalready re-expandedNormal breath sounds in the areaFully expanded lung on X-ray isthe most determinant indicator

o This means that theprimary purpose has beenserved

Important Concepts!!!When pulling out the Chest Tube

o Ask the patient to EXPIREo Thorax should be airtighto Petroleum gauze is

needed before pulling outthe tube

If Valsalva is included in thechoices in the board examination,CHOOSE VALSALVA

Interjected Concept!!!In the removal of the FoleyCatheter,

o Ask the patient toINSPIRE

This allows the patient to relax

GENITOURINARY TRACT

Important Concepts!

The female labia majora ishomologous to the male scrotumThe female clitoris is homologousto the male glans penisBoth these structures have a

special type of blood vesselcontaining erectilesThe meatus is the area where theurine is passed outThe female urethra is the avenuefor passage of urine while themale urethra is the avenue for thepassage of both urine and spermThe females have a vaginalopening a canal serving as thereceptacle for the penis

Both sexes have a rectum and ananus

CatheterizationDone to prevent urinary retentionand bladder distention

Important Concepts!!!The urinary bladder is paralyzedby anesthesiaVaginal Opening

o SpeculumFor pap smear For dilatation andcurettage

Vaginal Doucheo For Vaginitiso This is an acidic solutiono Contains lactic acid or

acetic acido Normal pH of the vagina is

4.5 to 5.5o Acidic environment aids to

prevent possible infectionEnema

o Applied to the rectumo For diagnostic purposes:

Barium EnemaWhite andmilky


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o For cleansing purposesBase enemaSoap enema

Important Concepts!!!

Upper GI Serieso Barium SwallowLower GI Series

o Barium Enema Skenes Gland in F emales

o Found at the sides of theurinary meatus

o For lubrication purposeso Homologous to the

Cowpers gland in males Bartholins Gland

o

Found at the sides of thevaginal openingo Also for lubrication

purposesSmegma

o This is the cheesy whitesubstance found aroundthe clitoris

Radical Perineal Prostatectomyo This is a procedure done

to maleso Therefore, males also

have a perineumFourchette

o Site of episiotomyo Site of episiorraphy

On the mons pubiso APOCRINE GLANDS are

presentSweat glandsPresent at puberty

o When young, these areECCRINE GLANDS

KIDNEYSPaired, comes in the same sizePosition

o Right kidney is lower dueto the anatomical positionof the liver

o Fat anchors the kidney tomaintain it at theretroperitoneal area

Important Concepts!!!

Glomerular Filtration Rate (GFR)Normal Valueo 125 ml per minute

Normal Urine Productiono 0.5 to 1.0 ml per minuteo 24 ml reabsorbed by the

kidneyMicturition Reflex

o 250 450 mlo 125 ml can still be

contained

Hydronephrosiso Drowning of the kidney inurine

Nephrotosiso Falling of the kidneyso When fat is losto Kidney fallso Ureter kinks

Nephrosclerosiso Hardening of the Kidney

Arteriosclerosiso Hardening of the arteries

Important Terminologies!!!Nephrolithiasis

o Stones in the kidneyUreterolithiasis

o Stones in the ureter Cystolithiasis

o Stones in the bladder Urolithiasis

o Stones in the urinary tractStones in the Biliary Tract

o CholelithiasisStones in the gallbladder

o CholedocholitihasisStones in the bile duct


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BREAST CANCERIdiopathicLeft breast

o Commonly first to developtumor

o

Less active tissue is tumor proneHeart is an involuntary organ

o Heart is activeo Thus, there is no cancer of

the heart

Predisposing Factors in BreastCancer

Familialo Genetic

Hormoneso Estrogeno Extremes of estrogen

Positive estrogenreceptor tumor Negative estrogenreceptor tumor In menopause,there is higher negative estrogenreceptor tumor Early Menarche(first menstruation)

Positiveestrogenreceptor tumor

o NulliparityUnable to give birthdue to inability tobecome pregnantReproductive age isfrom 15 to 45

o Also due to failure tobreast feed

o Andropause is malemenopause

o RadiationBreast tumor Breast gland tumor

Adenocarcinomao Obesity

20% and aboveideal weight

o Multiple Pregnancy

Presence of morethan one (1) fetusUniovular

One (1) zygoteMonozygotictwinsSame sex

Biovular Two (2) eggcellsTwo (2)

zygotesDizygotictwins or fraternaltwinsMay be of differentsexes

o IsograftGraft from identicaltwin

Signs and Symptoms of BreastCancer

Cysto Movable

Breast Tumor o Fixedo Non-encapsulatedo Therefore, it can

metastasizeo Commonly located at:

Upper outer

quadrant near theaxial (tail of Spence)Below the nipple

o This results toELEVATION when thetumor is SHALLOWLYLOCATED


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o This may also result toRETRACTION when thetumor is DEEPLYLOCATED

Usually painless INITIALLYo

Pain is present at VERYLATE STAGEWith discharge that may be clear or bloodySkin DimplingSkin ElevationLymphadenopathy on affectedarm

Important Concept!For non-lactating women with

breast discharge:o No cancer yeto Have check-up

Diagnostic Test for Breast Cancer Biopsy

o Excisional BiopsyTumor is removed

o Incisional BiopsyOnly a portion isremoved

o Needle BiopsyDone throughaspiration

Management of Breast Cancer Medical managementSurgical management

o LumpectomySurgical removal of non-cancerousmassWedge resection

o MastectomyRemoval of thebreast

o Radical Mastectomy

Removal of thebreast and other tissues

o Simple MastectomyBreast alone is

removedFat alone

Important Concepts!!!Post-mastectomy

o Elevate affected armabove chest or heart level

o Use pillows to elevate armHemovac

o SuctionCheck the back for bleeding

Protect affected armo Prevent overuse for firsttwo months

o Overuse of affected arm iscontraindicated

No exercise that is strenuousNo exposure to sunlightBreast Self Examination (BSE)

o Done one (1) week after menstruation

o Because estrogen iselevated

o Use one hando Three fingerso Outer to inner o Anytime of the dayo Lift up affected armo If lying down, put a pillow

at the backo If patient is already

menopause, BSE could bedone anytime

Interjected Concepts!!!In thyroidectomy, check the napeIn obtaining urine specimen:

o Get this early in themorning

o First void is discarded


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o Midstream void iscollected as specimen

Parasympathetic NervousSystem

o Increases smooth muscle

activity of glandso Salivation during sleepAtropine Sulfate

o Used to decreasesecretions

With anti-cholinergic effect

URINARY TRACTKidneys

Most aggressive

Functions of the Kidney:Homeostatic Functionso Fluid and Electrolyte

Balanceo Acid-Base Balanceo Hemoconcentration

Through filtrationSecretory Functions

o Urineo Renino Erythropoietin

Excretory Functionso Water o Electrolyteso Metabolic Wasteso Ureao Purines converted into uric

acido Creatinine

Metabolic wastefrom musclesReaction to tissuedamageVery crediblemeasure of kidneyfunction

o Presence of damagedtissues and cells results toincrease in Creatininelevels

o In Brain DamageCreatinine releasedis creatinine kinaseor BB

o In Heart Damage

Creatinine releasedis MBo In damage of other

musclesCreatinine releasedis MM

o Blood Urea NitrogenAffected by proteindiet

Vitamin D Synthesiso Vitamin D comes from

foodo Raw vitamin Do Goes to the kidney and the

skino Must be exposed to

ultraviolet radiation to beconverted to its active form

o Deficiency of Vitamin Dresults into weak bones

Ricketts in childrenOsteomalacia inadults

Abnormal Constituents of UrineNormal urine has hormonesGlucosuria

o Presence of glucose inDiabetes mellitus patients

Diabetes insipidus patients havedecreased levels of Anti-diureticHormone or ADH

o This leads to the two (2)Ps

PolyuriaPolydipsia

Diabetes mellitus patients haveproblems with insulin

o This leads to the three (3)Ps

Polyuria


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PolydipsiaPolyphagia

Types of Diabetes Mellitus

Type 1 Diabetes mellitusInsulin Dependent DiabetesMellitusJuvenile onsetMore controlled diet is necessaryMore severe type of diabetesPancreas could not produceinsulinInsulin is administered to thepatientFats and proteins are utilized by

the body in a process calledgluconeogenesisUtilization of fats results in theformation of ketonesThis leads to DIABETICKETOACIDOSISBlood becomes more viscousThere is less plasma due todehydration secondary topolyuria

