FINAL STUDY GUIDE Neurological System 1. Cranial nerves I. Olfactory (Smell) II. Optic (Vision) III.

Oculomotor (Eye movement, pupillary constriction, upper eyelid elevation) IV. Trochlear (Down and in eye movement) V. Trigeminal (Chewing, corneal reflex, face and scalp sensations) VI. Abducens (Lateral eye movement) VII. Facial (Expression in forehead, eye, and mouth; taste) VIII. Accoustic (Hearing, balance) IX. Glossopharyngeal (Swallowing, salivating, taste) X. Vagus (Swallowing, gag reflex, talking, sensations of the throat, larynx, and abdominal viscera) XI. Accessory (Shoulder movement/ head rotation) XII. Hypoglossal (Tongue movement) 2. Assessment findings Memory impairment, agnosia (inability to recognize objects), numbness/tingling, muscle wekness, twitching/spasm, HA, dizziness, fainting, loss of balance/coordination, N&V, ringing in the ears,emotional lability, blurred/double vision, change in bladder/bowel pattern, tremors, stiff neck, seizures, drooping eyelids 3. Glasgow Coma Scale Provides a quick, standardized account of neurological status. Assess opening response, motor response, and verbal response On a scale of 3 to15, a score of 7 or less indicates severe neurological damage 4. Diagnostic Testing and Procedure EEG (Noninvasive test of the brain that reveals a graphic representation of the brains electrical activity) o Nursing intervention before the procedure 1. Explain the procedure to the pt. 2. Determine the pt.s ability to lie still 3. Explain to the pt. that they will be subject to stimuli (lights and sounds) 4. Withhold medications, stimulants, and depressants for 24-48 hrs before the procedure Computerized tomography (CT) scan (Noninvasive test , which contrast may be used to visualize the brain and its structure) o Nursing intervention before the procedure 1. See if the pt. is allergic to iodine, seafood, and radiopaque dye 2. Explain the procedure to the pt.

3. 4. 5. 6.

Obtain signed consent form Tell the pt. they will have to lie still during the test. Possible throat irritation and flushing in the face, if dye is used Relieve anxiety and administer sedation, as prescribed

Magnetic Resonance Imaging (MRI) (Noninvasive scan using magnetic and radio waves to visualize the brain and its structure) o Nursing intervention before the procedure 1. Be ware that a pt. w/ a pacemaker, surgical or orthopedic clip, aneurysm clip, artificial heart valves, bullet fragment, ect. shouldnt be scanned 2. Assess for hx of claustrophobia 3. Remove jewelry and metal objects from the pt. 4. Determine the pt.s ability to lie still 5. Obtain signed consent form 6. Administer sedation as prescribed. Cerebral angiography (Invasive procedure using a radiopaque dye to examine the cerebral arteries) o Nursing intervention before the procedure 1. See if the pt. is allergic to iodine, seafood, and radiopaque dye 2. Obtain signed consent form 3. Possible throat irritation, flushing in the face, and ,metallic taste in the mouth o Nursing intervention after the procedure 1. Monitor VS 2. Check insertion site for bleeding 3. Maintain affected extremity in straight alignment for 6hrs, or as order to prevent a hematoma 4. Check pulse in affected extremity 5. Provide adequate hydration 6. Relieve anxiety Lumbar puncture (Invasive procedure that collects CSF from the lumbar subarachnoid space, measure CSF pressure, and injection of radiopaque dye for myelogram) o Nursing intervention before the procedure 1. Obtain signed consent form 2. Determine the pt.s ability to lie still in a flexed, lateral, recumbent position 3. The presence of increased intracranial pressure is a contraindication of the procedure because brain herniation may develop when CSF is removed o Nursing intervention after the procedure 1. Keep the pt. flat in the prone position for 2hrs, side-lying position for 2-3 hrs prone or supine position for 6 or more hrs 2. Check puncture site for bleeding 3. Monitor for HA 4. Encourage fluids to offset CSF leakage

(EMG) Electromyography (Noninvasive test , graphic recording of the electrical activity of a muscle ) o Nursing intervention 1. The pt. must flex and relax the muscles during the procedure 2. Cooperation is needed during the test 3. Pt. will feel some discomfort 4. Administer analgesics PRN after the procedure Skull x-ray (Radiographic picture of the head and neck bones) o Nursing intervention before the procedure 1. Determine the pt.s ability to lie still Positron emission tomography (PET) scan (Invasive procedure that involves injection of a radioisotope; provides visualization of oxygen uptake, blood flow, and glucose metabolism) o Nursing intervention 1. Determine the pt.s ability to lie still 2. Withhold alcohol, tobacco, and caffeine for 24hrs before the test 3. Withhold medications before the test 4. Check the injection site for bleeding after the procedure

5. Risk Factors Modifiable o Exposure to chemical or environmental pollutants o Substance abuse o Smoking o Alcohol o Participation in contact sports o Hypertension o Diabetes Nonmodifiable o Aging o Family hx of neurologic disease o Hx of cardiac disease o Hx of head injury o Exposure to viral or bacterial infection 6. Parkinsons Disease Progressive degenerative disease of the extrapyramidal system (EPS) associated with dopamine deficiency Pathophysiology

o Nerve cells in the basal ganglia are destroyed, resulting in impaired muscular function. Lack of dopamine results in inhibition of the synaptic transmitter for muscle tone and coordination Assessment findings o Pill rolling tremors o Shuffling gait o Masklike facial expression o Stiff joints o Cogwheel rigidity o Stooped posture Medical Management o High-residue, high-calorie, high-protein diet; soft foods o Anticholinergics o Antiparkinsonian agent o Antispasmodic o Antidepressant o Dopamine receptor agonists Nursing intervention o Prevent falls o Maintain a patent airway o Reinforce gait training o Reinforce independence in care o Assess neurovascular and respiratory status Pt. education o Stop smoking o Regular exercise o Stress reduction strategies o Avoid alcohol

