NCMB316 Lec Midterm

NCMB316 LECTURE: Exam Week
12
BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
Bachelor of Science in Nursing 3YB
Professor: Dr. Potenciana A. Maroma
Midterm Topics: Diabetes Mellitus
• Diabetes - A chronic metabolic disease characterized by
• DI, SIADH, Thyroid disorders hyperglycemia due to disorder of carbohydrate, fat and
• Adrenal and parathyroid gland disorders protein metabolism.
• Introduction to nervous system - Once u have it, sayo na yan lifetime (sanaol ung DM hindi
• Increased ICP, Head injury, CVA, SCI and Seizures ka na iniiwan, pero ung jowa d lifetime hays)
- Predisposing Factors:
DIABETES MELLITUS • Heredity – strongly associated with Type II DM
Pancreas • Obesity – Adipose tissues are resistant to insulin,
- Islets of Langerhans (containing beta cells, which produce therefore glucose uptake by the cells is poor
insulin. While alpha cells secrete glucagon) • Stress – Stimulates secretion of epinephrine, nor-
epinephrine, glucocorticoids  increased serum
carbohydrates
• Viral infection – increase risk to autoimmune disorders
• Autoimmune Disorders – more associated with Type I
DM
• Multigravida Women with large babies
Types of Diabetes Mellitus

1) Type I
2) Type II
3) Gestational Diabetes
4) Diabetes associated with other conditions or syndromes
- Pancreatic disease, Cushing’s syndrome
- Use of certain drugs:
o Steroids
o Thiazide diuretics
o Oral contraceptives
• Alpha cells
- Glucagon –  glucose levels (it function with Type I (IDDM) Insulin Dependent Diabetes Mellitus
gluconeogenesis) - Juvenile – onset, Brittle DM, Unstable DM
- Pag mababa ang blood sugar, glucagon will be released - Onset is less than 30 years
by alpha cells and it will raise glucose levels. - Common in children or in non-obese adults
• Beta cells - NO insulin production (there is destruction on pancreas,
- Insulin -  glucose levels by: therefore there’s no insulin production at all)
o Transcellular membrane transport of glucose - Prone for DKA (Diabetic Ketone Acidosis, because there is
o Inhibits breakdown of fats & CHON absolute deficiency of insulin, the body will burn protein
- Requires Na+ for transport of CHON and fat reserves) DKA develops when your body doesn't
- Requires K+ for production have enough insulin to allow blood sugar into your cells for
• Delta cells use as energy. Instead, your liver breaks down fat for fuel, a
- Somatostatin – inhibits action of growth hormone process that produces acids called ketones.
- Management:
• Diet
• Exercise
• Insulin lifetime
Type II (NIDDM) Non-Insulin Dependent Diabetes Mellitus

- Maturity – onset, Stable DM, Ketosis – resistant DM
- Onset is 40 years
- Common in obese adults
- Inadequate insulin production or cells do not respond to
insulin. (Meron pero konti lng)
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NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
- Prone for HHNKS (Hyperosmolar Hyperglycemic

Nonketotic Syndrome – high BP) mataas ang bp pero hindi
necessarily mataas ang ketone bodies because there is
still circulating insulin.
- Pwede rin sila magkaroon ng DKA, pero bihira lng.
Magkakaroon lng sila kapag may severely stress.
- Management:
• Diet
• Exercise
• OHA (Oral Hypoglycaemic Agents), Insulin in
STRESSFUL situation
Pathophysiology
- Pag kumain or nag ingest ng food ang patient dito na

papasok yung functioning ng mga absorption ng mga
nutrients galing sa food
- Isa ang pancreas sa mag se secrete ng mga chemicals at
yung isa doon is beta cells na nag p produce ng insulin.
- Ang insulin mag bi bind yan sa mga receptor nya para ma
decrease yung dami ng glucose sa katawan or ma balance
- Once na mag malfunction ang pancreas or magka problem
ang organ either hindi sya magpo produce ng insulin or
yung mga receptor is hindi mag fu function leading to
glucose will stay in the blood and result as diabetes either
type 1 or 2.
- Hyperglycemia: 3P’s
1) Polyuria
2) Polydipsia
3) Polyphagia
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- Paralysis
- Gastroparesis (delayed gastric emptying)
- Neurogenic bladder (bladder does not empty properly)
- Decreased Libido, impotence.
Diagnostic Test
• Random Blood Sugar (RBS)
- Blood specimen is drawn without preplanning.
(Kinukuhanan ng dugo agad ang pasyente without
preplanning)
- ≥ 200mg/dl + symptoms is suggestive of DM
• Fasting Blood Sugar (FBS)
- Blood specimen after 8 hours of fasting
- Normal (70-100 mg/dl), pre-diabetes (101 but < 126mg/
dl)
- Ketones act as CNS depressants and may decrease brain - DM – > 126 mg/dl
pH leading to coma. • Postprandial Blood Sugar
Protein metabolism - Blood sample is taken 2 hrs after a high CHO meal
- No DM (70-140mg/dl), prediabetes (≥140 but <200
mg/dl)
• Oral Glucose Tolerance Test (OGTT)
- Diet high in CHO is eaten for 3 days.
- Client then fast for 8 hours. A baseline blood sample is
drawn & a urine specimen is collected.
- An oral glucose solution is given, and time of ingestion
recorded.
- Blood is drawn at 30 minutes & 1, 2, and 3 hours after
the ingestion of glucose solution. Urine is collected.
o No DM (glucose returns to normal in 2-3 hours &
- Due to increased blood viscosity urine is negative for glucose)
• Sluggish circulation o DM (blood glucose returns to normal slowly; urine is
• Proliferation of microorganisms positive for glucose)
- Infections, Periodontal, UTI, Vasculitis, Cellulitis,
Vaginitis, Furuncles, Carbuncles, Retarded Wound
Healing
- MUST: thoroughly inspect your feet daily and keep
them clean and dry
Complications
• Macroangiopathy (malalaking blood vessels)
- Brain – Cerebrovascular accident
- Heart – Myocardial infarction
- Peripheral arteries – Peripheral vascular disease
• Glycosylated hemoglobin (HbA1c)
• Microangiopathy (maliliit na blood vessels)
- Single sample of venous blood is withdrawn.
- Kindeys – Renal failure due to nephropathy
- The amount of glucose stored by the hemoglobin is
- Eyes – Cataract due to retinopathy
elevated above 7% in the newly diagnosed client with
DM, in one who is noncompliant, or in one who is
inadequately treated.
- HbA1c is something that's made when the glucose
(sugar) in your body sticks to your red blood cells. Your
body can't use the sugar properly, so more of it sticks to
your blood cells and builds up in your blood.
• Neuropathy Management
- Spinal Cord/ ANS • Diet
- Peripheral neuropathy – Involves damage to the PNS, - Low caloric diet specially if obese
Affect movement, sensation, and bodily functions - Diet should be in proportion.
(numbness/ tingling) o 20% CHON
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o 30% Fats
o 50% CHO
• Consume complex CHO and HIGH fiber diet.
- inhibits glucose absorption in the intestines.
• Exercise
- This should be regularly
- Increases CHO uptake by the cells.
- Decreases insulin requirements.
- Maintains ideal body weight, serum carbohydrates &
serum lipids.
- Guidelines:
o Allow additional sources of CHO like snacks during
exercises. Oral Hypoglycemic Agents (OHA)
o Exercise is done 1-2hours after eating to prevent - for Type II
hypoglycemia. - Sulfonylureas
o Exercise must be regular pattern rather than - Nonsufonylureas
sporadic to maintain stable serum carbohydrate • Biguanides
levels. • Alpha-glucosidase inhibitors
• Thiazolidinediones
Medications • Meglitinides
Insulin
- Used for Type I diabetes Nursing Responsibilities in Insulin Therapy
- Used in Type II diabetes (client in stressful situation or • Route: Subcutaneous
hospitalized) - Slow absorption, less painful, 90° (thin) 45° obese
- Insulin preparations can consist of a mixture of: clients, no need to aspirate, do not massage site of
• beef and pork insulin injection
• Pure beef - IV insulin: given in emergency cases (DKA)
• Pure pork • Administer insulin at room temperature
• Human insulin - purest insulin and has the lowest - Cold insulin can cause lipodystrophy.
incidence of hypersensitivity o Lipoatrophy – loss of subcutaneous fat usually
- Human insulin is recommended for: caused by the utilization of animal insulin.
• All newly diagnosed Type I diabetics o Lipohypertrophy – development of fibrofatty masses,
• Type II diabetics who need short-term insulin therapy usually caused by repeated use of injection site.
• Pregnant client • Store vial of insulin in current use at Room
• Diabetic clients with insulin allergy or severe insulin Temperature
resistance - Insulin can be stored at RT for 1 month
- Other vials should be refrigerated
Insulin Onset Peak Duration
- In use – at room temperature
Rapid acting (clear) - Not in use – in refrigerator
5 30 mins
- Lispro (Humalog) 2 to 4 hrs • Rotate the site of injection
minutes - 1hr
- Aspart (Novalog) - To prevent lipodystrophy
Short acting (clear) - Lipodystrophy inhibits insulin absorption
Regular (Humulin R) 30 min 2 t0 4 • Gently roll vial in between the palms to redistribute
6 to 8 hrs insulin particles
(Novolin R) (Iletin II to 1 hr hrs
regular) • DO NOT Shake
- bubbles make it difficult to aspirate exact amount
Intermediate (cloudy)
- NPH
1-2 hrs 6 -12 hrs 18 to 24 hrs • Observe for side effects of insulin therapy
1-2 hrs 8 -12 hrs 18 to 24 hrs - Localized: Induration or Redness, Swelling, Lesion at
- Humulin N
1-2 hrs 8 -12 hrs 18 to 28 hrs the site, Lipodystrophy
Lente, Humulin L
- Generalized:
Long acting 5 to 8 14 to 20 o Edema – due to sudden resolution of hyperglycemia
30 to 36 hrs
- Ultralente hrs hrs
rs o Hypoglycemia
Glargine (Lantus) UK UK
o Somogyi phenomenon
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• Alpha-glucosidase inhibitors
o Miglitol (Glyset), Acarbose (Precose)
- Alpha-glucosidase is an intestinal enzyme that
breaks down carbohydrates into glucose, when this
enzyme is inhibited, the process of forming glucose
is slowed and glucose is absorbed more slowly from
the small intestine.
- Taken 15 minutes before meal.
- It will decrease the absorption of glucose in the
small intestine.
• Thiazolidinediones (TZDs)
o Rosiglitazone (Avandia), Pioglitazone (Actos)
- Help tissues use available insulin more efficiently.
- “insulin sensitizers”
- SE: weight gain, edema & liver damage (kaya
imonitor ang SGPT – Serum Glutamic Pyruvic
Insulin Therapy: Insulin Pumps Transaminase, a blood test performed to measure
- a computerized device that delivers insulin to patients the enzyme created in the liver called Alanine
automatically throughout the day Transaminase (ALT).
- Dosage instruction are entered into the pump small • Meglitinides
computer and the appropriate amount of insulin is then o Repaglinide (Prandin)
injected into the body in a calculated controlled manner - An “insulin releaser”
- closely mimic normal pancreatic functioning - SE: same as with sulfonylureas
- It contain a 3 ml syringe attached to a long (42-inch), OHA
narrow-lumen tube with a needle or Teflon catheter at the - Stress importance of taking the drug regularly
end - Avoid alcohol intake while on medication
- The needle or Teflon catheter is inserted into the • Sulfonylureas can precipitate extreme vomiting if given
subcutaneous tissue (usually on the abdomen) and with alcohol
secured with tape or a transparent dressing
- The needle or catheter is changed at least every 3 days General Nursing Interventions
- The pump is worn either on a belt or in a pocket • Monitor urine sugar and acetone (freshly voided specimen)
- The pump uses only regular insulin • Perform finger sticks to monitor blood glucose levels as
- Insulin can be administered via the basal rate (usually 0.5- ordered (more accurate than urine tests)
2.0 units/hr) and by a bolus dose (which is activated by a • Observe for signs of hypo and hyperglycemia
series of button pushes) prior to each meal • Provide meticulous skin care and prevent injury
• Maintain intake and output; weigh daily
Management • Provide emotional support; assist client in adapting to
Sulfonylureas “insulin releasers” change in life-style and body image
- Stimulate the beta cells to secrete more insulin. • Observe for chronic complications and plan care
- Increases the ability of insulin cell receptors to bind insulin. accordingly
- SE: weight gain, hypoglycemia, secondary failure of • Provide client teaching and discharge planning concerning:
pancreas due to overstimulation - Disease process
• Tolbutamide (Orinase) - Diet
• Acetohexamide (Dymelor) - Insulin - insulin at RT, gently roll vial between palms of
• Tolazamide (Tolinase) hands, Draw up insulin using sterile technique, If mixing
• Chlorpropamide (Diabenese) insulin, draw up clear insulin before cloudy insulin
• Glipizide (Glucotrol) • Provide many opportunities for return demonstration for
• Glyburide (micronase, Glynase) proper and correct insulin administration
• Glimepiride (Amaryl) • Perform good oral hygiene and have regular dental exams
Nonsulfonylureas • Regular checkup every 3 mos
• Biguanides • Have regular eye exams
o Metformin (Glucophage) • Care for the diabetics under stress
- Help tissues use available insulin more efficiently - Do not omit insulin or oral hypoglycemic agents if taking
- “insulin sensitizers” antibiotics since infection causes increased blood
- SE: Stomach upset, flatulence, diarrhea sugar
- no weight gain, no hypoglycemia unlike
sulfonylureas
- it will increase the sensitivity of insulin receptors.
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Hypoglycemia Diabetic Ketoacidosis (DKA)