Type 2 Diabetes mellitusAdult onsetNon-ketotic diabetesManagement:

o Dieto Exerciseo Oral hypoglycemics

Type 3 Diabetes mellitusGestational Diabetes

Type 4 Diabetes mellitusSecondary DMCaused by disease

Important Interjected Concepts!!!In polycythemia vera

o There is also increaseblood viscosity

o However, there is nodecrease in blood volume(this occurs in DM)

Hematuriao Blood in the urineo

This is ABNORMALPyuriao Pus in the urineo This is ABNORMAL

Proteinuriao Presence of protein in the

urineo This is ABNORMAL

Blood contains the following:o Albumino Globulino

FibrinogenAlbuminuriao Presence of albumin in the

urineo Results into decreased

albumin in the bloodo This brings about

DECREASED OSMOTICCOLLOID PRESSURE

o This leads to EDEMAo To compensate for

Albumin loss, lipid levelsincrease in the blood

o This results toHYPERLIPIDEMIA

o Hyperlipidemia contributesto both:

AtherosclerosisDeposition of fat at the bloodvessel

Arteriosclerosis

Hardening of the bloodvessels

Hypertensiono Increased pressureo Decreased perfusion

Thirty percent (30%) of oxygengoes to the extremities


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SEIZURE DISORDERSEpilepsyConvulsions

Types of SeizuresPetit mal seizureso Short-term seizures

Grand mal seizureso Involves the whole bodyo With aurao Lasts for one (1) to two (2)

minutesMyoclonic Seizures

o Involves the upper extremities

Akinetic Seizureso Patient collapseso Drop attack

Jacksonian Seizureso Partial seizureso Patient can still walk

Psychomotor Seizureso Decorticatedo Decerebrated

Types of ConvulsionsTonic

o Sustainedo Prolonged

Clonico kabilaan

Tonic-Clonico kabilaan at matagalan

Epiliptiformo Can recover quickly

Important Concepts!!!Epilepsy is more serious thanconvulsionsFainting always occurs withepilepsyIn epilepsy, EEG is needed

URINARY TRACT INFECTION (UTI)Urethra is affected

Females are commonly affectedo Due to the proximity of the

anus to the urinary meatusE. coli

o Normally present in the

colono Normal flora in the colono Comes out even during

flatus

Management of UTIIncrease fluid intakeCollect sterile urine specimen

o First void is discardedo Midstream void is

collectedo

For urine culture andsensitivity testProvide warm SITZ BATH

o In the hospital, warm water is used to submergepatient up to below thelevel of the umbilicus

o Also called HIP BATH Suob

o Warm compress

Medications for UTIAntibiotics are given

Important Concepts!!!Nystatin is givenIn cases of fungal infectionrelated to antibiotic therapyOral ThrushManagement

o Padded tongue depressor Swab

ACUTE GLOMERULONEPHRITIS(AGN)

Causative organismGroup A Beta-hemolyticStreptococcus (GABHS)


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Assess to rule outUpper Respiratory TractInfectionsTonsillitis6x or chronic type

Suggestive of tonsillectomyBoth are indication or complication of AcuteGlomerulonephritis andRheumatic Heart DiseaseAnasarca

o More prominent in lower extremities

o Prevent complicationsManagement of Lower ExtremityEdema

Modified trendelenbergElevate

Types of EdemaBipedal Edema

o Feet EdemaSacral EdemaAscitesCarpal EdemaFacial EdemaPeriorbital Edema

Important Concepts!!!Right-sided Congestive HeartFailure

o Systemic effectso Compromises the kidney

Important Concepts in AcuteGlomerulonephritis

This would bring aboutperforations in the glomeruli anddamage the permeability of theglomerular wallAssess for AlbuminuriaHypoalbuminemia or Albuminuria

o Gives rise to decreasedCOLLOID OSMOTICPRESSURE

o Decreased colloid osmoticpressure gives rise toEDEMA

Hearto Left-Sided Congestive

Heart FailureAffects thePulmonaryCirculation

o Right-Sided CongestiveHeart Failure

Affects theSystemicCirculation

Kidneyo Anasarca or full-body

edemaIncrease in Lipidso Hyperlipidemiao Gives rise to Hypertensiono Hypertension gives rise to

seizureso Seizures gives rise to

convulsionsEdema

o Results into decreasedblood volume

o Decreased blood volumetranslates to hypovolemia

Oliguriao Scanty urine

Hematuriao Blood in the urineo Brought about by

perforations in the kidneycaused by GABHS

Blood Urea Nitrogen Clearanceo The manner in which the

kidney can clear BloodUrea Nitrogen

o This decreases in AGNBlood Urea Nitrogen (BUN)

o Increases due to thepresence of oliguria

o Normal Value10 20 mg / dl


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o Other sources say it is:5 25 mg / dl8 25 mg / dl

o Lowest BUN value inFemales is 4 8 mg / dl

o

Therefore, always assessfor BUNAGN onset with Hypertension

NEPHROTIC SYNDROMEA cluster of diseasesEnd point of a variety of diseasesdamaging the permeability of theglomerular wallTherefore, there is POLYURIADuring the onset, there is. . .

o

HYPOTENSIONDuring the latter stage, there is. ..

o HYPERTENSIONWhen theglomerular wallbecomes perforatedand thepermeability isdamaged

Proteinuria Edema Hyperlipidemia Hypertension

Management of Edema

Use diuretics

1. Chlorothiazide GroupExample:

o Diuril

2. Loop DiureticsStops reabsorption of water atthe loop of HenleExample:

o Lasix

3. Potassium-sparing DiureticsFor patients with heart conditionAllows sodium out and letspotassium get inExample:

o Spironolactone

4. Osmotic DiureticsFor the brainI.V. route for quick effect

Example:o Mannitol

Important Concepts!!!To decrease lipid levels inhyperlipidimia

o Use LIPOSTATPrevents lipidproliferation

Hyperlipidemiao Increased lipid levels in

bloodo Results into scarring of

blood vesselso Blood accumulates in

scarred areaso Thrombus formation or

blood clots occur in thescarred areas of the bloodvessel walls

o Thrombus detaches fromthe blood vessel wall andis carried by the blood.Thrombus is now called anembolus