7. Multiple Sclerosis Progressive immune-mediate demyelinating disease of motor and sensory neurons that has periods of remissions and exacerbation Pathophysiology o Scattered demyelination occurs in the brain and spinal cord o Degeneration of myelin shealth results in patches of sclerotic tissue and impaired conduction of motor nerve impulses. Assessment finding o Weakness o Nystagmus

o Diplopia o Impaired sensation o Optic neuritis o Blurred vision o Fatigue o Pain Causes o Autoimmune disease o Virus o Genetic disposition o Environment exposure Medical management o Muscle relaxant o Immunosuppressant o Skeletal muscle relaxant o Glucocorticoids o Plasmapheresis o Physical therapy o Speech therapy Nursing interventions o Maintain active and passive ROM o Establish a bowel and bladder pattern o Maintain activity w/ adequate rest periods o Prevent injury o Maintain a stress free environment o Encourage fluids o Avoid exposure to others w/ infection o Avoid temperature extreme

8. Myasthenia Gravis Neuromuscular disorder that results in weakness of voluntary muscles Pathophysiology o Disturbance occurs in transmission of nerve impulses at the myoneural junction o Transmission defect results from deficiency in release of acetylcholine or deficient number of receptor sites o Thymus gland may remain active, triggering autoimmune reaction Assessment findings o Muscle weakness that with activity and with rest o Dysphagia o Diplopia o Dysarthria o Dysphonia o Respiratory distress

o Masklike expression o Drooling o Impaired speech Medical management o High calorie diet o Activity as tolerated o Glucocorticoids o Anticholinesterases o Immunosuppressants o Plasmopherisis o Antacids (Maalox) Nursing interventions o Assess swallow gag reflexs o Watch the pt. for choking while eating o Encourage small, frequent meals o Administer medications, before meals (maximize muscles for swallowing) o Provide oral hygiene o Avoid hot foods

9. Guillain-Barr Syndrome Peripheral polyneuritis characterized by ascending paralysis Pathophysiology o Preceding infection synthesizes lymphocytes, which attack the myelin sheath, causing demyelination o Demyelination is followed by inflammation around nerve roots, veins, and capillaries o Inflammatory process compresses nerve roots Assessment findings o Generalized weakness o Paralysis that starts in the legs (ascending) o Respiratory paralysis o Tachycardia o HTN o temp o Facial weakness o Dysphagia o Dysarthria o Ptosis Causes o Autoimmune disease o Infection o Virus o Pregnancy

o Vaccination Medical management o Diet: High calorie, high protein o Activity: bed rest, active and passive ROM, isometric exercise o Nutritional support: enteral feeding o Physical therapy o Glucocorticoids o Intubation and mechanical ventilation Nursing interventions o Semi-fowlers position o Assess muscle strength, gag and swallow reflexes o Maintain the position and patency of NG and ET tubes o Provide suction and turning o Encourage TCDB and use of incentive spirometry o Turn pt. q2hrs o Apply antiembolism stockings o Assess for Homans sign

10. Seizure Involuntary muscle contractions caused by abnormal discharge of electrical impulses from nerve cells Classification o Generalized (involvement of both hemispheres) Absence (petit mal)- sudden onset , last 5-10sec, loss of responsiveness, lip smacking Myoclonic (movement disorder, not a seizure) sudden, brief, shock-like involuntary contraction of one muscle group Clonic-opposing muscle contract & relax alternately in rhythmic pattern; mucus production Tonic- muscles are maintained in continuous contracted state (rigid posture); variable loss of consciousness, pupils dilate, eyes roll up, may foam @ mouth Grand mal (tonic-clonic)- violent total body seizure; aura, tonic 1st (2030sec), clonic 2nd (postictal symptoms) Atonic- drop & fall attack; loss of posture tone Akinetic- sudden brief loss of muscle tone or posture; temporary loss of consciousness o Partial (focal seizures) involvement of one hemisphere Simple (symptoms confined to one hemisphere) no loss of consciousness, hallucinations, tachycardia, flushing Complex (begins in once focal area but spreads to both) loss of consciousness , aura of visual disturbance

o Status epilepticus Prolonged or frequent repetition of seizures w/out interruption; consciousness not regained between seizures, last more than 30 minutes Assessment findings o Aura o Loss of consciousness o Muscle twitches & spasms o Dyspnea o Fixed & dilated pupils Medical management o Seizure precautions o Anticonvulsants o Diet: ketogenic o Bed rest o Labs: potassium, glucose Nursing interventions o Maintain a patent airway o Protect the pt. from injury o Observe and record seizure activity o Avoid alcohol

11. Increased Intracranial Pressure ICP elevated beyond the normal pressure exerted by blood, brain, and CSF within the skull Pathophysiology o Results in compromised cerebral circulation and anoxia, which can lead to brain injury Assessment findings o Restlessness o HTN o Bradycardia o Pupillary changes (sluggich reaction, dilation) o Altered LOC o Abnormal posturing (decortication/decerebration) o HA o Papilledema Causes o Brain tumor o Edema o Hemorrhage o Hydrocephalus Medical management o O2 therapy o Semi-Fowlers position

o Labs: postassium, glucose, sodium, osmolality, BUN, creatinine o Diuretics o Anticonvulant o Glucocortcoid o Bed rest, passive ROM Nursing interventions o Maintain fluid restriction o Maintain neutral alignment of the neck with his body o Maintain quite and dimly lit room o Administer O2 o Reposition q2hr o Enforce bed rest

12. Stroke Disruption of cerebral circulation due to ischemia or hemorrhage that result in motor and sensory deficit Pathophysiology o Disruption of cerebral blood flow Assessment findings o Sudden numbness or weakness on one side of the body o Sudden confusion or trouble speaking o Sudden visual disturbance o Sudden difficulty walking o Sudden severe headache Causes o Thrombosis o Embolism o Hemorrhage Risk factors o Smoking o HTN o Atrial fibrillation o Family hx o After age 55 o African Americans o Men o DM o Obesity o Migraines o Sickle cell disease Medical management o Maintain ABC o O2 therapy

o Antihypertensives o Physical, Speech, & Occupational therapy o Reperfusion agents: tissue plasminogen activator (Activase), if symptoms are recognized within 3hrs of onset o Semi-fowlers position o Active and passive ROM and isometric exercises Nursing interventions o O2 therapy o Monitor swallowing ability o Maintain aspiration precautions o Apply antiembolism stockings o Assess for receptive and expressive aphasia

