NURSING PRACTICE 4: NS2 term coverage - may be caused by a decreased number of

functioning acetylcholine receptor sites. It is

❖ Neuromuscular Disorders also associated with autoimmune disorders.
1. PARKINSON'S DISEASE (Paralysis Agitans) Acetylcholine - an excitatory neurotransmitter which
a degenerative disease that affects the extrapyramidal causes muscle contraction
system (EPS). This causes decreased dopamine - acholinergic: everything down except GI, GUT,
production. secretions
● Tremors: initial sign - cholinesterase: destroys ACH; muscle rest
- resting tremors (non-intention tremors); s/sx:
shakings are more severe when client is at rest - muscle weakness: worst in the afternoon;
● Rigidity: occurs due to decreased dopamine associated with activity relieved by rest
production (dopamine – neurotransmitter that - ptosis: drooping of the eyelids
promotes muscle relaxation). - diplopia, blank facial expression and dysphagia
- cogwheel rigidity and absence of arm swing complication: aspiration by dysphagia which may lead to
when walking. airway obstruction, pneumonia, atelectasis and
● Bradykinesia: slow muscle movement, not respiratory failure
associated with muscle weakness.
● Akinesia: absence of muscle movement, not Tx: Tensilon Test (Edrophonium)
associated with muscle weakness. - a short-acting cholinergic, IV 2mg then 8mg
Positive Tensilon Test is observed as improvement in
s/sx: muscular strength. Muscle weakness returns in 3- 5
- shuffling, festinating gait. (this is tiptoed minutes.
walking, starting at a slow pace which keeps on - Antidote: Atropine sulfate (anticholinergic).
increasing until the client assumes a running Mgt:
pace, the client is unable to stop until the - 20- 30 minutes before meals at an exact time
obstruction is met. (prevents myasthenic crisis that results to
- flattened effect (mask - like facial expression, respiratory distress).
stooped posture, (sticky skin), monotonous - Start meal with cold beverage - to contract
voice (microphonia), shaky, small handwriting muscles of the throat and improve ability to
(micrographia) swallow.
- Thick liquid diet
In Parkinson's Disease:
no intellectual impairment, Plasmapheresis - involves separation of antibodies from
no true paralysis. the plasma to inhibit autoimmune response.
no loss of sensation. Treatment
Mgt: Meds:
- Thickened liquid diet to soft diet (for - Acetylcholinesterase Inhibitors /
dysphagia), Cholinesterase Inhibitors: transmit
- Firm bed (prevent contracture) neuromuscular impulses by preventing the
- Aspiration Precaution destruction of acetylcholine. Therefore, there is
Meds: increase muscle strength.
- Anticholinergics - reduce the rigidity and some - Ex. Prostigmine (Neostigmine), Mestinon
of the tremors (Pyridostigmine), Mytelase (Ambenomium)
ex. Artane (Trihexyphenidyl), Cogentin (Benztropine), - Glucocorticoids: anti-inflammatory effects.
Akineton (Biperiden) - Antacids: prevent gastrointestinal upset due to
- Dopaminergics - improve muscle flexibility. glucocorticoids.
(ex. Levodopa, Carbidopa with Levodopa (Sinemet) and Surgery:
Dopamine (cannot cross blood - brain barrier) inform - Thymectomy (surgical removal of the thymus
client urine may discolor to reddish brown gland). 25% of people with MG have been found
- Dopamine Agonists/ Antiviral Drugs - act on to have thymoma (tumor of the thymus gland).
the dopamine receptors and produce This surgery achieves remission (symptom- free)
improvement in symptoms of Parkinsonism. for 5 to 10 years.
(ex, Symmetrel (Amantadine HCI), Parlodel - Thymus d/o produces antibodies which causes
(Bromocriptine Mesylate) and Requip (Ropinizole HCI) autoimmunity
- Other drugs: Monoamine oxidase B inhibitor -
inhibits the breakdown of dopamine, thus The 2 major complications of MG
prolonging the action of Levodopa. a. Myasthenic crisis - caused by under medication.
s/sx: sudden marked rise in BP due to hypoxia, increase
2. MYASTHENIA GRAVIS (MG) – HR, severe respiratory distress and cyanosis, absent
a PRIORITY : breathing, bawal ma late ang gamot cough and swallow reflex, increased secretions,
neuromuscular disorder; failure of transmission of increased diaphoresis and increased lacrimation,
nerve impulses at the myoneural junction. grave restlessness, dysarthria and bowel and bladder
muscle weakness incontinence
Mgt:
 - Increase doses cholinergic as long as the client
responds positively to Edrophonium treatment.
Possible mechanical ventilation if respiratory Meds:
muscle paralysis is acute. - Glucocorticoids, Immunosuppressants
(to reduce relapse of MS)
b. Cholinergic crisis - caused by excessive - Muscle Relaxants (relieve muscle spasm) –
medications Baclofen, Soma, Dantrolene (cyclobenzoprine),
s/sx: weakness with difficulty swallowing, chewing, Flexeril (has anti cholinergic effect)
speaking and breathing, apprehension, nausea and
vomiting, abdominal cramps and diarrhea, increased 4. ALZHEIMER'S DISEASE - degenerative disorder
salivation and secretions, sweating, lacrimation, of the cerebral cortex resulting to microscopic
fasciculations, and blurred vision. plaques.
- characterized by impaired intellectual function
Mgt: and progressive loss of ability to carry out ADL’s.
- Prevention: give medication on time - loss of recent memory occurs first but remote
- Prevent aspiration: flex the neck every time px memory may remain intact for a long period of
swallows (epiglottis closes avoiding aspiration) time.
- Discontinue all cholinergic drugs until - low in acetylcholine
cholinergic effects decrease, This is Idiopathic but may be associated with
- Provide adequate ventilator support. autoimmune disorders and heredity.
