Medical Surgical Nursing Review(NR) Notes Part I

By | May 25, 2021
Medical-Surgical Nursing Review(NR) Notes Part I

This medical surgical nursing review is a summary of the central nervous system,types of cells, blood brain barrier, hepatic encephalopathy,demyelinating disorder and pathogmonic sign.

CENTRAL NERVOUS SYSTEM

Brain and Spinal Cord.

A. CELLS

B. NEURONS 

Basic cells for nerve impulse and conduction.

PROPERTIES

Excitability the ability of neurons to be affected by changes in the external environment.

Conductivity the 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.

2. Stable

  • Capable of regeneration with limited time, survival period.
  • Kidney cells, Liver cells, Salivary cells, pancreas.

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 the blood brain barrier semi-permeable.

  • Majority of brain tumors (90%) arise from what is called astrocytoma.

2. Oligodendria

3. Microglia

4. Ependymal 

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)
  • Decreased LOC

PATHOGNOMIC 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 step ladder-like fever with chills.
10. TYPHOID rose spots in the abdomen.
11. DIPHTHERIA pseudomembrane 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 the umbilicus); (+) Grey turner’s 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 – exophthalmos.
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.

4. Hepatitis

  • Signs of jaundice (icteric sclerae).
  • Caused by bilirubin (yellow pigment)

5. Bilirubin

  • Increase bilirubin in the brain (Kernicterus).
  • Causing irreversible brain damage.

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 Interpretive 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 the 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 is the only antibody that passes 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)

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 increased contraction of the spinal column.

NURSING MANAGEMENT

1. Administer medications as ordered

a. ACTH (AdrenoCorticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site   

                 of demyelination to prevent paralysis.

b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrolene) – muscle relaxants.

c. Interferons – alter immune response.

d. Immunosuppressants

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. Bethanechol 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

    Antispasmodic agent 

    a. Propantheline 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.

Male

  • Urethra (20 cm, 8 inches)
  • urinate after intercourse
MICROGLIA
  • stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating), pinocytosis (cell drinking).
MACROPHAGEORGAN
MicrogliaMonocytesKupffer cellsHistiocytesAlveolar MacrophageBrainBloodKidneySkinLung
EPENDYMAL 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 in garbled speech.

2. Temporal

  • hearing
  • short term memory

3. Parietal

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

4. Occipital 

  • for vision

Insula (Island of Reil)

  • visceral function activities of internal organs like gastric motility.

Limbic System (Rhinencephalon)

  • controls smell and if damaged results in Anosmia (absence of smell).
  • controls libido
  • controls long term memory

Medical and Surgical Nursing Exam

2. BASAL GANGLIA

  • areas of grey matter located deep within each cerebral hemisphere.
  • release dopamine (controls gross voluntary movement.
NEUROTRANSMITTERDECREASEINCREASE
AcetylcholineMyasthenia GravisBi-polar Disorder
DopamineParkinson’s DiseaseSchizophrenia

3. MIDBRAIN/ MESENCEPHALON

  • acts as a relay station for sight and hearing.
  • The size of the pupil is 2 – 3 mm.
  • an 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 a 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
  • The late sign is deepening of voice.
  • The early sign for females is the larche and the 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

Increased intracranial pressure

 Alternate hot and cold compress to prevent HEMATOMA

  • CSF cushions the brain (shock absorber)
  • Obstruction of the flow of CSF will lead to enlargement of the skull posteriorly called hydrocephalus.
  • Early closure of posterior fontanels causes posterior enlargement of the skull in hydrocephalus.

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