13. (ALS) Amyotrophic Lateral Sclerosis (Lou Gehrig Disease) Progressive degenerative neurologic disease resulting in decreased motor function in the upper and lower motor neuron system Pathophysiology o Myelin sheaths are destroyed and replaced with scar tissue, resulting in distorted or blocked nerve impulses o Nerve cells die and muscle fibers have atrophic changes Assessment findings o Fatigue o Dysphagia o Muscle weakness of hands and arms o Awkwardness of fine finger movements Causes o Genetic predisposition o virus Medical management o Focus on symptomatic relief o Antispasmodics o Mechanical ventilator: negative pressure Nursing interventions o Assess swallow and gag reflexes o Monitor for choking when eating o Maintain tucked chin position while eating or drinking o Encourage active ROM and assist w/ passive ROM exercise 14. Meningitis Inflammation of the brain and spinal cord meninges Pathophysiology o Infecting organisms gain entry through basilar skull fractures w/ dural tears, chronic otitis media or sinusitis, neurosurgical contamination, penetrating head wounds, or septicemia

o Exudate formation causes meningeal irritation & ICP Assessment findings o Fever o Chills o Severe throbbing HA o Tachycardia o Petechial rash o Photophobia o Nuchal rigidity o LOC o Seizures Causes o Bacterial infection o Viral infection o Fungal infection Medical management o IV therapy: electrolyte replacement o O2 therapy o Antibiotics o Anticonvulsants o Diuretics o Diet: w/hold food & fluids as ordered; enteral or parenteral feeding as indicated o Isolation Nursing interventions o Maintain a quite, dimly lit environment o Maintain seizure precautions o O2 therapy o Bed rest in semi-fowlers position o Reposition q2hrs; provide ROM o Use a cooling blanket or tepid bath to control temperature

15. Bells Palsy Disease of the 7th cranial nerve that produces unilateral facial weakness or paralysis Pathophysiology o The conduction block is due to an inflammatory reaction around the nerve Assessment findings o Inability to close the eye completely on the affected side o Pain around the jaw or ear o Unilateral facial weakness o Ringing in the ears o Speech difficulties o Taste distortion on the affected anterior portion of the tongue Causes

o Infection o Hemorrhage o Tumor o Meningitis o Stress o Pregnancy (3rd trimester) Medical management o Corticosteroid o Moist heat o Physical therapy o Diet: soft o Semi-fowlers position Nursing interventions o Arrange for privacy at mealtimes o Protect eye w/ patch, as indicated o Apply moist heat to the face to reduce pain o Apply facial sling to improve lip alignment o Provide frequent oral care o Encourage active facial exercise o Teach pt. to chew on unaffected side of the mouth

Sensory Disorders 1. Diagnostic Tests & Procedures Extraocular eye muscle testing o Tests parallel alignment of the eyes o Test integrity of the nervous control of eye muscles (CN 3,4,6) o The pt. follows a pencil or finger as it moves in the shape of the letter H Risk Factors o Modifiable Eyes- work environment exposure , exposure to sun, sport activities Ears- work environment exposure, exposure to loud noise, use of earphones o Nonmodifiable Eyes- aging, diabetes, trauma, glaucoma, HTN, cataracts, family hx, eye surgery or trauma Ears- diabetes, aging, ear trauma, congenital or genetic abnormalities 2. Glaucoma Visual field loss because of damage to the optic nerve caused by IOP Pathophysiology o Open-angle: IOP is caused by resistance to aqueous humor drainage, resulting in neuronal & optic nerve degeneration o Acute-angle closure: resistance to aqueous humor flow caused by blockage of trabecular meshwork by the peripheral iris Causes

o DM o Family hx o Previous eye trauma or surgery o Plateau iris o Obesity o Smoking o Aging o African Americans o HTN Assessment findings o Open-angle (begins in 1 eye & progresses to the other eye, peripheral vision, IOP, mild HA, halos around lights) o Acute-angle (unilateral, acute eye or facial pain, halo vision, IOP, N&V, dilated pupils, redness in the eye, blurred vision) Medical management o Dietary restriction: sodium and fluids o Avoid drugs such as, atropine, anticholinergics, or others w/ pupil dilating effects o Topical beta-adrenergic agonist blocker & adrenergic agonist o Carbonic anhydrase inhibitors o Miotic agent o Surgery Nursing Interventions o Teach the pt. to avoid rubbing the eyes o Teach the pt. to wear protective glasses or goggles while participating in sports or swimming o Monitor for redness, discharge, watering, blurred or cloudy vision, halos, flashes of lights, and floaters

3. Retinal Detachment Separation of the sensory layers of the retina from the underlying retinal pigment epithelium. Vitreous humor leaks behind the retina Pathophysiology o Retinal separation occurs when vitreous body traction causes retinal tears or holes; fluids leak through holes or tears behind the retina Causes o Aging o Diabetic neovascularization o Trauma o Intraocular surgery o Hemorrhage o Myopia Assessment findings o Floating spots o Recurrent flashes of light

o Painless vision loss (maybe described as veil, curtain, or cobweb that eliminates part of the visual field Medical management o Complete bed rest with the retinal hole or tear at the lowest point of the eye o Eye patch o Restrict eye movement until surgical attachment o Surgical repair Nursing Interventions o Wash the face w/ no tear shampoo o Administer cycloplegic-mydriatic eye drops as ordered Post-op o Tell the pt. to avoid activities that IOP (coughing, sneezing, vomiting, lifting, straining, bending from the waist, & rapid head movement) o Protect the eye with a shield or glasses o Apply cold compression as ordered o Teach the pt. to report fever, yellow or green eye discharge, redness or puffiness, reduced vision o Teach pt. to wear a eye shield @ night