- 1 mg. IV atropine may be necessary to
counteract severe cholinergic reactions. Stage 1. Mild (Early confusion)
- Early cognitive decline: memory loss in one or
DRUGS TO AVOID: more areas, decreassed ADL, difficulties with
- Muscle relaxants, Barbiturates, Morphine names and recalling
sulfate, Tranquilizers and Neomycin Stage 2. Moderate
- These potentiate muscle weakness because of - Unable to perform complex tasks, unable to
effect on myoneural junction. concentrate; no knowledge of current events
- Hot baths – relaxes muscles Stage 3. Moderately severe (Early dementia)
- needs ASSISTANCE with ADL, disoriented
3. MULTIPLE SCLEROSIS - autoimmune disorder Stage 4. Severely (Dementia)
that causes destruction of myelin sheath of - needs ASSISTNACE with ADL, may forgot family
nerve fibers in the brain and spinal cord (CNS). relationship, unaware of surroundings,
Myelin sheath - produces faster impulse production but increased CNS disturbances (agitation, delusion,
because its damaged, there is slow impulses with paranoia. risk for: violence and behavior
problems in sensory (cannot feel pain) wonder)
- characterized by remissions and exacerbations. Stage 5. Very Severe (late dementia)
There is elevated 1g G in the CSF. - Unable to speak (speech limited to five words or
- MRI of the brain and spinal cord shows less), person may scream or make other sounds,
presence of MS plaques. Schwann's cells of the unable to ambulate, sit up, smile, or feed self;
myelin sheath are destroyed, results unable to hold head erect; will ultimately slip
interruption and distortion of impulse (slowed into stupor or coma.
or blocked) Mgt:
s/sx: - PRIORITY: Protect client from injury.
- Vision loss. - Provide close supervision, Close and secure
- Weakness or tingling sensation (paresthesia doors, Use ID bracelets and electronic
due to involvement of cerebrum and spinal cord) surveillance.
- Incoordination due to cerebellar involvement - Reduce hot water heater temperature.
(ataxic gait) - Orient client to the environment.
- Bowel and bladder dysfunction as a result of - Promote activity exercises such as walking with
spinal cord involvement. an escort.
- Muscle fatigue due to muscle spasticity. Meds: Aricept. Namenda, Exelon, Razadyne
Charcoat's Triad (SIN) - Tacrine - improve cognitive functions for mild to
- S - Scanning speech (syllabic speech) moderate Alzheimer's disease.
- I - Intention tremors - Exelon - G.l. upset is common adverse effect.
N - Nystagmus Weight loss may be a problem.

Mgt: 5. AMYOTROPHIC LATERAL SCLEROSIS (ALS)

- Patch the eye alternately for diplopia - progressive degenerative disease involving the
- Provide well – balanced diet, motor system aka Lou Gehrig's Disease.
- Physical Therapy to improve muscle strength - No cure: can die w/in 6 months
and to avoid contracture. - cause of the disease may be related to an
- Avoid hot baths (Heat increases weakness) excess of glutamate (chemical responsible for
- Speech therapy to relieve scanning speech relaying messages between the motor neurons)
Manifestation – Muscle paralysis and atrophy Steroids and Analgesics
- Fatigue, weakness while talking.
- Awkwardness of fine finger movements. 9. SPINAL CORD INJURY (SCI)
- Dysphagia (1st sign), - occurs from Falls, Diving, or Vehicular accident.
- Muscle wasting, Unilateral disability of arm and - Results in Paralysis, Loss of reflexes, Loss of
leg, Dysarthria, Fasciculations of the face, Jaw sensory and motor function, and Autonomic
clonus, Respiratory difficulty dysfunction
Mgt:
- Rilutek: slows progression of disease; Types of Injuries:
- life lasts 3-5 years 1. Central Cord Syndrome - Loss of motor function
- Supportive and symptomatic is more in the upper extremities; degrees and
. patterns of sensation remain intact.
6. GUILLAIN - BARRE SYNDROME (GBS) - acute 2. Anterior Cord Syndrome - Motor function, pain
infectious neuronitis of the cranial and and temperature sensation are lost below level
peripheral nerves; involves destruction of the of injury; ensations of position, vibration and
myelin sheath due to autoimmune disorder. touch remain intact.
- may follow swine flu vaccine. usually preceded 3. Posterior Cord Syndrome - Motor function
by mild upper respiratory infection or remain intact, but there is loss of vibratory
gastroenteritis. sense, crude touch and position sensation.
- The main problem is difficulty of breathing. 4. Brown Sequard Syndrome - injuries that affect
half of the cord. Motor function, vibration,
s/sx: Ascending or descending paralysis which may proprioception, and deep touch sensations are
progress to respiratory muscle paralysis. lost on the same side of the body (ipsilateral) as
- Tingling and numbness. Cardiac dysrhythmias. the lesion or cord damage.
Elevated protein level in the CSF. Abnormal EEG. - On the opposite side of the body (contralateral)
from the lesion or cord damage, the pain
Mgt: Symptomatic and supportive. sensation, temperature and the light touch are
- Monitor and promote respiratory function. affected.
Prevent complications of immobility. 5. Conus Medullaris Syndrome - Bowel and
bladder areflexia and flaccid lower extremities
7. TRIGEMINAL NEURALGIA (TIC DOULOUREUX) 6. Cauda Equina Syndrome - Areflexia of the
- manifested by excruciating, recurrent bowel, bladder and lower reflexes.
paroxysms of sharp, stabbing facial pain along
the trigeminal nerve (lips, gums, nose, cheeks) Clinical manifestations of spinal cord injury
- sensory disorder of the fifth cranial nerve. ● Cervical SCI - Injuries at C2 and C3 are usually
- pain aggravated by cold, washing the face, fatal; Quadriplegia, Respiratory muscle
chewing, hot or cold foods fluids, touch of paralysis. Bowel and bladder retention.
wind on the face. ● Thoracic SCI – Paraplegia (paralysis involving the
Mgt: lower extremities). Poor control of upper trunk.
- Instruct the client to avoid hot or cold foods Bowel / bladder retention. Autonomic
and beverages. Provide liquid and soft foods. dysreflexia with lesion or injury above T6 and
Meds: in cervical lesions.
- Elavil (Amitriptyline), Lioresal (Baclofen), ● Lumbar SCI – Paraplegia (flaccid paralysis).
Tegretol (Carbamazepine), Valium (Diazepam), Bowel and bladder retention.
Dilantin (Phenytoin) ● Sacral SCI – injury above S2 in males allow
Surgery: erection but there is no ejaculation
Alcohol injection of the nerves and Neurectomy - Injury between S2 to S4 prevents erection and
ejaculation. Bowel and bladder incontinence.
