NURSING RESPONSIBILITIES DURING RADIATION THERAPY

1. Provide education
- Many manifestations of radiation therapy do not develop until
approximately 10-14 days. And some do not subside until several weeks
after treatment.
- The nurse explains the procedure, delivery of radiation, describe the
equipment, the duration and the possible need of immobilizing the patient

2. Minimize side effects

- In women of child bearing age, RT may cause prolonged or permanent
infertility
- In prostate radiotherapy, when radioactive seeds have been implanted,
there is low, weakly penetrating radiation for others.
- Therefore the client should use a condom for sexual intercourse in the first
few weeks after the procedure.
- Also the client should avoid close contact (<6 feet) contact with pregnant
women and young children (younger than 3 years) for more than 5
minutes a day during the first 2 months following implantation.
- If systemic symptoms occur, such as weakness and fatigue occur, the
patient may need assistance with ADL and personal hygiene.
- When a patient has a radioactive implant in place, nurses and other health
care personnel need to protect themselves as well as the patient from the
effects of radiation.

3. Provide a non-stressful environment

- Some people who receive radiation to the head and neck experiences
redness and irritation in the mouth, a dry mouth, difficulty in swallowing,
changes in taste or nausea.
- Other possible side effects include a loss of taste, earaches and swelling
- Skin texture might change and jaws may feel stiff

4. Dental care
- If you wear dentures, they may no longer fit well because of swollen
gums. If your dentures can cause gum sores, you may need to stop
wearing them until your radiation therapy is over because sores can
become infected.
- Clean teeth and gums thoroughly with a very soft toothbrush after meals
and at least once a day each day.
- Use fluoride toothpaste that contains no abrasives.
- Use unwaxed dental tape to gently floss between once a day.
- Rinse your mouth well with cool water or a baking soda solution after
brushing. Use 1 tsp. baking soda in 1 quart of water.
- Apply fluoride regularly as prescribed by your dentist.

5. Many patients feel tired due to the radiation therapy which can affect their
emotions

6. Patients might feel depressed, afraid, angry, frustrated, alone or helpless

- Peer support groups may meet at your hospital
 - Emotional and spiritual encouragement also is important to the healing
process.

7. Side effects can include eating and digestion problems. You may completely
lose interest in food during your treatment.
- Even if you are not hungry, it is important to keep your protein and calorie
intake high.
- Doctors have found that patients who eat can better handle their cancers
and side effects.
- Eat when you are hungry, even when it is not meal time.
- Eat several small meals during the day rather than 2 or 3 large meals.
- Vary your diet and try new recipes.
- If you don’t drink alcohol, ask your doctor if you should avoid alcohol
during your treatment.
- Keep healthful snacks close by nibbling when you get the urge.
 Drink milkshakes or prepared liquid supplements between meals.
 Patient receives a low residue diet to prevent frequent bowel
movements.
 Radiation therapy may cause anorexia which may lead to inadequate
nutrition and hydration so small frequent feedings or use of nutritional
supplements may be required to maintain adequate nutrition.
 In radiation therapy, fatigue or malaise also contribute to poor
nutritional intake thus planned rest periods may provide relief of
fatigue providing increased energy for meal preparation or
consumption.
 Nutrition – to promote retention of nutrients, administer antiemetics as
prescribed.
 Encourage high calorie meals when child is least likely to be
nauseated. Praise a child’s effort to eat.
 Provide foods identified by child as special favorites.
 Serve easy to swallow food at tolerable temperature.
 If mucous membrane of mouth, pharynx or esophagus is irradiated,
modification of diet to bland, soft, or liquid foods will be necessary;
mouth is rinsed frequently with a mild alkaline mouthwash; teeth are
gently cleansed with absorbent cotton or gauze rather than the usual
brush.
 Avoids foods that are dry and thick.

8. For lactating mothers undergoing radiation therapy.

- Advise pt. not to breastfeed to prevent adverse effects to fetus.
- Advise pt. to drink plenty of fluids to prevent dehydration.
- Monitor nutritional status.

9. Miscellaneous.
- A urinary catheter will be in place (if ordered) and must be inspected
frequently to ensure that it drains properly.
- Any profuse discharge should be reported immediately to the radiation
oncologist or gynecologic surgeon.
- Observing the patient for temperature elevation, nausea, and vomiting.
The symptoms may indicate such complications as infection.
- Patient teaching includes informing the patient that abdominal fullness,
cramping, backache, and the urge to void are normal feelings during
therapy.
- Severe should not occur.
- Mild opioid agents, muscle relaxants or sedative medications may be
helpful.
- Private room, with private bathroom and facilities
- Room previously occupied with patients previously treated with
radionuclide treatment should not be used until the room has been
cleansed and surveyed for residual contamination.
- Items such as bedpans, urinals and basins if disposable may be disposed
of as radioactive waste. If these items are not disposable, they shall be
thoroughly washed with soap and running water.
- Any vomitus, gastric contents collected during the first 24 hours by
nasogastric aspiration or excessive sputum should be collected in a
waterproof container and held for disposal by radiation safety division
personnel.
- Wearing of lead apron
- The nurse must deal safety with radioactive body discharges by wearing
gloves and in some instances placing excreta in containers for special
disposal.
- For a child receiving radiation therapy
- Provide ample time to answer questions of children undergoing radiation
therapy
- Advise client to wear loose clothing as skin in the area being treated
might become more sensitive to touch.
Skin changes:
- The patient is observed for possible reactions:
 Slight redness for a brief period
 Transitory epilation
 Erythema with temporary sweat gland activity suppression
 Dry desquamation
- For large doses or sensitive skin; observe the following:
 Marked erythema followed by purple discoloration
 Blister formation and moist desquamation
 Slow healing, leaving skin atrophied, thin and very sensitive to
heat, cold and trauma.
 Permanent epilation and sweat gland destruction
- After treatment, the area is gently cleansed with tepid water and patted
dry; soap is not used and brisk rubbing is avoided.
- Alcohol, powders, oils, lotions, creams, ointments, deodorants are not
used unless prescribed by the doctor.
- The site is kept dry and may be covered lightly with smooth cloth/cotton
but adhesive tape is contraindicated, used an alternative instead.
- If larynx is treated with radiation, the patient is closely observed 3-4 days
for any difficulty in breathing; edema may develop and occlude airway
necessitating prompt intubation or a tracheostomy.
 - Frequent blood cell counts are done because the hemapoetic tissue is
extremely sensitive to radiation.
- Contact with persons with an infection should be avoided especially with
respiratory infection because of the patients lowered resistance.
- Patient should have an extra rest, increased fluid intake and a high
calorie, high protein, high vitamin diet.
- If the patient is allowed to go home, the importance of keeping the
appointments for his treatments is stressed.

Internal Radiation Therapy:

- Patient should receive a simple explanation of the procedure and
necessary precautions so he will know what to expect and what is
expected of him.
- Time is taken to answer his questions and dispel misconceptions.
- After implantation, temperature is taken every 4 hours, an increase
over 38 degrees is perorted.
- Any radioactive material should be handled with a long forceps, never
with hands.
- All dressings should be checked before disposal.
- Patient’s visitors are required to maintain a 3 feet distance from the
patient.
- Health workers should know the time at which the radioactive implant
is to be removed and should have necessary equipment in advance
and to remind the person responsible for removal.

Nursing responsibilities for the patient receiving radiation

therapy
Teletherapy
The radiation source is exterior to the tumor such as the use of linear accelerator.
1. Remove all opaque objects such as pins, buttons and hairpins and replace
clothing with a gown for body X-rays.
2. Have patient perfectly still; maintain position with the use of foam, plastic,
plaster (material) devices and/or variety of other materials that can conform
to the patient’s anatomy.
3. Tell the patient there will be no sensation or pain accompanying radiation
therapy.
4. Advise the patient that he will be alone in the room for the protection of the
technician, but will be in voice contact.
5. Determine from the physician what has been told to the patient about
radiation therapy
6. If series of treatments are to be given, include the patient in the planning
phase.

Brachytherapy
- The radiation source is used for surface, interstitial, or intracavity applications
1. The nurse should inform the patient that some skin reaction can be
expected but that varies from patient to patient.
2. Do not apply lotions, ointments, cosmetics, etc. to the site of radiation
unless prescribed by the physician. Cornstarch may be used when the skin
 is dry and or itchy. Discourage vigorous rubbing or scratching. It may
destroy skin cells.

Techniques while working with patients undergoing radiation therapy:

1. Put on shoe covers and protective gloves before entering patients room.
2. Work quickly but effectively and courteously. Minimize your time in the room.
3. Note: No matter how long you are in the room, you will not receive a
radiation exposure large enough to cause adverse effects.
4. Leave all trash, linens, and food trays in the room
5. After leaving the room, wash your hands.
6. Personnel should not smoke, eat or drink in areas where unencapsulated
radio active is used in patient treatment or if the possibilities of
contamination of the hands persist.

General procedures for obtaining specimens from therapy patients

1. Read the instructions posted in the door.
2. Specimen containers must be labeled with radioactive material labels or tape
to identify them as radioactive.
3. Put on a face mask if the patient has a tracheostomy or has symptoms of a
respiratory infection.
4. Never use sink for handwashing/ use telephone/ cellphones while in the room.

Nursing considerations in external radiotherapy:

1. It is important that the patient receive an explanation of the procedure and
precautions.
2. Orient the patient and his family in advance, answer their questions and
reassure them that the treatments are well controlled and adequate
protection is used.
3. Following the treatment, observe for possible reactions.
4. Instruct and suggest care of the skin
5. Avoid patient to contact with other persons with infections
6. General supportive care applicable to all patients receiving radiotherapy
include extra rest, an increase fluid intake and a high calorie, high protein,
high vitamin diet
7. When reaction develops, reassure that they are not unexpected and are not
an indication of a recurrence or worsening of his cancerous disease.

Nursing responsibilities in internal radiotherapy:

1. An explanation to the patient of the procedure and the precautions
2. Place the patient in isolation in a single room and indicate that no visitors are
allowed
3. Provide a telephone and radio or television and reading materials
4. In close contact with patient always wear a lead apron or gown and rubber
gloves
5. Wear a monitoring badge which records the amount of radiation received by
the patient
6. Visit patient once in a while
7. Nurse should wash hands thoroughly after any contact with patient and
other equipment
 8. Linens, dishes, syringes, needles and other treatment equipment are
monitored before being returned.

For infants and children

- No cream, no lotion should be applied to radiation areas until the treatment
series is completed.
- If creams contain any metal, these could distort or interfere with the entrance
of radiation.
- If the head will be irradiated, a dental consult may be suggested. This can
slow healing of a tooth extraction.

During treatment:
- Require them to be still for a period of time possibly on an uncomfortable
table.
- Assure patients and the child that during the treatment, just as there is no
sensation from x-ray exposure, the child may will experience no sensation
from radiation exposure.
- Infants are usually prescribed a sedative or conscious sedation before
therapy to ensure that they be still during the procedure.
- To make this approach affective, keep the child fairly active early in the day
and introduce activities after the sedative is administered.

After treatment:
- If head is involved in therapy, alopecia (hair loss) may result.
- Radiation to the head may reduce salivary gland function, leading to a
constantly dry mouth.
- Tooth growth may be halted due to root therapy.
- Radiation to bone marrow may depress blood cell and platelet production.
- Children undergoing radiation therapy need their leukocytes and platelet
counts monitored periodically for changes.

