MEDICAL SURGICAL NURSING – Endocrine Disorders ___

Gland >> Hormones >> Disorder o Rationale: Connected to vital

organs
PITUITARY GLAND DISORDERS 2. Cellular dehydration
➢ Local effect only
Pituitary gland Vasopressin
- A.k.a. Hypophysis ▪ A.k.a. Anti-dehydration hormone
- Found in the base of the brain ▪ Functions:
- Below the hypothalamus a) Conserves all fluids directly to the
- Master gland vascular fluid compartment plus the
o Has direct/indirect effect on hormones kidneys
- Two parts: b) Very potent vasoconstrictor
o APG c) Bp regulation
o PPG • Water = bp
Hypophysectomy
▪ Common route: Transphenoidal DIABETES INSIPIDUS vs. SIADH
o Passes through the upper lip and sinus
▪ WOF during post-op: Frequent Swallowing DIABETES INSIPIDUS SIADH
Deficiency or absence or Syndrome of INCREASED Anti-
o Rationale: Could be a sign of bleeding resistance of ADH Diuretic Hormone
Hypothalamus Two types: Cause:
- Produces ALL the hormones 1) Neurogenic 1. Adenoma in the pituitary
o PPG/Hypothalamus gland or hypothalamus
Anterior pituitary gland production or o Benign
- A.k.a. Adenohypophysis absent production of o Could progress to
- Hormones produced: ADH cancer
o Low storage by the o Pushes the gland >>
o Stimulating hormones PPG of ADH overproduction of the
Posterior pituitary gland o Due to: ICP, hormones
2. Hereditary condition
- A.k.a. Neurohypophysis CVA, brain infection,
o Producing too many
brain tumor,
- Does not produce hormones Simmonds disease, hormones of the PG
- Purpose: For storage and releasing of TBI o Could lead to
o More common Hyperpituitarism
hormones 3. ICP
2) Nephrogenic
ANTERIOR PITUITARY POSTERIOR PITUITARY o High pressure >>
o Increased resistance
GLAND GLAND pushes the gland >>
to ADH
Thyroid stimulating hormones Oxytocin overproduction of
o Kidneys refusing to
✓ T3 ✓ For uterine contractions accept ADH hormones
✓ T4 ✓ Artificial: Can be given by
o Due to: Renal failure,
5cm or latent phase
glomerulonephritis,
✓ For uterine contractions nephrotic syndrome
✓ Milk let down reflex
Clinical Manifestations: Clinical Manifestations:
Follicle stimulating hormones Antidiuretic hormone ✓ Polyuria ❖ Oliguria
✓ GnRH ✓ A.k.a. Vasopressin o >4L/day o <30cc/hr
✓ LH
✓ Polydipsia ❖ Anuria
Melanocyte stimulating hormone - ✓ No problems with blood ❖ Water retention
Growth hormone - sugar ❖ Weight gain
Adrenocorticotropic stimulating - ✓ Hypovolemia ❖ Fluid excess/overload
hormone ✓ Water loss ❖ Water intoxication
Interstitial cell stimulating - ✓ Fluid deficit ❖ Jugular vein distention
hormone ✓ Poor circulation ❖ Varicosities
✓ Testosterone ✓ Hypotension ❖ Hypervolemia
Prolactin stimulating hormones - ✓ Weight loss o Too much plasma
✓ Vascular dehydration ❖ Hypertension
✓ Poor skin turgor ❖ Metabolic Alkalosis
Three fluid compartments ✓ Sunken eyes o Too much water in the
VASCULAR CELLULAR INTERSTITIAL body
✓ Metabolic Acidosis
First space Second space Third space ✓ Respiratory Alkalosis ❖ Respiratory Acidosis
Most important and If damaged: Largest space o Hyperventilation o Hypoventilation
life-threatening ✓ Local effect (shallow breathing)
➢ Rationale: only ❖ NO EDEMA
Blood vessels o Rationale: Fluid is in
are connected the vascular space
to the vital ❖ Hydronephrosis
organs o Too much water in the
No body edema Body edema can Where body edema kidney
occur in this space mostly takes place URINE SERUM URINE SERUM

Diluted Viscous/ Concentrated Diluted

Two types of dehydration Concentrated
1. Vascular dehydration Cause of death: WOF:
➢ Systemic effect Hypovolemic shock Dilutional Hyponatremia
➢ More life-threatening ✓ Could suffer seizures
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Endocrine Disorders ___
✓ Troubleshoot: ✓ Arrhythmias Adenocarcinoma
Position px to
Modified - Cancer in vital organs
Trendelenburg - (+) Metastasis
Diagnostic tests: Diagnostic tests: Sarcoma
a. CT/MRI/PET scan a) CT/MRI/PET scan
✓ To visualize b) KFT - Cancer in connective tissues
pituitary and c) ABG
hypothalamus d) ECG/EEG -gram -scan
b. KFT ✓ For seizures and Iodine dye Radioactive dye
✓ To rule out renal arrhythmias
problem e) Serum electrolytes
c. Utz of the KUB f) Specific gravity
d. ABG ✓ (+) >1.030
e. Water deprivation test g) Serum osmolarity PARATHYROID GLAND DISORDERS
✓ (+)Despite ✓ (+) <280 mosm
deprivation,
there is still
Parathyroid glands
urine output - Found on the posterior of the thyroid gland
f. Specific gravity test - Composed of 4 nodules
✓ Checks urine
concentration
- Butterfly shaped gland
✓ N: 1.010 – - Hormones produced:
1.025 o Parathyroid hormone (PTH)
✓ (+) < 1.010
g. Serum osmolarity PTH functions
✓ Checks blood 1. Calcium and Phosphorous regulation
concentration ▪ Inversely proportional
✓ N: 280 – 295
mosm ▪ Calcium: Mineral
✓ (+) >295 o Acts as a “Cement”
Pharmacologic Management: Pharmacologic Management: ▪ How does PTH regulate calcium?
▪ Drug of choice: HRT of ▪ Drug of Choice:
ADH for life (Vasopressin) Demeclocycline o PTH will act as a
o Route: Intranasal or o Antibiotic “Withdrawer”
IV o Used for its off label
▪ Other drugs: effect
o PTH will take Calcium in the
o Chlorpropramide o Decreases ADH release bones >> Takes it to the blood
(Diabenase) o S/e: Weight loss, o Activates naturally during
✓ OHA in low polyuria
dose ▪ Furosemide (Lasix) hypocalcemia or
✓ Off-label effect o Loop diuretics hyperphosphatemia
✓ Helps stimulate o Fastest diuretics ▪ Calcium is stored in:
ADH release o Potassium wasting =
✓ Lessens Sodium o Bones
resistance from o Half-life: 6 hours o Pancreas
the kidneys o S/e: Ototoxicity and
▪ Anticoagulants PRN
▪ Normal Calcium:
photosensitivity
o For the viscous blood ▪ Antihypertensives o 8- 10 mg/dL or;
o Used as prophylaxis ▪ Anticonvulsants o 4.5 – 5.5 meq/L
- Surgical Management: ▪ Calcium functions:
▪ Hypophysectomy
o Post-op: HRT for life o Production of fibrinogen
Other Nursing Management: Other Nursing Management: (Clotting factor I)
▪ Hydration via IVF or OFI ▪ Diet:
▪ Monitor I&O
o For muscle contractions
o Sodium
▪ Weigh daily o Limit fluids
o Morning ▪ Sodium replacement as HYPOPARATHYROIDISM vs. HYPERPARATHYROIDISM
o Same time of the day needed
▪ Monitor electrolyte ▪ Monitor I&O HYPOPARATHYROIDISM HYPERPARATHYROIDISM
imbalance ▪ Weigh daily Low production of PTH or absent Overproduction of PTH
▪ Treat underlying cause PTH
Increased calcium deposits in the Low calcium deposits in the bone
bone ( Demineralization)
Weight
Decreased calcium deposits in the Increased calcium deposits in the
- Best indicator of fluid status blood blood
Simmonds Disease Increase phosphorous in the blood Low phosphorous in the blood
- Genetic condition Causes: Causes:
▪ Atrophy ▪ Adenoma in the parathyroid
- Hypopituitarism ▪ Activity gland
- Pituitary gland does not function well ▪ Cancer ▪ Hypertrophy or hyperplasia
Adenoma ▪ Autoimmune damage of the PTG
▪ Over treatment o Hypertrophy: size
- Tumor in vital tissues/organs o Radiation of cells
- Benign ▪ Surgery o Hyperplasia:
- Capsulated cell wall number of cells
▪ Over treatment of HRT
- (-) Metastasis ▪ Autoimmune inflammation

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Endocrine Disorders ___
Clinical manifestations: Clinical manifestations:
✓ Big, heavy, very rigid bones ✓ Weak, brittle, and spongy
✓ Increased density bones bones Iatrogenic Disease
✓ Thickening of the bones ✓ Decreased bone density - Acquired condition due to a medical treatment
✓ Weight gain o Bowing of bones or
✓ Pain bending
PTH CALCITONIN
✓ Conductive hearing loss ✓ Pain
Withdrawer Depositor
✓ Hypocalcemia ✓ Conductive hearing loss
✓ Hyperphosphatemia Bone to blood Blood to bone
✓ Risk of Pathologic
✓ Risk for bleeding fractures
✓ Prone to ✓ Risk of Secondary
bruising/Ecchymosis Osteoporosis
✓ Arrhythmias o Systemic bone loss ADRENAL GLAND DISORDERS
✓ Muscle weakness ✓ Abnormal posture
✓ (+) Tetany o Kyphosis (Dowager’s
o Paresthesia Hump)
1. Pheochromocytoma
o Muscle twitching ✓ Hypercalcemia 2. Addison’s Disease
o Carpopedal spasm
o WOF:
✓ Hypophosphatemia 3. Cushing’s Disease
o Triggers arrhythmias
Laryngobroncho ✓ Risk for clotting
4. Cushing’s Syndrome
spasm 5. Iatrogenic Cushing’s
o (+) Chvostek’s sign o Risk for CVA, MI
o (+) Trousseau’s sign ✓ Renal calculi 6. Cohn’s Disease
o Calcium Oxalate
stones
✓ Vascular/Valvular Adrenal glands
calcification - Located above the kidneys
o Hypertension
Diagnostic tests:
- 2 kidneys = 2 Adrenal Glands
1. X-ray
2. Bone Densimeter Scan Two parts of the Adrenal Glands
3. Serum electrolytes panel ADRENAL MEDULLA ADRENAL CORTEX
4. Bleeding and clotting parameters
Produces Catecholamines Produces Corticosteroids
5. ECG
a. Epinephrine
6. UTZ of the kidney and parathyroid
b. Norepinephrine
7. CT/MRI/PET scan
8. Serum PTH level
9. Alkaline phosphatase level Functions of Catecholamines
Pharmacologic Management: Pharmacologic Management:
▪ Drug of Choice: HRT for ▪ Drug of choice: Synthetic
▪ Produces sympathetic effect
life Calcitonin o Fight or Flight response
▪ Calcium supplements o Acts as a “Depositor” o “Adrenaline rush”
▪ Vitamin D injections and o Allows the calcium to
supplements go in the bone o Everything will be:
o For better absorption ▪ Analgesics ▪ Fast
of calcium ▪ Antineoplastic medications ▪ Increased
▪ Analgesics ▪ Steroids
▪ Antiarrhythmics ▪ Anticoagulants prn ▪ Elevated
▪ Tranexamic Acid ▪ Antiarrhythmics as needed ▪ Up
(Hemostan)
o To stop the bleeding
o Except for:
▪ Give Aluminum Hydroxide ▪ GI and GU function
(AmPHOjel) ▪ Activates during:
o Antacid
o Off label effect o Emergency
o Phosphate binder o Excessive amount of stress
o Gets the excessive o Presence of life-threatening situations
phosphorous in blood
>> excreted via stool
- Surgical Management: PHEOCHROMOCYTOMA
▪ Sub-Total or Total
Parathyroidectomy
Other Nursing Management Other Nursing Management:
- Excessive production of catecholamines
▪ Diet: ▪ Diet: o Unnecessary amounts
o High fiber o Low calcium diet - Affects the adrenal medulla
o S/e of Calcium is o High phosphorous diet
constipation ▪ Mild to moderate activities
- Presence of benign adrenal medulla tumor
o High calcium o Note: Handle (Adenoma)
o High Vitamin D extremities very gently o Causes px to over produce
o Low phosphorous ▪ Radiation Treatment as
▪ Hydration needed catecholamines
▪ Bedside equipment: - Can still progress to cancer
o ET set - Common in: Females > Males
o Trach set
o Ambu bag
ADENOMA INSIDE THE ADENOMA OUTSIDE THE
ADRENAL MEDULLA ADRENAL MEDULLA
Produces both Epinephrine and Produced Epinephrine only
Norepinephrine

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Endocrine Disorders ___
Pathophysiology o Urine retention
▪ Hereditary factors (Ex: Sipple’s Disease) >> o Hyperglycemia
presence of adenoma in the adrenal medulla >>
causes px to over produce unnecessary amounts *Note: Hypertension is not curable but controlled.
of catecholamines >> leading to excessive Systolic bp of > 130 with a Diastolic bp of >90 *
sympathetic effect
Diagnostic tests
MEN II A 1. MRI
- Multiple Endocrine Neoplasia ➢ Confirmatory test for
- A.k.a. Sipple’s Disease Pheochromocytoma
- An Autosomal Dominant Disorder 2. CT scan
- A lot of the endocrine glands have tumor ➢ 2nd best choice
growth 3. Utz
- Usually targets the: ➢ 3rd best choice
o Pituitary 4. Biopsy
o Adrenal glands ➢ Optional only
AUTOSOMAL DISORDERS X-LINKED DISORDERS o Rationale: Invasive procedure
Source of problem is in the 46 Source of problem is in the sex
chromosomes chromosomes
Screening tests
Trisomy 13 Patau’s Syndrome 1. VMA Test
Trisomy 18 Edward’s Syndrome ▪ Vanillylmandelic Acid Test
Trisomy 21 Down’s Syndrome
▪ 24-hour urine collection test
▪ Purpose: To check for urine
AUTOSOMAL DOMINANT AUTOSOMAL RECESSIVE
DISORDERS DISORDERS catecholamines
(+) Physical and anatomical (-) Physical and anatomical ▪ (+) VMA = (+) Pheochromocytoma
changes changes ▪ Contraindicated foods that cause
✓ Confirmatory: Blood tests
One parent is enough to transmit Requires both the parents to have false (+) result:
the condition to the offspring the genetic problem to acquire the o Vanilla
disease
If both parents have ADD: Usually common in blood
o Chocolates
✓ Symptoms are more severe disorders o Nuts
✓ Ex: G6PD o Caffeine
2. Serum Catecholamines Test
Clinical Manifestations ▪ Elevated = (+) Pheochromocytoma
▪ Triad symptoms: “PHE”
o Palpitations Nursing Management for Pheochromocytoma
o Hypertensive Crisis Diet ✓ High calorie
▪ Systolic: > 180 ✓ High carbohydrates
✓ High protein
▪ Diastolic: > 120 ✓ High fiber/roughage/residue
▪ (+)Neurologic s/s ✓ No stimulants
o Energy drinks
o Excessive sweating o Chocolates
▪ Compensatory for o Caffeine
hyperthermia due to ✓ Hydration
o Alleviates constipation
catecholamines o Controls body temp
▪ Other symptoms: o Prevents fluid and electrolyte
imbalance
o Hyperthermia Drug of choice Phentolamine (Regitine)
o Diaphoresis ✓ Direct acting vasodilator
o Hyperactivity ✓ Causes systemic dilation
✓ Route: Parenteral
▪ Insomnia ✓ Antidote for: MAOI toxicity
▪ Nsg Mngmnt: Px should be Pharmacologic ❖ Antineoplastic
placed far from nurse’s station o Methotrexate
o Cyclophosphamide
• Rationale: Lesser o Mitotane
stimulus ❖ Antihypertensives
o Propranolol
o Tremors • Controls bp and pulse
o Hyperventilation ❖ Laxatives
o Hyper metabolism Other treatments ❖ Radiation treatment
o Rationale: To dissolve the adenoma
▪ Increased appetite Surgery of choice ✓ Adrenalectomy
▪ Weight loss o Removes both the cortex and medulla
o Constipation o Two types:

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Endocrine Disorders ___
• Unilateral Reni-Angiotensin-Aldosterone-System (RAAS)
• Bilateral
Post-surgery ✓ HRT of corticosteroids
management o To prevent Addison’s Disease
o Unilateral:
• For 6 – 12 months
• Must be tapered
o Bilateral:
• HRT for life

ADDISON’S DISEASE vs. CUSHING’S DISEASE vs.

CUSHING’S SYNDROME vs. IATROGENIC CUSHING’S

Corticosteroids
1) Mineralocorticoids
2) Glucocorticoids Decreased bp & Decreased fluid volume >> Liver
3) Gonadotrocorticoids produces Angiotensinogen >> Renin is released from
the kidneys to convert Angiotensinogen to Angiotensin
MINERALO- GLUCOCORTICOIDS GONADO- I >> ACE is released from the lungs to convert
CORTICOIDS CORTICOIDS
Produces Produces Cortisol and Produces Sex
Angiotensin I to Angiotensin II >> Angiotensin II
Aldosterone Cortisone hormones targets the Adrenal Glands & Vessels
➢ Stress hormones
✓ Conserves ✓ Increases blood sugar: ✓ For secondary
sodium o Glycogenolysis sexual Targets Adrenal Cortex >> Release of Aldosterone >>
✓ Removes o Gluconeogenesis characteristics
potassium ✓ Lowers down immune Allows the kidneys to reabsorb Sodium and Water >>
✓
✓
Attracts water
For fluid
response
o By decreasing
Fluid retention >> Decreased urine output >> Increased
regulation WBC migration fluid volume
✓ For bp ✓ Lowers prostaglandin
regulation production
o Pain & Targets the Vessels >> Vasoconstriction >> Increased
inflammation bp
o Production
of mucus/shield
from
hydrochloric
acid ADDISON’S DISEASE CUSHING’S CUSHING’S
o HCL acid DISEASE SYNDROME
production A.k.a. Adrenal Insufficiency A.k.a. Paris Disease A.k.a. Hyper
Corticolism
o Stress =
Low or absent Increase corticosteroids Hyperactivity of the
peptic ulcers
corticosteroids Salt adrenal cortex
✓ Lowers calcium via
Salt Sugar ✓ More common
osmotic diuresis
Sugar compared to
o Prone to Sex
Cushing’s
fractures Sex
disease
Causes: Causes: Causes:
GLYCOGENOLYSIS GLUCONEOGENESIS 1. Autoimmune damage 1) Due to pituitary 1. Hypertrophy
of the adrenal cortex adenoma = 2. Hyperplasia
Breaks down glycogen that was Creation of sugar from new 2. Atrophy of the Overstimulation
stored in the liver to convert to sources such as muscles and fats adrenal cortex 2) Hyperpituitarism
glucose since glycogen from liver is 3. Cancer
already used 4. Infection
Normal process Last option or if there is no other 5. Trauma
option 6. Iatrogenic
7. Radiation
Effect: Energy Consumption Effect: Ketoacidosis 8. Chemotherapy
✓ Break down of fats and 9. Hypopituitarism
proteins muscle wasting Laboratory presentation: Laboratory presentation: Laboratory
❖ Steroids ❖ Steroids presentation:
❖ ACTH ❖ ACTH ❖ Steroids
ANTI-DIURETIC HORMONE ALDOSTERONE
❖ Simmon’s disease: ❖ ACTH
Directly conserves all fluids to Indirectly conserves fluids by Steroids, ACTH
the vascular space and the kidneys retaining sodium and removing Clinical Manifestations: Clinical Manifestations:
potassium ✓ Salt ✓ Salt
Faster to conserve Slower to conserve o Hyponatremia o Hypernatremia
o Hyperkalemia o Hypokalemia
o Arrhythmias o Water retention
o Water loss o Fluid overload
Stimulating hormones o
o
Fluid deficit
Hypovolemia
o
o
Hypervolemia
Weight gain
- Produced via (-) feedback mechanism o Hypotension o Edema (Salt/Sugar problem)
o Weight loss ▪ Truncal obesity
o Dehydration ▪ Moon face
o Shock ▪ Buffalo hump
✓ Sugar o Thin skin “Plethoric skin”
o Hypoglycemia ▪ Fragile skin
o ALOC ▪ Purple Striae
o Behavioral ✓ Sugar
changes o Hyperglycemia

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Endocrine Disorders ___
o Stress ▪ Muscle wasting
intolerance ▪ Thin extremities
o Fatigue & o Viscous blood *All pain medications, all analgesics, and all
weakness ▪ Poor circulation
o Leukocytosis ▪ Poor wound healing
corticosteroids should be taken WITH meals*
o Increased pain ▪ Risk for Gangrene toes
sensitivity o Low immune response
o Hypercalcemia ▪ High risk of infection
o Renal calculi o GI upset or Peptic Ulcer Disease COHN’S SYNDROME
o Prone to
clotting
o Hypocalcemia - A.k.a. Primary Aldosteronism
✓ Sex
o Arrhythmias o Male: - A.k.a. Hyper Aldosteronism
✓ Sex ▪ Gynecomastia
o Amenorrhea ▪ Mood swings
o Alopecia o Female: Pathophysiology
o Changes of ▪ Virilism
distribution in ▪ Hirsutism
▪ Hereditary Factors >> Cortical Adenoma >>
body hair ▪ Deep male voice Overproduction of unnecessary of Aldosterone
o Bronze ▪ Amenorrhea
pigmentation ▪ Breast atrophy without Renin
of skin
“Eternal Tan”
Causes • Hereditary/Genetics
o Libido
✓ WOF: Addisonian • MEN II A
Crisis Incidence Common in females > males
o Ttt: Just double Clinical manifestations ⬆️Salt
or triple the ✓ Hypernatremia
dosage for
corticosteroids
✓ Hypokalemia
Pharmacologic Pharmacologic Management: ✓ Water Retention
Management: ▪ Drug choice: Cyproheptidine (Periactin) ✓ Fluid overload
▪ Drug of choice: HRT o Lowers down ACTH production ✓ Hypervolemia
of Corticosteroids ▪ Spirinolactone (Aldactone) ✓ Weight gain
WITH meals o Aldosterone inhibitor or Potassium ✓ Edema
o S/e: Think of Sparring Diuretics ✓ Plethoric skin
Cushing’s o Controls bp
o Purple Striae
o 2/3 = AM o Urine output
o 1/3 == PM ▪ Potassium supplements as needed
Lab presentation ▪ ⬆️Aldosterone
o More is taken o Ex: Potassium Chloride ▪ ⬇️Renin
during the day o IVF incorporated with NSS Confirmatory tests 1) MRI
to mimic o Safest: 10meq/hr
normal release
2) CT scan
o Maximum: 40meq/L
o Hydrocortisone ▪ Antihypertensives
3) UTZ
= BS ▪ Calcium supplements as needed Drug of choice ✓ Aldosterone Inhibitors
o Fludrocortisone ▪ Tranexamic acid (Hemostan) o Spironolactone
= Na o Anti-fibrinolytic (Aldactone)
o Increases ▪ Anti-ulcer drugs Pharmacologic Management ▪ Anti-neoplastic
insulin demand ▪ Anti-neoplastic ▪ Antihypertensives
▪ Sodium Polysterene ▪ Potassium supplements
(Kayexalate)
▪ Potassium chloride IVF
o K+ binder
o Gets the Surgical Management: ➢ Radiation
potassium from ➢ Adrenalectomy
the blood and Nursing management ❖ Diet
excretes via ✓ ⬇️Sodium
stool
▪ Anticoagulants prn ✓ ⬆️Potassium
Surgical Management: - ✓ Limit OFI
▪ Radiation Treatment ❖ Monitor I&O
▪ Surgery for removal of tumor/adenoma ❖ Weigh daily
o Adrenalectomy
o Hypophysectomy
Other Nursing Other Nursing Management:
Management: ▪ Precaution: Reverse isolation
▪ Precaution: Reverse ▪ Diet:
Isolation o Sodium
▪ Diet: o CHO
o Sodium o Calorie
o CHO o Adequate CHON
o Calories o Potassium
o Protein o Potassium- rich foods
o Potassium o Ex: Apricot, avocado, watermelon,
▪ Sodium replacement melon, cantelope, papaya, apples,
as needed oranges, potato, sweet potato, raisins,
▪ Hydration prunes, banana, and pickles
o IVF or OFI ▪ Monitor I&O
o D5W ▪ Weigh daily
o PNSS ▪ Limit OFI
▪ Monitor I&O
▪ Weigh daily
▪ Treat underlying
cause
IATROGENIC CUSHING’S
✓ Due to excess use of drugs/steroids