4. Mnires Disease Inner ear disorder characterized by vertigo, tinnitus, a sensation of pressure in the ears, & neurosensory hearing loss Pathophysiology o Distention & fluid in the ear occur because of the volume of endolymph Causes o Autoimmune disorder o Allergic response o Abnormal hormonal influence on blood flow to the labyrinth o Injury Assessment findings o Vertigo w/ N&V o Tinnitus o Pressure or fullness in the ear o Fluctuating unilateral neurosensory hearing hearing loss of low tones Medical management o Low salt, sugar diet o Avoid alcohol, coffee, chocolate o Stop smoking o Benzodiazepine o Anticholinergic o Antihistamine o Diuretic Nursing Interventions o Assess hearing status

o Safety GI system 1. Diagnostic Test Endoscopy o NI before: W/hold food/fluids for 6-12hrs; obtain signed consent form o NI after: W/hold food/fluids until gag and cough reflex return Liver biopsy o NI before: W/hold food/fluids for 6-12hrs; obtain signed consent form; instruct the pt. to exhale & hold their breath during insertion of the needle o NI after: Check insertion site for bleeding; observe for signs of shock & pneumothroax; position on the right lateral side for hemostasis 2. Risk factors Modifiable o Diet o Smoking o Stress o Alcohol o inactivity Nonmodifiable o Family hx o Hx of GI dysfunction 3. Cholecystectomy (surgical removal of the gallbladder) Pre-op NI o Demonstrate TCDB, splinting, and ROM exercise for post-op o Obtain consent form Post-op NI o Check respiratory status & fluid balance o Wound care & dressing change o Reinforce TCDB & splinting incision o Semi-fowlers position o Teach pt. to avoid lifting for 6 wks o Adhere to a low fat diet for 6 wks 4. Gastric surgery Pre-op NI o Demonstrate TCDB, splinting, and ROM exercise for post-op o Obtain consent form o Administer bowel preparation Post-op NI o Reinforce TCDB & splinting incision, incentive spirometry o Wound care & dressing change

o o o o o

Semi-fowlers position Apply sequential compression devices Daily weight food intake gradually as tolerated; eat 6 small meals a day Limit fluids with meals

5. Hiatal Hernia Protrusion of the stomach through the diaphragm into the thoracic cavity Pathophysiology o The opening in the diaphragm where the esophagus enters the stomach becomes enlarged and weakened Cause o Congenital weakness o Trauma o abdominal pressure Contributing factors o Obesity o Pregnancy o Ascites o Aging Assessment findings o Dysphagia o Regurgitation o Sternal pain 1-4 hrs after eating (heartburn) o Vomiting o Pyrosis o Tachycardia Medical management o Small frequent meals o Avoidance of spicy or irritating foods o Semi-fowlers position o Proton pump inhibitors o H2 receptors antagonists o Avoid activities that intra-abdominal pressure Nursing interventions o Keep in Semi-fowlers position during and after meal o Avoid flexion @ the waist o Remain upright for 2hrs after eating o Avoid constrictive clothing o Avoid lifting, bending, straining, and coughing o Dont smoke o Loss weight 6. Peptic ulcer disease

Erosion of the mucosal or duodenal lining of the stomach Pathophysiology o emptying time of gastric acid from the gastric lumen into the small intestine causes inflammatory reaction w/ tissue breakdown o Combination of hydrochloric acid & pepsin gastric mucosa Cause o Drug induced o Gastritis o Infection: H. pylori o Smoking & alcohol abuse o Severe physiologic stress Assessment findings o Epigastric pain 1-2 hrs after eating o Hematemesis o Relief from pain after administration of antacids o Heartburn o Dyspepsia Medical management o Stop smoking o NPO if active bleeding, NG tube insertion o Semi-fowlers position o Triple therapy for infection: Amoxicillin, Clarithromycin (Biaxin), Prilosec o Tx: saline lavage by NG tube, if hemorrhage o Transfusion if needed Nursing interventions o Assess respiratory, GI and cardiovascular status o Small frequent meals as tolerated o Minimize environmental stress & maintain a quite environment o Monitor consistency, color, amount, & frequency of stools or emesis

7. Gastric cancer Malignant stomach tumor usually develops in the distal 3rd of the stomach Pathophysiology o Unregulated cell growth and uncontrolled cell division result in the development of a neoplasm o Most common neuoplasm is adencarinoma Risk factors o Family hx o Smoking o High alcohol intake o Type A blood o High intake of salty and smoked foods Assessment findings

o Weakness & fatigue o N&V o Wt. loss o Epigastric fullness and pain o Melena o Anorexia o Dysphagia Medical management o High protein and calorie diet o Radiation therapy o Gastric surgery o Analgesics o Vitamin supplements: folic acid & B12 Nursing interventions o Keep pt. in semi-fowlers position o Administer TPN & lipids until diet is resumed o Provide prophylactic skin & oral care o Teach pt. to avoid people w/ infectons

8. Ulcerative colitis Episodic inflammatory chronic disorder that causes ulceration of the mucosa of the colon Pathophysiology o Inflammatory edema of the mucous membrane of the colon and rectum leads to bleeding & shallow ulcerations o Mucosal ulceration begin in the distal end of the colon and ascend the large intestine Risk factors o Emotional stress o Allergies o Genetics Assessment findings o Bloody, purulent mucoid, watery stools (10-20 per day) o Abdominal tenderness and pain, cramping o Hyperactive bowel sounds o Abdominal distention o Jaundice o Wt. loss Medical management o Immunosuppressive agents o Diet: high protein & calorie, low residue, bland foods in small frequent feedings w/ restricted intake of milk and gas forming foods; NPO if severe o Semi-fowlers position o Corticosteroid Nursing interventions

o Monitor #, amount, and character of stools o Assess perineal excoriation, and provide perianal care and sitz baths o Teach pt. to avoid highly seasoned foods, raw fruits and vegetables and milk products o Reduce stress 9. Crohns disease Pathophysiology o Ulcerations of intestinal mucosa are accompanied by congestion, thickening of the small bowel, and fissure formations o Enlarged regional mesenteric lymph nodes accompany fibrosis and narrowing of the intestinal wall o Cobblestone appearance Risk factors o Allergies o Immune disorder o Genetics Assessment findings o Fatigue and weakness o Crampy, colicky pain in the RLQ o Chronic diarrhea o Elevated temp Medical management o Diet: small, freq. feedings; avoid dietary irritants (raw vegetables and fruit, milk and gas forming foods o Antidiarrheal o Anti-inflammatory o Immunosuppressants o Corticosteroids o Anticholinergics Nursing interventions o Minimize stress o Monitor #. Amount, and character of stools o Teach pt. to avoid laxatives and ASA 10. Diverticular disease Pathophysiology o Muscle tone is weakened in the intestinal wall, resulting in a saclike out pouching (diverticula) o Inflammation is caused by bacteria and fecal material trapped in the diverticula o Intestinal wall thickens and narrows o Typical sites: sigmoid colon Risk factors o Age

o Low intake of roughage and fiber Assessment findings o LLQ pain o Severe abdominal cramps o Change in bowel pattern o Bloody stool o Low grade fever o Constipation and diarrhea Medical management o Diet: high fiber, low fat; avoid foods with seeds, kernels or indigestible roughage o Antibiotics o Analgesic o Stool softener Nursing interventions o Assess bowel sounds and abdominal distention o Monitor stools for occult blood o Semi-fowlers position