- Causes: Overdose of insulin, omission of meals, Strenuous - Acute complication of DM characterized by:
exercise, G.I. upset (N&V) • Hyperglycemia
- Sign and symptoms: • Accumulation of ketones in the body; causes metabolic
• Shaking acidosis
• Sweating • Frequently occurs in DM Type I (IDDM)
• Anxious - Precipitating factors:
• Dizziness • Undiagnosed diabetes
• Hunger • Neglect of treatment
• Fast heartbeat • Infection, cardiovascular disorder
• Impaired vision • Other physical or emotional stress
• Weakness, fatigue - Assessment Findings:
• Headache • 3 P’s
• Irritable • N&V, abdominal pain
- Assessment: <60 mg/dl • Warm, dry, flushed skin
- Management: Simple Sugars p.o. • Dry mucous membranes; soft eyeballs
• 3-4 oz regular soft-drink • Kussmaul’s respirations or tachypnea; acetone breath
• 8 oz fruit juice or fruity breath
• 5-7 pcs lifesaver’s candies • Altered LOC, Hypotension
• 3-4 pcs hard candies • Tachycardia
• 1 tbsp sugar • Sobrang taas ng blood sugar, mataas ang osmotic
• 5 ml pure honey/ karo syrup pressure, ihi ng ihi ang pasyente kaya magkakaroon ng
• 10-15 gm CHO severe dehydration, metabolic acidosis – cns
• D50 W 20-50 ml IV push ( if unconscious) or 1 mg depressant
glucagon - Diagnostic Test:
• Monitor BS (blood sugar) • Serum glucose (up to 600 mg/dL) and ketones elevated
(positive urine ketones)
Hyperglycemia • BUN, Creatinine, Hematocrit are elevated (due to
- Causes: Stress (infection, surgery), Overeating, under dose dehydration)
of insulin • Serum sodium decreased, potassium (elevated due to
- Sign and symptoms: the acidosis)
• Extreme thirst • ABGs: metabolic acidosis with compensatory
• Frequent urination respiratory alkalosis
• Dry skin • Metabolic acidosis compatible with hyperkalemia
• hunger - Management:
• Blurred vision • Maintain a patent airway.
• Drowsiness • Maintain F&E balance.
• Nausea • Administer IV therapy as ordered.
- Assessment: o Normal saline (0.9% NaCl), then hypotonic (0.45%
• 3P’s (polyphagia if insulin is absent) NaCl) sodium chloride
• Warm flushed dry skin, Soft eyeballs o When blood sugar drops to 250 mg/dl, may add 5%
• Tachycardia, N&V, Abdominal pain dextrose to IV
• Kussmaul’s breathing, Fruity odor of breath o Potassium will be added when the urine output is
adequate.
• Urine (+) glucose & Ketones
• Observe for fluid and electrolyte imbalances, especially
• Altered LOC
fluid overload, hypokalemia & hyperkalemia
- Management:
• Administer insulin as ordered.
• Patent airway
o ONLY Regular insulin is given IV (drip or push) and/or
• O2 therapy
subcutaneously (SC).
• NSS + regular insulin IV
o If given IV drip, give with small amounts of albumin
• D10W once glucose reaches 250 mg/dl level
since insulin adheres to IV tubing
• KCI / Slow IV drip, once urine output is adequate o Monitor blood glucose levels frequently.
• Monitor blood sugar • Check urine output every hour
• Monitor vital signs
• Assist client with self-care
• Provide care for the unconscious client if in a coma
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• Discuss with client the reasons ketosis developed and • Release is coordinated with activity of the thirst center-
provide additional diabetic teaching if indicated regulates intake
• ADH binds with receptor sites of the collecting duct in
Hyperosmolar Hyperglycemic Nonketotic Syndrome kidney resulting in increased free-water resorption
(HHNKS) • ADH causes vasoconstriction
- A complication of DM characterized by: - Presence of ADH- renal tubule permeability to water is
• Hyperglycemia increased and water is reabsorbed
• Hyperosmolar state without ketosis - Absence of ADH- renal tubule permeability to water is
- Occurs in Type II DM decreased – renal excretion to fluids
- Precipitating factors are: • Plasma osmolality = Primary regulatory mechanism for the
• Undiagnosed diabetes release of ADH
• Infections, major burns, other stress • Receptors in the brain are sensitive to changes in
• certain medications (Dilantin, Thiazide diuretics) osmolality
• Dialysis, Hyper-alimentation, pancreatic disease • Receptors that trigger thirst mechanism are close to those
- Assessment Findings: that control ADH release
• Similar to ketoacidosis but without Kussmaul • Serum osmo greater than 295 mOsm/L triggers thirst
respirations and acetone breath ADH Feedback Loop
- Laboratory tests:
• Blood glucose level extremely elevated
• BUN, creatinine, Hct elevated (due to dehydration)
• Urine positive for glucose
- Nursing interventions:
• Treatment and nursing care is similar to DKA, excluding
measures to treat ketosis and metabolic acidosis
DI, SIADH, AND THYROID DISORDERS

SIADH
Brain Regulation
- Disorder of sodium and water balance is a common
complication following neurosurgery.
- Neuroscience patients must be continually assessed and
monitored for their response to therapy.
- Early detection is critical to the protection and integrity of
the brain.
Normal Brain Regulation
1) TBW accounts for 60% of body weight
- 20% ECF
- 40% ICF
2) Fluid shifts can occur depending on concentrations of
solutes in ICF and ECF Syndrome of Inappropriate Antidiuretic Hormone
3) Na and K are principal determinants in fluid shifts • SIADH: Persistent abnormally high (inappropriate) levels of
4) Osmolarity: amount of solute in fluid (urine, blood) ADH in the absence of stimuli with normal renal function
- Normal Serum Osmolarity: 270-295 mOsm/L - No longer regulated by plasma osmo and volume
5) Serum Osmo above 295 mOsm/L = water deficit - Imbalance of fluid and electrolytes
- Concentration is too great OR • Feedback system is impaired and posterior pituitary
- Water concentration is too little continues to release ADH
6) Serum Osmo below 270 mOsm/L = water excess • Renal tubules continue to reabsorb free water regardless
- Amount of particles or solute is too small in proportion of the serum osmolality
to the amount of water OR • Excessive activity of the neurohypophyseal system r/t brain
- Too much water for the amount of solute disease
Risk Factors
To maintain plasma or serum osmo within range, free • Post-Operative with pituitary surgery
water intake and excretion must balance • Acute head injury
• Antidiuretic Hormone (ADH): balances Na and water in • Pulmonary infections (Pneumonia)
body and controls water conservation • Nervous system infections (meningitis)
• Changes in pressure of ECF triggers release of ADH from Conditions
pituitary gland • Fluid status with accurate I&O
• Confusion
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• Dyspnea Diabetes Insipidus (DI)