Important Terminologies!!!Thrombosis

o Presence of plenty of thrombi


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Venous Thrombosiso Presence of plenty of

thrombi in the veinsThrombophlebitis

o Inflammation of the veins

Arteritiso Inflammation of thearteries

Interjected Concepts!!!Angio signifies arteriesThromboangitiis obliterans

o Buergers Disease o Brought about by smokingo Nicotine causes

vasoconstrictiono

Lower extremities usuallyaffected Raynauds Disease

o Affects mostly femaleso Upper extremity affectation

Avascularityo Peripheral Vascular

Diseases Raynauds Disease Buergers Disease

Gangrene

Massiveblood vesseldeathAmputationis needed ingangrene

All thrombi are blood clotso Therefore, all thrombi are

bloodBut not all emboli are blood

o Other types of emboli are:

Air emboliFat emboliAnticoagulants

o HeparinProvides quicker anti-coagulanteffect

Effect manifested inhours or in one (1)hour

o WarfarinProvides slower

anti-coagulanteffectEffect manifested intwo (2) to three (3)days

Heparino Protamine Sulfate

Antidote of heparinPartial Thromboplastin Time(PTT)

o Related to heparino

Normal is 26 to 32secondsThis is withoutheparin

o In the presence of heparinPTT increases toone and one-half totwo times its normalvalue (1.5x to 2.0xnormal value)Approximately sixty-four seconds (64secs.)PTT Range of 60 70 secondsindicates thatpatient is properlyheparinized

o Thromboplastin is clottingfactor number three

Warfarino Antidote is Vitamin K

Prothrombin Time (PT)o Related to warfarino Normal is 11 to 12

secondso Other sources say that

normal PT is 9.5 to 11.3seconds


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o This is in the absence of warfarin

o In the presence of warfarin, PT is lengthenedor increased to 1.5x to

2.0x its normal valueEffect of warfarin is manifested intwo (2) to three (3) days

NEPHROLITHIASISRenal CalculiTwo Types

o Acid Stoneo Alkali Stone

Acid Stone

Uric Acid StoneVitamin C

Alkali StoneCalcium oxalate

o Magnesiumo Phosphateo Ammonium

Vitamin D

Predisposing Factors inNephrolithiasis

Diet rich in the following:o Vitamin Co Vitamin Do Calcium

Immobilityo Blood stasis

Frequent Urinary Tract Infectionso Scanty urine that does not

irritate

Signs and Symptoms of Nephrolithiasis

Paino Flank paino In person with Cystitis

There is a dripOliguriaHydronephrosis

HematuriaHigh-grade fever with chills

Management of NephrolithiasisIncrease oral fluid intake

LithotripsyIntraurethral Lithotripsy

o No incisionPercutaneous Lithotripsy

o With small incisiono With suctiono Basket type

Extracorporeal Shock WaveLithotripsy (ESWL)

o Externalo

No incisiono Increase fluid intake toremove stones which havebeen rendered smaller insize by the procedure

LithotomyRemoval of stones

o NephrolithotomyRemoval of stonesin the kidney

o CystolithotomyRemoval of stonesin the urinarybladder

o UreterolithotomyRemoval of stonesin the ureter

Urolithotomyo Removal of stones in the

urinary tract

RENAL FAILURETwo (2) Types

Acute Renal FailureChronic Renal Failure

Acute Renal FailureCharacterized by:


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Onset of sudden loss of glomerular functionPotassium intoxicationMetabolic acidosis

Chronic Renal FailureCharacterized by:

Onset of gradual loss of glomerular functionPotassium intoxicationMetabolic acidosis

Important Concepts in Renal FailurePotassium goes out

This gives rise to potassiumintoxicationSodium gets inH+ goes out when sodium comesin

o This makes the bloodacidic

o This produces a decreasein bicarbonate (HCO 3-)levels, giving rise toMetabolic Acidosis

Signs and Symptoms of Renal FailureLethargy

o Due to cerebral hypoxiaEdema

o In the form of anasarcaDecreased blood volume

o Hypovolemiao Hypotensiono Dizzinesso No pain

Hypertensiono Occipital Headacheo Problems with blood

passagewayo They become more

constrictedo Dizziness then sets in

Pale

o Decreased blood supplyAscitesAbdominal PainAnorexiaWeight Loss

Body malaiseManagement of Renal Failure

Dietaryo Decreased protein or low

protein dietProtein contributesto nitrogenouswastes

Decreased sodiumo Presence of sodium

promotes edemaBed restPrevent infectionSkin Care

o Dry skinDue to edema andhypovolemia

o Cracked skino Injured skino Uremic frost occurs

Urea on skin Parang amag

Use dilute vinegar solution

Weigh the patiento There is increase in weight

due to edema

Pharmacological Management of Renal Failure

Diuretics

Medical Management of Renal Failure Dialysis

o Peritoneal DialysisInfection or peritonitis is acommoncomplication

Hemodialysis


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o Hemorrhage is a commoncomplication

Renal Transplanto Alternative surgical

management

Interjected Concepts!!!Levels of Consciousness

Alerto Awake, aware

Obtunded persono Awake but not awareo tulala

LethargyStupor

o Asleepo

Response to painful stimuliat sternum and sole of feetComa

o Deep Comao Cannot be revivedo Respirator sustains life

Euthanasia or mercy killing

GASTROINTESTINAL SYSTEM

Oxygen distribution to the differentbody organs:Brain 15% of oxygen in

the circulatingblood

Heart 5% of oxygen inthe circulatingblood

GI and Liver 25% of oxygen inthe circulatingblood

Renal System 25% of oxygen in

the circulatingbloodExtremities(upper andlower)

30% of oxygen inthe circulatingblood

Important Concepts!!!Small Intestine

o Final digestion occurs inthis organ

o Digested products areabsorbed by the villi

Moutho

Preliminary digestionoccurs hereo Initial digestiono Digestive juice is the

saliva, which containsenzyme for carbohydratedigestion:

AmylasePtyalin

Stomacho Partial digestion occurs

hereo Digestive juice in thestomach:

o Gastric JuiceHydrochloric AcidPepsin

o Food remains in thestomach for about two (2)to four (4) hours

o If food is fatty or has muchprotein content, foodremains in the stomach for about three (3) to four (4)hours

o Stomach is curved to theleft

Cardiac Sphincter Upper

sphincter Prevents

backflow of food to the

esophagusPyloric Sphincter Lower sphincter Preventsbackflow of food from the


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smallintestine

Small Intestineo Digestive Juice:

Bile

Pancreatic JuicePancreatic AmylasePancreaticLipasePancreaticTrypsinInduces sleepTryptophan inmilkWarm milk for

vaso-dilationIncreasestrypsin levelsInduces sleep

ProteasesLiver

o Produces bileo Bile passes through the

hepatic ducto Bile is stored in the gall

bladder Gall bladder

o Storage of bileo Bile passes through the

common bile ducto Bile passes through the

Sphincter of Oddi going tothe duodenum

After food is absorbed in theSmall Intestine, the absorbedproducts are carried by the blood

into the liver for storage

Organs Filtering the BloodKidney

o Filters out metabolicwastes

Liver o Filters out toxins

Spleeno Filters out resistant

microorganismso Red Blood Cells (old

RBCs are phagocytosedo

Main source of anti-bodiesLymph nodeso Also filters bloodo Destroys microorganisms

Important Concepts!!!Large Intestine

o No digestion occurs hereo Water absorptiono Electrolyte absorption

Diarrhea or Dehydrationo

Causes electrolyteimbalanceVomiting

o Sodium (Na +) is theelectrolyte that is mostabundantly lost in vomiting

Diarrheao Sodium (Na +) is the

electrolyte that is mostabundantly lost in diarrhea

Gastrointestinal Tracto Extracellular o Sodium is more abundant

Bloodo Extracellular o Sodium is more abundant

Important Concept!!!Question:

o Which electrolyte loss is of greater concern?

