Valerie I. Leek - Patho Phlash! Pathophysiology Flash Cards-F.A. Davis Company (2011)

Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page i Patho Phlash! Pathophysiology Flash Cards Valerie I. Leek, MSN, RN, CMSRN F. A. DAVIS COMPANY • Philadelphia Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page ii F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2012 by F. A. Davis Company Copyright © 2012 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Senior Acquisitions Editor: Thomas A. Ciavarella Director of Content Development: Darlene D. Pedersen Senior Project Editor: Meghan Ziegler Design and Illustration Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-2493-X/12 0 + $.25. Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page iii Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page iv Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page v v Dedication To my husband, David, and my sons, Jeffrey and Zachary, thank you for your love and support. To my family and friends, thank you for giving me latitude when I seemed glued to my computer screen. To my granddaughter, Cadence, just keep growing healthy and strong. Nona loves you. In remembrance of my Uncle Tommy and my friends Reuel and Sharon. Acknowledgments Thank you to all my past and present students. It is such a privilege to teach. I learn something new every day by the interesting inquiries from all of you that stimulate my thinking! Thank you to all the wonderful people at F. A. Davis Company, including Tom, Meghan, and Julie. You have the gift of making hard work seem pleasant! Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page vi Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page vii vii Reviewers Joyce B. Ceresini, ADN, BSN Anatomy/Med-Surg Instructor Lebanon County Career & Technical School Lebanon, Pennsylvania Gary Gudlin RN, MSN, Ed. M Senior Program Manager PSU Outreach Pennsylvania State University Bethlehem, Pennsylvania JoEllen Kubik, RN, MA, LMSW Assistant Professor Allen College Waterloo, Iowa Andrea R. Mann, MSN, RN Instructor, Third Level Chair Frankford Hospital School of Nursing Philadelphia, Pennsylvania Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page viii viii Debra Morrison, RN, BScn, MN (c) Academic Coordinator: Practical Nursing Program Faculty: Practical Nursing, Critical Care E-learning, online Patho.Anatomy and Physiology Durham College Oshawa, Ontario Mary J. Sletten, DM(c)m MSN, RN Associate Professor Dona Ana Community College Las Cruces, New Mexico Janet C. Stradtman, MSN, RN, CCRN, CNE, CNS Assistant Director Firelands Regional Medical Center School of Nursing Sandusky, Ohio Debbie Tavernier MSN, RN, BSN, School Nurse Credential Associate Professor of Nursing California State University Stanislaus Turlock, California Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page ix ix Icons Gastrointestinal System Disorders Cardiovascular System Disorders Endocrine System Disorders Respiratory System Disorders Urologic System Disorders Sensory System Disorders Immune System Disorders Dermatologic System Disorders Musculoskeletal System Disorders Mental Health Disorders Nervous System Disorders Women’s Health and Perinatal Disorders Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page x Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page xi xi Abbreviations AAA ABG ABI ac ACE AChE AChR ACLS ACTH ADH ADHD ADLs AED AF AFB AGC AIDS ALL ALP ALS ALT AMI abdominal aortic aneurysm arterial blood gases ankle-brachial index before meals angiotensin-converting enzyme acetylcholinesterase acetylcholine receptor advanced cardiac life support adrenocorticotropic hormone antidiuretic hormone attention-deficit/hyperactivity disorder activities of daily living antiepileptic drug atrial fibrillation acid-fast bacillus atypical glandular cells acquired immunodeficiency syndrome acute lymphocytic leukemia alkaline phosphatase amyotrophic lateral sclerosis alanine aminotransferase acute myocardial infarction AML ANA ANP anti-CCP APAP aPTT ARDS AS ASA ASC ASCA ASC-US AST AV AVM AVP BBB BCG acute myelogenous (myeloblastic) leukemia antinuclear antibody atrial natriuretic peptide anticyclic citrullinated peptide acetaminophen activated partial thromboplastin acute respiratory distress syndrome aortic stenosis acetylsalicylic acid atypical squamous cells anti–Saccharomyces cerevisiae antibody ASC of undetermined significance aspartate aminotransferase atrioventricular arteriovenous malformation arginine vasopressin bundle branch block bacille Calmette-Guérin BCP BD BHS bid BMI BMS BMT BNP BP BPH bpm BRM BROW BSA BSE BUN BUN BX C&S CA Ca+ Ca++ CABG CAD birth control pills Buerger’s disease beta-hemolytic streptococci two times a day body mass index bone marrow suppression bone