• Headache - Disordered regulation of water balance due to impaired
• Fatigue urinary concentrating ability secondary to inadequate
• Weakness secretion of ADH or resistance to ADH.
• Change in LOC - Four Types of DI:
• Lethargy 1) Central/Neurogenic (CDI)
• Vomiting 2) Nephrogenic (NDI)
3) Dipsogenic
• Muscle weakness and cramping
4) Gestational
• Muscle twitching
• Seizures
Pathophysiology of DI
Laboratory Diagnosis
• Central/Neurogenic
Serum Sodium Less than 135 mEq/L - Inadequate secretion of ADH due to loss or malfunction
of neurosecretory neurons that make up the posterior
Urine Sodium Greater than 20 mEq/L
pituitary.
Urine Osmolality Higher than serum - Vasopressin Sensitive
• Nephrogenic
Serum Osmolality Less than 275 mOsm/L - Inadequate response by the kidneys to ADH.
BUN/Creat WNL - A disorder of renal tubular function resulting in the
inability to respond to ADH in absorption of water.
Urine Specific Gravity Greater than 1.005 - Vasopressin Resistant
• Dipsogenic
Adrenal/threshold WNL
- Suppression of ADH secondary a defect or damage to
Serum Potassium Less than 3.5 mEq/L the thirst mechanism located in the hypothalamus
resulting in increased fluid intake or psychogenic
Treatment
causes
• Correct underlying cause Clinical Sign
• Fluid restriction 500-1000 ml/day • Dehydration! Excessive loss of water from body tissue and
• Severe hyponatremia: 3% NSS may be given imbalance of essential electrolytes (Na, K, Cl)
• Lasix may be given (watch K level) • Polydipsia (excessive thirst)
Nursing Management
• Polyuria (excessive amount of urine)
• Frequent Neuro assessment: Mental status and LOC
• Low specific gravity (1.001 to 1.005)
• Pulmonary assessment: s/s fluid overload
• Serum hyperosmolality and hypernatremia
• Cardiac assessment: Dysrhythmias and BP abnormalities Causes
• Monitor for seizure activity: Seizure precautions • Head Trauma
• Accurate I&O • Post-operative (hypophysectomy, pituitary tumor)
• Daily Weights: Same time each day, same scale, same • Brain Tumors
clothes
• CNS Infection (meningitis, abcess)
• Oral hygiene • Increased ICP
• Reduce stress, pain, discomfort
• Idiopathic
Correlation of Decreasing Sodium Levels and Symptoms
• ICH
Serum Sodium Level Symptoms • Stroke
Normal concentration, no • Hypoxia
145-135 mEq/L • Medications (Dilantin, clonidine, alcohol)
symptoms
• Damage to hypothalamus or posterior pituitary
135-120 mEq/L Generally no changes Investigate the following for DI
• Unquenchable thirst
HA, apathy, lethargy, weakness,
• Polydipsia
120-110 mEq/L disorientation, thirst, fatigue,
• Polyuria (hourly urine output > 200 mls)
seizures
• Unexplained weight loss
Confusion, hostility, lethargy, • Urinary frequency
110-100 mEq/L N/V, abdominal cramps, muscle • Dry skin/poor skin turgor
twitching • Tachycardia and hypotension
• Inability to respond to the increased thirst stimulus and
Delirium, convulsions, coma,
compensate for the excessive polyuria
100-95 mEq/L hypothermia, areflexia, Cheyne-
Stokes respirations, death
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• Hypernatremia that becomes severe and is manifested by- • After assessing fluid status and serum sodium level, treat
confusion, irritability, stupor, coma and neuromuscular both dehydration and hypernatremia
hyperactivity progressing to seizures. • For chronic neurogenic DI- require hormonal replacement
• Unconscious/intubated therapy: DDAVP (nasal vasopressin)
Labs and Diagnostics • Consultation with an endocrinologist is strongly
• Serum calcium recommended
• Glucose Removal of the underlying cause/offending drug
• Creatinine • DDAVP usually ineffective
• Potassium • Thiazide diuretic (HCTZ) is first line treatment
• Urea level • Adequate hydration
• The following may also be indicated: • Low-sodium diet + thiazide diuretics to induce mild sodium
- 24hr urine collection to quantitative polyuria depletion.
- CT/MRI - rule out pituitary causes, metastases, • Indomethacin may also be useful to reduce urine volume.
hemorrhage, neuronal damage, cerebral tumors. Nursing Management
- Radioimmunoassy: to measure circulating ADH • Hourly Neuro Checks
concentrations • Frequent Vital Signs
Lab Value Result • Evaluate for s/s of hypovolemic shock
• Strict I&O
Serum Sodium Above 145 mEq/L • Rehydrate for symptoms of extreme thirst
Serum Osmolality Above 290 mOsm/kg • Measure and record weight using the same scales at the
same time and with the patient wearing the same clothing
Urine Specific Gravity of the Below 1.005 • Assess mucous membranes and skin turgor and monitor
first morning voiding for symptoms of dehydration
• Provide rest
Urine Sodium Above 145 mEq/L
• Safety measures to prevent injury secondary to dizziness
Urine Osmolality Below 300 mOsm/L and fatigue
Diagnosis of DI should be considered in any person producing • Alert the health care team of problems of urinary frequency
large volumes of dilute urine and extreme thirst that interferes with sleep and activities.
Water Deprivation Test SIADH vs DI Lab Values
- After baseline measurement of: weight, ADH, plasma Finding SIADH DI
sodium, and urine/plasma osmolality, the patient is
deprived of fluids under strict medical supervision Less than 200 mls Greater than
Urine Output
- Frequent (q2h) monitoring of plasma and urine osmolality x 2hrs 250 mls x 2hrs
follows. Below 135 mEq/L Above 145
- The test is generally terminated when plasma osmolality is Serum Sodium
mEq/L
>295 mOsm/kg or the patient loses ≥3.5% of initial body
weight. Urine Sodium Below 25-30 mEq/L Decreased
- DI is confirmed if the plasma osmolality is >295 mOsm/kg
Urine Above 900 Below 400
and the urine osmolality is <500 mOsm/kg.
Osmolality mOsm/kg mOsm/kg
Nephrogenic DI vs Neurogenic DI
• DDAVP Challenge Plasma Below 275 Above 295
- Check urine osmolality 1-2hrs after 1mcg SQ DDAVP Osmolality mOsm/L mOsm/L
- If little or no change: likely NDI or dipsogenic DI
- If significant increase in urine osmolality, likely CDI Blood Pressure Normotension Hypotension
• 5 units vasopressin IV Fluid Status No Dehydration Dehydration
- Measure osmolality
- A significant increase (>50%) in urine osmolality after Confusion, Seizures, coma
Neuro
administration of ADH is indicative of CDI delirium, coma
Symptoms
Treatment with low Na
Correct the underlying cause and maintain adequate fluid
replacement. Complications to treatments of DI and SIADH
• DI Therapy varies with the degree and type of DI present or • Cerebral Edema!
suspected. • Central Pontine Myelinolysis: brain cell dysfunction caused
• IVF may be necessary to correct hypernatremia; avoid by destruction of the myelin sheath covering nerve cells in
rapid replacement brainstem
• Free water restriction • Na levels rise too fast or corrected too quickly
• s/s: (not necessarily immediate)
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- Acute paralysis • FNB (Fine Needle Biopsy)

- Dysphagia - Cytology (detection of malignant cells)
- Dysarthria • BMR (Basal Metabolic Rate)
Most Important Nursing Intervention for DI and SIADH - Measures O2 consumption at the lowest cellular activity
• Frequent Labs - Oxygen uptake is measured as an indirect
- We have severe electrolyte abnormalities measurement of metabolic rate
- Careful not to correct too quickly!! - increased utilization O2 (hyperthyroid)
- Na should not rise more than 0.5mEq/L/hr and 10 • Reflex Testing (Kinemometry)
mmol/L/24 hrs - Tendon of Achilles Reflex (TAR)
• Frequent neuro assessment • Goiter
- The nurse can pick up abnormal behavior and signs and - Enlargement of the thyroid gland associated with
symptoms first. Note any changes from baseline hyperthyroidism, hypothyroidism or euthyroidism
Thyroid Gland Disorder - A hyperthyroid goiter is called toxic goiter
- Secretes the following hormones
• T3 (Triidothyronine) Hyperthyroidism (Thyrotoxicosis)
 Metabolism and growth • Grave’s Disorder
• T4 (Thyroxine, tetraiodothyronine) • Basedow’s Disorder
 Catabolism and body heat production • Exophthalmic Goiter
• Thyrocalcitonin • Diffuse Toxic Goiter
 regulates serum Ca++ levels - Common in female, below 40 y/o
 bring down the blood Ca++ level - Causes:
Diagnostic Tests • Severe emotional stress
• T3/ T4 levels • Autoimmune Disorder
-  level: hyperthyroidism • Thyroid inflammation
-  level: hypothyroidism
• PBI (Protein-bound Iodine)
- Preparation: No foods, drugs, test dyes with iodine 7-10
days before the test
• RAIU (Radioactive Iodine Uptake)
- Tracer dose of I131 is used P.O. & at 2°, 6°, and 24° 
exposure to scintillation camera is done
- No foods, drugs, test dyes with iodine 7-10 days before
the test, temporarily discontinue contraceptive pills
(these may metabolic rate)
- Result:
o  iodine uptake: hyperthyroidism
o  iodine uptake: hypothyroidism
Hyperthyroidism: Key concepts
- What are the hormones produced by the thyroid gland?
• T3
• T4
• Calcitonin
- 3 BASIC CONCEPTS:
•  T3 =  metabolic rate
•  T4 =  body heat production
•  Thyrocalcitonin =  calcium
• Thyroid Scan Assessment Findings
- Radioisotope Iodine is injected IV • Restlessness, nervousness, irritability, agitation, fine
- Exposure to scintillation camera tremors, tachycardia, hypertension, voracious appetite to
eat, weight loss, diaphoresis, diarrhea, heat intolerance,
amenorrhea, fine silky hair, pliable nails
• Exophthalmos
- Due to accumulation of fluids, mucopolysaccharides at
the fat-pads behind the eyeballs
- It can lead to corneal ulceration,
• Von Graefe’s sign (LID LAG)
- Long and deep palpebral fissure is still evident when
one looks down
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• Jeffrey’s sign – Forehead remains smooth when one looks • Pre-op Care
up o Promote euthyroid state
• Dalyrimple’s sign (Thyroid stare) - Control of thyroid disturbance
- Bright-eyed stare, infrequent blinking - Stable VS
• Dermopathy o Administer Iodides as ordered – To reduce the size &
- Warm, flushed sweaty skin vascularity of thyroid gland, thereby prevent post-op
- Thickened hyper-pigmented skin at the pretibial area hemorrhage and thyroid crisis
Management o ECG – Heart failure/ cardiac damage results from HPN/
• Rest (non-stimulating cool environment) tachycardia
• Diet o Position : Semi-fowler’s with head, neck & shoulder
- HIGH Calorie, HIGH protein; vitamin and mineral erect
supplement o Prevent Hemorrhage: ice collar over the neck
- Increased fluid intake (if with diarrhea) o Keep tracheostomy set available for the first 48° post-
- Replace F&E losses op
- Avoid stimulants like coffee, tea and nicotine o Ask the patient to speak every hour (to assess for
• Promote safety recurrent laryngeal nerve damage)
• Protect the eyes o Keep Ca++ gluconate readily available – Tetany occurs if
- Artificial tears at regular intervals hypocalcemia is present. This may be secondary to the
- Wear dark sunglasses when going out under the sun accidental removal of the parathyroid gland
Management: Pharmacotherapy o Monitor Body Temperature: hyperthermia is an initial
• ß-blockers: Propranolol sign of thyroid crisis
o Monitor BP (hypertension may be a manifestation of
• Ca++ channel blockers
thyroid storm)
- These drugs are given to control tachycardia and HPN
o assess for Trousseau’s sign (hypocalcemia)
• Iodides: Lugol’s solution
o Steam inhalation to soothe irritated airways
- SSKI (Saturated Solution of Potassium Iodide)
o Advise to support neck with interlaced fingers when
- Are given to inhibit release of thyroid hormone
getting up from bed
- Mix with fruit juice with ice or glass of water to improve
o Observe for signs and symptoms of potential
its palatability
complications
- Provide drinking straw to prevent permanent staining of
- Hemorrhage
teeth
- Airway obstruction
- Side effects: Allergic reaction, Increased salivation,
- Tetany
colds
- Recurrent laryngeal nerve damage
• Thioamides
- Thyroid crisis / storm / thyrotoxicosis
- PTU (Propylthiouracil) & Tapazole (Methimazole)
- Myxedema
- These are given to inhibit synthesis of thyroid hormones
• Client Teaching
- Side effects of PTU
o ROM exercises of the neck 3 to 4 days after discharge
o AGRANULOCYTOSIS / NEUTROPENIA This is
o Massage incision site with cocoa butter lotion to
manifested by unexplained Fever, Sore throat, Skin
minimize scarring
rashes
o Regular follow – up care
o The nurse must elicit these symptoms and if present,
the physician must be alerte
Thyroid crisis/ storm
• Paracetamol for fever
- Sudden, life-threatening exacerbation of hyperthyroidism/
- Aspirin must be avoided because it can displace the
thyrotoxicosis
T3/T4 from the albumin in the plasma causing increased
- Causes: Stress, Infection, Unprepared thyroid surgery
manifestations
Assessment
• Dexamethasone
• Initial sign: Elevated temperature
- inhibit the action of thyroid hormones
• Tachycardia
- Steroids are given to prevent the conversion of T4 to T3 in
the peripheral tissues • Dysrhythmias
• Tremors, apprehension, restlessness
• Radiation therapy (Iodine)
- Need isolation for few days; body secretions are • Delirium, psychotic state, coma
radioactive contaminated • Elevated BP
- NOT recommended in pregnant women because of Management
potential teratogenic effects. Pregnancy should be • Monitor the following every hour
delayed for 6 months after therapy - Temperature
Surgery - Intake and output
• Subtotal Thyroidectomy- Usually about 5/6 of the gland is - Neurologic status
removed - Cardiovascular status
J.A.K.E 11 of 28
• Administer increasing doses of oral PTU • Irregular menstruation (menorrhagia, amenorrhea)