8. BELL'S PALSY (facial paralysis) - caused by lower Mgt:
motor neuron lesion of the seventh cranial - PRIORITY: promotion of respiratory function
nerve, may be caused by infection, trauma, especially in cervical SCI,
hemorrhage, meningitis or a tumor. - Immobilize in a flat, firm surface.
s/sx: - Apply cervical collar especially if cervical injury
- paralysis of one side of the face with drooping is suspected.
of the eyelid on that side (ptosis); - Transport client as a unit.
- inability to raise the eyebrows, frown, smile, - Do not attempt to realign body parts.
close the eyelids, or puff out the cheeks. Definitive management:
Mgt: 1. Traction
- Encourage facial exercises 2. Cast
- Protect the eyes from dryness and prevent 3. Surgery
injury. Potential complications of SCI:
- Promote frequent oral care, Instruct the client ● Spinal Shock (neural shock, areflexia): period of
to chew on the unaffected side, flaccid paralysis and a complete loss of all
Meds: reflexes occurs.
s/sx - Absence of sweating below the level of the lesion, - Limb malformations: Incomplete limb
bowel and bladder retention, hypotension, bradycardia development. Webbing of fingers and toes.
- If the lumbosacral segments are undamaged, - Absence of certain fingers and toes. Short
spinal shock wears off in 2 to 3 weeks forearms (underdevelopment of ulna and
- The first sign of resolution of spinal shock is the radius)
contraction of the quadriceps (hamstring) Mgt:
muscles and flexion or extension of toes on - Tracheostomy, Gastrostomy tube, Craniofacial
plantar stimulation surgery to the jaw, ears and eyes.
- Reflexive emptying of the bladder, reflex
defecation and return of sweating. 10. Meningitis
Meninges: covering of the brain and spinal cord
● Autonomic Dysreflexia - occurs in clients with Causative: bacterial (streptococcal pneumoniae)
SCI above T6; most often in cervical injuries. Deadliest: Neisseria meningitidies with petechiae
causes hyperstimulation of the sympathetic s/sx:
nervous system (SNS). ▪ Brain: Meningo Encephalitis
- triggered by noxious stimuli such as bladder ▪ BRUDZINSKI: when neck is flexed, there is knee
distention, fecal impaction, cold draft and skin and hip flexion
stimulation like pressure sore below the level of ▪ KERNIG’S: 90 degree hip flexion; when knee is
lesion. extended, there will he hamstring spams and
s/sx: pain
- evere throbbing, pounding headache ▪ NUCHAL RIGIDITY (stiff neck)
- blurring of vision, nasal congestion, N/V, Mgt:
hypertension, bradycardia - Isolate
- sweating above the lesion; pilomotor spasm MOT: droplet secretions
("goose flesh") below the lesion. - Obtain CSF sample
- The most dangerous effect of autonomic cloudy, (+) WBC, increase protein and sugar
dysreflexia is severe hypertension; may lead to Meds:
blindness and CVA. - Antibiotic:
Mgt: ceftriaxone, vancomycin (Ototoxic, nephrotoxic)
- Place client in a sitting position (lower BP by - Infuse IV less than 1hr to avoid Red Man
gravity) Syndrome
- Check bladder distention. Catheterize client as
indicated, Check fecal impaction. Perform ❖ Neurological Disorders
manual extraction as indicated. 1. Increased Intracranial Pressure
- Turn the client to sides at regular intervals. To occurs whenever there is an increase in the bulk of the
prevent pressure sores. brain (brain tissues, blood supply and CSF)
Meds: The disorders that increase the bulk of the brain tissues
Hexamethonium Chloride (a ganglionic blocking agent) are called space- occupying lesions, (cerebral tumor)
- Nitroprusside (a vasodilator) - Normal ICP 0-15 mmhg
Cerebral perfusion pressure / CPP = MAP – ICP
● Whiplash Injury - caused by violent FACTORS that increase the bulk of CSF:
hyperextension and flexion of the neck. - obstruction to the flow of CSF caused by brain
- It usually results from vehicular accident. tumor or ventricular system defects
damage to muscles, disks, ligaments and (hydrocephalus)
nervous tissues of the cervical spine. - overproduction of CSF caused by tumor in the
s/sx: pallor, weakness, gait disturbance, dizziness, N/V, choroid plexus.
nuchal rigidity, promote bed rest, occipital headache - Increased ICP causes cerebral hypoxia.
Monroe kelly hypothesis: cranium is a closed vault,
Mgt: increase volume in one content will result in the
- Apply cervical collar as needed. Apply hot packs decrease of other contents.
to the neck as indicated. (Ex. If brain increase = blood and CSF decreases)
- Administer analgesic and muscle relaxant as s/sx:
prescribed. - Restlessness (initial sign),
- Altered LOC, headache, N/V, Diplopia
● Miller Syndrome - Postaxial acrofacial - Cushing’s Triad: (3B)
dysostosis (craniofacial malformations and limb ● Blood Pressure (Inc systolic, normal
abnormalities.) diastolic and wide pulse pressure),
- Inherited autosomal recessive genetic disorder. ● Bradycardia and
Passed on when both parents have recessive ● Bradypnea.
gene with Miller Syndrome trait. - Aniscuria (unequal pupil)
- Underdeveloped cheekbones, small jay - Papilledema (edema of the optic disc)
(micrognathia), cleft palate, small, protruding,
"cup-shaped" ear, drooping of the lower Nurse Alert: Increased ICP is an emergency.
eyelids. ● cerebral cortex: hypoxia only for 3 - 5 minutes.
 ● medulla oblongata: hypoxia only for 10 to 15 - common among clients with organic
minutes brain lesion like frontal lobe tumor. Aura
Mgt: is present like numbness, tingling,
- Semi-Fowler's, lateral position (To promote crawling feeling
drainage of CSF and maximum lung expansion) - characterized by tonic clonic
Caution: do not elevate HOB at 90 degrees. This movements of group of muscles (e.g.
may cause brain stem herniation. hands, foot, or face, then it proceeds to
brain stem herniates, -> respiratory depression grand mal seizure)
- Adequate oxygenation
- Acidosis and alkalosis may increase ICP. ● PSYCHOMOTOR seizures
- Safety, Rest and Avoid factors that increase ICP - characterized by Aura, mental clouding
(N/V, valsalva maneuver, over suctioning, rectal - (being out of touch with the
exam, enema and bending or stooping) environment).