Answer:o Potassium (K +)

Rationaleo Heart suffers from

arrhythmia or absence of rhythm during increased or decreased levels of potassium

o Hypokalemia


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Decreased levels of potassiumDecreasedcontractionFlaccid

o

HyperkalemiaIncreased levels of potassiumIncreasedcontractionSpastic

Dysrhythmiao Irregular heart rhythms

Arrhythmiaso Lub-lub-dubo Lub-dub-dub

Initially, vomiting results intometabolic alkalosiso Hydrochloric acid is being

expelled through themouth

Initially, diarrhea results intometabolic acidosis

o Base (in the form of bitter,biting bile) is beingeliminated through theanus

Bileo Emulsifies fato Gives color to the stoolo Normal color of the stool

Yellowish browno Transitional color of the

stoolGolden Yellow

o Stool of infantsFrom greenish toyellow

o Adult StoolGolden Brown

o Abnormal color of theStool

Gray colored StoolAcholic Stool

Anuso End of the colon

Appendixo Living cello Composed of fecalith

matter o Immunologic

Contains anti-bodiesBut this is still under study

Interjected Concept!Nail beds and hair roots are alive,

just like the appendix, which iscomposed of living cells

Common Gastrointestinal Disorders

(these are manifestations only andare not considered as diseases)AnorexiaNausea

o Urge to vomitVomitingDiarrheaConstipation

Interjected Concept!The epiglottis, a flap-like structureand the glottis, an opening, areboth part of the respiratorysystem

Oral Cavity Disorder Gingivitis

PEPTIC ULCER Also called Gastric Ulcer Two (2) major causes:

Extrinsic Factor Intrinsic Factor

Extrinsic Factor Microbial invasion

o Viruso Bacteria


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Intrinsic Factor Integrity of Gastric MucosaMucosa

o Secretes gastric mucouso If gastric mucosa is

destroyed, acidity causesulcerationo Therefore, decreased

integrity of gastric mucosacauses ulceration

Frank hyperacidity

PREDISPOSING FACTORS in PEPTICULCER

1. Emotional Stress

Constriction of blood vesselsReaction is to produce more acidResults to hyperacidity

Interjected Concept!Ulcer due to severe burns iscalled CURLING ULCERAlso due to stress brought aboutby burns

2. Excessive SmokingNicotine causes constrictionDecreased blood flow bringsabout ischemia

3. Ingestion of Steroids (anti-inflammatory drugs)

Steroid releases HistamineHydrogen (H +)

o This reacts with chloride(Cl-) ion

Chloride ion is the most abundantanion outside the cell

o H+ + Cl - ----- HCl o Therefore, STEROIDS are

GASTRIC IRRITANTSNursing Responsibility

o Give with meals or after meals

Example is PREDNISONE

4. Irregular Eating Pattern

Interjected Concept!Number of times to chew before

swallowing solid food is:o Five (5) to ten (10) or o Six (6) to nine (9)

Assessment (to Rule Out GastricUlcer)

1. PainMid-upper abdomen

o Epigastric regionMay start a couple of hours when

stomach is empty and after eatingRelieved by eating and by anantacid Antacid relieveshyperacidity onlyOccurs at night

o Due to parasympatheticactivity

o This occurs whether patient had taken meals or not

2. Dietary Pattern

2.1) Types of FoodsEnsure nutritious meals

o To promote healing

2.2) Avoid the following foods:

Spicy Foodso Have vasodilating effect

but are irritatingGreasy and Fatty Foods

o These are hard to digestGas-forming Foods

o Most common in foods richin carbohydrates

o Sweet potato, yam, ube,hard-boiled eggs


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o Can increase pressureinside

2.3) Avoid prolonged use of milk andcream

Patients with ulcer can consumesome milk but PROLONGEDUSE IS DISCOURAGEDLactic acid is produced as a by-product of milk digestion

o This results into LACTIC ACIDOSIS

Also contraindicated in UlcerativeColitis patients

o There is lactoseintolerance due to the

absence of lactulase2.4) Avoid Alcohol

Alcohol promotes release of GastrinAlcohol triggers pancreatitis(similar to drugs)

2.5) Avoid beverages causingvasoconstriction

Teao Green Tea contains the

least amount of caffeineamong the different typesof tea

Colao With caffeineo Contains citric acido Also avoid all other types

of soda with the samecolor as soda (i.e. rootbeer, sarsa parilla)

CoffeeCaffeine

2.6) Avoid Snacks at BedtimeCommon in cold weather countriesIncreases acid levels

Increases pain, which attacks atnight

2.7) Provide Iron for HealingHeme is iron

Heme + globulin --- HemoglobinHemoglobin carries oxygenIncreased oxygenation coupledwith increased blood flow andvenous return enhances healingIron is present in the followingfoods:

o Green leafy vegetableso Liver o Egg yolk

3. Observe for Complications

3.1) HemorrhageCoffee ground emesis

o Old bloodMelena

o Black tarry stoolo Sign of Upper GI bleeding

Hematamesiso Vomiting of blood

Hematocheziao Fresh blood in the stoolo Sign of Lower GI bleeding

Interjected Concepts!!!Spicy foods do not causehemorrhoids

o Rather, it makeshemorrhoids more severe

o Spicy foods trigger moredilation

Pregnancy and increasedpressure causes hemorrhoids

3.2) Perforation

3.3) Pyloric Obstruction

Implementation:


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What to do during Ulcer?

1. Medications

1.1) Antacids

BasicGiven one (1) hour after mealMg(OH) 2

o Milk of magnesiao Side effect is diarrhea

Al(OH) 2o Amphojelo Side effect is constipationo Absorbs water and

phosphateNaHCO 3

CaCO 3 MgAl(OH)o Maaloxo Simecoo Mylantao No diarrheao No constipation

1.2) Sucralfate and CarafateGiven one (1) hour antecebumProtective agent

o Coats the lining of thestomach

Again, give before eating

1.3) Anti-cholinergicAnti-parasympathetic drugsAtropine Sulfate

o Anti-diarrhealTo decrease themotility of the bowel(diarrhea)

o Anti-emeticTo decrease GImotility

o Increased heart rateo Indicated for Bradycardiao A chronotropic drug

1.4) Histamine

H2-receptor Antagonisto Taken per orem

Cimetidineo Tagamet

Ranitidineo

Zantac Coats chloride toprevent theformation of hydrochloric acid

2. Reduce Stressful SituationsNon-specific

3. Promote Rest

4. Provide Health TeachingsDietary therapy

5. Provide Dietary Control

6. Observe for Complications

7. Provide Moral Support

Interjected Concepts!!! Inotropic Drugs

o Increases cardiaccontractility

o Examples are:DopamineDobutamineDigoxin

Beta-Adrenergic Blockerso Decreases heart rate in

tachycardic patients

Surgery for Ulcer

VagotomyCutting of the vagus nerve(pneumogastric nerve)Innervates the upper region of the respiratory tract (increasedintracranial pressure during GIsuctioning