- (200 to 300 mg q 6 hrs) as ordered, following a loading • Husky, hoarse voice
dose of 800 to 1,200 mg. p.o as ordered • Extreme fatigue
• Administer iodide preparation as ordered • Slow speech
• Administer dexamethasone to help inhibit the release of • Enlarged tongue
thyroid hormone • Increased sensitivity to sedatives, narcotics, and
• Administer propranolol to control hypertension and anesthetics
tachycardia
• Implement measures to lower fever
- cooling devices
- cold baths
- acetaminophen (avoid aspirin)
• Administer oxygen as needed
• Maintain quiet, calm, cool, private environment until crisis
is over
Hypothyroidism
- results from deficiency of thyroid hormones
- What are the hormones produced by the thyroid gland?

• T3
• T4
• Calcitonin Management
- 3 BASIC CONCEPTS: • Monitor vital signs
•  T3 =  metabolic rate • Be alert for signs and symptoms of cardiovascular
•  T4 =  body heat production disorders
•  Thyrocalcitonin =  calcium • Monitor the weight daily
- Causes • Diet: LOW Calorie, High fiber (constipation)
• Autoimmune – Hashimoto’s disease or chronic • Provide warm environment during cold climate
lymphocytic thyroiditis - an autoimmune disorder in Pharmacotherapy
which your immune system inappropriately attacks your • Thyroid hormonal replacement
thyroid gland causing an inflammation - Proloid (Thyroglobulin)
• after surgery (thyroidectomy) - Synthroid (Levothyroxine)
• after radiation therapy (radioactive iodine) - Dessicated Thyroid Extract
• antithyroid drugs - Cytomel (Liothyronine)
Assessment o Before administration, the nurse should monitor BP
• Slowed physical, mental reactions, apathy & PR
• Dull, expressionless, mask-like face o Start with low dose and gradually increase
• Anorexia Myxedema Coma
• Obesity - Extreme, severe stage of hypothyroidism, in which the
• Bradycardia client is hypothermic and unconscious
• Hyperlipidemia & atherosclerosis - Management includes:
• Cold intolerance, subnormal temperature • IV thyroid hormones
• Constipation • Correction of hypothermia
• Coarse, dry, sparse hair • Maintenance of vital function
• Brittle nails • Treat precipitating factors
J.A.K.E 12 of 28
ADRENAL AND PARATHYROID GLAND DISORDERS - Mineralocorticoids (Aldosterone)

Adrenal Gland Diseases • Promotes Na & H2O reabsorption & K+ excretion.
- Adrenal gland – also known as suprarenal gland, small - Glucocorticoids (Cortisol)
triangular shapes gland located on the top of the both • Affects CHO, CHON, Fat metabolism.
kidneys. 4-5 grams in weight. - Body’s response to STRESS
- Consists of: • Emotion stability
• Zona glomerulosa is the outermost region of the adrenal • Immune Function
cortex and is the only zone of the adrenal gland that - Sex Hormones
contains the enzyme aldosterone synthase (CYP11B2). • Major source of androgen in women
• Zona fasciculata, the middle zone of the adrenal cortex Assessment
secretes glucocorticoids which are important for
• Fatigue, muscle weakness
carbohydrate, protein and lipid metabolism. (Regulates
• Anorexia, N&V, abdominal pain, weight loss
blood sugar)
• Frequent hypoglycemic reactions
• Zona reticularis produces androgens (sex hormones)
• Hypotension, weak pulse
• Bronze like pigmentation of the skin
- Due to MSH (Melanocyte-stimulating hormone) 2° to
loss of adrenal-hypothalamic-pituitary feedback system
• Decreased capacity to deal with stress.
Addison’s Disease
- Hypofunction of the adrenal cortex resulting to a
decreased secretion of the
• Mineralocorticoids
• Glucocorticoids
• Sex hormones
- Causes:
• Idiopathic atrophy of the adrenal cortex possibly due to Diagnostic Tests
an autoimmune process • Low cortisol levels
• Destruction of the gland secondary to tuberculosis or • Hyponatremia
fungal infection • Hypovolemia
• Tumor (not secreting adequate hormone – • Hyperkalemia
hypopituitarism) • Acidosis
- Key Concept: Know the functions of the hormones and • Hypoglycemia
you will know the signs & symptoms.
J.A.K.E 13 of 28
Nursing Intervention Assessment Findings

• Administer HRT as ordered. (kung kulang ng hormone, edi • Muscle weakness, fatigue
bigyan ng hormone, HRT – Hormonal Replacement • Obese trunk with thin arms and legs, muscle wasting
Therapy) (pendulous abdomen)
- Glucocorticoids (Cortisone, Hydrocortisone) – simulate • Irritability, depression, frequent mood swings
diurnal rhythm of cortisol release, give 2/3 of dose in • Moon face, buffalo hump
early morning and 1/3 of dose in afternoon. • Purple striae on trunk, acne, thin skin
- Mineralocorticoids (Fludrocortisone acetate) • Signs of masculinization in women; menstrual dysfunction,
• Monitor VS decreased libido
• Decrease stress in the environment. • Osteoporosis, decreased resistance to infection
• Provide rest periods; prevent fatigue. • Hypertension, edema
• Prevent exposure to infection. Diagnostic test
• Monitor I&O, weigh daily. • cortisol levels
• Provide proper nutrition in small, frequent feedings of diet • slight hypernatremia
high in Sugar (carbohydrate), Salt (sodium) and Protein
• hypokalemia
• Provide client teaching and D/C planning concerning:
• hyperglycemia
- Use of prescribed medications for lifelong replacement
When cushing’s is suspected, a blood sample will be
therapy; never omit medications.
taken for laboratory analysis.
- Need to avoid stress, trauma, and infections, and to
1) ACTH- 7.2- 52 pg/ml
notify physician if these occur as medication dosage
2) Plasma cortisol - 10-20mcg/dl
may need to be adjusted
- It decreases in the evening- during early phase of
- Stress management techniques
sleep
- Diet modification
3) Dexamethasone suppression test (Confirmatory test)
- Use of salt tablets (if prescribed) or ingestion of salty
- Measures the response of adrenal glands to ACTH.
foods (potato chips) if experiencing increased sweating.
Dexamethasone 1mg is given oral at 11pm.
- Importance of alternating regular exercise with rest
- Plasma cortisol is obtained at 8am…>50% reduction in
periods, avoidance of strenuous exercise especially in
plasma cortisol
hot weather
4) MRI/ CT scan
• Emergency condition: Addisonian crisis is a life-
Medical Management
threatening situation that results in low blood pressure,
low blood levels of sugar and high blood levels of • Mitotane- [Lysodren] to decrease production of
potassium. (circulatory failure or shock, it could be cause glucocorticoids
by a sudden withdrawal of corticosteroids on patient who • Korlym [Mifepristone]- Cortisol Receptor blocker
has having high dose of corticosteroids) • Ketoconazole
Cushing Syndrome • Metyrapone [Metopirone]
- Hyperfunction of the adrenal cortex resulting to an • Insulin
excessive secretion of the: Nursing Intervention
• Mineralocorticoids • Maintain muscle tone (Provide ROM exercises, assist with
• Glucocorticoids ambulation) there is instability because of muscle
• Sex hormones weakness
- Causes: • Prevent accidents or falls and provide adequate rest
• Overproduction of ACTH- hyperpituitarism • Protect client from exposure to infection
• Benign or malignant tumors • Maintain skin integrity.
• Prolonged corticosteroids therapy • Provide meticulous skin care.
• Exogenous • Prevent tearing of skin: use paper tape if necessary.
- Key Concept: Know the functions of the hormones and • Minimize stress in the environment
you will know the signs & symptoms • Monitor VS: observe for hypertension, edema
- Mineralocorticoids (Aldosterone) • Measure I&O and daily weights
• Promotes Na & H2O reabsorption & K+ excretion • Provide diet that is:
- Glucocorticoids (Cortisol) - low in calories and sodium
• Affects CHO, CHON, Fat metabolism - high in protein, K+, Ca++
• Body’s response to STRESS - vitamin supplements
• Emotion stability • Monitor urine for glucose and acetone; administer insulin if
• Immune Function ordered
- Sex Hormones • Provide psychological support and acceptance.
• Major source of androgen in women • Prepare client for hypophysectomy or radiation if condition
is caused by a pituitary tumor.
J.A.K.E 14 of 28
• Prepare client for an adrenalectomy if condition is caused Diagnostic tests

