Patients eligible for DBS are those who have: Responded to levodopa but are

impaired by dyskinesias, and have had the disease for at least 5 years, and are
disabled by tremor

Patients with dementia and atypical PD are usually not considered for surgical
Medical Surgical 2 (NCMB 316) procedures.

FINALS
MEDSURG2 (NCMB 316) | 2nd SEM | BSN 3-Y2-14 | [ transes created by MDL and LBM ]

●​ Clinical Manifestations: Gradual onset – Parkinson’s disease has a gradual onset and
symptoms progresses slowly (4 Cardinal Signs)
FINALS WEEK OUTLINE ●​ Resting Tremors: fingers moves as if rolling a pill between fingers (pill-rolling
I.​ Week 13: Degenerative Diseases P1 (PD, MS, MG) tremor)
II.​ Week 14: Degenerative Diseases P2 (GBS, HD, ALS)
➔​ This is evident
- Disappears when the
with voluntary extremities
movement are sleep.
and during at rest or motionless, and it becomes
III.​ Week 15: Musculoskeletal System
apparent with purposeful
- Most noticeable movement
when extremities are at and
rest. during sleep.
IV.​ Week 16: Special Senses (Eyes)
V.​ Week 17: Problems in Perception (Ears) ➔​ Present in majority of patients at the time of diagnosis
●​ Rigidity: resistance to passive movement, passive movement can cause cogwheel
rigidity (jerking movement)
W13: DEGENERATIVE DISEASES PART 1 ➔​ Stiffness of arms, legs, face, and posture are common with rigidity
●​ Bradykinesia (Akinesia)- Common feature of Parkinson’s disease
PARKINSON’S DISEASE ➔​ Slowing of active movement
➔​ Patients take longer to complete activities such as rising from a sitting position or
●​ is a disorder that involves dopamine-producing neurons in the brain turning in bed
●​ A degenerative disorder of the basal ganglia – causing abnormal movement,
●​ Postural instability- Head bent forward and walks with propulsive gait.
voluntary movement is affected
●​ Symptoms include: ➔​ The gait is caused by forward flexion of the neck, hips, knees, and elbows
○​ Tremors ➔​ Patient walks faster and faster trying to move the feet forward under the body’s
○​ Rigidity center of gravity. Shuffling gait – places the patient increase risk for falls
○​ Bradykinesia – slowness of movement and speed ●​ Other Clinical Manifestations
○​ Akinesia – causes a person to lose the ability to move their muscles on their own ○​ visual problems ○​ hypokinesia (abnormally diminished
○​ Mask like expression movement after tremors)
○​ olfactory changes ○​ freezing phenomenon (transient
MULTIPLE SCLEROSIS inability to actively move–there is a
temporary inability to move. It is a
●​ Abnormal immune response that damages myelin sheath. It only affects nerves in the extreme form of bradykinesia)
CNS ○​ micrographia – patient ○​ dysphonia characterized by soft
●​ Caused by patchy areas of plaques that damage the covering of the nerves. cannot perform skills slurred speech, low pitch, and less
Remissions and exacerbations develop as the condition progresses using the hands audible speech
●​ Symptoms include: (decreased dexterity)
○​ Visual problems ○​ mask like – ○​ dysphagia and drooling – patient is
○​ Dec. hearing expressionless faces placed at risk for choking and
○​ Numbness aspiration
○​ Vertigo
○​ Facial nerve problems ○​ Psychiatric: may be related to the disorder or due to biochemical abnormalities
○​ Weakness ➔​ depression, anxiety, dementia, hallucination and psychosis
○​ Depression
○​ Autonomic symptoms (basal ganglia affectation): seborrhea (skin breakdown),
sweating, orthostatic hypotension, constipation, urinary retention, sexual dysfunction
MYASTHENIA GRAVIS
●​ Diagnostics: lab and imaging tests are not helpful in the diagnosis; Diagnosis is
●​ A chronic autoimmune disease caused by antibodies against acetylcholine receptors made from patient history and presence of 2 of 4 cardinal signs
which affect neuromuscular junction ○​ Levodopa trial: confirm diagnosis when symptoms are relieved
●​ It comes w/o warning, causing difficulty in swallowing, high-pitched voice, and ●​ Medical Management: no medical and surgical approach to prevent disease progression
decreased energy that improves with rest. The body literally attacks itself ●​ Pharmacologic: Antiparkinsonian Medications
○​ Progressive muscle fatigue ○​ Levodopa- most effective and mainstay treatment; converted to dopamine in the
○​ drooping head – hindi kayang itayo ang ulo basal ganglia which produces relief but it is metabolized before reaches the brain
○​ diplopia of eyes – double vision ○​ Carbidopa- added to levodopa to prevent levodopa from metabolism prior it reaches
○​ affects muscles of mouth and throat the brain
●​ Stereotactic Procedure
PARKINSON’S DISEASE ○​ Deep Brain Stimulation- implantation of electrodes in the brain and stimulates
dopamine release or block cholinergic release thus improves tremors and rigidity
●​ slowly progressing neurological movement disorder; affects men more than women,
○​ Thalamotomy and Pallidotomy- ablative procedure that destroys tissues, treats
symptoms usually appear 50 years of age. pwede mag appears as early as the 30s.
symptoms but rarely used due to permanent destruction of brain tissues
●​ Risk Factors: age, environment and genetics
●​ Nursing Management: GOAL – to control symptoms and maintain functional
●​ Dopamine - is a neurotransmitter produced by neurons located in the substantia nigra of
independence (so that they can perform ADL) Avoid rushing the client with activities.
the midbrain of the basal ganglia.
○​ Administration of medication as ordered - antiparkinsonian medications
○​ It plays several roles in the body, such as its involvement in reward-motivated
behavior, lactation, memory, and sleep regulation. ○​ Provide safe environment
konti dopamine ○​ The most distinct role of dopamine regarding Parkinson's disease is in movement, as ❖​ Side rails on bed and handlebars on toilet
kaya mas
madami ang the manifestations of Parkinson's disease are distinctively notice in the patient's ❖​ No scatter rugs (madulas or nakaka-trip)
acetylcholine
control of body movements ❖​ Spring-loaded chair para madaling makatayo
●​ Acetylcholine - is excitatory while dopamine is inhibitory. The loss of dopamine results in ○​ Provide measures to increase mobility The patient or person performs the movement themselves
more excitatory than inhibitory neurotransmitters. ❖​ Active range of motion exercises (AROMEs) without any assistance.
○​ If excitatory neurotransmitter is more dominant, this will lead in impaired control of ❖​ Passive range of motion exercises (PROMEs) The joint is moved through its range of motion by someone
else, not the individual.
refined movements and uncontrolled complex body movements ❖​ Stretching
○​ The noticeable body movements include tremors, rigidity, bradykinesia (slowness of ❖​ Assistive devices uses
movement), and postural instability. ❖​ Suggest thinking of something to walk over if the client freezes
●​ 2 Forms: ○​ Improve communication abilities by instructing patient to:
○​ Idiopathic- unknown cause; most common form ❖​ Read aloud Instruct the client to avoid foods high in vitamin B6 because they
block the effects of antiparkinsonian medications. (beef liver,
○​ Secondary- known or suspected ❖​ Listen to own voice chicken, fish [salmon, tuna], potatoes)
●​ 2 Major Subtypes: tremors o panginginig, lalo na sa kamay habang nagpapahinga (resting tremor). ❖​ Practice pronounce each syllables clearly Instruct the client to avoid monoamine oxidase inhibitors because
they will precipitate hypertensive crises
1.​ Tremor Dominant – most other symptoms are absent ○​ Maintain adequate nutrition
2.​ Non-Tremor Dominant – akinetic-rigid and postural instability ❖​ Cut food into small pieces Increase fluid intake to 2000 mL/day
●​ Pathophysiology: bradykinesia
balanse).
(pagbagal ng galaw), muscle rigidity (paninigas ng kalamnan), at postural instability (problema sa
❖​ Small Frequent feedings Monitor for constipation.
○​ Normal: Dopamine is main proponent of this disease; Dopamine is a ❖​ Allow Time for meals
neurotransmitter produced in substantia nigra in the midbrain Provide high-calorie, high-protien, high-fiber soft diet with small, frequent feedings

○​ Abnormal: MULTIPLE SCLEROSIS

●​ an autoimmune disorder, it is an immune-related, progressive demyelinating disease of
the CNS results in impaired conduction of impulses.
○​ T-cells promote damage to the immune system (meaning–T-cells [immune cells],
attacks myelin sheath, kaya humihina ang nerve signal transmission)
○​ Demyelination = nasisira ang myelin sheath (or protection of nerves)
●​ Based on Maam Flor’s PPT: It is an immune-mediated, progressive demyelinating
disease of the CNS resulting to impaired transmission of nerve impulses
○​ Affects women than men
●​ Peak of Onset: 20-50 years old
●​ Cause: Idiopathic (unknown), more common in colder climates; thought to be related
to obesity, lack of vitamin D, and high salt diet
●​ Pathophysiology:

MDL & LM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ pg. 1

 ●​ Diagnostics: Presence of plaques (scar tissues formed due to demyelination) is an
important component in diagnosis.
○​ MRI- determine multiple plaques in CNS and shows areas of demyelination
○​ CSF electrophoresis- detects presence of oligoclonal banding (bands of
immunoglobulin)
○​ CT-scan- determine if there is an increase density of white matter in relation to
demyelination
○​ Urodynamic Studies – to diagnose bladder dysfunction
○​ Neuropsychological Testing – to assess cognitive impairment
○​ Sexual History – to identify changes in sexual function
●​ Management: NO CURE!
○​ Goal
❖​ Delay progression of disease
❖​ Manage chronic symptoms
❖​ Treat acute exacerbation
○​ NOTE: In normal circumstances, T-lymphocytes and BLymphocytes enters the BBB ○​ Disease Modifying Agents – to reduce the frequency of relapse, reduce duration of
to check for presence of antigens in the CNS then leave relapse, and reduce the number of plaques
○​ T-lymphocytes and B-lymphocytes remain in the CNS and promote the infiltration of ❖​ Interferon beta 1A and 1B – nireregulate and immune system para ma reduce
agents and other agents that damage the immune system. yung attack sa myelin sheath and nerves
○​ The damaged immune system is the own immune system that leads to the ➔​ WOF: flu like symptoms (normal side effect [admnister
inflammation and destruction, particularly the white matter of the CNS myelin and acetaminophen/ibuprofen]) and increased liver enzymes, leukopenia,
Oligodendrocytes cells. depression, skin necrosis
○​ The white matter of the CNS is the one that insulates the axon and speeds the ➔​ Administer subcutaneously
conduction of impulses along the axon. ❖​ Glatiramer acetate (Copaxone)
○​ Oligodendrocytes cells are the one that produces myelin sheath in the CNS. ➔​ SE: flushing ((sudden reddening of face due to increase blood flow) ;
○​ Demyelination happens and leads to interruption of flow of nerve impulses that leads administered subcutaneous watch out for injection reaction
to plaques on demyelinated axons which may further the interruption of nerve ❖​ Teriflunomide, Fingolimod, Dimethyl Fumarate – Administered orally, For
impulses or permanent and irreversible damage. those with injection reactions
●​ 4 Clinical Forms: ❖​ IV Methylprednisolone – key agent for acute relapse and has an
They experience periods of new symptoms or
○​ Remitting-Relapsing Multiple Sclerosis (RRMS) relapses that develop over days or weeks anti-inflammatory effect of T-cells and cytokines
➔​ It is characterized in each relapse recovery is usually complete, however if there ➔​ Administered for 3-5 days followed by an oral prednisone
is remission, residual deficit may occur. ➔​ Side effects: mood swings, weight gain, electrolyte imbalances
➔​ This residual deficit may accumulate over time which can contribute to the ❖​ Mitoxantrone (Novantrone) – minomodify ung cells sa nervous system, stops
decline of functions and T and B lymphocytes from entering BBB from brain para di mag cause ng
➔​ 85%; recovery is usually complete but if there is remission residual deficits may damage
occur ➔​ Check for cardiac toxicity
➔​ Relapsing (occurrence of symptoms) and Remitting (period of recover) ➔​ Administered thru IV for 3 months
➔​ 50% of patients with RRMS can progress to SPMS within 10 years; 90% can ○​ Symptoms Management
progress to SPMS within 25 years. ❖​ Baclofen (Lioresal) [GABA agonist] – Medication of choice for spasticity
➔​ In each relapse, the recovery is usually complete, but if there is remission, ➔​ Administered orally or Intrathecal (via spinal cord) for severe spasticity
residual deficits may occur over time which it can also contribute to decline of ➔​ Has a sedative effect
functions
❖​ Amantadine (Symmetrel) – treatment for fatigue
○​ Secondary-Progressive Multiple Sclerosis (SPMS) - disease progression occurs,
❖​ Beta-blockers, anti-seizure agents, benzodiazepines – for ataxia
without relapses.
No remission, gradual deterioration: Sa PPMS, walang ❖​ UTI – vitamin C (increases acidity of urine)
➔​ Begins at remitting-relapsing remission o recovery period, kundi gradual deterioration
(pagkawala ng function) ng neurologic function. ●​ Surgical Management
➔​ Associated w/worsening symptoms
○​ Intrathecal Baclofen Pump – implantation of baclofen pump near spinal cord
○​ Primary-Progressive Multiple Sclerosis (PPMS) gradual deterioration of
neurologic function without remission of symptoms. ○​ Deep Brain Stimulator
➔​ Potential treatment for tremors involves the use of implanted electrodes that
➔​ Is characterized by disabling symptoms which increase with temporary minor
shock the thalamus.
improvement.
➔​ Not suitable for everyone with MS, and MD usually not consider it as an option
➔​ There is a gradual deterioration of neurologic function without remission of signs for a person who can manage their MS symptoms with medications and other
and symptoms, and there is progressive disability and primary progressive is therapies.
associated with quadriparesis.
○​ Rhizotomy
➔​ Quadriparesis (muscle weakness in all limbs), cognitive function, visual loss.
PRMS ay ang ➔​ Involves cutting away a section of a nerve.
pinakabihirang uri, ➔​ Common among 40-60 years old
kung saan may mga ➔​ Address facial pain and treat severe spasticity
○​ Progressive-Relapsing Multiple Sclerosis (PRMS) - Least common (5% of pt)
relapses (pabalik-
●​ Nursing Management
balik na sintomas) na
may continuous ➔​ Is characterized by relapses or symptoms with continuous disabling ○​ Promote physical mobility
disabling progression progression between exacerbation or worsening.
o patuloy na paglala ➢​ Walking – improves gait and loss of position sense
ng kondisyon ➔​ The client's condition does not return to baseline, there is an absence of
➢​ Daily exercise
between
remission, and the deterioration occurs over several years.
exacerbations. ➢​ Stationary bicycling, swimming, progressive bearing - reduce spasticity in legs
➔​ Absence of remission
○​ Minimize spasticity
○​ Other types: Radiologically Isolated Syndrome (RIS) – consists of MS-like lesions
that are identified on MRI in the absence of clinical signs and symptoms ➢​ Warm packs – To minimize spasticity 1 pack may be beneficial; avoid hot baths
○​ Clinically Isolated Syndrome (CIS) – presence of acute or subacute clinical because of risk of burn injury secondary to sensory loss, and avoid extreme
findings for at least 24 hours colds.
➢​ Stretch-hold-relax - This helps relax and treat muscle spasticity
●​ Clinical manifestations: depends on the site of lesion or plaque and the primary
symptoms include "WiND-F" ➢​ Hot baths – avoid risk of burn injury secondary to sensory loss
○​ General: fatigue (most disabling), depression, weakness and numbness ○​ Minimize effects of immobility – coughing and deep exercise – minimize
complications of immobility
○​ If lesion occur in Cerebellar and Basal ganglia manifestations include:
○​ Prevent Injury – walking w/ feet apart widens the base of support t
➔​ ataxia – difficulty in coordination ➔​ intention tremor – ○​ Enhance bowel and bladder function – encourage scheduled toileting rounds
involuntary rhythmic muscle
ADSIN ○​ Enhance communication and manage swallowing difficulties – suctioning,
contractions
careful feeding, proper position for eating
➔​ dysarthria (difficulty of speaking) ➔​ nystagmus (rhythmic ○​ Vision problems (Diplopia) – patch one eye – restrict visual input in eye only to
➔​ scanning of speech – type of involuntary eye prevent the brain from getting two images
dysarthria wherein the pt pauses movements) – involuntary ○​ Healthy eating, weight reduction, avoid alcohol, no smoking - to reduce weight
in every syllable, or syllable are rhythmic side-to-side, and assist in mobility impairments
pronounced very slowly up-down, circular motion of
the eyes. ➔​ NOTE: many patients with MS are overweight due to corticosteroid medication
and mobility impairments
○​ If lesions occur in Sensory pathways manifestations include:
Tingling o "pins and needles" na ➔​ proprioception loss Nawawala ang ability to sense body
3 P'S D ➔​ pain sensation. position at movement. MYASTHENIA GRAVIS
➔​ paresthesia ➔​ Dysesthesia (unpleasant sensation) ●​ uncommon, autoimmune disease which affects myoneural junction that causes weakness
○​ If lesions occur in Optic nerve lesions or their connection: of voluntary muscles.
➔​ visual disturbances = ➔​ scotoma (patchy blindness) ●​ Myoneural junction – neural connection between the motor nerve and muscle
blurred vision ●​ Pure motor disorder (no effect on sensation and coordination)
➔​ diplopia (double vision) ➔​ total blindness ●​ Affects women more than men
○​ If lesions occur at the Pyramidal tract of CNS: ●​ In normal circumstances, a chemical response promotes the release of Acetylcholine
➔​ spasticity (hypertonicity of muscle) ●​ The release of acetylcholine comes from the vesicles of the nerve terminals of myoneural
➔​ increased stretched resistance and deep tendon reflex neural junction.
➔​ diminished superficial reflexes ●​ Once released, this will attach to the receptor sites (found in the motor end plate) it will
➔​ Usually occurs in lower extremities lead to stimulation of muscle contraction.
●​ Acetylcholine - chief neurotransmitter of the parasympathetic nervous system that
○​ If lesions occurred in Frontal and Parietal Lobe: cognitive and psychosocial
contracts the smooth muscle, dilates blood vessels, increases body secretions and slows
changes
heart rate.
○​ Other complications:
●​ Types of MG
➔​ bladder, bowel and ➔​ constipation 1.​ Autoimmune – It’s an autoimmune condition where the cause isn’t well understood
sexual dysfunctions but the likely cause is the production of certain types of antibodies (immune system
➔​ UTI ➔​ pedal edema proteins). This is the most common type.
○​ Charcot’s Triad: Scanning of Speech, Intention tremors and Nystagmus ○​ Ocular: Eye and eyelid muscles weaken, leading to drooping eyelids and difficulty
keeping the eyes open. Some may experience double vision. Eye weakness is often

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 2

 the first sign of myasthenia gravis, which can progress to a generalized form in ➤​ Produces temporary reduction in circulating antibodies
nearly half of those diagnosed. ○​ Thymectomy – surgical removal of thymus glands
○​ Generalized: Muscle weakness affects the eye muscles and face, neck, arms, legs ➤​ Since patients with myasthenia gravis have enlarged thymus gland
and throat. May find it difficult to speak or swallow, lift arms over the head, stand up ➤​ Antigen-specific immunosuppression
from a seated position, walk long distances and climb stairs. ➤​ Only treatment that can result in complete remission 35% in all cases
2.​ Neonatal: A fetus gets certain antibodies from their birth mother who has
●​ Nursing Management
myasthenia gravis. An infant may have a weak cry or sucking reflex at birth. These
temporary symptoms usually go away after three months. ○​ Teaching strategies to conserve energy – rest, minimize walking, maintain good
3.​ Congenital: It isn’t an autoimmune condition, and a genetic change causes this sleep patterns
type. ○​ Minimize risk of aspiration
●​ Pathophysiology: ➔​ Mealtime coincides the peak effect of medication
➔​ rest before meals
➔​ sit upright when eating
➔​ soft diet to facilitate swallowing
○​ Eye problems
➔​ Tape the eyes – to prevent corneal damage when eye does not close completely
due to ptosis
➔​ artificial tears

W14: DEGENERATIVE DISEASES PART 2

GUILLAIN-BARRE SYNDROME
●​ AKA Idiopathic Polyneuritis (Polyradiculoneuritis)
●​ autoimmune demyelinating disease of the peripheral nervous system which results in an
acute, rapid, segmental demyelination of peripheral nerves and some cranial nerves
which produces ascending weakness.
●​ In Guillain Barre Syndrome, the weakness is usually symmetrical and bilateral
affectations.
○​ If your myasthenia gravis is having a set up or pattern of descending weakness or
descending paralysis, GBS has an ascending weakness.
○​ If your myasthenia gravis starts the weakness in the brain, in GBS it starts in muscle
and peripheral nerve.
○​ In GBS the weakness usually symmetrical and bilateral affectations
●​ It is an immunologic reaction that causes a segmental demyelination of the axons
●​ Types of GBS
1.​ Acute inflammatory demyelinating polyradiculoneuropathy (AIDP), the most
common form in North America and Europe. The most common sign of AIDP is
muscle weakness that starts in the lower part of the body and spreads upward.
2.​ Miller Fisher syndrome (MFS), in which paralysis starts in the eyes. MFS also is
●​ Descending Paralysis: represents descending motor weakness from CNS to motor associated with an unsteady walk. MFS is less common in the U.S. but more
muscles
●​ Diagnostic: Acetylcholinesterase Inhibitor Test a.k.a Tensilon Test – stops common in Asia.
acetylcholine breakdown making it available for binding in myoneural junction 3.​ Acute motor axonal neuropathy (AMAN) and acute motor-sensory axonal
○​ Edrophonium Chloride (Tensilon) – Fasting acting anticholinesterase is neuropathy (AMSAN) are less common in the U.S. But AMAN and AMSAN are
administered IV more frequent in China, Japan and Mexico.
➔​ 30 seconds after injection: resolution of symptoms (facial muscle weakness and ●​ Precursor Cause: Viral infection; Campylobacter jejuni, Cytomegalovirus, EBV,
ptosis) Mycoplasma pneumoniae, H. influenzae, Zika virus
➔​ 5 mins after – confirms the diagnosis ○​ The cause of GBS is unknown but this is sometimes triggered by respiratory
➔​ Atropine (anticholinergic) antidote for side effects (WOF: slow heartbeat or infection and stomach flu, but most often antecedent precursor is viral infection.
bradycardia and muscle spasm) ○​ Viral infection – this is the cause of GBS but not necessary the cause, if the patient
○​ Ice Test - for patient w/cardiac problems and asthma just suffered or encounter GBS, they have viral infection prior to GBS
➔​ Apply ice pack on patient eye for 1 minute, ptosis should temporarily resolve ●​ Pathophysiology: Post infection → related to molecular mimicry → immune system
○​ Repetitive Nerve Stimulation - a decrease in successive action potentials in attacks the PNS myelin sheath = influx of macrophages and other immune agent →
patients with Myasthenia Gravis inflammation and destruction of the PNS myelin = axonal loss and leads to interruption of
○​ Single–Fiber Electromyography (EMG) - detects a delay or failure of nerve conduction → remyelination = Schwann cells are spared from the damage + allows
neuromuscular transmission; uncomfortable for patients remyelination (takes months or years; often recovery is incomplete)
○​ MRI - detects enlarged thymus gland; thymus gland is a acetylcholine receptor ●​ Clinical manifestation: depending on the site of demyelination
antibody production hence enlargement of thymus gland ○​ Based on the module: Tachycardia, Hypotension, Sweating, Ascending Paralysis
●​ Medical Management: NO CURE; treatments do not stop the production of (Involves respiratory muscles)
acetylcholine receptor antibody ○​ Assessment findings:
1.​ Improve function ➔​ Mild sensory changes; in some clients severe misinterpretation of sensory
2.​ Reduce and remove circulating acetylcholine receptor antibody stimuli resulting in extreme discomfort
○​ Anticholinesterase Medications ➔​ Clumsiness: usually first symptom
➤​ Pyridostigmine Bromide – first line of therapy ➔​ Progressive motor weakness in more than one limb (classically is ascending
★​ inhibits breakdown of acetylcholine and increases availability of and symmetrical)
acetylcholine at the neuromuscular junction. First line of treatment with ➔​ Cranial nerve involvement (dysphagia)
fewer side effects. Dosage is gradually adjusted, usually 4x a day ➔​ Ventilatory insufficiency if paralysis ascends to respiratory muscles
★​ Increases acetylcholine availability or helps electrical signals travel to ➔​ Absence of deep tendon reflexes
muscle therefore reduces muscle weakness ○​ PNS demyelination: Ascending weakness - Muscle weakness in the legs, may
★​ Takes effect a few hours – kaya inaadminister q6 or q4 depende sa case progress upward (symmetrical, bilateral)
niya and ang dose depende sa weight ❖​ Hyporeflexia, areflexia (absence of reflexes)
★​ Gradually adjusted ❖​ NOTE: In patients with GBS, Hyporeflexia, areflexia, and weakness may progress to
★​ Complications: Myasthenic Crisis – underdosage and Cholinergic tetraplegia (paralysis of the lower and upper body
Crisis – overdosage ❖​ Dyskinesia – pt unable to execute voluntary movement
★​ Myasthenic crisis (underdosage) – there is exacerbation of the disease; ❖​ Paresthesia - numbness, tingling, pricking, pins and needles sensation
there is severe generalized muscle weakness, respiratory muscle ○​ Cranial Nerve demyelination:
weakness and bulbar weaknesses which may result in respiratory failure. ❖​ Blindness (CN II)
★​ Cholinergic crisis (overdosage) – rare but may also result in respiratory ❖​ Bulbar muscle weakness (CN IX) – can result to manifestations of dysphagia,
failure inability of the client to clear secretions
★​ Tensilon Test: Pyridostigmine bromide (Neostigmine) for relief of ❖​ Autonomic demyelination (CN X) – includes tachycardia, bradycardia,
symptoms hypertension or orthostatic hypotension
★​ Atropine (anticholinergic) - if exacerbations of signs and symptoms due ❖​ Does not affect cognitive function
to cholinergic crisis ●​ Diagnostic: GBS occurs after a viral infection: Check for history of viral illness in the
○​ Immunosuppressive Therapy previous week
➤​ Corticosteroid – daily for 1-2 months ○​ Serum lab tests are not useful however lab test has Elevated protein in CSF
★​ Suppresses immune response (Lumbar Tap, Spinal Tap, Lumbar Puncture)
★​ Decreasing amount of antibodies ○​ Vital capacity changes, (-) inspiratory force – suggest impending neuromuscular
➤​ IV Immunoglobulin (IVIG) – Used to treat exacerbations respiratory failure which my result to death
★​ Complications include headache, aseptic meningitis, flu-like symptoms. ○​ EMG shows slowed nerve conduction
★​ AVOID PROCAINE (usually used as anesthesia by dentist) it exacerbates ●​ Medical Management: GBS is considered an emergency!
Myasthenia gravis ○​ If respiration is impaired: hook in mechanical ventilation
➤​ Azathioprine – inhibits T Lymphocytes and reduces antibody level ○​ Due to weakness and Immobility → may lead to thrombosis embolism:
★​ Procaine is avoided administration of anticoagulants (Heparin); antiembolic stocking is prescribed
★​ Dentist is informed of diagnosis (if pupunta sa dentist ipa-inform ang dentist ○​ To directly affect the PNS myelin sheath: therapeutic plasma exchange;
na merong M.G. kasi di pwede gamitan ng procaine – anesthesia para sa Intravenous immunoglobulin administration
gums (hindi pwede gamitin kasi mag eexacerbate ng symptoms at risk for ○​ Due to autonomic dysfunction: ECG monitoring; Administration of
prolonged muscle weakness) alpha-adrenergic blocking agents (if hypertensive and tachycardic) Increase amount
○​ Plasmapheresis (Plasma Exchange) of intravenous fluid (if hypotensive). Kapag hindi nakain
➤​ Patient’s plasma and plasma components are removed through a centrally ●​ Nursing Management: GOAL: MONITOR COMPLICATIONS!
placed large-bore double lumen catheter ○​ Monitor for changes in vital capacity and negative inspiratory force
➤​ Blood cells and antibody is separated then plasma substitute are reinfused ○​ Maintain adequate ventilation (Oxygenation and/or mechanical ventilation)