- Control hypertension - reduces cerebral tissue - the client appears intoxicated: loss of
perfusion consciousness (confusion, amnesia and
- Limit fluid intake (1,200 - 1,500 ml/day) to need for sleep)
reduce CSF production. - The client may commit violent or
Meds: antisocial acts, (e.g., going naked in
- Mannitol and Lasix: reduces cerebral edema by public, running amok during the time of
increasing urine output. loss of consciousness)
- Decadron (Dexamethasone) corticosteroid -
anti-inflammatory effect and reduces cerebral ● FEBRILE SEIZURES
edema. This is the only corticosteroid that can - common among children under 5 years
pass through the BBB. of age, body temperature is rising.
- Anticonvulsants to prevent seizures. Dilantin
(Phenytoin Sodium), Phenobarbital (Sodium STATUS EPILEPTICUS: occurring in rapid succession and
Luminal) and Tegretol (Carbamazepine) consciousness is not regained between seizures.
- AVOID: Valsava maneuver and morphine - Brain damage: hypoxia and exhaustion.
- can cause respiratory depression which - The client is often in a coma for 12 - 24 hours or
leads to respiratory acidosis and longer, during which time recurring seizures
vasodilation = increase pressure occur. The attack is usually related to failure to
take or sudden withdrawal of prescribed
2. Seizure Disorder (convulsions) are sudden, anticonvulsants.
excessive, disorderly electrical discharges of Epilepsy - characterized by the repeated occurrence of
the neurons. any of the various forms of seizures.
● Generalized seizure: GRAND MAL (common) Mgt:
- characterized by aura (may be flashing - Stay with client
lights unusual smells, spots before the - PRIORITY: Protect from injury (but do not apply
eyes, dizziness) restraint or insert tongue blade)
- Tonic - clonic phase: dyspnea, drooling of - Promote patient airway by turning to the side,
saliva, urinary incontinence. loosening clothing, especially around the neck
- Post - ictal phase: exhaustion, headache,
drowsiness, deep sleep of 1 to 2 hours, Meds: Anticonvulsant (sedatives)
disorientation. ● Hydantoins: least toxic effect and non addicting.
Stages of seizure Therapeutic 10-20mcg/ml (ex. Phenytoin) prevent
1. Prodromal: symptoms start before actual gingival hyperplasia (gums that bleed easily) by using
seizure soft-bristled brush. Only mixed with NSS (avoid D5W)
2. Aura: warning sign right before; Weird smell or ● Barbiturates: phenobarbital, amobarbital
taste, altered vision, dizziness Amytal: status epilepticus
3. Ictus: seizure stage Primidone – psychomotor seizures
4. Post Ictus: (recovery), headache, possible ● Benzodiazepines: diazepam, alprazolam
injury, confusion, tiredness ● Valproates: valproic acid, divalprex
Others – succinimides, oxazolidones
● Absence Seizure: PETIT MAL Not advisable for pregnant women – may cause NTD,
- not preceded by an aura, and/or little loss of folic acid, Vit K inhibitor (bleeding)
or no tonic - clonic movements.
- characterized by blank facial 3. Altered Levels of Consciousness
expression and automatism like lip - decreased level of consciousness may be due to primary
chewing, cheek- smacking. brain injury or disease or systemic conditions like
- regain of consciousness is as rapid as it (metabolic encephalopathies, hypoxic encephalopathies,
was lost; lasts for 10 to 20 seconds. toxicity, and deficiency conditions)
- it usually occurs during childhood and Mgt:
adolescence. - Maintain stimulation (speak before touching),
● Focal Seizure: JACKSONIAN nutrition (enteral or parenteral feedings),
 elimination (stool softeners as ordered), a. Ischemic stroke – blockage; thrombotic or
circulation (change patient position regularly), embolic; blood flow is cut off which leads to
normal body temperature, safety (bed in lowest ischemia
position and put up padded side rails) activity - decreased blood and O2 caused by thrombus
(passive ROM exercises) maintain skin integrity Transient Ischemic Attacks (TIA) – aka “mini-stroke”
and good hygiene. transient cerebral ischemia with temporary episodes of
neurologic dysfunction.
4. Headache (Cephalgia) No cerebral infarction occurs;
atherosclerosis at the carotid artery
5. Migraine Surgery: Carotid endarterectomy
is caused by inflammation and dilatation of blood Mgt:
vessels in the brain; one side of the head is more - flat on bed: this increases BP but is ideal;
affected than the other; lasts for hours to days. aka permissive HPN
The pain is throbbing and pulsatile. (but should not exceed >220 systolic)
s/sx: Meds: fibrinolytic therapy; TPA (tissue plasminogen
- Aura includes visual field defects, confusion, activator) dissolves blood clot
paresthesia, paralysis (in extreme cases) b. Hemorrhagic stroke – bleeding; ruptured
- irritability, sweating, edema, photophobia, artery, aneurysm or uncontrolled HPN,
phonophobia (sound sensitivity) collection of blood in the brain that leads to
Mgt: ischemia and increased ICP
- quiet, dark environment Stress therapy and
relaxation techniques, SFF Ruptured Aneurysm aka the worst headache I ever had
Meds: Contraindicated:
- Beta- adrenergic blockers, CCB, Tricyclic Antiplatelet, Anticoagulant and Thrombolytics
antidepressants, NSAIDS, Opioid analgesics, Mgt: stop bleeding and prevent increased ICP
- Triptans (Selective Serotonin Receptor Agonists) Meds: DOC - Amino caproic acid
cause vasoconstriction which reduces inflammation and - blood clotting
relieves migraine. - semi fowler’s to drain the blood
- Sumatriptan, almotriptan, ergotamine - avoid anti-platelet, thrombolytics and
taken only when theres pain (aka abortive therapy) anticoagulant
TYPES: - prevent more bleeding
a. Cluster: episodes clustered together in quick Ruptured Cerebral Aneurysm: severe / worst head
succession for a few days or weeks with ache; deadliest form of stroke
remission that lasts for months. - Stroke in evolution: worsening signs and
s/sx: the pain is intense, throbbing, deep and often symptoms
unilateral - Complete stroke: fixed signs and symptoms
- begins in the infraorbital region and spread to
head and neck. Remember: if stroke occurs on left side of brain, right
- flushing, tearing of eyes, nasal stuffiness, side of body will be affected
sweating and swelling of temporal vessels s/sx: FAST
Meds: Narcotic analgesic (acute phase) F – face drooping, uneven smile
b. Tension: related to tension and muscle A – arm weakness; numbness and cant lift arm
contraction; episodic and vary with stress. S – speech difficulty; slurred
s/sx: usually bilateral, involves neck and shoulders or T – time to call 911
sustained contraction of the head and neck muscles
Meds: Non-narcotic analgesics (ex acetaminophen), Mgt:
Elavil, Relaxation techniques Aphasia
- Practice one word at a time,
6. Cerebrovascular Accident (CVA) or Stroke - Give simple commands,
caused by disruption of the blood supply to the brain, - Allow the client to verbalize, no matter how
causing neurologic deficit. long it takes him
- middle cerebral artery (MCA) is most - Reinforce success in speech (therapy)
commonly affected. Hemianopsia
cause: - Approach client from the unaffected side of the
thrombosis -> embolism, -> cerebral hemorrhage visual field,
CVA thrombosis and embolism: sleep or rest period - Teach the client scanning technique.
