DEGENERATIVE DISORDERS

Syringomyelia & Syringobulbia

• Syringomyelia - abnormal fluid-filled cavity, called a syrinx, forms in the spinal cord causing pressure on the spine
• Syringobulbia - fluid-filled cavity now reaches the brainstem
• associated with Arnold-Chiara malformations (protrusion of the brainstem inward blocking CSF flow) and spina bifida
• Signs and Symptoms
• sensory deficits/defects
• dysphagia
• nystagmus
• ataxia
• impairment of pain and temperature sensations
• disturbed bladder control
• muscle wasting/weakness
• especially shoulder muscles
• cranial nerve palsies
• ptosis (drooping of eyelids)
• anhidrosis (lack of sweating)
• miosis (pupillary constriction)
• Nursing Diagnoses & Management
• Altered Thermoregulation r/t absence of sweating
• tepid sponge bath
• light clothing
• Risk for Injury r/t loss of pain & temperature sensation
• keep sharp objects away
• avoid floor wax
• check temperature of water before bath
• Activity Intolerance r/t shoulder muscle atrophy
• cluster activities
• ROM exercises
• assist with ADL's
• provide rest periods

Huntington's Disease

• discovered by George Huntington
• area affected: striatum of the basal ganglia
• onset: 30-40 years
• increased amount of glutamine and mutant Huntingtin (mHtt) causes damage to the brain
• results: decreased GABA & acetylcholine; increased dopamine (produces chorea)
• NO CURE
• Signs and Symptoms
• chorea (jerky, random, uncontrollable movements)
• athetosis (writhing movements of hands and feet)
• dementia (loss of cognitive ability for at least 6mos)
• emotional decline
• intellectual decline
• Nursing Diagnoses and Management
• Disturbed Thought Process r/t intellectual decline
• provide intellectual stimuli everyday; e.g. crossword puzzles, sudoku
• frequent reminders of things to do
• promote independence
• Impaired Communication r/t unintelligible words
• provide ample time for patient to talk
• do not hurry conversations
• Risk for Injury r/t uncontrollable movements
• assist in ambulation
• provide assistive devices
• wear sturdy shoes
• avoid slippery floors

Parkinsons's Disease / Paralysis Agitans

• discovered by James Parkinson
• area affected: substantia nigra of the basal ganglia
• onset: 30-60 years
• death of dopamine-producing cells in the brain
• results: decreased dopamine; increased acetylcholine
• NO CURE
• Signs and Symptoms
• PILL-ROLLING TREMORS
• BRADYKINESIA
• RIGIDITY
• POSTURAL INSTABILITY
• festinating gait (small steps in walking; difficulty in starting to walk and difficulty to stop)
• speech and swallowing disturbances
• Treatment
• LEVODOPA-CARBIDOPA (Sinermet) - drug of choice; supplies much needed dopamine
• dopamine agonists (bromocriptine [Parlodel], pergolide) - stimulates live dopaminergic cells to produce dopamine
• anticholinergics (ipratropium) - reduces levels of acetylcholine
• Nursing Diagnoses and Management
• Disturbed Thought Process r/t intellectual decline
• provide intellectual stimuli everyday; e.g. crossword puzzles, sudoku 
• frequent reminders of things to do
• promote independence
  
• Impaired Movement r/t joint rigidity
• Risk for Falls r/t postural instability
• perform ROM exercises
• assist in ambulation
• provide assistive devices
• wear sturdy shoes
• avoid slippery floors
• Risk for Aspiration r/t difficulty in chewing and swallowing
• allow ample time to chew
• eat in an upright position
• soft diet
• Impaired Communication r/t unintelligible words
• provide ample time for patient to talk
• do not hurry conversations