Laboratory presentation:
✓ Steroids
✓ ACTH

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Endocrine Disorders ___

PANCREATIC DISORDERS DM TYPE 1 DM TYPE 2

A.k.a. Insulin Dependent Diabetes A.k.a. Non-Insulin Dependent
Mellitus (IDDM) Diabetes Mellitus (NIDDM)
1) DM Type 1 ✓ Approved ✓ Not approved anymore
2) DM Type 2 Juvenile Diabetes Mellitus (JDM) Adult/Maturity onset
3) GDM ✓ Not approved ✓ Approved
4) Pancreatitis (Read GI handouts) ✓ Age, risk
Pancreas <30 years old onset >30 years old onset
Total absence of Beta cell Low production or high levels of
- Located at the epigastric area or LUQ function resistance to insulin
- Adjacent to the stomach More dangerous More common
✓ 10% higher mortality rate
Causes: Causes:
Function of the pancreas ▪ Autoimmune ▪ Obesity
EXOCRINE FUNCTION ENDOCRINE FUNCTION o Damage to B-cells o (+) fats creates
Functional unit: Acinus Functional unit: Islet of o Leading cause double wall in cells
Langerhans ▪ Genetics/Hereditary which leads to
Produces digestive enzymes Regulates the Cells in the Islet of resistance to insulin
Langerhans o BMI: >30
Digestive enzymes: Cells in the Islets of Langerhans: ▪ Increased resistance is better
answer than low production
▪ Overweight
1) Amylase 1. Alpha cells o BMI: 25 – 29.9
✓ Digests CHO 2. Beta cells ▪ Lifestyle and Diet
2) Lipase 3. Delta cells Differential Clinical Differential Clinical
✓ Digests fats 4. PP cells Manifestations: Manifestations:
3) Trypsin ✓ Weight loss ✓ Weight gain
✓ Digests CHON ✓ (+) DKA ✓ (+) Hyperglycemic
Hyperosmolar Non-ketotic
Syndrome (HHNS)
✓ DKA
HORMONES FUNCTION o Can still happen in the
SECRETED later stages or in
Alpha cells Glucagon ⬆️Blood sugar via uncontrolled types
glycogenolysis Similar Clinical Manifestations:
Beta cells Insulin ▪ ⬇️Blood sugar ✓ Polyuria
and Potassium o Due to osmotic diuresis
▪ Allows o Risk for dehydration
potassium to go ✓ Polyphagia
in the cell o Due to cell starvation
Delta cells Somatostatin ➢ Regulates ✓ Polydipsia
Alpha and Beta o Compensatory for polyuria
cells ✓ Hyperglycemia
➢ A growth o Viscous blood
hormone o Poor circulation
inhibiting o Risk for infection
hormone o Risk for gangrene
➢ Blocks the o Poor wound healing
effect of Insulin o Dark/dusky color of skin
F-cells (PP cells) Pancreatic Regulates food o Risk for clotting
polypeptide intake, hunger, and ✓ ALOC
GI function ✓ Behavioral changes
✓ Fatigue weakness
✓ Altered sensation
o Neuropathy
DM TYPE 1 vs. DM TYPE 2 o Risk for diabetic foot
✓ Blurred vision
✓ Hypertension
Diabetes Mellitus ✓ Diabetic coma
- Mellitus Symptoms of Hypoglycemia
o Chronic and metabolic disorder of ✓ Blurred vision
✓ ALOC/Behavioral Changes
CHO, CHON, and fats ✓ Fatigue and weakness
- A beta cell condition ✓ Dizziness
✓ Light-headed
- Problem of insulin production ✓ Diaphoresis
- Total absence/low production/ high levels of ✓ Cold clammy skin
resistance to insulin ✓ Tremors/shakiness
✓ Seizures
- Total absence: DM Type 1 ✓ Diabetic coma
- Low production/resistance: DM Type 2 o Both in hypoglycemia and hyperglycemia
- Non-curable but controllable and preventable Diagnostic Tests:
1) HBA1C
• Confirmatory test for DM
Normal BMI • A.k.a. Glycosylated HGB Test
▪ 18 – 24.9 • Checks the amount of glucose binded to the hemoglobin

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Endocrine Disorders ___
• Reflects average blood sugar for the last 3-4 months (100-
120 days)
• Lifetime of RBC: 120 days
Diabetes Mellitus Complications
• No need for NPO/fasting MICROVASCULAR MACROVASCULAR
COMPLICATIONS COMPLICATIONS
• Purpose: To monitor long-term control or compliance to
Diabetic Retinopathy Stroke
management
Diabetic Neuropathy Myocardial Infarction
• Normal in undiagnosed: 4– 6 %
Diabetic Nephropathy Peripheral Vascular Disease
• Normal in diagnosed w/ good control: <7.5%
• Normal in diagnosed w/ fair control: 7.6% - 8.9%
• Normal in diagnosed w/ poor control: >9%
2) OGTT DIABETIC NEPHROPATHY
• 2nd best dx
• 3 days prior to test: high carb diet
• 3rd night: NPO for 6 – 8hrs; Max of 10hrs Kidney
• 4th day: BS will be checked 30 minutes before and 30 ▪ Contains blood sugar threshold
minutes after an intake of glucose solution (75g/100g) o Normal sugar threshold: 160 –
• Monitor BS hourly for the next 3 – 4 hours
• Expected outcome: Gradual decline or normalization of 180mg/dL
sugar o Glomerular damage: > 180mg/dL
• (+) DM: if not in gradual decline or (-) normalization of ▪ Resulting to glucosuria >> if
values
3) FBS not controlled >> intra renal
• Normal: 70 – 110mg/dL failure >> diabetic
• Convert to mmol: ➗18 nephropathy
• (+) DM: >140 mg/dL on 2 or more occasions
Screening Tests:
3 methods of renal damage
a. Random blood sugar PRE-RENAL INTRA-RENAL POST-RENAL
b. CBG CAUSE CAUSE CAUSE
c. 2-hour post-prandial glucose test Due to poor Due to internal Due to (+)
Pharmacologic Management: Pharmacologic Management: perfusion damage to the obstruction
▪ Drug of choice: Insulin ▪ Oral Hypoglycemic Agents nephron and
o Main management (OHA) glomeruli
o Only effective if there ✓ (-) poor
is still beta-cell perfusion
function ✓ (-) obstruction
▪ Insulin Ex: Shock, D.I. Ex: SLE, Ex: Renal Calculi,
Diet: Pyleonephritis, BPH, Thrombus
✓ Diabetic Diet Nephrotic Syndrome,
o 1,500 – 2,000 cal/day Cancer, DM,
o Inclusion: 3 major meals with snacks Nephrotoxic drug
o Use a diabetic exchange list
✓ Use Diabetic Exchange List
o Food alternatives
Special Complications of Diabetes Mellitus ⭐️
✓ Caloric distribution 1) Diabetic Ketoacidosis (DKA)
o Complex Carbohydrates: 40% - 60% 2) Hyperosmolar Hyperglycemic Non-Ketotic
o Fats: 20% - 30%
o CHON: 10% - 20% Syndrome (HHNS)
❖ Rationale: To lessen renal damage
✓ Sodium intake DIABETIC KETOACIDOSIS
o 2 – 3 grams/day only
✓ Adequate hydration
✓ SFF - Can happen in both DM type 1 and DM type 2
Nursing management for Hypoglycemia
▪ If px is unconscious: No oral sugar is given
o Give glucose (IV/IM)
2 critical problems that developed because of DKA
o IV: D50W - bolus 1. Metabolic Acidosis
o IM: Glucagon 2. Dehydration
▪ If px is conscious: Oral sugar
o Short-term ttt: Simple Sugar
❖ Ex: Hard candy, orange juice, chocolate, glucose tabs Pathophysiology of DKA in DM type 1
o Long-term ttt: Complex Sugar ▪ Total absence of insulin >> Blood sugar greater
Other Nursing Management: Other Nursing Management:
▪ Diet and Exercise ▪ Main management: Diet than 300mg/dL >> Total cell starvation >>
▪ Refer to podiatrist and Exercise Gluconeogenesis >> catabolism of protein and
o At least 2x – 3x a
week
fats >> produces by-product >> ketosis =
o At least 20 – 30 mins ketones = acid >> METABOLIC ACIDOSIS
▪ Refer to podiatrist >> px will develop hyperventilation >>
GESTATIONAL DIABETES
▪ Starts to go up during 2nd trimester Kussmaul’s respirations
▪ Full blown GDM by 3rd trimester ▪ Blood sugar greater than 300 mg/dL >>
▪ Confirmatory test: OGTT
▪ Baby in Macrosomia GDM CPD C-section Osmotic diuresis >> DEHYDRATION >>
▪ Baby out Hypoglycemia Hypoactive Cry and Hypoactive reflexes shock >> renal damage >> death
▪ Baby in: INSULIN
▪ Baby out: Glucose Water (baby) if mother does not have breast milk
▪ Only nutrient not found in breast milk: IRON

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Endocrine Disorders ___
Leading Cause 1. Skipped/missed/inadequate o Rationale: To prevent sudden drop of
dosage of insulin blood sugar (Hypoglycemia)
o Can be a negligence of o If potassium is low, give Potassium
the nurse Chloride
2. Stress, infection, or surgery o Q15mins – Q30mins
o Rationale: Stress ❖ Continue monitoring BS & K+
hormones = ⬆️blood o If BS is already stable, change back
sugar to PNSS
Confirmatory tests a. (+) Serum Ketones Test o If K+ is already stable, stop the
b. ABG + Blood sugar test Potassium Chloride infusion
(screening tests) Drug of choice for ▪ SODIUM BICARBONATE
o Rationale: Faster to be DKA o Antacid
done since this is an o Neutralizes acidity
emergency situation
Screening tests (+) Urine Ketones Test
o Rationale: Faster
detection but less
accurate
Clinical Manifestations ✓ Ketonemia
THYROID GLAND DISORDERS
✓ Ketonuria
✓ Kussmaul’s Respirations 1) Hypothyroidism
o A.k.a. Air Hunger
o Continuous, deep, and 2) Hyperthyroidism
fast breathing
✓ Acetone “fruity” breath odor
✓ GI upset
Thyroid gland
✓ Signs of dehydration - Located in neck area
✓ Glucosuria - Anterior to parathyroid glands
- Composed of 6 nodules
- Produces 3 hormones
HYPEROSMOLAR HYPERGLYCEMIC NON-KETOTIC
SYNDROME (HHNS)
Hormones produced
THYROCALCITONIN T3 & T4
For calcium and phosphate ✓ For cellular metabolism
- Can happen in early stages of DM Type 2 regulation o Breaking down of
- Only happens when insulin is still present ✓ “Depositor” nutrients for energy
o Effects of energy: Heat
DKA HHNS
& Sympathetic effect
Faster onset Slower onset
✓ For growth and development
✓ Takes time to develop
in children
Activates during hypercalcemia -
Pathophysiology of HHNS in DM type 2 and hypophosphatemia
▪ Decreased insulin production >> increased
HYPOTHYROIDISM vs. HYPERTHYROIDISM
resistance to insulin >> w/ blood sugar greater
than 600mg/dL >> massive osmotic diuresis >> HYPOTHYROIDISM HYPERTHYROIDISM
MASSIVE DEHYDRATION & SHOCK >> A.k.a. Myxedema (Maturity onset) A.k.a. Grave’s Disease
renal damage A.k.a. Cretinism (Child onset) A.k.a. Thyrotoxicosis (Toxic Goiter)
Low T3 & T4 High T3&T4
▪ Insulin still present >> no total cell starvation Causes & Type: Causes & Type:
>> no gluconeogenesis >> no ketosis >> (-) 1. Primary Hypothyroidism
o TG is the problem
1) Primary Hyperthyroidism
o Thyroid Gland itself is the
ketones o Underactivity or absent problem
Leading Cause 1. Inadequate fluid activity of the TG o Overactivity of the TG
replacement o Due to: o Due to:
➢ Autoimmune ➢ Autoimmune (leading
2. Stress, infection, surgery damage cause)
(Hashimoto’s ➢ Adenoma in the TG
Confirmatory tests (+) Serum Osmolarity Test + Blood Disease) ➢ Hypertrophy or
Sugar Tests ➢ Atrophy of the Hyperplasia
TG ➢ Genetics
Clinical Manifestations ✓ Symptoms of Dehydration ➢ Cancer ➢ Over treatment
➢ Iatrogenic 2) Secondary Hyperthyroidism
➢ Genetics/ o Pituitary gland is the problem
Congenital o Overstimulation of the PG
➢ Iodine o Due to:
deficiency ➢ Adenoma
2. Secondary Hypothyroidism ➢ Hyperpituitarism
Algorithm Nursing Management for both DKA & o Underactivity of the
PG
HHNS ⭐️ o Due to:
Initial management RAPID IV fluid resuscitation ➢ Cancer
✓ PNSS ➢ CVA
✓ Give in bolus ➢ Brain infection
➢ Simmonds
Pharmacologic Give insulin via IV (Clear Insulins)
disease
management ✓ Regular acting/Short acting ➢ Iatrogenic
✓ Rapid acting insulin Laboratory Presentation: Laboratory Presentation:
Other nursing ❖ Check blood sugar and potassium level ▪ Primary hyperthyroidism ▪ Primary hyperthyroidism
management o If BS is < 200mg/dL, change IVF o T3 o T3
temporarily to D5W or D10W o T4 o T4
o TSH o TSH
______________________________________________________________________________________________________________________________ 9
Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Endocrine Disorders ___
▪ Secondary hyperthyroidism ▪ Secondary hyperthyroidism 4. Thyroid Ultrasound
o T3 o T3 ➢ Considered to be safer than
o T4 o T4 other tests
o Rationale: No
o TSH o TSH
radiation exposure
Clinical Manifestations: Clinical Manifestations:
Drug of choice Drug of Choice
✓ All is slow & decreased ✓ All is fast & increased
✓ HRT of thyroid hormones for ✓ Antithyroid drugs
✓ Everything is ✓ Everything is Sympathetic
life o Lowers down T3 and T4
Parasympathetic ✓ Diarrhea
o -thyro production
✓ Constipation o A parasympathetic effect
o Elevates T3 & T 4 o Ex: Tapazole, Methimazole,
o A sympathetic effect ✓ Hand tremors
o S/e: Think of PTU
✓ BP o Earliest symptom
hyperthyroidism ➢ S/e: think of
✓ HR ✓ BP o Best time to take: A.M. hypothyroidism
✓ RR ✓ PR Before meals o WOF: Sore Throat and Fever
✓ Temp ✓ RR ✓ TSH HRT for life if cause is o Adverse effect:
o Cold intolerance o Hyperventilations secondary hypothyroidism Agranulocytosis or Blood
✓ Metabolism ✓ Temp Dyscrasia
o Anorexia o Heat intolerance Pharmacologic Management: Pharmacologic Management:
o Weight gain o Active sweat and oil glands ▪ Laxatives as needed ▪ RAI treatment
o Cholesterol ✓ Metabolism ▪ Steroids o Via injection of Sodium
o Always eating o If cause is Hashimoto Iodide 131
✓ Peristalsis
o Weight loss ▪ Iodine supplements as needed o Iodine is radioactive
✓ LOC ▪ Anti-lipidemic o Will destroy the hyperactive
✓ Increased peristalsis
✓ Energy (Earliest o Diarrhea o -statins or the abnormal nodules of
symptom) ✓ Increased size of thyroid gland o HMG – COA the thyroid gland
o Fatigue (Goiter) inhibitors o Will act as a “Trojan Horse”
o Weakness o SOB o Increases good o (+) Body fluid radioactive
✓ Dry scaly skin ✓ Exophthalmus cholesterol precaution
✓ Brittle nails and hair o Due to high internal pressure o Decreases bad ➢ Flush toilet
✓ Goiter >> bulging of eyes cholesterol more than twice
o SOB o May lead to Dalrymple’s o Ex: Simvastatin, ➢ Hydrate the
✓ Irregular menstruation Sign Rosuvastatin, patient
➢ A.k.a. Thyroid stare Atorvastatin ➢ Check KFT
➢ Reddened eyes, o S/e: Hepatotoxic o Radiation will only remain
infrequent blinking o Best time to take: for 48 hours
o Lid Lag Sign Hours of sleep ▪ Antineoplastic as needed
➢ A.k.a. Von Graefe’s ▪ Steroids as needed
Sign ▪ Antihypertensives
➢ Slow closing and o Propranolol
opening of eyelids ➢ Controls bp and
✓ Fine straight hair palpitations
✓ Soft smooth skin ▪ Lugol’s solution
✓ Breast enlargement o A.k.a. SSKI
✓ Pliable nails o An iodine solution
✓ Jefrey’s sign o Decreases the size and
o Forehead remains smooth vascularity of the thyroid
even when looking up gland
✓ Irregular menstruation o Normal: Metallic & Salty
WOF: MYXEDEMA COMA WOF: THYROTOXIC CRISIS taste
✓ Severe low nutrient levels ✓ A.k.a. Thyroid Storm o Normal: Warm, flushed
✓ Worsened s/s of ✓ Worsened s/s of Hyperthyroidism feeling
Hypothyroidism ✓ Early symptom: Constant elevation ➢ Monitor the px.
of heart rate together with elevation May be a sign of
of temperature allergy
✓ COD: Cardiac Arrest o Commonly used: Before
Diagnostic Tests: Diagnostic Tests: surgery
1) Thyroid serum tests 1. Thyroid serum tests o Note: Use straw to avoid
➢ Serum TSH ➢ Serum TSH staining of teeth
➢ Free T3 & T4 ➢ Free T3 & T4 o WOF: Allergies in shellfish
➢ Biotin: ➢ Biotin: ▪ Artificial tears or eyedrops
o Can cause false o Can cause false results o Administer eyedrops by
results o Discontinue at least 12 looking up
o Discontinue at hours – 2 days before ➢ Rationale: To
least 12 hours – blood test prevent spillage
2 days before 2. Radioiodine Uptake test of medication
blood test ➢ Take a small, oral dose of Surgical management: Surgical Management:
radioactive iodine ▪ Treat underlying cause ▪ Thyroidectomy
(radioiodine) to see how o Total
much will collect in the o Subtotal
thyroid gland ➢ More common
➢ Checked after four, six or 24 ➢ Never stop anti-
hours thyroid drugs
o Rationale: To see how before surgery
much iodine the
thyroid has absorbed ▪ Hypophysectomy
➢ Uptake: Other Nursing Management: Other Nursing Management:
o Indicates that thyroid ▪ Diet ▪ Diet
gland is producing too o Calorie o Calorie
much thyroxine o CHO o CHO
o Graves' disease o CHON o CHON
➢ Uptake:
o Fat o Fiber
o Indicates that the
o Fiber o No stimulants
thyroxine stored in the
▪ Warm comfortable ▪ Hydration via IV or OFI
gland is leaking into
environment ▪ Avoid stress, fatigue, infection
the bloodstream
▪ Thick clothing ▪ Place patient in a cold, comfortable
o Thyroiditis
▪ Moisturizing lotion and low stimuli environment
3. Thyroid Scan
▪ Lubricating lotion o Rationale: To prevent
➢ Radioactive isotope injected
▪ Monitor GCS closely insomnia
into the vein
➢ This test shows how iodine
collects in the thyroid.
______________________________________________________________________________________________________________________________ 10
Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
Pathophysiology
2 areas to consider ▪ (+) obstruction of peripheral arteries secondary
1. Heart to blood clot >> oxygenated blood cannot pass
2. Blood vessels through going to systemic circulation >> tissue
ischemia >> creates a sensation of pain and
PERIPHERAL VASCULAR DISEASES inflammation
▪ Untreated ischemia >> leads to formation of
- Affects distal extremities gangrene
2 Types ▪ Untreated gangrene >> could spread to other
1. Arterial disorder tissues including healthy tissues
a) Buerger’s Disease
Incidence Males > Females
b) Reynaud’s Disease
Common area affected Lower Extremities
2. Venous disorders Predisposing Factors • Smoking/Vaping
a) Varicose Veins o Leading factor
b) DVT o Nicotine causes
vasoconstriction
c) Thrombophlebitis ➢ Makes blood viscous
➢ Viscous + narrowed
ARTERIAL BLOOD FLOW VENOUS BLOOD FLOW vessels = Prone to clotting
Direction: Down Direction: Up • Viscous blood
Flows with gravity Flows against gravity o Ex: DM, Calcium,
Oxygenated blood Deoxygenated blood dehydration, cholesterol
Target: Systemic Circulation Target: Pulmonary Circulation • Sedentary lifestyle
o Blood stays longer in one area
• Virchow’s Triad “SHE”
RIGHT SIDE OF THE HEART LEFT SIDE OF THE HEART
o Triad for creating clots
Receives unoxygenated blood Oxygenated blood leaves the heart
o Stasis of blood
from the vein
o Hypercoagulation
➢ Hereditary condition
➢ Dx Tests: Protein C&S,
D- dimer
o Endothelial wall damage
• Constrictive or tight clothing
WATCH OUT FOR SUPERFICIAL VEINS
➢ Small veins can be partially
affected by blood clots
Clinical Manifestation ✓ Cold affected extremity
✓ Pulselessness or pulse deficit on the
affected extremity
o Pulse Deficit: Difference
between apical pulse and
peripheral pulse
✓ Decreseased pulse quality/pulse
grading
o Normal quality: +4
ARTERIAL DISORDERS ❖ +4
❖ Checks all pulse sites
o Normal grading: +2
2 major types ❖ +2
❖ Checks the peripheral
1) Vaso-occlusive pulse sites only
❖ More specific to Buerger’s
a. Buergers Disease Disease
2) Vaso-spastic ✓ Ischemic pain
✓ Altered sensation
a. Reynauds o Necrotic portions: No pain
dead nerves
VASO-OCCLUSIVE VASO-SPASTIC o Non-necrotic areas: Can still
Ex: Buerger’s Disease Ex: Reynaud’s Disease feel pain
Presence of complete obstruction Altered blood flow ✓ Decrease tissue size or muscle
(+) Ischemia (+) Ischemia wasting
(+) Gangrene (-) Gangrene o On affected areas only
(+) Necrosis (-) Necrosis ✓ Dry ulceration
✓ Hair loss
BUERGERS DISEASE Cardinal sign INTERMITTENT CALUDICATION
✓ On and off pain
- A.ka. Thromboangitis Obliterans o Pain on the legs aggrivated by
- Presence of clot that obstructed the artery that walking
o Relieved by resting
causes pain and inflammation Diagnostic Tests 1) Arteriogram
- Due to blockage/obstruction of the peripheral o Iodine dye injected
arteries and arterioles secondary to a blood o Monitor for allergies
clot
______________________________________________________________________________________________________________________________ 1
Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
▪ Anaphylactic shock Clinical ✓ Ischemic pain
give Epi Manifestation ✓ Pulse deficit
▪ Conscious: SQ/IM ✓ Poor wound healing
▪ Uncononscious: IV/ET ✓ Paresthesia
▪ Allergies give ✓ Risk for infection
Antihistamine ✓ Bilateral and Symmetrical
o Post-op: EOFI o Both extremities are equally
2) Doppler UTZ affected
✓ Decreased pulse quality and grading
✓ Cold extremity during the white and
blue phase
Medical management for Buergers ✓ Warm extremity during the red phase
WATCH OUT FOR Orthostatic hypotension during the Red
Pharmacologic 1. Thrombolytics
Phase
Management o tPA
✓ Risk for injury or risk for falls
o Streptokinase
✓ Blood goes to the peripheries from the
o Given first before
central area
anticoagulants
2. Anticoagulants Cardinal sign PROGRESSIVE COLOR SHIFTING
▪ White: Due to lack of blood flow
o Prophylaxis
➢ Constrict
3. Analgesics
o For pain ➢ Peripheral to central
➢ Start intervention in this phase
4. Vasodilators
▪ Blue: Vessels dilate to keep blood in
o Alpha Adrenergic Blockers
▪ Known to be tissues
➢ More constriction
peripheral acting
➢ Peripheral to central
vasodilators
▪ Also an ▪ Red: Blood flow returns
➢ Dilation
antihypertensive
➢ Due to Reynaud’s Phenomenon
▪ -zosin
5. Oxygen therapy • Due sudden
Surgical Management ❖ Debridement unexplained
o First option vasodilation
o Removal of dead tissue ➢ Constrict >> increased
o Rationale: To allow healthy constriction >> dilation >>
tissues to grow Reynaud’s phenomenon
❖ Amputation ➢ Constrict >> peripheral >> central
o Last option >> goes back to peripheries >>
Red Phase
Nursing management ▪ Hydration
▪ Treat/correct underlying cause Diagnostic Tests 1) Ice water test
o Strongly advice to stop ✓ Confirmatory
smoking 2) Arteriogram
o Treat DM 3) Doppler utz
✓ Place affected extremity below
Position
level of heart or dependent position Management “VAWACSS”
o Follow flow of heart!
o Arteries flow by downward ❖ Vasodilator
direction o Alpha blocker
✓ Pain worsened by elevating o Given during white and blue phase
o Contraindicated: During red phase
❖ Avoid stress
o Do relaxation exercises
REYNAUD’S DISEASE
❖ Warm clothing
- Due to the vasospasm of the peripheral
❖ Avoid injury to the extremity
arteries and arterioles
o Rationale: Poor wound healing
❖ Caution patient’s safety
Pathophysiology
o Fall precaution
▪ Vasospasm of peripheral arteries >> leads to
❖ Stop smoking
tissue ischemia >> production of lactic acid >>
❖ Steroids prn
leading to pain and inflammation >>
❖ Position affected extremity below level of heart
▪ No complete obstruction >> no necrosis
Incidence Females > males
Common area Fingers and toes VENOUS DISORDERS
affected ✓ Temperature-sensitive body parts
Predisposing Factors • Cold exposure VARICOSE VEINS
o Leading cause
o Triggers spasms
• Stress - Distended/Tortous Veins
• Smoking and vaping - Protruding
• Connective Tissue Disorder
(Autoimmune)
- Due to retention or pooling of unoxygenated
o Ex: Rheumatoid Arthritis, SLE, blood secondary to damage/incompetent
Scleroderma valves
o All 3 triggers vasculitis