CVA hemorrhage: awake, characterized by extensive, - Turn the head from side to side to be able to see
permanent loss of function. the entire visual field.
there is rapid onset of hemiplegia and rapid progression Thalamic syndrome
into a coma, it is usually fatal. - due to the affectation of the thalamus that has
- The second most frequently affected is the a center for feelings and control of emotional
internal carotid artery (ICA) expression.
Types:
Intracranial Tumors: most common type is glioma
Mgt: ● Dysplasia - cells that differ in size, shape, and
- provides activities and diver client’s attention arrangement from other cells of the same tupe
Surgery: Supratentorial and Infratentorial Craniotomy of tissue
7. Head Trauma ● Neoplasia - uncontrolled cell growth; benign or
involves injury to the scalp, skull, and/or brain tissues. malignant
● Anaplasia - cells that lack normal cellular
CONCUSSIONS: jarring of the brain against the skull. characteristic; malignant
There is a transient period of unconsciousness, may
cause retrograde amnesia. TMN classification – describe the extent and check the
CONTUSION: bruising of blood cells. amount of spread and severity of cancer; staging
Coup- Contrecoup injury: (the brain moves ● TUMOR
inside the skull due to high energy or high impact injury TO - no tumor
mechanisms) Tx - tumor cannot be identified/assessed
LACERATION: tearing of tissues caused by a sharp - require more detailed examination
object. Hemorrhage may cause a hematoma. T1S - carcinoma in situ (stationary/in place)
COMPRESSION OF THE BRAIN: results from a depressed - no tumor but there is cancer
fracture of the skull that causes hemorrhage and T1 - tumor is less than 3cm
edema. T2 - tumor 3-5cm (less than 5)
T3 - tumor 5-7 cm (starts at 5.1cm)
Head injury T4 - greater than 7cm with metastasis
Epidural hematoma
Subdural hematoma ● NODES - regional lymph nodes; clusters of
Basilar skull fractures lymph nodes (inguinal, cervical, axillary.,etc)
s/sx: NO - no lymph nodes involved (intact immune response)
CSF leak from ears (otorrhea) and nose (rhinorrhea). Nx - cannot be identified
- Battle's sign: (hematoma at the mastoid N1 - less than 4 regions involved
process/ behind the ear) N2 - more than 4 regions involved
- Raccoon eyes: (periorbital ecchymosis) N3 - all lymph nodes involved
- Halo or ring sign: (yellowish ring encircles the
blood if CSF is present) ● METASTASIS
Nurse Alert: Basilar head injury causes compression of M0 - no metastasis (benign)
the brainstem. The client may have cardiopulmonary M1 - localized metastasis (within area of primary tumor)
arrest anytime. aka local spread
Mgt: M2 - nearest organ (ex. tumor in breast metastasize to
- The same with the care of the client with IICP lungs, throat, etc.)
- Monitor for drainage from the ears and nose. M3 - nearest area aside from the primary tumor
Test the fluid for glucose; CSF is positive for glucose location; can be found anywhere in the body
- Monitor the client for signs and symptoms of
meningitis, atelectasis, pneumonia, urinary tract TONOMO – means no cancer at all
infection. (No Tumor, Nodes, Metastasis)
-
Brain surgery REMEMBER: Initially cancer is PAINLESS
1. Supratentorial craniotomy: above the head Bone cancer is the most PAINFUL cancer
2. Infratentorial craniotomy: nape / back incision
3. Transsphenoidal hypophysectomy – under the LUNG CANCER
upper lip incision Types: (LAOS)
Post op: 1. Large cell carcinoma
- Avoid brushing the tooth 2. Adenocarcinoma (most common)
- Nasal packing of 3-4 days 3. Oat cell/small cell carcinoma
- No blowing of the nose 4. Squamous cell carcinoma (2nd most common)
(to avoid CSF leak)
Complication: Diabetes Insipidus, DHN, IICP and CSF leak Leading factor – smoking / vaping
Predisposing: 2nd hand smoking, genetics, air pollution,
STAGING OF CANCER chemical exposure, uncontrolled COP, recurrent
Stage 1 – limited number of cancer cells, local pulmonary infections, radiation
Stage 2 – limited but regional spread s/sx:
Stage 3 – extensive local and regional Early - chronic nagging cough
Stage 4 – distant metastasis Late – hemoptysis
Others: respiratory difficulty: SOB/DOB,
Patterns of Cell Growth dyspnea/orthopnea, abnormal lung sound,
● Hyperplasia - increase in the number of cells of hyporesonance, increase tactile fremitus
a tissue; rapid growth Diagnostic test:
● Metaplasia - replacement of mature cell into
another cell type
 1. Screening: CXR, CT scan/MRI, Gammopathies – overproduction of immunoglobulin
ventilation-perfusion (uses radioactive dye:
flush the toilet twice) Immune deficiencies:
2. Biopsy: confirmatory test; can be done during ● Primary: results from improper development of
thoracentesis immune cells / tissues; congenital or inherited
Mgt: ● Secondary: deficiency results from some
- O2 as ordered, high fowler, bronchodilators interference with an already developed immune
Surgery: system; acquired later in life
a. Pneumonectomy – removal of a lung
(post-op: lie on the affected side) Types of vaccine:
chemotherapy, radiation, surgery Attenuated: contains weaken live pathogen
b. Lobectomy – removal of one lobe (example: BCG, Rota, Measles, MMR)
(chemotherapy, radiation, surgery) Inactivated: made from pathogens that was killed by