by an adrenal tumor or hyperplasia. • Increased plasma levels of catecholamines
• Provide client teaching D/C planning concerning: • Elevated blood sugar
- Diet modifications • Glycosuria
- Importance of adequate rest • Elevated urinary catecholamines and urinary
- Need to avoid stress and infection vanillylmandelic acid (VMA) levels
- Change in medication regimen (alternate day therapy or
• Presence of tumor on x-ray
reduced dosage) if cause of the condition is prolonged
Laboratory Test
corticosteroid therapy.
Conn’s Syndrome (Hyperaldosteronism) • Serum epinephrine – 0-140 pg/ml [764.3 pmol/L
- Excessive aldosterone secretion from the adrenal cortex • Norepinephrine – 70- 1700pg/ml or 413.8- 10048.7pmol/L
- Seen more frequently in women (30-50 y/o) • Catecholamine test uses a sample of blood or urine to
- Cause by a tumor or hyperplasia of adrenal gland measure levels of some adrenal hormones.
- Key Concept: Mineralocorticoids (Aldosterone) – • Normetanephrine – 18- 111 pg/ml
Promotes Na+ & H2O reabsorption & K+ excretion • Metanephrine – 12-60 pg/ml
Assessment findings • Urine catecholamines – 14-110mcg/24 hrs
• Headache • VMA – Vanillyl Mandelic Acid is produced in the liver and
• Hypertension is a major product of epinephrine and norepinephrine
• Muscle weakness metabolism which is excreted in the urine.
- Preparation: No food and fluid with coffee, tea, cocoa,
• Polyuria, polydipsia
chocolate for 48 hours before the test
• Metabolic alkalosis
- Normal level 2-7 mg/24 hours
• Cardiac arrhythmias (due to hypokalemia)
Nursing interventions
Diagnostic tests
• Monitor vital signs, especially blood pressure.
•  Serum K+
• Administer medications as ordered to control hypertension.
• Alkalosis
• Promote rest; decrease stressful stimuli.
• Urinary aldosterone levels elevated
• Monitor urine tests for glucose and acetone
Laboratory Test
• Provide high-calorie, well-balanced diet; avoid stimulants
• Plasma aldosterone- in supine position with normal such as coffee, tea.
sodium diet • Provide care for the client with an adrenalectomy as
• 2-9 ng/dl or 55-250 pmol/L, with upright /standing position ordered; observe post adrenalectomy client carefully for
or seated for at least 2hrs is 2-5x supine value shock due to drastic drop in catecholamine level.
• Urine aldosterone - 14-56 nmol/24 hrs • Provide client teaching and discharge planning: same as
Nursing Interventions for adrenalectomy.
• Monitor VS, I&O, daily weigh
• Maintain sodium restriction as ordered Parathyroid Gland
• Administer spironolactone (Aldactone) and potassium - Produces parathyroid hormone (PTH) or parathormone
supplements as ordered which regulates calcium and phosphorous balance.
• Prepare the client for an adrenalectomy if indicated • Hyperparathyroidism – Hypercalcemia
• Provide client teaching and discharge planning concerning: • Hypoparathyroidism – Hypocalcemia
- Use and side effects of medication if the client is being
maintained on spironolactone therapy
- Signs of symptoms of hypo/ hyperaldosteronism
- Need for frequent blood pressure checks and follow-up
care
Pheochromocytoma
- A condition of hyper-functioning tumor of the adrenal
medulla resulting to excessive secretion of epinephrine &
norepinephrine
- Occurs most commonly between ages 25-50, hereditary in
some cases
Assessment findings
• Severe headache, apprehension, palpitations, profuse
Hyperparathyroidism
sweating, nausea
- Characterized by excessive secretion of the PTH
• Hypertension, tachycardia, vomiting, hyperglycemia, - Causes:
dilation of pupils, cold extremities
• parathyroid adenoma
• congenital hyperparathyroidism
J.A.K.E 15 of 28
• multiple endocrine neo plasia- a group of disorders that - Serum phosphate- 2.5-4.5 mg/dl
affect the body’s network of hormones producing - Alkaline phosphatase- 44- 147 IU/L
glands Medical Management
• Secondary hyperparathyroidism can occur due to • Surgery to remove the adenoma
o rickets (softening of the bone) • Increased fluids to force diuresis
o vitamin D deficiency • Dietary restrictions of calcium
o chronic renal failure • Medications – Furosemide and ethacrynic acid, oral
o phenytoin and laxative abuse calcitonin, oral potassium phosphate
Pathophysiology Nursing Interventions
- Record I&O accurately
- Strain all urine to check for stones
- Monitor electrolyte levels (Na+, K+, Mg++)
- Be alert for pulmonary edema if IVF therapy is initiated
- Prevent injury due to fracture: Provide a safe environment
to ensure against complications related to potential
osteoporosis and joint and bone pain
- Monitor for cardiac arrhythmias and decreased cardiac
output
- Increase fluids, 2-3 L, cranberry juice
- Encourage mobility
Assessment
Hypoparathyroidism
- Deficiency of PTH, that leads to hypocalcemia and
produces neuromuscular symptoms ranging from
paresthesia to tetany
- Causes:
• Congenital absence, autoimmune disease
• Removal of the parathyroid glands
• Post-thyroidectomy
• Massive thyroid radiation therapy
Clinical Manifestations
• Positive Chvostek’s and Trousseau’s sign
• Tetany, paresthesia
• CNS – psychomotor and personality disturbances, loss of
• INCREASED neuromuscular irritability,  DTR
memory, depression, psychosis, confusion, disorientation,
• Psychosis
stupor and coma
• Dysphagia, abdominal pain
• GI – abdominal pain, anorexia, nausea, vomiting,
• Arrhythmias, bronchospasm, laryngospasm
dyspepsia and constipation
• Cataracts
• Neuromuscular – fatigue, marked muscle weakness and
atrophy • Hair loss, brittle nails, dry skin
• Renal – nephrolithiasis, renal insufficiency • Weakened tooth enamel
• Skeletal – chronic lower back pain, fractures, bone Diagnostic Test
tenderness and joint pain - PTH
• Vision impairment – scleritis/ red eye keratopathy, - serum calcium
asymptomatic conjunctival - serum phosphate
• Calcification and conjunctivitis - X-ray reveals increased bone density
- ECG- prolonged QT intervals and QRS complex and ST
Diagnostic test
segment changes
• Increased serum calcium, with decreased level of
Medical Management
phosphate
• X-rays will show diffuse demineralization of bones, bone • Therapy includes vitamin D supplements, and
cysts, erosions supplemental calcium like Calcium Citrate, Caltrate Plus,
Calcium carbonate, given with meals bec. It requires
• Elevated urine and serum calcium
stomach acid to dissolve and absorb it.
• Increased alkaline phosphatase levels
- Life-threatening hypocalcemia is managed by IV
• UTZ, MRI
calcium gluconate to raise calcium levels.
• Normal Values
• Sedatives and anti-convulsant are used to prevent seizures
- PTH- 10-55 pg/ml
- Serum Calcium- 8.6- 10 mg/dl
J.A.K.E 16 of 28
Nursing interventions • A review of the medical history, including a system-by-

• Maintain a patent IV line & keep calcium gluconate 10% system evaluation, is part of the health history.
solution available • The nurse should be aware of any history of trauma or
• Administer prescribed sedatives, anticonvulsants & falls that may have involved the head or spinal cord.
calcium gluconate (slow IV) • Questions regarding the use of alcohol, medications,
• Institute seizure precaution and il- licit drugs are also relevant.
• Keep a tracheostomy set and endotracheal tube available - The history-taking portion of the neurologic assessment is
• Watch out for cardiac arrhythmias and decreased cardiac critical and, in many cases of neurologic disease, leads to
output an accurate diagnosis.
• Encourage to take high calcium and low phosphate diet Physical Assessment
early in the disease process - 5 Components of Neurologic Assessment:
consciousness and cognition, cranial nerves, motor
• Creams and lotions can be used to sooth dry skin
system, sensory system, and reflexes.
INTRO TO NERVOUS SYSTEM
Diagnostic tests
Radiographic examinations
1) X-ray Examinations of the Skull and Spine
- used to determine
- bony fractures
- curvatures
- bone erosion
- bone dislocation
- possible calcification of soft tissue w/c can damage the
nervous system
• you will be asked to lie on the x-ray table or sit in a
chair
• your head may be placed in a number of positions
• several views are taken: anteroposterior, lateral,
Assessment of the Nervous System oblique & when necessary, special views of the
Health History facial bones
- An important aspect of the neurologic assessment is the - Nursing responsibilities before:
history of the present illness. • Explain that it is similar to that for a chest x-ray
- The initial interview provides an excellent opportunity to procedure
systematically explore the patient’s current condition and • Need to remain still during the procedure
related events while simultaneously observing overall • Exposure to radiation is minimal
appearance, mental status, posture, movement, and affect. • Remove hairpins, glasses, hearing aids
- Neurologic disease may be stable or progressive,
• Patient in traction & no portable x-ray= accompany
characterized by symptom-free periods as well as
patient to assist in positioning
fluctuations in symptoms.
• Patient who cannot walk & transfer fr wheelchair to
- The health history therefore includes details about the:
x-ray table = stretcher
• Onset, character, severity, location, duration, and
- Nursing responsibilities after: follow up care is not
frequency of signs and symptoms
required
• Associated complaints. 2) Cerebral Angiography (Arteriography/ Arteriogram)
• Precipitating, aggravating, and relieving factors - used to visualize cerebral vessels & detect tumors,
• Progression, remission, and exacerbation; and aneurysms, occlusions, hematomas, abscesses
• The presence or absence of similar symptoms among - injection of radiopaque substance into the cerebral
family members. circulation via carotid, vertebral, femoral, brachial
- Common signs and symptoms associated with artery followed by x-rays
neurologic disease: - DSA – Digital Subtraction Angiography
• Pain • x-ray images of the area are obtained b4 and after
• Seizures the injection of the contrast agent
• Dizziness & vertigo • images obtained before contrast injection are
• Visual disturbances digitized and subtracted from post - contract images,
• Muscle weakness thus removing bones and other background
• Abnormal sensation structures from the final digital images
- Past Health, Family, and Social History - Nursing responsibilities before:
• The nurse may inquire about any family history of • signed consent (after explaining the procedure,
genetic diseases. usually the radiologist)
J.A.K.E 17 of 28
• check for allergy to iodinated contrast agents • check I & O, resultant diuresis may require
o =infreq. pt may have an immediate or delayed replacement of fluids
allergic rxn to the iodine contained in the 4) Positron Emission Tomography (PET)
contrast agent - provides information about the function of the brain
o Manifestations: dyspnea, n&v, sweating, - specifically glucose, O2 metabolism and cerebral blood
tachycardia & numbness of extremities flow
o Int: report to physician at once - it can be used to image what the brain is doing
o Tx: adm of epinephrine, antihistamines, or - A PET scan can show patterns in the brain which aid the
corticosteroids physician in diagnosing and treating Parkinson's
o Addtnal risks: vessel injury, bleeding & CVA Disease
• necessity for not moving during the procedure • Client is placed on a stretcher
• NPO 4-6 hours before the test – well hydrated, clear • IV line is started to inject isotope (deoxyglucose)
liquids permitted up to the time of regular • isotope emits activity in the form of positron which
angiography are scanned & converted into a color image by
• remove hairpins & jewelries computer
• record neuro & v/s • more active a given part of the brain = the greater the
• empty bladder glucose uptake
- Nursing responsibilities after: • client may be blindfolded with earplugs
• v/s, neuro signs & neurovascular checks as ordered; • client is asked to perform certain mental functions
compare with pre-angiography signs to activate different areas of the brain
• restricted to bedrest for several hours - Nursing responsibilities before:
• monitor VS & neuro checks • signed consent form
• extremity used is kept straight & immobilized for the • instruct the client to withhold caffeine, alc &
duration of the bedrest – if w/ hematoma, (localized tobacco for 24 hrs (accdg to agency policy)
collection of blood), ice bag may be applied, • NPO for 6-12 hours (if diabetic=no insulin before the
intermittently to the puncture site test)
• check for the extremity’s skin color & temp, pulses • no glucose solution nor any drugs that alter glucose
distal to the injection site, capillary refill metabolism
• inspect injection site for evidence of bleeding - Nursing responsibilities after:
• increase oral or IV fluids if not contraindicated • increase fluid intake (radioisotope is eliminated in
3) Computed Tomography/ Computed Axial Tomography the urine)
(CT/ CAT scan) • ff-up care is not required
- used to detect intracranial & spinal cord lesions 5) Single-Photon Emission Computed Tomography
- used to monitor effects of surgery or other therapy (SPECT)
- uses ionizing radiation - limitation of PET may be overcome.
- skull & spinal cord are scanned in successive layers by - less expensive than PET but resolution of images is
a narrow beam of x-rays limited
- computer construct a picture of the internal structure of - particularly useful in studying:
the brain • Cerebral blood flow
- contrast media may or may not be used • Head trauma
- Nursing responsibilities before: • Stroke
• signed consent • Seizures
• if w/ contrast agent: notify physician if client has risk • Dementia
factor & food is withheld for 4-6 hours; fluids are • Persistent Vegetative state
generally not withheld • AIDS
• patients must remove all metallic materials (may be • Brain death
required to change into a hospital gown) • Amnesia
• remove hairpins, hairpieces or wigs • Psychiatric disorders
• to provide clear images: patients must remain as • Neoplasms
still as possible - uses a radiopharmaceutical agent that enables
• the technician is able to see the patient and radioisotopes to cross the blood-brain barrier via IV
communicate through an intercom system injection (1hr before the scan)
throughout the procedure - positioned on an x-ray table in a quiet dark room
- Nursing responsibilities after: If w/ contrast agent: - gamma cameras scan the head
• check for delayed allergic response to contrast - images are downloaded to a computer
medium if used - it is able to provide true 3D information
• increase fluid intake if contrast medium was used
J.A.K.E 18 of 28
2) Lumbar puncture/ Spinal tap