Alzheimer's Disease / Primary Degenerative Dementia

• discovered by Alois Alzhemier
• area affected: neurons of the cerebral cortex
• onset: 65 years and older
• caused by neurofibrillary tangles (aggregates of proteins supporting the microtubules; meaning, clumps of the proteins that help give shape to your cell) and neuritic/amyloid plaques (insoluble fibrous proteins) in the neurons of the brain
• results: decreased acetylcholine
• NO CURE
• Types
• familial - early onset, below 65 years, runs in the family
• sporadic - late onset, above 65 years, doesn't run in the family
• Signs and Symptoms
• AGNOSIA - loss of ability to recognize objects, persons, sounds, shapes, etc.
• AMNESIA - loss of memory
• APHASIA - inability to produce and/or comprehend language
• APRAXIA - loss of ability to carry out purposeful movements
• Stages
• Early / Mild
• increased self-centeredness
• forgetfulness
• difficulty learning
• confusion
• poor judgment
• irritable
• unable to do simple tasks
• Middle / Moderate
• wandering
• agitation
• disorientation
• physical impairment
• delusions
• depression
• impaired decision making
• Late / Severe
• immobility
• inability to recall names
• total dependence
• impaired motor and verbal skills
• bowel and bladder incontinence
• aspiration pneumonia
• Treatment
• acetylcholinesterase inhibitors (galantamine, rivastigmine [Exelon], donepezil) - reduces rate of breaking down acetylcholine
• Nursing Diagnoses and Management
• Disturbed Thought Process r/t intellectual decline
• provide intellectual stimuli everyday; e.g. crossword puzzles, sudoku 
• frequent reminders of things to do
• promote independence
  
• Risk for Injury r/t forgetfulness
• assist in ambulation
• provide assistive devices
• wear sturdy shoes
• avoid slippery floors
• provide identification
• always close doors
• cover electrical sockets, chemical containers, and other dangerous objects

Amyotrophic Lateral Sclerosis / Lou Gehrig's Disease / Charcot's Disease

• area affected: motor neurons of the anterior horn of the spinal cord
• onset: 40-60 years
• excess glutamate leads to cell injury and then cell death
• NO CURE
• Signs and Symptoms
• MUSCLE WASTING & WEAKNESS
• difficulty moving
• dysphagia - difficulty swallowing
• dysarthria - difficulty speaking
• spasticity - muscle spasms
• hyperreflexia - overexaggerated reflexes
• present Babinski's reflex - fanning of toes
• bowel and bladder incontinence
• ultimately, respiratory arrest due to weakening of diaphragm and intercostal muscles
• Treatment
• riluzole - reduces glutamate
  
• Nursing Diagnoses and Management
• Impaired Movement r/t muscle weakness
  
• Risk for Injury r/t difficulty in movement
  
• perform ROM exercises
  
• assist in ambulation
• provide assistive devices
• wear sturdy shoes
• avoid slippery floors
• Risk for Aspiration r/t difficulty in chewing and swallowing
• allow ample time to chew
• eat in an upright position
• soft diet