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Indicated for hypersecretion of acid

o Do vagotomyo Complication is diarrheao No more acids are present

for digestion2. Gastroenterostomy or Pyloroplasty

Decreases stimulation of GastrinFormation in the antral regionStomach and Small intestine areanastomosedShortening of the pylorusReinforcement of the pylorusBariatic surgery

o Indicated for obese

patients3. Partial Gastrectomy

Complication is hemorrhageIncreased pressure leads tohematamesisTwo types:

o Billroth Io Billroth II

3.1) Billroth I or Gastroduodenostomy

Removal of the pylorusHigh abdominal incision results topulmonary complicationsAnastomosis is done

3.2) Billroth II or GastrojejunostomyTwo structures are removed:

o Pyloruso Duodenum

Anastomosis is done

Important Concept!-plasty means repair or reinforcement

Post-operative Complications

1. Hypovolemic ShockDecrease in blood volume

2. Hematamesis

3. Pulmonary ComplicationsAtelectasiso First complicationo Lung collapseo Loss of function of the

lungso Anesthesia may cause

atelectasisBronchitis

o Infectiono This may occur around

three (3) days post-operativelyPneumonia

4. Fluid and Electrolyte Imbalance

5. Dumping Syndrome Recline patient or place patient inrecumbent position after meals

6. Hemorrhage

7. DiarrheaDue to vagotomy

8. Vitamin B 12 deficiencyDue to malabsorption syndromeVitamin B 12 is cyanocobalaminThis is for RBC maturationThere is no absorption of VitaminB12

o A GIT problemo An intrinsic problem

9. AnemiaAbsence of Vitamin B 12 results topernicious anemiaDecreased levels of RBC if thereis a GIT problem with intrinsicfactor


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Interjected Concepts!If GIT is functional and VitaminB12 is lacking

o Extrinsic Problemo

Megaloblastic Anemiao Vitamin B 12 and Vitamin B 9needed for maturation

Decrease in Irono Iron deficiency anemia

Decrease in foodo Nutritional anemiao An Extrinsic problem

Yellow Bone Marrowo Indirect Red Blood Cell

formation

Red Bone Marrowo Direct Red Blood Cellformation

Bone Marrow Extractiono Pelvic Bone

This has lesscomplications

o Sternum and ScapulaHas pulmonarycomplications

In Bone Marrow Extractiono Consider the following

bones in the followingorder:

PelvisPosterior

Iliac CrestPosition

patient ataffected sidefor preventionof bleeding

ApplypressureSternumScapula

Flat bones contain Red BoneMarrowIschial Tuberosity

o inuupuan

o nangingitim Ischial Spine

o Reference for fetaldescent

If Bone Marrow does not produce

RBCo The resulting RBCdeficiency is called

APLASTIC ANEMIAIn SICKLE CELL ANEMIA

o RBCs have decreasedoxygen-carrying capacity

In whatever type of anemia, ablood loss of five-hundredmilliliters (500 ml) and aboveREQUIRES BLOOD

TRANSFUSIONBLOOD TYPING AND CROSSMATCHING

Blood Type Oo The universal DONOR

Blood Type ABo The universal RECIPIENT

Consider the following figure:In cross matching, arrowindicates which blood type couldbe a donor to which blood typeNo counter flow is observed

o Meaning blood type,where arrow points,cannot be a donor to theblood type where thearrow begins

No crossing of vertical or horizontal lines is allowed (exceptwhen there is an arrow indicatingsource can donate blood towhere arrow is pointing)

o Meaning, that blood typesconnected by lines withoutarrows cannot donate toeach other.


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Type O

Type A Type B

Type AB

Therefore, from the figure aboveType O individuals could

o Donate blood to type Aindividuals

o Donate blood to type Bindividuals

o

Donate blood to type ABindividualsType A individuals could

o Donate blood to type ABindividuals

Type B individuals couldo Donate blood to type AB

individualsType O individuals could notreceive blood from any of theother blood groupsType A individuals cannot receiveblood from type B individualsType B individuals cannot receiveblood from type A individualsAll blood types can receive bloodfrom other individuals with thesame blood type

ERYTHROBLASTOSIS FETALIS

Important Concepts!!!Blood type is in the Red BloodCellThe liver and the spleen of thechild is responsible for the RBCof the childTypes of Placental Separation

o Duncan sideDull sideSide is tearing off Bloody separationRevealed placental

expulsionDurkyo Schultz side

Center is tearing off Shiny sideConcealedplacental expulsion

When placenta separates either:o At birtho During birtho Abortiono

Still BirthBlood from theinfant may flow tothe mother

Direction of flow upon placentalbreakage is from the newborn tothe mother

o If the mother is type AB(universal acceptor) therein no incompatibility

o If the mother is type O(universal donor) there ishigh-risk for incompatibility

Therefore, always check if theplacenta is intact

o The placental breakageduring separation causesincompatibility

If the mother is Rh- and thenewborn is Rh+, upon placentalseparation there is flow of fetalblood to the mother.

o The mother will thendevelop antibodies for Rh+

o This situation would giverise to problems with thesubsequent fetuses whichare also Rh+

Second child or fetus with Rh+


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blood will haveincreased risk for fatality due tohemolysis asmother has

antibodies for Rh+Third child or fetuswith Rh+ blood willhave even greater risk for fatality, alsodue to hemolysis,again, as mother has antibodies for Rh+

Preventive measure would be theadministration of RHOGAM within

seventy-two (72) hours after delivery or abortion or still birth.If antibody is inactive, thisindicates that RHOGAM ISEFFECTIVEIf antibody is active, and it causeshemolysis and fatality to thesecond or third child, thenRHOGAM IS INEFFECTIVE

CHRONS DISEASE Regional Enteritis

VolvolusIntertwining of the bowelsCommon in pediatric patients

IntussusceptionTelescoping of the bowelPart or segment of the intestinegoes into another segment

ColitisInflammation of the LargeIntestine

Ulcerative ColitisOccurs at right side or at

ASCENDING COLONClassical sign is DIARRHEA

Reabsorption of water is a normalfunction of the large intestine

o If the large intestine isinflammed, it cannotreabsorb water

o

This gives rise to diarrheaMilk cannot be administered toUlcerative Colitis patient

o There is lactoseintolerance

o LACTAMASE cannot beproduced (lactobacilli)

o If the large intestine isimpaired, lactamasecannot be synthesized

DiverticulumOut-pouching of the membrane inthe sigmoid area

DiverticulosisExists when multiple diverticulaare present without inflammationor symptoms

DiverticulitisOccurs when food and bacteriaare retained in a diverticulumThis produces infection andinflammation that can impededrainage and lead to perforationor abscess formationWith left side painAt side of sigmoid

HemorrhoidsProtrusion of rectal vein at therectum

VaricosityA ballooning of the vein

AneurysmA ballooning of the artery

INTESTINAL HERNIA


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1. Inguinal Hernia (bituka) Part of intestine goes to the malescrotum

2. Femoral HerniaHerniation along the femoral

head3. Umbilical Hernia

4. Incisional HerniaAfter appendectomyEvisceration is an example of incisional hernia

APPENDICITISCharacterized by the presence of pain at the right lower region

Rebound Tenderness is presentPalpate at the left side McBurneys Point McBurneys Sign

o To rule out appendicitiso Do Rovsings Test o Pinch at the left side of the

abdomeno There will be pain at the

right side of the abdomeno Presence of pain indicates

positive for McBurneyssign.