marrow transplant brain natriuretic peptide blood pressure benign prostatic hyperplasia beats per minute biologic response modifier barley, rye, oats, and wheat body surface area breast self-examination blood urea nitrogen blood urea nitrogen biopsy culture and sensitivity coronary artery serum calcium calcium cardiac artery bypass graft coronary artery disease Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page xii xii cap CBC CBI CBT CD4 CD8 CEA CFTR CHF CIN CK CK-MB CLL CML CNS CO COMT COPD COX-2 CPHSS capsule complete blood count continuous bladder irrigation cognitive behavioral therapy T-helper cells cytotoxic cells carcinoembryonic antigen cystic fibrosis transmembrane regulator congestive heart failure cervical intraepithelial neoplasia creatine kinase serum creatine kinase, myocardial bound chronic lymphocytic leukemia chronic myelogenous leukemia central nervous system cardiac output catechol-O-methyltransferase chronic obstructive pulmonary disease cyclooxygenase 2 inhibitors Cincinnati Prehospital Stroke Scale creatine phosphokinase continuous passive motion cardiopulmonary resuscitation CR controlled release CREST calcinosis, Raynaud’s phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia (cluster of features of systemic sclerosis scleroderma) CRP c. reactive protein CRS-R Conners Rating Scales–Revised CS cardiogenic shock CS cesaerean section CSF cerebrospinal fluid CSF colony-stimulating factor CT computerized tomography CV cardiovascular CVA cardiovascular accident CVC central venous catheter CVP central venous pressure CXR chest x-ray D5/0.9 5% dextrose and normal NaCl saline solution (0.9% NaCl) D5/1/2/NS 5% dextrose and half normal saline solution (0.45% NaCl) CPK CPM CPR 5% dextrose in water diastolic blood pressure dermatology dual-energy x-ray absorptiometry DFV Doppler flow velocimetry DHT dihydrotestosterone DI diabetes insipidus DIC disseminated intravascular coagulation DISIDA diisopropyl iminodiacetic (scan) acid (cholescintigraphy) DJD degenerative joint disease DKA diabetic ketoacidosis dL deciliter DMARD disease-modulating antirheumatic drug DNA deoxyribonucleic acid DRE digital rectal examination DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision DTR deep tendon reflexes DTs delirium tremens DVT deep vein thrombosis ECG electrocardiogram ECHO echocardiography D5W DBP Derm DEXA Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page xiii xiii ECMO ECT EEG EENT EF EGD ELISA EMA-IgA EMG EMS Endo EP EPS ER ERCP ESR ESRD ESWL ET-1 ETOH extracorporeal membrane oxygenation electroconvulsive therapy electroencephalogram eye, ear, nose, and throat ejection fraction esophagogastroduodenoscopy enzyme-linked immunosorbent assay immunoglobulin A antiendomysial electromyography emergency medical services endocrine extrapyramidal extrapyramidal symptoms extended-release endoscopic retrograde cholangiopancreatography erythrocyte sedimentation rate end-stage renal disease extracorporeal shock wave lithotripsy endothelin-1 ethal alcohol F and E FAP FBS FDA FFP FHT FISH G, g, gm GABA GABAB GABRB3 GB GERD GFR GGT GH GI GnRH GTT GU fluid and electrolyte familial adenomatous polyposis fasting blood sugar U.S. Food and Drug Administration fresh frozen plasma fetal heart tone fluorescence in situ hybridization gram gamma-aminobutyric acid gamma-aminobutyric acid type B GABAA receptor gene Guillain-Barré gastroesophageal reflux disease glomerular filtration rate gamma-glutamyl transferase growth hormone gastrointestinal gonadotropin-releasing hormone glucose tolerance test genitourinary GVHD H&H H1N1 H2 H5N1 HAART HAV HBV HCP Hct HCV HDL HDV HELLP HEPA HER2 HEV Hgb HGSIL graft-versus-host disease hematocrit and hemoglobin hemagglutinin type 1 and neuraminidase type 1 histamine 2 hemagglutinin type 5 and neuraminidase type 1 highly active antiretroviral therapy hepatitis A hepatitis B health-care professional hematocrit hepatitis C high-density lipoproteins hepatitis D hemolysis, elevated liver enzymes, low platelets high-efficiency particulate air human EGF (epidermal growth factor) receptor 2 hepatitis E hemoglobin high-grade squamous intraepithelial lesion Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page xiv xiv HIDA (scan) HIV HLA HOB HPV HR HRT HTN HSIL HSV I&O ICD ICP ICS IDM IgE IgG IL-1 IL-8 INR IOL IOP hepatobiliary iminodiacetic acid (cholescintigraphy) human immunodeficiency virus human leukocyte antigen head of bed human papillomavirus heart rate hormone replacement therapy hypertension high-grade squamous intraepithelial lesion herpes simplex virus intake and output implantable cardioverter defibrillator intracranial pressure intercostal space infants of diabetic mothers immunoglobulin E immunoglobulin G interleukin 1 interleukin 8 international