HELPFUL MNEMONICS

• Functions of Frontal Lobe = PIMS (thank you sir john teodoro)
• P - personality
• I - intelligence
• M - memory
• S - speech
• Errors of Refraction = My Cave is Far from Vex
• MYopia, conCAVE lens; FAR sightedness (hyperopia), conVEX lens
• Eye Accommodation = FaD Flat NeC Bulge
• FAr Vision -- ciliary muscle Dilates; lens FLATtens
• NEar Vision -- ciliary muscle Constricts; lens BULGEs
• Warning Signs of Cancer = CAUTION
• C - change in bowel/bladder patterns
• A - a sore that doesn't heal
• U - unexplained weight loss, anemia, bleeding
• T - thickening of lump
• I - indigestion
• O - obvious change in wart/mole
• N -  nagging cough
• Sickle Cell Anemia Management = HOP
• H - hydration
• O - oxygen
• P - pain medications
• Blood Transfusion Problems = HAPCATCH (thank you sir john teodoro)
• H - hemolytic reaction
• A - allergic reaction
• P - pyrogenic reaction
• C - citrate reaction
• A - air embolism
• T - thrombocytopenia
• C - circulatory overload
• H - hyperkalemia
• # of Bones and Muscles = #s 2, 0 6 (thank you sir john teodoro)
• # of Muscles - 620
• # of Bones (Child) - 260
• # of Bones (Adult) - 206
• Femoral Fracture = TENI - Trochanter Extracapsular, Neck Intracapsular
• CPR Priority = CAB - Compression, Airway, Breathing
• Celiac Disease Contraindications = BROW - Barley, Rye, Oat, Wheat
• Glaucoma = AICO - Acute Imbalance Chronic Obstruction
• Cellular Ions = PISO - Potassium Inside Sodium Outside (thank you jb abad)
• Heart Valves = LABRAT - Left Atrium Bicuspid, Right Atrium Tricuspid
• Levels of Consciousness = ACLOSC - Alert, Confused, Lethargic, Obtunded, Stuporous, Comatose
• Hypoglycemia & Hyperglycemia Skin
• Cold and clammy need some candy, Warm and dry sugar high
• PLANTar flexion occurs when you squash a PLANT
• SOUPination (supination) is holding the SOUP up with your palm; POURnation (pronation) is POURing the bowl of soup with your palm
• Stages of Grief = DABDA - Denial, Anger, Bargaining, Depression, Acceptance
• ADEK - four fat-soluble vitains
• Drugs contraindicated for G6PD Deficiency = AAA - Antibiotics, Antimalarials, Antipyretics
• Cardinal signs for tetralogy of fallot = DROP - ventricular septal Defect, Right ventricular hypertrophy, Overriding aorta, Pulmonary stenosis
• Cell Cycle Stages (for cancer drugs) = "Go Sally Go! Make Children!" G1 phase, SG2 phase, Mitosis, Cytokinesis phase,
• Hypersensitivity Reactions = ACID - Anaphylactic (Type I), Cytotoxic (Type II), Immune complex (Type III), Delayed (Type IV)
• Pain Assessment = OLDCART - Onset, Location, Duration, Characteristic, Aggravating factor, Relieving factor, Treatment
• CVS (Chorionic Villi Sampling) - "Chorionic" has 9 letters and is measured during 9th week
• Amniocentesis - measures alphafetoprotein - "alphafetoprotein" has 16 letters and is measures during the 16th week
• Blue Bloater Bronchitis; Pink Puffer emPhysema
• Congenital CYANOTIC Heart Diseases = 4 T's - Truncus arteriosus, Tricuspid atresia, Transposition of great arteries, Tetralogy of fallot
• Pediatric Milestones = 1234
• 1 year - 1 word said
• 2 years - 2 step commands
• 3 years - rides TRIcycle
• 4 years - draws SQUARE
• drugs ending with "olol" are Beta Blockers - stick "o" and "l" together to make an inverted "b", flip them together to get "bb" which stands for Beta Blockers
• Anti-TB drugs = RIPES - Rifampicin, Isoniazid, Pyrazinamide, Ethambutol, Streptomycin
• "You have 1 HEART and 2 LUNGS" - Beta 1 receptors affect the heart, Beta 2 affect the lungs
• "You have 1 NOSE and 2 EYES" - Cranial Nerve 1 Olfactory, Cranial Nerve 2 Optic
• Heart Conduction Pathway = "SAVe HIS KIN" - SA node, AV node, bundle of HIS, purKINje fibers
• Pituitary Hormones = FLAGTOP - FSH, LH, ADH, GH, TSH, Oxytocin, Prolactin
• Compartment Syndrome = 5 P's - Pain, Palor, Pulselessness, Paresthesia, Pressure
• Language Areas: language IN, letter "I", wernIcke's area; language OUT, letter "O", brOca's area

ANTENATAL COMPLICATIONS

Abortion

• Interruption of pregnancy before the age of VIABILITY (20 weeks)

Spontaneous Abortion

• Causes
• Abnormal fetal formation
• Low progesterone levels
• Implantation abnormalities
• Infection
• Teratogens
• Signs and Symptoms
• VAGINAL SPOTTING

Threatened Abortion

• Unexplained scant bright red vaginal bleeding
• No cervical dilatation
• Most common cause of 1st trimester bleeding
• Nursing Care
• Avoid strenuous activity
• No coitus for 2 weeks

Imminent/Inevitable Abortion

• Bleeding with cervical dilation and uterine contractions
• Treatment
• Save any tissue fragments discharged for later examination
• If no FHT is detected, D&C is performed to remove conceptus

Complete Abortion

• All of conceptus is expelled without any assistance; profuse bleeding which stops after a few days
• Treatment
• Go directly to hospital for assistance
• Fragments of conceptus may be checked to prevent further bleeding
• Oxytocin or methergine to stop bleeding