11. Intestinal Obstruction Pathophysiology o Gas, fluid, and digested substances accumulate proximal to the obstruction o H2O and electrolytes are secreted into the blocked bowel o Dehydration from fluid loss Cause o Fecal impaction o Tumors o Strangulated hernias o Paralytic ileus o Toxicity Assessment findings o Abdominal cramping o Vomiting green colored bile o Abdominal distention o Absent bowel sounds below the obstruction o Wt. loss Medical management o NPO until the obstruction is relieved, then high fiber diet o GI decompression: NG tube o Semi-fowlers position o Bed rest Nursing interventions o Measure and record abdominal girth o Monitor color, frequency, amount of stools

o Teach pt. to avoid constipation foods 12. Peritonitis Pathophysiology o Peritoneal irritants cause inflammatory edema, vascular congestion, and hypermotility of bowel sounds o Movement of extracellular fluids into the peritoneal cavity leads to hypovolemia and urine output Cause o Bacterial infection o Pancreatitis o Chemical inflammation o Inflammation of kidneys or colon o Intestinal perforation Assessment findings o Constant, diffuse, and intense abdominal pain o Rebound tenderness o Elevated temp o Abdominal rigidity and distention o Weak, rapid pulse o or absent bowel soundsa o Shallow respiration Medical management o NPO o Semi-fowlers position o Antibiotics o LMWH Nursing interventions o Assess bowel sounds o TCDB and incentive spirometry o Turn q2hrs and encourage ambulation as soon as able 13.Cholecystitis & Cholelithiasis Pathophysiology o Inflamed gallbladder can contact in response to fatty foods entering the duodenum because of obstruction by calculi or edema o Accumulated bile is absorbed in the blood Cause o Infection of the gallbladder o Reduced blood supply to the gallbladder o Estrogen therapy o Prolonged immobility o Chronic dieting o Opioid abuse

o Cholesterol Assessment findings o Jaundice o Episodic colicky pain in the epigastric area, radiates to the right shoulder and back o N&V, chills o Murphy signs (tenderness over the RUQ that on inspiration) o Belching o Clay colored stools o Low grade fever o Severe UQ pain o Indigestion or CP after eating fatty or fried foods Medical management o Low fat diet, small freq. meals o Semi-fowlers position o Tx: tepid baths w/out soap, incentive spirometry Nursing interventions o TCDB

14. Pancreatitis Pathophysiology o Acute: pancreatic enzymes are activated in the pancreas rather than the duodenum, resulting in tissue damage & autodigestion of the pancreas o Chronic: chronic inflammation results in fibrosis and calcification of the pancreas, obstruction of the ducts, and destruction of the secreting acinar cells Cause o Biliary tract disease o Alcoholism o Metabolic and endocrine disorders o Bacterial or viral infection Risk factors o Heredity o Renal failure and kidney transplantation o Medication induced: steroids, thiazide diuretics, hormonal contraceptives Assessment findings o N&V o Aching, burning, stabbing, pressing pain o Tachycardia o Intense epigastric pain centered close to the umbilicus, radiating to the back between the 10th thoracic and 6th lumbar vertebrae o Abdominal tenderness and distention o Hypotension o Wt. loss o Dehydration

o or absent bowel sounds o Position chest-knee, fetal, or lean forward to relieve pain o Cullens sign (irregular, bluish hemorrhagic patches on skin around umbilicus) o Turners sign (bruiselike discoloration of the skin) Medical management o Respiratory support o Diet: gradual increase of low fat and protein diet o Semi-fowlers position o Stop alcohol and caffeine intake o Antidiabetic Nursing interventions o Encourage incentive spirometry, TCDB o Turn q2hrs o Monitor urine ad stool color, character and amount o Teach pt. to avoid large meals and alcohol consumption

15. Cirrhosis Pathophysiology o Inflammation causes liver parenchymal cell destruction, w/ subsequent fibrosis o Fibrotic changes cause obstruction of hepatic blood flow and normal liver function; obstruction causes portal hypotension o liver function leads to secretion of aldosterone, prolonged clot time, ineffective detoxification of protein waste Assessment findings o N&V o Anorexia o Jaundice o Pain RUQ o Weakness and fatigue o Indigestion o Hepatomegaly o Melena Medical management o Diuretics o Ammonia detoxicant: lactulose (Cephulac) o Diet: high calorie, low sodium; small freq. feedings, restricted alcohol and fluid intake o Semi-fowlers position o Regular exercise unless active bleeding o Stool softener o Vitamins: zinc Nursing interventions o Assess neurologic, GI, and fluid balance status o Low sodium diet

o o o o

TCDB, incentive spirometry Monitor for S/S of infection Bed rest and quite environment Teach pt. to avoid use of OTC meds, alcohol, people w/ infections, and straining while defecating, blowing the nose, coughing, and hard tooth brush