normalized ratio intraocular lens intraocular pressure IVP JNC 7 K+ KOH KS KUB LDH LDL LEEP LFT LLQ LOC LP LR LSIL LVAD MAO-B MELD MG Mg+ MgSO4 intravenous pyelogram The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure potassium potassium hydroxide Karposi’s sarcoma kidney-ureter-bladder lactate dehydrogenase low-density lipoprotein loop electrosurgical excision procedure liver function tests left lower quadrant level of consciousness lumbar puncture lactated Ringer’s (solution) low-grade squamous intraepithelial lesion left ventricular assist device monoamine oxidase-B Model for End-Stage Liver Disease myasthenia gravis magnesium magnesium sulfate MI MM MRgFUS MRI NAA NG NGT NK NMDA NMJ NMS NPO NSAIDs O2 OCD OmpC ORIF OSHA OTC PA PABA myocardial infarction multiple myeloma MR-guided focused ultrasound surgery magnetic resonance imaging nucleic acid amplification nasogastric nasogastric tube natural killer N-methyl D-aspartate neuromuscular junction neuroleptic malignant syndrome nil per os (nothing by mouth) nonsteroidal antiinflammatory drugs oxygen obsessive-compulsive disorder outer membrane porin C open reduction with internal fixation Occupational Safety and Health Administration over-the-counter placenta abruption para-aminobenzoic acid Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page xv xv PaCO2 PAD P-ANCA PAO2 Pap PCOS PCR PD PD PDA PE PEEP PET PFT pH PIH PIPIDA (scan) PND PP partial pressure of carbon dioxide in alveolar gas peripheral arterial disease perinuclear antineutrophil cytoplasmic antibody alveolar oxygen partial pressure Papanicolaou polycystic ovarian syndrome polymerase chain reaction Parkinson’s disease peritoneal dialysis patent ductus arteriosus pulmonary embolism positive end-expiratory pressure positron emission tomography pulmonary function test potential of hydrogen pregnancy-induced hypertension 99mTc-para-isopropylacetanilido-iminodiacetic acid (cholescintigraphy) paroxysmal nocturnal dyspnea placenta previa PRBCs PSA PSV PT PUBS PUVA PVC PVR QFT-G R/O RA RAIU RBC RD RF RFT RLQ ROM RSV RUQ SA SAD SARS SBP packed red blood cells prostate-specific antigen peak systolic velocity prothrombin time percutaneous umbilical blood sampling psoralen ultraviolet A premature ventricular contraction peripheral vascular resistance QuantiFERON-TB Gold rule out rheumatoid arthritis radioactive iodine uptake red blood cell Raynaud’s disease rheumatoid factor renal function tests right lower quadrant range of motion respiratory syncytial virus right upper quadrant sinoatrial seasonal affective disorder severe acute respiratory syndrome systolic blood pressure SCI SDAT SERM SGA SIADH SJS SLE SNS SOB SPECT SPF SSRI STD T3 T4 T6 TB TEE TEN TENS spinal cord injury senile dementia of the Alzheimer type selective estrogen receptor modulator small-for-gestational-age syndrome of inappropriate diuretic hormone Stevens-Johnson syndrome systemic lupus erythematosus sympathetic nervous system shortness of breath single-photon emission computed tomography skin protection factor selective serotonin reuptake inhibitor sexually transmitted disease triiodothyronine tetraiodothyronine thoracic nerve pair 6 tuberculosis transesophageal echocardiogram toxic epidermal necrolysis transcutaneous electrical nerve stimulation Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page xvi xvi TG THR TKR TN TNF TNF-I TNF-α TNM TPN thyroglobulin total hip replacement total knee replacement trigeminal nerve tumor necrosis factor tumor necrosis factor inhibitors tumor necrosis factor alpha tumor-node-metastasis total parenteral nutrition TPO TRAP criteria TSH tTG TUMA thyroid peroxidase tremor, rigidity, akinesia or postural instability bradykinesia, and postural instability thyroid-stimulating hormone antitransglutaminase transurethral microwave antenna TURP UC US UTI UV V/Q VF VT WBC transurethral resection of the prostate ulcerative colitis ultrasound urinary tract infection ultraviolet ventilation/perfusion ventricular fibrillation ventricular tachycardia white blood cell Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page xvii xvii Introduction Students who study alterations in health states must learn to link assessment data, laboratory and diagnostic studies, medical and surgical treatment, possible complications, client teaching, and important findings in order to develop a comprehensive understanding of specific disease management. After many years of health instruction, watching learners attempt to synthesize and integrate client information, I noticed that the novice learner in health care had difficulty connecting all the pieces of the puzzle. It is for this reason that I developed Patho Phlash. These cards make the connection between all the aspects of disease management. Each card