- the insertion of a spinal needle into the subarachnoid
spacebetween the 3rd & 4th (sometimes L4/L5, L5/S1)
lumbar vertebrae
- used to do the ff:
• obtain pressure readings with a manometer.
• Normal: 60-150 mmH2O
• obtain CSF for analysis protein, sugar, cytology, C/S,
color
• significance of CSF findings
• check for spinal blockage attributable to spinal cord
lesion
• inject contrast medium or air for diagnostic study
• inject spinal anesthetics
- Left: SPECT scans of the brain of a three year old male near
• inject certain medications
drowning patient shown shortly after the accident showing
decreased brain activity. The patient presented in a • reduce mild to moderate increased ICP in certain
persistent vegetative state, and was pronounced blind with conditions
severe spasticity. - Nursing responsibilities before:
- Right: SPECT scans of the same child taken 9 months later • signed consent form
demonstrating increased brain activity and blood flow • void before the test
following 120 hyperbaric oxygen treatments. The child was • position in lateral recumbent with head & neck
now alert, responsive, laughing, eating and drinking flexed onto the chest & knees pulled up; “fetal
normally, walking, speaking bi-lingually, and had regained position”
normal vision. • explain the need to remain still during the procedure
Other diagnostic tests - Nursing responsibilities after:
1) Magnetic Resonance Imaging (MRI) • label specimens
- produces images superior to CT scan computer-drawn, • keep client flat for 4-8 hours or 12-24 hours as
detailed pictures of structures of the brain & body prescribed by physician or as determined by hospital
through the use of large magnet, radio waves policy – to prevent CSF leakage
- used to detect intracranial & spinal cord • check puncture site for bleeding or CSF leak
- abnormalities assoc with disorders such as: • increase fluid intake (to 3000ml unless
• cerebrovascular diseases contraindicated) – facilitate CSF production
• tumors • assess sensation and movement in lower
• abscesses extremities
• cerebral edema • monitor VS
• hydrocephalus • analgesics for headache – a ↓ in CSF may cause
• multiple sclerosis severe, throbbing headache =spinal headache
- for enhancement of images, may use gadolinium = a • If LP is done to ↓ ICP, perform rapid neuro check
non-iodine-based contrast
- Nursing responsibilities before:
• signed consent form
• remove jewelry, glasses & other metals
• contraindicated to:
o anyone with orthopedic hardware
o IUDs, tattoos
o Pacemaker
o internal surgical clips
o other fixed metallic objects in the body
• warn client of normal audible humming & thumping
noises during the scan = may wear earplugs
• instruct to remain still, lasts for 45-60 mins
• help prevent claustrophobia = offer open MRI
• void before the test
- Nursing responsibilities after:
• Follow-up care is not required.
J.A.K.E 19 of 28
3) Electroencephalography (EEG) • head position depends on the dye used:

- graphic recording of electrical activity of the brain by o oil-based or water-soluble =elevated
several electrodes placed on the scalp o air =positioned lower than the trunk
- used to: • administer analgesics for headache or backache as
• Detect focus or foci of seizure activity prescribed
• used to quantitatively evaluate level of brain • encourage fluids to help excrete the contrast
function (determine brain death) material
• diagnose sleep disorders (sleep EEG) • monitor I & O to ensure adeq fluid intake, facilitate
- sleep EEG: excretion of contrast material and determine adeq
• You will be placed in a room that encourages urine output – at least 30mL/hr
relaxation
• asked to fall asleep
• while brain's electrical activity is recorded
• last about 2-3 hours / sometimes 6 hours
- Nursing responsibilities before:
• withhold sedatives, tranquilizers, stimulants for 2-3
days
• not to consume caffeine before the test.
• avoid using hair styling products (hairspray or gel) on
the day of the exam
• for sleep EEG, client may be asked to stay awake the
night before the exam
• remove electrode paste with acetone & shampoo
hair
• any medications withheld are reinstituted
INCREASED ICP, HEAD INJURY, CVA, SCI AND SEIZURES
• may need a nap if sleep deprived
Increased ICP
Radiographic or Non-radiographic?
1) Myelography / Myelogram - means, an ↑ in intracranial bulk due to an ↑ in any of the
- injection of dye or air into the subarachnoid space to intracranial
detect abnormalities of the spinal cord and vertebrae - Components: brain tissue, CSF or blood
• procedure begins with a lumbar puncture radiologist - Causes: trauma, hemorrhage, abscesses, growths or
may remove some of the CSF from the spinal canal tumors, hydrocephalus, edema or inflammation
• next, a portion of contrast dye will be injected into • Can impede circulation to the brain
the spinal canal through the hollow needle • Can impede the absorption of CSF
• the needle will remain in place and will be placed in • Affect functioning of nerve cells
prone position • Lead to brainstem compression
• x-ray table will be tilted in various directions to allow • Death
gravity to move the contrast dye to diff areas of the - To understand intracranial pressure, think of the skull as a
spinal cord (patient is be held in place by a special rigid box.
brace or harness) - After brain injury, the skull may become overfilled with
• more contrast dye will be administered during this swollen brain tissue, blood, or CSF.
process through the secured lumbar puncture - The skull will not stretch like skin to deal with these
needle changes.
• required x-rays or CT scan pictures will be taken - The skull may become too full and increase the pressure
- Nursing responsibilities before: on the brain tissue. This is called increased intracranial
• informed consent pressure.
- ICP is usually measured in the lateral ventricles, with the
• provide hydration for at least 12 hours before the
normal pressure being 0 to 10 mm Hg, and 15 mm Hg being
test
the upper limit of normal (Brunner & Suddarth’s Textbook
• solid foods are avoided
of MS 12th ed)
• assess for allergies to contrast agents, iodine or
shellfish
• if taking phenothiazine: hold medication -lowers the
seizure threshold
• premedicate for sedation as prescribed
• assess v/s & neuro condn freq as prescribed
J.A.K.E 20 of 28
Monro-Kellie Principle
- This concept holds that the skull is a rigid compartment

that contains 3 components:
• brain tissue
• blood (arterial & venous)
• CSF
- These components are balanced in a state of dynamic
equilibrium.
- If an increase occurs in the relative volume of one
component, such as brain tissue = the volume of one or
more of the other components must decrease or an
elevation in ICP will result.
Assessment
• Earliest sign: Deterioration in the level of
consciousness
- Early: confusion, restlessness, lethargy, and
disorientation first to time, then to place, and then to
person
- Later: stupor then coma
• Pupillary dysfunction relative to size, shape, and
reaction to light
- Early: gradual dilation, a slightly ovoid shape, and a
sluggish response to light ipsilateral to the lesion
- Later: signs are dilation of the ipsilateral pupil and a
non-reactivity to light (from compression of CNIII)
- Final: bilateral dilation and fixation
• Motor weakness and sensory deficits
- Early: monoparesis, contralateral hemiparesis, and
decreased visual acuity, such as blurred vision &
diplopia
- Later: hemiplegia, decortication or decerebration
(either unilateral or bilateral)
• Headache, possible seizures, projectile vomiting, (+)
Babinski’s reflex
- Late sign: Changes in vital signs
o Hypertension systolic BP rises while diastolic
pressure remains the same (widening pulse
pressure-a difference of more than 50 mm Hg )
o Bradycardia
o abnormal respiratory pattern
o elevated temperature
• Cushing's triad – a very late presentation of brain stem
dysfunction
J.A.K.E 21 of 28
Nursing interventions Post procedure interventions:

1) Elevate head of bed to 30-40 degrees as prescribed. 1) Position the client supine and turn from the back to the
2) Avoid Trendelenburg’s position. nonoperative side.
3) Prevent flexion of the neck and hips. 2) Monitor for signs of ↑ing ICP resulting from shunt failure.
4) Monitor respiratory status and prevent hypoxia. -leads to 3) Monitor for signs of infection.
brain swelling
5) Avoid the administration of morphine sulfate to prevent the
occurrence of hypoxia.
6) Maintain mechanical ventilation as prescribed.
- PaCO2 at 30-35 mmHg → vasoconstriction of cerebral
blood vessels → ↓ed blood flow = ↓ed ICP
- Hypercarbia=vasodilation= ↑ ICP;
- Hypocarbia=too much vasoconstriction
7) Maintain body temperature.
8) Prevent shivering –can ↑ICP
9) Decrease environmental stimuli.
10) Monitor electrolyte levels and acid-base balance.
11) Monitor I& O.
12) Limit fluid intake to 1200 mL/day.
13) Instruct client to avoid straining activities, such as
coughing and sneezing. Head Injury
14) Instruct the client to avoid Valsalva’s maneuver. - trauma to the skull, resulting in mild to extensive damage
Medications to the brain
1) Anticonvulsants - usually caused by car accident, falls & assaults
- as prophylactic to prevent seizures → ↑metabolic - immediate complications: cerebral bleeding, hematomas,
requirements & cerebral blood flow & volume → ↑ing uncontrolled ↑ed ICP, infections and seizures
ICP - changes in personality or behavior cranial nerve deficits &
- phenytoin (Dilantin) any other residual deficits depend on the area of the brain
2) Antipyretics & Muscle Relaxants damage & the extent of the damage
- prevents temp elevation & shivering
- temp reduction → ↑metabolism, cerebral blood flow +
ICP
- acetaminophen (Tylenol), diazepam (Valium)
Blood Pressure Medications
- to maintain cerebral perfusion at a normal level
- notify physician if BP is <100 or >than 150mmHg systolic
- beta blockers (Propanolol)
3) Corticosteroids
- stabilize the cell membrane & reduce the leakiness in
the blood-brain barrier ↓ cerebral edema
- S/E: ↑gastric secretion (give histamine blocker) ; - Types of head injuries:
adrenal crisis (withdrawn slowly from corticosteroid 1) Open
therapy) • Scalp lacerations
- dexamethasone (Decadron) • Fractures of the skull
4) Hyperosmotic Agents • Interruption of the dura mater
- Mannitol (Osmitrol) is a hyperosmotic agent that 2) Closed
↑intravascular pressure by drawing fluid from the • Concussion
interstitial spaces & from the brain cells • Contusions
- monitor renal function ; -diuresis is expected • Fractures
5) Intravenous Fluids Concussion Contusion
- administered via infusion pump to control the amount
delivered • widespread • localized (coup-contra
- hypertonic IVs are avoided bec of risk of promoting • microscopic coup)
addtnal cerebral edema • jarring of the brain • macroscopic
Surgical Intervention within the skull • bruising type of injury to the
Ventriculoperitoneal Shunt • temporary loss of brain
- shunts CSF from the ventricles into the peritoneum consciousness • noticeable loss of functions
J.A.K.E 22 of 28
Assessment
- Assessment findings depend on the injury
- Clinical manifestations usually result from ↑ed ICP
• Changes in LOC
• visual disturbances, pupillary changes & papilledema
• airway & breathing pattern changes
• headache, n&v
• weakness & paralysis
• posturing
• v/s changes
- CSF drainage: ears / nose
Fractures Nursing intervention
Types of skull fracture include: 1) Maintain patent airway & ventilation; V/S, neuro checks,
• Linear or hairline: a break in a cranial bone resembling a monitor signs of ↑ICP, seizures, hyperthermia
thin line, without splintering, depression, or distortion of 2) Observe CSF leak
bone - check discharge for glucose (strip test); bloody spot
• Depressed: a break in a cranial bone (or "crushed" portion encircled by watery, pale ring on pillowcase or sheet
of skull) with depression of the bone in toward the brain - never attempt to clean the ears or nose; never use nasal
• Compound: a break in or loss of skin and splintering of the suction unless ordered
bone 3) If a CSF leak is present:
• Comminuted: a fracture of many relatively small fragments - instruct not to blow nose
Hematoma - elevate HOB 30 degrees
• Subdural Hematoma - observe for signs of meningitis, antibiotics as ordered
- occurs under the dura as a result of tears in the veins - place cotton ball on ear to absorb otorrhea
crossing the subdural space - gently place sterile gauze pad at the bottom of the nose
- forms slowly for rhinorrhea
- results from a venous bleed 4) Prevent complications of immobility
• Intracerebral Hematoma 5) Prepare the client for surgery if indicated
- accumulation of blood within the cerebrum - Depressed skull fracture-surgical removal or elevation
of splintered bone; debridement & cleansing; repair of
dural tear
- Epidural / subdural hematoma-evacuation of
hematoma
6) Monitor for signs of infection
Cerebrovascular Accident (CVA)

- Destruction (infarction) of brain cells caused by a
reduction in cerebral blood flow and oxygen
- Affects men more than women; incidence increases with
age
- Caused by thrombosis, embolism, hemorrhage
- Risk factors:
• Hypertension
• diabetes mellitus
• arteriosclerosis/atherosclerosis
• cardiac disease (valvular disease/replacement, chronic
atrial fibrillation, MI)
• life-style (obesity, smoking, inactivity, stress, use of oral
contraceptives)
- A stroke can happen when:
• A blood vessel carrying blood to the brain is blocked by
a blood clot.
• This is called an ischemic stroke.
• A blood vessel breaks open, causing blood to leak into
the brain. This is a hemorrhagic stroke.
• If blood flow is stopped for longer than a few seconds,
the brain cannot get blood and oxygen.
J.A.K.E 23 of 28
• Brain cells can die, causing permanent damage. 7) Maintain adequate elimination.
• Offer bedpan or urinal every 2 hours, catheterize only if
absolutely necessary.
• Administer stool softeners and suppositories as
ordered to prevent
constipation and fecal impaction.
8) Provide a quiet, restful environment.
9) Establish a means of communicating with the client.
10) Administer medications as ordered.
• Hyperosmotic agents, corticosteroids to decrease
cerebral edema
• Anticonvulsants to prevent or treat seizures
• Thrombolytics given to dissolve clot (hemorrhage must
- Pathophysiology: interruption of cerebral blood flow for 5 be ruled out)
minutes or more causes death of neurons in affected area a) tissue plasminogen activator (tPA, Alteplase)
with irreversible loss of function b) streptokinase, urokinase = must be given within 2
Stages of development: hours of episode
1) Transient ischemic attack (TIA) • Anticoagulants - stroke in evolution or embolic stroke
- warning sign of impending CVA a) heparin
- brief period of neurologic deficit (visual loss, b) warfarin (Coumadin) for long-term therapy
hemiparesis, slurred speech, aphasia, vertigo) c) aspirin and dipyridamole (Persantin) – to inhibit
- may last less than 30 seconds, but no more than 24 platelet aggregation in treating TIAs
hours with complete resolution of symptoms • Antihypertensives - if indicated for elevated blood
2) Stroke in evolution – progressive development of stroke pressure
symptoms over a period of hours to days Rehabilitation
3) Completed stroke – neurologic deficit remains unchanged 1) Hemiplegia: results from injury to cells in the cerebral
for a 2- to 3-day period motor cortex or corticospinal pathway
Assessment a) Turn every 2 hours (20 minutes only on affected side)
• Headache b) Use proper positioning & repositioning to prevent
• Generalized signs: vomiting, seizures, confusion, deformities
disorientation, decreased LOC, nuchal rigidity, fever, c) Support paralyzed arm on pillow or use sling while out
hypertension, slow bounding pulse, Cheyne-Stokes of bed
respirations d) Elevate extremities to prevent dependent edema
• Focal signs (related to site of infarction): hemiplegia, e) Provide active & passive ROM exercises every 4 hours
sensory loss, aphasia, homonymous hemianopsia 2) Susceptibility to hazards
• Diagnostic tests a) keep side rails up at all times
1) CT and brain scan: reveal lesion b) institute safety measures
2) EEG: abnormal changes c) inspect body parts frequently for signs of injury
3) Cerebral arteriography: may show occlusion or 3) Dysphagia (inability to swallow or difficulty in swallowing)
malformation of blood vessels a) check gag reflex before feeding the patient
Nursing interventions b) maintain calm, unhurried approach
Acute stage: c) place in upright position
1) Maintain patent airway and adequate ventilation. d) place food in unaffected side of mouth
2) Monitor VS, neuro checks, observe for signs of ed ICP, e) offer soft foods
shock, hyperthermia, and seizures. f) give mouth care before and after meals
3) Provide complete bed rest as ordered. 4) Homonymous hemianopsia
4) Maintain F& E balance and ensure adequate nutrition. a) approach client on unaffected side
• IV therapy for the first few days b) place personal belongings, food on unaffected side
• NGT feedings - if unable to swallow c) teach client by scanning
5) Emotional lability: mood swings, frustration
• Fluid restriction as ordered - to decrease cerebral
a) create a quiet, restful environment with a reduction in
edema
excessive sensory stimuli
5) Maintain proper positioning and body alignment.
b) maintain a calm, nonthreatening manner
• Head of bed may be elevated 30°-45° to  ICP
c) explain to family that the client behavior is not
• Turn and reposition every 2 hours (only 20 minutes on
purposeful
the affected side)
6) Aphasia – most common in R hemiplegics bec. Left-
• Passive ROM exercises every 4 hours. hemisphere dominance for language
6) Promote optimum skin integrity: turn client and apply a) Receptive:
lotion every 2 hours
J.A.K.E 24 of 28
• give simple, slow directions - Medical management: Immobilization & maintenance of

• give one command at a time; gradually shift topics normal spine alignment – to promote fracture healing
• use nonverbal techniques of communication 1) Horizontal turning frame / Stryker frame
b) Expressive: 2) Skeletal traction
• listen & watch very carefully when client attempts to a) cervical tongs (Crutchfield)
speak b) halo traction
• anticipate clients need to decrease frustration & - Surgery
feelings of helplessness • Decompression laminectomy
• allow sufficient time & client to answer • Spinal fusion
7) Sensory/ perceptual deficits – more common in left Assessment
hemiplegics – characterized by impulsiveness, unaware of 1) Spinal Shock
disabilities, visual neglect - occurs immediately after the injury as a result of the
a) assist with self-care insult to the CNS
b) provide safetty measures - temporary condition lasting from several days to 3
c) initially arrange objects in env of unaffected side months
d) gradually teach clients to take care of the unaffected - characterized by:
side & to turn frequently & look at affected side • Absence of reflexes below the level of lesion
• Flaccid paralysis
Spinal cord injury • Lack of temperature control
- trauma to the spinal cord which causes partial or complete • Hypotension w/ bradycardia
disruption of the nerve tracts & neurons • Retention of urine & feces
- Causes 2) Level of Injury
• traumatic: motor vehicle accidents, diving in shallow a) Quadriplegia
water, falls, industrial accidents, sports injuries, - Cervical injuries (C1-C8) → paralysis of all 4
gunshot or stab wound extremities
• non-traumatic: tumors, hematomas, aneurysms, - respiratory paralysis → lesions above C6 (phrenic
congenital defects nerve at C4-C5 level) =the nerve that governs
- SCI is classified according to: movement of the diaphragm during breathing
• Extent of injury b) Paraplegia
• Level of injury - thoracolumbar injuries (T1-L4) → paralysis of the
o Cervical lower half of the body involving both legs
o Thoracic 3) Extent of Injury
o Lumbar a) Complete Cord Transection
• Mechanism of injury - loss of all voluntary movement and sensation below
o Hyperflexion the level of injury
o Hyperextension b) Incomplete lesions
o Axial loading – force exerted straight up or down - varying degrees of motor or sensory loss between
spinal column (ex: diving) the level of the lesion depending on which
- May affect the vertebral column. neurologic tracts are damaged & which are spared
• Fracture Nursing Interventions
• Dislocation Emergency Care:
- May affect anterior & posterior ligaments 1) Assess ABC
• compression of spinal cord - do not move patient during assessment
- May affect the spinal cord & its roots: - if airway obstruction or inadequate ventilation exists; do
• Concussion not hyperextend neck to open airway, use jaw thrust
• Contusion 2) Perform a quick head to toe assessment; check for LOC,
• Compression or laceration by fracture / dislocation signs of trauma; check for leakage of fluid from ear
• penetrating (ex. GSW, missile) 3) Immobilize client
- Axial Loading 4) Assist in immobilizing head and neck with cervical collar &
• Fall from a height, landing on one's feet is typical of this place on spinal board; avoid flexion of the spinal column
fracture Acute Care:
1) Maintain optimum respiratory function
• axial loading applied to intravertebral disc results in
- observe for weak or labored respirations
increased pressure and stresses
- prevent pneumonia and atelectasis; turn every 2 hours;
• a large central posterior- superior fragment occurs as a
cough and deep breathe
result of these forces
- tracheostomy & mechanical ventilation may be
- Pathophysiology: hemorrhage & edema → ischemia →
necessary
necrosis & destruction of cord
J.A.K.E 25 of 28
2) Maintain optimal cardiovascular function Autonomic Dysreflexia