c. Segmentectomy – removal of half a lobe heat or chemicals, acellular (subunit) - uses antigenic
d. Wedge resection – portions of a lobe proportions of a pathogen
(all three others post-op: lie on the unaffected side) Conjugate: conjugating bacterial capsular antigens to
molecules (toxoid)
COLORECTAL CANCER – commonly affects the
rectosigmoid area HUMORAL IMMUNE RESPONSE (B cells) - bacterial
a. Ascending right colon cancer – occult blood in phagocytosis and lysis, anaphylaxis, bacterial infection
stool, anemia, anorexia, weight loss, abdominal CELLULAR IMMUNE RESPONSE (T cells) – transplant
pain above umbilicus and palpable mass in the rejection, tumor surveillance/destruction,
area viral/fungal/parasitic infections
b. Distal colon and rectal cancer – rectal bleeding
(hematochezia) changed bowel habits, pencil or 2 MAJOR ARMS OF IMMUNITY:
ribbon shaped stool, tenesmus (involuntary ● Humoral immunity
straining), sensation of complete bowel always involves in production of antibodies (AMI)
emptying and abdominal pain below umbilicus involves B cells that recognize antigen or pathogen that
Initial manifestation – change in bowel habits are circulating in the lymph node or blood
(alternating constipation and diarrhea)
● Cell mediated immunity
Classification of colorectal cancer immune response that doesn’t involve antibody;
▪ Stage A – confined to bowel mucosa involves activation of many different cell types,
▪ Stage B – invades mucosal wall of the colon (ex: T-helper cells, natural killer cells, granulocytes etc.)
▪ Stage C – lymph node involvement Acquired immunity: immunity results from the active
▪ Stage D – metastasis / locally unresectable production of protective antibodies
tumor less than 5% in a 5 year survival rate
Diagnostic Exam 1. ACTIVE ACQUIRED IMMUNITY
▪ Annual digital rectal examination (DRE) after - antibodies produced within a person’s body;
age of 40 years, protection is long lasting
▪ Annual occult blood test (50 years) a. Natural AAI – naturally occurring; acquired in
▪ Protosigmoidoscopy – for 2 years with (-) response to entry of live pathogen; response to actual
results then every 3-5 years thereafter infection; occurs when exposed to live pathogen,
Management develops disease & become immune
▪ Surgery: Hemicolectomy – for ascending and b. Artificial AAI – immunity that is acquired in response
transverse colon cancer to vaccine
▪ Abdomino – perineal resection (APR / mile’s 2. PASSIVE ACQUIRE IMMUNITY
surgery) for rectosigmoid cancer – this involves - person receives antibodies produced by another
2 incisions: one lower abdominal incision to person; temporary protection
remove the sigmoid and one perineal incision to a. Natural PAI – acquired by fetus when it receives
remove the rectum. Requires permanent maternal antibodies
colostomy b. Artificial PAI – short-term immunization by injection
▪ Chemotherapy: fluorouracil – most effective of antibodies such as gamma globulin
drug for colorectal cancer NATURAL ACTIVE:
▪ Radiotherapy – adjuvant treatment - exposure/sick of the disease
NATURAL PASSIVE:
IMMUNOLOGY
- placental transfer (IgG)
⮚ Immunity – body’s specific protective response
to a foreign agent / organism - breastmilk (IgA)
Immune system – functions as the body’s defense ARTIFICIAL ACTIVE:
mechanism against invasion - vaccines and toxoid
- Basic function us to remove foreign antigens ARTIFICIAL PASSIVE:
such as viruses and bacteria to maintain - antitoxin/antiserum (IgG)
homeostasis
 Only IgG and IgM antibodies can activate complement
ANTIBODIES: large proteins called immunoglobulin; pathways.
defend against foreign invaders
- The primary function of immunoglobulins is to T-LYMPHOCYTES
elicit humoral immunity by binding to the - primarily responsible for cellular immunity
foreign antigen. 1. Effector T cells (Helper): CD4 cells. Attacks
- The antibody-mediated humoral immune foreign invaders (antigens) directly
response kills the invading microbes and - Initiates inflammatory response
prevents infections from spreading to other 2. Cytotoxic T cells – CD8 cells. Lysis cells infected
regions of the body. with virus; plays a role in graft rejection

TYPES OF IMMUNOGLOBULIN (DGAME) Genetic Engineering: uses recombinant DNA technology

❖ IgD: function is not clear to alter the genetic makeup of an organism
- Recurrent/chronic infections GMO: any organism whose genetic material has been
(ex. Herpes zoster – shingles) altered using genetic engineering techniques.
❖ IgG: most common and abundant Gene therapy: is a medical approach that treats or
immunoglobulin; enhances phagocytosis prevents disease by correcting the underlying genetic
- Primarily constitute 20% of blood problem.
plasma; longest life span: 23 days Stem cell therapy: (aka regenerative medicine),
- Only one capable of crossing the promotes the repair response of diseased, dysfunctional
placenta; maybe secreted into mother’s or injured tissue using stem cells or their derivatives.
milk
❖ IgA: found in many body secretion;
concentration is high in Breast Milk FRACTURE
- (aka secretory antibody); protects the - Any impairment in bone integrity.
body from bacterial growth and
colonization Types of Fracture
❖ IgM – aka natural antibody; first class of IMG 1. Complete: entire circumference of the bone is
made by B cells as they mature impaired.