is a brief but comprehensive snapshot of an alteration in health. Pharmacological interventions are listed in drug classes, ideally used with Pharm Phlash Pharmacology Flash Cards. Using these cards gives the learner all of the important information necessary to adequately prepare for care of any client. Key memory aids are “Clue” boxes for selfassessment of knowledge and “Remember” or mnemonics to help identify important assessment or care information. Fifty NCLEX style questions formatted self-tests on the DavisPlus Web site are available for knowledge application by students and assignments by faculty. The cards include body system icons to remind the learner which system is affected, and a list of common abbreviations for easy reference. The front of each card has the name of the disorder with its phonetic spelling along Leek_FM_i-xviii.qxd 7/14/11 7:33 PM Page xviii xviii with a Clue box. On the back of each card you will find 1. Pathophysiology 2. Assessment and Diagnostic Findings 3. Complications 4. Medical and Surgical Treatment 5. Keep in Mind (includes information to be taught to the client) 6. Make the Connection, which is crucial information to remember about assessment and treatment for that disorder This learning system does not replace a comprehensive medical-surgical book or pharmacology text. It is a tool that integrates all aspects of medical and nursing inquiry and treatment of disease states. Students who utilize these cards with Pharm Phlash will have at their fingertips completely integrated information to deal with diseases. Best of all, the cards can be easily carried in their pocket! Best of luck to all! 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 1 GASTROINTESTINAL Celiac Disease, 1 Gastritis, 2 Gastroesophageal Reflux Disease, 3 Histal Hernia, 4 Peptic Ulcer Disease, 5 Gastric Cancer, 6 Obesity, 7 Hepatitis, 8 Abdominal Hernias, 9 Laënnec’s Cirrhosis, 10 Liver Cancer, 11 Esophageal Varices, 12 Pancreatitis, 13 Cholecystitis, 14 Pancreatic Cancer, 15 Bowel Obstruction, 16 Ulcerative Colitis, 17 Colon Cancer, 18 Diverticulosis, 19 Appendicitis, 20 Crohn’s Disease, 21 Peritonitis, 22 Hemorrhoids, 23 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 1 Gastrointestinal Disorders 1 Celiac Disease (se-le-ak di-zez) Clue: Diagnostic or Clinical Findings Bloating, diarrhea, rashes, anemia, malnutrition, and failure to thrive. + Hydrogen breath test. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 1 Gastrointestinal Disorders Pathophysiology • Malabsorption disorder caused by antibody • • response to gluten or gliadin proteins in barley, rye, oats (some), and wheat (BROW) affecting up to 1% of U.S. population. Damages small intestinal villi; prevents fat, iron, calcium, and B-vitamin absorption. Genetic link that is not well understood, but human leukocyte antigen (HLA), of which the cell surface receptor type protein human leukocyte antigen (HLA-DQ) is one, is found in family members with a high incidence of celiac disease; pediatric and adult clients affected. Assessment and Diagnostic Findings • Diarrhea, steatorrhea, cramps, hyperactive bowel sounds, dermatitis herpetiformis (rash). • Complete blood count (CBC) with differential, • vitamin and iron profile, and antibody tests (immunoglobulin A antiendomysial [EMA-IgA], IgA/IgG, antitransglutaminase antibodies [ATA]) elevation. Screening with endoscopic biopsy, hydrogen breath test, and DEXA scan. 1 Complications • Anemia due to B-vitamin and iron deficiency. • Osteoporosis and osteopenia (calcium malabsorption). • Hemorrhage (vitamin-K deficiency related to decreased B-vitamin activity in bowel). • Neuropathies and mental status changes (Remember: B vitamins are for Brain/Blood). • Bowel cancers and autoimmune organ destruction. Medical Care and Surgical Treatment • Antirheumatics and tumor necrosis factor inhibitors. • Monoclonal antibodies. • Corticosteroids and other immunosuppressants. Keep in Mind • Awareness of BROW-containing foods, food fillers, and pharmaceutical agents is important. Make the Connection • Monitor I&O, calories, and stools. • Assess for development of vesicular rash on knees, elbows, and buttocks. • Monitor for SOB, pallor, poor pulse oximetry (anemia), and bleeding tendencies (vitamin K). 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 2 Gastrointestinal Disorders 2 Gastritis (gas-tri-tis) Clue: Diagnostic or Clinical Findings Epigastric burning or discomfort associated with tobacco use, alcohol ingestion, stress, or NSAID use. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 2 Gastrointestinal Disorders Pathophysiology • Gastric mucus forms a physical and chemical • • barrier, protecting the epithelial cells lining the stomach and trapping bicarbonate between the mucus and the cells. Hydrogen production outpaces bicarbonate production during physiologic or psychological stress. Common gastric irritants include alcohol, stress, tobacco, caffeine, NSAIDs, Helicobacter pylori (H. pylori) bacteria, and shock. Assessment and Diagnostic Findings • Complaints of epigastric pain or burning, hyper• • acidity of the stomach, eructation, pressure, nausea and vomiting, or hematemesis in severe cases. CBC with differential to screen for pernicious anemia. Endoscopy with direct visualization of inflammation with biopsy urease testing, urea breath test, and IgG antibody test for H. pylori. Complications • Upper gastric bleeding, peptic ulcer disease with possible perforation and peritonitis. • Mental status changes and pernicious anemia are common with vitamin-B12 deficiencies 2 (Remember: B vitamins are for Brain/Blood), especially in the elderly. Medical Care and Surgical Treatment • Proton pump inhibitors, Pepto-Bismol, H2 blockers, and antibiotics. • Antacids, coating agents, prostaglandin-containing agents may be utilized. • PRBC cell infusion and vasopressin in cases of hemorrhage. • Perforation may require gastric reduction surgery. Keep in Mind • Avoid gastric mucosal irritants. • Avoid and channel psychological and physiologic stress. Make the Connection • Assess intake/use of gastric irritants. • Chemotherapy and radiation treatments over the stomach are atypical causes of severe gastritis. • Chronic use of over-the-counter medications for gastritis may lead to alteration in absorption of other medications and nutrients (↑pH). 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 3 Gastrointestinal Disorders 3 Gastroesophageal Reflux Disease (GERD) (gas-tro-e-sof-a-je-al re-fluks di-zez) Clue: Diagnostic or Clinical Findings Chest pain or severe burning occurring within an hour of eating. Discomfort is worse when lying down after meals and may occur during the night. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 3 Gastrointestinal Disorders Pathophysiology • Meals that are large, high-fat, spicy, or consumed • concurrently with alcohol cause relaxation of the lower esophageal sphincter, allowing hydrochloric acid and pepsin present in gastric contents to reflux, or pass back, into the esophagus. The esophagus is easily damaged by acidic gastric contents, resulting in inflammation, edema, and scarring over time. Assessment and Diagnostic Findings • Chest pain and burning within an hour of meals. • Endoscopy with biopsy and pH measurement. • Barium swallow. Complications • Scarring of the esophageal tissue that can cause • • narrowing of the esophagus and noncompliance of the lower esophageal sphincter. Chronic irritation of the esophagus may lead to Barrett’s esophagus (a dysplastic change of normal squamous cells to columnar epithelial cells in areas of irritation), and esophageal CA. Respiratory difficulties related to aspiration of acidic gastric contents; pain with respiration. 3 Medical Care and Surgical Treatment • Antacids, H2 blockers, proton pump inhibitors, • • coating agents, prostaglandins, antiemetics that increase emptying. Dilation of the esophagus if narrowing occurs. Nutritional and lifestyle changes. Keep in Mind • Avoid large, fatty meals; alcohol use; and tobacco use. • Clothing should be loose around the waist. • Sit upright for 2 hours after eating; don’t eat • within 3 hours of retiring; elevate the head of the bed (HOB) 6–8 inches using shock blocks. Consume liquids separately from meals to avoid stomach distention. Make the Connection • Assess lifestyle choices for clients with GERD and teach accordingly. • Rule out cardiac problems that mimic GERD. • Monitor for signs of chemical pneumonia and respiratory problems, especially in very young and very old or debilitated clients. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 4 Gastrointestinal Disorders 4 Hiatal Hernia (hi-a-tal her-ne-a) Clue: Diagnostic or Clinical Findings Burning, chest pain, heartburn, dysphagia, GERD, a feeling of fullness. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 4 Gastrointestinal Disorders Pathophysiology • A weakness in the hiatus of the diaphragm • coupled with intra-abdominal pressure forcing protrusion of the stomach and esophagus upward through the hiatus. Hiatal hernias include the “sliding” type and the “rolling” type. Assessment and Diagnostic Findings • • Discomfort increases when lying down and decreases when standing or sitting upright after meals. Endoscopy; barium swallow with x-ray, fluoroscopy, and swallowing studies can show the upward displacement of the stomach. Complications • Scarring and narrowing of the esophagus with noncompliance of the lower esophageal sphincter. • Chronic irritation of the esophagus may lead to Barrett’s esophagus and esophageal CA. • Respiratory difficulties related to aspiration of acidic gastric contents, pain with respiration. Medical Care and Surgical Treatment • Antacids, H2 blockers, proton pump inhibitors, coating agents, prostaglandins, antiemetics that increase gastric motility and emptying. 