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 3

 ○​ Enhance physical mobility to avoid thrombus formation ●​ Areas affected: Affects motor neurons, the nerve cells in the brain and spinal cord that
➔​ Passive range of motion exercises in paralyzed limbs at least 2x a day control voluntary muscle movement and breathing.
➔​ Position changes ●​ 2 Types of ALS based on the cause:
➔​ Anticoagulant administration 1.​ Sporadic ALS: An estimated 90% of all ALS cases are sporadic. This means that
➔​ Antiembolic stocks the condition happens randomly. It isn’t inherited (passed from biological parents to
➔​ Padding of bony prominences children).
○​ Maintain adequate nutrition (IV fluids, parenteral nutrition) 2.​ Familial ALS: About 10% of ALS cases are familial. A gene change (mutation)
○​ Maintain effective communication with picture cards, eye/blink systems. Ineffective causes it. You inherit the gene change from one or both of your biological parents
communication due to bulbar symptoms during conception.
○​ Decrease fear and anxiety (diversional activity, referral to support group) ●​ Pathophysiology: Motor neurons in the anterior horns of the spinal cord and motor
nuclei of lower brainstem dies → Muscle fibers that they supply undergo atrophic
changes → Neuronal degeneration may occur in both upper and lower neuron system
HUNTINGTON’S DISEASE
●​ Leading theory: overexcitation of nerve cells by neurotransmitter glutamate leads to cell
●​ is a chronic, progressive, hereditary disease of the nervous system that results in injury and neuronal degeneration.
progressive involuntary choreiform movement and dementia
●​ Diagnostic Test: ALS is diagnosed on the basis of the signs and symptoms, because no
●​ The disease affects approximately 1 in 10,000 men or women clinical or laboratory tests are specific to this disease.
●​ Every person has the gene that causes HD–however, only those who inherit the
○​ Electromyography and muscle biopsy studies of the affected muscles indicate
expansion of the gene will develop the disease and pass it onto their children
reduction in the number of functioning motor units.
➔​ Because it is transmitted by an autosomal dominant gene, each child of a parent ○​ MRI scan may show high signal intensity in the corticospinal tracts; this differentiates
w/ HD has a 50% chance of inheriting ALS from multifocal motor neuropathy.
●​ A genetic mutation in HD, the presence of a repeat in the Hungtington gene (HTT), has ○​ Neuropsychological testing can assist in assessment and diagnosis
been identified
●​ Clinical Manifestations:
●​ Genetic Testing can identify people who will develop this disease but it cannot predict
timing of disease onset ○​ Chief symptoms:
●​ Pathophysiology: premature death cells in the striatum (caudate and putamen) of the ➔​ fatigue
basal ganglia, the region deep w/n brain that is involved in the control of movement. Cells ➔​ progressive muscle weakness
are lost in the cortex, the region of the brain associated with thinking, memory, ➔​ cramps
perception, judgement, and behavior, and in the cerebellum, the area that coordinates ➔​ fasciculations (twitching)
voluntary muscle activity. Why the protein destroys only certain brain cells is unknown, ➔​ lack of coordination
but several theories have been proposed to explain the phenomenon. One possible ○​ Loss of motor neurons in the anterior horns of the spinal cord results in:
theory is that glutamine, a building block for protein–abnormally collects in the cell ➔​ progressive weakness and atrophy of the muscles of the arms, trunk, or legs.
nucleus, causing cell death. ➔​ Spasticity
➔​ deep tendon stretch reflexes become brisk and overactive
○​ Weakness starts in the muscles supplied by the cranial nerves, and difficulty in
talking, swallowing, and breathing occurs.
○​ Death usually occurs as a result of infection, respiratory insufficiency, or aspiration.

Based on the module

UPPER MOTOR NEURON SIGNS LOWER MOTOR NEURON SIGNS
●​ Very little wasting ●​ Wasting (atrophy)
●​ Increased tone (spasticity) ●​ Low or normal tone (flaccidity)
●​ Brisk reflexes (hyperreflexia) ●​ Reduced or absent reflexes
●​ Primitive reflexes (Babinski sign) (hyporeflexia or areflexia)
●​ Fasciculations (low threshold for
irritation of the motor neuron)

●​ Medical Management
●​ Clinical Manifestations ○​ No cure exists for ALS (Vacca, 2020). The main focus of medical and nursing
○​ The condition is characterized by a triad symptoms that includes– management is on interventions to maintain or improve function, well-being, and
quality of life.
Motor Dysfunction ●​ The most prominent is chorea– or rapid, jerky, involuntary, ○​ Pharmacologic Therapy
purposeless movements
➔​ Riluzole and Edaravone – Precise action of these drugs is not clear, but both are
Cognitive Impairment ●​ Problems w/attention and emotion recognition considered disease modifying treatments for ALS.
Behavioral features ●​ Apathy and blunted affect ➔​ Baclofen, Dantrolene Sodium, or Diazepam – useful for patients troubled by
○​ As the disease progress, constant writhing, twisting and uncontrollable movements spasticity, which causes pain and interferes with self-care.
may involve the entire body–Facial movements produce tics and grimaces ➔​ Modafinil – used for fatigue, and additional medications may be added to manage
○​ Speech becomes slurred, hesitant, often explosive and eventually unintelligible. the pain, depression, drooling, and constipation that often accompany the disease.
○​ Chewing and swallowing are difficult and there is constant danger of choking and ○​ Mechanical ventilation – (using negative-pressure ventila-tors) is an option if
aspiration alveolar hypoventilation develops.
○​ Choreiform movement persist during sleep but are diminished ○​ Noninvasive positive-pressure ventilation – helpful at night and postpones the
○​ emotional disturbance: fits of anger, suicidal depression , impaired judgment & decision about whether to undergo a tracheotomy for long-term mechanical
memory, hallucinations, delusions & paranoid thinking ventilation
○​ Death follows from complications such as choking, fall, infection, pneumonia or heart ○​ Enteral Feeding – for patient experiencing aspiration and swallowing difficulties
failure and generally occurs 10-20 years after onset of the disease. ➔​ PEG tube is inserted before the forced vital capacity drops below 50% of the
●​ Diagnostic Tests: predicted value. The tube can be safely placed in patients who are using noninvasive
○​ Clinical presentation of characteristic signs and symptoms positive-pressure ventilation for ventilatory support.
○​ (+) family history and the known presence of the genetic ○​ Decisions about life support measures are made by the patient and family and
marker–cytosine-adenine-guanine (CAG) repeating on huntington gene (HTT) should be based on a thorough understanding of the disease, the prognosis, and the
○​ CT or MRI scans shows symmetrical striatal atrophy before motor symptoms appear implications of initiating such therapy.
●​ Medications ○​ Patients are encouraged to complete an advance directive to preserve their
autonomy in decision making.
1.​ Phenothiazine – blocks dopamine receptors
2.​ Reserpine – depletes presynaptic dopamine ●​ Surgical Management
3.​ Tetrabenezine – reduces dopaminergic transmission ○​ Tracheostomy for breathing support
●​ Nursing Management ○​ Laryngectomy to prevent aspiration
○​ Gastrostomy for nutrition
○​ Frequent assessment/ evaluation of patient’s motor signs
○​ Interact with the patient in a creative manner ●​ Nursing Management
○​ Learn how this particular patient expresses need and want ○​ Provide intellectual stimulating activities, because the client typically experiences no
cognitive deficits and retains mental abilities.
○​ Provide client and family teaching.
AMYOTROPHIC LATERAL SCLEROSIS (ALS)
○​ Promote measures to enhance body image.
●​ A disease of UNKNOWN cause in which there is loss of motor neurons in the anterior ○​ Promote client and family coping as the client and his family deal with the poor
horns of the spinal cord & the motor nuclei of the lower brain stem prognosis and the grieving process
●​ Onset occurring usually in the 5th or 6th decade of life ○​ Provide referrals.
●​ It is often referred to as Lou Gehrig disease, after the famous baseball player who ○​ Maximize functional abilities
suffered from the disease.
➔​ Prevent complications of immobility
●​ As motor neuron cells die, the muscle fibers that they supply undergo atrophic changes.
➔​ Promote self-care
Neuronal degeneration may occur in both the upper and lower motor neuron systems
➔​ Maximize effective communication
●​ The leading theory held by researchers is that over-excitation of nerve cells by the
neurotransmitter glutamate results in cell injury and neuronal degeneration. ○​ Ensure adequate nutrition
●​ ALS most commonly occurs between 40 and 60 years of age and affects all social, racial, ○​ Prevent respiratory complications
and ethnic backgrounds, with men being affected at slightly higher rates than women. ➔​ Promote measures to maintain adequate airway
●​ The majority of cases of ALS arise sporadically, but 5% to 10% of cases are familial ALS ➔​ Promote measures to enhance gas exchange, such as oxygen therapy and ventilator
resulting from an autosomal dominant trait carried by one parent. Familial ALS occurs 10 assistance.
years earlier than the ALS average, and those afflicted tend to have a shorter life span ➔​ Promote measures to prevent respiratory infection
●​ Causes:
1.​ Genetic: Changes or variants in certain genes may cause ALS in up to 70% of W15: MUSCULOSKELETAL SYSTEM
familial cases and 5% to 10% of sporadic cases. There are more than 40 genes ●​ Composed of the bones, joints, tendons, muscles, ligaments and bursae of the body.
related to ALS. The most common affected genes include the C9orf72, SOD1, ●​ Major functions: small fluid-filled sacs that reduce friction between moving parts
TARDBP and FUS genes that regulate how neurons function. ○​ Protection – for vital organs in your body's joints