Incomplete Abortion

• Part of the conceptus is expelled, usually the fetus, and the placenta and membranes are left
• Treatment
• Dilatation and Curettage (D&C)
• Make sure the woman knows that the pregnancy is already lost

Missed Abortion

• The fetus dies but is not expelled
• Treatment
• Dilatation and Curettage (D&C)
• Make sure the woman knows that the pregnancy is already lost
• MISOPROSTOL (Cytotec) - to dilate cervix and stop bleeding

Habitual Abortion

• Also known as Recurrent Pregnancy Loss; 3 spontaneous miscarriages at roughly the same gestational age
• Causes
• Defective sperm or ova
• Endocrine disorders
• Uterine defects
• Infections
• Autoimmune disorders

Induced Abortion

• Artificial induction of abortion via mechanical or chemical means

Ectopic Pregnancy

• Implantation of the zygote outside the uterine cavity; most commonly on the ampullar region of the Fallopian tube
• Causes
• Salpingitis - may cause scarring of Fallopian tube and subsequent blockage
• PID
• Use of IUD
• Smokers
• Uterine tumors
• Signs and Symptoms
• Bleeding during 6-12 weeks
• SHARP STABBING PAIN
• CULLEN’S SIGN – bluish tinge on the umbilicus
• Falling hCG
• Shock
• Treatment
• Ligation of bleeding vessels
• Unilateral salpingectomy
• METHOTREXATE FOLLOWED BY LEUCOVORIN - to destroy remaining tissue
• Mifepristone - to induce labor

Abdominal Pregnancy (Ectopic)

• Growth of the fetus outside of the uterus
• Signs and Symptoms
• Fetal outline easily palpable directly below the abdominal wall and not inside the uterus

Hydatidiform Mole / Gestational Trophoblastic Disease

• the abnormal proliferation and degeneration of trophoblastic villi
• Most common cause of 2nd trimester bleeding
• Complete Mole - trophoblastic villi swell and become cystic, “empty ovum” was fertilized; usually lead to choriocarcinoma
• Partial Mole - some of the trophoblastic villi form normally but is swollen and misshapen, has 69 chromosomes; usually doesn’t lead to choriocarcinoma
• Causes
• Asians
• Low protein intake
• Older than 35 years of age
• Signs and Symptoms
• Elevated hCG
• High weight gain for gestational age
• No FHT
• Discharge of clear fluid filled vesicles
• Treatment
• No pregnancy for 12 months
• Let mother express concerns, feelings and emotions
• o METHOTREXATE FOLLOWED BY LEUCOVORIN - to destroy remaining tissue
• o Dactinomycin - alternative to methotrexate

Hyperemesis Gravidarum

• Projectile vomiting during pregnancy
• Causes
• Increased levels of hCG
• Treatment
• Monitor I&O
• TPN
• IV fluid replacement
• Soft diet
• Antiemetics – METOCLOPRAMIDE (Plasil, Reglan)

	Hyperemesis Gravidarum	Morning Sickness
Skin Color	yellow, jaundiced	normal
Duration	Exceeds 1st trimester	1st-2nd trimester
Skin Turgor	dehydrated	hydrated
Electrolytes	abnormal	normal

Incompetent Cervix

• Also known as Premature Cervical Dilation
• Signs and Symptoms
• Pink show
• Painless dilation
• Treatment
• CERVICAL CERCLAGE – MCDONALD (taped) & SHIRODKAR (sutured) TECHNIQUE
• Modified Trendelenburg position

Placenta Previa & Abruptio Placenta

• Types of Placenta Previa
• Low - placenta is in close proximity to the cervical os
• Partial - placenta covers a portion of the cervical os
• Total - placenta completely covers cervical os
• Degrees of Separation (Abruptio Placenta)
• 0 - no separation
• 1 - minimal separation, no fetal distress, vaginal bleeding
• 2 - moderate separation, fetal distress, uterus is tense and painful
• 3 - extreme separation, no immediate intervention, shock, death
• Treatment
• NO VAGINAL EXAMS
• Amniocentesis to assess fetal lung maturity
• BETAMETHASONE – to improve lecithin:sphingomyelin ratio of lung surfactants