16. Hepatitis Pathophysiology o Inflammation of the liver tissue leads to diffuse injury and necrosis of hepatocytes Cause o Hep A: contaminated food, milk, H2O, feces o Hep B: parenteral , sexual, oral, transmitted through contact w/ any body fluids o Hep C: blood or stream transmitted through contact with any infected body fluids Assessment findings o Fatigue o Anorexia o Clay colored stools o Dark urine o Jaundice o Hepatomegaly o Wt. loss o Elevated temp o HA, photophobia Medical management o High calorie, moderate protein diet; avoid alcohol o Frequent rest periods during activity o Antivirals o Alpha interferons Nursing interventions o Provide skin care o Teach pt. to avoid people w/ infections, alcohol use o Increase fluid intake to 3L/day o Safe sex practices 17. GERD Pathophysiology o Reflux occurs when lower esophageal sphincter (LES) pressure is deficient or when pressure within the stomach exceeds LES pressure Cause o Impaired LES functioning o intra-abdominal pressure (obesity, pregnancy, constrictive waistline, bending over) Risk factors o Alcohol ingestion

o Hiatal hernia o Smoking o Ingestion of peppermint or spearmint o Gastric distention (large meals or ascites) Assessment findings o Dyspepsia o Pain worsens with lying down or bending over o Regurgitation of warm, sour, or bitter fluid o Laryngitis o Chronic cough o Chronic pain radiating to the neck, jaws, and arms that may mimic angina pectoris Medical management o Position upright after meals; sleep w/ the HOB elevated o Small, freq. meals w/ fluid intake; avoid meals b4 bed o Stop smoking

18. Appendicitis Pathophysiology o Lumen of the appendix becomes obstructed and inflamed o Mucosa continues to secrete fluids and pressure in the lumen continues to increase o Blood flow is restricted and infection occurs Cause o Mucosal ulceration o Fecal mass o Foreign body o Stricture Assessment findings o Abdominal rigidity o Rebound tenderness o Sudden cessation of pain (indicates rupture) o Generalized pain that becomes localized in RLQ o N&V o Anorexia Medical management o NPO until after surgery o Best rest until after surgery o Antibiotics o Analgesic Endocrine system 1. Risk factors Modifiable o Medication o Stress

o Diet o obesity Nonmodifiable o Aging o Hx of trauma o Family hx

2. Adrenalectomy Removal of one or both adrenal glands Pre-op NI o Obtain signed consent o Administer steroids and vasopressors as prescribed Post-op NI o Monitor I&O and electrolyte levels (mineralocorticoid & glucocorticoid secretion alters levels) o Assess cardiac respiratory, & neurologic status o Inspect the surgical dressing o TCDB, incentive spirometry, and splinting the incision o Maintain quite environment o Teach pt. to avoid people w/ infection, and extreme temperatures o Teach pt. to recognize S/S of infection, hypovolemia, and hypoglycemia 3. Thyroidectomy & Parathyroidectomy Pre-op NI o Obtain signed consent form o Administer iodine preparation and anti-thyroid medications Post-op NI o Assess respiratory status o Inspect surgical dressing for bleeding, especially behind the neck; change dressing as directed o TCDB, incentive spirometry, and splinting incision o Keep pt. in semi-fowlers position, neutral alignment, support the neck o Keep calcium gluconate or calcium chloride and tracheostomy tray availabe o Assess for thyroid storm o Discourage talking o High calcium diet w/ Vit. D for parathyroidectomy care 4. Hyperthyroidism Pathophysiology o Thyroid-stimulating antibodies have a slow sustained stimulating effect on thyroid metabolism o Accelerated metabolism causes synthesis of thyroid hormones Cause o Autoimmune and genetic factors

o Graves disease o TSH secretion o Pituitary tumors o Thyroid adenomas o Stress o Infection o DKA o Excessive iodine intake o Surgery Assessment findings o Heat intolerance o Diaphoresis o Tachycardia o Bruit or thrill over thyroid o Mood swings o Flushed, smooth skin o Fine hand tremors o Weakness Medical management o Radiation therapy o Bed rest o Restrict stimulants o Lab: T3 & T4 o Glucocorticoids o Beta-adrenergic blocking agent: Propranolol (Inderal) Nursing interventions o Rest periods in a quite, cool environment o Stop smoking o Teach s/s of thyroid storm (tachycardia, delirium, agitation, coma, dehydration, diarrhea, arrhythmias, death) o Avoid exposure to people w/ infection

5. Hypothyroidism Pathophysiology o Thyroid gland falls to secrete a satisfactory quantity of thyroid hormone o Hyposecretion of thyroid hormone results in overall decrease in metabolism Cause o Autoimmune disease: Hashimotos thyroiditis o Thyroidectomy o Malfunction of the pituitary gland o Use of radioactive iodine o Overuse of antithryoid drug Assessment findings

o Fatigue o Wt. gain o Dry, flaky skin o Cold intolerance o Mental sluggishness o Hypothermia o Thick tongue, swollen lips o diaphoresis Medical management o Thyroid hormone replacement o Caution w/ contact sports or heavy physical labor o Monitor VS, I&O, and labs (T3 &T4) Nursing interventions o Encourage physical activity and mental stimulation as tolerated o Encourage fluids o S/S of myxedema coma (severe stress, severe hypothyroidism) o Provide warm environment o Avoid sedation o Exercise regularly

6. Hyperparathyroidism Pathophysiology o PTH secretion ; serum calcium level elevates o Excessive compensatory production of PTH stems from a hypocalcemiaproducing abnormally outside the parathyroid gland that isnt responsive to PTH Cause o Chronic renal failure o Bone disease o Malignant tumor of the parathyroid gland o Vit. D deficiency Assessment findings o Recurring nephrolithiasis o Arrhythmias o N&V o Muscle weakness in legs o Personality disturbance o Polydipsia o Polyuria o Cataracts o Skin necrosis o Chronic low back pain Medical management o fluid intake to 3000ml/day

o Bisphosphonate: Alendronate (Fosamax) o Calcitonin o Antineoplastic o Phosphate salts o Dialysis using calcium-free dialysate o Vit. D o Glucocorticoid Nursing interventions o Assess bone and flank pain o Move the pt. carefully to prevent pathologic fractures o Keep a tracheostomy tray @ bedside o Support the pt. head and neck w/ sandbags