2.​ Environmental: Exposure to certain toxic substances (lead or mercury), viruses or ○​ Framework – supports body structures
physical trauma may cause ALS. ○​ Mobility – body moves because of the presence of muscle and skeletal system

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 4

 ○​ Thermoregulation – heat produced during movement ●​ Post-Op Nursing Considerations:
○​ Venous Return – movement facilitate this ○​ elastic bandage is worn for 2 to 4 days
○​ Reservoir of Immature Blood Cells (Red Marrow) & Minerals such as Calcium, ○​ keep joints extended and elevated
Phosphorus, Magnesium, Fluoride ○​ monitor neurovascular status
○​ avoid strenuous activity of the joint — exercise must be approved by the PCP
ASSESSMENT – INDICATORS OR PERIPHERAL NEUROVASCULAR DYSFUNCTION
6 Ps of Neurovascular Assessment (common na ginagamit ito kapag meron fracture): i.​ Arthrocentesis
includes the assessment of CMS ●​ aka.joint aspiration
0 = absent pulse and 3+ = strong and bounding pulse
●​ Circulation Kapag worsening, pwedeng mag-cause ng cyanosis (blue discoloration), tapos kung hindi pa rin narestore ●​ obtain synovial fluid
○​ pulse, ang blood supply, magiging black ang tissue — sign na may tissue death (anoxia)
●​ Purpose: (1) analyze synovial fluid and (2) relieve pain
○​ pallor which is pale or white skin >> cyanosis or bluish color then mag tuturn into >> ●​ NursingConsiderations:
black due to tissue anoxia, ○​ offer assurance that pain meds will be administered
○​ mottled skin or patches of white or red over the skin surface ○​ apply ice on the operative site
○​ poikilothermia inability ng skin to regulate temperature, kaya nagiging cold to touch ang apektadong bahagi.
Paralysis
○​ blanch test tapos ang result ng capillary refill ay > 3 seconds
CAST
●​ Motion – paralysis and weakness
●​ rigid external immobilizing device molded to the contours of the body, to provide complete
●​ Sensation – pain (relenting), pain on passive stretch, paresthesia, absence of feeling immobilization and provide a protected environment for bone healing
●​ Take Note: if more than 6 hrs walang supply ng blood ang CNS it can result to ●​ mainstay of tx for many fractures
permanent loss of function Plaster of Paris
●​ Purpose:
- Cheaper, molds well
➔​ immobilizes and reduce fractures - Dries slowly (24–72 hrs to
DIAGNOSIS
➔​ corrects a deformity fully dry)
a.​ Bone X-Ray ➔​ support and stabilize weakened joint - Heavy and not
●​ determine bone density, texture, erosion, widening, natrowing, signs of irregularity ●​ 2 Most Common Materials of Casting: water-resistant
●​ Nursing Considerations: - Handle with palms only
➔​ Plaster of Paris
○​ remove all jewelry because it will block the anatomy ➔​ Fiberglass
when wet to avoid dents
○​ instruct to remain still to avoid blurred images
○​ inform PCP if female client is pregnant
FRACTURE
●​ a complete or incomplete disruption in the continuity of bone structure
b.​ CT Scan & MRI
●​ descriptions:
●​ visualize, assess tumors, injury to soft tissues and ligaments, tendons
○​ Complete Fracture – break across the entire cross-section of the bone
●​ ginagawa ito usually if inconclusive ang results ng x-ray
○​ Incomplete fracture – break is through only a part of the cross section of the bone
●​ Nursing Considerations: no conclusion or definite result
○​ Comminuted Fracture – break produces several bone fragments shattered bone
○​ determine allergy to IV contrast
●​ Causes – direct blows, crushing forces, sudden twisting motions, extreme muscle
○​ remove metal containing objects contractions
Sa lakas ng magnet ng MRI, kaya nitong burahin ang magnetic strip ng
○​ credit card infos can be erased credit/debit cards. ●​ Complications – soft tissue edema, hemorrhage, joint dislocation, ruptured tendons,
○​ remove any nicotine patch, NTG transdermal, clonidine transdermal because it severed nerves, damaged blood vessels
have a thin layer of aluminum and pwede masunog yung pinaglagyan ng patch ●​ Types:
Classification of Open Fractures:

- Type 1: <1cm wound and clean.

○​ Closed Fracture (Simple) does not break thru skin - Type 2: 1-10cm wound and clean.
c.​ Bone Scan ➔​ Simple fracture - Type 3A: >10cm wound and high-energy, but with adequate soft
tissue coverage.
●​ detect bone cancer, osteomyelitis, fractures, aseptic necrosis ➔​ Does not cause a break in the skin - Type 3B: >10cm wound and high-energy, but with inadequate soft
●​ monitor progression of bone disease such as osteoporosis ○​ Open Fracture (Compound) - breaks thru skin
tissue coverage.
- Type 3C: All injuries with vascular injury.
●​ can diagnose bone disease before it can be identified on x ray
➔​ Compound or complex fracture
●​ involves administration of radioisotopes para makita agad ang image ng affected
➔​ Skin or mucous membranes wound extends to the fracture bone
bone
➔​ Classifications:
●​ Nursing Considerations:
❖​ Type I – a clean wound less than 1 cm long and simple fracture pattern
○​ consent
❖​ Type II – a larger wound w/minimal soft tissue damage, no flaps or avulsions
○​ determine allergy to isotopes
❖​ Type III – most severe, highly contaminated, and has extensive tissue
○​ inform PCP if female client is pregnant
damage
○​ empty bladder prior bone scan if pelvic bone ang involve sa bone scan
○​ Intra-articular fracture
○​ drink 4 to 6 glasses of water after bone scan to wash out / flush out the
radioisotopes ➔​ Fracture extends into the joints of a bone or the cartilaginous tissue so they are
non radiopaque therefore hindi sya makikita through xray
➔​ MRI or arthroscopy confirms the diagnosis because hindi nakikita yung
d.​ Bone Biopsy fracture sa cartilage using an xray
●​ determine structure and composition of bone marrow, bone muscle, synovium in ➔​ Often leads to osteoarthritis
between the joints
●​ Specific types:
●​ involves excision of bone tissue using needle
○​ Avulsion – fragment of bone has been pulled away from its main body by a tendon
●​ pinaka common na pinag kukuhanan ng specimen ay ang iliac crest
and its attachment
●​ Nursing Considerations:
○​ Compression – bone has been compressed, ligaments are driven inward kaya there
○​ offer assistance of pain meds or sedative, pre-op and post-op is associated decreased in height
○​ monitor site of insertion for complications such as pain, bleeding, edema, ○​ Depressed – fragments are driven inward
hematoma, and possible infection ○​ Epiphyseal – treatment through the epiphysis
○​ apply ice if there is bleeding or edema ○​ Greenstick – one side of bone is broken, the other is bent only occurs in juveniles kasi di pa formed bones
○​ antibiotics as prescribed ○​ Impacted – a bone fragment is driven into another bone fragment
○​ Transverse – fracture straight across the bone shaft
e.​ Electromyography ○​ Oblique – fracture at an angle across the bone
●​ provide information about electrical potentials of muscles and nerves ○​ Pathologic -- fracture that occurs through an area of a diseased bone
●​ evaluate weakness, pain and disability ○​ Spiral -- twists around the shaft of the bone
●​ uncomfortable procedure because it involves insertion of needle electrodes ○​ Stress -- fracture that results from repeated loading of bone and muscle
●​ Nursing Considerations:
○​ determine if the patient is taking anticoagulants because there is a risk for
bleeding
○​ determine if the patient has skin infections kasi we can introduce bacteria sa
bone, muscle or circulation
neuromuscular disorders, inflammatory diseases, muscular dystrophies, or infections affecting muscle tissue.
f.​ Muscle Biopsy
●​ can detect muscle disorders, metabolic defects of muscle, or infections of the muscle
and difference between nerve and muscle disorder
●​ Nursing Considerations: fasting is not necessary

g.​ Arthrogram / Arthrography

●​ “Arthro” pertains to joints
●​ identify the course of unexplained joint pain and progression of joint disease
●​ involves injection of contrast material into the joint cavity
○​ (+) TEAR if the contrast agent leaks out from the joint cavity
●​ Nursing Considerations:
○​ determine allergy to contrast dye
○​ notify PCP if female patient is pregnant
○​ remove jewelries
●​ Clinical Manifestations:
h.​ Arthroscopy ○​ Acute pain - more intense when muscle spasms occur in the area of fracture
●​ allows direct visualization of a joint ○​ Loss of function - depends on the integrity of bones where muscles are attached
●​ treats tears, defects, and disease process ○​ Deformity - displacement, angulation, rotation of the fracture extremity
●​ Pre-Op Nursing Considerations: ➔​ compare the affected to unaffected side para ma check if may deformity
○​ consent ○​ Shortening of the extremity - due to compression of the fracture bone, or
○​ do not consume any food or fluid for 8 to 12 hours overlapping of the distal and proximal site of the fracture
○​ patient may be instructed to shave the joint area ○​ Crepitus - a crumbling sensation when extremity is gently palpated (popping,
○​ hospital gown crackling or leaking sounds)

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 5

 Wound
○​ Localized edema and ecchymosis - due to trauma, bleeding into tissues ➔​ wound irrigation (to prevent infection and delay ng healing using NSS) &
Irrigation:
○​ Muscle spasm and tenderness debridement (remove necrotic tissues [usually color black or yellow] yung out
Flushes
●​ Emergency Management! tissue na wala ng supply ng blood and oxygen kasi pag di inalis mabubulok
Wound Irrigation: lang
debris,
○​ if suspected with a fx — - Flushes out siya,
Wound and ineexpose natin sa debridement ay fresh or healthy tissues
Irrigation:
debris, bacteria, may and
bacteria,
and exudate presence
Flushes outdapat ng bacteria,
debris, bleeding, usually yung debridement ay ginagawa regularly
exudate
➔​ immobilized thru adequate splinting (any wood or empty box [karton] + clean andonce orrisk
twice a week para hindi lumaki ang sugat)
exudate
- Reduces infection
cloth as tali) first
- Promotes check the
➔​healing temperature because increase in temp may indicate infectionReduces
by creating
➔​ check neurovascular status before and after
➔​Reduces
a clean wound bed infection
elevate risk
affected extremity to reduce pain, inflammation swelling and infection risk
○​ if open fx — - Often done
➔​ before dressing
check the neurovascular status
➔​ cover wound with sterile dressing changes orPromotes healing by creating
debridement Promotes
➔​ never attempt to reduce the fx a clean wound bed healing by
●​ 1st Complication | Hypovolemic or Traumatic Shock: creating a
●​ Medical Management for Fractures
○​ prevent
Oftenfurther hemorrhage
done before (kaya may hemorrhage because of fracture)
dressing clean wound
○​ Reduction — restoration of fx fragments to anatomic alignment and positioning ○​ wechanges or debridement
have to stabilize the fracture bed
➢​ NursingConsideration: ○​ we have to restore BV and circulation (IV fluid muna tsaka lang tayo mag blood
■​ secure consent transfusion pag may severe blood loss) Often done
■​ administer analgesics as prescribed ■​ to consider it as hemorrhage dapat 500 ML yung blood loss
before
■​ handle the affected extremity gently dressing
○​ relieve pain NCLEX Q: Answer: FES
changes or
○​ Close Reduction — Cast, splint, traction only ○​ proper immobilization A patient sustained a fracture to the femur. The patient has
debridement
➢​ involved manipulation, manual traction, percutaneous pinning ●​
suddenly become confused, restless, and has a respiratory
2nd Complication | Fat Embolism Syndrome (FES): rate of 30 breaths per minute. Based on the location of
➢​ involves application of cast, splint or another device to reduce fx ○​ yung fats ay nanggaling sa yellow bone marrow
fracture and the presenting symptoms, this patient may be
experiencing what type of complication?
➢​ xray to verify correct alignment ○​ pag sumama na sa circulation yung fats it will lead to hypoxia, tachypnea,
Uses general / regional anest
➢​ traction may be used tachycardia, pyrexia elevated temp
○​ Open Reduction — involves a surgical approach with the use of internal fixation ○​ pag pumunta na sa kidney it will result in petechiae on chest
(pins, wired, screws, plates, nails, rods) ○​ free fat urine
○​ Open Reduction Internal Fixation (ORIF)— most common orthopedic surgical ●​ 3rd Complication | Compartment Syndrome
procedure used to treat severe fx’s
○​ Immobilization —
COMPARTMENT SYNDROME
➢​ accomplished by external or internal fixation
●​ Characterized by: elevation of pressure within an anatomic compartment that is above
➢​ Methods of External Fixation:
normal perfusion pressure
■​ bandages, casts, splint, continuous tracking ●​ What is the Problem in CS? — dahil sa increase yung pressure sa compartment which
■​ external fixators (OREF/Open Reduction External Fixation) can compromise yung blood supply sa tissue that may lead to cell death, necrosis,
●​ What Are External Fixators? permanent dysfunction
○​ devices that manage fxs ●​ What is a Compartment Area?—the area within your body that is enclosed with bone or
○​ Purposes: fascia which composed of muscle, nerves
➔​ complicated fx of the humerus, femur, tibia, pelvis ●​ body has 46 compartments and 36 are located in the extremities (CS usually happen sa
➔​ corrects defects, treat non union, lower extremities)
➔​ lengthen limbs ●​ most common in young adults Late sign of CS: Pulselessness
➔​ provide skeletal ability for severe comminuted fx splintered) (crush or involves ●​ Causes of CS:
surgical insertion of pune through skin into the bones with attachment of ○​ edema, bleeding, or restrictive cast or masikip ang pagkakalagay ng cast
external frame ○​ Fractures — the most common cause
○​ Nursing Considerations (Post Application): ★​ Take Note: Tibial fx's have the highest risk
➔​ elevate the affected extremity to the level of the heart ●​ Clinical Manifestations:
➔​ cover sharp points with caps ○​ Cardinal Sign — Pain
➔​ assess neurovascular status every 2 to 4 hrs ○​ severe pain and out of proportion to the injury (paginobserbahan mo parang wala
➔​ clean pin site to prev. infection lang or di mo alam saan galing yung pain)
➔​ check signs of infection ○​ deep and burning pain which is not relieved by medication or intractable pain
➔​ isometric and active exercises to prevent embolism ●​ Management:
➔​ never adjust clamps! because it can delay wound healing ○​ Bivalving — if the cause is restrictive cast or inappropriate application we use
○​ Univalving — pag ang cast ay sa buong extremities
○​ Cast is cut in half longitudinally — to help release the pressure
○​ Elevate extremity not higher than the heart level — to promote arterial perfusion
or para may blood flow parin
Roger Anderson External Fixator: usually used for long bone ○​ "E"Fasciotomy
EMERGENCY! Fasciotomy — if fall treatment did not work eto ang gagamitin, (we cut open the
fracture fascia to release pressure)
○​ Monitor neurovascular status