Analgesics are not giveno They mask the symptoms

of pain

ACCESSORY ORGANS OF THEGASTROINTESTINAL TRACT

LIVER CIRRHOSIS DegenerativeNecroticHepatocytes are no longer functional

Important Interjected ConceptsViral infections are self-limitingThere are five (5) types of hepatitis:

o Hepatitis AInfectious hepatitisOral Fecal route

o Hepatitis BSerum hepatitis

BloodDeath throughhepatitis B isquicker than deaththrough AIDSDeath throughhepatitis B may onlybe months away

o Hepatitis Co Hepatitis Do Hepatitis E

Liver Cirrhosis (continued)A chronic progressivedegenerative disease of he liver with structural changesScarring is the biological or structural change

Types of Liver Cirrhosis

1. Laennecs Cirrhosis This is the original liver cirrhosisPortal, nutritional or alcoholiccirrhosis

2. Post-necrotic CirrhosisPost-hepatitis or toxin inducedhepatitisViruses excrete toxins; after thedeath of liver cells

3. Biliary CirrhosisRelated to prolonged biliaryobstructive jaundice due toinfectionJaundice is yellowishdiscoloration due to bilirubinMay involve any of the following:


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o Bile ducto Biliary duct and biliary

stoneso Cholelithiasiso Choledocholithiasis

4. Cardiac CirrhosisRelated to long-standingCongestive Heart FailureRight-Sided CHFWith Primary and SecondaryHypertension due to arterialsystem constraint

Scar Structural change

Decreased blood flow to the liver Most blood stays in the portalveinPortal hypertension occursPortal veins are dilatedThis is localizedVasopressin or Pitressin

o Used to constrict bloodvessels

o If vessels are notreinforced, portal vein willexplode

Backflow of pressure is towardthe Gastrointestinal Tract / GIsyndrome composed of:

o Esophageal Variceso Hemorrhoids

Caput Medusae

Pathophysiology of Liver Cirrhosis

Toxic Effect on Liver

Common causes are alcohol, drugs

or nutrition; with incidence in men

Liver Cells are Damaged

Tissue Scarring and Fibrosis Distortion of Normal Liver Structure

Interferes with blood flow through theliver Portal Hypertension(Enlargement of umbilical, esophageal,and rectal veins resulting to liver dysfunction) Insufficient removal of metabolic wastes Fluid retention in peritoneal cavity

Hepatic encephalopathy Coma

Types of JaundicePhysiologic TypePathologic Type

Physiologic JaundiceImmature body part or organOccurs in infants onlyImmature liver of the infant

o Lacks enzymeso Glucoronyl Transferase is

lackingo Conjugation of bilirubin is

not facilitatedJaundice occurs after twenty-four hoursYellowish skin is exhibited withinseven (7) to ten (10) daysPatient is most yellowish ataround third (3 rd) to fourth (4 th)dayAlways get the middle!!!

Pathologic JaundiceJaundice within twenty-four (24)hours


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Erythroblastosis fetalis

Interjected Concepts!!!Liver

o The biochemist of the

bodyo The biochemist of all thebody functions

o Filters toxinsIf this is notfacilitated, thetoxins will stay inthe bloodToxins will get tothe brain and wouldlead to

encephalopathy,hepatic coma andbrain comaAlters proteinsynthesisDecreased levels of protein in bloodresults todecreased colloidosmotic pressureThis would lead toEdema or ascites

o Cirrhosis is a term used for the liver only

Infarction is a term used for theheart and the brainCerebral Infarction

o Brain infarctionMyocardial Infarction

o Heart infarction

Adult JaundiceIt is always PATHOLOGIC

Types of Adult Jaundice

1. Hepatocellular JaundiceHepatocytes die

2. Hemolytic Jaundice

RBCs are hemolyzedIncreased bilirubin escapes

3. Obstructive JaundiceBiliary problemsGall stones

Important Concepts!!!Increased bilirubin in blood

o UnconjugatedIndirect bilirubinAlso known as b 1 Normal value istwice that of b 2 Normal value is 0.8mg / dl

o Conjugated

Direct bilirubinAlso known as b 2 Normal value isabout half of b 1 Normal value is 0.4mg / dl

o Total BilirubinRepresents thecumulative value of Unconjugated (b 1)and Conjugated (b 2)bilirubinNormal value is 1.2mg / dlThis is a gaugeused to determine if there is jaundiceAt birth, if TotalBilirubin level is 2.0,then there isphysiologic jaundice

Signs and Symptoms of Liver Cirrhosis

1. Anorexia, dyspepsia, indigestion,change in bowel habits, flatulence,constipation, fatigue

Anorexia


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o Gives rise to weight lossand body weakness

Dyspepsiao Inability of the stomach to

produce pepsin for

digestiono The absence of pepsingives rise to indigestion

Flatulenceo Kabag leads to flatus

formationo Due to increased pressure

(blood flows back to theGIT)

2. Hepatomegaly, Splenomegaly and

JaundiceIncreased PT or prothrombin timeNewborn

o Prone to bleed at umbilicalcord

o Immature liver cannotproduce prothrombin

o Therefore, give Vitamin Ko Administer via I.M. routeo Site is at vastus lateralis

Never inject at thebuttocksSciatic nerve maybe damaged andthis will causeirreversibleparalysis

o Allow the child to walk firstbefore administeringinjections at the buttocks

3. Edema of the Extremities, Ascites,Hematamesis

4. Caput medusaeProminent abdominal wall veinsBig ones

5. Anemia, Esophageal varices,Emaciation

Anemiao Pernicious anemiao GI is affected

Esophageal Variceso Use Sengstaken-

Blakemore tubeEmaciationo Excessive or severe

weight loss or cachexia

6. Altered Hair Distribution, Spider nevi, Angiomas

Altered Hair Distributiono Decreased keratin

synthesis by the liver o This affects the skin, the

hair and the nailso Deceased collagensynthesis by the liver affects the structure of theinternal organs

Deficiency incollagen leads toSystemic LupusErythematosus

Important Interjected Concepts!!!In order for adults to fart, placethem in NICHES POSITION

o If not, use a rectal tubeand a basin of water

In infants, COLIC is equivalent toflatulenceProne position is best

Hagod sa likod nagburp pataas ThoracentesisIf air is to be removed, inserttrocar at the level of the second(2 nd ) or third (3 rd) intercostalspaceIf fluid (i.e. water) is to beremoved, insert trocar at the levelof the sixth (6 th) to eighth (8 th)intercostal space


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Implementation in Liver Cirrhosis

1. Provide adequate nutritional intakeHigh Calorie diet

o 3,000 calories per day

Carbohydrateso 300 400 grams per dayProteins

o If pre-coma70 100 grams per day

o If comatoseTotally eliminateproteins from thediet

Fatso

100 150 grams per dayLow sodium dieto 0.5 to 1.0 gram per day

2. Bed rest

3. Maintain clean and dry skin

4. Assess level of pain and preventbleeding

5. Maintain Fluid Balance1.0 to 1.5 liters per day

6. Monitor for signs of mentaldeterioration

Allow the client to demonstratesignature dailyAvoid tranquilizers and sedatives

o These drugs mask thesigns of mentaldeterioration

o Cardiovascular andneuromuscular drugs areall hepatotoxic

o Liver cannot detoxify thesedrugs

Administer lactulose if orderedo Duphalac is an ammonia

detoxicant

o Also a laxative for easypassage of stools

Stool softeners soften the stool

Important Interjected Concepts!!!