- First to be produced in response to 2. Incomplete: only partial circumference of the
bacterial and viral infections bone is impaired.
- Present as antigen receptor on B cell 3. Transverse: the line of break is across the bone.
surface 4. Oblique: the line of break goes diagonally along
- Causes microorganisms to agglutinate the bone.
or clump together 5. Spiral: the line of break goes around the bone.
(ex. Immunologic phase of Leptospirosis) 6. Greenstick: one side of the bone is impaired,
❖ IgE – when antigens bind to these, the cell is the other side is bent. It affects cartilaginous
stimulated to release chemicals such as bones; common in children.
histamine 7. Comminuted: bone ends are splintered into 2 or
- Appears in serum; takes part in allergic and more small pieces.
hypersensitivity / anaphylactic reactions 8. Impacted: ne bone end enters the
- Ex. Seafood allergy intramedullary spaçe of another bone
9. Closed or simple: no break in skin integrity.
TYPES OF MECHANISMS: 10. Open or compound: break in skin with or
1. Neutralization: focuses on inactivating without protrusion of bone.
pathogens. 11. Stress - due to prolonged, repeated use of the
When the antibody binds to the functional part of the bone.
virus or bacteria, it inactivates the virus’s ability to bind 12. Pathologi - due to other systemic diseases
to the surface of healthy cells. 13. Traumatic - due to injury.
As a result, the biological effect of the toxins released by The clinical manifestations of fracture:
bacteria and viruses is neutralized. - Pain: aggravated by motion, tenderness.
2. Opsonization: antibodies recognize and label - Loss of motion
the infected or cancerous cells. - Edema
The labeled cells are then digested and removed by - Ecchymosis (after 24 hours),
phagocytic cells such as macrophages or cytotoxic - Crepitus (grating sound as bone rubs together)
T-cells. In short, the opsonization mechanism enhances - Shortening of the limb due to spasm of muscles
phagocytosis. and Obvious deformity.
3. Complement Activation: The binding of X-ray: confirms fracture.
immunoglobulins to pathogens leads to the
activation of complement proteins. ● TRACTION AND REDUCTION
Upon activation, these proteins build a membrane Closed Reduction with External Fixation (CREF)
attack complex (MAC). - this is done through manual manipulation
The MAC proteins then cause cell lysis by punching followed by the application of a cast.
holes in the cell membrane of the bacteria. Open Reduction with Internal fixation (ORIF)
 - this is done through surgery that involves the GOUT ARTHRITIS
application of pins, Wires, screws, and plates to A disorder of purine metabolism; characterized by high
the affected bone. levels of uric acid in the blood and in the urine.
Complications of Fractures: s/sx:
1. Hypovolemic Shock: due to massive bleeding - precipitation of urate crystals (tophi) in the
2. Fat embolism: usually follows fracture of the joints causes inflammation and pain
long bones and may lead to acute respiratory - joint pain, redness, heat, swelling; great/ big toe
distress and ankle.
3. Compartment Syndrome: results from fractures - tachycardia, fever, tophi in the great toe, outer
of arms or leg where closed compartments are ear, hands and feet.
present. A Compartment contains blood vessels, Meds:
nerves, and muscles that are enclosed by fascia. DOC: Colchicine – used for acute attack
5 P's (pain, pallor, pulselessness, paresthesia, paralysis) Mgt:
- Maintain fluid intake of at least 2L - 3Lml/day to
RHEUMATOID ARTHRITIS avoid kidney stones.
Chronic systemic disease characterized by inflammatory - Avoid purine - rich foods
changes in joints related structures, specifically the (caffeine, alcohol, organ meats)
synovial membrane. Occurs in women more
s/sx: OSTEOPOROSIS - systemic skeletal disease characterized
- Painful warm, swollen joints with limited by low bone mass leading to enhanced bone fragility
motion, stiff in the morning s/sx:
- Crippling deformíty in long-standing disease - Decreasing height: due to collapsing vertebrae
and muscle weakness - Back pain
i. Sjoren’s syndrome - Excessive dryness of - Dowager's hump (curved upper back)
the eyes, mouth, and vagina - Fracture with minimal trauma.
ii. Felty's Syndrome - Leukopenía and Mgt:
Splenomegaly (causes hemolytic anemia - Dual energy X - ray Absorptiometry (DXA) -
because trapped RBC's in the spleen commonly used bone mineral density screening
undergo hemolysis) (BMD)
Nursing Diagnosis: - Diet and supplementation: calcium, vitamin D.
Activity intolerance related to fatigue and pain - Exercise (increases bone mass and total body
calcium)
Mgt: Meds:
- Bed rest and cold application during acute pain - Evista (Raloxifene)
- Passíve ROM exercises of joints. - Fosamax (Alendronate sodium)
- Splint painful joints. - Actonel (Residronate)
- Encourage px to alternate period of rest and Medications are best taken with full glass of water after
activity throughout the day rising in the morning.
- Warm bath in the morning to relieve morning
stiffness. MUSCULAR DYSTROPHY
Meds: Is a muscular disease characterized by progressive
- Aspirin muscle weakness and deformity.
a mainstay of treatment; has both analgesic and
anti-inflammatory effects. Types:
Duchenne type (the child will be confined to a
Surgery: wheelchair by age 8 to 10 years )
Osteotomy - surgical removal of a wedge from the joint Pelvic girdle weakness (the child waddles and falls).
Synovectomy - removal of synovia Gower's sign (uses hands to push up from the floor.)
Arthroplasty - replacement of joints with prostheses Scoliosis (weakness of shoulder girdle)
contractures and hypertrophy of muscles.
HYPERTROPHIC ARTHRITIS (Osteoarthritis) Diagnostic tests:
Chronic, a nonsystemic disorder of joints characterized Muscle biopsy - shows degeneration of muscle fibers
by degeneration of joint cartilage. and replacement of fibers with fat.
commonly affected: weight-bearing joints (spine, knees, EMG - shows a decrease in amplitude and duration of
hips and end of fingers) potentials.
s/sx: Elevated Serum enzymes (CK- MM)
- Pain aggravated by use and relieved by rest. Mgt:
- Stiffness of joints. - Maintain function at optimal level;
- Decreased ROM and crepitus - Keep child active and independent.