PRESSURE INJURIES / PRESSURE SORES

●​ tissue anoxia and ulcer due to pressure from cast or inappropriately applied brace (hindi
maganda yung pagkakalagay ng cast so may naiipit na tissues, pwedeng magsugat)
●​ Most susceptible areas are those w/ bony prominences such as:
Ilizarov External Fixator: for angulation and rotation of fracture ○​ heel, malleoli (nasa labas- lateral and medial) , dorsum of the foot, head of fibula,
and used to treat non union and lengthen the limbs anterior surface of the patella
○​ medial epicondyle of the humerus (malapit sa heart), ulnar styloid
●​ Clinical Manifestations:
○​ pain and tightness under the cast
○​ warm area on cast —erythema
○​ skin breakdown and tissue necrosis
Delta External Fixator: usually use in fx of tibia bone near the ●​ Management: appropriate application by the doctor and as a nurse you support the cast
ankle, this is used to treat pilon fracture by using the surface of your palm
○​ Univalving, Bivalving
○​ Windowing — appropriate for univalving kasi buong extremities yung kasama sa
univalving, it is use to access for assessment and medication / treatment
●​ Management for Simple / Minor Injury ○​ Take Note: hindi pwede kamutin ang loob ng cast kasi pwede magkaroon ng
abrasion what we can do here is to tell the PCP so that he/she can prescribe
antihistamine
R I C E
Rest the injured Ice for 20 mins, Compress to help Elevate the injured
area for 48 hrs (2 then 4-8x/day reduce swelling limb 6-10 inch DISUSE SYNDROME
days) above the heart ●​ muscular atrophy and loss of strength due to Immobilization from cast, splint, or braces
(nag decrease se ang size and structure ng muscle atrophy because of immobility)
○​ elevate at the LEVEL OF THE HEART ●​ possible management is isometric exercise, ginagawa to immediately to prevent muscle
atrophy
○​ diff or sprain to strain:
●​ Management:
○​ Instruct the patient to perform isometric contraction
Injury Affected Cause Site
○​ It is performed hourly while awake
Sprain Ligament Twisting/trauma Ankle, knee, wrist
Strain Muscle/Tendon Overuse, Lower back,
overstretch hamstring JOINT DISORDERS
OSTEOARTHRITIS
●​ Nursing Management for Fractures: ●​ aka.Degenerative Joint Disease
○​ Closed Fracture — ●​ noninflammatory degenerative disorder of the joints and the most common form of joint
disease
➔​ control of edema and pain
●​ it is considered irreversible ang minamanage nalang natin ay yung symptom
➔​ exercises on the unaffected side (to promote strength and prevent weakness,
kaya yung unaffected yung ieexercise kasi kailangan gumagalaw siya to prevent ●​ Classifications:
immobility and also to promote independence) ○​ Idiopathic (primary) — unknown and it is not related to any bone disorder
➔​ proper use of assistive devices for daily activities ○​ Secondary — end result or complication of bone disorder
○​ Open Fracture — ●​ Distinguishing Factors:
➔​ high risk for infection kasi nga open wound ○​ OA does not involve autoimmune or inflammation
➔​ Common Infection: Gas Gangrene ○​ symptoms are limited to the affected joints
➔​ IV antibiotics and tetanus toxoid ●​ Onsets: begins in 30 years of age (slow progression)

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 6

 ●​ Peaks:between 50 to 60 years of age ●​ Cause: repetitive hand and wrist movements (Increased risks: assembly line workers,
●​ Risk Factors: increased age, obesity (may pressure because of the weight bearing joints hairdressers, construction machinists ) workers,
like feet, knees, lumbar spine) , previous joint damage, mechanical injury, anatomic ●​ associated with Rheumatoid Arthritis, Diabetes, Hyperthyroidism, and Trauma
deformity (bone enlargements) , genetic and hormonal factors ●​ More common in women:
●​ Clinical Manifestations: ○​ 30 to 60 yrs old
○​ joint pain (ang pwede mong gawin ay irest ang joints) and stiffness ○​ taking birth control pills, estrogen pills
○​ functional impairment because of pain and stiffness which can decrease the ●​ Clinical Manifestation:
functional ○​ pain,numbness, paresthesia
○​ enlarged affected joint (yung mga daliri ay nagkakapalan, yung mga kasukausan ○​ weakness along the median nerve distribution (responsible in movement of the ff:) —
lumalaki, yung mga daliri sa paa ay lumalabas yung buto) thumb, index, middle fingers
○​ decreased ROM may bukol o umbok sa dulo ng daliri.
○​ night pain, fist-clenching upon awakening (common in px with CTS)
○​ Heberden's Nodes the bone enlargement ay nasa DIP (aka. Distal Interphalangeal) ○​ (+) Tinel Sign (px will report tingling, numbness and pain and it requires
○​ Bouchard's Nodes bone enlargement ay nasa PIP (aka. Proximal Interphalangeal intervention)— Electric-like sensation when median nerve (located in the inner
Joints [nasa gitna]) May umbok din pero nasa gitna ng finger. aspect of the wrist) is percussed lightly (especially sa thumb and index finger)
"cracking" o "grinding" sound kapag ginagalaw ang joint.
○​ Crepitus rubbing together of 2 joints or 2 bones) Nangyayari ito kapag nagkikiskisan ang dalawang buto ○​ (+) Phalen's Test — if the thumb and finger becomes numb when pt is asked to hold
○​ mid joint effusion (mild inflammation) her wrist in maximum flexion
○​ Boutonniere Deformity sa fingers Parang naka-bend yung gitna at nakataas yung dulo ng daliri. ●​ Medical & Nursing Management:
○​ Swan-Neck Deformity Nakaangat ang gitna at nakayuko naman ang dulo ng daliri, kaya parang leher ng swan (swan neck). ○​ Corticosteroid — oral or intra articular injection inflammation
●​ Assessment & Diagnosis: blood tests and synovial fluid are not useful but X-ray can ○​ NSAIDS to reduce
detect the following — ○​ Acupuncture w/ or w/o electrical stimulation
○​ narrowing of joint space because of osteophyte formation (collision of bone spurs- ○​ Application of Splints — to prevent hyperextension and prolonged flexion
formation ng bone that protrudes inside the joint cavity) formation ●​ Surgical Management:
○​ another possible cause of narrowing of joints is dense, thick subchondral bone ○​ Traditional Open Nerve Release — wrist is cut open and median nerve is exposed
(tissue that thickened between joints that’s why makapal yung result niya sa x-ray) to release compression
●​ Medical & Nursing Management: ○​ Endoscopic Release for Carpal Tunnel Syndrome (ERCTS) — to remove and
○​ pain and stiffness — maintain or improve joint mobility free nerves from compression. Pain and numbness will be experienced for several
○​ exercise (aerobic [cardiomuscular], isometric) days to weeks after this procedure
○​ weight loss (prevent pressure sa weight bearing joints) ○​ Take Note: After these procedures, the patient should wear hand splint to limit the
○​ orthotic devices or assistive devices such as splints, braces use of hand during healing and because of this, patient may need assistance for
○​ heat (dahil wala kang inflammatory process) and joint rest personal care
●​ Pharmacologic — WOF: Liver toxicity esp. if >4g/day or w/alcohol
★​ Acetaminophen (Tylenol) - 1st line DOC for mild - moderate OA pain; reduces pain and inflammation LOW BACK PAIN
★​ NSAIDS, COX-2 blockers (Celecoxib or celebrex ) (pag di acetaminophen) ●​ affected bone is lumbar and sacral
★​ Glucosamine gumana and Chondroitin (to promote degeneration of cartilage) ●​ Causes:
●​ Health Education about the pharmacologic and pharmacologic therapy ○​ Acute Lumbosacral Strain Biglaang injury or overstretching ng muscles or ligaments sa lower back
○​ Unstable Lumbosacral Ligament & Weak muscles (ligaments and tissue that holds
GOUT lumbosacral vertebrae is weak)
Mahinang support tissue madaling
●​ most common form of inflammatory arthritis metabolic disorder caused by hyperuricemia ○​ Intervertebral Disc Problems (it works ma-strainas shock absorber that is located in between
ang vertebrae
(mataas ang uric acid sa dugo/ circulation more than 6.8dL) vertebrae) Disc acts as a "shock absorber" sa pagitan ng vertebrae. If damaged, may cause pain or nerve compression (herniation)
●​ Urine Acid: by product ng purine metabolism na makikita sa kinakain natin na meat ○​ Unequal Leg Length Nagiging imbalance ang
products ○​ Cauda Equina Syndrome May bladder/bowel dysfunction, saddle anesthesia, weakness
posture stress sa spine
●​ Take Note: ang concentration ng uric acid natin sa katawan ay affected by our diet or ➔​ Compression of cauda equina and these are are bundles of spinal nerves
medication, depende sa pinoproduce ng katawan natin located in the lower portion of spinal cord
●​ Pathophysiology: ○​ For older clients, low back pain is associated with: osteoporosis, osteoarthritis of the
○​ occurs when the body does not properly metabolize uric acid → increased amount of spine, spinal stenosis (spaces in the spinal cord are narrowed)
uric acid in the blood uric acid crystals (tophi or uric acid crystalline) accumulate in ●​ Clinical Manifestations:
joints (and peripheral areas- paa, daliri sa paa sa fingers or meron din sa ears) ) → ○​ acute back pain that are less than 3 months, chronic back pain that are more than
JOINT PAIN 3 months or longer w/o improvement and fatigue (clinical manifestation that should
○​ Impaired kidney function (dapat ineexcrete ng kidney yung uric acid kapag hindi it be noted)
could lead to kidney stone or → uric acid crystals in the kidney → URATE LITHIASIS ○​ Cauda Equina s/sx — neurologic deficits (abnormal function of a body part may
●​ Common Causes of Hyperuricemia: Kapag gutom, nasisira ang body proteins occur), bowel or bladder dysfunction, asymmetrical paresthesia of the perineum,
Kapag ○​ Severe dieting or starvation Kapag more uric nasisira
gutom, acid production
ang body proteins thigh or buttocks
gutom, ○​ Excessive intake of foods high moreinuric
purines such as shellfish, organ meats,
acid production ○​ Radiculopathy — pain radiating down the leg / from diseased spinal nerve
nasisira sardines, scallops, anchovies, herring (tawilis), asparagus, dried beans, mushroom, ○​ Sciatica — pain radiation from an inflamed sciatic nerve
ang body peas, spinach ➔​ Take Note: when symptom are present it suggest nerve root involvement so it
proteins ○​ Heredity will affect the px’s gait, spinal mobility, reflexes, leg length, leg motor strength
more uric○​ Medications that can cause uric acid underexcretion such as diuretics (thiazide and and sensory perception
acid furosemide it could lead to uric acid under secretion) , low-dose salicylates (it can ○​ loss of normal lumbar curve
production also lead to uric acid under secretion)
○​ possible spinal deformity
●​ Clinical Manifestations: ●​ Diagnostic Findings:
○​ Acute Gouty Arthritis or severe recurrent attack of inflammation in joints and it is ○​ Xray of the Spine — determines fracture or dislocation
common early manifestation ○​ Bone Scan & Blood Studies — can detects infection, tumor, bone marrow
➔​ Metatarsophalangeal of the big toe is commonly affected joint abnormalities
○​ Tophi Formation — crystalline deposit accumulate in the articular tissue and is ○​ CT Scan / MRI — may reveal problem in vertebral disc and it permits visualization of
associated with more frequent, and severe inflammatory episode, and high uric acid the bone (its nature and location of spinal pathology)
concentration and it is commonly occur in synovium, olecranon bursa, subchondral ○​ Electromyography / Nerve Conduction Studies — to evaluate nerve root disorder
bone, or the bony plates that support the cartilage and it can also occur in achilles such as radiculopathies
tendon ○​ Ultrasound — can detects tears in ligaments, tendons, muscles
○​ Gouty Nephropathy — renal impairment manifestation, malalaman mo pag di ●​ Medical Management: most back pain are self-limited and goes away on its own
lumalabas yung uric acid sa kidney itetest mo ang blood BUN and BUA more than ○​ It relieves for 4-6 weeks with the use of analgesics, rest and avoidance of strain
6.8 dL possible may kidney impairment ka na)
●​ Pharmacologic Therapy:
○​ Uric Acid Urinary Calculi — kidney stone na makikita sa CT scan or MRI
○​ For acute back pain
●​ Assessment and Diagnosis:
➔​ NSAIDS
○​ High Serum Uric Acid
➔​ Muscle relaxants (Cyclobenzaprine)
○​ Polarized Light Microscopy of Synovial Fluid (ang kinukuha rito ay synovial fluid and
dapat makikita na mataas ang concentration ng uric acid, it is also considered as ○​ For Chronic low back pain —
definitive test for gout) ➔​ Tricyclic antidepressants (Amitriptyline)
○​ Polymorphonuclear Leukocytes in the Fluid (decrease ang urine acid) ➔​ Duloxetine
●​ Medical & Nursing Management: ➔​ Gabapentin– prescribed if pt reports radiculopathy (pain radiates down to the
○​ For acute attacks — merong severe inflammation leg)
➔​ Colchicine (administered orally or parenteral) ●​ Nonpharmacologic Therapy:
➔​ NSAID(Indomethacin) ○​ hot and cold tx
➔​ Corticosteroid ○​ Spinal Manipulation = Chiropractic
○​ Once acute attack subsided — or wala na yung inflammation so ang goal natin is to ○​ Cognitive —Behavioral tx
lower the uric acid ➔​ Biofeedback Mechanism wherein mind body technique is used to control body
➔​ Xanthine Oxidase Inhibitors —Allopurinol, Febuxostat (DOC) function
➔​ physical therapy, acupuncture and massage
○​ Uricosuric Agent — Probenecid (to increase secretion of uric acid, prevent
reabsorption of uric acid, tophi formation) ○​ alteration of activities such as — to prevent aggravation movement of body
○​ Lifestyle Changes — avoid purine-rich foods, weight loss, decrease alcohol ○​ Take note that movement is very important such as exercise in managing low back
consumption pain
➔​ position changes (promotion of mobility)
CARPAL TUNNEL SYNDROME ➔​ avoid twisting, bending, lifting, reaching (because these are stresses the back)
➔​ limit sitting position to 20-50 minutes (i can put pressure in the lower back and
●​ entrapment neuropathy (nerve entrapment) of the median nerve of the wrist
the length depends on the level of comfort)
●​ Occur when the median nerve of the wrist is compressed by:
➔​ absolute bed rest is not recommended
kapag kumapal ang tendon sheath, naiipit ang nerve bone deformities or fractures sa wrist
➔​ resume typical ADL
Thickened Flexor Tendon Sheath Skeletal Encroachment ➔​ low-stress aerobic exercise such as yoga, short walking and swimming
Edema Soft Tissue Mass ➔​ walking
pamamaga ng surrounding tissues na nagdudulot ng pressure tumor or cysts na sumisiksik sa carpal tunnel space
➔​ back and trunk exercises (prevents recurrent pain)
●​ Nursing Management: relief of pain, improve physical mobility by performing exercise