______________________________________________________________________________________________________________________________ 2
Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
*All valves in the body will serve as a one-way ✓ Diuretics
o For the excess edema
gateway. Direction of blood flow is proportional to ✓ Anticoagulants
direction of opening of valves* o Given first before
thrombolytics
✓ Thrombolytics as needed
Incidence Females > males
✓ Sclerotherapy
Risk Factors ▪ Aging
o Effective only to
o Most common
spider veins
o The higer the age the higher the risk
o Could still possibly
o Wear and tear
come back after
o Valves will age eventually
therapy if underlying
▪ Prolonged standing
cause is not treated
▪ Prolonged sitting
Surgical Management ❖ Laser surgery
▪ Sedentary lifestyle
❖ Radio ablation
▪ Obesity pregnancy
o For spider veins only
▪ Congenitals/Genetics
❖ Vein stripping and ligation
o Ex: Marfan Syndrome
Other Nursing Management ▪ Treat underlying cause
➢ Thin connective tissue
▪ Bedside item: Tape Measure
disorder
o Rationale: To monitor
▪ Hormonal changes
leg size
o Increased estrogen >> weakens the
valves
▪ Medications DVT vs. THROMBOPHLEBITIS
o Oral contraceptive pills
o Increases estrogen DVT THROMBOPHLEBITIS
o Increases calcium
Presence of (+) Blood clot in veins
➢ Prone to clotting
clots
▪ Trauma
Location Deep larger veins Superficial smaller veins
o Constrictive clothing
o Contact sports
▪ Lifestyle and diet Size of clot Big clots Small clots
o Smoking Inflammation (+) nonvisible (+) visible
o Alcohol Redness Nonvisible Visible
Common are Lower extremities Common site Lower extremities Anywhere
affected Risk of
Clinical ✓ Warm skin tender to touch on the affected embolism
Manifestations area Cardinal sign HOMAN’S SIGN
✓ Pain due to increased Peripheral Venous Symptoms of Same Same
Pressure (PVP) varicose
✓ Purplish blue discoloration of the skin Predisposing 1. Varicose
(Hemosiderin) factors 2. Virchow’s triad
o Unoxygenated blood 3. Obesity pregnancy
✓ Peripheral edema 4. Prolonged standing
o Leading to increased leg size 5. Prolonged sitting
o No generalized edema 6. Medications
➢ Rationale: Pooling in first 7. Smoking
space only 8. Lifestyle and diet
✓ Wet ulcer 9. Viscous blood
✓ Decreased pulse quality/grading 10. Trauma
Complications ❖ DVT 11. Constrictive tight clothing
❖ Thrombophlebitis 12. DM
Diagnostic Tests 1) Venogram Diagnostic ▪ Venogram
2) Doppler utz tests ▪ Doppler
3) Physical Assessment
Medical Management for both DVT &
Pathophysiology Thrombophlebitis
▪ Damaged valves in veins >> backflow of blood Position Above heart level
>> regurgitation >> retention/pooling of Pharmacologic Management ✓ Thrombolytics
✓ Anticoagulants
unoxygenated blood >> protruding veins ✓ Antiplatelets
Spider veins ✓ Analgesics
✓ Diuretics as needed
- Small and No distention Surgical Management ❖ Embolectomy
- Still with retention of unoxygenated blood ❖ Thromboectomy
- If untreated: can lead to varicose veins Other Nursing Management ▪ Treat underlying cause
▪ Bedside item: Tape Measure
Organs that trigger generalized edema ▪ Anti-embolic stockings or
1. Heart compression stockings
2. Liver o Wear before arising
o Rationale: To keep the
3. Kidney clot in place until it
will be dissolved by
Medical Management for Varicose Veins the thrombolytics
o Remove 3 – 4x a day
Position Elevate affected extremity above
to promote circulation
the heart
o Do not let the patient
Pharmacologic Management ✓ Analgesics move when wearing
o For pain the stockings
______________________________________________________________________________________________________________________________ 3
Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______

HEART SOUNDS CARDIAC TAMPONADE

- “ASVA”
- A build-up of blood or other fluid in the
pericardial sac (>30 – 50cc)
- Both sides of the heart are affected
✓ Fails at the same time
NORMAL HEART CONTRACTION IN
CONTRACTION CARDIAC TAMPONADE
Arterial BP: Arterial BP:
Venous BP: Venous BP:

Pathophysiology of Cardiac Tamponade

▪ Overaccumulation of fluid/blood in the
pericardial spaces >> casues too much pressure
NORMAL HEART SOUNDS
S1 “ATM” S2 “SAP”
pushing the heart >> decrease contractility >>
▪ Due to closure of ATM Due to closure of SAP blood can’t go out of the heart to the arteries >>
▪ Separates right atrium and blood can’t go into the heart from the veins >>
right ventricle
AV valves Semilunar Valves
decreases cardiac output >> arterial bp
✓ Tricuspid (right) ✓ Aortic decreases or is low >> increase venous bp >>
✓ Mitral (left) ✓ Pulmonic both sides of the heart fail together
Sound generated during closure of Sound generated during closure of
TM valves AP valves ▪ Blood cannot come out of the heart >> goes
✓ LUB ✓ DUB back up to the lungs >> Pulmonary Edema
Best heard at: Best heard at: Pericardial fluid
✓ Apex (PMI) ✓ Base of the heart
✓ Left 5th intercostal space - For lubrication to prevent friction between
MCL parietal and visceral
Higher Pitch Sound Higher Pitch Sound - Normal: 5 – 10 ml
✓ Use diaphragm of ✓ Use diaphragm of
stethoscope stethoscope Predisposing factors
Position during assessment Position during assessment ▪ Untreated pericarditis
✓ Upright forward leaning ✓ Upright forward leaning
position position
▪ Trauma
▪ Autoimmune
ABNORMAL HEART SOUNDS ▪ Hypertension
S3 “V” S4 “A” Clinical Manifestations of Cardiac Tamponade
A.k.a. Ventricular Diastolic A.k.a. Atrial Diastolic Gallop ▪ Cardinal sign: “BKP”
Gallop
Accompanied by a fast heart rate Accompanied by a fast heart rate o Beck’s triad “JAM”
Ventricles are moving faster Atrium is moving faster ▪ Jugular vein distention
Due to Ventricular Compensation Due to Atrial Compensation • Blood can’t go in
✓ Compensation due to excess ✓ Due to ventricular heart
water/fluid damage ▪ Arterial BP is low
➢ Best answer • Blood can’t go out
✓ Due to increased activity
✓ Due to atrial malfunction ▪ Muffled heart sound
Lub dub dub Lub lub dub • Or distant heart
✓ S1, S2, S3 ✓ S4, S1, S2 sound
Low pitch sound Low pitch sound
✓ Left lateral position ✓ Left lateral position o Kussmaul’s sign
✓ Use bell of stethoscope ✓ Use bell of stethoscope ▪ JVD upon inspiration
Normal in the ff patients: Normal in the ff patients: o Pulsus Paradoxus (Arterial)
✓ Pregnant (3rd trimester) ✓ > 50 years old
✓ Young adults ➢ Rationale: ▪ Inhale: Decrease BP and HR
✓ Athletes Ventricles • 10mmhg difference
degenerates as we
age (Wear and Tear) ▪ Exhale: Normal or near
normal BP and HR
Abnormal in the ff patients: Abnormal in the ff patients: NORMAL PATIENTS PULSUS PARADOXUS
✓ > 30 – 50 years old ✓ < 50 years old Inhalation: Increase BP Inhalation: Decrease BP & HR
➢ Due to CHF or ➢ Myocardial Infarction Exhalation: Normal Exhalation: Normal or Near
Cardiac Tamponade ➢ CardioMyopathy Normal
➢ Fluid overload ➢ Chronic hypertension
conditions: ➢ Infection of the heart
• Renal ➢ TakoTsubo ▪ Other s/s of Cardiac Tamponade
Failure Cardiomyopathy (Respiratory)
• Liver • Broken Heart
Cirrhosis Sndrome o SOB/DOB
• Heart • Due to severe o Pallor/cyanosis/Dusky
Failure downer emotions o Fatigue and weakness
______________________________________________________________________________________________________________________________ 4
Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
o Pulmonary congestion Surgery for Cardiac Tamponade
o Increased pulmonary capillary wedge ▪ Pericardiocentesis
pressure (PCWP) o Aspiration of excess fluid in
▪ Normal: 4 – 12 mmHg pericardium
o Pulmonary hypertension o Do not discard!
o Hemoptysis o Send to lab right away
o Pulmonary edema
▪ Cardinal sign: Pink frothy
sputum CONGESTIVE HEART FAILURE
o Crackles/rales
o Cough - A cardiac disorder wherein there is fluid/blood
o Wheezing overaccumulation of indefinite amount inside
▪ Other s/s of Cardiac Tamponade (Circulation) the inner chambers of the heart
o Varicosity
o Increased CVP ACUTE CHF CHRONIC CHF
▪ Normal: 4-10cmh20 Heart fails one side at a time Symptoms for both left and right
Either left or right heart failure are affected together like cardiac
o Systemic congestion tamponade
o Generalized edema
o Anasarca Pathophysiology of CHF
o Ascites ▪ Overaccumulation inside the chambers >>
o Weight gain leads to decrease contractility >> decrease
o Heaptomegaly, spleenomegaly, cardiac output >> arterial bp decrease, venous
hydronephrosis bp normal >> left side CHF
WHEEZING STRIDOR
(+) Narrowing (+) Obstruction
▪ Venous bp increase, arterial pressure normal >>
Expiratory Inhalation right side CHF
SONOROUS SIBILANT - Predisposing factors for chf
✓ Low ✓ High
▪ MI
pitch pitch ▪ Arrythmia
✓ Like musical o Atrial fibrillation
snoring sound
✓ Like ▪ Fluid overload
whistling o Renal failure
o Liver cirrhosis
Conduction ▪ Endocarditis
- Increases together with HR ▪ Myocarditis
Normal LVP ▪ Valvular disorders
- 100 – 150mmhg o Mitral alve prolapse
Afterload ✓ Amount of resistance or ▪ Cardiomyopathy
pressure that the left
ventricle needs to overcome ▪ Pulmonary embolism
to promote adequate ▪ Hypertension
circulation (cardiac ouput)
✓ Equivalent to systemic
pressure (systemic bp)
✓ Normal: Should be lesser
than the lvp
✓ Normal afterload: Same
with systemic bp
Preload ▪ Amount of blood that the
right side receives LEFT SIDE CHF RIGHT SIDE CHF
Cardiac Output ✓ Amount of blood ejected ✓ SOB/DOB ▪ JVD
from the heart per minute ✓ Pallor/cyanosis/Dusky ▪ Varicosity
✓ Average: 5-6L/min ✓ Fatigue and weakness ▪ Increased CVP
✓ Formula: ✓ Pulmonary congestion o Normal: 4-10cmh20
✓ Increased pulmonary ▪ Systemic congestion
capillary wedge pressure ▪ Generalized edema
(PCWP) o Anasarca
o Normal: 4 – 12 mmHg o Ascites
✓ Pulmonary hypertension ▪ Weight gain
Stroke Volume ▪ Amount of blood ejected ✓ Hemoptysis ▪ Heaptomegaly,
from the heart per ✓ Pulmonary edema spleenomegaly,
contraction o Cardinal sign: Pink hydronephrosis
frothy sputum
✓ Crackles/rales
✓ Cough
✓ Wheezing

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
Complications of Cardiac Tamponade and CHF ➢ Conduction
(electricity)
❖ Multiple Organ Failure or System Failure ➢ Ex: Sodium
❖ Cardiogenic Shock or Pump failure o (+) Inotropic
o Arterial BP: Low ➢ Contractility
o Venous BP: High ✓ TSL: 0.5 – 2ng/ml
✓ Toxic: >2ng/ml
✓ Antidote: Digibind/Digifab
Diagnostics tests for both CHF & Cardiac Tamponade ✓ Ineffective: <0.5ng/ml
1) Chest X-ray - ✓ Other inotropic drugs:
2) ABG - o Dobutamine
3) Cardiac CT - o Dopamine
scan o Norepinephrine
✓ Expected effects
4) 2D Echo ✓ A.k.a. Ultrasound Cardiography
o Polyuria
✓ Best exam
➢ Rationale: Circulation is
✓ For visualization and checks the
restored to the Kidneys
strength of the heart
o Weight loss
✓ Also checks the Ejection Fraction (EF)
o Normal EF: 55 -77% Fluid should be -
o More than 77: Heart pumping decreased
strong After load should be ✓ By giving Nitroglycerin
o Less than 55: Heart pumping decreased
weak Sodium Restriction -
➢ CHF Tests to monitor: ✓ Digoxin Levels
➢ Cardiac Tamponade ✓ ABG
5) Pro – BNP Test ✓ B-type Natriuretic Peptide ✓ Electrolytes
✓ Blood test for congestion
✓ Checks only the strength
✓ Enzymes that go out when ventricles are
ECG/EKG
having difficulties with
working/pumping >> release of - Measures and records electrical activity of the
Natriuretic Peptide
✓ Normal: <100pcg heart
✓ (+) Congestion: >100pcg - Controlled by: Pacemaker
6) Hemodynamic ✓ Swanz Ganz Catheter
o Type of central line
o 3 natural pacemakers in the body
Monitoring
o To check pressures of the heart “SAP”
o Tip of the catheter should be SA NODE AV NODE PURKINJE
placed at the right atrium FIBERS
➢ Checks all parts of the heart Primary pacemaker Secondary PF: main producer of
➢ When inserting, instruct px to pacemaker electricity
inhale and exhale, bear Location: Right Location: right ✓ Location of
down/Valsalva maneuver atrium, upper atrium lower PF: lower
➢ Rationale: To increase posterior near the posterior near the ventricles
intrathoracic pressure vena cava valves ✓ Location of
❖ To prevent air BH: septal wall
embolism Produces 60 – 100 Job: Regulate or Composes of 2 fibers
❖ (+) embolism: Position electrical impulses prevents ✓ One on right
px to left side lying per minute which overstimulation of ventricle
then trendelenburg translates to 60 – 100 electrical impulses ✓ One on left
❖ 0 level of the bpm ✓ Shields the
manometer should be heart from
at the phlebostatic area getting too
Gold Standard for Diagnosing Congestion many impulses
✓ Weight Gain >1k per 24 hours Ratio of electrical If SA Node is If SA and AV are not
➢ Can be used to diagnose Congestion without the tests impulse to heart rate damaged or not working, PF &
✓ 1:1 working: AV node bundle will take over
produces electrical ✓ 20 – 40 EI/min
impulses ✓ 20 – 40bpm
Medical management of both “UNLOAD FAST” ✓ 40 – 60 EI/min ✓ Results to
Upright position ✓ For oxygen purposes ✓ 40 – 60bpm severe decrease
Nitroglycerin ✓ Vasodilator ➢ Leads to cardiac output
✓ Decreases afterload and preload decrease
➢ Best answer: Afterload cardiac
Loop Diuretics ✓ For excessive fluids output
Oxygen Administration - ✓ Cannot take
Aminophylline ✓ Bronchodilator over SA node’s
✓ Helps lessen the congestion in the function for a
lungs long time
✓ Lessens SOB - If SA Node is fully If purkinje fibers are
Digoxin ✓ DRUG OF CHOICE functional, AV node damaged, heart will
✓ A.k.a. Digitalis does not produce stop working already
✓ Cardiac Glycoside electrical impulses
✓ Has 3 effects: ✓ Will only serve
o (-) Chronotropic as a pathway of
➢ HR the electrical
o (-) Dromotropic impulses

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
Electrical conduction of the heart How to check if it is a Normal Rhythm or not
▪ SA Node >> AV Node >> Bundle of his >> 1. In one 5 big boxes, there should be 1 sequence
bundle branches >> Purkinje Fibers 2. > 1 sequence: Tachy
Medication that can make the SA node stop working 3. < 1 sequence: Brady
- CC blockers 4. If waves are shaking or chaotic or bizarre or
- Beta blockers coarsed or quickvering: FIBRILLATION
ECG checks the ff: 5. Faster way to check: Check HR of px
✓ Rate
✓ Rhythm ECG Waves
✓ Strength ❖ P-wave (Atrial contraction)
✓ Electrolyte imbalance o Atrial depolarization
✓ Injuries ❖ QRS complex (Ventricle Contraction)
✓ Ischemia o Atrial repolarization
o Ventricular depolarization
❖ T – wave (Ventricle Relaxation)
BASIC ECG READING
o Ventricle repolarization

Commonly used
▪ 3 – second strip Depolarization
o Minimum seconds to read an ECG - Represents contraction
▪ 6 – second strip Repolarization
ECG graph paper - Represents relaxation
1 Small Box ✓ 0.04 seconds/4ms If P-wave is abnormal If QRS is abnormal
✓ Size: 1mm
1 Big Box ▪ 0.20 seconds/20ms It is an atrial problem It is a ventricular problem
▪ Size: 5/mm
5 Large Boxes ✓ 1 second Depends on which is dominan Depend on which is dominan
Horizontal Axis • Checks the speed
Vertical Axis ✓ Checks the strength
COMMON ARRHYTHMIAS
Normal ratio ATRIAL FIBRILLATION
▪ In 1 big box: 5sb
o Vertical and - Excessive quivering of atrium
horizontal
ECG machine
▪ Normal rate of
measurement
o 25mm/sec: 25sb
o 25sb: 5bb
o 5bb: 1 second

Normal ECG reading for a healthy adult

- Normal Sinus Rhythm ECG manifestations
Rate ✓ 300 – 600 shakings per
How to check if it is a Normal Sinus or not minute
1. Check the ECG waves first ✓ Variable
Rhythm ▪ Irregularly – irregular
✓ PQRST should ALL be present P waves ✓ Excessive, chaotic, bizarre
✓ PQRST should ALL be in sequence ✓ Nondiscernible
properly P-R ▪ Nondiscernible
QRS ✓ Normal to slightly increased
2. Nature of the problem: Sinus, atrial, activity
ventricular ✓ Narrow (0.08 – 0.012)
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
Complications: Complications
❖ CHF - Same with a-fib
o Retention of blood Management
❖ Clot - Same with a-fib
o Stasis of blood
❖ Embolism VENTRICULAR FIBRILLATION
o Dislodgement of clot
❖ Decreased cardiac output - Excessive quivering of both the atrium and
o Blood cannot come out ventricles
❖ Cardiogenic shock
o A.k.a. Pump failure
o Not circulating blood
Management
PHARMACOLOGIC MANAGEMENT
Anticoagulants ✓ Heparin is fast acting
Thrombolytics ✓ As needed
Diuretics ✓ Loop diuretics
✓ For possible congestion
(+) Inotropic Drugs ▪ Digoxin ECG Manifestations
▪ Dobutamine Rate ✓ Indefinite
▪ Dopamine Rhythm ▪ Chaotic & irregularly &
▪ Norepinephrine disorganized
Antiarrhythmia ✓ Amiodarone P waves ✓ Unrecognizable
✓ Lidocaine P-R ▪ Unrecognizable
✓ Procainamide QRS ✓ Unrecognizable
✓ Quinidine
Oxygen therapy • Due to altered circulation
and oxygenation NO CARDIAC OUTPUT
Cardioversion - No oxygen to the body
✓ To correct the electrical problem Complications
▪ Absent Cardiac Output
▪ Pulseless
▪ No BP
ATRIAL FLUTTER
▪ Loss of consciousness
▪ Cardiac arrest
- Excessive atrial contraction or very fast
▪ Cardiogenic shock
contraction and strong
ATRIAL FLUTTER ATRIAL TACHYCARDIA Management
Excess, fast, strong Excess, fast, not strong 1. Defibrillation/AED
✓ Defib first before CPR
✓ Resume CPR after shock
✓ CPR: 30:2 in 5 cycles (trained
individuals)
✓ CPR: Compressions only (untrained)
o At least 100
compressions/min
o Adult: 2 – 2.4 inches
o Teenager: 2 inches
o Baby: 1 – 1.5 inches
ECG Manifestations ▪ 2 fingers
Rate ✓ 250 – 350 (atrium) o 2 fingerbreadths above the
✓ 125 – 175 (ventricles)
Rhythm ▪ Usually, regular xiphoid process
P waves ✓ Flutter waves 2. CPR
✓ “Sawtooth” pattern 3. Epinephrine
✓ Excessive p-wave with
narrowed interval ✓ Dosage: 0.5 – 1mg every 3 – 5
P-R ▪ Nondiscernible minutes (IV/ET)
QRS ✓ Narrow
✓ Normal activity or slightly
o Equal to 1 ampule
increased 4. Antiarrhythmia

Common AV ratio in Atrial Flutter

▪ 5:1
▪ 5 atrial contractions
▪ 1 ventricular contraction
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
Complications
VENTRICULAR TACHYCARDIA • Absent or decreased cardiac output
• Ventricular damage or cardiomyopathy
- Excessive strong, fast contractions of the
• May lead to v-fib
ventricles
• Cardiogenic shock
• Cardiac arrest

Management
PULSELESS WITH PULSE
Same with V-Fib ✓ Cardioversion
✓ Oxygen
✓ Antiarrhythmia

SUPRAVENTRICULAR TACHYCARDIA
ECG Manifestations
Rate ✓ 150 – 250
Rhythm ▪ Usually regular
P waves ✓ Not present
✓ Absent activity
P-R ▪ Not present
T-wave ▪ Not present
QRS ✓ Excessive widened,
heightened levels and
Bizarre - Rate: 150 – 250 bpm
✓ > 0.12sec
✓ Narrowed interval - Subvariant of VTACH
- Both atrium and ventricles are going fast but
Normal QRS complex NOT STRONG
- 0.08 – 0.12 secs or; - No T-wave: No relaxation
- 2 – 3 small boxes - Excessive PQRS narrowed interval

What is ocurring inside the atrium Complication and managmenet

PULSELESS V-TACH V-TACH WITH PULSE - Same with VTACH with pulse
Absent activity Minimal to normal acitivity
ASYSTOLE
Pulseless V-Tach
▪ Absent activity atrium >> Ventricles keep on - A.k.a. Cardiac Standstill/Agonal Rhythm
conracting without receiving any blood from the - Absent activity of both the atrium and
atrium >> no blood coming out >> no pulse ventricles
V-Tach with Pulse
- Same ECG with PVTACH
- ECG cannot pick up the P-wave because it is
too weak
ECG wave forms of V-Tach
MONOMORPHIC POLYMORPHIC
Sustained intensity of Variable intensity
ventricles ECG manifestations
Symmetrical Asymmetrical
appearance ▪ Flatline
- More life-threatening Management
✓ Unpredictable 1) Check patient’s v/s and LOC first
✓ Harder to monitor
- WOF: ➢ Check the electrodes or connections as
✓ Torsades de Pointes well
✓ “Banner” like appearance
✓ “Tidal wave” appearance
2) CPR
✓ Due to Hypomagnesemia 3) Epinephrine
✓ DOC: Magnesium Sulfate ➢ Dosage: 0.5 – 1mg for every 3 – 5
➢ TSL: 4 – 7mg/dL
minutes or 1 ampule
➢ IV/ET
4) Additional inotropic drugs
5) Do not DEFIB!
➢ Rationale: No Rhythm

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
Protocol for Suspected Covid patients outside hospital
setting (untrained and trained)
- Put mask on nurse first, then to the patient
- Compressions only!

