Medical Surgical Nursing Review Notes PDF

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MEDICAL-SURGICAL NURSINGNERVOUS SYSTEMOverview of structures and functions: Central Nervous System  Brain  Spinal Cord Peripheral Nervous System  Cranial Nerves  Spinal Nerves Autonomic Nervous System  Sympathetic nervous system  Parasympathetic nervous systemAUTONOMIC NERVOUS SYSTEM Sympathet...

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MEDICAL-SURGICAL NURSING NERVOUS SYSTEM Overview of structures and functions: Central Nervous System 

Brain



Spinal Cord

Peripheral Nervous System 

Cranial Nerves



Spinal Nerves

Autonomic Nervous System 

Sympathetic nervous system



Parasympathetic nervous system AUTONOMIC NERVOUS SYSTEM

Sympathetic Nervous System (ADRENERGIC) - Involved in fight or aggression response. - Release of Norepinephrine (cathecolamines) from adrenal glands and causes vasoconstriction. - Increase all bodily activity except GIT

Parasympathetic Nervous System (CHOLINERGIC, VAGAL, SYMPATHOLYTIC) - Involved in fight or withdrawal response. - Release of Acetylcholine.

EFFECTS OF SNS - Dilation of pupils(mydriasis) in order to be aware. - Dry mouth (thickened saliva). - Increase BP and Heart Rate. - Bronchodilation, Increase RR - Constipation. - Urinary Retention. - Increase blood supply to brain, heart and skeletal muscles. - SNS

EFFECTS OF PNS - Constriction of pupils (meiosis). - Increase salivation. - Decrease BP and Heart Rate. - Bronchoconstriction, Decrease RR. - Diarrhea - Urinary frequency.

I. Adrenergic Agents - Give Epinephrine. Signs and Symptoms: - SNS Contraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma).

I. Cholinergic Agents - Mestinon, Neostigmine. Side Effects - PNS

II. Beta-adrenergic Blocking Agents - Also called Beta-blockers. - All ending with “lol” - Propranolol, Atenelol, Metoprolol. Effects of Beta-blockers B – roncho spasm E – licits a decrease in myocardial contraction. T – reats hypertension. A – V conduction slows down.  Should be given to patients with Angina Pectoris, Myocardial Infarction, Hypertension.

II. Anti-cholinergic Agents - To counter cholinergic agents. - Atropine Sulfate Side Effects - SNS

ANTI- HYPERTENSIVE AGENTS 1. Beta-blockers – “lol” 2. Ace Inhibitors – Angiotensin, “pril” (Captopril, Enalapril) 3. Calcium Antagonist – Nifedipine (Calcibloc)  In chronic cases of arrhythmia give Lidocaine(Xylocaine)

- Decreases all bodily activities except GIT.

CENTRAL NERVOUS SYSTEM 

Brain and Spinal Cord.

I. CELLS A. NEURONS 

Basic cells for nerve impulse and conduction.

PROPERTIES Excitability – ability of neuron to be affected by changes in external environment. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another. Permanent Cell – once destroyed not capable of regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Labile 

Capable of regeneration.



Epidermal cells, GIT cells, GUT cells, cells of lungs.



Capable of regeneration with limited time, survival period.



Kidney cells, Liver cells, Salivary cells, pancreas.

2. Stable

3. Permanent 

Not capable of regeneration.



Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

B. NEUROGLIA 

Support and protection of neurons.

TYPES 1. Astrocytes – maintains blood brain barrier semi-permeable. 

Majority of brain tumors (90%) arises from called astrocytoma.

2. Oligodendria 3. Microglia 4. Epindymal SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER 1. Ammonia 

Cerebral toxin



Hepatic Encephalopathy (Liver Cirrhosis)



Ascites



Esophageal Varices

Early Signs of Hepatic Encephalopathy 

asterixis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy 

Headache



Dizziness



Confusion



Fetor hepaticus (ammonia like breath)



Decrease LOC

PATHOGNOMONIC SIGNS 1. PTB – low-grade afternoon fever. 2. PNEUMONIA – rusty sputum. 3. ASTHMA – wheezing on expiration. 4. EMPHYSEMA – barrel chest. 5. KAWASAKI SYNDROME – strawberry tongue. 6. PERNICIOUS ANEMIA – red beefy tongue. 7. DOWN SYNDROME – protruding tongue. 8. CHOLERA – rice watery stool. 9. MALARIA – stepladder like fever with chills. 10. TYPHOID – rose spots in abdomen. 11. DIPTHERIA – pseudo membrane formation 12. MEASLES – koplik’s spots. 13. SLE – butterfly rashes. 14. LIVER CIRRHOSIS – spider like varices. 15. LEPROSY – lioning face. 16. BULIMIA – chipmunk face. 17. APPENDICITIS – rebound tenderness. 18. DENGUE – petechiae or (+) Herman’s sign. 19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain). 20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm). 21. TETANUS – risus sardonicus. 22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots. 23. PYLORIC STENOSIS – olive like mass. 24. PDA – machine like murmur. 25. ADDISON’S DISEASE – bronze like skin pigmentation. 26. CUSHING’S SYNDROME – moon face appearance and buffalo hump. 27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus. 28. INTUSSUSCEPTION – sausage shaped mass 2. Carbon Monoxide and Lead Poisoning 

Can lead to Parkinson’s Disease.