For clients undergoing radiation:

- Clients with radioactive implants are a source of radiation to the immediate
environment.
- The nurse who is in close contact with such clients also needs to wear a lead
apron.
- Nurses must deal safely with radioactive body discharges by wearing gloves
and in some instances placing excreta in containers for special disposal.
- The nurse must wash gloved hands well before and after removing the gloves
and placed contaminated materials in a special containers for special
disposal.
- Nurses must make sure they understand treatment and the precautions they
need to take. Often such clients are restricted to bed or to a confined area to
protect others.
- These clients need emotional support to deal with the precautions and will
likely accept treatments and precautions better when they know what will
happen, when and why.
- Exposure of the reproductive organs of mice and rabbits to X rays has caused
gene mutations that resulted in malformed offsprings and geneticist believe
that comfortable effects can occur in humans.
 - Knowing these, great care is taken to protect both the nurse and patient from
unnecessary exposure.

- Chemotherapy and radiation therapy: knowledge of the appropriate routes,

doses and reactions is required.
- Infection control: nurses must be aware of standard infection control
precautions.
- Nausea and vomiting are most likely to occur when the radiation dose is high
or if the abdomen or another part of the digestive tract is irradiated.
Sometimes nausea and vomiting occur after radiation to other regions, but in
these cases the symptoms usually disappear within a few hours after
treatment.
- Nausea and vomiting can be treated with antacids, Compazine, Tigan or
Zafran.
- Fatigue frequently starts after the 2nd week therapy and may continue until
about 2 weeks after the therapy is finished.
- Patients may need help to limit their activities, take naps and get extra sleep
at night.

Nursing Diagnoses and its Nursing Interventions

Nursing Diagnosis: Impairment of skin integrity due to irradiation

Nurisng interevntions:
- For patients with xerostomia undergoing irradiation
- Patient education
- Nursing care involves assesing the physical and emotional aspects of the
patient before, during and after a course of head and neck irradiation, and
providing interventions, education and support.
- During radiation therapy, the patient should be very gentle with the skin in
the treatment area.
 This nurses can suggest the following:
- Avoid irritatitng treated skin.
- When washing, use only lukewarm water and mild soap, pat dry.
- Do not wear tight clothing over the area.
- Do not rub, scrub or scratch the skin in the treatment area.
- Avoid putting anything that is hot or cold, such as heating pad or ice packs on
treagted skin.
- Ask the doctor or nurse to recommend skin care products that will not cause skin
irritation.
- Do not use any powders, creams, perfumes, deodorants, body oils, ointments,
lotions or home remedies in the treatment area while you’re being treated and for
several weeks afterward unless approved by the doctor.
- Do not apply skin lotion within 2 hours of treatment.
- Avoid exposing the radiated area to the sun during treatment, after is over, ask the
doctor or nurses how long you should continue to take extra precautions in the sun.
- Avoid extremes of temperature
- Avoid rough and tight garments.
- Avoid rubbing or scratching the area the nurse needs to explain that during
treatment, the patient must stay in absolute bedrest.
- Nurses should know also that over exposure to radiation may include burning and
scarring of the skin or lungs; a tendency to develop cataracts; a tendency to
develop cancer; to destroy blood producing tissue.

- Use only luke warm water and mild soap. Just let water run over the treated area.
Do not rub.
- Do not wear tight clothing over the treatment area.
- Try not to rub, scrub or scratch any sensitive spots.
- Avoid exposing the area to the sun during treatment and for at least 1 year after
the treatment is completed.
- If you expect to be in the sun for more than a few minutes, wear protective clothing
and sunscreen. Ask your doctor or nurse about using sunscreen lotions.
- Wash the irritated area gently each day with sitter water alone on a mild soap and
water.
- Use your hand rather than a washcloth to be more gentle.
- Rinse soap thoroughly from your skin.
- Take care not to remove the markings that indicate exactly where the beam of
radiation is to be focused.
- Dry the irradiated area with potting motions rather than rubbing motions, using a
clean, soft towel
- Use no powders, ointments, lotions, or creams on your skin at the radiation site
unless they are prescribed by your radiologist.
- Wear soft clothing over the skin at the radiation site.
- Avoid exposure of the irradiated area to the sun.
- A void heat exposure.
- Mild erythema to moist desquamation similar to appearance to a second-degree
burn.
- The nurse assesses the patient’s skin, nutritional status and general feeling of well
being.
- The skin and oral mucosa are assesses frequently for changes.
- The skin is protected from irritation and the patient is instructed to avoid using
ointments, lotion or powder on the area.
- Pressure is avoided by avoiding tight clothing’s and prolonged lying on the area of
treatment.
- No hot or cold is applied on the site and must be protected from direct sunlight.
- If itching and irritation accompanying erythema, you may suggest application of
plain calamine lotion without phenol; or cornstarch.
• Dryness and pruritus may occur at an accumulated dose of 2000 to
28000 Cgy (1.2) and is caused by obliteration of sebaceous glands
within the field.
• This is an acute phenomenon that correlates with the depletion of
actively proliferating basal cells in the epidermal layer of the skin,
a fixed percentage of which die with each dose fraction of
irradiation.
• Remaining basal cells are stimulated and their cell cycle
shortened.
• Subsequent peeling of the skin is defined as dry desquamation.
• The skin becomes dry and patient may notice itching and burning
sensations.
 • Dry skin is susceptible to further injury through scratching and/or
formation of fissures – augmenting the risk of infection and tissue
necrosis.

Nursing Diagnosis: Potentials for infection due to bone marrow depression

Nursing Intervention:
- Monitor blood counts weekly.
- Teach person to avoid infection by frequent handwashing and good nutrition,
hygiene and good habits.
- Teach persons signs of infection to report to physician.

Nursing Diagnosis: Potential for bleeding due to BM depression:

Nursing Interventions:
- Monitor platelet counts weekly
- Teach person to avoid physical trauma and aspirin while platelets are low
- Teach person signs of hemorrhage to report to physician
- Monitor stool, integument for signs of hemorrhage
- Use direct pressure over injection sites until bleeding stops

Nursing Diagnosis: Activity intolerance due to anemia

Nursing intervention:
- Discuss fatigue and its causes with person
- Encourage good nutrition and plenty of rest

Nursing Diagnosis: Alteration in Nutrition: Less than body requirements due to

anemia
Nursing intervention:
- Monitor diet for efficient calories
- Contact dietitian if indicated
- Monitor weight weekly or daily
- Assess person’s understanding of nutrition and teach as necessary

Nursing Diagnosis: Alteration in mucous membranes due to irradiation

Nursing interventions:
- Monitor oral cavity daily
- Encourage bland diet, no smoking, no alcohol
- Good oral hygiene and saline rinses every 2 hours while awake may help
- Ensure professional dental care
- Avoid foods that are dry and thick

Care of the teeth, gums, mouth and throat

- Avoid spices and coarse foods such as raw vegetables, dry crackers and nuts
- Do not eat or drink very hot foods
- Do not smoke, chew tobacco or drink alcohol because tobacco and alcohol
can further irritate mouth sores.
- Stay away from sugary foods and snacks.
- Ask your doctor or nurse to recommend a good mouthwash. The alcohol
content in some mouthwashes has a drying effect on mouth tissues.
- Sip cool drinks often throughout the day.
- Eat or chew sugar free candy or gum to help keep your mouth moist
 - Moisten food with gravies and sauces to make eating easier.
- Gentle oral hygiene is essential to remove debris, prevent irritation and
promote healing
Mucositis: do not remove membrane

Nursing Diagnosis: Alteration in bowel elimination: diarrhea due to irradiation

Nursing interventions:
- Monitor stool
- Give low residue diet/antidiarrhea medication as prescribed.

Nursing Diagnosis: Alteration in comfort and vomiting due to irradiation

Nursing interventions:
- Plan rest periods before and after meals
- Administer antiemetics as prescribed
- Monitor fluids and electrolytes

Nursing Diagnosis: Alteration in comfort: headache due to irradiation

Nursing Interventions:
- Monitor pain
- Administer analgesics as prescribed

Nursing Diagnosis: Disturbance in self concept due to alopecia

Nursing interventions:
- Encourage verbalization of feelings
- Suggest use of wigs, scarf’s, hats, etc
- Instruct person on hair care

Nursing Diagnosis: Alteration in urinary elimination patterns due to irradiation

Nursing interventions:
- Monitor urine for blood
- Monitor for dysuria or urinary frequency
- Encourage fluid intake

Nursing Diagnosis: Social isolation due to irradiation

Nursing Interventions:
- Explain and discuss irradiation precaution
- Encourage telephone calls
- Suggest television, radio or tape player
- Stop by door to say “hello”

HYPERSENSITIVITY REACTIONS
 • Exaggerated or inappropriate response to specific antigen
• Anaphylaxis, allergies, transfusion reactions, graft rejections

TYPE I – Anaphylactic / Immediate Hypersensitivity Reaction

Common antigens: Insect bites, drugs, food, pollen, x-ray contrast medium
Signs and Symptoms: Urticaria(hives) caused by foods- eggs, fish , nuts, drugs
Atopic allergies – less severe and more common form seen in
about 15% of the
population. Atopy means inherited hypersensitivity.
Common Antigens
include:
Inhalants – dust, pollens, mold spore, animal
dander
Contactants – fibers in wool, fur, nylon, plant oils,
osaps,
cosmetics, perfumes, hair dyes, nickel in
jewelry, clothings, occupational chemicals,
changes in temperature and stress

Pathophysiology:
IgE attach to the surface of mast cells and basophils providing a site for allergens to
bond the cells. This causes the cells to releases vasoactive substances including
histamine leading to:
1. Constriction of smooth muscles in the bronchi – bronchospasm
2. Increase in vascular permeability – urticaria(hives or tissue edema
3. Increase in mucus secretions – hay fever and asthma
Symptoms: wheezing, sneezing, rhinitis with conjunctivitis; urticaria, angioedema,
rash: diarrhea; fever,
malaise, joint pains, hematopoietic suppression, anaphylaxis
Sensitizing Dose – initial contact with allergen that triggers the synthesis of specific
antiallergenic IgE
antibodies
Shocking, Challenging Dose – subsequent contact with allergen, indi exhibits the
symptoms of Type I
Nursing Process:
Assessment – history taking
Diagnostic Test – skin test, radioallergosorbent test, one-week food diary test
Nursing Diagnosis: Alerted health maintenance; Knowledge deficit
Implementation:
1. Prevent anaphylactic reaction
- Epinephrine; Benadryl; aminophylline, tracheal intubation; shock therapy
2. Allergen immunotherapy
3. Control the environment – house dust; animal dander; pollens; fungus
4. Facilitate learning – remind physician of allergy if new medications are
prescribed; read all labels of nonprescription drugs before taking the new
drug; examine all labels of new prepared foods for presence of allergens;
avoid eating unknown foods when travelling; use non allergenic soaps and
cosmetics – coat nickel containing jewelry with clean nailpolish; use gloves
to handle allergen; report side effects of prescribed medication
TYPE II – Cytotoxic Hypersensitivity
• Caused by antibodies (IgG and IgM) directed against antigens on a person’s
red blood cells, lymphocytes or platelets or tissue cells. The reaction of
antibodies and antigens usually leads to activation of the complement
system.
• Damage cells by causing lysis as in compatible blood transfusion reactions