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 7

 ○​ assess previous successful pain control methods 4.​ Conjunctiva which lines the eyelids and covers exposed sclera surfaces
○​ observe for presence of discomfort
➔​ observe gait and posture
○​ instruct not to remain in bed rest (period of inactivity is ineffective and can result to
deconditioning)
○​ increase lumbar flexion and can achieve by elevating the head and thorax at least 30
degrees (by using pillow or done by slightly flexing the knees)
○​ lateral position with knees and hips flex with support of pillow
○​ avoid prone position because it will worsen low back pain and lordosis
○​ muscle stretching and relaxation 30 mins before daily exercise
○​ Good body mechanics and posture (to avoid recurrent of pain)

METABOLIC BONE DISORDERS

OSTEOPOROSIS ●​ Cornea: the clear surface of the outer eye and the main refracting part of the eye, this
●​ most prevalent bone disease in the world A bone disease that develops when bone can be damaged by infections
mineral density and bone mass decreases or when the quality or structure of bone ●​ Iris: gives the eye color
changes (osteopenia) bone density loss ●​ Pupil: black hole within the iris that lets the light into the eye, the pupil changes in size in
○​ Osteopenia is the precursor of osteoporosis response to light level
○​ The consequence of osteoporosis is bone fractures ●​ Lens: internal focusing element of the eye and characterized by a curve side and the
●​ this can lead to a decrease in bone strength that can increase the risk of fractures clear lens becomes cloudy when a cataract forms
●​ most prevalent bone disease in the world ●​ Conjunctiva / Sclera: a thin lining of the inside of the eyelid and extends over the front of
●​ Risk Factors: the white part of the eye and serves as the barrier to the external environment
○​ Advancing Age — 40 yrs (bone mass and density losses) Parathyroid Hormone ●​ Choroid / Retina: light sensitive part of the eye, extension of the optic nerve
○​ Hormonal Changes — ↓calcitonin ↓estrogen, ↓testosterone, PTH ↑ ●​ Optic Nerve: transmits impulses from the retina to the occipital lobe of the brain
❖​ Calcitonin promotes bone formation reabsorption and ○​ Take note that in glaucoma the rise in fluid pressure in the eye damages the nerve
❖​ Estrogen inhibits bone breakdown fibers entering the optic nerve from the retina
❖​ Testosterone risk factor for men promotes bone breakdown

❖​ Increased PTH promotes bone turnover resorption or The Eyeballs (Globe)

❖​ Take note: changes in concentration of these hormones will greatly affects the ●​ it is situated in the bony protective orbit that is lined with muscle, connective and adipose
loss of bone mass overtime tissue
○​ Postmenopausal Women ●​ it is moved through all fields of gaze by the extraocular muscles
intake ❖​ Low Ca and Vit. D intake ●​ Wall of the eyeball is composed of 3 layers:
nagbabaw ❖​ High PO4 intake nagbabawas ng ○​ Outer Dense Fibrous Protective Layer — including the sclera (white of the eye
as ng○​ Nutrition — if px has calcium
low calcium leveland vitamin d intake or if pz has high phosphate posteriorly) and cornea (window of the eye anteriorly)
calcium (decrease calcium concentration and calcium and phosphate acts opposite) intake ○​ Middle Vascular Layer — containing the uveal tract which include the iris (gives
level (hypophosphatemia) or drinks carbonated beverages these can result to the eye color), ciliary body (produces the aqueous humor which keeps the eye
osteoporosis Carbonated drinks = high phosphate shape) and choroid (structure that supplies blood and oxygen in the outer retina and
○​ Sedentary Lifestyle (Lifestyle Choices) – alcohol intake, smoking, and lack of also assist in absorbing scatter light)
exposure to sunlight ○​ Inner Neural Layer — including the retina, optic nerve, visual pathway
○​ Medications — that contributes to bone mass loss for more than 3 months such as ➔​ Photoreceptors:
corticosteroids, antiseizure, thyroid hormone 1.​ Rods — helps see images that comes in our peripheral / side vision, night
○​ Comorbidities — anorexia, hyperthyroidism, malabsorption syndrome, renal failure or low vision
●​ Diagnostic Test: detects bone loss only when severe (translucent bones) 2.​ Cones — essential for visual acuity, color discrimination, and fine detail
○​ Xray — only seen if there is significant demineralization (translucent or transparent 3.​ Take note that together the rods and cones are the cells responsible
bone) gold standard for BMD measurement converting for light into electrical impulses that is transmitted to the brain
○​ Dual-Energy Absorptiometry X Ray (DEXA) — provides information about bone where seeing actually occurs
mineral density and it is recommended for postmenopausal women more than 60 y/o
or has osteoporosis risk factors (where osteoporosis is diagnosed) The Process of Vision
○​ These can confirm the diagnosis of osteoporosis — ●​ process of vision starts with an object, light waves from an object enter the eye first
➔​ Low Serum Calcium through the CORNEA or the main refracting surface of the eye and the clear dome in
➔​ High Serum Phosphate front of the eye
➔​ Urine Calcium Excretion ●​ from the cornea, the light then progress through the PUPIL or the circular opening in
●​ MedicalManagement: the center of the colon iris or the blackhole within the iris that lets the light in the eye
○​ ↑Calcium and Vit. D — taken for life ●​ the light passess through the crystalline LENS
➔​ Female >50 years / aged 51 yrs old should take 1200 mg of Ca everyday ●​ initially, the light waves are bent or converged first by the CORNEA and then further by
➔​ Male should take 1000 mg of Ca everyday the CRYSTALLINE LENS to a nodal point so that is located immediately behind the back
○​ Dietary Modifications — prevent osteoporosis and the recommended calcium surface of the lens — and at that point the image becomes reversed (the object has
intake for turned backwards) and inverted (the object turned upside down)
●​ the light continues throughout the VITREOUS HUMOR or the clear gel that makes up
➔​ 3 glasses of skimmed Vit D — enriched milk
about 80% of the eyes volume — then ideally back to a clear focus on the retina behind
➔​ Foods high in Ca — cheese, dairy products, salmon, broccoli the vitreous
➔​ 1 cup of Ca fortified orange juice — has 300 mg of calcium ●​ Take Note: a small central area of the retina is the macula, which provides the best
○​ Regular Weight Bearing Exercise — to promote bone formation such as vision of any location in the retina and if the eye is considered to be a type of camera, the
stair-climbing, walking, dancing retina is equivalent to the film which is inside the camera and that film inside the camera
●​ Pharmacologic Therapy: is similar to the megapixel in digital camera as of today
○​ Ca & Vit. D Supplementation ●​ the retina’s function then is to register the tiny photons of light which interact with the
➔​ taken with meals and beverages high in vit. C to promote absorption retina
➔​ split-doses into 2, not taken in single dose ●​ Within the layers of the retina, light impulses registered are changed into electrical
➔​ abdominal distention and constipation as side effects signals
○​ Bisphosphonates (Alendronate Fosamax) — taken with calcium and Vit. d this ●​ electrical impulses are sent through the optic nerve along the visual pathway
inhibits osteoclast function nd taken in an empty stomach with full glass of water ●​ to the occipital cortex at the posterior or back of the brain
●​ Other Medical & Nursing Management: ●​ actually, we do not “see” with our eyes, but with our brains — our eyes are merely the
○​ Calcitonin — direct inhibits osteoclast beginning of the visual process
○​ Estrogen Agonist / antagonist (Raloxifene) —
➔​ formerly known as Selective Estrogen Receptor Modulator (SERMS) CATARACT
➔​ prevent bone marrow disease without estrogenic effect in the uterus and ●​ opacity or cloudiness of the lens
contraindicated to SERMS is history if thromboembolism ●​ leading cause of blindness in the world
○​ Teriparatide – stimulates osteoblast / bone formation ●​ can develop in one or both eyes at any age
●​ Nursing Management: ●​ 3 Types:
○​ Improve Bowel Elimination — prevent constipation ○​ Traumatic — clouding of the lens after a traumatic injury which disrupts the fibers of
the lens
➔​ high fiber
○​ Congenital — clouding of the lens occurs before birth this is caused probably by
➔​ increase fluid intake
genetic abrasions
➔​ stool prescribed softeners as
○​ Senile — age related
○​ Promote Physical Activity — prevent injury
➔​ Nuclear Cataract: central opacity
➔​ isometric exercises, walking, good body mechanics ➔​ Cortical Cataract: anterior, posterior, equatorial cortex of the lens opacity
➔​ kyphosis or dowager’s hump: gradual collapse of thoracic vertebrae wherein ➔​ Posterior Subcapsular: opacity in front of the posterior capsule, this is usual in
it results to outward curvature and it could lead to loss of height, pulmonary young people and for patients with prolonged use of corticosteroids and/or
insufficiency, risk for fall diagnosed with diabetes
➔​ avoid sudden bending, jarring, strenuous lifting to avoid damage to bone density
●​ Risk Factors:
○​ Aging — the most common risk factor
W16: EYE & VISION DISORDERS
➔​ accumulation of yellow brown pigment due to breakdown of lens protein, there is
●​ a sensitive, a highly specialized sense organ subject to various disorders and many of clumping and aggregation of the protein which leads to light scattering
the disorders can lead to impaired vision which can affect the overall quality of life, ➔​ decrease oxygen uptake
independence of patient self care, sense of self esteem and safety
➔​ decrease levels of vitamin C, protein and glutathione
●​ Eye Is protected by:
➔​ increase in sodium and calcium where in there is presence of calcifications
1.​ Bony Orbits and Pads of Fat surrounding the eye dorsally ➔​ loss of lens transparency
2.​ Eyelids and Eyelashes which close over the eyes
○​ Infection —such as herpes zoster
3.​ Lacrimal Apparatus / Glands which is important in lubricating and washing off the
○​ Retinal Detachment / Surgery
foreign particles