PREMATURE VENTRICULAR CONTRACTIONS (PVC)

Couplet 2 PVCs or 2QRS

- Ventricles prematurely contracted before the

atrium
- Prequel for V-Tach
Causes
❖ Post MI
o Leading cause
❖ Due to genetic problem or congenital heart V-tach
conditions - More than 5 PVC leads to V-Tach
❖ Cardiomyopathy Sequence of complications
❖ Heart infections ▪ PVC >> V-Tach >> V-Fib >> Cardiac Arrest
❖ Drug toxicity Management
❖ Electrolyte imbalance 1. Cardioversion
2. Antiarrhythmia
PHYSIOLOGICAL PVCs PATHOLOGICAL PVC
<6 episodes/min >6 episodes/min 3. Oxygen therapy
Not reportable Report to MD! 4. Treat underlying cause
Continue monitoring -

AV BLOCK / HEART BLOCK

Clinical manifestation
- “Skipped a heartbeat” - Purkinje Fibers are the only working
pacemaker
- Heart rate: < 40bpm
- Poor circulation
Types
1) First degree
2) Second degree
3) Third degree
ECG Manifestations FIRST DEGREE HEART BLOCK
Rate ✓ N/A
Rhythm ▪ Temporary delay caused by
compensatory pause - Asymptomatic
P waves ✓ None o Body can still tolerate
P-R ▪ None How to identify
T-wave ▪ Not present
o Rationale: Due to 1. Check PR interval
compensatory pause ➢ P wave until Q wave
QRS ✓ Found prematurely before ➢ Normal PR interval: 0.12 – 0.20
the p-wave
✓ Widened (>0.12 seconds) seconds or 3 - 5 small boxes
✓ Followed by a compensatory ➢ Interval from atrial contraction and
pause
ventricular contraction
PR interval in 1st degree
Variants of PVC - Always delayed
Bigeminy Every other beat
o > 5 small boxes
o Constant and Non-Progressive

Trigeminy Every 3rd beat

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
CC blockers and Beta Blockers
- Causes heart blocks THIRD DEGREE HEART BLOCK
Electrolyte imbalance - A.k.a. Complete heart block
- Causes heart blocks - Can cause sudden death
Management - Complete loss of communication between the
- Continue monitoring atria and the ventricles
- Treat underlying cause
How to identify
MOBITZ I SECOND DEGREE HEART BLOCK 1. Check PQRST
PQRST
- Symptomatic - Can be randomly / individually seen
Two types: - No correlation between atrium and ventricles
a) Mobitz I
➢ A.k.a. Wenckebach
b) Mobitz II

Management
- Treat underlying cause
- Artifical pacemaker
How to check
1. Check PR interval ECG CHANGES FOR ANGINA AND MYOCARDIAL INFARCTION

PR interval ECG
- Still delayed - Fastest way to detect Angina and MI
o 3 consecutive and progressive delay - But not confirmatory
o After 3rd delay, there is a sudden Cardiac markers / enzymes
drop/loss of QRS - Confirmatory
T-WAVE ST ELEVATION PATHOLOGIC Q-
INVERSION WAVE
Clinical manifestations A.k.a. Zone of A.k.a. Zone of Injury A.k.a. Zone of
▪ S/s Decreased circulation Hypoxia or Ischemia Infarction or Necrosis
Heart did not relax Most common ECG Q wave: Very low
change for px with ✓ Ventricles are
Management MI weak due to
- Treat underlying cause necrosis
- Artificial pacemaker - “Tombstone” -
appearance
o External - T-wave: too much -
▪ Done first relaxation
▪ For emergency purposes
o Internal
▪ Needs surgical implantation
▪ For maintenance purposes

MOBITZ II SECOND DEGREE HEART BLOCK

- Like the combination of first degree and

mobitz 1
PR interval
- 3 consecutive delays and non-progressive
- After 3rd delay, sudden drop/loss of QRS
S/s and management
- Same with Mobitz I

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
▪ Hypertension & Hypercoagulation
ELECTROLYTE CHANGES IN ECG o Two types:
▪ Primary / Essential
• Cause:
Hypokalemia and o Idiopathic
Hypernatremia “PST” o Lifestyle and
▪ Prominent U-wave diet
▪ ST depression ▪ Secondary
▪ T-wave inversion • Due to a disease or a
o Depends if medical condition
electrolyte ▪ Embolus or Thrombus
or Heart ▪ Stress/Smoking
condition
Major Coronary Arteries
Hyperkalemia and Left Anterior Circumflex Artery Right coronary
Hyponatremia “PWT” Descending artery
▪ Prolonged PR Coronary Artery
(LADA)
interval Most common site to Most dangerous area Least common area
o Can lead to get a problem to get a problem to get a problem
heart block ✓ Circles or hugs
the heart
▪ Widened QRS
▪ Tall, peaked T-wave Supplies O2 blood Supplies more than Supplies O2 blood in
Hypercalcemia and hypophosphorous particularly to two 50% of the heart the inferior wall of
areas: ✓ Supplies O2 the heart
▪ Shortened QT interval ✓ Anterior wall blood to the left ✓ Necrosis is
o Checks how much time for the o (+) lateral, right inside
obstruction lateral and
ventricles to contract until it relaxes = Anterior posterior wall
Hypocalcemia and hyperphosphorous wall MI
▪ Widened QT interval ✓ Septal wall
o (+)
o Checks how much time for the obstruction
ventricles to contract until it relaxes = Septal
wall MI

ACUTE MI ANGINA PECTORIS

A.k.a. Heart Attack / Acute A.k.a. Chest Pain / Intermittent
Coronary Syndrome Coronary Syndrome
ANGINA & MYOCARDIAL INFARCTION Total absence or destruction of Partial loss or disruption of
coronary oxygenated blood flow coronary blood flow
Timeline of Necrosis: No Timeline of Necrosis
#1 cause of Angina and MI ▪ > 15 mins of absence of O2
❖ CAD blood = Necrosis will start
o Happens on a
“cellular” level
Predisposing Factors of both Angina & MI “ACHES” ▪ > 6 hours of absence of O2
▪ Atherosclerosis / Arteriosclerosis blood = “Physical” changes
on the heart tissue
ATHEROSCLEROSIS ARTERIOSCLEROSIS
o Significant loss of
Reversible Irreversible
cardiac function
Early stage of CAD Late stage of CAD o Increase mortality rate
W/ plaque (atheroma) that causes Total loss of elasticity, weakening o Livor and Rigor mortis
obstruction and hardening of the vessels of the heart will start to
✓ Bad Choleterol exist
o Heavy o First 6 hrs: Window
o Sticks to vessels period to save the
patient
▪ Cholesterol is high ➢ Acute ttt
should
LDL / VLDL / HDL
already be
TRIGLYCERIDES
given
Bad cholesterol Good cholesterol o Goal: Restore
Heavy Does NOT stick inside the arteries Coronary blood flow
✓ Sticks in the walls of vessels or blood vessels or Reperfusion
✓ Scoops the bad cholesterol ▪ 2 -3 days post-MI
and brings it to the liver for o Granulation / Scar
emulsification tissue
When exposed to cold temp, it When exposed to cold temp, it o “Kugan” phase
hardens does NOT harden
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
Nursing Diagnosis: Nursing Diagnosis: Complication: Complication:
1. Altered Tissue Perfusion 1. Altered Tissue Perfusion ❖ Arrhythmia
2. Acute pain 2. Acute Pain o Most common 1. MI
3. Activity Intolerance 3. Activity Intoleranc o Most life-threatening
4. Decreased Cardiac Output o Ex: PVC’s, VT, VF
Clinical Manifestations: Clinical Manifestations: ❖ CHF
• Chest pain ▪ Chest pain ❖ Cardiogenic Shock
o Location: Substernal o Location, Radiation, ❖ Dressler’s Syndrome
or Retrosternal type of Characteristic: Same o Rare condition post-MI
chest pain (deep w/ MI o Cause injury to
behind the chest) o Less than 15 mins pericardium >> releases
o Can be mistaken for o Relieved by neo-antigen >> triggers
Costrochandritis Nitroglycerine less antigen-antibody
o Can be mistaken for than 3 doses together immune complex
Heart burn with oxygen response (Type III
o Cannot be pinpointed o Same with MI hypersensitivity
by an exact location reaction) >>
o Severity: Moderate – Autoimmune response
Severe in pericardium >>
o True pain: Left side Pericarditis >> Cardiac
radiation Tamponade
o Characteristic: o DOC: Corticosteroids
Crushing, squeezing, Diagnostic Tests:
burning, tightness,
heaviness, pressing, 1. ECG
choking sensation 2. Cardiac CT scan
o Duration: > 15 mins 3. 2D echo
unrelieved even by 4. Multi-gated Acess (MUGA) scan
taking more than 3 o Uses radioactive dye
doses Nitroglycerin o Visualizes heart itself
• (+) Levine Sign 5. Angiogram
o Guarding behavior 6. Thalium scan
• SOB/DOB o Visualizes vessels
• Pallor or Dusky color 7. Treadmill test / Stress Test / Exercise Tolerance Test
• Anxiety o Contraindications: Unstable patients
• Nausea and vomiting o Purpose: Differentiates the type of Angina
• Diaphoresis o Clothing: Wear comfortable rubber shoes
• ALOC/Behavioral changes o Duration: 1 hr
o Specially Geriatrics o Pre-procedure: Light meals before the test
patients 8. X-ray
• Fatigue and Weakness 9. CBC
o ESR
Acute Management in -
➢ Normal: 0 – 30 mm/hr
Emergency Department:
➢ For MI patients
“ONMAT”
o WBC
1. Oxygen Administration +
➢ Normal: 5k – 10k
positioning
10. SGOT / AST
2. Nitroglycerin via IV
o Liver enzyme that is also found in the heart
3. Morphine Sulfate o Comes out when there is heart damage
o Opiod o For MI patients
o Downer o Normal: 0 – 35u/ml
o Main purpose: 11. Cardiac Enzymes
oxygen demand o Confirmatory Test
o WOF: LOC, o Blood test
RR (Priority),
OHP, urinary
retention, constipation,
Pathophysiology of MI
dependency/addiction ▪ Destruction of coronary oxygenated blood
o Antidote: via ET, floow >> myocardial ischemia >> anaerobic
intranasal or IV
➢ Naloxone response >> production of lactic acid >> chest
➢ Nalterexene pain
➢ Nalmefene ▪ Untreated ischemia and chest pain >> leads to
4. ASA / Aspirin
o Prevents clotting myocardial necrosis >> irreversible
o Dose: 240 – 300mg Pathophysiology of Angina
o If suspected MI: Chew
Aspirin & put under
▪ Partial loss >> myocardial ischemia >>
tongue anaerobic response >> production of lactic acid
➢ Rationale: >> chest pain
Lessens the
progression ▪ Partial obstruction >> no necrosis
of MI
5. Thrombolytics Window period
o tPA
WINDOW PERIOD OF TREATMENT
o Give within 6hrs
STROKE MI
Additional Management: 3 hours 6 hours
✓ CBR w/o TP

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Cardiovascular Disorders ______
Nitroglycerin o Primary ✓ Vasospasm of the
trigger coronary arteries
- 3 doses every 5 minutes total of 15 minutes o Ex: and cardiac
- Shelf life: 6 months Climbing muscles
the stairs
- If travelling: Continue taking nitroglycerine ▪ Emotion
every 5 minutes until you have reached o Sudden
hospital shift of
emotion
o Will not overdose after 3 doses ▪ Exposure to cold
▪ Rationale: Nitroglycerine is o Rationale:
Cold temp
short-acting constricts
- After first dose and pain is still present, take the vessels
the next dose while dialing 911 ▪ Excessive
smoking
- After 3 dose and pain is still present, go to ▪ Excessive eating
hospital Marker of adequate - -
Cardiac Biomarkers cardiac health for
TROPONIN ✓ Most sensitive post-MI:
✓ Most accurate ✓ Can climb 2 – 3
✓ Best confirmatory of MI flight of stairs
o Troponin I w/o chest
➢ More sensitive discomfort
o Troponin T o Can resume
➢ Sensitive ADLs
✓ Onset: 3hours – 1 hour o Do in
✓ Peak: 7 days – 14 days after MI gradual
✓ Normal Value: manner
o <0.6 Management: Management: Drug of choice:
o <0.2ng/mL ✓ Rest ✓ Multidose of ✓ Verapamil
CK – MB ▪ 2nd most sensitive and 2nd most ✓ Nitroglycerin Nitroglyceri (Isoptin)
confirmatory enzyme for MI o Sublingual n together o Calcium
▪ Most specific enzyme to cardiac Tissue o Rationale: with Oxygen Channel
▪ Onset: 4 hours – 6 hours Faster than Blockers
▪ Peak: 18 – 24 hours oral since it o Blocks the
▪ Normal value: 0- 5 ng/ml is highly spasms
▪ 3 specific groups vascularize o Relaxes
o CK BB d and blood
➢ Brain bypasses vessels
o CK MM the liver o Oxygen
➢ Musculoskeletal o More to the heart
o CK MB potent o Workloa
➢ Heart vasodilator d of heart
compared ✓ Can take
MYOGLOBIN ✓ First enzyme and fastest enzyme during
to CC Nitroglycerin
MI
blockers after taking
✓ Not accurate
o OTC Verapamil if BP
✓ Can come out when there is any type of
✓ Oxygen therapy is already stable
muscle damage
✓ Onset: 30minutes – 1 hour after an
infarction
✓ Peak: 4 – 6 hours Additional
✓ Normal value: 0 – 85mcg/ml Management:
LACTIC ▪ Last to come out ✓ Oxygen Therapy
DEHYDROGENASE ▪ Contributes to chest pain and burning
(LDH) sensation
▪ Onset: 24 hours
Sample Question
▪ Normal: 140 – 280 iu/L 1. What is the main purpose of giving Morphine
▪ Normal LDH 1: 14 – 16% Sulfate to a MI patient
▪ Normal LDH 2: 29 – 39%
▪ LDH Flip a. Pain
o Present in MI b. Anxiety
o LDH 1 > LDH 2
c. Venous return
d. Cardiac workload
ANGINA PECTORIS e. Oxygen Demand
*Note: if SATA, select all*
Types of Anginas Step-down drug for Opiod Addiction
STABLE UNSTABLE VARIANT
Predictable Unpredictable Prinzemetal’s Angina ▪ Methadone
✓ A.k.a. o Mid-class narcotic
Crescendo o Rationale: To prevent withdrawal
✓ A.k.a. Pre-
infarction When giving Narcan
Angina - Tell the patient to expect for PAIN
Triggered by: 5 E’s Angina at rest Due to:
▪ Exertion
o Rationale: Negates the effect of
Morphine/ Analgesia
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Respiratory Disorders ______
Cardinal sign: Cardinal sign:
✓ BARRELED CHEST ✓ CHRONIC EXCESSIVE
CHRONIC OBSTRUCTIVE PULMONARY o Presence of bullae NON-PRODUCTIVE
DISEASE the pushes the chest MUCUS & COUGH
wall causing the o Non-productive cough
chest causes increase oxygen
- A.k.a. Chronic Airflow Limitation (CAL) o Causes abnormal AP demand >> cyanosis
- Controllable, preventable but not curable diameter ✓ EDEMA
➢ 2:2 o “Bloater” appearance
➢ Symmetrical o Can cause weight gain
Predisposing factors o Causes “puffing”
1. Smoking/Vaping appearance
Clinical Manifestations -
2. Genetics ✓ Less oxygen (Hypoxia)
3. Air pollution ✓ Increased CO2 retention
4. Chemical exposure (Respiratory acidosis)
✓ Anemia
➢ Asbestos o Less oxygen, less
o Used to build firewall in the pigmentation of the
blood ‘
1970s o Causing “Pink”
➢ Paint appearance
➢ Occupational hazard o Can cause weight
loss
5. Recurrent lung infections WOF: WOF:
6. Malnutrition ✓ Close Pneumothorax ✓ COR Pulmonale
7. Aging o “Pink popper” o A.k.a. Right ventricular
o Due to hypertrophy
excessive o Thick right ventricles
A1A positive >> imapired
pressure in the contractility >> Can
- A.k.a. Alpha 1 – Anti Trypsin pleural space lead to right sided heart
- Decreased in px with COPD >> Leads to failure>>systemic
- Enzyme that the body naturally produces atelectasis >> congestion >> edema
leads to ARDS ✓ Pneumonia
- Function: Controls elastase o Mucus >>favorable
o Erases elastin environment for growth
▪ Elastin is for the elasticity of of bacteria
Symptoms for both:
the airways ✓ Restlessness
- (+) A1A >> low elastase >> increase elastin o Initial sign of hypoxia
✓ SOB/DOB
✓ Dyspnea/Orthopnea
Pathophysiology ✓ ALOC/Behavioral Changes
▪ Low A1A >> Increase elastase >> low elastin ✓ Finger clubbing
✓ Adventitious lung sounds
>> decreases elasticity of airways o Wheezing: Narrowing
o Stridor: Obstruction
ARDS o Crackles: Fluid
o Rales: Fluid
- A.k.a. Stiff lung ✓ Px speaks in short jerky sentences
Normal AP diameter ✓ Uses accessory muscles for breathing
- 1:2 ✓ Nasal flaring
Diagnostic tests
Normal mucus production 1. Chest X-Ray
- 5 – 10 ml per hr 2. ABG
3. O2 saturation
o Normal in COPD: 88% - 92%
4. Pulmonary function test
o Vital capacity
EMPHYSEMA CHRONIC BRONCHITIS o Tidal volume
o Inspiratory Volume
A.k.a. Pink Puffer A.k.a. Blue bloater
o Expiratory Volume
Primary area affected: Primary area affected:
o Ventilation Perfusion Scan
✓ Alveoli ✓ Bronchus/Bronchioles/Airway
o Peak flow meter
o Loss of recoil, loss of o Decreased elasticity >>
➢ Green: Normal = 80% - 100%
surface area, loss of narrowing of bronchus
➢ Yellow: Warning = 50% - 79%
elasticity due to inflammation >>
▪ Ttt: Lesser activities & Increase meds
o Leading to increased production of
➢ Red: Danger = < 50%
Overdistention of mucus >> stasis of
▪ Ttt: Emergency meds & Admission
alveoli or a.ka. Bleb mucus >> mucus plugs
5. Spirometer
o Bullae: Bigger bleb >> (+) obstruction >>
o Gold standard
leading to severe oxygen
➢ FEV 1 = FVC Ratio
loss or hypoxia >>
▪ Normal: > 70%
cyanosis >> causes
▪ COPD: <70%
“blue” appearance
➢ FEV 1: Forced Expiration Volume within 1 second
o Leads to severe CO2
➢ FVC: Forced Vital Capacity
retention >> respiratory
▪ Forced air during inhaltion and exhalation
acidosis
Problems due to distention Problems due to blockage
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Respiratory Disorders ______
TYPES OF PNEUMOTHORAX
MEDICAL MANAGEMENT FOR COPD 1) Close ✓ Most common type
Nursing ❖ Palliative care pneumothorax ✓ Skin is still intact
Management ➢ Rationale: COPD is not curable or ✓ No open wound
❖ Treat underlying cause Spontaneous ✓ Chest wall is intact
❖ Frequent rest periods or Simple
➢ Divide activities equally per day pneumothorax Causes:
Pharmacologic ✓ Bronchodilators ▪ Ruptured bleb
management ✓ Anti-cholinergics o Leading factor
✓ Mucolytics ▪ Blunt trauma
✓ Expectorants ▪ Fistula
✓ Antihistamine o Due to infection or cancer
✓ Antitussive ____________________
✓ Nebulization
Priority: Breathing
______________________________________
Goal: remove (+) pressure from the pleural
❖ Oxygen administration: 1 – 2 L only space thru thoracentesis
➢ Venturi
▪ Best device
▪ Most accurate Other ttt: Chest Tube
▪ A.k.a. Air entrainment ✓ Achieve re-expansion by 3 – 4 days
mask 2) Open ▪ Due to penetrating trauma
➢ Low flow nasal cannula pneumothorax o Ex: GSW, Stab, shrapnel, hacking
Surgical ▪ Metal plates and screws wound
Management ▪ ORIF o Most common
▪ Thoracentesis and CTT ▪ Due to medical procedures
o As needed o Ex: Thoracentesis, dislodged CTT
o If with hemothorax and ▪ (+) Open wound/ open chest wall
pneumothorax ▪ Accompanied by Hemothorax
o > 500ml of blood loss: Shock
▪ Produces a “Sucking” & “Blowing”
TYPES OF COUGHS sound
Non-productive cough ✓ Dry thick sticky mucus
✓ Mucus does not come out
✓ Ttt: mucolytic
Priority: Breathing and Circulation
Dry cough ▪ No mucus
▪ Ttt: antitussive Goal: to stop the flow of air to the open wound
Productive cough ✓ Ttt: expectorant
Allergic cough ▪ Ttt: antihistamine
Management:
NORMAL PX W/ COPD ✓ Sucking sound: Cover the open wound
Carbon Dioxide drive to eliminate Hypoxic drive with dry sterile gauze
dioxide ✓ Blowing sound: Do NOT cover. Let it
- Breathing in and breath out when out to prevent tension pneumothorax
low oxygen ✓ Thoracentesis
- They are used to breathing in low ✓ CTT
oxygen
3) Tension ▪ (+) Trapping of positive pressure air in
Pneumothorax the pleural space
PNEUMOTHORAX ▪ No exit point for the positive pressure air
>> will produce continuous pressure
towards the affected side
- Due to excessive Positive Pressure inside the ▪ Most dangerous and most fatal of all
Pleural space >> Atelectasis >> ARDS types of pneumothorax
Cardinal sign:
TRACHEAL DEVIATION
Cardinal sign ✓ Towards the Unaffected side
▪ Absent or decreased breath sound in either one
or two lung fields Other s/s:
o Common: 1 lung field ▪ Mediastinal Shifting
o Towards the unaffected side
▪ Unilateral or Assymetrical lung expansion or
___________________________
chest movement Priority: ABC
Other s/s Goal: To remove the trapped air immediately.
▪ SOB/DOB STAT
▪ Orthopnea/Dyspnea ___________________________
Management:
▪ Pallor/Cyanosis ✓ Thoracentesis
▪ ALOC/Behavioral changes ✓ CTT
▪ Fatigue/Weakness ✓ Remove the seal
Confirmatory Test for All Types
▪ Chest X-ray

Other Diagnostic Tests

- CT
- MRI

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Respiratory Disorders ______

SUMMARY OF ALL RESPIRATORY CARDINAL SIGNS

FLAIL CHEST Emphysema Barreled Chest
Chronic Bronchitis ✓ Chronic Excessive Non-
- Due to multiple rib fracture Productive Mucus & Cough
o Closed fracture ✓ Edema
- Secondary to non-penetrating trauma Pneumothorax ▪ Absent or decreased breath
- Leads to lose chest wall sound in either one or two
lung fields
o Common: 1 lung field
Types of fracture
▪ Unilateral or Asymmetrical
lung expansion or chest
movement
Tension Pneumothorax Tracheal Deviation
✓ Towards the
Unaffected side
Flail Chest Paradoxical Chest Wall
Movement or Respiration

Cardinal sign
PARADOXICAL CHEST WALL MOVEMENT OR
RESPIRATION

Other s/s ▪ Bruising on the chest

▪ Dimpling and bulging on the chest
o Dimpling: inhalation
o Bulging: exhalation
▪ Crepitation
▪ SOB/DOB
▪ Orthopnea/Dyspnea
▪ Pallor/Cyanosis
▪ Fatigue/Weakness
▪ ALOC/Behavioral Changes

Complications ✓ Pulmonary contusion

o Tissue injury
✓ Hemothorax
✓ Shock
✓ Closed pneumothorax
✓ ARDS

Confirmatory test X-ray

MEDICAL MANAGEMENT FOR FLAIL CHEST

Priority ✓ Immobilize the area
o NOT total immobilization
o By splinting and bandaging the
chest
• Wrap with elastic
bandage
o Rationale: Bones will
spontaneously heal on its own
• As long as the fractured
bones are still touching
each other

Pharmacologic ✓ Analgesics
management o For the pain
✓ Oxygen therapy
✓ Tranexamic acid
o To control bleeding
o Promotes clotting on the affected
area
Surgical ▪ Metal plates and screws
Management ▪ ORIF
▪ Thoracentesis and CTT
o As needed
o If with hemothorax and
pneumothorax