Types of Transfusion Reactions:

1. Acute hemolytic Reaction/hemolytic transfusion reaction
- Infusion of ABO incompatible with blood, RBCs or components containing
10 ml or more RBC’s antibodies in the recipients plasma attach to the
antigens on transfused RBC’S ---RBC destruction. Chills, fever, low back
pain, flushing, tachycardia, tachypnea, hypotension, vascular collapse,
hemoglobinuria, bleeding, ARF, shock, cardiac arrest, death
2. Febrile, Non Hemolytic ( most common)
- Sensitization to donor’s WBC’s, platelets or plasma proteins
- Sudden chills and fever, headache, flushing, anxiety, muscle pain
3. Mild Allergic reaction involves sensitivity to foreign plasma proteins
- Flushing, itching, urticaria
4. Anaphylactic reaction
- Infusion of IgA protein to IgA deficient recipient who has developed IgA
antibody
- Anxiety, urticaria, wheezing, tightness and pain chest, difficulty
swallowing, progressing to cyanosis, shock and possible cardiac arrest
5. Delayed hemolytic reaction
- An amnestic immune response that occurs 7-14 days after transfusion.
Sensitization to RBC antigen not ABO system
- Fever, chills, back pains, jaundice, anemia, hemoglobinuria
6. Graft-versus-Host Disease_Pt.
- Immunodeficient person receives lymphocytes begin to reject cells 4-30
days after the transfusion.
- Anorexia, nausea, diarrhea, high fever, rash, stomatitis, liver dysfunction
Prevention of transfusion Reaction: Accurate laboratory testing; careful blood
administration

TYPE III – Hypersensitivitis/Immune Complex

- Involves antigens, antibodies (IgG and IgM) and the complement system.
When certain ratios of antigen to antibody occur, the immune complexes
are small enough to escape phagocytosis, but they become trapped in
the basement membrane under the endothelium of blood vessels, where
they activate complement and cause inflammation
- Glomerulonephritis and rheumatoid arthritis
- Antihistamines and salicylates; steroids – prednisone; epinephrine

TYPE IV – Cell mediated or Delayed Hypersensitivity Reaction

- Usually appears 12-72 hours after exposure to an allergen. Occurs when
allergens are taken up by antigen-presenting cells that migrate to lymph
nodes and present the allergen to Tcells, which then proliferate. Some of
the new Tcells return to the site of allergen entry into the body, where
 they produce gamma interferon, which activates macrophages, and
tumor necrosis factor, which stimulates an inflammatory response.
- Mycobacterium tuberculosis, poison ivy

Graft and Organ Donation

- Types: Isograft/syngraft: Autograft; Synthetic Graft; Xenograft: Allograft
- Purposes: Art/Aesthetic; prevention of infection; prevent fluid loss
- Forms of Graft: skin graft; flap graft; flee graft
- Pre-op and Post-op Care
- Recipient Site: free of infection; good vascularization in the area; cleaned
aseptically before surgery/ prevent fluid collection on the graft; prevent
infection; prevent graft movement; promote adequate circulation in the
area
- Donor Site: celan site; free of infection/ cover dressing during the 1 st 24
hours within mesh gauze until the site is dried up; promote circulation;
analgesics; nutrition

Tissue Rejection – healthy defense mechanism of the body

First set rejection: recipient receives unmatched skin
2-3 days the body accepts the skin, there is vascularization
6 - 10TH day + lympadenopathy
10 – 14th day + appearance of rejection taking place with the
appearance of
macrophages and T lymphocytes on the site of transplant
12 – 40th day + necrosis, tissue implanted will now shed off
Second set rejection: no vascularization, direct sloughing off tissue

Organ Transplantation for end stage or failure and do not respond to conventional
therapy
Recipient: free of irreversible of infection or malignancy
End stage of failure and do not respond to conventional therapy
No anatomical problem that would lead to difficulty of
transplantation
Therapeutic or benefit of the patient
Ability of the family to pay costs; age; functional ability;
rehabilitation potential;
ability to return to work; psychological status; family
support system, ability to
buy post transplantation regimen
Donor: cadaver-brain death; no existing disease; no transmissible
disease; no malignancy; family with no history of death of
unknown causes

Types of Rejection: hyper acute; acute; chronic

Therapies to prevent Rejection: Immunosuppressive drugs; cyclosporine;

azaththjioprine; glucocorticoids; ALG
Summary of Hypersensitivity Reactions

Property Type I Type 2 Type 3 Type 4 Cell

Anaphylactic Cytotoxic and Immune Mediated or
Cytolytic Complex Delayed
Response
Mediators IgE, IgG, IgG, IgM, IgG, IgM T cells,
Baasophils complement macrophages
mast cells sytem
Allergens Drugs, stings BT Soluble agents PTB, Ca
like drugs
Response to (+) wheal and Not done Erythema, Tissue
Skin Test flare within 30 edema induration
minutes
Pathophysiolog Secondary to Destruction of Acute Tissue
y and effect prostaglandin, cells, RBC inflammatory destruction
bradykinin, reagent
serotonin,
histamine
Examples Systemic ABO Serum TB, organ
anaphylaxis, incompatibility sickness donation
asthma

DISRUPTIVE INFLAMMATORY RESPONSES

COMMUNICABLE DISEASE IN CHILDREN

Nursing Process Overview
Assessment: History Taking: Local or systemic infection; history of travel; any
contact with animal or animal products; any animal or insect bites; any illnesses
that compromises body defenses; what medications taken; vaccination history

Clinical Manifestations:
1. Assess for clinical manifestation of infection
 2. Obtain specimens of blood, urine, stool, sputum, throat swabbing, nasal
secretions, pyrogenic exudates for bacteriologic studies
3. Secure/Assist in securing blood smears or other materials for microscopic
studies
4. Assist with spinal aspiration of lumbar tap, BM or any other fluids or tissues
for cytologic, serologic or bacteriologic study
5. Carry out appropriate skin tests for specific diagnostic reactions as directed

Nursing Diagnosis:
1. Fluid and electrolyte imbalance
2. Altered thermoregulatory status
3. Fever
4. Potential for spread of infection
5. Altered respiratory status
6. Altered elimination status
7. Potential for serious systemic complications
8. Ineffective coping and social isolations
9. Knowledge deficit

Planning and Implementation:

1. Implement therapeutic plan to treat infection
2. Ensure hemostasis
3. Measure to prevent cross contamination of infection
4. Prevent overwhelming infection in the immunocompromised patient
5. Relief of symptoms of infection
6. Enhance coping mechanism to promote adaptation

Immunization – receiving immunity against a number of dangerous infections.

Immunity – ability to combat a particular antigen, passive or active
Active Immunity – when the child produces antibodies after the natural invasion of a
pathogen
Naturally Acquired Active Immunity – ability to produce antibodies rapidly
should be specific
antigen invade again; lasting.
Artificially Acquired Active Immunity – when pathogens are artificially injected
into the child by
immunization. Should be specific antigen enter again, antibodies are
produced against the pathogen that are just as lasting as those
produced are in naturally acquired active immunity.
Passive Immunity – IgG antibodies that a woman possesses, either through
immunization or through
having a disease are transferred across the placenta to a fetus in utero.
Naturally Acquired Passive Immunity – fetus does not make antibodies but
received them.
Artificially Acquired Passive Immunity – injection of antibodies made
synthetically or obtained
from animal serum to the child to give rapid immunity lasting
approximately for six weeks.
Immunization Schedule

Vaccine Indication Age Dose Frequenc Route Side

y effects
BCG Tuberculo At birth 1 dose 2x Intradermal Pain,
(1 dose at sis School (0.5 ml) deltoid fever,
birth) entrant local
abscess
DPT 0.5 ml 3x IM vastus Swelling,
(3 doses) lateralis fever
OPV 2 drops 3x oral None

HEP B 0.5 cc 3x IM vastus Local

(3 doses) lateralis reaction –
swelling,
fever
MEASLES 9 months 0.5 cc once Subcutaneo Fever,
us, deltoid, local
gluteal reaction

EXAMINATION – HIGHER CEREBRAL FUNCTION

MEMORY TEST
Testing requires alertness and is not possible in a confused or dysphasic patient.
IMMEDIATE memory – Digit span – Ask patient to repeat a sequence of 5, 6, or 7
random numbers.
RECENT memory – ask patient to describe present illness, duration of hospital stay
or recent events in
the news.
REMOTE memory – ask about events or circumstances of occurring more than 5
years previously.
VERBAL memory – ask patient to remember a sentence or a short story and test
after 15 minutes.
VISUAL memory – ask patient to remember objects on a tray and test after 15
minutes.

Note: Retrograde amnesia – loss of memory of events leading up to a brain injury or

insult.
Post traumatic amnesia – permanent loss of memory of events for a period following
a head injury.

REASONING AND PROBLEM SOLVING

Test patient with two-step calculation, e.g. “I wish to buy 12 articles at 7 pence
each. How much change will I receive from L1?
Ask patient to reverse 3 or 4 random numbers.
Ask patient to explain proverbs.
Ask patient to sort cards into suits.
The examiner must compare patient’s present reasoning ability with
expected abilities based on
job history and/or schoolwork.
EMOTIONAL STATE
Note: Anxiety or excitement
Depression or apathy
Emotional behavior
Uninhibited behavior
Slowness of movement or responses
Personally type or change

COGNITIVE SKILL
Dominant hemisphere disorders
Listen to language pattern – hesitant Expressive dysphasia
- fluent Receptive dysphasia
Does the patient understand Receptive dysphasia
simple/complex spoken commands?
e.g. “Hold up both arms, touch the right
ear with the left fifth finger.”
Ask the patient to name objects Nominal dysphasia
Does the patient read correctly? Dyslexia
Does the patient write correctly? Dysgraphia
Ask the patient to perform numerical Dyscalculia
calculation, e.g. serial 7 test, where 7 is
subtracted serially from 100.
Can the patient recognize objects? E.g. Agnosia
ask the patient to select an object from a
group.
Non- Dominant hemisphere
disorders
Note patients ability to find his way Geographical agnosia
around the ward or his home.
Can the patient dress himself? Dressing apraxia
Note the patient’s ability to copy a Constructional apraxia
geometric pattern, e.g. ask the patient
to forma star with matches or copy a
drawing of a cube.

Mild mental function tests and Functional activity questionnaire are used in the
assessment of DEMENTIA

MENTAL BEHAVIOR

Level of Consciousness:

Alert - awake, quick, clear mentation, normal response to tactile,

verbal, painful
stimuli
Drowsy - responds to stimulus, may be aroused quickly but easily falls
asleep; may
 yawn frequently, fall asleep during meal or lengthy
conversation.
Obtunded - can be aroused and responsive, but he’s usually confused and
falls back
to sleep as soon as he is not directly stimulated
Stuporous - does not respond spontaneously to environment, vigorous, often
painful
stimuli are necessary to arouse the patient. When stimulated, he
move
but movements are not purposely.
Semi-comatose - Responsive only to deep painful stimulation
Comatose - no response to any stimulation, movement are absent except for
some
muscle reflex contraction
Confusion - state of mental confusion and excitement
Apathy - lack of emotional response
Aura - a sensory phenomenon that may precede a convulsion, such as
flash of
light, or ringing bells.