4 • Dilation of the esophagus if narrowing occurs. • Fundoplication, a surgical procedure in which the • fundus is wrapped around the lower esophagus, stabilizes the upper stomach, preventing herniation. Nutritional counseling. Keep in Mind • Clothing should be loose around the waist. • Sit upright for 2 hours after eating; don’t eat • • within 3 hours of retiring; elevate the head of the bed (HOB) 6–8 inches using shock blocks. Consume several small meals daily instead of three large meals. Consume liquids separately from meals to avoid stomach distention. Make the Connection • Rule out cardiac problems that mimic hiatal hernia symptoms. • Monitor for signs of chemical pneumonia and respiratory problems, especially in very young and very old or debilitated clients. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 5 Gastrointestinal Disorders 5 Peptic Ulcer Disease (pep-tik ul-ser di-zez) Clue: Diagnostic or Clinical Findings Gnawing, burning pain in either the midepigastric area 2–4 hours after meals or the left epigastric area with meals. Weight loss and presence of melena. Low H&H. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 5 Gastrointestinal Disorders Pathophysiology • Eighty percent of all peptic ulcer disease is caused • • • by Helicobacter pylori (H. pylori) infection that causes inflammation and erosion of the mucosal barrier in the stomach. Gastric mucus provides a physical and chemical barrier, protecting the epithelial cells lining the stomach and trapping bicarbonate between the mucus and the cells. Hydrogen production outpaces bicarbonate production during physiologic or psychological stress. Common gastric irritants or contributors to gastritis include alcohol, stress, tobacco, NSAIDs, H. pylori bacteria, and shock. Assessment and Diagnostic Findings • • • Duodenal ulcer: Midepigastric pain 2–4 hours after meals, relieved with food intake. Gastric ulcer: Left epigastric pain that increases with food intake, especially 1–2 hours after meals; hematemesis is more common than melena. Urea breath test, IgG antibody test for H. pylori, H. pylori culture, barium swallow with x-ray, EGD. 5 Complications • Bleeding, anemia, perforation with peritonitis or • • pancreatitis (severe back pain) or obstruction (pyloric scarring), upper gastrointestinal (GI) bleed. Gastric cancer (chronic irritation and regeneration of cells). Dumping syndrome after subtotal gastrectomy. Medical Care and Surgical Treatment • Antibiotics, proton pump inhibitors, H2 blockers, coating agents, antacids. • Vagotomy. • Subtotal gastrectomy. Keep in Mind • Avoid spicy foods, alcohol, tobacco, and caffeine; manage stress; eat small, frequent bland meals. Make the Connection • Monitor CBC for anemia. • Assess patterns of pain and weight loss. • Assess emesis for frank bleeding or coffee-ground appearance; test stools for melena. • In the acute stage, the client will be NPO. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 6 Gastrointestinal Disorders 6 Gastric Cancer (gas-trik kan-ser) Clue: Diagnostic or Clinical Findings Indigestion, anorexia, weight loss, nausea and vomiting, anemia, melena. Pain relieved by antacids. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 6 Gastrointestinal Disorders Pathophysiology • Epithelial cells undergo mutation related to • chronic irritation or exposure to carcinogens. Cells that are damaged must be replaced. The chance of a mutation occurring is proportional to the rate of new cell growth. Implicated causes are chronic or autoimmune gastritis; exposure to lead dust, grain dust, glycol ethers, or leaded gasoline; or a diet high in smoked fish or meats. Assessment and Diagnostic Findings • Indigestion that responds to antacids. • Anorexia and weight loss, nausea and vomiting, gastric distention. • Complete blood count (CBC) reveals anemia. Stool is positive for occult blood. • Barium swallow with x-ray, gastric fluid analysis for cytology, serum gastrin levels. • Positive diagnosis is made by gastroscopy and biopsy. Complications • Nutritional deficit. • Metastasis. • Bleeding, perforation, and peritonitis. • Death. 