	Abruptio Placenta	Placenta Previa
Skin Color	painful	painless
Blood Color	dark	bright red
Amount of Bleeding	profuse	scant
Palpation	board-like, rigid, tender	soft, boggy, not tender

 

Pregnancy-Induced Hypertension (PIH)

• Signs and Symptoms
• HYPERTENSION
• EDEMA
• PROTEINURIA
• Treatment
• Bed rest
• Nutritious Diet
• Care During Seizures
• Place pillow under head
• Raise side rails
• Side-lying position
• No sudden stimuli
• NPO
• MAINTAIN PATENT AIRWAY

Mild Preeclampsia (PIH)

• Signs and Symptoms
• BP 140/90
• Proteinuria +1 to +2
• Edema on face and upper extremities

Severe Preeclampsia (PIH)

• Signs and Symptoms
• BP 160/110
• Proteinuria +3 to +4
• Extreme edema on face and hands
• Hyperreflexia and ankle clonus

Eclampsia (PIH)

• Signs and Symptoms
• Seizures
• Signs and symptoms of preeclampsia
• Stages of Tonic-Clonic Seizures
• Tonus – muscles of the body contract and stiffen
• Clonus – muscles contract and relax repeatedly and limbs flail wildly
• Post-ictal state – in a semicomatose state
• Drug of Choice
• MAGNESIUM SULFATE

HELLP Syndrome

• Hemolysis, Elevated Liver enzymes, Low Platelet
• Signs and Symptoms
• Nausea
• Epigastric pain
• General malaise
• Right upper quadrant tenderness
• Thrombocytopenia
• Treatment
• Platelet transfusion
• IV Dextrose

Multiparity

• Signs and Symptoms
• Elevated alpha-fetoprotein
• Faster rate of increase in size of uterus
• Multiple FHT
• Nursing Care
• Bed rest
• Cesarean section upon delivery

Fetal Death

• No FHT
• MISOPROSTOL w/ OXYTOCIN - to induce labor and stop bleeding

Hydramnios

• Amniotic fluid more than 2000mL
• Normal amount: 500-1000mL
• Signs and Symptoms
• Unusual rapid enlargement of uterus
• Shortness of breath
• Weight gain
• Varicosities
• Tx
• Bed rest
• Stool softeners
• Amniocentesis

Post Term Pregnancy

• Exceeds 42 weeks of gestation
• Treatment
• Cesarean section
• Assessment of maturity
• Labor induction
• Treatment
• MISOPROSTOL - induces labor
• PROSTAGLANDIN E1 - induces labor
• Oxytocin - induces labor

Preterm Labor

• Labor before the 37th week of gestation
• Causes
• Chorioamnionitis
• Other infections
• Incompetent cervix
• Signs and Symptoms
• Early uterine contractions
• Rx
• Tocolytics - MAGNESIUM SULFATE - halts contractions
• BETAMETHASONE IM q24h 12mg - improves lung surfactant ratio
• DEXAMETHASONE IM q12h 6mg - improves lung surfactant ratio
• β-sympathomimetic drugs - TERBUTALINE & RITODRINE - halts contractions

TORCH Complex

• Toxoplasmosis, Other infections, Rubella, Cytomegalovirus, Herpes Simplex
• Vaccination, Antibiotics, and Cesarean Section

PROM (Premature Rupture of Membranes)

• Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks
• Signs and Symptoms
• Blue Nitrazine test result
• Sudden gush of clear fluid
• Treatment
• FIBRIN-BASED SEALANT - glues membranes
• AMNIOINFUSION - infusion of fluid into amniotic sac
• Bed rest - reduces fluid loss
• Antibiotics - prophylactic measure for infection

Rh Incompatibility

• Also known as Isoimmunization
• Develops when Rh- mother with Rh+ baby
• Baby may develop erythroblastosis fetalis - maternal antibodies destroy the Rh+ fetal RBC
• The destruction of red blood cells from erythroblastosis fetalis releases large amounts of unconjugated bilirubin leading to a condition known as kernicterus, wherein the unconjugated bilirubin is deposited in the brain and damages it
• Caused when the father is Rh+
• Appears as Coombs’ Test Negative
• Treated with RhoGam

DIC (Disseminated Intravascular Coagulation)