HANDOUT IN NEUROLOGIC NURSING

NOMENCLATURE
Abberration - deviation from normal structure of behavior
Decerebrate - deprived of cerebral function
Denervate - to interrupt motor/sensory nerve supply to a party by
drug
injection or operation
Contrecoupinjury - injury to the brain produced on the side opposite that of
the
primary injury
Cerebral Concussion - brain injury resulting from violent jarring of the
brain due to blow
to the head, fall

SURGICAL PROCEDURE
Craniotomy - surgical opening through the cranium
Craniectomy - the surgical removal of a part of the skull
Chordotomy - division of the long tract of the spinal cord, referring usually to
the
antero-lateral pathways that transmit pain

CSF
Hypoglycoorrhakia - low sugar in CSF
Pleocytosis - increased WBC in CSF
Xaantochromia - yellowish discoloration of the CSF

HEAD
Macrocephalous - having an unusually large head
Microcephalous - having an unusually small head
Cephalococle - protrusion of the brain from the cranial cavity
Cephalhematoma - subcutaneous swelling containing blood found in the head

GAIT
“Foot drop” gait - due to weakness in dorsiflexing the ankle, the patient
elevates the
affected foot higher than normal and the foot tends to
point
downward.
Spastic gait - associated with spastic weakness, movement is slowed
and
flexion of the knee and hip joint is slowly and imperfectly
performed; affected leg tends to remain adducted. The
patient has to swing the affected leg around (circunduct)
since he cannot flex and elevate it.
Parkinson Gait - the patient shows loss of arm swing, short-stepped,
with the
trunk developing a forward list, eventually forcing the
patient, with his difficulty in stepping, to have to run
forward to “catch up” with the center of gravity, affected
arm is characteristically held in semiflexion at the elbow
and wrist.
Ataxic - patient show either or both of these abnormalities:
1. He cannot accurately place one foot in front of the
other and leg movement is jerky and uncoordinated:
tends to fall on one side.
2. He may be unable to stabilize his trunk in the vertical
posture so that he tends to jerk back and forth
(titubation) + Rombryg test (sensory)
Titubation - staggering gait
Festination - morbid acceleration of gait
1. Propulsion - tendency to push or fall forward in walking
2. Retropulsion - walking backward, involuntary
Scissors - short, slow steps, with legs alternately crossing over each
other

POSITION
Emprosthothonus - lying with the body in curved and resting upon the
forehead and
feet with face downward.
Opisthotonus - an arched position of the body with the feet and
head on the floor
or bed.
Pleurothotonus - titanic spasm in which the body position is arched
to one side
Orthotonus - titanic spasm marked by rigidity of the body in a straight
line

MOVEMENTS, COORDINATION, TONE

Coordination - harmonious action of muscle groups in performing
complex
movement
Apraxia - inability to perform certain acts or purposeful
movements
without motor loss.
Dyskinesia - defect in voluntary movements
Akinesia - absence of muscle
synergia - lack of coordination between muscle groups; movements
are in
serial order instead of being made together
Dysmetria - inability to fix the range of a movement; undershoots or
overshoots
Pass-pointings - tendency to veer to one side of tip of nose or finger
when trying
to touch it
Bradykinesia - extreme slowness of movement
Spasm - involuntary, sudden movement or muscular
contraction
Fasciculation - produce localized, incoordinated, involuntary twitching of
a single
muscle group while muscles are at rest.
Tic - coordinated, stereotyped spasmodic muscular contraction
of the
face, neck or shoulder muscles that may be involuntary or
the result of a habit
Tremor - rhythmic quivering: involuntary movement of a part of the
body
resulting from the alternate contraction of opposing
muscles
1. Coarse Tremors – oscillations are relatively slow (6-7
per sec.)
2. Fine Tremors – rapid, characterized by oscillation of 8-
10 times per second
Twitching convulsions - quick spasmodic contraction of muscles paroxysm
of involuntary
muscular contractions and relaxations
1. Clonic movement - one having intermittent
contractions, muscles alternately contract and relax
2. Tonic – one which the contractions are maintained for
a time which usually draw joints into position of
flesion/extension
Chorea/Choreiform - hallmark of chorea; are purposeless, rapid, jerky usually
involving
the movements extremities and trunk with facial
grimacing, ex. Flexing and extending fingers
Ballismus - quick jerky shaking movement
Hemiballismus - quick jerky movement involving half of the body
Athetosis - repeated involuntary movement of slow, squirming,
writhing,
 twisting type.
Nystagmus - involuntary movement of the eyeballs
Rigidity - resistance all through the ROM
Spasticity - resistance of movement at the beginning then, giving in
Cogwheel Rigidity - Muscular resistance is characteristically intermittent when
the
muscles are palpated.
Rest Tremors - involuntary muscle movement at rest
Intention Tremors - involuntary movement seen when doing something
Hypotonia - decreased muscle tone
Flaccidity - muscular weakness, softness and flabbiness, no motor
response
Nuchal rigidity - stiffness of the neck
Paralysis - temporary suspension or permanent loss of voluntary
motion and
sensation in a body part
Spastic Paralysis - involved part of the body is in a state of muscular rigidity
or
tenseness
Flaccid Paralysis - involved part is completely relaxed or limp
Paraplegia - paralysis of the lower half of the body
Hemiplegia - paralysis of the longitudinal half of the body
Diplegia - paralysis of like parts on either side of the body
Quadriplegia - paralysis of the four extremities
Paresis - muscle weakness of partial or incomplete paralysis
Blepharopthosis - dropping of the upper eyelid

SENSATION
Paresthesia - peculiar sensation of numbness, prickling, tingling.
Hyperesthesia - unusual sensitivity to pain or sensory stimuli
Neuralgia - severe Lancination pain along the course of a nerve
Myalgia - muscular pain
Agnosia - loss of comprehension of audio-v, visual or other
sensation
1. Auditory – inability to interpret sounds
2. Optic – inability to interpret images seen
3. Tactile – inability to distinguish objects by using sense
of touch
Asteriognosis - is the inability to recognize familiar objects by
touch or
manipulation
Diplopia - double vision
Anopsia - loss of vision in one eye
Homonymous Hemianopsia- loss of one-half of the field of vision in one
eye
Anosmia - absence of the sense of smell

SPEECH AND LANGUAGE

Dysarthria - difficulty in articulation
Dysphasia - impairment in speech
Aphasia - loss or the inability to use or understand spoken or
written
language; it may exist without intellectual impairment
1. Sensory (receptive aphasia) – inability to comprehend
or understand oral or written communication
2. Motor (broca’s) aphasia - can’t speak, write
although can comprehend
3. Global aphasia – an almost total language loss
manifested in minimal response in every phase of
language
4. Auditory aphasia – difficulty of understanding spoken
word
5. Nominal aphasia – inability to attach meaning to words
read
Alexia - inability to read, word blindness
Agraphua - inability to express oneself in writing
1. Absolute – complete inability to write
2. Acoustic – inability to write words head
3. Cerebral – inability to express thoughts in writing
4. Motor- inability to write due to muscle coordination
5. Optic – inability to copy words

INTRACRANIAL HEMORRHAGE
Extradural/Epidural - bleeding beneath the cranium and outside the dura,
frequently
Subdural Hemorrhage - hemorrhage between the dura and arachnoid;
increasing ICP
develop slowly; personality changes maybe the first
noticeable sign
Subarachnoid Hemorrhage - hemorrhage between the arachnoid and pia
mater into
CSF

NEUROLOGIC SIGNS
A. Cardinal symptoms: increasing or widening pulse pressure
Decreasing PR
Increasing headache
Pappil edema
Decreased mental awareness
Decreased in RR
B. Other signs and symptoms which may or may not develop:
1. Vomiting – may or not be projectile
2. Motor deficits – weakness or paralysis of any part of the body
3. Sensory Disturbances of any part of the body
4. Awkwardness – may mean weakness; difficulty or coordination
5. Speech disturbances
6. Convulsion
7. incontinence/retention
C. Localizing Symptoms
1. Frontal Lobe – aphasia
 Confusion
Changes in personality
Jacksonian convulsion- convulsion begins in one part of the
body and
spread in orderly manner to all of the body parts.
2. Parietal Lobe – convulsion, sensory disturbance, asteriognosis
3. Temporal Lobe – defects in visual field, taste or hearing, smell of burning
rubber
4. Occipital Lobe – visual disturbance
5. Cerebellum
Ataxia – muscle coordination especially manifested when voluntary
muscular
movements are attempted.
Tremors, nystagmus, hypotonia
6. Basal Ganglia
Athetosis, chorea, hemiballismus, tremor

Pathopysiology

Cause: excessive alcohol consumption, reduced protein intake, exposure to certain

chemicals or infectious schistosomiasis
↓
Episodes of necrosis involving the liver cells
↓
Destroyed liver cells are replaced by scar tissue, the amount of which in time may
exceed that of the functioning liver tissue
↓
Early in the disease, the liver is apt to be large and its cells loaded with fat
↓
Later as replacing scar tissue contracts, it becomes small
↓
Also, its surface often becomes rough, bec the scar within it is disposed in coarse
bundles, which contract and pull in the capsule at certain points and cause the
island of residual normal tissue and of new regenerating liver tissue to project in the
little lumps
↓
Liver Enlargement → Activity Intolerance r/t fatigue
↓
Portal Obstruction and Ascites → Ineffective Breathing Pattern r/t
↓ intra- abdominal fluid collection
(ascites)
 Body Image Disturbed r/t personal
vulnerability
Infection and peritonitis → Impaired Skin Integrity r/t
compromised
↓ immunologic status
Gastrointestinal varices → Risk for Injury and bleeding r/t
altered clotting
↓ Mechanism
Edema → Fluid Volume Excess r/t
compromised
↓ regulatory mechanism
Vit deficiency and anemia → Nutrition Imbalanced: less than body
↓ requirements r/t oral intolerance and
liver
Cirrhosis
Mental deterioration → Risk for acute confusion r/t
inability of the liver
to detoxify certain enzymes or drugs

Prioritization of Problems:
1. Nutrition Imbalanced: less than body requirements r/t oral intolerance and
liver cirrhosis - overt
2. Ineffective Breathing Pattern r/t intra- abdominal fluid collection (ascites) -
overt
3. Fluid Volume Excess r/t compromised regulatory mechanism - overt
4. Impaired Skin Integrity r/t compromised immunologic status - overt
5. Activity Intolerance r/t fatigue - overt
6. Body Image Disturbed r/t personal vulnerability - overt
7. Risk for Injury and bleeding r/t altered clotting mechanism -covert
8. Risk for acute confusion r/t inability of the liver to detoxify certain enzymes or
drugs – covert
Assessment Pathophysiolog Objectives Intervention Rationale Evaluation
y