7. Hypoparathyroidism Pathophysiology o PTH decreases stimulation to osteoclasts, resulting in decreased release of calcium and phosphorus from bone o blood calcium causes a rise in serum phosphates and decreased phosphate exertion by the kidney Cause o Autoimmune disease o Massive thyroid irradiation o Parathyroidectomy o Hypercalcemia o hypomagnesmia Assessment findings o Tingling in the fingers, around the mouth and occasionally in the feet o deep tendon reflexes o N&V o Abdominal pain o Brittle nails personality changes dyspnea Medical management o High-calcium, low phosphorus o Oral calcium salts Nursing interventions o Keep a tracheostomy tray and IV calcium gluconate available o Maintain a calm environment 8. Cushings syndrome Pathophysiology o Hypothalamic stimulation of the pituitary gland causes excessive secretion of corticotrophin o Excessive secretion of corticotropin causes increased plasma cortisol Cause

o Hyperplasia of the adrenal glands o Hypothalamic stimulation of the pituitary Assessment findings o Wt. gain o HTN o Moon face o Truncal obesity w/ thin extremities o Mood swings o Fragile skin o Poor wound healing o Buffalo hump Medical management o Radiation therapy o Glucocorticoids o Adrenal suppressants o Hypoglycemic o Diet: low sodium, high calorie, potassium, and protein Nursing interventions o Protect the pt. from infection o Check for infections of the skin and the respiratory and urinary tracts o Keep the HOB elevated at least 30 degrees o Avoid activities that increase intracerebral pressure o Avoid exposure to people w/ infections

9. Addisons disease Pathophysiology o Chronic hypoactivity of the adrenal cortex, resulting in insufficient secretion of glucocorticoids (cortisol) and mineralocorticoids (aldosterone) Cause o Tuberculosis o Idiopathic atrophy of adrenal glands o Surgical removal of adrenal glands o Autoimmune disease o Infection o Pituitary hypofunction Assessment findings o Hypoglycemia o Weakness and lethargy o Orthostatic hypotension o Wt. loss o Bronzed skin o Craving of salty foods o Chronic diarrhea

Medical management o Mineralocorticoids o Glucocorticoids o Diet: high-carbohydrate , protein, and sodium, low potassium; in small freq. feedings before steroid therapy; high potassium and low sodium when on steroid therapy o Bed rest (adrenal crisis) Nursing interventions o Protect pt. from falls o Encourage fluid intake o Maintain quite environment o Teach pt. to avoid strenuous exercise especially in hot weather and avoid using OTC drugs o fluid intake in hot weather

10. Pheochromocytoma Pathophysiology o Tumor in the adrenal medulla secretes large amounts of catecholamines (epinephrine and norepinephrine) Cause o May be inherited as an autosomal dominant trait Risk factors o Anesthesia o Medication o Radiation contrast dye o Childbirth Assessment findings o Labile malignant HTN o Throbbing HA o Diaphoresis o Tachycardia o Tachypnea o Vertigo o Tremors Medical management o Diet: high protein o Alpha adrenergic blockers o Beta adrenergic blocker Nursing interventions o Semi-fowlers position o Protect the pt. from falls o Rest periods and minimize environmental stress o Assess the wound and dressing for signs o Stop smoking

Reproductive disorders 1. Prostate surgery Transurethral resection of prostate (TURP): insertion of a restopscope into the urethra to excise prostatic tissue Pre-op NI o Demonstrate TCDB, incentive spirometry, splinting, and leg ROM exercise o Obtain a signed consent Post-op NI o Semi-fowlers position o Encourage the pt. to express his feelings about the surgery and fear of sexual dysfunction o Administer stool softeners o Evaluate urine appearance o Avoid giving enemas and taking rectal temp o Avoid Valsalvas maneuver, lifting, vigorous exercising, or prolonged sitting in the car 2. Benign Prostatic Hyperplasia Pathophysiology o Enlarged prostate gland compresses urethra, resulting in urinary obstruction and retention Risk factors o Age o Intact tests Assessment findings o force and amount of urine stream o Urinary hesitancy and urgency o Interrupted urine stream o Nocturia, hematuria o Dribbling, incontinence Medical management o Prostatectomy o TURP o Encourage fluids Nursing interventions o Assess urine output for amount and appearance o Monitor and record: vital signs, I&O Musculoskeletal system 1. External fixation Fracture immobilization in which transfixing pins are inserted through the bone above and below the fracture and attached to a rigid external metal frame Pre-op NI

o Monitor fracture complications o Maintain the position of the affected extremity w/ sandbags and pillows, tracts, or a splint Post-op NI o Semi-fowlers position o Active and passive ROM , isometric exercises (strengthening & muscle tone by contracting muscles against resistance ) o Provide wound care o Maintain balanced suspension traction

2. Amputation Pre-op NI o TCDB, incentive spirometry, splinting, ROM exercises o Prepare pt. for the possibility of phantom limb sensation or pain o Provide emotional support o Obtain signed consent form Post-op NI o Provide wound care o Active and passive ROM , isometric exercises (strengthening & muscle tone by contracting muscles against resistance ) o Elevate the affected extremity o Inspect stump for bleeding, infection, and edema o Maintain a rigid dressing for the stump prosthesis o Provide trapeze 3. Carpal tunnel release Surgical ligation of the transverse carpal ligament to relieve compression of the median nerve in the carpal canal of the wrist Pre-op NI: o TCDB, incentive spirometry, splinting, ROM exercises o Obtain signed consent form Post-op NI o Elevate hand and apply ice o Apply splint o Encourage movement of the fingers to swelling o Provide wound care 4. Open reduction internal fixation (ORIF) Surgical reduction and stabilization of a fracture, using orthopedic devices or hardware (Austin Moore prosthesis, Smith-Peterson nail, Jewett nail, intramedullary nails, and compression screws) Pre-op NI o Demonstrate TCDB, incentive spirometry, splinting, ROM exercises o Keep the extremity in position w/ sandbags and pillows or traction

Post-op NI: o Assess cardiac and respiratory status o Semi-fowlers position: no higher then 30 degrees o Use abductor pillow and trochanter rolls o Apply compression stockings o Administer anticoagulants o Administer stool softeners