Epilepsy



Treat with ANTIDOTE: Calcium EDTA.

3. Type 1 DM (IDDM) 

Causes diabetic ketoacidosis.



And increases breakdown of fats.



And free fatty acids



Resulting to cholesterol and (+) to Ketones (CNS depressant).



Resulting to acetone breath odor/fruity odor.



KUSSMAUL’S respiration, a rapid shallow respiration.



Which may lead to diabetic coma.



Signs of jaundice (icteric sclerae).



Caused by bilirubin (yellow pigment)



Increase bilirubin in brain (Kernicterus).



Causing irreversible brain damage.

4. Hepatitis

5. Bilirubin

Astrocites  Maintains integrity of blood brain barrier. Oligodendria 

Produces myelin sheath in CNS



Act as insulator and facilitates rapid nerve impulse transmission.

DEMYELINATING DISORDERS 1. ALZHEIMER’S DISEASE 

Atrophy of brain tissues.

Sign and Symptoms 4 A’s of Alzheimer a. Amnesia – loss of memory. b. Agnosia – no recognition of inanimate objects. c. Apraxia – no recognition of objects function. d. Aphasia – no speech (nodding). *Expressive aphasia 

“motor speech center”



Broca’s Aphasia

*Receptive aphasia 

inability to understand spoken words.



Wernicke’s Aphasia



General Knowing Gnostic Area or General Interpretative Area.

DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX.

2. MULTIPLE SCLEROSIS 

Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord.



Characterized by remission and exacerbation.



Women ages 15-35 are prone



Unknown Cause



Slow growing virus



Autoimmune disorders



Pernicious anemia



Myasthenia gravis



Lupus



Hypothyroidism



GBS

Ig G – only antibody that pass placental circulation causing passive immunity. - short term protection. - Immediate action. Ig A – present in all bodily secretions (tears, saliva, colostrums). Ig M – acute in inflammation. Ig E – for allergic reaction. Ig D – for chronic inflammation. * Give palliative or supportive care. Signs and Symptoms 1. Visual disturbances 

blurring of vision (primary)



diplopia (double vision)



scotomas (blind spots)

2. Impaired sensation 

to touch, pain, pressure, heat and cold.



tingling sensation

 

paresthesia numbness

3. Mood swings 

euphoria (sense of well being)

4. Impaired motor function 

weakness



spasticity



paralysis

5. Impaired cerebral function 

scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait, (+) Romberg’s test)

CHARCO CHARCOTS TS TRIAD IAN

Intentional tremors

Nystagmus

6. Urinary retention/incontinence 7. Constipation 8. Decrease sexual capacity DIAGNOSTIC PROCEDURE 

CSF analysis (increase in IgG and Protein).



MRI (reveals site and extent of demyelination).



(+) Lhermitte’s sign a continuous and increase contraction of spinal column.

NURSING MANAGEMENT 1. Administer medications as ordered a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. c. Interferons – alter immune response. d. Immunosupresants 2. Maintain side rails to prevent injury related to falls. 3. Institute stress management techniques. a. Deep breathing exercises b. Yoga 4. Increase fluid intake and increase fiber to prevent constipation. 5. Catheterization to prevent retention. a. Diuretics b. Bethanicol Chloride (Urecholine) Nursing Management 

Only given subcutaneous.



Monitor side effects bronchospasm and wheezing.



Monitor breath sounds 1 hour after subcutaneous administration.

c. For Urinary Incontinence Anti spasmodic agent a. Prophantheline Bromide (Promanthene)

 

Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange. To acidify urine and prevent bacterial multiplication.

COMMON CAUSE OF UTI Female 

short urethra (3-5 cm, 1-1 ½ inches)



poor perineal hygiene



vaginal environment is moist

Nursing Management 

avoid bubble bath (can alter Ph of vagina).



avoid use of tissue papers



avoid using talcum powder and perfume.



Urethra (20 cm, 8 inches)



urinate after intercourse

Male

MICROGLIA 

stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating), pinocytosis (cell drinking).

MACROPHAGE Microglia

ORGAN Brain

Monocytes

Blood

Kupffers cells

Kidney

Histiocytes

Skin

Alveolar

Lung

Macrophage EPINDYMAL CELLS 

Secretes a glue called chemo attractants that concentrate the bacteria.

COMPOSITION OF BRAIN 

80% brain mass



10% blood



10% CSF

I. Brain Mass PARTS OF THE BRAIN 1. CEREBRUM 

largest part



composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum.