S: “Nahihirapan Cause: excessive STO: After 8  DX: Monitor Rapid shallow STO: fully met
akong huminga” alcohol hours of health respiratory rate, respirations/dyspne pt is no longer
consumption, care depth and effort smay be present dyspheric and
O: v/s reduced protein interventions pt bec. Of hypoxia and O2 is no longer
Temp: 36.7°C intake, exposure will be free of or fluid needed
BP: 110/60 to certain dyspnea, accumulation in
mmHg chemicals and cyanosis, w/  Auscultate abdomen Factors:
PR: 94/min infectious ABG’s and vital breath sounds, Indicates Pt is very
RR: 18/min schistosomiais capacity w/in noting crackles, developing cooperative and
acceptable wheezes, complications, willing to
Conscious:
Necrosis of liver range rhonchi increasing risk of participate in
dyspheric
cells LTO: After 2  Investigate infection any therapy
Prefers to be
weeks of health changes in level
in bed
Destroyed liver care intervention of consciousness Changes in LTO: fully met if
Prefers to cells are pt will establish pt will establish
sleep mentation may
replaced by scar a normal reflect hypoxemia a normal or
Assisted w/ tissue effective effective
and respiratory
ADL by SO respiratory respiratory
 Monitor temp. failure w/c often
Easily pattern pattern
note presence of accompany hepatic
fatigued: Scar tissue chills, increased coma.
pallor exceeds that of coughing,
Appears weak functioning liver changes in Indicative of onset
and restless tissue color/character infection ex.
On O2 at 1- of sputum Pneumonia
2\LPM/NC
 Monitor serial
Irritable thus ABG’s pulse
changes Portal
oximetry, vital
position once obstruction and
capacity
in a while ascites Reveals changes
measurements,
(+) coughing, chest x-rays in respiratory status
non- Ineffective developing
 Tx: keep head
productive Breathing pulmonary
of bed elevated.
Enlarged Pattern complications
 abdomen Position on sides
(ascites)
Facilitates
A: Ineffective  Provide breathing by
Breathing supplemental o2 reducing pressure
Pattern r/t as indicated on the diaphragm
Ascites and minimizes risk
of aspiration of
secretions
Conserve pt’s Maybe necessary
strength by to treat/prevent
providing rest hypoxia. If
periods and respiration/oxygena
assisting with tion inadequate/
activities mechanical
Change ventilation maybe
position in required
every 2 hours Reduces
metabolic and
Assist with oxygen
paracentesis or requirements
thoracentesis
as indicated

Promotes
Ed Encourage expansion and
frequent oxygenation of all
repositioning areas of the lungs
and deep Paracentesis and
breathing thoracentesis are
exercises/cough performed to
ing as remove fluid from
appropriate the abdominal and
Demonstrate thoracic cavities
respectively.
 with respiratory
adjuncts Aids in lung
expansion and
mobilizing secretion

Reduces
incidence of
atelectasis,
enhance
mobilization of
secretions

Assessment Pathophysiolog Objectives Intervention Rationale Evaluation

y

S: “wala akong Cause: excessive STO: After 8  DX: Measure Provide STO: not met
ganang kumain” alcohol hours of health dietary intake by information Pt was not able to
consumption, care intervention calorie count about intake demonstrate
O: v/s reduced protein pt will be able to needs or progressive
Temp: 36.7°C intake, exposure demonstrate  Weigh as deficiencies weight gain
BP: 110/60 to certain progressive indicated, It maybe
mmHg chemicals and weight gain compare difficult to use Factors:
PR: 94/min infectious toward goal with changes in fluid weight as Pt doesn’t like to
RR: 18/min schistosomiais pt appropriate status, recent indicator of eat because he
normalization of weight history, nutritional status claims that he is
Conscious
Necrosis of liver laboratory values skin fold in view of edema already full
Always in bed
cells LTO: After 1 measurement. and ascites. Skin
and asleep
month of health fold Recommendation
Appears weak Destroyed liver care :
measurement
and restless cells are replaced interventions pt Pt needs
are useful in
Globular or by scar tissue will attain encouragement
assessing
enlarged desirable weight NGT insertion
changes in
abdomen Scar tissue with optimal muscle mass and
Prominent exceeds that of maintenance of  Tx: Provide subcutaneous fat LTO:
abdominal functioning liver health diet high in reserves. fully met
veins tissue carbohydrates Provide calories if pt will attain
Tenderness on with protein for energy, desirable body
all quadrants Vit deficiency and intake consistent sparing protein weight with
Dull abdomen anemia with liver for healing optimal
upon function maintenance of
percussion  Elevate head health
Anorexia: food Nutrient of bed during Reduces
intolerance imbalanced: less meals. discomfort from Not met:
than body abdominal If pt will not
Slender body
requirement distention and attain desirable
built
decreases sense body weight with
Increased
of fullness optimal
bowel sounds
produced by maintenance of
Oral health
pressure of
intolerance
 Offer smaller, abdominal
(-) nausea and
more frequent contents and
vomiting
meals ascites in the
(-) fever stomach.
 Provide salt
(-) diarrhea
substitutes, if Decreases
allowed, avoid feeling of
those containing fullness, bloating
ammonia Salt substitutes
enhance the
flavor of foods
and aid in
increasing
 Restrict intake appetite
of caffeine, gas ammonia
producing or potentiates risk
spicy and for
excessively hot encephalopathy.
or cold foods. Aids in
reducing gastric
irtrtation/diarrhe
 Promote a and abdominal
undisturbed rest discomfort that
periods may impair oral
especially before intake and
meals digestion.
Conserving
 Provide oral energy reduces
hygiene before metabolic
meals demands on the
aesthetically liver and
pleasing setting promotes cellular
at mealtime regeneration.
 Ed: Suggest Promotes
soft foods, appetite and
avoiding sense of well-
roughage if being.
indicated.
 Recommend
cessation of Hemorrhage
smoking. form esophageal
varices may
 Encourage pt occur in
to eat meals and advanced
supplementary cirrhosis.
feedings Reduces
excessive gastric
stimulation and
risk of irritation
or bleeding.
Encouragement
is essential fo the
pt w/ anorexia
and
gastrointestinal
discomfort.
 NEUROLOGIC INFECTIONS
BACTERIAL MENINGITIS
- Is an inflammation of the arachnoid, pia, and intervening CSF. The infection spreads throughout the
subarachnoid space about the brain and spinal cord and usually involves the ventricles.
FACTORS PREDISPOSING TO BACTERIAL MENINGITIS
 head trauma
 systemic infection
 post surgical infection
 meningeal infection
 other systemic illness

When pathogenic organisms enter the subarachnoid space >inflammatory reaction (CFS clouding, exudates
formation, changes in subarachnoid arteries (e.g., engorgement with blood, rapture, thrombosis), and congestion of
adjacent tissues.
The pia arachnoid becomes thickened and adhesions form, especially in the basal cisterns. Little change occurs
in brain structures in the early stages.
 Almost any bacteria can enter the body causing meningitis
o The most common are:
 Meningoccocus (Neisseria meningitides)
 Pneumococcus (Streptoccous pneumonia)
 Haemophilus influence
 These organisms are often present in nasopharynx.
 It is not known how they enter the blood stream and the subarachnoid space.

 Clinical manifestations
 Headache
 Prostration
 Chills
 Fever
 N/V
  Backpain
 Stiff neck
 Generalized seizures
 Later stage, confused, stuporous, or semicomatose, petechial, or
hemorrhagic rash may develop

 The patient may be irritable at first, but as the infection progresses the
sensorium becomes clouded and coma may develop
o Signs of meningeal irritation:
 Nuchal rigidity (rigidity of the neck)
 Positive finding of Brudzinski’s sign
 Positive finding of Kernig’s sign

MENINGITIS

infectious organisms gain access to meninges and subarachnoid spaces (viral,

bacterial, yeast)

Exudate forms
↓
Meningeal irritation/inflammation
↓
Cortical inflammation
↓
Cerebral edema
↓
Increased ICP
↓

Vasculitis Increased infection Petechial Hemorrhages Neuritis

Hydrocephalos
↓ ↓ ↓ ↓ ↓
Cortical Brain abscess Septic Emboli Cranial
nerve Increased
Necrosis Septicemias involvement ICP
↓ ↓ ↓
Adrenal DIC Seizures
Compression of
Hemorrhage brain
structures

Hemorrhage Hypoxia
Inadequate perfusion
Shock
↓
DEATH
HEADACHES
 Is a symptom of an underlying disorder rather than a disease itself. The cause
must be identified so that appropriate treatment can be given.
Clients often-self treat headaches with OTC medication without prescription.
Most headaches do not indicate serious disease however; the nurse should
encourage clients with persistent or recurrent headaches to seek neurologic
assessment.
Serious disorders that typically produce headache include intracranial tumors
and infection, bacterial or viral meningitis, head injuries, cerebral hypoxia, severe
HPN, acute or chronic diseases of the eye, nose, ear, throat.

COMMON TYPES OF HEADACHES

I. Migraine
- Are paroxysmal disorders characterized by recurrent throbbing
headaches
- Episodes begin during puberty or ages 20-40 years
- They decrease in frequency and severity with advancing years
- Affects 5-10% of the population
- Women are more susceptible than men are
- Occurs at irregular intervals, frequency varies from several times a week
to several times a year
PATHOPHYSIOLOGY
(vascular theory is currently accepted)
- Constriction of intracranial vessels > neurologic symptoms
- Intense throbbing headache is due to dilation of extracranial and intranial
branches of the external carotid artery
 Psychological factors influence migraine headache
o Perfectionist
o Fatigue
o Excess sleep
o Hunger
o Refractive errors
o Bright light
o Surprises
o Mental and emotional excitement
o Excessive smoking
o High altitudes
o Drinking alcoholic beverages

 Certain foods that seem to precipitate migraine episodes, food

containing beta-phenylethylamine
o Chocolate
o Cheese
o Citrus fruits
o Coffee
o Pork products
o Dairy products
 Familial tendency
  Oral contraceptive may exacerbate migraines or induce their
onset in women previously free from significant headaches. It can
occur during menstruation.
I.1. Classic or Typical Migraine
o Preceded by an aura or prodromal phase in which the client may feel
depressed, irritable, restlss, and perhaps anorexic
o May experience transient neurologic disturbances (visual phenomena,
e.g., flashes of lights, bright spots, distorted vision, diplopia), vertigo, nausea,
diarrhea, abdominal pain, paresthesis (numbness of tingling of lips, face, or
extremities); may lasts a few minutes or several hours.
o Has a “cresendo” quality. It gradually increases in severity until the
pain becomes intense and all-encompassing.>mild discomfort, >prostrating,
throbbing pain >seclusion and lie in bed in a darkened room.
o Pain described as dull and boring, pressing, throbbing, or hammering.
o Unilateral and may be localized to the front, back, or side of the head,
often the temple and eye areas.
o Acute migraine episodes lasts 4-6 hours (accompanied by
photophobia, N/V, vertigo, tremor, diarrhea, excessive sweating or chilliness).
o General sensitivity of all sensory organs and client withdraws from
light and sound.
o Arteries of the head may become prominent and the amplitude of their
pulsation increase, scalp may be very tender, swelling, redness, and excessive
tearing of the eyes, and swelling of the nasal mucosa (sometimes
accompanied by epistaxis) may occur.

I.2. Atypical or Common Migraine

o Begins suddenly with or without prodromal symptoms, may be
generalized or unilateral, and may or may not be accompanied by N/V.

MANAGEMENT:
1. Treat the two phases of migraine, vasoconstriction and vasodilation,
analgesics such as acetaminophen may relieve mild H/A.
2. Severe headaches respond to ergot preparations but only if they are taking
30-60 minutes after headache onset. Ergot must be taken before the vessels
become rigid from edema in their walls.
- Prescribed orally IV or rectally
- Once the migraine becomes intense ergot is of little value, stronger
analgesic such as codeine sulfate, diphenhydramine hydrochloride
(Benadryl).
3. Apply pressure on the common carotid artery and the affected superficial
artery.
4. Lying in a dark, quiet room with ice on the back of the neck during acute
episodes.
5. Relaxation techniques, biofeedback, or counseling directed at preventing
episodes by helping the client understand tensions and resolve major life
conflicts.
6. Follow a restrictive diet, avoid food and beverages that contain tyramine and
have vasoactive qualities.