Mesenteryo Membrane that suspendsan organ

Omentumo Organ to organ

suspensionCollagen

o Internal protein or proteinof internal organs

Desquamationo tuklap ang balat

Infant with Desquamationo Due to environmentaladaptation to externalenvironment

Important Concepts!!!Liver Flap

o Flapping Tremorso Asterixis

Sign of impendinghepatic comaDue toaccumulation of ammonia in thebloodstream

Hyperthyroid Person has FINETREMORSProtein is metabolized toammoniaAmmonia is converted by theliver to ureaUrea is removed by the kidneysTherefore, the liver and thekidney are both blood filtersRenal Failure

o Characterized by:o Increased levels of Blood

Urea Nitrogeno Decreased levels of Blood

Urea Nitrogen Clearance


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o Decreased protein or controlled protein diet

o Decreased intake of sodium due to thepresence of edema

Liver Cirrhosiso Characterized by:o Controlled protein intakeo Controlled fat intake (as

bile is not produced)o Decreased intake of

sodium due to thepresence of edema

Important Concepts in theManagement of Renal Failure and

Liver CirrhosisIn Renal Failureo Bed rest is neededo Skin is Dryo Skin is whitish due to the

presence of UREMICFROST

o Therefore, apply vinegar In Liver Cirrhosis

o Bed rest is neededo Skin is dry due to edema

and dehydrationo Urticaria is presento Rashes are present

Implementation in Liver Cirrhosis(continued. . .)

7. Assist client to comply withprescribed bed therapy

8. Maintain normal respiratoryfunction

9. Encourage patient to expressfeelings

Sengstaken-Blakemore TubeThis tube is inserted at the nose

It has three (3) lumenso First lumen

For nasogastric suctionSuction to preventvomiting

o

Second lumenFor inflation of esophageal balloon

o Third lumenTo inflate thegastric balloon

Complicationo Congestion in the lungo Keep scissors readyo If respiratory depression or

arrest occurs:

Cut the tubeDeflate the balloonRemove theSengstaken-Blakemore Tube

Interjected Concepts!!!Striae Gravidarum

o In primigravidaThis is pinkish

o In multigravidaThis is silvery white

Increased pigmentation is due toestrogen

o This intensifies the activityof Melanin

For neurologic problem and heartproblem patients, give stoolsofteners and not laxatives

Medications used in the Managementof Liver CirrhosisNeomycin

Anti-biotic that reduces colonicbacteriaIt decreases the number of microorganisms thriving inammonia


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If normal flora in the colonbecomes violent, there isinfection

Pitressin or VasopressinDecreases portal blood pressure

This constricts the dilated veinsLactulose

Cephulaco For ammonia

detoxificationo As a laxative

FurosemideLasix

o A diuretic

SpironolactoneAldactoneDiureticAldosterone antagonistPotassium sparingRetains potassium but notsodium

Vitamin B 9 Folic AcidFor maturation of RBCs topromote healingIncreased RBC levels leads toincreased oxygenationIncreased oxygenation facilitateshealingVitamin B 12 is also for maturationof RBCs

CHOLELITHIASISStones in the gall bladder

CHOLECYSTITISInflammation of the gall bladder Not always due to the presenceof stones

Renal CalculiTwo (2) Types:

Acidic CalculiBasic Calculi

Important Concepts!!!Gall Stones

o

Are alkali onlyThe following are all basic:o Bileo Bile pigmento Cholesterolo Calcium

In Cholelithiasis and cholecystitis,there is pain at the UPPERRIGHT QUADRANTIn Appendicitis, there is pain atthe RIGHT ILIAC or the RIGHT

LOWER QUADRANT Murphys Signo For Cholelithiasis with

cholecystitis McBurneys Sign

o For Appendicitis

Important Concepts in Cholelithiasisand Cholecystitis

Fatty foods are not givenSteatorrhea

o Foul-smelling stoolo Fatty stoolo Frothy stool

Frequent Stool (diarrhea)

Important Interjected Concepts!!!In asthma

o Avoid antitussiveso Avoid anti-biotics

Important Concepts!!!Acholic Stool

o Clay-colored stoolLiver Cirrhosis patients are withnasogastric tube (NGT)For Gall Bladder with stones,medical management mayinvolve LITHOTRIPSY

o Percutaneous Lithotripsy


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o Extracorporeal ShockwaveLithotripsy

Cholelithotomyo Removal of stones in the

gall bladder

Cholecystectomyo Removal of the gallbladder

o T-tube is used withJackson-Pratt (JP) Drain

o Initially, there will becopious drainage from theJP drain

This is because thebile duct isinflammed

Failure to drainwould result tocongestion

o Later, if there is lessdrainage,

Bile duct is nolonger inflammedBile goes to theduodenum

PANCREATITISThe head of the pancreas islocated posterior to the liver The body and tail of the pancreasis locate near the stomach at theleft upper quadrantTherefore, pain in pancreatitis issituated at the left upper quadrant

Inflammation of the Pancreas is dueto the following:

1. Fat necrosisIncrease in pancreatic amylaseand pancreatic lipase gives riseto lipolysisThis can trigger autodigestion of the pancreas

Pancreatic Lipase levels is amuch better determinant of thepresence of pancreatitis

2. Pancreatic Edema

3. Acute Hemorrhagic PancreatitisDeadly

Important Concepts in PancreatitisDemerol

o Drug of choice in thetreatment of pancreatitis

Non-narcotico Does not cause

drowsinesso

Blocks prostaglandinsynthesisMorphine

o Can constrict the sphincter of Oddi

Interjected Concepts!!!In checking for the proper placement of the Nasogastric Tube or NGT, thefollowing could be done:

X-rayo Most effective

Aspirateo Second most effective way

is to check the pHAuscultate

o This is the most commonmethod of checking

o Gurgling sound at theabdominal region indicatesproper placement

Dipping the end of the tube inwater and noting for bubbles

o This indicates that theNGT is displaced and is inthe lungs

o Not an advisable thing todo


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Damage to heart muscle isindicated by increased levels of CK-MB and CK-MM

o Troponin T and Troponin Iare more reliable

indicators of cardiac tissuedamage

Peculiarity of PancreatitisHematomaEcchymosis around the navel

o Also known as CullensSign

Petechiae

Interjected Concept!

Cullens Sign is also present inECTOPIC PREGNANCY

Important Additional Concepts inPancreatitis

Gray Turners Spot o Ecchymosis at the flanko Indicative of Hemorrhagic

PancreatitisIncrease in Trypsin levels

o Pancreatic enzyme thatpromotes sleep

o Patient is not awakened bythe pain he feels butmoaning is present

o Defecation and urination ispresent in the late stagesof pancreatitis

MUSCULOSKELETAL SYSTEMMuscle is composed of three (3) types:

Skeletal MuscleCardiac MuscleSmooth Muscle

Types of Skeleton:Axial Skeleton

o Skullo Ribso Spinal Cord

Appendicular Skeletono Clavicleo Scapulao Limbs

Joints Also called arthrosesArticulating joints

Three (3) Types of Joints based onMotion

1. SynarthrosisFibrous jointCreates no motionNo movement

2. AmphiarthrosisCartilaginous jointCreates small amount of motion

3. DiarthrosisSynovial jointMaximum amount of motionCreates large amount of motion

Muscle has two (2) types of proteinActinMyosin

Important Concepts!!!Calcium is needed in muscular contractionAcetylcholine is aneurotransmitter needed inmuscle contractionMyasthenia Gravis is anautoimmune disorder wherein thebody destroys acetylcholinereceptor sites