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 8

 ○​ Chemical / Toxic Factors — cigarette smoking, alkaline chemical eye burn, and ○​ Direct Mechanical Theory — this suggests that a high IOP damages the retinal
high doses of corticosteroids in long term layer as it passess through the optic nerve
○​ Nutrition – obesity and poor nutrition ○​ Indirect Ischemic Theory — this suggests that high IOP compresses the
○​ Physical Factors – blunt trauma, perforation of lens microcirculation in the optic nerve resulting in cell injury and death
○​ Systemic Diseases & Syndrome — Diabetes because high blood sugar can lead ●​ an intact drainage system and an open angle of 45 degrees between the iris and cornea
to structural changes in lens of the eye and Down Syndrome because common ang promotes unimpeded blood flow (if may changes in this angle it can contribute to the
abnormal lens increase IOP)
●​ Clinical Manifestations: ●​ Types:
○​ Hallmark Sign — painless, blurry vision 1.​ Wide Angle Glaucoma and
○​ light scattering is the behavior of light when it is absorbed by a medium followed by 2.​ Narrow Angle Glaucoma
subsequent radiation to a particular radiation ●​ Other Signs & Symptoms:
➔​ for example: is the sunrays that passess through the clouds ★​ silent thief of sight
○​ reduced contrast sensitivity which is the ability of the eye to identify clear outlines ★​ blurred vision
of a small objects ★​ halos around lights
○​ sensitivity to glare or the strong light ★​ difficulty focusing and adjusting eyes in low lighting
○​ reduced visual acuity or the ability of the person's eye to identify object at a given ★​ Hallmark Sign — loss of peripheral vision
distance ★​ discomfort around eyes
○​ myopic shifts, there is return of the ability to do close work or may increase na sa ★​ headache
degree ng nearsightedness so the patient can read fine prints again this happens ●​ Difference of Vision:
because of the significant changes in the nucleus of the lenses
○​ astigmatism this occurs because of the refractive error due to irregularity of the
curvature of the cornea where in the bending of light rays are abnormal once it
passess the object
○​ monocular diplopia or double vision
○​ brunescent cataracts where in the color of the lens become more brown in color
●​ Diagnostics:
○​ Take note that a decrease in visual acuity is directly proportional to cataract density
or the thickness
○​ Snellen Chart —to established the degree of cataract formation, to determine
distant visual acuity
○​ Ophthalmoscopy — used to examine the eyes and evaluate visual problems
○​ Slit Lamp Examination — evaluate the structure of the eye with the use of ●​ Assessment & Diagnostic Tests:
microscope that emits a bright light during examination ○​ patient ocular and medical history
●​ Medical Management: ○​ Tonometry used to measure the IOP
○​ Take note that there is no non surgical treatment that can cure cataracts ○​ Ophthalmoscopy to inspect the optic nerve
○​ Prevention — stop smoking, weight reduction, blood glucose control, wear ○​ Central Visual Field Testing to determine visual losses
sunglasses ●​ Medical Management:
●​ Surgical Management: indicated for function and visual impairment and if both eyes ○​ prevent optic nerve damage
have cataract, treat one eye first!! (and the second procedure should be delayed at least ○​ lifelong therapy
several weeks or months para mag provide ng time for the first eye to recover and ●​ Pharmacological Therapy: usually when treating glaucoma one eye is treated first, the
evaluate the first procedure) other eye is used as the control to determine the efficacy of the medication and once the
○​ Phacoemulsification — ECCE Extracapsular Cataract Surgery (a portion of the efficacy is established treatment of the other eye will be done
anterior capsule is removed allowing extraction of the lens, nucleus and cortex
○​ Beta Blockers such as Timolol and Betaxolol to decrease aqueous humor
leaving the posterior capsule intact, and then the surgeon makes small incision in the production
upper edge of the cornea and with that incision mag inject ang doktor ng viscoelastic
○​ Miotics such as Pilocarpine and Carbachol to increase aqueous humor production
substance into the space between the cornea and the lens that will facilitate the
insertion of the intraocular lens) ○​ Alpha Adrenergic Agonist such as Epinephrine to decrease aqueous humor
production
○​ Lens Replacement — we have 3 options
○​ Carbonic Anhydrase Inhibitors such as Acetazolamide and Dorzolamide to
➔​ Aphakic Glasses: rarely use and has several limitations
decrease aqueous humor production
➔​ Contact Lenses: needs to be removed occasionally putting the eyes at risk for
○​ Prostaglandin Analogues such as Latanoprost and Bimatoprost to increase
infection
uveoscleral outflow or the drainage of the ocular aqueous humor from the anterior
➔​ Intraocular Lens (IOL) Implants: the most common approach, and implanted after chamber into the anterior chamber angle
ECCE or phacoemulsification
●​ Management of Acute Angle Closure Glaucoma: emergency eye condition so meron
●​ Pre-Op Nursing Management: syang special management!
○​ standard of pre operative test such as CBC, ECG, UA ○​ Hyperosmotics to attract the excessive water
○​ hold anticoagulant ○​ Acetazolamide to decrease aqueous humor production
○​ to assess the severity of the cataracts we may anticipate the administration of ○​ Topical Ocular Hypotensive decreases pressure in eyes
dilating meds (mydriatics)
○​ Laser Iridotomy wherein surgical incision is made in the iris to release the blocked
○​ hold tamsulosin (alpha antagonist a medication for enlarged prostate) because it aqueous humor and reduce IOP
can interfere with pupil dilation and can cause intraoperative floppy iris syndrome,
○​ Pilocarpine Eye Drops (unaffected eye is also treated to avoid similar attacks)
which is characterized by meiosis where there is excessive constriction of the pupils
of the eyes and if constriction happens it may place difficulty in the part of the ●​ Surgical Management:
surgeon ○​ Laser Trabeculoplasty — trabecular meshwork (tissue in the anterior chamber of
○​ to prevent post op infection expect the administration of antibiotics, the eye which serves as drainage for most of the fluids that the eye drains)isopened
corticosteroids, and anti-inflammatory eye drops by application of laser beam to widen the canal of Schlemm(this canal drain aqueous
●​ Post-Op Nursing Management humor from the eyes into the systemic circulation)
○​ Eye Protection such as eye patch, sunglasses during the day, eye shield at night for ➔​ promoted outflow of aqueous humor and decrease the IOP
about first 24 hours after the surgery ➔​ indicated if the pharmacological therapy has not controlled the IOP
○​ Medications as prescribed such as acetaminophen, antibiotic, anti inflammatory ➔​ not indicated if trabecular meshwork cannot be visualized because of narrow
○​ Recognition of Complications — avoid lying on the affected side (prevent increase angles
intraocular pressure [IOP]) ➔​ a transient increase in IOP after 2 hours of surgery may occurs as a
○​ Activities to Avoid — lifting, pushinh, pulling objects heavier than 15 lbs because it complication
can lead to several complications such as increase IOP ○​ Laser Iridotomy — opening is made in the iris to remove the pupillary blockage
○​ Emergency Care / Abnormal Complication of Cataract Surgery — floaters in ➔​ indicated for pupillary block glaucoma
vision (moving dots), flashing lights, decrease in vision, pain, increase in redness ➔​ not indicated in patients with corneal edema because it can interfere with laser
(this manifestations indicate retinal detachment and they must inform the PCP as targeting and strength
soon as possible) ➔​ Complications: burns, transient elevated IOP, closure of iridotomy, blurring,
●​ Nursing Management | Care of Patients w/ IOL Implants: uveitis
○​ wear glasses or eye shields (eye patch) ○​ Filtering Procedures—creating an opening (fistula) in the trabecular meshwork
○​ hand washing prior touching the eyes ➔​ allows the aqueous humor to flow and exit by different route (such as tears)
○​ clean from inner to outer canthus ➔​ Take Note: bleb is the fluid collection outside of the eye
○​ Safety Precautions — be careful when climbing or descending stairs to prevent falls ➔​ Trabeculectomy: is a standard filtering technique,which includes removing part
or injury of the trabecular meshwork
➔​ Complication: uveitis, hemorrhage, extremely low or elevated IOP,
GLAUCOMA cataracts,bleb failure,bleb leak,endophthalmitis
●​ used to refer to a group of ocular conditions characterized by elevated IOP ○​ Drainage Implants or Shunts— implanting tubes in the anterior chamber
●​ if left untreated, the increase in IOP damages the optic nerve and nerve fiber layer (these toshuntaqueoushumorto the episcleral ate into the conjunctival space
nerve fiber layer has collection of visual impulses) and the optic nerve damage is caused ➔​ indicated when the trabeculectomy failed
by congestion in the aqueous humor in the eye (clear watery fluid in the eye, which ➔​ shunting lasts for 45 mins to 1 hour under general anesthesia and can heal in 2
provides nutrition in the lens and also maintains normal IOP) to 6 weeks
●​ no cure but the disease can be controlled
●​ Factors Affecting IOP: A. WIDE ANGLE GLAUCOMA
○​ rate of aqueous humor production (how much our body produces) ●​ usually bilateral, the anterior chamber angle is open and appears normal
○​ by the resistance met by aqueous humor when it flows in passageway or drainage, ●​ Types of Wide Angle Glaucoma:
○​ venous pressure of the episcleral veins ○​ Normal Tension Glaucoma
●​ Normal IOP: 10 to 21mmHg IOP less than or equal to 21 mmHg Optic nerve damage
●​ Other Factors that Increases IOP: Visual field defects
○​ blinking, tight lid squeezing, upward gazing or pag tirik ng eyes ○​ Ocular Hypertension
○​ diabetes, uveitis or inflammation of the eye, and retinal detachment elevated IOP headache
●​ Theories how an IOP can affect the optic nerve: possible ocular pain

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 9

 B. TRACTION RETINAL DETACHMENT
B. NARROW ANGLE GLAUCOMA ●​ tension or pulling force is the cause of retinal detachment
●​ a complete or partial closure of the angle which leads to obstruction of aqueous humor ●​ Predisposing Factors:
and increase IOP ○​ diabetic retinopathy
●​ Types of Narrow Angle Glaucoma: ○​ vitreous hemorrhage
○​ Acute Angle Closure Glaucoma (Pupillary Block) — rapidly progressive ○​ retinopathy of prematurity this happens in babies
periocular visual pain, impairment, conjunctival hyperemia and congestion, pain
associated with nausea, vomiting, bradycardia and profuse sweating, reduced C. COMBINATION OF RHEGMATOGENOUS & TRACTION RETINAL DETACHMENT
central visual acuity, elevated IOP, corneal edema, pupil is vertically oval and ●​ a result of production of serous fluid under the retina from the choroid
unreactive to light and accommodation
●​ Predisposing Factors: uveitis and macular degeneration
○​ Subacute Angle Closure Glaucoma
➔​ transient blurring of vision or temporary blurring of vision
AGE RELATED MACULAR DEGENERATION (AMD)
➔​ halos around lights
●​ characterized by tiny, yellow spots called “Drusen” the beneath the retina
➔​ temporal headache
➔​ ocular pain ○​ or the small clusters of debris or waste materials that lies deep within the retina
pigment epithelium and when drusen is located in the macula it can affect the vision
➔​ semi dilated pupil
●​ the most affected is the loss of central vision
○​ Chronic Angle Closure Glaucoma
●​ many patients retain peripheral vision
➔​ progression glaucomatous of cupping (may enlargement of the optic cup)
●​ Types:
➔​ significant visual field loss
1.​ Wet Type and
➔​ ocular pain and headache
2.​ Dry Type
➔​ normal or elevated IOP

What is AMD – Dry Type?