II. Cluster headaches (Histamine headaches)

 - Sometimes classified as a form of migraine. Most clients experiencing
cluster headaches do not have a history of migraine headaches.
- Excruciating painful, unilateral , and tend to occur in clusters. There is
usually no aura.
- Episodes may occur within a few days, weeks, or occasionally months,
followed by a remission with no symptoms for months or years. Then the
headaches again recur in clusters. Cluster headache may recur at
irregular intervals for many years, often related to times of stress
anxiety, or emotional upset.
- Men are affected five times more often than are women. Episodes usually
begin in middle life and are often worsened by alcoholic consumption.
- The mechanism underlying cluster headache is not well understood but is
believed to be in vascular origin. These headaches were formerly
believed to be caused by sensitivity to histamine.
- During episode, the client experiences:
 Excruciating, throbbing, or steady pain arising high in the nostril
and spreading to one side of the forehead, around and behind the
eye on the affected side.
 The nose and affected eye water, and the skin reddens on the
affected side
 Nasal congestion and conjunctival infection are common.
 Intervention is ineffective because of shortness of episodes.

MANAGEMENT:
1. Lying in a dark, quiet room with ice on the back of the neck during acute
episodes.
2. Indomethacin (Indocin) medication of choice
3. Tricyclic antidepressant
4. Supportive care – clients tend to become depressed over their condition and
fearful recurrent episodes. Some feel they cannot survive another episode.

III. Tension headaches (muscle Contraction Headaches)

- Results from the long-sustained contraction of skeletal muscles around
the scalp, face, and neck and upper back.
- Muscles become tender → client tenses more (primary source of many
headaches associated with excessive emotional tension, anxiety and
depression.)
- Vasodilation of associated cranial arteries may also contribute to muscle
irritability and head pain
- Begin in adolescence but occur most often in middle age. They may
increase significantly in menopause. Pre-menstrual headaches are of this
type.
- Pain is steady, non-pulsatile ache (unilateral or bilateral) in any region of
the head, but more so in the occipital and upper cervical regions and
extends diffusely over the top of the head
- Onset is gradual, with N/V (late reaction), could also be accompanied by
dizziness, tinnitus or lacrimation
- Pain could be precipitated by combing the hair, wearing a hat or
exposure to cold
- Maybe unrelieved for weeks, months or years.
MANAGEMENT:
1. Eliminate source of stimulation (diseased teeth)
2. Psychotherapy for those with prolonged and recurrent muscle tension
headaches of psychological in origin
3. Symptomatic relief: massage affected muscles, apply local heat, rest and
various relaxation techniques
4. Responds well to a combination of non-narcotic analgesic with an anxiety
relieving drug, occasionally a stronger analgesic is needed (e.g., Codeine
sulfate).

CLIENT EDUCATION GUIDE

PREVENTING MIGRAINE HEADACHES

Many things can trigger a migraine headache. It is important for the client to
find out what triggers the headache and avoid the trigger, if possible; if avoidance
of the trigger is not possible, the dose of medication can be adjusted.
Adjusting Medications During Menstrual Cycles. Menstruation and ovulation
may trigger migraines. If medications are taken for migraines, a larger dose may be
required during these times.

Adjusting Dietary Triggers. Alcohol increases the size of blood vessels

(vasodilation) and may increase headache. Some foods contain beta-
phenlethylamine and should be considered possible triggers. These items include
chocolate, cheese, citrus fruits, coffee, pork products and dairy products. The lack
of eating may lower blood sugar and may lead to headache. In this case, small
frequent meals may avert headaches.

Identifying the Role of Stress. Stress may trigger migraines. If stressors cannot
be reduced, then medications may need to be increased. Heat intolerance (such as
vacationing in warm climates) may increase headaches. Other factors related to
stress that might trigger headaches include fatigue, excess sleep, and bright
sunlight causing a glare from water, roads, or car hoods.
 HEMOPHILIA

• A disorder characterized by impaired coagulation of blood and a tendency to

bleed.
• Hereditary coagulation disorder. both hemophilia A (Factor VIII deficiency)
and Hemophilia B (Factor IX deficiency) are inherited as sex linked recessive
disorder and are therefore almost exclusive for males.
• Hereditary and limited to males.
• X-linked recessive disease – it means that, it is common to males but is being
transmitted by females.
• All daughters of hemophiliacs become carrier.
• Transmitted by a female trait carrier
• Absence deficiency or malfunction of any one of clotting factors

TRANSMISSION OF HEMOPHILIA

Genotype of parents Female Male

N Carrier Hemophili N Hemophilia
ac c
Carrier+N male 50% 50% 0% 50% 50%
N 0% 100% 0% 100% 0%
female+Hemophiliac
Carrier+hemophiliac 0% 50% 50% 50% 50%

COMMON TYPES OF HEMOPHILIA

1. Hemophilia A (Classic Hemophilia)

• 80% hemophiliacs
• Factor VIII deficiency (anti hemophilic factor)
 2. Hemophilia B (Christmas Factor)
• Factor IX deficiency (Plasma Thromboplastin component)
3. Hemophila C
• Factor XI deficiency (Plasma Thromboplastin antecedent)

STAGES
1. Mild: clotting factor level 6 to 30%
• Bruise easily, tendency to nose/gum bleeding
2. Moderate:2 to 5 %
• More frequent bleeding episodes; excessive bleeding after surgery or
trauma
3. Severe: 1% or less
• Spontaneous bleeding; severe bleeding
• Hemarthrosis

MANIFESTATIONS:
• Diagnosed usually in infancy or early childhood
• History of excessive bleeding into any part of the body sponataneoulsy
following trauma
• History of excessive bleeding following circumcision and dental extraction
• PTT of Hemophilia A and hemophilia B is prolonged
• Platelet count and prothrombin time is normal

TREATMENT
• Replace deficient coagulation factor when bleeding episodes do not respond
to local treatment (ice bags, manual pressure or dressing, immobilization,
elevation and topical coagulants such as fibrin foam and thrombin)
• Since the deficient factors are contained in the plasma, fresh plasma and
blood or fresh frozen plasma Is given.
• In major hemorrhage, adequate blood levels were difficult to maintain
without overloading person’s circulation with large volumes of blood and
plasma.
• In classic hemophilia, treatment of choice in acute bleeding is infusion of
concentrate of antihemophilic factor (Factor VII)
• Concentrates prevent circulatory overload and produce fewer adverse effects
• Usually people who are being transfused with Factor VIII concentrates are
easy to acquire AIDS because donors are not screened that well

MANAGEMENT:
I. Blood Factor replacement Therapy
 FFP: all clotting factors present
 Cryoprecipitate: factor VIII, fibrinogen
  Lyophilized factor VIII concentrates
 Vit. K dependent complex: Factor VIII, IX, XI, prothrombin
II. Desmopessin for Mild Hemophilia A
 It triggers the release of Factor VIII

CLOTTING FACTORS
1. Factor I – Fibrinogen
2. Factor II – Prothrombin
3. Factor III – Thromboplastin
4. Factor IV – Calcium
5. Factor V – Proaccelerin, labile factor, accelerator globulin
6. Factor VI – omitted
7. Factor VII – Proconvertin, stabile factor, serum prothrombin conversion
accelerator (SPCA)
8. Factor IX – Plasma thromboplastin component (PTC)
9. Factor X - Stuart power factor
10.Factor XI – Plasma Thromboplastin antecedent (PTA)
11.Factor XII – Hageman Factor (HF)
12.Factor XIII – Fibrin Stabilizing Factor

Extrinsic System Intrinsic System

Factor III Factor XII

Factor VII Factor XI

Factor IX

Factor VIII

Scheme of clotting Platelet lysis

Mechanism

Factor X
Factor V

Calcium
Prothrombin Thrombin
 Plasminogen Activator Urokinase
Plasminogen Plasmin

COMMON BLEEDING AND COAGULATION BLOOD TESTS

TEST DESCRIPTION NORMAL VALUES

Bleeding time -Evaluation of vascular 2 to 9 minutes
platelet factors – the time
it takes for a small stab
wound to stop bleeding
Clotting time (CT) -time required for solid 5 to 10 minutes
clot to form (less sensitive
test than PTT)
Prothrombin Time (PT) -indicates rapidity of blood 11 to 16 seconds
clotting (indicates
adequacy of extrinsic
coagulation pathways for
factors I, II, V, VII and X)
Partial Thromboplastin -more sensitive test than 60 to 90 seconds
Time (PTT) PT to evaluate adequacy
of intrinsic coagulation
pathway (Fibrin formation)
Activated Partial -modified PTT; more 26 to 42 seconds
Thromboplastin (APTT) sensitive; quicker to
perform, frequently used
to monitor heparin
therapy and hemoglobin
HYPERTENSION:
• Elevated blood pressure
• A sustained blood pressure greater than 90 mmHg or a sustained systolic
pressure in excess of 140 mmHg is considered to constitute hypertension.
• About 90-95 of hypertension is idiopathic and apparently primary (Essential
hypertension)
• Of the remaining 5-10%, most is secondary to renal disease or less often, to
narrowing of the renal artery, usually by an atheromatous plaque
(Renovascular hypertension)
• Infrequently, secondary hypertension is the result of disease related to the
adrenal glands.

REGULATION OF NORMAL BLOOD PRESSURE:

The magnitude of the arterial blood pressure depends on two hemodynamic
variables:
a. Cardiac output
b. Total peripheral resistance

CARDIAC OUTPUT:
• Influenced by blood volume, which Is greater dependent on body sodium
• Thus, sodium homoestasis is central to blood pressure regulation

TOTAL PERIPHERAL RESISTANCE:

• Predominantly determined at the level of the arterioles and depends on
lumen size, itself dependent on the thickness of the arteriolar wall and the
effects of neural and hormonal influences that either constrict or dilate these
vessels.
 • Normal vascular tone depends on the competition between:
a) Vasoconstricting influences
 Angiotensin II
 Catecholamines
 Thromboxane
 Leukotrienes
 Endothelin
b) Vasodilators:
 Kinins
 Prostaglandins
 Nitric oxide

• Certain metabolic products….

a. Lactic acid
b. Hydrogen ions
c. Adenosine
And hypoxia…can also function as local vasodilators!

GENETIC FACTORS:
• It is now thought that essential hypertension results from an interaction of genetic
and environmental that affect cardiac output or both.

ENVIRONMENTAL FACTORS:
• Environmental factors are thought to contribute to expression of the genetic
determinants of
increased pressure.
• Stress, obesity, physical inactivity, and heavy consumption of salt have all been
implicated as exogenous factors in hypertension.
• In both the major pathways for hypertension – primary renal and primary vascular
defects – heavy sodium intake augments hypertension.