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Gastrointestinal Disorders _
o Systemic damage >> causes
LIVER CIRRHOSIS Hepatomegaly >> high venous
pressure >> portal
- Damage in the parenchymal tissues in the hypertension >> liver damage
Liver o Systemic damage >> Failure
- Hepatocytes are dying to provide O2 blood to the
- Reversible during earlier stages liver because liver is already
- Irreversible in late stages occupied with too much
unoxygenated blood
Hepatocytes 4) Post-necrotic Cirrhosis
- Functional units in the liver ▪ A.k.a. Macronodular Cirrhosis
▪ (+) Big nodules in liver
Types of Liver Cirrhosis “LBC PO” ▪ Due to infection
1) Laennec’s o Hepatitis
▪ A.k.a. Micronodular Cirrhosis o Leptospirosis
▪ (+) Tiny nodules o Helminths
▪ Leading Cause: LAKLAK ▪ Liver flukes
o Chronic Alcohol Consumption ▪ Due to hepatotoxic drugs
▪ Addictive substance in Alcohol o Anti-TB drugs (RIPE)
o Ethanol or Methanol o Some antibiotics
▪ Normal Blood Alcohol level: ▪ Tetracyclines
0.08gram g/dL o Acetaminophen
▪ Leading cause of Liver Cirrhosis ▪ Tylenol
▪ Decreased Vitamin B1 or Thiamine ▪ Paracetamol
o Very low during chronic • TSL: 10 –
alcohol consumption 20mcg/mL
o Adverse effect: Korsakoff’s ▪ Antidote: N-
Psychosis and Wernicke’s Acetylcysteine
Encephalopathy (Mucomyst)
▪ Psych conditions
▪ Antidote for alcohol poisoning: Types of hepatitis
Fomepizole 1. Hepatitis A
o Blocks the effect of alcohol ▪ Feco-oral
2) Billiary Cirrhosis ▪ Contaminated food and water
▪ Due to bile obstruction secondary to ▪ Infectious hepatitis - Most common
presence of gallstones feco-oral hepa
o Diet: fat 2. Hepatitis B
o Fatty liver disease ▪ Blood borne
▪ Storage of bile: Gallbladder ▪ Serum hepatitis - Most common
▪ Produces bile: Liver blood hepa
▪ Pathophysiology 3. Hepatitis C
o Gallstones >> obstruction in ▪ Blood borne
bile duct ▪ Transfusion hepatitis
o Food reaches the small o Common in blood transfusion
intestine >> liver release bile 4. Hepatitis D
>> bile passes obstructed bile ▪ Blood borne
duct >> cannot pass through ▪ Reactivation hepatitis
>> goes back to liver >> bile o Cant have hepa D if you did
will get activated inside the not have hepa B before
liver >> AUTODIGESTION 5. Hepatitis E
inside the liver ▪ Feco-oral
▪ Management ▪ Contaminated food and water
o NPO first if obstruction still 6. Hepatitis G
present ▪ Blood borne
o Low fat if no obstruction ▪ Dialysis hepatitis
3) Cardiac Cirrhosis
▪ Due to Right sided congestive heart
failure (RCHF)
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
 MEDICAL SURGICAL NURSING – Gastrointestinal Disorders _
Clinical manifestation High fever
▪ RUQ pain - Infection
▪ Abdominal swelling and tenderness Low grade fever
▪ Low grade fever - Inflammation and swelling
▪ Jaundice
o Skin Albumin
o Sclera ▪ CHON >> Liver >> Albumin
o Mucosa ▪ Converted thru oncotic pressure
o Will cause tremendous itchiness & o “Sealant” of fluids in blood vessels
dryness ▪ Damaged liver >> low albumin >> no oncotic
▪ Severe fatigue and weakness pressure >> no sealant of fluids >> fluid goes
o Due to low blood sugar to third space (cellular) >> causing edema >>
▪ Vitamin Deficiency weight gain
o Malnutrition ▪ Ammonia: created by colonic bacteria: E.coli
▪ ADEK is affected
o Bleeding tendencies Complications
▪ ALOC ▪ Liver cancer
o Due to increased metabolic waste >> o Fast deterioration
increase Ammonia ▪ Treatment is hard
▪ Indigestion ▪ Hepatic encephalopathy
o Causes flatulence and belching o Liver damage >> ammonia >> enters
▪ Steatorrhea brain >> brain irritation >> brain will
o Fatty foul smelling stool inflammation >> fluid shifting >>
▪ Clay colored stool cerebral edema >> skull will resist the
o Grey expansion >> puts pressure to brain
o Due to loss of bile salts >> increased ICP >> irreversible brain
▪ Tea colored or dark colored urine or cola damage
colored ▪ Portal hypertension
o Kidney will remove more metabolic o Lead to bleeding esophageal varices
waste since liver is not functional ▪ Increase venous pressure
▪ Fetor hepaticus o There is distention esophageal veins
o Halitosis due to high venous pressure
▪ Hypoalbuminemia o Distention of esophageal veins >>
o Low plasma protein increase risk for point of rupture of the
▪ Ascites veins >> risk for aspiration >> prone
o Can cause SOB to shock
▪ Weight gain o Can be detected by endoscopy
▪ Asterexis ▪ Malnutrition
o “Liver flap”
o Flapping tremors Management
o Due to excess ammonia >> CNS ▪ Place a tube on the affected area
irritation >> hyperreflexia o Tube: Sengstaken-Blakemore Tube
o How to check: ▪ Balloon tip tube
1) Ask patient to raise arms ▪ Composed of 3 lumens
forward ▪ 1 lumen: esophageal ballon
2) Push their fingers then after ▪ 1 lumen: anchor
few seconds release the ▪ 1 lumen: gavage lavage
pressure o Puts pressure on bleeder
3) Observe their fingers if its o Disadvantage
flapping ▪ Mucus can accumulate on
▪ Spider angiomas top of the tube >> might be
o Due to increase permeability of blood aspirated
vessels due to loss of Vitamin K ▪ Place Minnesota tube
o Common in abdomen o Composed of 4 lumen
o Can be found anywhere o 4th lumen: secretion suctioning
▪ Kernictirus? ▪ Bedside item
o Scissors
▪ Cuts the inflator
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
 MEDICAL SURGICAL NURSING – Gastrointestinal Disorders _
▪
To establish airway ▪ TPN as needed
▪
After cutting >> pull out the ▪ No NGT
tube ▪ IV albumin or blood transfusion of albumin
▪ Coil first then cut o Plasma expanders
o Trach set o 1 -2 hrs transfusion time
o Bag valve mask ▪ Wash skin with plain warm water and baking
soda
Normal ICP o To lessen itchiness
- 5 – 15 mmHg ▪ Blood transfusion as needed
- 7 – 25 cmH20 ▪ Paracentesis
▪ Treat underlying cause
Diagnostic ▪ Glucagon prn
▪ LFT ▪ Dextrose fluid prn
o SGPT
▪ Specific to liver FRBC and PRBC
▪ N: 0 – 30 u/ml - 4 hrs
o SGOT
▪ Specific to liver and heart Whole blood
▪ N: 0 – 35 u/ml - 4 – 6hrs
▪ CT scan
▪ MRI FFP, Cryoprecipate, Platelet concentrate
▪ Fibro scan - Fast drip within 30 minutes
o Checks for fibrosis or scarring of the - To control bleeding
liver
▪ Abdominal utz Albumin plasma
▪ Serum bilirubin levels - 1 – 2 hrs
o Increase
▪ Serum alkaline phosphatase Medications
o Increase 1. Vitamin K injections
▪ Serum ammonia 2. Vitamin D injections
o High ▪ Helps with calcium absorption
▪ Serum albumin 3. Tranexamic acid
o Low 4. Mannitol prn
o Low Oncotic pressure ▪ Cross BB barrier
▪ CBC ▪ Lowers ICP
o Hemoglobin and HCT 5. Lactulose
▪ Low ▪ Duphalac
o ESR and WBC ▪ Laxative
▪ High ▪ Prevents ICP
▪ Bleeding parameters ▪ “Labay ammonia”
▪ Blood sugar test ▪ Ammonia binder
o FBS is enough o Gets ammonia from blood
o Screening bs test are enough and excretes via stool
▪ Liver biopsy 6. Neomycin
o During procedure: left side ➢ Amino glycoside
o After procedure: affected side ➢ Broad spectrum
Management ➢ Can be used in all types of liver
▪ NPO if with obstruction cirrhosis
▪ No obstruction ➢ Prevents new formation of ammonia
o Low fat o By lowering the colonic
o Low protein bacteria >> decreases
o High carbs ammonia converters >>
o High calorie decrease ammonia production
o High fiber 7. Sylimarin
▪ Easy removal of fats 8. Phospholipids
▪ Prevents constipation
• To decrease ICP
o Limit fluids
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
 MEDICAL SURGICAL NURSING – Gastrointestinal Disorders _
▪ Hurried meals: Improperly chewed
PEPTIC ULCER DISEASE meals could result to more production
of HCL
Predisposing factors 8. Eating Disorders
1. Stress ▪ Anorexia: Does not eat + purging
▪ Stress decreases prostaglandin and ▪ Bulimia: Hurried meals + purging
causes decreases mucus productions 9. Genetics
o Increases hydrochloric acid ▪ Type O blood type
2. H. Pylori Infection o Increase pepsinogen
▪ Wastes of the bacteria adds acidity ▪ Base product to
▪ Produces additional acid produce HCL acid
▪ DOC: Metronidazole & Bismuth 10. Type A personality
o Also given for amoebiasis ▪ Stress personality
o Avoid any intake of alcohol 11. Burns
▪ Rationale: has ▪ A.k.a. Curling’s Ulcer
Antabuse-like effect o If ulcer is triggered by burns
• Aversion ▪ Burns >> fluid loss >> hypovolemia
Therapy for >> ischemia >> necrosis
Alcoholism o No blood flow to the stomach
• Prevents >> less mucus production in
addiction stomach
from alcohol 12. Age
• Can cause ▪ Higher age: Increase risk
violent nausea 13. Cancer
and vomiting 14. Radiation or Chemotherapy
• Even a smell ▪ Affects good and bad cells
of alcohol can ▪ Iatrogenic
trigger 15. Co-morbidities
antabuse-like ▪ Cushing’s syndrome
effect
GASTRIC ULCER DUODENAL ULCER
3. Long-term use of NSAIDS, Analgesics, A.k.a. Poor man’s Ulcer A.k.a. Executive Ulcer
Steroids Laborer’s Ulcer Rich man’s Ulcer
▪ If cannot take with meals: Take Busy man’s ulcer
Epigastric pain
Enteric coated medications ✓ “Burning pain or Gnawing pain”
o Rationale: Melts in the Onset: Onset:
intestine, not in the stomach 30 minutes after meals or right 2 – 3 hours after meals
after meals ✓ Common at night
o Never crush enteric coated ✓ Mouth to stomach within 30
drugs minutes
Common site: Common site:
4. Zollinger Ellison Syndrome Upper Portion (Antrum) Lower end of the stomach + first
▪ Having PUD secondary to a pancreatic 2cm of duodenum
tumor Radiation of pain: Radiation of pain:
Going to the left Going to the right
o Gastrinoma: A type of tumor Relief of pain: Relief of pain:
that produces acid By vomiting By eating
5. Smoking and Alcoholism Pain worsened by: Pain worsened by:
Eating
▪ Smoking is a stimulant of HCL Weight: Weight:
▪ Too much alcohol causes dryness to ✓ Weight loss ✓ Normal weight
the mucosa inside the stomach ✓ Prone to malnutrition ✓ Normal nutrition
Risk of cancer: Risk of cancer:
6. Diet 10% Higher of malignancy Lesser risk
▪ Spicy foods Acid level: Acid level:
▪ Carbonated Lesser HCL production Higher HCL production
Metabolic Alkalosis Metabolic Alkalosis
▪ Stimulants (Coffee) Higher risk Lesser risk
▪ Acidic fruits Bleeding: Bleeding:
▪ Vitamins Hematemesis Melena Black tarry stools
✓ Upper GI bleeding
o Sodium ascorbate: Complications of both:
Alternative for it to be less ✓ Hemorrhage
acidic o Most common
✓ Perforation
7. Skipped or Hurried Meals
▪ Could trigger auto-digestion
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
 MEDICAL SURGICAL NURSING – Gastrointestinal Disorders _
Cause of Death: ➢ Issue: Crosses BBB >> Nerve Tangles >> affects
✓ Shock neurological symptoms & ALOC
Diagnostic Tests ➢ Cimetidine: Crosses the BBB the most; most potent
1. Endoscopy or EGD ▪ Avoided in Geriatrics
o A.k.a. Esophagogastroduodonoscopy ➢ Ranitidine: Safest! Least potent
o Confirmatory test o PPI
o Lidocaine spray to suppress gag reflex ➢ Similar with H2 blockers
➢ Do not feed right after procedure ➢ -prazole
2. CT Scan or MRI ➢ Does NOT cross BBB
3. Abdominal UTZ ➢ Safer compared to H2
4. Gastric or PH analysis o Cyto-protectives
5. Barium swallow ➢ “Coaters”
o A.k.a. Upper GI series ➢ To coat ulcerated parts
o Uses Radioactive Dye ➢ Best time: 30 minutes before meals
6. ABG ➢ S/e: Constipation
7. CBC ➢ Ex: Succralfate (Carafate)
Management o Prostaglandin Analogues
▪ Treat underlying cause ➢ “Fillers”
▪ Diet: ➢ Agonists
o Bland diet everything is low ➢ Elevate Prostaglandin = mucus = shield
o Soft diet ➢ Best time: 30 minutes before meals
o TPN ➢ Ex: Misoprostol (Cytotec)
o No NGT ➢ S/e: Constipation
▪ Blood Transfusion as needed ➢ A/e: Uterine Contractions >> Abortifacient
o Increment ratio: 1 bag = 1g/dL Hgb 2 – 3% Hct ▪ Surgery
o Small gauge, blood set o Vagotomy
o Most Common to cause reaction: Whole Blood then RBC ➢ Lowers down HCL production
o Least common to cause reaction: Platelet concentrate o Gastrectomy or Gastric Bypass or Bariatric Surgery
o Main reason BT reaction: ABO incompatibility ➢ Last option!
o Most common reaction: Febrile reaction ➢ Many complicaitons
o Most life-threatening: Anaphylactic shock then Hemolytic
o Consume within: 30 minutes
o First 30 minutes: KVO rate to monitor BT reactions Food Travel time
o KVO rate during BT: 20 – 25 - Mouth to stomach: Within 30 minutes
o KVO rate of PNSS: 10 – 15 - Mouth to small intestine: 2 -3 hours
o Multiple BT:
➢ 1 bag = 100 mg Citrate - Mouth to colon: 6 – 8 hours
➢ Prevents production of Calcium >> Hypocalcemia
➢ If > 3 bag: Ca Gluconate
o Hyperkalemia causes:
Hematochezia
➢ Due to hemolysis - Lower GI bleeding
➢ Old blood
➢ Prolonged time of infusion
➢ Heat Diagnostic test for Melena
o Whole Blood: 4 – 6 hours - OBT, GUAC, Cassette Tape Test
o PRBC: 4 hours
o FRBC: 4 hours
o Done in 3 consecutive days
o FFP: Fast drip within 30 minutes o No Dark Colored Foods (NDCF )
o Cryoprecipitate: Fast drip within 30 minutes
o Platelets: Fast drip within 30 minutes
o Albumin: 1 -2 hours 2 types of Gastrectomy
▪ Anti-ulcer medication 1) Billroth I
o Antacids
➢ Neutralizes HCL acidity
▪ Gastroduodenostomy
➢ Best time: After meals to prevent indigestion ▪ Connect to the remaining duodenum
➢ If with (+) Hx of hyperacidity: Before meals ▪ Indicated for: Gastric Ulcer
➢ Ex: Aluminum Hydroxide (AmPHOjel)
▪ Phosphate binder: Decreases Pho = Increases Ca 2) Billroth II
▪ S/e: Constipation ▪ Gastrojejunostomy
▪ A/e: Renal Calculi & Arrhythmia ▪ Connect to jejunum
➢ Ex: Magnesium Hydroxide (Milk of Magnesia)
▪ S/e: Diarrhea ▪ Indicated for: Duodenal Ulcer
➢ Best antacid: MAALOX or Combination
▪ Kremil-S
▪ Magnesium and Aluminum Hydroxide
Post Gastrectomy Complications
▪ Results to normal bowel movement 1. Dumping Syndrome
➢ Ex: Calcium Carbonate (Tums)
▪ Also a calcium supplement
2. Pernicious Anemia
▪ S/e: Constipation
▪ A/e: Renal Calculi & Arrhythmia DUMPING SYNDROME
➢ Ex: Sodium Bicarbonate
▪ DOC: For metabolic acidosis >> Duodenal Ulcer
o H2 Blockers - Rapid emptying of gastric contents going to
➢ Histamine 2 antagonists the LGI secondary to a shortened GI tract
➢ Decreasing HCL acid production o Leading to fast digestive process
➢ -tidine
➢ Best time of the day: Hours of sleep - Self-limiting behavior
➢ Best time: After meals o Will go away on its own
➢ If with (+) Hx of hyperacidity: Before meals

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Patricia Marie A. Braulio, BSN - Velez College - SLRC
 MEDICAL SURGICAL NURSING – Gastrointestinal Disorders _
Common in o Ex: Loperamide (Diatabs)
- Billroth II ▪ Anti-spasmodic
o Ex: Hyoscine (Buscopan)
Average recovery
- 6 – 12 months PERNICIOUS ANEMIA
Onset
- 5 – 30 minutes after meals - Due to low levels of Vitamin B12
Duration (Cyanocobalamin)
- 15 – 30 minutes o Sources: Animal sources
- Usually common in Vegan
Clinical manifestations
▪ Increased bowel sounds Low B12
o Rationale: Peristalsis - Decreases production of Intrinsic Factor
o A.k.a. Borborygmi Bowel sound o Low RBC production = low blood
volume
▪ Diarrhea
▪ Pain or Abdominal cramps
▪ Diaphoresis Pre-disposing Factors
▪ Surgery
▪ Cold clammy skin
▪ Risk for dehydration ▪ Genetic problem
o Ex: Autoimmune
▪ Metabolic Acidosis
▪ H. Pylori
▪ Fatigue
▪ Light headed ▪ Diet
o Pure vegan diet
▪ Electrolyte imbalance
▪ Low sugar ▪ Pancreatitis
o Due to overstimulation of pancreas =
Clinical Manifestations of Pernicious Anemia
insulin ▪ Classic symptoms of anemia
▪ Shock-like symptoms ▪ Cardinal signs
o Red beefy tongue
Normal Bowel Sounds o RBC morphology: Megaloblastic
- 5 – 30 clicks/min
▪ Big RBC, count
▪ Compensatory to prevent
Management for Dumping Syndrome sudden shock
1. Diet ▪ Remaining RBC will increase
▪ Low CHO in size >> under the tongue is
o Rationale: CHO is fast to highly vascularized >> Red
digest beefy tongue
▪ No simple sugar Complications
▪ Moderate to high fat 1. Shock
o Rationale: Fats are hard to 2. Organ failure
digest
▪ Dry meals Cooley’s Anemia
o Anything with sauce or soup - Immune system attacking RBC causing
are contraindicated hemolysis
▪ SFF
o Avoid bulk Kawasaki vs. Scarlett fever
▪ Fluid should be taken IN-BETWEEN - Kawasaki: red strawberry tongue
meals - Scarlet: white strawberry tongue
▪ Instruct the patient to lie down for at
least 30 minutes after meals Diagnostic Tests for Pernicious Anemia
▪ No ambulation, No abdominal 1) CBC
massage, No heat application for at 2) Blood Electrophoresis
least 30 minutes after meal ▪ Detailed CBC
o Rationale: To prevent 3) Schilling’s Test
stimulation of peristalsis ▪ CONFIRMATORY test
2. Medications ▪ 24 hour urine test
▪ Anti-motility ▪ To check ability on absorption of
o Rationale: To slow down vitamin B 12
peristalsis
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
 MEDICAL SURGICAL NURSING – Gastrointestinal Disorders _
▪ Stage 1: Patient is given radioactive ▪ Flatulence
vitamin B12 ▪ Belching post heavy meal
o Co57 or Co58 ▪ Jaundice
o Oral or IM ▪ Yellowish, dry, itchy skin
o (+) Vitamin B12 = (-) PA ▪ WOF: Hypocalcemia
o >10% given Vitamin B12 o There are calcium deposits in the
urine = (-) PA Pancreas
o Inversely proportional ▪ Calcium from the pancreas
▪ Stage 2: Co57 or Co 58 + Intrinsic will leak to peritoneum
Factor ▪ Nausea and vomiting
o Directly proportional ▪ Cold clammy skin
▪ First voided urine: Discard ▪ Diaphoresis
▪ 2nd voided urine: Save for the next 24 ▪ Malnutrition
hours ▪ Weight loss
▪ Placed in cold temperature
▪ Make sure there is label Cardinal Signs
1. Cullen’s Sign
Management ▪ Bluish-purple discoloration of the
1. Treat underlying cause umbilical region
2. Blood Transfusion as needed ▪ Or bruising, ecchymosis
3. Drug of choice ▪ Due to Hemorrhage >> blood pools by
▪ Artificial B12 gravity in umbilical region
▪ IM, once every month, for life 2. Grey Turner Sign
▪ Bluish-purple discoloration in the
flank region
PANCREATITIS
Diagnostic Tests
Two types of Pancreatitis 1) ERCP
1) Acute Pancreatitis ▪ Endoscopic Retrograde Cholangio
2) Chronic Pancreatitis Pancreaotography
▪ Confirmatory Test
Pathophysiology ▪ Can also be a management
▪ Obstruction >> digestive enzymes are o Rationale: Can get Gallstone
activated inside the pancreas >> Auto- obstruction
digestion >> injury or inflammation ▪ Uses Contrast medium for better
visualization
ACUTE PANCREATITIS CHRONIC PANCREATITIS ▪ WOF: Allergies to Contrast Media
Gallstone obstruction in the Alcoholism >> scarring >>
pancreatic duct or Duct of stenosis >> obstruction 2) CT scan & MRI of the abdomen
Santorini 3) Abdominal UTZ
(+) OBSTRUCTION 4) Elevated serum bilirubin level elevated
5) CBC
▪ ESR/WBC
Complications of Pancreatitis
1. Hemorrhage ▪ Hgb/Hct
▪ Most common 6) Serum Amylase
2. Perforation ▪ 3 – 4x higher than its normal level
3. Shock ▪ Amylase: Peaks within 6hrs
▪ Cause of death ▪ Lipase: within 12hrs
4. Diabetes ▪ Trypsin: within 18hrs
▪ Type 2 DM 7) Serum Alkaline Phosphatase level
▪ Alkaline Phosphatase
Clinical Manifestations of Pancreatitis 8) Serum electrolytes
▪ Severe epigastric and LUQ pain ▪ Low Ca
▪ Sharp pain radiating to the shoulder ▪ High Phosphorous
▪ Abdominal swelling and tenderness 9) ECG
▪ Low-grade fever 10) Bleeding Parameters
▪ Indigestion
o Steatorrhea
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
 MEDICAL SURGICAL NURSING – Gastrointestinal Disorders _

Management for Pancreatitis

▪ If (+) Obstruction APPENDICITIS
o NPO
o TPN - Acute inflammation of the vermiform
▪ If (-) Obstruction appendix
o Low fat - Appendix: Accessory Organ
o Low CHO o RLQ
o Low CHON o Right Ileac Region
o High Fiber o McBurney’s Point
o Soft Diet Leading cause
▪ Medications - Obstruction secondary to Fecalith
o Analgesics o Stone made up of feces
▪ Morphine o Impacted feces
▪ Meperidine (Demerol) - Trauma
▪ WOF: Spasm of Sphincter of - Infection
ODI >> Contributes to
additional pain Clinical manifestations
o Pancrease & Cholestyramine ▪ Severe RLQ pain
▪ Synthetic digestive enzymes ▪ Abdominal swelling and tenderness
▪ If patient accidentally eats ▪ Low-grade fever
when NPO ▪ Diaphoresis
o Ursodiol (UDCA) ▪ Cold clammy skin
▪ Dissolves the Gallstone ▪ Decreases Bowel sounds
o Calcium Gluconate o Less than 5
▪ For hypocalcemia ▪ WOF: Sudden loss of pain
o Tranexamic Acid (Hemostan) o Possible sign of ruptured appendix
▪ To stop possible bleeding ▪ Peritonitis >> sepsis
▪ Lithotripsy • Board-like rigid
o Lith: Stone abdomen
o Tripsy: “Shock” Cardinal signs
o 2 types: 1. Blumberg’s Sign
▪ Extracorporeal ▪ Bouncing pain in the RLQ
▪ Percutaneous ▪ A.k.a. Rebound tenderness
• More effective but 2. Rovsing’s sign
more invasive ▪ Palpation at LLQ, pain elicited at RLQ
▪ Surgery ▪ Reverse pain
o Whipple’s procedure 3. Psoas sign
▪ A.k.a. ▪ Pain elicited at RLQ when leg is
Pancreaticuduodonostomy flexed towards the hip
▪ A.k.a. Pancreatic Bypass 4. Obturator sign
▪ Last option ▪ Right leg internal rotation causes RLQ
▪ Pancreatic duct is removed pain
▪ Anastomosing of the 5. Dunphys sign
pancreatic head directly to the ▪ Coughing causes RLQ pain
duodenum 6. Kosher’s sign
▪ Palpation at umbilical region causes
RLQ pain