Optic Cup
●​ 85 to 90% with AMD has this type
●​ Central portion of the optic disc and should be small, however, in glaucoma this optic cup
enlarges ●​ considered to be the non neovascularization and non exudative type of AMD
●​ the change in size of the cup signifies loss of function, dies when blood flow is loss due to ●​ the outer layer of the retina slowly breaks down which results to the appearance of
the increase pressure in the eye drusen
●​ the role of the optic cup gives rise to many structure of the eye ●​ Medical Management: no known cure for dry AMD(non exudative)

What is AMD – Wet Type?

●​ considered to be the neovascularization and exudative type of AMD
●​ caused by choroidal neovascularization that can leak fluid and blood
●​ more abrupt onset, more damaging to the vision
●​ patient will report straight lines which appear crooked or letters appear broken

RETINAL DETACHMENT
●​ the most commonly layers implicated are sensory retina and retinal pigment epithelium
(RPE)
●​ this refers to the separation of the retinal pigment epithelium from sensory layer
●​ 4 Types: ●​ Medical Management:
1.​ Rhegmatogenous RD ○​ Vasogenic Endothelial Growth Factor (VEGF) is the angiogenic stimulus of vaso
2.​ Traction RD proliferation
3.​ Combination of Rhegmatogenous and Traction ○​ treatment targets the progression of angiogenesis
4.​ Exudative RD ○​ VEGF Inhibitors such as Ranibizumab and Broluvizumab — administered by
●​ Clinical Manifestations: intravitreal injection or sa mata
○​ curtain like vision ●​ Nursing Management:
○​ cobwebs ○​ monitoring the sudden onset or distortion of vision using the Amsler Grid
○​ bright flashing lights ➔​ given in patients to use in their homes
○​ sudden onset of great number of floaters ➔​ may provide the earliest sign that AMD is getting worse
○​ patient will complain no pain but take note that this is an ocular emergency ➔​ encourage patient to look at the grids one eye at a time, for several times each
●​ Assessment & Diagnostics: week and if may manonote na changes or distortion instruct them to contact
their PCP immediately
○​ Visual Acuity Test
○​ Dilated Fundus Examination using an Indirect Ophthalmoscope — the PCP
uses mitiotics to dilate the pupil to better evaluate the fundus of the eyes W17: EAR AND HEARING DISORDERS
○​ Slit Lamp Biomicroscopy — evaluate various structure and functions of the eye
○​ Stereo Fundus Photography — done by taking photographs of the said area in External Ear
different positions and it detects eye abnormalities such as glaucoma, cataract ●​ Auricle: collects sound waves and direct vibrations into the external auditory canal
formation or macular degeneration ○​ Auricle + pinna – structures that attached at the side of the head, composed mainly
○​ Fluorescein Angiography — it use and evaluate blood vessels in the eyes to of cartilages
evaluate the presence of effective blood flow ●​ External Auditory Canal: approximately 2 to 3 cm long and ends at the tympanic
○​ Optical Coherence Tomography and Ultrasound — both use for complete retinal membrane ○ it serves as the funnel of sound vibrations through the external auditory
assessment canal which causes the tympanic membrane to vibrate
●​ Surgical Management:
○​ Scleral Buckle — compression if a scleral buckle to indent the scleral wall from the Middle Ear
outside of the eye and bring the retinal layers in contact with each other ●​ an air filled cavity that is connected with nasopharynx by the eustachian tube (this tube is
normally close but it opens during yawning, swallowing and performing valsalva
maneuver)
●​ Tympanic Membrane: 1 cm in diameter, pearly, gray and translucent
○​ this protects middle ear and conduct sounds vibration from the external canal to the
ossicles
●​ Ossicles: composed of the 3 smallest bones in the body — malleus, incus, stapes
○​ assists in the transmission of sounds from the tympanic membrane into the inner ear

Internal Ear
●​ located within the temporal lobe
○​ Vitrectomy — dissects epiretinal membranes under visualization direct which may ●​ Parts Include: Cochlea, Semicircular Canals (both located in the bony labyrinth), CNVII,
be combined with scleral buckling to repair retinal detachments CN VIII
➔​ gas bubble, silicone oil, perfluorocarbon, and liquids may be injected into the ●​ Membranous Labyrinth:
vitreous cavity to help push the sensory retina up against the RPE ➔​ bathed in fluid called perilymph
○​ Pneumatic Retinopexy — for repair of rhegmatogenous RD and considered least ➔​ important in rotational movement
invasive ●​ Organ of Corti: the end organ for hearing
➔​ transforms mechanical energy into neural activity
A. RHEGMATOGENOUS RETINAL DETACHMENT
●​ most common form Anatomy & Physiology of Ear | Major Functions:
●​ hole or tear develops in the sensory retina which results in some of the liquids to seep ●​ Hearing – air conduction (more efficient pathway) and bone conduction
through and cause the detachment from the RPE ●​ Sound Conduction and Transmission – when sound enters the external auditory canal
●​ Predisposing Factors: it will cause the tympanic membrane to vibrate and those vibrations or mechanical energy
○​ high myopia or nearsightedness will travel into the ossicles and from the ossicles pupunta sya sa inner ears until it is
○​ aphakia after cataract surgery where in there is absence of natural lens interpreted into the temporal cortex of the brain
○​ trauma ●​ Balance and Equilibrium — the systems below sends information to the brain
○​ proliferative retinopathy where in diabetic neovascularization occurs or meron new ➔​ Musculoskeletal System: Proprioceptive
blood vessel formation ➔​ Eyes: Visual
➔​ Labyrinth: Vestibular

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 10

 ➔​ Vertigo troublesome the most complain where in the patient may also manifest
HEARING LOSS diaphoresis, a persistent feeling of imbalance and this equilibrium may awake
●​ a national survey of hearing loss in the Philippines was conducted last 2020 and it the patient at night
determines prevalence of moderate or worse hearing loss — ➔​ Sensorineural Hearing Loss involves damage in the cochlea
○​ prevalence of moderate or worse hearing loss in children below 18 yrs old is 7.5% vestibulocochlear and nerve and this is also associated with Tinnitus which is
○​ prevalence of moderate or worse hearing loss in adults between 18 and 65 yrs old is characterized by ringing, buzzing and hissing sounds
14.7% ○​ Other Signs — feeling of pressure or fullness in the ear accompanied with N&V
○​ prevalence of moderate or worse hearing loss in adults more than 65 yrs old is ●​ Assessment & Diagnostics:
49.1% ○​ History Taking — important to detect the frequency, severity, duration and character
○​ therefore, hearing loss can be associated with aging, +++ middle ear condition, of vertigo
socioeconomic status and wax occlusion ○​ Weber Test — results may reveal lateralization to the ear opposite to the hearing
●​ Genetic Syndrome Associated with Hearing Impairment: loss
➔​ Waardenburg Syndrome ○​ Audiogram — reveals a sensorineural hearing loss in the affected ear
➔​ Usher Syndrome ○​ Electronystagmogram — evaluate vertigo, this is done when pressure is introduced
➔​ Pendred Syndrome to the ear either air or water
➔​ Jervell & Lange-Nielsen Syndrome ➔​ findings may be normal or reduced vestibular response
●​ Hearing loss may be acquired: TORCH Infections – TOxoplasmosis, Rubella, ●​ Medical Management:
Cytomegalovirus and Herpes ○​ most patients can be successful treated with Diet — low sodium which is 1000 to
●​ occurs more often in men because of the lifestyle and environment 1500 mg or less per day
●​ Different Types: ○​ psychological cognitive evaluation therapy or may be beneficial if the patient is
○​ Conductive Hearing Loss — usually a result of ear disorder such as impacted anxious, uncertain, fearful or depressed
cerumen, otitis media or otosclerosis ●​ Pharmacologic Therapy:
○​ Sensorineural Hearing Loss — a result from damaged of cochlea or vestibular ○​ Diuretics — Hydrochlorothiazide, Triamterene, Spironolactone this can lower
nerve symptoms by decreasing pressure in the endolymphatic system
○​ Mixed Hearing Loss — may have a conductive and sensorineural hearing loss as a ○​ Meclizine — an antihistamine that can shorten the attacks of symptoms
result of dysfunction of air and bone conduction ○​ Diazepam—a tranquilizer that can help control vertigo
○​ Functional Hearing Loss or — unrelated to detectable structural changes in the ○​ Promethazine — to prevent emesis, N&V
hearing mechanism, and this is usually a manifestation of an emotional reaction ➔​ pwede toh through suppository administration
●​ Risk Factor: ○​ Gentamicin — this is used to cause ablation of vestibular hair cells
➔​ Noise is the most common ➔​ administered via tympanic injection
➔​ congenital malformations ➔​ ototoxic drug so WOF for significant hearing loss
➔​ family history ●​ Surgical Management: indicated if vertigo can cause reduction of quality of life where in
➔​ low birth weight of <1500 grams the symptoms are disabling
➔​ perforation of the tympanic membrane ○​ Endolymphatic Decompression or Shunting — this procedure equalizes the
➔​ recurrent infection pressure in the endolymphatic space
➔​ use of ototoxic medications such as Gentamicin and Loop Diuretics ➔​ first line of surgical approach to treat vertigo as favored by otolaryngologist
●​ Clinical Manifestations: ○​ Vestibular Nerve Suctioning — provides a greatest success rate in eliminating
○​ deafness that can be partial or complete attacks of vertigo which is approximately 98%
○​ Early Signs — tinnitus, increasing inability to hear when in a group, the need to turn ○​ Labyrinthectomy — done to remove the labyrinth to treat vertigo
up the volume of a tv or radio ●​ Nursing Management:
○​ changes in attitude, ability to communicate, awareness of the surroundings ○​ during acute episodes of vertigo, provide safe, quiet dimly lit environment and
○​ uninterested, inattentive student enforce complete bed rest
○​ pedestrian may not hear an approaching car ○​ to prevent the worsening of vertigo instruct client to make slow movements
○​ may miss conversations ○​ psychological assistance support and
○​ less interaction with others ○​ diet and lifestyle changes — such as salt and fluid restriction
●​ Medical & Nursing Management:
○​ Aural Rehabilitation — indicated if hearing loss is permanent or untreatable or if the
patient elects not to be treated, the purpose of this is to maximize the communication
skills of a patient with hearing loss
➔​ auditory training, speech reading, use of hearing aids, use of hearing guide dogs
○​ determines how the person prefers to communicate with others, do not always
assume kung ano yung best prefer technique nila
○​ devote full attention to what the person is saying
○​ do not try to appear as if you understand
○​ written communication is an excellent resource
○​ always face the person when speaking

CONDITIONS OF THE MIDDLE EAR

OTOSCLEROSIS
●​ a condition that involves the stapes
●​ formation of a new, abnormal spongy bone around the oval window (which is a
connective tissue between the middle and inner ear) which results in the fixation of
stapes
➔​ the fixation of the stapes prevents it to vibrate and carry the sound to the inner ear as
conducted by the malleus and incus kaya it will lead to decrease hearing
●​ more common in women
●​ a familial condition can progress to complete deafness
●​ Clinical Manifestations:
○​ may involve one or both ears
○​ progressive conductive or hearing loss
○​ may or may not complain of tinnitus
○​ and in Rhine testing, bone conduction is greater than air conduction
●​ Medical Management: hearing aid
●​ Surgical Management:
○​ Stapedectomy — removal of stapes structures and insertion of prosthesis
○​ Stapedotomy — instead of removing the stapes structures, the surgeon will drill a
small hole to hold the prosthesis
○​ Post Op — Sodium Fluoride may be anticipated to increase the success rate of the
procedure or the hearing ability post operatively

MENIERE'S DISEASE
●​ an abnormality in the inner ear fluid balance caused by malabsorption in the
endolymphatic sac or blockage in the endolymphatic duct
●​ more common in adults
●​ Onset: 40’s
●​ equally common in men and women and usually bilateral
●​ symptoms begins between 20 to 60 yrs of age
●​ Predisposing Factors:
○​ Endolymphatic Hydrops — where in the endolymphatic space dilates, the dilation
causes pressure in the inner ear increase
○​ Sodium Retention — if there is sodium retention, water retention will also occur
○​ Spasms of the Internal Auditory Artery – this spasms can increase pressure in the
inner ear and may lead to the symptoms of allergic reactions
○​ Stress – emotional reaction that can also be a predisposing factor
●​ Clinical Manifestations:
○​ Triad of Signs:

MDL & LBM | BSN 3-Y2-14​ ​ ​ ​ ​ ​ ​ ​ pg. 11