MECHANISMS:
• What then are the primary defect in essential hypertension?
• Two overlapping pathways are proposed:
a. Renal retention of excess sodium
 The existence of genetic factors that result in reduced renal sodium
excretion – in the presence of normal arterial pressure – as the
initiating event.
 Decreased in sodium excretion leads to an increased in fluid
volume and a high cardiac output.
 In the face of an increasing cardiac output, peripheral
vasoconstriction occurs as a result of auto regulation to prevent the
over perfusion of tissues that would ensue from an increase cardiac
output.
 Auto regulation leads to an increase in peripheral resistance,
however, and along with it an elevation of blood pressure.
  At the higher setting of blood pressure, enough additional sodium
can be excreted by the kidneys to equal intake and prevent fluid
retention.
 Thus, an altered but steady state of sodium excretion is achieved
(resetting of pressure natriuresis) but at the expense of stable
increases in blood pressure
b. Vasoconstriction and vascular hypertrophy
 Such increased resistance is caused either by factors that induce
functional vasoconstriction or by stimuli that induce structural
changes in the vessel wall like
a. Remodeling
b. Hypertrophy
c. Hyperplasia of smooth muscle cells
 Leading to thickened wall and narrowed lumen or by both effects.
 Vasoconstrictive influences may consist of:
1. Behavioral or neurogenic factors – as exemplified by the
reduction of blood pressure achieved by meditation
(therelaxation response
2. Increase released of vasoconstrictor agents (eg. Rennin,
catecholamines, endothelin)
3. Increased sensitivity of vascular smooth muscle to constricting
agents.
 Such vasoconstrictive influences, if exerted chronically, or repeatedly
may themselves cause structural thickening of the resistance vessels,
thus perpetuating increased blood pressure.
 Certain vasoconstrictors (eg. Angiotensin II) also function as growth
factors causing smooth muscle hypertrophy, hyperplasia and matrix
deposition.
 Conversely, there is evidence that structural changes in the vessel wall
may occur early in the hypertension, preceding rather than strictly
secondary to the vasoconstriction.
 Such evidence has led to a hypothesis that genetic or environmentally
induced defects in intracellular signaling in smooth muscle cells affect
cell cycle genes and ion fluxes that modulate both smooth cell growth
and increased vascular tone resulting in wall thickening and
vasoconstriction respectively.

SUMMARY:
• Essential hypertension is a complex disorder that almost certainly has more
than one cause.
• It may be initiated by environmental factors – stress, salt intake, estrogens…
Which affect the variables that control blood pressure in the genetically
predisposed individual.
• In established hypertension, both increased cardiac output and increased
peripheral resistance contribute to the increased pressure.

VASCULAR PATHOLOGY:
 • Hypertension accelerates atherogenesis and causes structural changes in the
walls of blood vessels that potentiate both aortic dissection and cerebral
hemorrhage.
• Hypertension is associated with two forms of small blood vessel disease.
a. Hyaline arteriosclerosis
b. Hyperplastic arteriosclerosis
 Both lesions are related to elevations of blood pressure, but other
causes may also be involved.

HYALINE ARTERIOSCLEROSIS:
• The vascular lesion consist of homogenous, pink hyaline thickening of the
walls of arterioles with loss of underlying structural detail and with narrowing
of the lumen.
• It is believed that the lesions reflect leakage of plasma components across
vascular endothelium and increasing extracellular matrix production by
smooth muscle cells.
• Presumably, the chronic hemodynamic stress of hypertension or a metabolic
stress in diabetes accentuates endothelial injury, thus resulting in leakage
and hyaline deposition.
• The narrowing of the arterial lumens causes impairment of the blood supply
to affected organs particularly well exemplified in the kidneys.
• Thus, hyaline arteriosclerosis is a major morphologic characteristic of benign
nephroscerosis in which the arteriolar narrowing causes diffuse renal
ischemia of the kidneys.

HYPERPLASTIC ARTERIOSCLEROSIS:
• Related to more acute or severe elevation of blood pressure and is therefore
characteristic of but not limited to malignant hypertension (diastolic pressure
more than 110 mmHg).
• This form of arteriolar disease can be identified with the light microscopy by
virtue of its onion skin, concentrated laminated thickening of the walls of
arterioles with progressive narrowing of the lumens.

Note:
• The kidneys play a very important role in blood pressure regulation.
• Renal dysfunction is essential for the development and maintenance of both
essential and secondary hypertension.
• The kidney influences both peripheral resistance and sodium homeostasis,
and the rennin-angiotensin system appears central to these influences.
• Rennin elaborated by the juxtaglomerular cells of the kidney transforms
plasma angiotensin to angiotension I.
• angiotension I is converted to angiotension II by angiotension converting
enzyme (ACE)
• angiotension II alters blood pressure by increasing both peripheral resistance
and blood volume.
• Increasing peripheral resistance is achieved largely by its ability to cause
vasoconstriction through direct action on vascular smooth muscle.
 • Blood volume is increased by stimulation of aldosterone secretion --- which
increases distal tubular reabsorption of sodium and thus, of water.
• The kidney produces a variety of vasodepressor or antihypertensive
substances that presumably counterbalance the vasopressor effects of
angiotensin. These include:
a. Prostaglandins
b. Platelet activating factor
c. Urinary kalikrein – kinin system
d. Nitric oxide
• When blood volume is reduced; the GPR falls, this, in turn leads to increased
reabsorption of sodium by the proximal tubules in an attempt to conserve
sodium and expand blood volume.
• GFR – independent natriueretic factors, including atrial natriuretic factor
(ANF), a peptide secreted by heart atria in response to volume expansion,
inhibit sodium reabsorption in distal tubules and cause vasodilation.
• Abnormalities in these renal mechanisms are implicated in the pathogenesis
of secondary hypertension in a variety of renal diseases, but they also play
important roles in essential hypertension.

PATHOGENESIS OF ESSENTIAL HYPERTENSION:

• Arterial Hypertension occurs when changes develop that after the
relationship between blood volume and total peripheral resistance.
• In renovascular hypertension, renal artery stenosis causes decreased
glomerular flow and pressure in the afferent arteriole of the glomerulos and
induces rennin secretion by the juxtaglomerular cells.
• This initiates angiotension II induced vasoconstriction --- increased peripheral
resistance; through the aldosterone mechanism, --- increased sodium
reabsorption and increased blood volume.
• In Pheochromocytoma, a tumor of the adrenal medulla, catecholamines
produced by tumor cells cause episodic vasoconstriction and thus induce
hypertension.

PARKINSON’S DISEASE
 Brain disorder causing progressive deterioration, with muscle rigidity,
akinesia, and voluntary tremors
 Usual cause of death: aspiration pneumonia
 One of the most common crippling diseases in the United States
  Affects more men than women
 Occurs in middle age or later

Pathophysiology:
• Dopaminergic neurons degenerate, causing loss of available dopamine
• Dopamine deficiency prevents affected brain cells from performing their
normal inhibitory function
• Excess excitatory acetylcholine occurs at synapses
• Nondopaminergic receptors are also involved
• Motor neurons are depressed

Causes:
• Usually unknown
• Exposure to such toxins as manganese dust and carbon monoxide

Common Characteristics:
 Muscle rigidity and tremor
 Resistance to passive muscle stretching
 Akinesia and dysarthria and drooling
 High-pitched, monotonous voice, and loss of posture control
 Excessive sweating and decreased GI motility
 Orthostatic hypotension and oily skin and eyes fixed upward
 Complications: injury from falls; food aspiration; urinary tract
infections; skin breakdown

Assessment:
 Insidrous (unilateral pill-roll) tremor, which increases during stress or anxiety
and decreases with purposeful movement and sleep
 Dysphagia
 Fatigue with activities of daily living (ADLs)
 Muscle cramps of legs, neck, and trunk
 Increased perspiration and insomnia, mood changes

Treatment:
• Small, frequent meals and high-bulk food
• Physical therapy and assistive devices to aid ambulation
• Medication: Dopamine replacement drugs, anticholinergics, antiviral agents,
enzyme-inhibiting agents and tricyclic antidepressants
• Surgery used when drug therapy fails
• Destruction of ventrolateral nucleus of thalamus
 New research on the pathogensis of Parkinson’s disease focuses on
damage to the substantia nigra from oxidative stress. Oxidative stress is
believed to:
 Alter the brain’s iron content
 Impair mitochondrial function
 Alter antioxidant and protective systems
 Reduce glutathione
  Damage lipids, proteins, and deoxyribonucleic acid

Nursing Diagnoses:
• Interrupted family processes
• Imbalanced nutrition: less than body requirements
• Bathing or hygiene self-care deficit
• Disturbed body image
• Chronic low self-esteem
• Constipation
• Dressing or grooming self-care deficit
• Feeding self-care deficit
• Impaired physical mobility, social interaction, verbal communication
• Ineffective coping and risk for injury

The patient will:

 Perform ADLs and develop alternative means of communicating
 Avoid injury and maintain adequate calorie intake
 Express positive feelings about himself
 Develop adequate coping behaviors and seek support resources

Nursing Interventions:
• Take measures to prevent aspiration
• Protect the patient from injury
• Stress the importance of rest periods between activities
• Ensure adequate nutrition
• Provide frequent warm baths and massage
• Encourage the patient to enroll in a physical therapy program
• Provide emotional and psychological support
• Encourage the patient to be independent

Monitor:
 Vital signs, intake and output
 Drug therapy and adverse reactions to medications
 Postoperatively: signs of hemorrhage and increased intracranial pressure

MYASTHENIA GRAVIS
 Abnormal fatigability of striated (skeletal) muscles
 Sporadic but progressive weakness
  Muscle weakness exacerbations by exercise and repetitive movement
 Muscle weakness improved by anticholinesterase drugs
 Initial symptoms related to cranial nerves
 With respiratory system involvement, may be life-threatening
 Spontaneous remissions in about 25% of patients
 Occurs at any age
 Three times more common in women than men
 Highest in women ages 18 to 25, in men ages, 50 to 60
 Transient myasthenia in about 20%of infants born to myasthenic mothers

Pathophysiology:
• Blood cells and thymus gland produce antibosies that block, destroy, or
weaken neuroreceptors (which transmit nerve impulses)
• The result is failure in transmission of nerve impulses at the neuromuscular
junction

Causes:
• Autoimmune disorder associated with the thymus gland
• Accompanies other immune and thyroid disorders

Common Characteristics:
 Weak eye closure, ptosis and
 Diplopia
 Skeletal muscle weakness; paralysis
 Complications in respiratory distress, pneumonia, aspiration

Assessment:
 Varying assessment findings
 Progressive muscle weakness
 Extreme weakness and fatigue (cardiac symptoms)
 Ptosis and diplopia (the most common sign and symptom)
 Difficulty chewing and swallowing
 Jaw hanging open (especially when tired) and
 Head bobbing
 Symptoms milder on awakening worsen as the day progresses
 Short rest periods that becomes more intense during menses, after emotional
stress, after prolonged exposure to sunlight or cold, and with infections

Physical Findings:
 Sleepy, masklike expression
  Drooping jaw
 Ptosis
 Decreased breath sounds and tidal volume
 Respiratory distress and myathenic crisis

Treatment:
 Plasmapheresis
 Emergency airway and ventilation management
 Diet as tolerated
 Activity as tolerated; exercise may exacerbate symptoms
 Medication: Anticholinesterase drugs, cortiscosteroids, I.V, immune globulin
 Surgery: Thymectomy