• Fibrinogen levels fall below effective limits
• Extreme bleeding at one site because most of the fibrin and platelets rush to another area; not enough is left for the rest of the body especially at the site of implantation
• Signs and Symptoms
• Easily bruised
• Treatment
• HEPARIN

ANTENATAL CARE

Presumptive Signs

• Amenorrhea – for 3 consecutive mos.
• Breast Changes – nipples larger and more pigmented; breast may be enlarged w/ more prominent veins; small elevations on the areola may appear (Montgomery’s Tubercles)
• Skin Pigmentation
• Melasma/Chloasma – brownish facial pigmentation
• Linea Nigra – dark vertical line on the abdomen below xiphoid process
• Striae Gravidarum – stretch marks that appear on abdomen, buttocks, thighs
• Nausea and Vomiting – “morning sickness”, 2-6 weeks after conception and may disappear at the end of the 1st trimester, caused by rising levels of hCG
• Fatigue
• Frequency of Urination – caused by pressure of the expanding uterus on the urinary bladder
• Enlargement of Abdomen – noticed around 12 weeks due to expanding uterus
• Quickening – sensations of fetal movement

 Probable Signs

• Hegar’s Sign – softening of lower uterine segment
• Chadwick’s Sign – bluish/purplish discoloration of the vagina
• Goodell’s Sign – softening of the cervix
• Braxton-Hicks Contractions – “false labor”, periodic uterine tightening
• Ballottement – sinking and rebounding of fetus in surrounding amniotic fluid in response to palpation
• Positive for hCG – during urine or blood test
• Sonographic Evidence of Gestational Sac - not totally positive; may be indicative of hydatidiform mole
• Fetal Outline Felt by Examiner

Positive Signs

• Fetal Heart Tones
• 18-20 weeks by fetoscope
• 10-12 weeks by Doppler stethoscope
• Fetal Movement Felt by Examiner
• Sonographic Evidence

 Psychologic Maternal Changes

• Ambivalence – mixed emotions, fear and excitement
• Emotional Liability – frequency of changes in emotional state, mood swings
• Body Image Changes – changes in woman’s perception of her body image, may be positive or negative
• Introversion and Passivity – needs to rest and do quiet things
• Primary Narcissism – causes woman to consider her own needs

Physiologic Maternal Changes

• Other than the presumptive, probable and positive signs, other changes include:
• Formation of OPERCULUM (vaginal plug near the cervix)
• Cessation of oogenesis
• Change in center of gravity
• Decreased bladder capacity and tone
• Hemorrhoids
• Ptyalism (excessive salivation)
• Gum tissue may swell and easily bleed
• Increased O2 requirements
• Supine Hypotension Syndrome
• Increased circulation

 Discomforts

• First Trimester
• N/V – dry crackers, avoid empty or full stomach, increase protein intake
• Frequent Urination – Kegel’s exercises
• Second Trimester
• Spider Nevi – avoid prolonged standing
• Leukorrhea – use sanitary pads
• Third Trimester
• Shortness of Breath – good posture and rest
• Braxton-Hicks Contractions – rest, breathing, ambulate
• Leg Cramps – ambulate
• Ankle Edema – elevate hips and legs
• Supine Hypotension Syndrome – side lying position during sleep

Care for a Pregnant Mother

• Increase Fe, Ca, Folic Acid intake
• Iron - increased O2 requirement and blood levels due to growing fetus
• Calcium - to avoid growing fetus from drawing calcium from mother's bones
• Folic Acid (Vit B9) - prevents neural tube defects
• Wear a support bra
• Nap/rest every AM/PM
• Medium to low heel shoes
• Avoid prolonged standing
• No constrictive clothing
• Wear cotton underwear
• Regular breast care
• Left side-lying position when lying down
• Regular exercise
• Dry crackers for N/V

Prenatal Check-Up Schedule

• Every 4 weeks for the 1^st-32^nd week
• Every 2 weeks for the 32^nd-36^th week
• Every week for the 36^th week up to delivery

Psychological Tasks of the Mother

• 1^st Trimester – accepting the pregnancy
• 2^nd Trimester – accepting the baby
• 3^rd Trimester – preparing for parenthood

Cervical Consistency

• Not pregnant – feels like the tip of nose
• Pregnant – feels like earlobes
• About to give birth – feels like butter