Diagnostic Tests
1) MRI & CT scan
▪ Confirmatory
2) Abdominal UTZ
▪ Less accurate, less reliable
▪ Note: No deep palpation
3) CBC
▪ WBC
4) KFT
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
 MEDICAL SURGICAL NURSING – Gastrointestinal Disorders _
▪To rule out kidney problems Clinical Manifestations
▪(-) results = (+) appendicitis ▪ Severe RUQ pain
▪ Sharp pain radiating to the shoulders
Management ▪ Jaundice
▪ Never give analgesics or pain meds ▪ Abdominal swelling tenderness
o Rationale: May mask s/s of rupture ▪ Low-grade fever
▪ Diet ▪ Indigestion
o NPO o Flatulence
▪ Rationale: If with peristalsis o Belching
>> causes rupture to appendix o Steatorrhea
▪ TPN
▪ IV fluids Cardinal signs
o Isotonic Solutions 1. Murphy’s sign
▪ D5W or PNSS ▪ Inability to breath in when fingers are
▪ Position placed on the RUQ secondary to pain
o Supine position 2. Boas Sign
▪ NEVER bend on your waist ▪ Not accurate
o Side – lying position ▪ (+) Hyperesthesia
▪ (+) pain: Left side o Hypersensitivity of the RUQ
▪ (-) pain: Right side to light touch
• Rationale: To localize
the leakage from the Diagnostic Test
rupture. Prevents 1. ERCP
spreading 2. CT scan & MRI
▪ Avoid any form of exertion 3. Abdominal Utz
o Heavy lifting 4. CBC
o Coughing 5. Serum Bilirubin
▪ IAPePa ▪ Elevated
▪ Neomycin 6. Serum alkaline phosphatase
o Antibiotic; Aminoglycosides ▪ Elevated
o Pre-op meds
o Rationale: To decrease colonic Management
bacteria - Same management of pancreatitis
▪ Surgery - Surgery
o Appendectomy o Cholecystectomy

CHOLECYSTITIS

- Inflammation of Gall bladder

- Accessory organ
- For extra storage of bile

Leading cause
- Obstruction of bile duct secondary to
gallstones
o Autodigestion of bile inside the
gallbladder

Predisposing Factors “F5”

1. Fat
▪ Obesity, overweight, fat diet
2. Female
▪ Estrogen = fat
3. Forty and above
▪ Slow metabolism
4. Fertile
5. Fair

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Patricia Marie A. Braulio, BSN - Velez College - SLRC
 MEDICAL SURGICAL NURSING – Neurological Disorders ______
▪ IV Endorphonium
Nervous system o A fast acting cholinergic drug
1. CNS o Short-acting
▪ Brain & Spinal Cord 2) Ice test
2. ANS ▪ A localize test to check for muscle
▪ Sympa/Parasympa function
3. PNS ▪ Acetylcholinesterase is thought to be
▪ Spinal nerves and cranial nerves inhibited by cold
▪ 31 pairs of spinal nerves 3) Plasma Analysis
▪ Plasma contains antibodies
▪ Test used to detect excess antibodies
MYASTHENIA GRAVIS ▪ A.k.a. Immunoglobulin test
▪ IgA & IgG most common to cause
- Neuromuscular condition Autoimmune attack
- CNS condition specifically the brain 4) Single fiber EMG
- Imbalance of acetylcholine & ▪ Invasive procedure
acetylcholinesterase ▪ Checks muscle activitiy
▪ Most sensitive but non-specific
Incidence ▪ Analgesics are given prior to
- Female > Men procedure
- Common: 15 – 35 years old ▪ Normal: Bruising, but should not be
progressive
Main neurotransmitter involved ▪ Stimulants are not allowed
✓ Acetylcholine (ACH) ▪ Avoid medications that affects muscle
o Functions: function
▪ Necessary for muscle 5) CT Scan & MRI
Contraction of the voluntary
TENSILON TEST ✓ (+) if ptosis and weakness
muscles resolvee after 30 seconds of
▪ For Cognitive function IV tensilon was given
✓ Effect last only up to 5-
10mins only
ACETYLCHOLINE AUTOIMMUNE
✓ Confirmatory test
Main dysfunction: Contraction of Antibodies attacks and damages ✓ Emergency medication for
muscles the ACH receptor sites Myasthenic Crisis
Due to: Acetylcholinesterase (-) receptors for ACH ICE TEST ▪ (+) if a >2 mm rise in the
Generalized muscle weakness of Voluntary muscles eyelid occurs after the ice is
removed
▪ Cold = temporary muscle
Function of Acetylcholinesterase strength
- Allows the muscle to relax SINGLE FIBER EMG Shows a “jitter” and a “blocking”
in a pair of muscles
Alzheimers vs. MG
▪ ACH + contraction problems = MG Clinical Manifestations
▪ Progressive descending voluntary muscle
▪ ACH + cognitive problems = Dementia
weakness
▪ Ptosis
Leading Cause of MG
o Initial symptom
✓ Autoimmune
o Affects the levator palpebrae
Remission vs. Relapse
▪ Muscle in eyelids
- Remission: Removal of s/s
▪ Diplopia
- Relapse: Return of s/s
▪ Strabismus
o “Libat”
Exhibited by
▪ Mask-like facial expression
- Excacerbations and Remissions
o Flat affect: No reaction at all
- Descending Weakness
o Blunt: Little reaction
▪ Dysphonia
Diagnostic Tests
o Voice impairment
1) Tensilon Test
o Weak voice
▪ Confirmatory test
o Creates a “Nasal voice” “Nasal
▪ A systemic check of all the muscles in
Twang”
the body
▪ Dysphagia
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Neurological Disorders ______
▪ Dysarthria ▪ Bedside items
o A.k.a. Slurred speech o ET set, trach set, bag valve mask
▪ SOB/DOB ▪ Isotonic exercise, PROM
▪ Shallow breathing ▪ Plasmapheresis
▪ Muscle Atrophy or Wasting o Cleans the plasma
▪ Body malaise ▪ Rationale: To remove
excessive amount of
Complications antibodies
1. Respiratory failure ▪ Surgery
▪ Usual cause of death o Thymectomy
2. Hypostatic Pneumonia ▪ Removal of thymus gland
with a chest incision
Management for Crisis ▪ To lessen immune response
▪ Medications ▪ Decreases
o Corticosteroids Acetylcholinesterase
▪ Ex: Prednisone ▪ Thymus: Supplies T-cells
▪ Strongest Corticosteroids to
suppress immune system AMYOTROPHIC LATERAL SCLEROSIS (ALS)
o Immunisuppressants
▪ Ex: Methotrexate, - A.k.a. Lou Gehrig’s Disease
Cyclophospamide - Neuromuscular conditions
▪ Positive pressure room - CNS problem
o Anticholinesterase - There is an area that hardened, damaged, or
▪ Ex: Pyridostigmine Bromidie peeled off
▪ -stigmine - Progressive motor neuron disease
▪ Anti-erase - Sensory neurons still intact
▪ Controls Acetylcholinesterase - (+) Ascending muscle weakness
▪ Long-acting cholinergic drug
▪ For maintenance 4 A’s
▪ Taken orally ▪ ALS
▪ Best time take: Before meals ▪ Anterior Horn
▪ Initial sign that drug is ▪ Anterior Cortex
effective: Increase strength in ▪ Ascending muscle weakness
chewing and swallowing
▪ Side effects: EARLY STAGES LATE STAGES
• All fluids go out Affects spinal cord Affects brain
(+) Hardening/damaged lower (+) Hardening/damage upper
▪ Adverse effect: motor neurons motor neurons
• Cholinergic Crisis ✓ Anterior horn of SC ✓ Anterior Cerebral Cortex
Muscle weakness of the lower Muscle weakness of the upper
▪ Place patient in cold environment extremities extremities

MYASTHENIC CRISIS CHOLINERGIC CRISIS

Worsened s/s of MG Worsened s/s of MG +
Cholinergic s/s POSTERIOR INTERNEURON ANTERIOR
Due to undermedication Due to overmedication Sensory neurons Both sensory & Motor neurons
Improved strength upon use of Improved weakness upon use of motor
Tensilon tensilon For sensation Both sensation and For muscle
Pupils Dilate Pupils constric movement contraction &
Tachycardia Bradycardia movement
Worsened by giving Tensilon
Relieved by: Relieved by: Paralysis
Tensilon Atropine
Increase Dosage of Lower the Dosage of - Cant move and cant feel
Anticholinesterase Anticholinesterase - (-) sensory & motor

Incidence
General management for MG - Men > Women
▪ Diet - Age group: 40 – 70 yrs old
o Soft diet - Lifespan: 2 – 6 years old
o No clear liquids
o NGT, TPN Primary Cause
▪ O2 therapy / Mech Vent as needed - Idiopathic
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – Neurological Disorders ______
Incidence
Predisposing factors - Commonly afftecting half of the size
✓ Increased Glutamate - Women > men
o In high levels: Toxic
✓ Genetics Primary Predisposing factures
✓ Autoimmune - Autoimmune
✓ Age
Factor that will Trigger
Clinical Manifestations ✓ Viral infections
▪ Progressive muscle weakness and atrophy o Fast morphology
o Starting from the lower extremity ✓ Immunizations
▪ Fasciculations
o Involuntary muscle twitching visible Clinical Manifestations
under skin ▪ Exacerbations and remissions
▪ SOB/DOB ▪ Facial palsy
▪ Shallow breathing ▪ Facial dropping, sagging or wrinkling
▪ Dysphagia ▪ Flat nasolabial fold
o Risk for choking and risk for ▪ Loss of expression and sensation on the
aspiration affected side
▪ Dysarthria ▪ Corneal redness and dryness
▪ Dysphonia o Patient does not have blinking reflex
▪ Weak voice, nasal voice, nasal twang, ▪ Loss of taste and sensation over the anterior
hoarseness of voice 2/3 of tongue
▪ Blunt affect
▪ Ptsosis, diplopia, strabismus How to check for facial palsy
✓ Focus on lips, teeth, gums, and eyes
Complications ✓ “Sir show me your teeth”
- ARDS ✓ Open close eyes
- Pneumonia ✓ Raise eyebrows
✓ Check for nasolabial fold
Diagnostic tests
1. CT scan, MRI, PET scan Diagnostic tests
2. EMG 1. CT scan & MRI to rule out stroke
3. Myelogram 2. Nerve conduction velocity test
4. Plasma analysis 3. Plasma analysis
5. Serum glutamate levels
6. Muscle biopsy Management
▪ Palliative care
Management ▪ Diet
▪ No cure, no specific treatment o Soft diet
▪ Palliative care o Avoid too hot food and fluid
▪ Riluzole (Rilutek) o Chew on unaffected side
o Glutame Antagonists o Can have clear liquids
o Delays progress o NGT or TPN as needed
▪ Same management fo the problem ▪ DRUG OF CHOICE
o Steroids
▪ Other medications
o Vitamin B complex
BELL’S PALSY neuroprotectives
▪ B1
- PNS disorder ▪ B6
- CN 7: Facial nerve ▪ B12
- Motor and sensory function loss ▪ Can help with memory
- Temporary facial paralysis retention
- Self-limitIng behavior ▪ Avoid use of any aerosol products
o Average: 3- 5 months o Rationale: (-) blinking reflex
▪ Manually close eyelids when about to sleep
▪ Wear protective glasses or eyepatch
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 MEDICAL SURGICAL NURSING – Neurological Disorders ______
▪ Avoid stress, fatigue, and infection ▪ Diet
▪ Practice relaxation techniques o Soft diet
o Avoid too hot and avoid too cold
o Food should be room temperature
TRIGEMINAL NEURALGIA o NGT or TPN as needed
o Analgesics
- PNS condition o Antidepressants as needed
- CN 5: Trigeminal Nerve condition ▪ A.k.a. Thymoleptics
o Nerve pain o Indoor activities only
- Motor sensory disorder o Muscle relaxants
- A.k.a. Tic douloureux ▪ For twitching of the face
o “Painful tic” ▪ Ex: Baclofen (Lioresal)
- Involuntary twitching of the face secondary to • Only muscle relaxant
pain that can be given
straight to the spinal
Incidence canal or intrathecal
- Women > men • Major s/e: Dry mouth
- Elderly women o DRUG OF CHOICE
▪ Carbamazepine (Tegretol)
Branches of Trigeminal Nerve ▪ Anticonvulsant
✓ Ophthalmic ▪ Controls twitching
o Corneal reflex ▪ (+) Muscle relaxant effect
✓ Maxillary ▪ (+) Analgesic effect
o Facial sensation ▪ TSL: 5 – 12mcg/mL
✓ Mandibular ▪ WOF: Sore throat & fever
o Chewing mastication ▪ A/e: Agranulocytosis or Blood
Dyscrasia
Nerve pain in Trigeminal Neuralgia “SSS” o Other medications
- Sudden ▪ Dilantin (Phenytoin)
- Severe pain • S/e: Gingival
- Shooting Hyperplasia
▪ Gabapentin
Leading factor o Nerve blocking
- Idiopathic ▪ Via injection of an alcohol or
phenol in the face of the
Risk factors patient may lead to temporary
✓ Autoimmune anesthesia that lasts in an
✓ Genetics average 6 – 18 months
✓ Trauma o Surgery
✓ Chemical exposure ▪ Retrogasserian Rhizotomy
• Intracranial surgery
Diagnostic tests • Incises the nerves to
1. CT scan MRI prevent pain
2. Nerve conduction velocity test • Result to permanent
anesthesia
Clinical Manifesations • A palliative surgery
▪ Tampering or touching the branches of
Trigeminal nerve induces severe pain
▪ Facial grimacing GUILLAIN – BARRE SYNDROME
▪ Frquent blinking and tearing of the eyes
▪ Poor hygiene habits - Non-gender specific condition
▪ Poor eating habits - Occurs at any age
▪ Social isolation - A.k.a. Acute Polyneuritis
o Can lead to depression - A.k.a. Radiculo Polyneuritis
- A.k.a. Viral Polyneuritis
Management
- A PNS Disorder
▪ Avoid anything that could tamper the 3 o Spinal nerves are affected
branches
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 MEDICAL SURGICAL NURSING – Neurological Disorders ______
o Acute spinal nerve / Rhizome 5. Plasma analysis
inflammation secondary to minor 6. CBC
sclerosis and demyelination ▪ ESR, WBC
7. ABG
Primary cause
- Autoimmune
Management
Risk factors ▪ Palliative care
✓ Viral infections ▪ Plasmapheresis
o Ex: Corona Virus & Rotavirus ▪ IV ImmunoGlobulins
✓ Vaccines o Replaces better antibodies
o Ex: Flu, OPV, HPV ▪ Medications
o Immunosuppresants
Myelin sheaths o Corticosteroids
- Cover of the nerves
- Allows the nerves to be near to each other for MULTIPLE SCLEROSIS
better transmission of nerve signals/impulses
- A.k.a. Disseminated Sclerosis
Pathophysiology - A CNS condition
▪ Demyelinization >> Leads to temporary - Affects the brain and the spinal cord
shutdown of motor and sensory function >> o Specifically the Myelin sheaths
To allow self-preservation or healing of the o Affects the White matter of the brain
myelin sheaths >> leads to temporary body - Demyelinization of CNS
paralysis
o Average duration of paralysis: 3 -6 Myelin sheaths
months - A.k.a. Nerve transmission pathway
- Allows good transimission of impulses in the
Cardinal sign CNS
▪ Ascending paralysis - (+) Damaged Myelin Sheaths = Impaired
o A.k.a. Landry’s paralysis nerve impulse conduction or transmission
▪ Descending recovery
Incidence
Other clinical manifestations - Women > men
▪ Paresthesia of the lower extremity
o INITIAL SYMPTOM Pathophysiology
▪ Clumsiness ▪ (+) Demyelinization >> poor transmission of
▪ Absent or decreased DTR impulses >> miscommunication between the
▪ Muscle atrophy or wasting brain and the body
▪ Bed ulcers
o Most common site: Sacral Primary cause
▪ Urine retention - Autoimmune
▪ Constipation
▪ SOB/DOB Risk factors
▪ Brady Arrhythmia ✓ Viral infections
▪ Dysphagia ✓ Vaccines
▪ Dysphonia
▪ Dysarthria Cardinal sign
▪ Charcot’s Triad “SIN”
Cause of death o Scanning speech
- ARDS ▪ A.k.a. Stacatto speech
- Hypostatic Pneumonia ▪ Priority: Safety
- Cardiac Arrest o Intentional tremors
▪ When patient moves, tremors
Diagnostic Tests occur
1. CT scan, MRI, PET scan ▪ Priority: Safety
2. Myelogram ▪ Recommended activity:
3. Nerve conduction velocity test Painting
4. EMG o Nystagmus
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 MEDICAL SURGICAL NURSING – Neurological Disorders ______
▪Involuntary eye-rolling ▪ Ex: Avonex, Betasetron, Copaxone
movement ▪ Best time: A.M.
*(+) Charcot’s Triad = (+) Multiple Sclerosis* ▪ S/e: Flu-like symptoms

Other Clinical Manifestations “BAD SISA”

▪ Bowel & Bladder dysfunction PARKINSONS DISEASE
o Alternating urinary retention or
incontinence - A.k.a. Paralysis Agitans
o Alternating Diarrhea or Constipatio - CNS condition affecting Brain
▪ Ataxia - Irreversible
o Problems with gait, balance, - Due to degeneration of the ff: “BES”
coordination o Basal Ganglia
o Two tests to assess: ▪ Produces Dopamine II
▪ Nose to Finger test o Extrapyramidal Area
• Checks for ▪ Produces Dopamine II
smoothness of the o Substantia Nigra
movement ▪ Produces Dopamine II
▪ Heel to shin test - Decreased Dopamine II
▪ Diplopia & Depression o Low motor & mental function
▪ Spasticity of muscle
o Can develop to muscle Normal function of Dopamine II in the brain
weakness/paralysis - Necessary for:
o Can develop pain o Motor function: Inhibits excessive
▪ Impotence; Sexual Dysfunction movement i.e., fine/gross motor skills
▪ Scotoma & Seizures o Mental function: Stimulates cognitive
o Blind spots in the eyes function
o Prone to injury Incidence
▪ Apraxia - Men > women
o Difficulty in performing purposeful - Above 65 years old
movements or ADLs

*Exhibited by exacerbations and remissions* Early stage Parkinsons

✓ Motor function is affected first
Tremors in MS & Parkinsons o Resting Fine Tremors (Pill-rolling)
▪ MS: Move = Shake ▪ EARLIEST Sx
▪ Parkinsons: Resting Tremors o Bradykinesia >> hypokinesia >>
akinesia
Diagnostic Tests o Dysphagia
1. MRI o Muscle Rigidity
▪ GOLD STANDARD ▪ A.k.a. Cogwheel Rgidity
2. CT Scan or PET scan ▪ Sudden stiff movement
3. Myelogram o Shuffling gait
4. Nerve conduction velocity test o Stooped posture
5. EMG o Dysarthria
6. Plasma Analysis ▪ Monotonous speech
7. CBC o Micrographia

Management Late Stage Parkinsons

▪ Not curable, but controllable ✓ Decreased cognitive function
▪ Palliative care o Parkinsonian Dementia
▪ Plasmapheresis o Mask-like facial expression
▪ Drug of choice: Corticosteroids o Agnosia
▪ Other meds o Aphasia
o Immunosupressants o Inability to learn
o ABC drugs (Interferons)
▪ Antiviral Predisposing factors
▪ Anti-inflammatory ✓ Aging
▪ Immune system modulator ✓ Genetics
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 MEDICAL SURGICAL NURSING – Neurological Disorders ______
✓ Lifestyle and diet - Used to check ICP
✓ Chemical exposure - Manometer: Manual
✓ Head Trauma - Transducer: Electronic
o Ex: Boxers - Best position: Supine
✓ Infection o Maximum: 30 degrees
✓ Autoimmune Pressure in the cranium
- Should be equal to the pressure of the Spinal
Diagnostic Tests Canal
1. MRI, CT, PET scan
2. Serum Dopamine levels Lumbar Puncture
3. EMG - Contraindicated when ICP is increased
4. Neuropsycho testing - A/e: Brainstem herniation >> Brain stem
damage >> Death
Management
▪ Diet ICP Hypothesis
o Soft diet ✓ Monroe Kelly Hypothesis
o No clear liquids o Purpose: Maintenance of ICP balance
o Thick liquids o Cranium:
o Cut food into bite-size pieces ▪ Hard / Rigid
▪ Postioning ▪ “Close Vault”
o Modified Prone or Side-lying ▪ Non-adjustable
▪ To prevent aspiration o Internal components of the cranium:
▪ To start Ambulation ▪ Brain, CSF, Blood
o Instruct patient to rock back and forth • CSF produced by
▪ Nurse will help patient to Choroid Plexus
stand • Normal CSF: 50 –
o Provide AWD >> walker or cane 150ml
o Nurse should stand: At patient’s back ▪ B, C, B are all adjustable
▪ Rule: If 1 component
▪ Suctioning as needed increases or rises up, the other
▪ PT / OT / ST 2 components should decrease
▪ Medications their value to maintain ICP
o DOC: Dopaminergics balance
▪ Elevates Dopamine II Astrocytoma
▪ Ex: Levodpa, Amantadine, - Most common brain tumor
Carbitopa
o Anti-cholinergics Clincial manifestations
▪ To prevent secretions ▪ ALOC
o Muscle relaxants o Earliest symptom
▪ Dopaminergics S/e: “BUCO PANDAN” o First LOC change: Restlessness
o + Weight gain o Late LOC change: Lethargy
o Priority: Orthostatic Hypotension ▪ Cushing’s Triad
▪ Dopaminergics A/e: Psychosis o Late sign of increased ICP
o Mngmnt: Acknowledge, Present, o Hyper, brady, brady
Divert ▪ Widening pulse pressure
▪ Surgery • Systolic hpn
o Deep Brain Stimulation Implant ▪ Bradycardia
▪ “Pacemaker of the brain” ▪ Bradypnea
• Irregular breathing
INCREASED INTRACRANIAL PRESSURE o Other S/s: Hyperthermia
▪ Severe headache
- Pressure gradient within the Cranium + Spinal ▪ Projectile vomiting
Canal & Spinal cord ▪ Papilledema
- Normal: 5 – 15 mmHg o Edema and inflammation of the optic
- Normal: 7 – 25 cmH2O disc of the eyes
o Affects visual acuity = blurred vision
Intraventricular Catheter ▪ Contralateral hemiparesis
- Connected to a manometer and tranducer ▪ Ipsilateral mydriasis
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 MEDICAL SURGICAL NURSING – Neurological Disorders ______
o Dilation of pupil of the eye same side ▪ Hastens the effect of removing
as the brain lesion excess water
▪ Seizures ▪ Mannitol: Brain to body
▪ Loop: Body to outside world
Normal pulse pressure
- 30 – 40mmHg o Anti-emetics
▪ Ex: Promethazine, -setron
Lateralization ▪ Increases gastric emptying
- Left controls the right, right controls the left ▪ Contraindications
o Never give strong narcotics if ICP
Brain control
▪ Ex: Morphine, Meperidine,
▪ Body
Nalbufine, Oxycodone,
o Opposite
Phentanyl
▪ Vision
▪ Rationale: Will mask the s/s
o Opposite
▪ Pupils of ICP or s/s Respiratory
o Same Depression
▪ Surgery of Choice
o Craniotomy
Management
▪ A.k.a. Burr Holes
▪ Position
▪ Two types:
o Low to semi fowlers
• Supratentorial
▪ 30 – 45 degrees
o Post-op:
▪ Avoid any form of exertion
Upright
▪ Diet
o Low sodium • Infratentorial
o High fiber o Post-op: Flat
o Limit fluids on bed
▪ Initially, hyperventilate the patient via bag o Craniectomy
▪ Removal of a skull flap or
valve mask or mech vent
skull cap
o Rationale: To stabilize the px ▪ Skull cap: Placed on the
o Induces vasoconstriction abdomen
o To prevent hypercabia
• Rationale: To
▪ Hypercabia = cerebral
preserve it
vasodilation = blood flow
▪ Glasgow Coma Scale “EVM” *insert pic gcs*
o To prevent brain hypoxia
o Eye Opening
o Brain Hypoxia = Brain Swelling
o Verbal Response; Best
▪ Medications
o Motor Response; Best
o Mannitol
▪ Crosses BBB
Decorticate
o Steroids
- Flexion of the upper extremity and hands are
▪ Ex: Dexamethasone
letter C
• Only steroid that
- Lower extremity extension
crosses BBB - Plantar flexion, internal rotation
o Laxatives
- Damaged cerbral cortex
▪ Ex: Lactulose
• Ammonia Binder Decerebrate
• Osmotic laxative - Extension upper extremity
• Gathers water - Flexion of wrist, hand are letter E
o Antitussive - Lower extremity same with decorticate
▪ Ex: Codeine Sulfate - Internal or external rotation
• Best Antitussive - Damaged brain stem
• Mild narcotic
analgesic
o Loop Diuretics
▪ As adjuntive therapy with
Mannitol