Functions of Cerebrum 

integrative



sensory



motor

Lobes of Cerebrum 1. Frontal 

higher cortical thinking



controls personality



controls motor activity



Broca’s Area (motor speech area) when damaged results to garbled speech.

2. Temporal 

hearing



short term memory



for appreciation



discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.

3. Parietal

4. Occipital



for vision

Insula (Island of Reil) 

visceral function activities of internal organ like gastric motility.

Limbic System (Rhinencephalon) 

controls smell and if damaged results to Anosmia (absence of smell).



controls libido



controls long term memory

2. BASAL GAGLIA 

areas of grey matter located deep within each cerebral hemisphere.



release dopamine (controls gross voluntary movement.

NEURO TRANSMITTER Acethylcholine Dopamine

DECREASE Myasthenia Gravis Parkinson’s Disease

INCREASE Bi-polar Disorder Schizophrenia

3. MIDBRAIN/ MESENCEPHALON 

acts as relay station for sight and hearing.



size of pupil is 2 – 3 mm.



equal size of pupil is isocoria.



unequal size of pupil is anisocoria.



hearing acuity is 30 – 40 dB.



positive PERRLA

4. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. Thalamus 

acts as relay station for sensation.

B. Hypothalamus 

controls temperature (thermoregulatory center).



controls blood pressure



controls thirst



appetite/satiety



sleep and wakefulness



controls some emotional responses like fear, anxiety and excitement.



controls pituitary functions



androgenic hormones promotes secondary sex characteristics.



early sign for males are testicular and penile enlargement



late sign is deepening of voice.



early sign for females telarche and late sign is menarche.

5. BRAIN STEM 

located at lowest part of brain

Parts of Brain Stem 1. Pons 

pneumotaxic center controls the rate, rhythm and depth of respiration.

2. Medulla Oblongata 

controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation and constriction of bronchioles).

3. Cerebellum 

smallest part of the brain.



lesser brain.



controls balance, equilibrium, posture and gait.

INTRA CRANIAL PRESSURE Monroe Kellie Hypothesis

Skull is a closed container Any alteration or increase in one of the intracranial components

Increase intra-cranial pressure (normal ICP is 0 – 15 mmHg)

Cervical 1 – also known as ATLAS. Cervical 2 – also known as AXIS. Foramen Magnum

Medulla Oblongata Brain Herniation

Increase intra cranial pressure * Alternate hot and cold compress to prevent HEMATOMA  CSF

cushions brain (shock absorber)

 Obstruction  Early

of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus.

closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.

NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. Causes: 

head trauma/injury



inflammatory condition (stroke)



localized abscess



hydrocephalus



cerebral edema



tumor (rarely)



hemorrhage

Signs and Symptoms (Early) 

decrease LOC



lethargy/stupor



restlessness/agitation



coma



irritability

Signs and Symptoms (Late) 

changes in vital signs



blood pressure (systolic blood pressure increases but diastolic remains the same).



widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).



heart rate decrease



respiratory rate decrease



temperature increase directly proportional to blood pressure.



projective vomiting



headache



papilledema (edema of optic disc) abnormal posturing



decorticate posturing (damage to cortex and spinal cord).





decerebrate posturing (damage to upper brain stem that includes pons, cerebellum and midbrain).



unilateral dilation of pupils called uncal herniation



bilateral dilation of pupils called tentorial herniation



resulting to mild headache



possible seizure activity

Nursing Management 1. Maintain patent and adequate ventilation by: a. Prevention of hypoxia and hypercarbia Early signs of hypoxia 

restlessness



agitation



tachycardia

Late signs of hypoxia 

Bradycardia



Extreme restlessness



Dyspnea



Cyanosis

HYPERCARBIA 

Increase CO2 (most powerful respiratory stimulant) retention.



In chronic respiratory distress syndrome decrease O2 stimulates respiration.

b. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. c. Assist in mechanical ventilation 2. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. 3. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). 4. Monitor strictly input and output and neuro check 5. Prevent complications of 6. Prevent further increase ICP by: a. provide an comfortable and quite environment. b. avoid use of restraints. c. maintain side rails. d. instruct client to avoid forms of valsalva maneuver like: 

straining stool



excessive vomiting (use anti emetics)



excessive coughing (use anti tussive like dextromethorphan)



avoid stooping/bending



avoid lifting heavy objects

e. avoid clustering of nursing activity together.

7. Administer medications like: a. Osmotic diuretic (Mannitol) 

for cerebral diuresis Nursing Management



monitor vital signs especially BP (hypotension).



monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.



administered via side drip



regulated fast drip to prevent crystal formation.

b. Loop diuretic (Lasix, Furosemide)  Drug of choice for CHF (pulmonary edema)  Loop of Henle in kidneys. Nursing Management



Monitor vital signs especially BP (hypotension).



monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.



administered ...