Skeletal Muscle

1. Synergist MusclesGroup of muscles


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When they contract, they stabilizethe areaExamples are:

o Pectoraliso Intercostals

Antagonist MusclesWhen one muscle contracts, theother relaxesFor reciprocity of motion

Prime Mover When they contract, maximumamount of motion is created

Range of Motion

360 degreeso Shoulder Joint180 degrees

o Cervical Joint

FRACTURESBreak in the continuity of thebone

o Traumao Accidento Crashingo Twistingo Compression

Pathologico Potts Disease

Tuberculosis of thespineGibbus formation isthe pathognomonicsign of PottsDisease

o Spina BifidaNeural Tube Defect

o CysticaPresence of a bulge

o MeningocoelMeninges protrudeCerebrospinal Fluid

o MyelomeningocoelSpinal cord lesions

Herniated NucleusPolposus

o OccultaPresence of adepression or a

dimplingo Lumbar SpineBears most of thebody weight

o Lumbar Comao Slipped disko Lordosis

Waddling walko Not a flirting walk

Types of Fractures

Closed Fractureo Did not penetrate the skino Immediate care

Do not moveOpen Fracture

o Broken portion of the boneprotrudes through the skin

Fracture PatternsTransverseLongitudinalObliqueSpiralDepressedComminutedImpactedStellate

o Fracture radiates from apoint

Important Concepts!!In comminuted or crushedfractures, bone debridement isdoneMandibular Wiring

o Use wire cutter o Suction


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Anticipate vomitingto preventaspiration

Interjected Concept!

Types of Fetal LieLongitudinalTransverseOblique

Important Concepts regardingFractures!!!

First Aido At the site of the incident,

IMMOBILIZETreatment at the Hospital

o

Bone Reductiono Re-alignment of the bone

Treatment of Fractures

1. Reduction or Re-alignmentFor Closed Reduction

o Castingo Splintingo Sling

For Open Reductiono Surgical plates, pins, rods,

wireso Uses plates (metal or

stainless steel)o Uses screws and nailso Uses pins intramedullary

pins

2. Immobilization

3. Restoration of Function

Important Concepts!!!Casting

o Utilizes plaster of ParisScoliosis

o Utilizes Harrington RodWires

o Used for flat bones (i.e.mandible)

TRACTIONTwo forces are applied in

opposite directionPurposes of Traction

To immobilize the affected partBone re-alignmentRegain normal strengthReduce muscle sprain

Types of TractionMechanical Traction

o With screw and pino

With invasiono SteinmanUsing pins

o Kirchner Using wires

o Crutch-FieldTongs for cervicalaffectations

Balanced Suspension Tractiono Thomas Splint with

Pearsons Attachment Skin Traction

o No invasiono Pad areas which are

pressuredo Russell

For fractured femur Pulls the knees andthe foot

o CervicalCervical spasm

o PelvicRelieves low backpain

Important Concepts!!!Bryant Traction

For children


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Signs and Symptoms of FractureSwellingHeatImpaired functionRedness

PainCrepituso Grating sound

Deformityo Contracture

Shortening of boneDiscoloration

o Bluish and reddishindicative of hematoma

BleedingTenderness

o

Pain aggravated by touchSTAGES OF WOUND HEALINGImportant Concepts!!!

In pediatric patientso Wound healing is faster o Occurs in about three (3)

to four (4) weekso Due to quicker Basal

Metabolic RateIn adults

o Wound healing occurs inabout eight (8) to twelve(12) weeks

1. Hematoma FormationOccurs after twenty-four (24)hours

2. Cellular ProliferationProduction of OSTEOIDSBridging of blood vessels

3. Callous FormationBridging large mass of differentiated tissues

3. OssificationFractured ends meet together Three lipids in cell membrane:

o Glycolipids

o Phospholipidso Cholesterol

4. RemodellingCompact-bone formation

Complications of FracturesPulmonary EmbolismFat Embolism

o Common emboluso From the marrowo Pure cholesterol

Gangreneo Blood vessel problemo Massive avascularity

Tetanuso

Burnso Fractureso Causative agent is

Clostridium tetanio Signs and Symptoms

include:Risus sardonicusLockjawOphistotonus

Seizure witharching of

the backVertigoEnvironment ismoving, swirling

Dizzinesso Preventive measure

Tetanus Toxoidvaccine

MUSCULOSKELETAL DISORDERS

1. OsteomyelitisInflammation or infection of thebone marrowAffects weight-bearing bonesCausative agent isStaphylococcus aureus

2. Supracondylar Fracture


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Elbow affectation

3. Congenital Club FootTalipes EquinovarusUse Dennis Browne shoe

Cast4. Hip Dislocation

Unilateral or BilateralIf unrelieved, TOTAL HIPREPLACEMENT usingprosthesis is doneKept abducted

o Use abductor splint or pillow between the legs

o Reinforce with

TROCHANTER ROLL or blanket

5. Coxa PlanaAseptic necrosis of the femoralheadLegg-Calves PerthesNo infectionsTen times more common in whitechildren than in blacks

6. ScoliosisGait is changedSpinal Column deformityLateral CurvatureBased on Origin:

o StructuralLigaments holdingthe spine haveproblemsCan be relieved byexercise

o FunctionalWork

Managemento Bottleblowing for scoliosiso Swimming is best for

scoliosiso Milwaukee brace

Pelvis to chin cup

Worn for twenty-three (23) hours ina day and one (1)free hour for inspections

Scoliotic to the lefto Right hip is upo Left shoulder is up

7. Potts Disease Tuberculosis of the Spine

8. ArthritisRheumatoid Arthritis

o Systemic, bilateral,

symmetricalOsteoarthritiso Weight-bearing jointso Unilateral

Gouty Arthritiso Affects great toeo Uric acido Monosodium urate crystalso Tophi

9. Slipped DiscLaminectomy is the surgery of choiceHerniated Nucleus Polposus

10. Intertrochanteric FractureGreater to lesser or letter togreater trochanteric break

Interjected Concepts!!!Combination disorders:

o Scoliokyphosiso Kyphoscoliosiso Lordokyphosiso Kypholordosis

Sickle Cell Anemiao Blacks are mostly the ones

affected


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CARE OF CASTS1. If not yet dry, use the palm in movingto avoid deforming its contour 2. If dry, also use the palm in moving for safety

Cast should not be too tightThis may impede circulationFingers and toes should be ableto wiggleCast should not be too loose

3. Observe for cyanosis4. Open fractures

Use window type of cast

5. Observe odor

Foul odor may indicate infectionImportant Concept!!!

When there is itchiness, blow air under the cast to eliminatemoisture

ASSISTIVE DEVICES

1. CanePrinciple in use:

o Use on the HAND ONTHE UNAFFECTED SIDE

2. Walker If patient is a child

o Rota Walker o andador o No sense of direction

If patient is an adulto Four-legged walker

3. Crutch (saklay) Principle in use:

o Weight of body borne bythe ARM not by the axilla

o Therefore, it should beb t t (2) i h f

to the axilla there shouldbe about two (2) inches)

o Tip of crutch from foot isabout six (6) to eight (8)inches (to side)

Four-Point Gaito Two (2) crutches usedo Two (2) legs usedo First to move:

Crutch before

Documents

38078786 Medical Surgical Nursing II