MULTIPLE SCLEROSIS
• Progressive demyellination of white matter of brain and spinal cord
• Characterized by exacerbations and remissions
 • May progress rapidly, causing death within months
• Prognosis varies (70% lead active lives with prolonged remissions
• Highest in women, among people in northern urban areas, in higher
socioeconomic groups
• Family history increases with living in a cold, damp climate
• Major cause of chronic disability in young adults ages 20 to 40

Pathophysiology:
• Sporadic patches of demyelination occur in the central nervous system (CNS),
resulting in widespread and varied neurologic dysfunction

Causes:
• Exact cause unknown
• Slowly acting viral infection
• An autoimmune response of the nervous system
• Allergic response
• Events that precede the onset:
 Emotional distress
 Overwork
 Fatigue
 Pregnancy
 Acute respiratory tract infections
• Generic factors possibly also involved

Risk Factors:
• Trauma, Anoxia, and toxins
• Nutritional deficiencies
• Vascular lesions
• Anorexia nervosa

Common Characteristics:
• Dependent on the extent and site of myelin destruction
• Sensory impairment
• Muscle dysfunction
• Bladder and bowel disturbances
• Speech problems and fatigue
• Complications in injuries from falls, urinary tract infections, constipation,
contractures, pressure ulcers and pneumonia

• Multiple Sclerosis (MS)described as:

  Elapsing remitting – clear elapses with full recovery lasting disability.
Between attacks, the disease doesn’t worsen
 Primary progressive – steady progression or worsening of the disease
from the onset with minor recovery or plateaus
 Secondary progressive begins as a pattern of clear-cut relapses and
recovery but becomes steadily progressive and worsens between
acute attacks
 Progressive relapsing – steadily progressive from the onset but also
has clear, acute attacks. Differential diagnosis must rule out spinal
cord, multiple small strokes, syphilis or another infection, thyroid
disease and chronic fatigue syndrome

Assessment:
• Symptoms related to extent and site of myelin destruction, extent of
remyelination and adequacy of subsequent restored synaptic transmission
• Visual problems and sensory impairment (the 1st signs)
• Blurred vision or diplopia
• Urinary problems
• Emotional lability
• Dysphagia
• Bowel disturbances (involuntary evacuation or constipation)
• Fatigue (typically the most disabling symptom)
• Poor articulation
• Muscle weakness of the involved area
• Spasticity; hyperreflexia
• Intention tremor and gait ataxia
• Paralysis, ranging from monoplegia to quadriplegia
• Nystagmus scotoma
• Optic neuritis and Ophthalmoplegia

Treatment:
 General for acute exacerbations, for the disease process and for related signs
and symptoms
 High fluid and fiber intake in case of constipation
 Frequent rest periods
 Medications: I.V. steroids followed by oral steroids, immunosuppresants,
antimetabolics, alkylating drugs, biological response modifiers

Nursing Diagnoses:
• Activity intolerance
• Interrupted family processes
 • Imbalanced nutrition: less than body requirements
• Ineffective role performances
• Disturbed thought processes
• Impaired urinary elimination
• Chronic low self-esteem
• Constipation
• Fatigue
• Impaired physical mobility
• Compromised family coping
• Ineffective coping
• Deficient knowledge chronic pain
• Risk for infection and injury

The patient will:

 Perform activities of daily living
 Remain free from infection
 Maintain joint mobility
 And range of motion
 Express feelings of increased energy and decreased fatigue
 Develop regular bowel and bladder habit
 Use support systems and coping mechanism

Nursing Intervention:
• Provide emotional and psychological support
• Assist with physical therapy program
• Provide adequate rest periods
• Promote emotional stability
• Keep the bedpan or urinal readily available because the need to void is
immediate
• Provide bowel and bladder training if indicated
• Administer medications
• Monitor:
o Response to medications
o Adverse drug reactions
o Sensory drug reactions
o Muscle dysfunction
o Energy level
o Signs and symptoms of infection
o Speech
o Elimination patterns vision changes
o Laboratory results
 AMYOTROPHIC LATERAL SCLEROSI
 Most common motor neuron disease of muscular atrophy
 Chronic, progressive and deliberating disease that’s invariably fatal
 No cure
 Also known as Lou Gehrig’s disease
 3 times more common in men than in women
 Affects people ages 40 to 70

Pathophysiology:
• An excitatory neurotransmitter that accumulates to toxic levels
• Motor units that no longer innervate
• Progressive degeneration of axons that cause loss of myelin
• Progressive degeneration of upper and lower motor neurons
• Progressive degeneration of motor nuclei in the cerebral cortex and
corticospinal tracts

Causes:
• Exact cause unknown
• 10% of patients with amyotrophic lateral sclerosis (ALS) inherit the disease as
an autosomal dominant trait
• Virus that creates metabolic disturbances in motor neurons
• Immune complexes such as those formed in autoimmune disorders

Precipitating factor that cause acute deterioration:

• Severe stress, such as myocardial infraction
• Traumatic injury
• Viral infections
• Physical exhaustion

Common Characteristics:
• Muscle weakness
• Atrophy
• Fasciculations
• Respiratory tract infections
• Complications of physical immobility

Assessment:
 Mental function intact
  Family history of ALS
 Asymmetrical weakness 1st noticed in one limb
 Easy fatigue and easy cramping in the affected muscles

Physical Findings:
 Location of affected motor neurons
 Severity of the disease
 Fasciculations in the affected muscles
 Progressive weakness in muscles of the arms, legs and trunk
 Brisk and overactive stretch reflexes
 Difficulty talking, chewing, swallowing and breathing
 Shortness of breath and occasional drooling

Treatment:
 Rehabilitation
 May need tube feedings
 No restrictions : as tolerated
 Medication: muscle relaxants, dantrolene, Baclofen
 I.V. or intrathecal administration of thyrotropin-releasing hormone

Nursing Diagnoses:
 Imbaanced nutrition: less than body requirements
 Anticipatory grieving
 Anxiety
 Bathing or hygiene self-care deficit
 Dressing or grooming self-care deficit
 Feeding self-care deficit
 Hopelessness
 Impaired physical mobility
 Impaired airway clearance
 Ineffective breathing pattern
 Ineffective coping
 Compromised family coping
 Deficient knowledge (ALS)
 Risk for impaired skin integrity
 Risk for infection

The patient will:

• Maintain a patent airway and adequate ventilation
• Maintain joint mobility and range of motion (ROM)
• Maintain daily calorie requirements
 • Seek support systems and exhibit adequate coping behaviors
• Remain free from infections

Nursing Interventions:
 Provide emotional and psychological support
 Teach about active exercises and ROM exercises
 Promote independence
 Teach about meticulous skin care
 Turn and reposition the patient frequently
 Administer ordered medication
 Teach how to perform deep-breathing and coughing exercises
 Provide airway and respiratory management
 Promote nutrition
 Teach about swallowing regimens and aspirations precautions
 Monitor:
o Muscle weakness
o Respiratory status
o Speech
o Swallowing ability
o Skin integrity
o Nutritional status
o Response to treatment
o Complications
o Signs and symptoms of infection

• Modifying the home for a Patient with ALS

Guidelines:
• Explain basic safety precautions, such as keeping stairs and pathways
free from clutter, using nonskid mats in the bathroom and in place of
loose throw rugs; keeping stairs well lit; installing handrails in
stairwells and the shower, tub and toilet areas and removing electrical
and telephone cords from traffic areas.
• Discuss the need for rearranging the furniture moving items in or out
of patient’s care area, and obtaining such equipment as a hospital bed,
a commode, or oxygen equipment.
• Recommend devices to ease the patient’s and caregiver’s work such
as extra pillows or wedge pillows to help the patient sit up, a draw
sheet to help him move up in bed, a lap tray for eating, or a bell for
calling the caregiver.
• Help the patient adjust to changes in the environment. Encourage
independence.
 • Advise the patient to keep suction due to handy to reduce the fear of
choking due to secretion accumulation and dysphagia. Teach him to
suction himself.

GUILLAIN-BARRE SYNDROME
 A form of polyneuritis
 Acute, rapidly progressive, and potentiaaly fatal

Three Phases:
• Acute – lasting from 1st symptoms, ending in 1 to 3 weeks
• Plateau – lasting several days to 2 weeks
• Recovery – coincides with remyelination and axonal process regrowth;
extends over 4 to 3 years; recovery possibly not complete

Pathophysiology:
 Segmented demyclination of peripheral nerves occurs, preventing normal
transmission of electrical impulses
 Sensorimotor nerve roots are affected; autonomic nerve transmission may
also be affected

Causes:
 Unknown
 Virus can cause cell-mediated immunologic attack on peripheral nerves

Risk Factors:
 Surgery
 Rabies or swine influenza vaccination
 Viral illness
 Hodgkin’s or some other malignant disease
 Lupus erythematosus

Common Characteristics:
 Symmetrical muscle weakness initially in lower extremities and progressing
to upper extremities
 Parethesia
 Diplegia
 Dyshagia
 Hypotonia
 Areflexia
Complications:
 Thrombophlebitis
 Pressure ulcers, contractures and muscle wasting
 Aspiration and respiratory and cardiac compromise

Assessment:
 Minor febrile illness 1 to 4 weeks before symptoms
 Tingling and numbness (paresthesia) in the legs
 Progression of symptoms to arms, trunk and finally, the face
 Stiffness and pain in the calves

Physical Findings:
 Muscle weakness (major neurologic sign)
 Sensory loss, usually in the legs (spreads to arms)
 Difficulty in taking, chewing and swallowing
 Paralysis of the ocular, facial and oropharyngeal muscles
 Loss of position sense
 Diminishes or absent deep tendon reflexes

Diagnostic Procedures:
• Cerebrospinal fluid (CSF) analysis may slow a normal white blood cell count,
an elevated protein count and in severe disease, increased CSF pressure.

Others:
• Electromyography may demonstrate repeated firing of the same motor unit
instead of widespread sectional stimulation
• Nerve conduction studies show marked slowing of nerve conduction velocities

Treatment:
 Primarily supportive
 Possible endocrinal intubation or tracheotomy
 Volume replacement
 Plasmapheresis
 Possible tube feeding with endotracheal intubation
 Adequate calorie intake
 Exercise program to prevent contractures
 I.V. beta-adrenergic blockers and parasympatholytics
 I.V. immune globulin and possible tracheostomy
  Possible gastrotomy or jejunotomy feeding tube insertion

Nursing Diagnoses:
• Imbalanced nutrition: less than body requirements
• Impaired urinary elimination
• Anxiety and fear
• Impaired gas exchange and impaired physical mobility
• Impaired verbal communication and ineffective breathing pattern
The patient will:
 Maintain a patent airway and adequate ventilation
 Develop alternate means of expressing self
 Maintain required calorie intake daily
 Establish routine urinary elimination patterns
 Maintain joint mobility and range of motion (ROM)

Nursing Interventions:
 Establish a means of communication before intubation is required
 Turn and reposition the patient
 Encourage coughing and deep breathing
 Begin respiratory support at the first sign of dyspnea
 Provide meticulous skin care
 Administer passive ROM exercises
 In case of facial paralysis, provide eye and mouth care
 Prevent constipation
 Provide emotional support
 Administer medications, as ordered
 Monitor:
o Vital signs
o Breath sounds
o Arterial blood gas measurements
o Level of consciousness
o Continual respiratory function
o Pulse oximetry
o Signs of thrombophlebitis
o Signs of urine retention
o Response to medications