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – EENT Disorders_______________________
4) Trauma
HEARING LOSS
Cardinal Sign
1) Sensorineural Hearing Loss ▪ Meniere’s Triad “VTS”
▪ Nerve damage / Malfunction o Vertigo
▪ CN 8: Vestibulocochlear Nerve ▪ Priority: Safety
o Purpose: For balance and o Tinnitus
hearing o Sensorineural hearing loss
o A.k.a. Auditory nerve
▪ Vestibulo: Balance Other Clinical Manifestations
▪ Cochlear: Hearing ▪ Dizziness
2) Conductive Hearing Loss ▪ Nausea and Vomiting
▪ Bone Malfunction or Bone Disorder ▪ Retching
3) Mixed Hearing Loss ▪ Sense of “fullness” of the ears
▪ Both Conducitve and Sensorineural ▪ Ear Pain
o Rare!
SENSORINEURAL CONDUCTIVE MIXED ▪ (+) Rinne’s Test
Nerve Damage Bone Damage Both
All inner ear Outer and middle ear All areas of the ear
conditions Vertigo vs. Dizziness
Air conduction Bone conduction Both air and bone - Vertigo: Vision is spinning
problem problem
✓ Absence or not
o Longer duration and can be
vibrating progressive
enough - Dizziness: “Just like riding a boat” / Motion
Ex: Ex: -
✓ Meniere’s ✓ Otosclerosis
sickness
Disease o Sudden or Short term
✓ Acoustic ✓ Otitis media
neuroma ✓ Otitis externa
✓ Presbycusis
Diagnostic Tests
1) CT scan & MRI
Bones in the ears “MIS” 2) Otoscopy
✓ Maleaus 3) Audiometry
✓ Incus ▪ Measures hearing
✓ Stapes ▪ Normal hearing capacity: 20 – 20,000
o Smallest bone in the body HTZ
▪ Normal: 0 – 85 Decibel
MENIERE’S DISEASE 4) Whisper test
▪ Whisper in a certain distance
- A.k.a. Endolymphatic Hydrops 5) Romberg Test
- Endo: Inner ear ▪ Balance
- Lymphatic: Lymphatic network or vessels ▪ Checks for:
- Hydrops: Water o Ear: Vestibulo
o Brain: Cerebellum
Basic Definition 6) Rinne’s Test & Weber’s Test ‼️
- Over accumulation or over production of ▪ Tool: Tuning Fork
excessive fluids in the inner ear and lymphatic o Emits low frequency sound in
vessels
an average of 512 HTZ
o Fluid is from the lymphatic vessels ▪ Rinne’s Test (Quantitative)
- Causes excess pressure towards the Cranial 1) Tap tuning fork in any hard
Nerve 8 surface
o CN 8 malfunction or damage 2) Place tuning fork directly to
the mastoid bone
Causes 3) Listen and measure the length
✓ Idiopathic of the sound
▪ Primary reason 4) As the sound disappears, place
tuning fork 1 – 2 cm beside
Predisposing Factors the ear
1) Chemical exposure 5) Listen and measure the length
2) Autoimmune of sound
3) Genetics
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – EENT Disorders_______________________
▪ Webber’s Test (Qualitative) Ramsey Hunt Syndrome
1. Tap tuning fork to any hard - Autoimmune disorder that affects CN 7 & 8
surface
2. Place tuning fork directly in Diagnostic Test
the middle of the head 1. MRI & CT scan
3. Listen and assess the equality ▪ Confirmatory
of sound 2. Biopsy
▪ Optional only
3. Rinne’s & Webbers
Results of Rinne’s Test 4. Audiometry
If air conduction > bone Normal
conduction and minimum 5. Otoscopy
length of sound is 2x 6. Whisper test
If bone conduction > air Conductive hearing loss 7. Romberg’s test
conduction ✓ (-) Rinne’s Test
If bone conduction = air Conductive hearing loss 8. Nerve conduction velocity test
conduction ▪ Rationale: To check for facial
If air conduction > bone Sensorineural hearing loss paralysis
conduction but length of sound ✓ (+) Rinne’s Test
is less than 2x
If no sound Mixed type Management for Acoustic Neuroma
▪ Antineoplastic
Results of Webber’s Test ▪ Radiation
Bilateral hearing, symmetrical Normal
sound ▪ Surgery
If with chief complaint of ✓ Sensorineural Hearing Loss o Last option
hearing “SUCA” ✓ Unaffected ear (if sound is
louder)
o SOC: Craniotomy or Burr holes
✓ Conductive hearing loss ▪ Infratentorial Craniotomy
✓ Affected ear (if sound is o Flat on bed after procedure
louder)
If no sound hear on both ears Mixed

PRESBYCUSIS

Management for Meniere’s Diseasde

- Degenerative loss of hearing
1) Diet
- Due to aging
▪ Low sodium and limit fludis
2) Ambulation assistance
“Pres”
3) Instruct the patient to turn with the body
slowly, not with the head - Meaning degenerative
4) Diuretics
Management for Presbycusis
5) Analgesics for pain
▪ No cure
6) Surgery
▪ Hearing aid only
▪ Tympanostomy
o For ear drainage
o Takes an average 4 – 6 weeks
OTOSCLEROSIS
for hearing gradually goes back
▪ Myringotomy - A.k.a. Otospongiosis
o For ear drainage - Overproduction of spongy bones in the middle
o Takes an average 4 – 6 weeks ear
for hearing gradually goes back - Fixation of bone in the middle ear
o Losing the ability of the bones to
ACOUSTIC NEUROMA
vibrate >> Conductive hearing loss
- Due to benign or a non-malignant tumor at the
Common bone affected
CN 8
✓ Stapes
o Affects the Schwann cells
- Causes sensorineural hearing loss
Sclerosis
- Can also affect balance
o A.k.a. Ataxia - Damage and hardening
In severe casess
Causes
- CN 7 can be involved or affected
▪ Hereditary
- May possibly lead to Bells Palsy
▪ Autosomal Dominant
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – EENT Disorders_______________________
Cardinal sign
✓ Schwartz Sign GLAUCOMA
o A.k.a. Flamingo Pink Sign 🦩
o Mixture of bone and blood vessels - Due to high levels of IOP
o White bone & red vessels = pink
o Area is highly vascularized Normal IOP
- 10 – 21 mmHg
Other Clinical Manifestations - Uses Tonometer thru Tonometry
▪ Sense of fullness
▪ Ear pain CLOSE ANGLE GLAUCOMA OPEN ANGLE GLAUCOMA
Higher IOP IOP not too high, not too low
Initially symptomatic Initially not too low IOP
Diagnostic tests ✓ Asymptomatic
1) MRI & CT Emergency condition Poor prognosis
✓ If not treated, can
2) Cranial X-ray lead to permanent
3) Otoscopy blindness
4) All hearing tests A.k.a. Acute Angle A.k.a. Chronic Angle
Early detection Late detection
Lesser chance of blindness Higher chance of blindness
Management of otosclerosis Earliest symptom: Earliest symptom:
▪ Sodium Fluoride otic drops ✓ Pain ✓ Blurred vision
#1 causative factor: #1 causative factor:
o To control the bone growth ✓ (+) Obstruction of the Canal ✓ Overproduction of Aqueous
▪ Surgery of Schlemm Humor
o Stapedectomy ✓ Produced by ciliary body
✓ Accumulates at Anterior
▪ Removes excess stapes chamber
▪ Position post-op: unaffected
side Predisposing factors for both
▪ Takes about 4 – 6 weeks to 1. Genetics
gradually improve or 2. Age
normalize hearing 3. Trauma
4. Eye Surgery
5. Medication
OTITIS MEDIA & EXTERNA
▪ Steroids
▪ Mydriatics
- A.k.a. Swimmer’s Ear
o Ex: Atropine & Scopolamine
- Due to dirty water staying and contaminating
6. Infection
the outer ear
▪ Conjunctivitis
▪ Keratitis
Common in the ff:
✓ Swimmers/Divers
Mydriatics
✓ Infants
- Dilates the pupil
o V. Humor mixes with A. Humor,
Complications
adding more pressure to anterior
✓ Meningitis
chamber
- Constricts the canal and blood vessels at back
Clinical Manifestations
of the eye
▪ Ear discharges
o Harder to drain >> retention of fluid to
▪ Pain
anterior chamber >> increases IOP
▪ High-grade fever
▪ Conductive hearing loss
Conjunctivitis
▪ Sensation of “fullness” of ears
- Inflammation of conjunctiva
▪ Pedia: Constant tugging of ears
- Adds pressure to canal of schlemm
- Can be bacterial or viral
Management for Otitis Media & Externa
o Viral: More contagious
▪ Antibiotic Otic drops
o Bacterial: More dangerous
o Proper pulling of ears
Keratitis
▪ Rationale: To straighten the
- Infection and inflammation of the cornea
ear canal
o Drop at the walls of the ear canal,
NOT directly to the ear canal
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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – EENT Disorders_______________________
Hordealum ▪ Constricts pupil to control
- A.k.a. Stye mixture of V.humor to
- Acute infection of the eyelids with the A.humor
presence of a cyst with pus ▪ Given as optic drops
- Causative agent: S. Aureus ▪ Press lacrimal duct for 1 – 2
- Cause: Constant rubbing of eyes minutes after eye drops
administration to prevent
Blepharitis systemic absorption
- Chronic infection of the eyelids without cyst, ▪ Ex: Pilocarpin, Timolol,
but have many crusts Betaxolol
▪ Systemic a/e: Drops BP
Clinical Manifestations of Glaucoma ▪ Surgery
▪ Tunneled Vision o Iridotomy
o CARDINAL SIGN o Trabeculectomy, Trabeculotomy,
o Loss of peripheral vision Trabeculoplasty
o Mngmnt: Place things in front or at
center *What happens to the pupil, happens to your
▪ Halos around lights bronchus*
▪ Nausea and vomiting
▪ Headache RETINAL DETACHMENT

Macular degeneration Leading Factor

- Loss of central vision - Direct physical trauma
- Due to aging
- Mngmnt: place things on side Predisposing factors
- No cure ✓ Genetics
o Ex: Marfan’s Syndrome
Astigmatism ▪ Connective Tissue Disorder
- Starbursts-light vision ▪ Thin connective
- Cause: Unequal lens ✓ Aging

Management for Glaucoma Ultimate complication

▪ Position: Low to Semi 30 – 45 degrees ✓ Permanent Blindness
▪ Position post-op: Lie on unaffected side
▪ If both eyes, post-op position: Low to Semi Cardinal signs
fowlers ▪ Curtain Veil Vision
▪ Mydriatics given BEFORE surgery ▪ Floaters or burst of black spots
▪ Miotics given AFTER surgery o Ex: “Can you see the circles?”
▪ Avoid any form of exertion o Indicates bleeding
o How much weight patient can carry:
5lbs Other Clinical Manifestations
▪ Diet ▪ Blurred vision
o High fiber diet ▪ Periorbital swelling
o Low sodium ▪ Eye pain
o Soft diet ▪ Headache
o Limit fluids
▪ Medications Diagnostic tests
o Diuretics 1. Ophthalmoscopy
▪ Ex: Carbonic Anyhydrase 2. Slit-lamp test
Inhibitors 3. CT scan & MRI
• Targets the Ciliary ▪ For severe cases
Body
• Decreases production Cardinal eye gaze
of A. Humor - Controlled by CN 3, 4, 6
o Analgesics for pain and the headache
o Miotic
▪ DRUG OF CHOICE

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Patricia Marie A. Braulio, BSN – Velez College - SLRC
 MEDICAL SURGICAL NURSING – EENT Disorders_______________________
Management of Retinal Detachment Diagnostic tests
1) If acute phase of detachment 1. Ophthalmoscopy
▪ Eye patch BOTH eyes 2. Slit-lamp test
o Rationale: To prevent rapid 3. Snellen chart
eye movement >> contributes ▪ Does not confirm
further detachment ▪ Checks only blurred vision
▪ Lie down on the AFFECTED side ▪ 20ft away from chart
▪ Rationale: To prevent further bleeding ▪ At 3 months old: First clear vision of
& trauma baby is achieved
2) Post-surgery ▪ 3 colors: Baby can only see R, W, B
▪ Postion the patient on the unaffected ▪ 6 -12 years old: 20/20 vision is
side achieved
▪ Dim light room 4. Ishihara chart
3) Surgery of choice ▪ For color blindness
▪ Scleral Buckling o A.k.a. Achromatopsia or
o Rationale: To repair Dantenopia
o Cones are affected
o Cannot distinguish colors
CATARACT
Management for Cataract
- A.k.a. Senile lens ▪ Treat underlying cause
- Opacity of crystalline lens secondary to ▪ Laser surgery
overgrowth tissues ▪ Phacoemulsification
- Senility: Aging o Less invasive
▪ Extra Capsular Cataract Extraction
Leading factor o Dangerous
✓ Aging ▪ Artificial lens implant

Other risk factors

SUMMARY
▪ Diabetes
▪ Medications
o Steroids EYE DISORDER CARDINAL SIGN
▪ Increases blood sugar Glaucoma ✓ Tunneled Vision
o Statins ✓ Halos around lights
Macular Degeneration Loss of central vision
▪ Genetics or Congenital Astigmatism Starbursts-light vision
o Smoking during pregnancy Retinal Detachment ✓ Curtain veil vision
▪ Smoking ✓ Floaters or bursts of
black spots
▪ Recurrent eye infections Cataract ▪ White cloudy vision or
▪ Constant Trauma seeing white spots
▪ Over exposure to sunlight or UV rays ▪ Milky appearance of
lens

Ultimate complication
✓ Blindness

Cardinal signs
▪ White cloudy vision
o Seeing white spots
▪ Milky appearance of the lens

Other signs and symptoms

▪ Blurred vision
▪ Decrease visual acuity
▪ Absence of red eye reflex
o Can be checked using slit-lamp test
▪ Photosensitivity

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✓ Protection
FUNDAMENTALS OF MUSCULOSKELETAL o Protection of the vital organs
SYSTEM ✓ Movement and Locomotion
✓ Hematopoiesis
o Blood cell production
SKELETAL SYSTEM
3 types of Bone Cells
Structure of the skeletal system OSTEOBLASTS OSTEOCYTES OSTEOCLASTS
Building of Maintenance of Bone resorbing cells
- Composed of 206 bones in the body immature cells mature bone cells
- 2nd largest system of the body Use: Bond/cement Use: Main cells of Use: Repair of bones
4 categories of bones foundation of bones the bones
1) Long bones
➢ Humerus
MUSCULAR SYSTEM
➢ Femur
2) Short bones
Structure of the muscular system
➢ Phalanges
- Has more than 600 named muscles
➢ Fingers
- Composed of 40 – 60% of body weight
3) Flat bones
- 85% of body heat comes from muscle
➢ Skull
contractions
➢ Scapulae
Facts about the muscles
4) Irregular bones
▪ Biggest: Gluteus Maximus
➢ Vertebrae
▪ Smallest: Tensor Tympani and the Stapedius
Bone anatomy
✓ Inner ear
▪ Epiphysis
▪ Strongest: Masseter
o End part or distal part of the bone
✓ Jaw
▪ Metaphysis ▪ Hardest working: Heart or Cardiac muscle
o Narrowest portion of the bone
o Most common site of osteomyelitis 3 types of muscles
▪ Diaphysis CARDIAC SKELETAL VISCERAL
o Longest Involuntary Voluntary Involuntary
✓ Striated ✓ Smooth
portion
(shaft) Clinical terms used for basic muscle disorder
▪ Periosteum 1. Myopathy
o Thick ➢ Disease
outer 2. Myalgia
surface ➢ Pain
▪ Endosteum 3. Myositis
o Thin ➢ Inflammation
inner 4. Muscle dystrophy
surface ➢ Weakness
▪ Epiphyseal Exercise
line/plate
• Considered as health enhancing activity
o A.k.a.
• Purposeful bodily exertion
Growth
✓ Intentional
plate
o In-charge • Benefits:
of the longitudinal growth ✓ Fitness
o Closes by the age of: ✓ Weight loss
▪ Female: 13 – 15 years ✓ Better lung and heart function
▪ Male: 15 – 17 years old ✓ Muscle strength
✓ Improved mental clarity
Attachments of the Musculoskeletal System ✓ Self-esteem
JOINTS TENDON LIGAMENTS ✓ Mood and emotional stability
Bone to bone Bone to muscle Bone to joint
DIFFERENT TYPES OF MUSCLE CONTRACTIONS
Functions of the skeletal system Isotonic ✓ Same tone
✓ Length changes
✓ Support ✓ Two types:
✓ Mineral storage o Eccentric: Muscle
o 98% of calcium is stored in the bones lengthens
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
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o Concentric: Muscle ▪ Steppage gait
shortens
o Neuropathic gait
Isometric Length does not change o High stepping
Spastic Excessive movement o Ex: Multiple Sclerosis/ALS
Flaccid Lacks movement
Atonic Loss of muscle tone
▪ Waddling gait
o Myopathic
Purpose of range of motion exercises o Ex: Pelvic disorders
✓ Increase strength and endurance ▪ Congenital Hip Dysplasia
✓ Delay degenerative changes ▪ Hemiplegic gait
o Paralysis/Hemiplegia
Therapeutic Exercises: RANGE OF MOTION o Ex: Stroke patients
PASSIVE ACTIVE - ACTIVE
ASSISTIVE
Exercise done Exercise done Exercise done 3 Phases of Gait Cycle
completely partially dependent completely STANCE STRIDE SWING
dependent independent Start phase Longest phase End phase

Checking of joint function

ARTICULAR SYSTEM ▪ Abduction
▪ Adduction
Three types of Joints
SYNARTHROSIS AMPHIARTHROSIS DIARTHROSIS
▪ Protraction
Immovable joints Slightly immovable Freely movable o Under bite
joints joints ▪ Retraction
Ex: Skull and Ex: Vertebrae Ex: Knee and
Sutures Shoulder
o Overbite
Connective Tissue: Connective Tissue: Connective Tissue: ▪ Pronation
Cartilaginous Cartilaginous Synovial ▪ Supination
▪ Extension
▪ Flexion
ASSESSMENT ▪ Circumduction
o Diarthrosis joints can do this
Check for: ▪ Rotation
✓ Pain ▪ Inversion
✓ Altered sensations ▪ Eversion
✓ Posture
✓ Gait 3 things to consider for Neurovascular status
✓ Bone integrity 1) Motor function
✓ Joint function ➢ Weakness and paralysis
✓ Muscle strength and size 2) Sensory function
✓ Skin intactness ➢ Paresthesia, numbness, and pain
✓ Neurovascular status 3) Circulation
➢ Color, temperature, and CRT

Types of Posture Terminologies for abnormalities in musculoskeletal

KYPHOSIS LORDOSIS SCOLIOSIS system
Forward bending of Backward bending of Lateral bending of
spine spine spine 1. Ankylosis
➢ Scarring within a joint
Abnormal gaits 2. Atrophy
▪ Shuffling gait ➢ Muscle wasting
o Festinating gait 3. Hypertrophy
▪ Fast gait ➢ Increase in size of muscle
▪ A.k.a. Parkinsonian Gait 4. Contractures
o Ex: Parkinson’s Disease ➢ Resistance to movement of muscle or
▪ Antalgic gait joint
o Against pain 5. Crepitations
o Due to foot/ankle/toe injuries ➢ Crackling sound or grating sensations
▪ Ataxic gait
o Intoxication
▪ Scissor-like gait
o Ex: Cerebral Palsy
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DIAGNOSTIC EVALUATION Risk factors for subluxation and dislocation

▪ Repeated injury
1. X-ray studies ▪ Contact sports
➢ Most common o Such as repetitive overhead arm
➢ Non-invasive motion
➢ Confirmatory for fractures ▪ Throwing
2. CT scan ▪ Swimming
3. MRI ▪ Volleyball
➢ Remove all metallic objects prior the ▪ Congenital looseness
procedure Management for subluxation and dislocation
4. Arthrogram ▪ Joint manipulation
➢ X-ray of joints o Must be well-trained to do this
5. Bone densitometry o Best action
➢ For patients at risk for osteoporosis ▪ Joint immobilization
➢ Invasive o First action
6. Bone scan or scintigraphy ▪ Physical therapy
7. Electromyography ▪ Pain relief
➢ Electrical activity of the muscles
TEST TAKING STRATEGY
TEST TAKING STRATEGY Initial/First Action Best Action
Confirmatory Tests Screening Tests Independent interventions Highly Dependent interventions
Always Conclusive Simply suggestive Simply for alleviating the Ultimately solves the problem
✓ Gold Standard symptom

FRACTURES
MUSCULOSKELETAL TRAUMA
Types of fractures
Types 1) Complete
1. Strain 2) Incomplete
➢ For muscle 3) Close/Simple
2. Sprain 4) Open/compound
➢ For ligament 5) Transverse
3. Subluxation 6) Linear
4. Dislocation 7) Oblique
5. Fractures 8) Spiral
9) Comminuted
STRAIN vs. SPRAIN
10) Impacted
STRAIN SPRAIN 11) Greenstick
Pull or tear of a muscle Overextension or twisting of 12) Stress
ligament 13) Pathologic
Management for strain and sprain How fractures are categorized
▪ Pain relievers ✓ Skin involvement
▪ Cold compress for first 12 hours o Ex: Open/Compound
▪ Warm compress after cold compress ✓ Breaks
▪ Elevation o Ex: Complete/incomplete
o Rationale: To relieve edema ✓ Lines
o Ex: Transverse
Arm and leg
- Are attached to a socket COMPLETE INCOMPLETE
Separation of bone into 2 Bone does not separate
SUBLUXATION vs. DISLOCATION
CLOSE/SIMPLE OPEN/COMPOUND
SUBLUXATION DISLOCATION Skin is intact Penetrates the skin
Incomplete dislocation where Adjoining of bones to completely Nursing Diagnosis: Altered Nursing Diagnosis: Risk for
joint surfaces still touch not touch together Tissue Perfusion Infection

TRANSVERSE LINEAR
Across the bone Along the bone
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
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o Slow drying
OBLIQUE SPIRAL ▪ Provides later weight
Slanted on the bone Around the bone
✓ One-sided only
bearing
o Water-susceptible
COMMINUTED IMPACTED Purpose of cast
3 or more fragments Two bones jammed together ✓ Immobilization
✓ Maintain body alignment
Greenstick fractures ✓ To correct any deformity
- Most common pediatric fracture ✓ To apply uniform pressure to underlying soft
- Bends and breaks tissue
Stress fractures ✓ To support and stabilize weakened joints
- Hairline fractures
- Very minute Cast care
Pathologic fractures 1. Neurovascular checks
- Break due to an underlying disease 2. Windowing
- Ex: Osteoporosis ➢ Putting a hole on pressure areas
➢ 4 pressure areas:
Clinical manifestations o Elbow
• Pain o Wrist
o Most common o Knee
• Loss of motion o Ankle
• Edema after 24 hours 3. Bivalving
• Crepitus ➢ Splitting cast into two
o Joint popping 4. Carry newly casted part with palm
• Ecchymosis 5. Elevate extremity
• Shortening of limb ➢ Rationale: To prevent edema
• Obvious deformity 6. Expose to air to dry
7. Observe for hotspots
Management of fractures 8. Petaling
▪ Cast application ➢ Applying waterproof tape or
▪ Bone reduction adhesives around the cast
▪ Immobilization ➢ Apply on edges to prevent cuts
▪ Traction lacerations or injuries
▪ Analgesia
Compartment syndrome
MUSCULOSKELETAL CARE MODALITIES - Pain, Warm itchiness on pressure areas
Short-arm cast Wrist and distal Nursing diagnosis of fractures
Long-arm cast Elbow and upper arm
Short-leg cast Foot and ankle ❖ Acute pain
Long-leg cast Knee thigh and skin o Short term priority
Walking cast Can bear weight and can ambulate ❖ Impaired physical mobility
Shoulder Spica cast Dislocation and humeral fractures
Short leg hip Spica cast For pediatric patients
o Long term priority
Hip Spica cast For adult patients ❖ Self care deficit
❖ Risk for peripheral neurovascular dysfunction
Casting materials o Potential
1. Non-plaster cast *Tip: Actual nursing diagnosis first before potential
➢ A.k.a. Fiberglass nursing diagnosis*
➢ More common
o Lighter Management for Closed Fractures
o Stronger or sturdier ▪ Control of pain and edema
o Fast drying o Edema occurs after 24 hours
▪ Provides earlier ▪ Use assistive device properly
weight bearing ▪ Modify environment to provide safety
o Waterproof o Remove carpets
2. Plaster cast ▪ Self-care
➢ Less common
o Heavier Management for Open Fractures
o Not as strong or sturdy ▪ WOF: Osteomyelitis, tetanus, and gangrene
o Tetanus – give toxoid vaccine
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
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▪ IV antibiotics TRACTION COUNTER-TRACTION
Weights and Sandbags Patient’s weight
o Rationale: Patient at risk for infection
▪ Monitor for delayed primary wound healing
▪ Control of pain and edema What is the main purpose of traction?
▪ Neuromuscular assessment ✓ Guides the body part back into place and holds
it steady
Complications of fractures ✓ Regain normal length and alignment of
1. Hypovolemic shock involved bone
➢ Open and compound fracture ✓ Decrease painful muscle spasms that
➢ Narrowing of pulse pressure accompany fractures
2. Fat embolism
➢ Long bone fractures Types of tractions
3. Compartment syndrome 1. Skin
4. Nerve palsy 2. Skeletal
5. Avascular necrosis 3. Bryants traction
SKIN TRACTION SKELETAL BRYANT’S
6. Delayed union/malunion TRACTION TRACTION
7. Regional pain syndrome Primary purpose: Purposes: Combination of Skin
Immobilization ✓ Immobilization and Skeletal Traction
✓ Bone repair
Used less than 8 Used more than 9 Appropriate
COMPARTMENT SYNDROME weeks weeks positioning:
✓ Buttocks are
- Excessive pressure builds up inside an slightly
elevated and
enclosed muscle space clear off the bed
INTERNAL PRESSURE EXTERNAL PRESSURE ✓ Should not be
Due to bleeding and edema Due to tight cast touched or
Management: Management: resting on the
✓ Fasciotomy ✓ Windowing bed
o First intervention Short term Long term -
✓ Replacement Uses splints, Uses splints and -
o Best intervention bandages, adhesives, weights + tongs, pins,
✓ Bivalving and weights screws
Non-invasive Invasive -
Signs and symptoms >> Irreversible! >> report ASAP! Nursing Diagnosis: Nursing Diagnosis: -
Altered Tissue Risk for infection
✓ Pain unrelieved by analgesic Perfusion
✓ Paresthesia
✓ Pallor Maintaining effective traction
✓ Pulseless ✓ Maintain positioning
✓ Paralysis ✓ Prevent skin breakdown
✓ Cyanosis o Rationale: Can give moisturizers if
✓ Cool to touch on affected extremity dry skin
✓ Monitor neurovascular status
TRACTIONS
For every traction, there should always be a counter-traction
✓ Pin site care
o For skeletal tractions only
Principles of effective traction ✓ Promoting exercise
1) Temperature check ✓ Never remove weights from any traction
2) Ropes should hang freely unless a life-threatening situation occurs
➢ Must be freely hanging o Authorized person to do this:
➢ No knots! Physician
3) Alignment o Needs doctor’s orders
4) Circulation check
5) Type and location Complications of tractions
6) Increase hydration 1. Pressure ulcers
➢ Rationale: At risk for constipation ➢ Ttt: Provide Egg-crate mattress
7) Overhead trapeze 2. Pneumonia
8) No weights on the floor ➢ For thoracic injuries
➢ Weights should be freely hanging 3. Constipation and anorexia
o Rationale: For it to be 4. Infection
effective 5. Venous thromboembolism