- monitor vital signs: observe for bradycardia, arrythmias, - rise in blood pressure, sometimes to fatal levels
hypotension - reflex response to stimulation of the sympathetic nervous
- apply thigh-high elastic stockings system
- change position slowly & gradually elevate the head of - occurs in clients with cord lesions above T6
the bed to prevent postural hypotension - most commonly in clients with cervical injuries
- observe for signs of DVT - stimulus: overdistended bladder or bowel, decubitus ulcer,
3) Maintain fluid & electrolyte balance & nutrition chilling, pressure from bedclothes
- NGT may be inserted until bowel sounds return - Symptoms: severe headache, hypertension, bradycardia,
- maintain IV therapy as ordered sweating, goose bumps, nasal congestion, blurred vision,
- check bowel sounds before feeding convulsions
- progress slowly from clear liquid to regular diet - Interventions:
- provide diet high in protein, CHO, calories • raise client to sitting position to decrease BP.
4) Maintain immobilization & spinal alignment always • check for source of stimulus (bladder, bowel, skin)
- turn every hour on turning frame • remove offending stimulus (e.g. reposition client
- maintain cervical traction at all times if indicated catheterize client, digitally remove impacted feces,)
5) Prevent complications of immobility • monitor BP
6) Maintain urinary elimination • administer antihypertensives (e.g. hydralazine HCl
- provide intermittent catheterization or indwelling [Apresoline]) as ordered
catheter Medications
- increase fluids to 3000ml/day 1) Dexamethasone (Decadron)
- provide acid-ash foods/ fluids to urine = a diet - used for its anti-inflamm & edema reducing effects
consisting largely of meat or fish, eggs, and cereals with - may interfere with healing
a minimal quantity of milk, fruit, and vegetables, that 2) Dextran (plasma expander)
when catabolized leaves an acid residue to be excreted - used to increase capillary blood flow within the spinal
in the urine. cord and to prevent / treat hypotension
7) Maintain bowel elimination 3) Dantrolene (Dantrium), Baclofen (Lioresal)
8) Monitor temperature control - used for clients with upper motor neuron injuries to
9) Observe for & prevent infection control muscle spasticity
10) Observe for & prevent stress ulcers
Chronic care Seizures
1) Nonreflexive/ Areflexive or lower motor neuron bladder - An abnormal, sudden, excessive, uncontrolled electrical
/ LMN bladder discharge of neurons within the brain that may result in
- spinal shock: when reflex arc is not functioning due to alteration of consciousness, motor or sensory ability,
initial trauma and/or behavior
- no reflex activity of the bladder occurs, resulting in - Epilepsy – a chronic disorder characterized by recurrent,
urine retention with overflow unprovoked seizure activity. Cause unknown in 75% of
- Failure to Empty epilepsy cases.
- lesion: Complete destruction of Sacral Micturition - THEREFORE: Seizure is a symptom of epilepsy
Center (S2–S4) at S2 or below Pathophysiology
- Management: - Normally neurons send out messages in electrical
• intermittent catheterization every 6 hours impulses periodically, and the firing of individual neurons is
• Crede’s maneuver or rectal stretch regulated by an inhibitory feedback loop mechanism.
• regulate intake to 1800-2000 ml/day → to prevent - With seizures, many more neurons than normal fire in a
overdistention of bladder synchronous fashion in a particular area of the brain; the
2) Reflex or upper motor neuron bladder / UMN bladder energy generated overcomes the inhibitory feedback
- reflex activity of the bladder may occur after spinal mechanism.
shock resolves
- bladder is unable to store urine very long and empties
voluntarily
- Failure to Store (Incontinence)
- lesion: Above Sacral Micturition Center (above S2)
- Management:
• intermittent catheterization every 4 hours and
gradually progresses to every 6 hours
• regulate fluid intake to 1800-2000 ml/day
• bladder taps → to cause reflex emptying of the
bladder
J.A.K.E 26 of 28
Type of Seizure Clinical Findings - Begins in focal area (anterior

temporal lobe) but spreads to both
I. Generalized seizures Complex partial
hemispheres.
seizure
- May be preceded by aura - Impairs consciousness.
- tonic and clonic phases - May be preceded by aura.
- Tonic phase: limbs contract or
stiffen; pupils dilate and eyes roll up
and to one side; glottis closes,
causing noise on exhalation; may be
Major motor
incontinent; occurs at same time as
seizure (grand
loss of consciousness; lasts 20–40
mal)
seconds.
- Clonic phase: repetitive
movements, increased mucus
production; slowly tapers.
- Seizure ends with postictal period of
confusion, drowsiness.
- Related to organic brain damage.
Akinetic seizure Sudden brief loss of postural tone,
(atonic) and temporary loss of
consciousness.
- Associated with brain damage, may
be precipitated by tactile or visual
sensations.
- May be generalized or local.
Myoclonic
Brief flexor muscle spasm; may
seizure
have arm extension, trunk flexion.
Medical management (Drug therapy)
- Single group of muscles affected;
1) Phenytoin (Dilantin)
involuntary muscle contractions =
- It is one of the drugs of choice for :
myoclonic jerks.
• Generalized tonic-clonic seizures
- Usually nonorganic brain damage
• Partial seizures
present; must be differentiated from
Absence seizure - Phenytoin should not be used to treat absence seizures
daydreaming.
(petit mal) or myoclonic seizures.
- Sudden onset, with twitching or
- Serum blood level determinations may be necessary for
rolling of eyes; lasts a few seconds.
optimal dosage
- Common in 5% of population under
- adjustments – the clinically effective serum level is
5, familial, nonprogressive; does not
usually 10-20 mcg/mL
generally result in brain damage.
- Common side effects of phenytoin include:
Febrile seizure Typically tonic-clonic.
- Seizure occurs only when fever is • swollen, tender gums – gum hyperplasia
rising. • growth of facial and body hair
- EEG is normal 2 weeks after seizure. • enlarged or rough facial features
Status epilepticus • acne
- Usually refers to generalized grand mal seizures. • skin rash
- Seizure is prolonged (there are repeated seizures without - Serum phenytoin level
regaining consciousness) and unresponsive to treatment. • The therapeutic range is 10-20 mcg/mL.
- Can result in decreased oxygen supply and possible • Plasma levels (mcg/mL) have an association with
cardiac arrest. acute neurological symptoms.
II. Partial seizures o Lower than 10 - Rare
- Seizure confined to one hemisphere o Between 10 and 20 - Occasional mild nystagmus
of brain. o Between 20 and 30 - Nystagmus
Simple partial - No loss of consciousness. o Between 30 and 40 - Ataxia, slurred speech,
seizure - May be motor, sensory, or nausea, and vomiting
autonomic symptoms. o Between 40 and 50 - Lethargy and confusion
o Higher than 50 - Coma and seizures
- Considerations:
• Phenytoin may decrease the effectiveness of
hormonal contraceptives (birth control pills, patches,
J.A.K.E 27 of 28
rings, injections, implants, or intrauterine devices). b) Keep airway open.

Use another form of birth control while taking • place in side-lying position.
Phenytoin. • suction excess mucous.
• Phenytoin is listed in Pregnancy Category D. This c) Observe and record seizure.
means that there is a risk to the baby, but the • note any preictal aura.
benefits may outweigh the risk for some women. - affective signs: fear, anxiety
• Often used with Phenobarbital for its potentiating - psychosensory signs: hallucinations
effect. - cognitive signs: "déjà-vu" symptoms
a) elevates the seizure • note nature of the ictal phase.
b) threshold and inhibits the - symmetry of movement
c) spread of electrical discharge - response to stimuli; LOC
2) Carbamazepine - respiratory pattern
- It is used alone or in combination with other • note postictal response: amount of time it takes to
medications to treat certain types of seizures in orient to time and place; sleepiness
patients with epilepsy.
- It is also used to treat trigeminal neuralgia (a condition
that causes facial nerve pain).
- It works by reducing abnormal excitement in the brain.
- Common side-effects:
• fatigue
• dizziness GOOD LUCK EVERYONE!!
• nausea & vomiting
- Carbamazepine can lower the white blood cells.
- Serious side effects:
• Fever
• sore throat
• headache with a severe blistering, peeling & red skin
rash
• pale skin
• easy bruising or bleeding
• jaundice (yellowing of the skin or eyes
3) Valium
- It slows the central nervous system and is used to treat
anxiety related disorders and conditions that cause
severe muscle spasms and convulsions.
- Valium is administered rectally. Liquid Valium is
absorbed fast from the rectum.
- The effect should take place 5-15 minutes after the
injection.
- Valium should not be used on a daily basis because it
can cause withdrawal.
Surgery
- to remove the tumor, hematoma, or epileptic focus
Diagnostic tests
• Blood studies to rule out lead poisoning, hypoglycemia,
infection, or electrolyte imbalances
• Lumbar puncture to rule out infection or trauma
• Skull x-rays, CT scan, or ultrasound of the head, brain scan,
arteriogram to detect any pathologic defects
• EEG may detect abnormal wave patterns characteristic of
different types of seizures
Nursing interventions (During seizure activity)
a) Protect from injury.
• prevent falling, gently support head.
• decrease external stimuli; do not restrain.
• do not use tongue blades (they add additional stimuli).
• loosen tight clothing.
J.A.K.E 28 of 28

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NCMB316 LECTURE: Exam Week

Types of Diabetes Mellitus

Type II (NIDDM) Non-Insulin Dependent Diabetes Mellitus

- Prone for HHNKS (Hyperosmolar Hyperglycemic

- Pag kumain or nag ingest ng food ang patient dito na

Hypoglycemia Diabetic Ketoacidosis (DKA)

DI, SIADH, AND THYROID DISORDERS

• Dyspnea Diabetes Insipidus (DI)

- Acute paralysis • FNB (Fine Needle Biopsy)

• Administer increasing doses of oral PTU • Irregular menstruation (menorrhagia, amenorrhea)

- What are the hormones produced by the thyroid gland?

ADRENAL AND PARATHYROID GLAND DISORDERS - Mineralocorticoids (Aldosterone)

Nursing Intervention Assessment Findings

• Prepare client for an adrenalectomy if condition is caused Diagnostic tests

Nursing interventions • A review of the medical history, including a system-by-

2) Lumbar puncture/ Spinal tap

3) Electroencephalography (EEG) • head position depends on the dye used:

- This concept holds that the skull is a rigid compartment

Nursing interventions Post procedure interventions:

Cerebrovascular Accident (CVA)

• give simple, slow directions - Medical management: Immobilization & maintenance of

2) Maintain optimal cardiovascular function Autonomic Dysreflexia

Type of Seizure Clinical Findings - Begins in focal area (anterior

rings, injections, implants, or intrauterine devices). b) Keep airway open.

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