5. Rheumatoid Arthritis Pathophysiology o Inflammation of the synovial membranes is followed by formation of pannus, an inflammatory exudates, and destruction of cartilage, bone, ligaments o Pannus is replaced by fibrotic tissue and calcification Cause o Autoimmune disease o Genetic transmission Assessment findings o Painful, swollen joints o Symmetrical joint swellinig o Morning stiffness o Crepitus o Enlarged lymph nodes o Limited ROM due to deformity Medical management o NSAIDs o Disease modifying anti-rheumatic drugs: Arava, Rheumatrex, Remicade, Enbrel, Plaquenil o Glucocorticoids: Deltasone, Cortef o Heat & cold therapy Nursing interventions o Keep joint extended; provide ROM exercises o Check for swelling, pain, redness o Teach pt. to avoid stress, cold, and infection o Complete skin & foot care daily 6. Osteoarthritis (DJD) Degeneration of articular cartilage affecting the wt. bearing joints (spine, knees, hips) Pathophysiology o Cartilage softens w/ age narrowing the joint space o Cartilage flakes enter the synovial lining which fibroses Cause o Aging o Obesity o Joint trauma

o Congenital abnormalities Assessment findings o Pain relieved by rest o Joint stiffness o Crepitation (grating sensation associated w/ DJD that can be heard and felt o Smooth, taut, shiny skin Medical management o Heat & cold therapy o ASA o NSAIDs o Isometric exercises, strengthening exercise, aerobic exercises o Wt. reduction o Canes, walkers Nursing interventions o Provide rest o Maintain calorie count o Provide moist compresses and paraffin bath (heat therapy) o Teach proper body mechanics o Passive ROM

7. Osteomyelitis Bacterial infection of the bone and soft tissue Pathophysiology o Organisms reach bone through an open wound or via the bloodstream o Infection causes bone destruction o New bone cells form over the necrotic bone fragments during healing, results to nonunion Cause o Staphylococcus aureus o Hemolytic streptococcus Risk factors o Open wound o infection Assessment findings o Bone pain o Localized edema, redness, and warmth o pain w/ movement o temp o Tachycardia o Muscle spasms o Nausea Medical management o Antibiotics

o Cast or splint o Wound care o Heat therapy o Diet: high calorie, vitamin C & D, protein, and calcium Nursing interventions o Encourage fluids up to 3L/day o Turn q 2hrs o Teach pt. to avoid others w/ infection

8. Osteoporosis Metabolic bone dysfunction that results in reduced bone mass and porosity Pathophysiology o Rate of bone resorption exceeds the rate of bone formation o phosphate stimulates parathyroid activity; estrogen bone resorption Cause o Calcium, vit. D, & protein deficiency o Bone marrow disorder o Liver disease o Cushings syndrome hyperthyroidism Risk factors o Age o Female o Family hx. o Smoking o Immobility o Postmenopause o Corticosteroid use Assessment findings o Back pain: thoracic and lumbar o Kyphosis (Dowagers hump) o Loss in height o Joint pain o weakness Medical management o Diet: high calcium, protein, vitamins, minerals, and boron o Limit caffeine and alcohol o Weight bearing exercise program o Calcitonin o Calcium supplement o Hormone replacement Nursing interventions o Prevent falls o Assist in planning Weight bearing exercise program

9. Fractures Pathophysiology o Fractures occur when stress is placed on the bone more than it can withstand o Localized tissue injury, results in muscle spasms, edema, hemorrhage, compressed nerves and ecchymosis Risk factors o Aging o Immobility o Malnutrition o Osteoporosis o Contact sports o Bone tumor o Previous fracture Assessment findings o Pain aggravated by motion o Loss of function or motion o Deformity o Edema o Ecchymosis o Crepitus Medical management o Elevate extremity (25 degrees for hip); keep pt. flat w/ leg abducted for fracture hip o Active and passive ROM; isometric exercise o Ice packs, abductor pillow (fractured hip) o Skin traction o Skeletal traction: Crutchfield tongs (neck) o Cast or closed reduction o Cast or pin care o ORIF Nursing interventions o Elevate and apply ice o Skin care, pin, and cast care o Turn q2hrs o Provide trapeze o Maintain traction to ensure proper body alignment and proper healing o TCDB, incentive spirometry 10. Systemic Lupus Erythematosus (SLE) Chronic inflammatory autoimmune disorder that affects connective tissue Pathophysiology o Defect the body immunologic mechanism produces serum autoantibodies directed against components of the pt. cell nuclei

o Affects connective tissue cells throughout the body (heart, brain, muscles, kidneys, skin, joints, mucous membranes, blood vessels Risk factors o Stress or emotional upset o Streptococcal or viral infection o Exposure to sunlight or ultraviolet light o Injury o Surgery o Immunization o Abnormal estrogen metabolism o Exhaustion Assessment findings o Painful or swollen joints o Butterfly erythema on face o Malaise and weakness o Low grade fever o Raynauds phenomenon o Abdominal pain o Wt. loss Medical management o Corticosteroids o NSAIDs o Immunosuppressants o Plasamapheresis o Regular exercise program Nursing interventions o Provide rest o Prevent infection o Minimize environmental stress o Teach pt. to avoid others w/ infection and sunlight exposure

Immune disorders 1. AIDS Pathophysiology o HIV is transmitted by contact w/ infected blood or body fluids. Infected lymphocytes are carried on semen, vaginal secretions, and blood o Transferred through minute breaks in the skin and mucosa, transfusion, & fetal circulation o A retrovirus selectively infects human cell containing CD4 antigen on their surface; majority are T4 lymphocytes o HIV virus reproduces within T4 lymphocytes, destroy them; destruction of T4 diminishes resistance to disease Cause o Exposure to blood containing HIV: transfusions, contaminated needles, utero

Assessment findings o Anorexia o Wt. loss o Recurrent diarrhea o Night sweats o Disorientation, confusion, dementia o Pallor o Fever o Weakness o Malnutrition Medical management o IV therapy: hydration, electrolyte replacement, and saline lock o O2 therapy o Active and passive ROM o TPN if pt. cant take food by mouth o Tx.: chest physiotherapy, postural drainage, incentive spirometry o Transfusion therapy: fresh frozen plasma, platelets, and packed RBCs o Antibiotics o Highly active anti-viral therapy Nursing interventions o Encourage TCDB and use of incentive spirometry o Monitor VS, I&O, labs, daily wt. and pulse oximetry o Provide skin and mouth care o Teach pt. to refrain from donating blood; use condoms during sexual intercourse; avoid using alcohol and recreational drugs