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Patricia Marie A. Braulio, BSN - Velez College - SLRC
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ASSISTIVE LOCOMOTION Left foot Achilles tendon tear 3-point gait
repair
Right above the knee Swing through gait
Canes amputation
▪ Position: COAL Right ACL repair 3rd day post 3-point gait
o Cane Opposite Affected Leg op
▪ Maneuver: CWS
o Cane, weak leg, strong leg Wheelchair
▪ Wheeled assistive device with back, arms and feet
Walkers support
▪ Correct way to use a walker ▪ Recommended for patients:
o Pick it up o With paralysis of the lower body
o Set it down (forward) o Not allowed to bear weight on both lower
o Walk to it extremities
▪ Correct way to get up from a chair using a walker ▪ Types
o Hold on to the chair o Manual propulsion
o Stand up o Remote controlled
o Grab the walker o Breath and voice operated
Nursing considerations
Crutches 1. Lock wheels if not moving
▪ Correct measurement 2. Transfer patient via the stronger side or the
o 2-3 finger breadths below the axilla body
o Laterally and slightly in front of the foot 3. Always lead with the larger wheels when
o Elbow flexion must be 30 degrees entering elevators
▪ Types of gaits 4. On inclined areas
4-point gait ✓ Slowest ➢ Push when climbing up
✓ Most stable
✓ Right crutch, left foot, left ➢ Back up when going down
crutch, right foot
2-point gait • Military gait Morton’s neuroma
• Right crutch and left foot,
left crutch and right foot - Pain in 3rd and 4th digit of the toes
3-point gait ✓ Classic gait Impingement syndrome
✓ Most common - Tendons of the rotator cuff of the shoulder are
✓ Both crutches and affected
leg, unaffected leg pinched as they pass between the top of the
Swing to gait • Both crutches, both legs upper arm and the tip of the shoulder
level to crutch Dupuytren’s contracture
Swing through gait ✓ Fastest gait
✓ Both crutches, both legs past - Base of fingers
the crutch
CARPAL TUNNEL SYNDROME
▪ Crutch walking gaits
o Going up and down the stairs up with the - Median nerve compression or squeezing
good down with the bad Common affected parts ✓ Wrist
▪ Good leg, bad leg with the crutch ✓ Thumb
✓ Index
✓ Middle finger
Principle in choosing a gait Causes ➢ Repetitive wrist maneuvers
1) Even for even, odd for odd ➢ Common: Typewriting
Hallmark sign Tinel’s sign
2) Even gait ✓ A tingling “pins and
➢ Bilateral condition needles” feeling when the
healthcare provider taps the
➢ Acute case: 2-point gait skin over a nerve
➢ Severe case: 4-point gait Provocative sign Phalen’s sign
3) Odd gait ✓ Reverse prayer maneuver
✓ Expectation: Tingling
➢ Unilateral condition sensation after flexing the
4) Use swing through wrist to 90 degrees after 1
➢ For non weight bearing full minute
Signs and symptoms ➢ Tinel’s sign
➢ For amputees ➢ Phalen’s sign
➢ Poor grip strength
APPROPRIATE TYPE OF GAIT ➢ Clumsiness and dropping
Early-stage Rheumatoid 2-point gait objects unintentionally
Arthritis ➢ Poor ROM of wrist
Bilateral total knee replacement 4-point gait Preventive Management Avoid repetitive flexion of wrist
Advanced stage ALS 4-point gait Surgical Management Surgical release of transverse
carpal ligament
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
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a) Traditional
- Open
- More risk for infection SCOLIOSIS
b) Endoscopic
- Close
Other Management ✓ Rest and splint the wrist
- Abnormal lateral curvature of the spine
✓ NSAIDS
✓ Corticosteroids Signs and symptoms ✓ Prominent scapulae and ribs
✓ Carpal Canal Cortisone ✓ Asymmetry of shoulders
Injection ✓ Uneven waistline
- Uneven skirts and bra
straps
Diagnostic tests a. Bend test
- Screening
OSTEOMYELITIS b. X-ray
- CONFIRMATORY
c. Routine assessment
- Bone infection causing swelling that can lead - As early as 10 years
old (females)
to bone damage and loss - Rationale: They are
- Most common infection via the blood stream more at risk compared
to adolescents due to
heavy backpacks
Low-grade fever vs. High-grade fever Complications Respiratory Depression
• Low fever ✓ Compresses the lungs
✓ Localized
✓ Chronic
TYPES OF SCOLIOSIS
• High fever Structural Functional
✓ Systemic S – shaped C – shaped
✓ Most common
Common affected parts Metaphysis Primary scoliosis Secondary scoliosis
Causes Staphylococcus Aureus bacteria Cause: Unknown Causes:
(Staph infection) ✓ Congenital Hip Dysplasia
Risk factors ✓ Traumatic injury or wound ✓ Posture
✓ Blood infection ✓ Torticollis
✓ Artificial joint (hip - Twisting of the
replacement) sternocleidomastoid
✓ Metal implants muscle
✓ Deep pressure ulcers or
injuries When it deviates:
Signs and symptoms ➢ High fever
➢ Diaphoresis ▪ Dextroscoliosis
➢ Chills o To the right
➢ Limited and painful
movement
▪ Levoscoliosis
➢ Irritability and lethargy o To the left
➢ Purulent drainage Management
- Pus, abscess and
exudates 1) Postural exercise
Diagnostic tests a. Needle biopsy ➢ < 20 degrees
- GOLD STANDARD ➢ Teaching patient how to sit and stand
b. Biomarkers for
inflammation straight
- WBC ➢ Proper posture
- ESR
c. Radioactive bone scan
2) Pelvic traction
d. Imaging tests ➢ >20 degrees
- Least sensitive ➢ Ex: skin traction
- Ex: X-ray
Complication ✓ Recurrent accumulation of 3) Milwaukee/Boston brace
abscess ➢ Used 23 hours daily
✓ Osteonecrosis
✓ Stunted growth
➢ 1 hr: for rest and bathing
Surgical Management Debridement ➢ Worn within 2 – 3 years
✓ Most advisable ➢ Shirt first (cotton), brace after
Other Management ➢ IV antibiotics
➢ Anti-fungals
➢ Do not apply creams, powders, lotion
➢ Needle aspiration when using the brace
➢ Pain relievers o Keep skin dry
4) Spinal fusion with Harrington rod
5) Preferred management
➢ Structural
o Spinal fusion

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Patricia Marie A. Braulio, BSN - Velez College - SLRC
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o Steel rods on spine Management for Rheumatoid Arthritis
(Harrington Rods) ▪ Surgeries
➢ Functional a. Osteotomy (Bone cutting)
o Postural exercise ➢ Manages bone erosion
o Pelvic traction b. Synovectomy
o Milwaukee/Boston brace c. Arthroplasty

Common deformities of Osteoarthritis “HB”

OSTEOARTHRITIS vs. RHEUMATOID ▪ Heberden’s nodes
ARTHRITIS o Small bony growths that appear on the
distal phalanges
OSTEOARTHRITIS RHEUMATOID ARTHRITIS ▪ Bouchard’s nodes
Problem: Cartilage loss Problem: Synovial Inflammation
✓ Degenerative ✓ Inflammatory
o Bony bumps on the proximal
Risk Factors: Risk Factors: phalanges
✓ Genetics ✓ Systemic Cause of both Heberden’s and Bouchard’s Nodes
✓ Old age ✓ Autoimmune
✓ Obese ✓ Chronic
✓ Fibrosis due to synovial tissue
✓ Overuse
Unilateral/Asymmetrical Bilateral/Symmetrical GOUTY ARTHRITIS
Big bones Small bones and Joints
✓ Hips and knees ✓ Hands and feet
Harbeden’s and Bouchard’s nodes Presence of nodule - Monoarticular (isolated joint) acute attacks
✓ Extra articular effects caused by elevated serum uric acid levels
Morning stiffness Morning stiffness
✓ <1 hour ✓ >1 hour
Diagnostics: Diagnostics: TYPES OF GOUTY ARTHRITIS
✓ Normal ESR and C-Reactive ✓ Elevated ESR & C-reactive Primary Secondary
protein Genetic Medication and Lifestyle
Management: Management: ✓ Most common type
✓ Occupational therapy ✓ Rest ✓ Ex: Alcoholism and Diet
✓ Viscosupplementation ✓ DMARDS
o Joint lubricants ✓ NSAIDS
o Contains hyaluronic
acid Common sites of Tophi ▪ Big toes
✓ NSAIDS formation ▪ Ears
▪ Fingers
▪ Joints
Common deformities of Rheumatoid Arthritis Causes Uric acid levels
1) Swan neck deformity ✓ Most common
Hallmark signs 1. Tophi formation
➢ Most common - Uric acid crystals
➢ Proximal Interphalangeal (PIP) Joint - Visible palpable soft
tissue masses with
hyperextension. whitish or yellowish
➢ Flexion of Distal Interphalangeal deposits
(DIP) joint - Chalky-white deposits
2. Podagra
2) Ulnar drift - Pain on big toes
➢ Metacarpophalangeal (MCP) joints 3. Renal calculi
become swollen which causes fingers 4. Low-grade fever
Diagnostic tests a. High serum uric acid level
to bend abnormally towards the pinky - > 7mg/dL
finger - CONFIRMATORY
3) Boutonniere deformity b. ESR
- Inflammation
➢ PIP joint flexion - >30mm/hr
➢ DIP hyperextended - Screening test
c. X-ray
4) Hallux Valgus Deformity - Presence of Tophi
➢ A.k.a. Bunions - Screening test
➢ Base of the big toe or d. Synovial fluid aspiration
- Presence of Urate
Metatarsophalangeal (MTP) joint is crystals
affected Management for Acute attacks ▪ Colchicine
➢ Misalignment of MTP joint - First medication to
give
- Maximum of 12 tabs a
Pannus formation in RA causes: day
- WOF: Diarrhea >>
✓ Bone erosion increase hydration
✓ Cartilage destruction ▪ NSAIDS
✓ Ligament damage Management for Prolonged use ✓ Probenecid (Benemed)
✓ Allopurinol (Zyloprim)

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Patricia Marie A. Braulio, BSN - Velez College - SLRC
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Both stop uric acid formation and Management
enhances excretion of uric acid
Other Management ▪ Hydration
1) Abduct the affected leg with knees flexed
▪ Diet and lifestyle ➢ Pavlik harness
modification ➢ Hip spica cast
▪ Avoid high PURINE foods
- Organ meat ➢ Frejka splint
- Alcohol ➢ Triple diapers
- Seafood (Shellfish, 2) Avoid sitting on low chair
Sardines, Scallops)
- Anchovies 3) Avoid prolonged sitting

OSTEOPOROSIS
Summary of Management for Arthritis
RHEUMATOID OSTEOARTHRITIS GOUTY - Disorder when bone mineral density and bone
ARTHRITIS mass decreases
▪ Naproxen NSAIDS Short term
▪ Sulindac (Clinoril) ✓ Colchicine - Most common metabolic bone disease
▪
▪
Arcoxia
Ibuprofen (Motrik)
Herbal supplements:
✓ Glucosamine
✓ NSAIDS - Females > males
▪ Diclofenac ✓ Chondroitin - Affects upper extremities
▪ Salicylates
- For its Anti-
inflammatory Risk factors “ACCESS” ▪ Alcohol use
function ▪ Corticosteroid use
▪ Tumor necrosis If patient is obese Long term ▪ Calcium is low
factor blockers ✓ Total hip replacement ✓ Allopurinol ▪ Estrogen is low
▪ Etanercept ✓ Viscosupplementation ✓ Probenecid ▪ Smoking
▪ Methotrexate ✓ Weight loss
▪ Sedentary lifestyles
(DMARD) Patient teaching
▪ Gold salts ✓ Diet and Signs and symptoms ✓ Decreasing height (10cm –
▪ Glucocorticoids hydration 15cm)
✓ Risk for depression ✓ Back pain (T5 – L5)
✓ Decreased libido ✓ Dowager’s hump
✓ High sugar ✓ Fracture with minimal
✓ High salt trauma
- Pathologic fractures

Disease Modifying Anti Rheumatic Drugs “MASH” Diagnostic tests 1) X-ray

- Every year
- All immunosuppressants or immune 2) Dual energy x-ray
modulators absorptiometry
- Uses: interferes with inflammatory cascade 3) Bone mass density
- CONFIRMATORY
- Methotrexate 4) Laboratories
o Most used - Serum calcium
- Azathioprine - Serum phosphate
- Serum alkaline
- Sulfasalazine phosphate
- Hydrochloroquine - ESR
Preventive Management ✓ High calcium and Vitamin D
diet
✓ Cessation of smoking
CONGENITAL HIP DYSPLASIA ✓ Decrease in alcohol intake
✓ Regular weight bearing
exercises
- Displacement of femoral head form the - Brisque walking
acetabulum Pharmacologic Management ▪ Selective Estrogen Receptor
Modulators
- Rolaxifene
Signs and symptoms ▪ Bisphosphonates
- Alendronate
▪ Barlow sign (Fosamax)
o (+) Dislocation upon adduction - Resendronate
o Seen in children more than 1 year old (Actonel)
- Ibandronate (Boniva)
▪ Allis/Galeazzi’s Sign
o Unequal knee height
o Shortened affected leg
▪ Limitation of movement
▪ Ortolani’s sign
o (+) Abnormal clicking sound upon
abduction
o Less than 12 months
▪ Trendelenburg’s sign
o Waddling gait
▪ Asymmetrical gluteal fold
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
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OSTEOMALACIA FAT EMBOLISM

- Marked softening of your bones, caused by - Fat moves from bone marrow to bloodstream
severe vitamin D deficiency o From yellow marrow
- Affects lower extremities - Can go into:
- Can be mistaken with Osteoporosis o Lung
o Brain
Pediatric counterpart o Heart
✓ Rickets Disease Common in: Closed, long bone fractures
particularly the femur
Signs and symptoms Triad symptoms ▪ Respiratory changes
▪ Bowed legs - Tachypnea
▪ Bone pain - Hypoxia
▪ Neurological changes
▪ Muscle weakness - Restlessness
▪ Porous bones - Confusion
Management ▪ Petechial rash
- Fat globules affect
1) Vitamin D and calcium supplementation dermal capillaries
2) Adequate sun exposure Hallmark sign Ventilation-perfusion mismatch
3) Assisting in ADLS ✓ Lungs receive O2 without
blood flow or vice versa
➢ Wheelchair Supportive Management ▪ Early immobilization of
REMEMBER ‼️ fracture
OSTEOMALACIA OSTEOPOROSIS ▪ Adequate oxygenation
Cause: Lack in vitamin Cause: Multifactorial ▪ Adequate hydration
Lower extremities Upper extremities ▪ Maintenance of
✓ Legs ✓ Spine hemodynamic stability
Common in Pedia Common in Elderly

OSTEOGENESIS IMPERFECTA NECK / CERVICAL DYSTONIA

- Autosomal dominant genetic disorder due to - Conditions of the head and neck muscle
loss of collagen making bones fragile and hard stiffness
to form o A.k.a. Spasmodic torticollis
- A.k.a. Brittle bone disease - Torti/Tortus: Twisting
- Irreversible and non-curable - Collis: Neck or collar

Signs and symptoms Common affected parts Sternocleidomastoid muscle

Types of Torticollis ▪ Rotated: Torticollis
▪ Brittle bones and teeth ▪ Sideward: Laterocollis
▪ Loose joints ▪ Backward: Retrocollis
▪ Kyphosis ▪ Forward: Anterocollis
Complication Vertebral or Postural Deviation
▪ Blue sclera Preventive Management ✓ Stretching or postural
o Sclera contains collagen deviation
o If lacking collagen, sclera will thin ✓ Firm pillow support
Other Management ▪ Analgesia
and then blue ▪ Warm compress
▪ Triangular-shaped face ▪ Muscle relaxants
o Broad forehead ▪ Botox injection
▪ Small body
CONGENITAL ACQUIRED
o Since epiphyseal plates are also Birth trauma Cold exposure
affected Ocular abnormalities Unbalanced carrying
Management ✓ Most common
Tumor Posture
1) Preventive
➢ Bisphosphonates
20/20 vision
o Slows down the progression of the
- Achieved by the age of 6 years old
disease
20/150 vision
2) Rehabilitative
- At birth vision
➢ Physical and palliative therapy
➢ Intramedullary bonding
o Metal rods
▪ At risk for osteomyelitis
o Casting

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Patricia Marie A. Braulio, BSN - Velez College - SLRC
____________________________________ORTHOPEDIC NURSING___________________________________
BASILAR SKULL FRACTURE DUCHENNE’S MUSCULAR DYSTROPHY

- Head injury that involves a break in at least - Genetic disorder causing muscle weakness
one of the bones of the skull due to loss of a muscle protein, Dystrophin
- Bones are not affected!
Common affected part Temporal bone - Irreversible
Causes ▪ High impact blunt trauma
▪ Motor vehicular accidents
▪ Assault Signs and symptoms
▪ Falls
▪ Suspect abuse in women and ▪ Gower’s sign
children o They cannot stand appropriately
- If no other related o Difficulty standing up
medical hx
- First to suspect o Splinting their hand to stand on the
Incidence Common in males with high-risk floor or knee
activity occupation ▪ Tiptoeing
Hallmark sign Hemotympanum
Signs and symptoms ✓ Bloody otorrhea ▪ Weak muscles over diaphragm and heart
✓ CSF rhinorrhea and otorrhea ▪ Calf hypertrophy (fat and fibrosis
✓ Battle’s sign replacement)
✓ Raccoon eyes
- Develops in 6 – 12 ▪ Lordosis
hours ▪ Waddling gait
✓ Cranial nerve deficits
✓ Decreased auditory acuity
▪ Protruded belly
✓ Tinnitus Management
✓ Dizziness 1) No known cure
✓ Nystagmus
Complications ▪ CSF leak and fistula 2) Glucocorticoid
▪ Cranial nerve injury ➢ Deflazacort (Emflaza)
▪ Cerebrovascular injury 3) Physiotherapy
▪ Meningitis
▪ Hearing loss ➢ For muscle strength
▪ Vertigo 4) Braces and wheelchair
▪ Intracranial hemorrhages ➢ For mobility
- Most fatal 5) WOF
complication ➢ Developmental delays
- Bleeding internally
Diagnostic tests 1. CT scan
▪ Still cannot walk by 3 years
2. X-ray can miss 70% – 80% old
of skull fractures ➢ Risk for injury
- Not recommended for
BSF ➢ Respiratory arrest or cardiac failure
3. Physical examination ▪ Most fatal
4. MRI
Management ▪ No special treatment
▪ Check for: CLUBFOOT
- Signs of bleeding
- Level of consciousness
- Nerve deficits
- A.k.a. Talipes Disorders
▪ Do not insert NGT and - Complex deformity of the ankle and foot
Nasopharyngeal suction - Affects the ligaments
▪ Symptoms will disappear 24
– 72 hours after
- Chronic overextension of the ligament

TYPES OF TALIPES
Talipes Varus Inversion
EPIDURAL vs. SUBDURAL HEMORRHAGE Talipes Valgus Eversion
Talipes Equinus ✓ Plantar flexion
Epidural Hemorrhage Subdural Hemorrhage ✓ Toes are lower than the heel
Convex/lens shaped Concave/crescent shaped Talipes Calcaneus ▪ Dorsiflexion
Pear shaped Banana shaped ▪ Toes are higher than the heel
Rapidly expanding with arterial Slowly expanding with venous
blood blood
✓ Emergency
Common in head trauma, injury, Common in shaken baby Management
or fracture syndrome ▪ Ponseti Method
o Serial manipulation and casting
weekly for 3 – 6 months
▪ Change of cast every week
▪ Rationale: To restore the
deformity to its normal place
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Patricia Marie A. Braulio, BSN - Velez College - SLRC
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▪ Achilles Tenotomy SAMPLE QUESTIONS
o Releases tension/tightness in the heel
cord 1. An adult has a fracture left radius, which has
▪ Bracing been casted, while performing an assessment of
o Boot and bar this client, the nurse will correctly identify
which of these findings as emergent?
HEADACHE a. Pain at the fracture site
b. Swelling of fingers of left hand
- Stimulation of pain-sensitive structure of the c. Diminished capillary refill of fingers of
head and neck left hand
Types d. Warm, dry fingers of left hand
1) Primary
a. Chronic 2. Following a motor-vehicle accident, a patient
b. Recurrent arrives in the emergency department with
2) Secondary massive right lower-leg swelling, which action
a. Abrupt or acute will the nurse take first?
➢ Most dangerous a. Elevate the leg on pillows
TYPES OF HEADACHES b. Apply a compression bandage
Primary Secondary c. Place ice packs on the lower leg
Chronic and recurrent Abrupt and acute
✓ Most dangerous d. Check leg pulses and sensation

3. A client with a recently applied plater leg cast

HEADACHE CLASSIFICATION complains of unrelieved pain and paresthesia in
Cluster Tension Migraine the affected extremity. The assessment by the
Least common Most common 2nd most common
Idiopathic Due to: Due to:
nurse reveals diminished pulse, pallor, and
✓ Associated with ✓ Muscle stiffness ✓ Cortical increased pain on passive motion. What must
Trigeminal ✓ Dehydration spreading the nurse do first?
Neuralgia ✓ Lack of sleep depression
Duration: 30 minutes Duration: Variable Duration: 4 – 72 a. Monitor the client for the next hour
– 3 hours hours b. Administer an analgesic for pain
Characteristics: Characteristics: Characteristics: c. Administer an anxiolytic
✓ Stabbing ✓ Both sides ✓ Pulsatile
✓ Sharp ✓ Temporal or ✓ One day onset d. Notify physician immediately
✓ Orbital Frontal ✓ Unilateral
✓ Unilateral ✓ Non-pulsatile ✓ N/v 4. What must you do initially for fat embolism?
✓ Ptosis ✓ Band-like ✓ Disabling
✓ Partial Horner a. Place the patient in high-fowler’s
Syndrome position to maximize lung expansion
Continuous and Waxing and Waining “Worst headache of
Explosive ✓ Like having a
b. Administer 100% oxygen via non-
my life”
rubber band on breather mask
the head c. Make sure the patient has patient IV
Management: Management: Management:
▪ Sumaptriptan ▪ Analgesics ▪ Hydration
line and administer IV fluid
▪ Oxygen (NSAIDS) ▪ Analgesics d. Put the patient in recumbent position
▪ Intranasal ▪ Acetaminophen (NSAIDS) 5. A 63 – year old woman has been taking
Lidocaine ▪ Caffeine ▪ Antiemetics
▪ Sumatriptan prednisone (Deltasone) daily for several years
after a kidney transplant to prevent organ
rejection. What is most important for the nurse
to assess?
a. Staggering gait
b. Ruptured tendon
c. Back or neck pain
d. Tardive Dyskinesia

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Patricia Marie A. Braulio, BSN - Velez College - SLRC