Heberden's nodes - bony overgrowth at terminal - Plan diet to avoid obesity.
interphalangeal joints.
Bouchard's nodes – bony overgrowth at the proximal
interphalangeal joints.
PAGET'S DISEASE (Osteitis Deformans) - Hematuria
Increased rate of bone tissue breakdown (resorption) - Tea-colored urine
by osteoclasts followed by excessive abnormal bone - Fever
formation by the osteoblasts. - Anemia:
The diseased bone is weak and prone to fracture. (erythropoietin production in kidney is destroyed)
Usually affected: - Edema (because RAAS is stimulated)
the femur, tibia, lower spine, pelvis, and cranium. Mngt – Penicillin, isolation and dec protein (causes
s/sx: enlarging of ulcer)
- Bone pain and deformity,
- Pathologic fractures, KIDNEY TRANSPLANTATION
- Nerve compression, - human kidney from a compatible donor is
- Blindness and hearing loss due to the implanted into a recipient
involvement of the cranium Cadaver Donors:
Meds: - must meet the institution’s criteria for brain
- ASA /NSAID death
- Calcitonin/Etidronate - to retard bone - must be younger than 70 y.o
absorption. - must have a normal renal function
- Cytotoxic Antibiotic (Mithracin) - to decrease - no malignant disease outside CNS
hydroxyproline, serum alkaline phosphatase. - no generalized infection/communicable disease
- no renal trauma
Cold Ischemic Time
URINARY TRACT INFECTION/CYSTITIS - the time elapsed between the cessation of
ca: Escherichia coli (most common etiologic agent) blood flow to the kidney and the time required
1. Upper UTI – pyelonephritis (UTI of kidney) for anatomosis of the kidney in the recipient;
- ascending UTI. maximum time is up to 72hrs
- lumbar pain costovertebral angle GRAFT REJECTION:
2. Lower UTI – bladder (cystitis) and ● HYPERACUTE REJECTION - occurs at the time of
- urethra (urethritis) anatomosis of the organ; immediate removal
s/sx: should be done
- suprapubic pain (bladder), ● ACUTE REJECTION - potentially reversible with
- chills, pyuria, frequency, urgency, dysuria increased immunosuppression and if treated
(burning), foul-smelling urine, malaise, fever, early, administer corticosteroid
nausea and vomiting, low back pain ● CHRONIC REJECTION - occurs slowly months to
- routine urinalysis has a presence of rbc, wbc, years after transplantation an mimics CKD
pus, and bacteria in the urine Mgt:
Mgt: - monitor U/O, fluids, daily weight, laboratory
- IOFI 3-4L per day (include cranberry), results (BUN, hematocrit, serum creatinine,
- hot sitz bath, specific gravity)
- Practice 3W's ( wash, wear, wipe) - hemodialysis
Meds: - maintain aseptic technique
Analgesic: Pyridium (phenazopyridine hydrochloride) - administer medication as prescribed
(can cause red-orange discoloration),
Antibiotic : Amoxicillin and tetracycline, if chronic
DIALYSIS
TOXIC SHOCK SYNDROME - severe infection due to a procedure that is used to remove fluid and uremic
staphylococcus aureus waste from the body when the kidneys can’t function
- caused by blood-soaked packing like tampons,
nasal packs, and vaginal packs that encourage Two Methods:
the proliferation of microorganisms 1. HEMODIALYSIS : removal of fluid and uremic
waste from the blood
BENIGN PROSTATIC HYPERPLASIA - enlargement of the function:
prostate gland with hypertrophy and hyperplasia of ● cleanses the blood of accumulated waste
normal tissue products
s/sx ● removes the byproducts of protein metabolism
- Nocturia (urea, creatinine, uric acid from the blood)
DOC: Finasteride (Proscar) ● removes excess body fluid
Surgery: TURP ● maintains/restore the buffer system of the body
- After TURP there is hematuria that is dangerous ● corrects electrolyte levels in the body
because blood clot could go to the bladder.
Managed by bladder irrigation to remove clot WITHHOLD: antihypertensive, water soluble vitamins,
antibiotics, digoxin
ACUTE GLOMERULO NEPHRITIS (maliit na butas) DIALYZER: artificial kidney, acts as a semi-permeable
Cause: aerobic GABHS (can lead to mitral valve stenosis) membrane that filters at a rate of 300-500ml/min
s/sx:
DIALYSATE: the solution composed of all important xoxo,
electrolytes in the ideal extracellular concentration MARY NOVELLE CASTIGADOR CASIPE
Vascular Access - internal jugular, femoral, subclavian

AV fistula - permanent access; the forearm joins the

artery to the vein
AV graft - subcutaneously interposing synthetic graft
between an artery and a vein
WOF: DISEQUILIBRIUM SYNDROME

2. PERITONEAL DIALYSIS - serves as a semi

permeable membrane in the peritoneal
membrane
Mgt:
- monitor weight
- symptoms of uremia
WOF: PERITONITIS (cloudy dialysate)
BLEEDING

LEUKEMIA
- malignant disorders of blood forming cells
characterized by uncontrolled proliferation of
WBC in the bone marrow, liver, spleen and
lymph nodes
Mgt:
- rest
- pain control: ASA, Codeine, Demerol
- fluids
- vitamin supplements
Meds:
Neomycin
(prevent infection protect patient from his own flora)

● ACUTE LEUKEMIA
uncontrolled proliferation of immature cells that
suppresses bone marrow function, leads to severe
anemia, thrombocytopenia and granulocytopenia

Acute Lymphocytic:
- most common
- prognosis: fair
- fatigue, weakness, anorexia
- petechiae
- ecchymoses
Acute Myelogenous:
- prognosis: poor
- lymphadenopathy, splenomegaly
- auer rods in myeloblast

● CHRONIC LEUKEMIA
uncontrolled proliferation of differentiated cells, slow
suppression of bone marrow function
Chronic Lymphocytic:
- prognosis: fair
- insidious onset
- low immunoglobulin levels
- infection
Chronic Myelogenous
- prognosis: poor
- nights sweats
- splenomegaly
- philadelphia chromosome
- PANCYTOPENIA: decreased RBC, WBC, platelets
(anemia, leukopenia, thrombocytopenia)