6 Medical Care and Surgical Treatment • Subtotal or total gastrectomy. • Dumping syndrome related to subtotal or total gastrectomy. • Chemotherapy and radiation, biological therapies. Keep in Mind • Manage stress. • Pain medication should be taken before the pain is severe. • Teach pre- and postoperative therapies (nasogastric [NG] tube will be in place after gastrectomy). • Teach the side effects of chemotherapy and radiation and how to mitigate them. Make the Connection • Monitor nutritional status with daily or • • • weekly weights and laboratory values like total protein, CBC, and blood chemistries. If client is on chemotherapy, monitor for hyperuricemia. Assess for excessive diarrhea or nausea, and cold sweats (dumping syndrome). Assist with psychosocial needs. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 7 Gastrointestinal Disorders 7 Obesity (o-be-si-te) Clue: Diagnostic or Clinical Findings BMI >30 kg/m2, degenerative joint disease, type 2 diabetes, total cholesterol >200 mg/dL. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 7 Gastrointestinal Disorders Pathophysiology • Behavioral, genetic, medication, or hormonal etiology. • Imbalance between food energy consumed and energy expended. Assessment and Diagnostic Findings • • Overweight is defined as a body mass index (BMI) of 25 to <30 kg/m2. Obesity is defined as a BMI of >30 kg/m2. Complications 7 • Bariatric surgery: • Roux-en-Y. • Gastric banding. Keep in Mind • Reduction of 500 kilocalories (kcal) per day results in weight loss of 1–2 lb/wk. • Walking for 30–60 minutes daily is the safest method of exercise. • Prevention of obesity is the goal. Eat a variety of colorful foods and exercise 35 minutes daily. • Degenerative joint disease (DJD). • Cardiovascular, renal, and neural damage related • • • • • to hypertriglyceridemia and hypercholesterolemia, resulting in atherosclerosis. Enlargement and infiltration of the liver with fat. Type 2 diabetes mellitus. Dumping syndrome related to bariatric surgery. Intertriginous skin breakdown. Dyspnea. Medical Care and Surgical Treatment • Total hip, knee, and ankle replacement. • Angioplasty or coronary bypass surgery. • Oral antidiabetic agents or insulin therapy. • Dialysis. Make the Connection • Monitor I&O carefully following bariatric • • • surgery. Once gastric leaking is ruled out, the client may begin taking 1–2 ounces of liquids per meal. Rupture of the gastric pouch after bariatric surgery may occur with excessive food intake. Behavioral interventions must be coupled with surgical intervention. Monitor cardiac and respiratory status when an approved diet and exercise regimen is prescribed. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 8 Gastrointestinal Disorders 8 Hepatitis (hep-a-ti-tis) Clue: Diagnostic or Clinical Findings Lethargy, malaise, headache, anorexia, low-grade fever, right upper quadrant pain, jaundice. Elevated ALT and AST levels. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 8 Gastrointestinal Disorders Pathophysiology • Inflammation of the liver caused by direct cellular • • • • injury and secondary injury by the immune response; those with a lesser immune response may become carriers rather than infected. Hepatitis A (HAV): Spread by the oral-fecal route. Hepatitis B (HBV; often coexistent with hepatitis D [HDV]): Spread by blood and body fluids. Hepatitis C (HCV): Spread by contact with contaminated blood, IV drug use, unprotected sex. Hepatitis E (HEV): Spread by contaminated water. Assessment and Diagnostic Findings • Preicteric phase: Weeks to months depending on • • type; characterized by malaise, lethargy, nausea, vomiting. Icteric phase: Characterized by jaundice, pale stools, dark tea-colored urine, and rashes. ↑ ALT and AST, ↑ bilirubin, presence of virusspecific antigen, prothrombin time >11.6 seconds, ↑ ESR, ↑ serum ammonia levels, abnormal hepatocytes revealed through liver biopsy. Complications • Acute or chronic liver failure and encephalopathy. • Hemorrhage; liver cancer. 8 Medical Care and Surgical Treatment • Avoid hepatotoxic medications like acetaminophen. • Bedrest; avoid injections to prevent hemorrhage. • Small, frequent meals that contain high calories, • high protein (titrate protein to ammonia levels), low sodium, and moderate fluid intake. Immunoglobulin therapy on exposure; hepatitis A and B vaccination for prevention. Keep in Mind • Teach client dietary regimen, to rest, and avoid hepatotoxic substances. • Report confusion, asterixis, abdominal distention, or edema of legs/feet. Make the Connection • Monitor ALT, AST, bilirubin, stool and urine color, mental status, and presence of ascites. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 9 Gastrointestinal Disorders 9 Abdominal Hernias (ab-dom-i-nal her-ne-a) Clue: Diagnostic or Clinical Findings Abdominal area that bulges out, especially when intra-abdominal pressure is ↑. Gentle pressure can cause reduction or popping back of the abdominal contents. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 9 Gastrointestinal Disorders Pathophysiology • A weakness in the abdominal wall allows the • • • • bowel or omentum, along with peritoneal tissue, to herniate outward. Weakened areas include the umbilical area, along the linea alba, incisional areas, and areas that have not completely closed after birth (the inguinal rings). Umbilical hernias are caused by incomplete closure of the umbilical orifice and commonly occur in children and obese clients. Ventral hernias are caused by weakness in the linea alba and are aggravated by obesity. Inguinal hernias are caused in both males and females by incomplete closure of the inguinal rings. Incisional hernias occur after underlying muscle is cut and scar tissue forms, weakening the area. Assessment and Diagnostic Findings • May be reducible. • Straining causes the hernia to protrude. • Inguinal hernias may cause a dragging feeling or occasional discomfort. • May be present in newborn males with hydrocele. • Diagnosed through physical examination, computerized tomography (CT) scan, magnetic 9 resonance imaging (MRI), or direct endoscopy. Complications • Incarcerated or strangulated hernia results in necrosis of the bowel or omentum, which is a surgical emergency. Medical Care and Surgical Treatment • Stool softeners or bulk laxatives to prevent straining at stool. • Herniorrhaphy or hernioplasty (open or closed surgical procedure). Keep in Mind • Postsurgical care includes avoidance of coughing or straining. • Males need to use ice packs and elevate the scrotum. • Avoid lifting, driving, and sexual activity as prescribed. Make the Connection • Assess ventral hernias for bowel sounds. • Assess for pain that may be a sign of strangulation. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 10 Gastrointestinal Disorders 10 Laënnec’s Cirrhosis (la-e-neks si-ro-sis) Clue: Diagnostic or Clinical Findings Chronic condition associated with alcohol consumption. Elevated ALT and AST, ascites, and edema in the lower extremities. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 10 Gastrointestinal Disorders Pathophysiology • Chronic heavy consumption of alcohol causes inflammation of the cells of the liver. • Fatty infiltration of the liver occurs related to • decrease in fatty acid oxidation and increase in gluconeogenesis. The liver enlarges first. The stellate cells to produce fibrous connective tissue and becomes resistant to blood flow from the portal vein; portal HTN and ascites result. Assessment and Diagnostic Findings • ↑ GGT and ALP, abnormalities in hepatocytes revealed by liver biopsy. • ↑ ALT, AST, and bilirubin levels. • Anorexia, nausea, vomiting, right upper quadrant • • • • discomfort, presence of ascites and lower extremity edema, enlarged liver, pruritus. Presence of alcohol withdrawal symptoms. Pale stools, dark tea-colored urine, jaundice. History of alcohol abuse; starburst hemorrhages under the skin. B-vitamin deficiency, (Remember: B vitamins are for Blood/Brain), as in wet beriberi. Complications • Chronic liver failure, encephalopathy, and death. 10 • Portal hypertension, ascites, edema. • Hepatorenal syndrome. • Hemorrhage, bleeding esophageal varices. Medical Care and Surgical Treatment • Nutritional assessment and dietary intervention: • Small, frequent high-calorie, low-sodium meals. • Protein is titrated according to the serum ammonia levels. • Lactulose for high ammonia levels; diuretics and/or albumin for ascites. • Alcohol cessation program. • Paracentesis to remove ascitic fluid if respiratory embarrassment occurs. • Transjugular intrahepatic portosystemic shunt. Keep in Mind • Teach client to avoid hepatotoxic substances. Make the Connection • MELD score indicates the likely survival of the client for 90 days (score ranges from 6 to 40). • Assess laboratory values, respiratory and mental status; assess. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 11 Gastrointestinal Disorders 11 Liver Cancer (liv-er kan-ser) Clue: Diagnostic or Clinical Findings Elevated ALT and AST, ascites, edema in the lower extremities, ↑ bilirubin. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 11 Gastrointestinal Disorders Pathophysiology • Chronic irritation of hepatocytes or surrounding parenchyma causes mutation of cells. • The liver is a common site of mastastasis. Assessment and Diagnostic Findings • ↑ ALT and AST, ↑ ALP and ↑ bilirubin level. • Anorexia, nausea, vomiting, right upper quadrant • • • discomfort, presence of ascites and lower extremity edema, enlarged liver, pruritus. Presence of alcohol withdrawal symptoms. Pale stools, dark tea-colored urine, jaundice. Liver biopsy is positive for carcinoma. Complications • Chronic liver failure, encephalopathy, and death. • Portal hypertension, ascites, edema. • Hepatorenal syndrome. • Hemorrhage; bleeding esophageal varices. Medical Care and Surgical Treatment • Chemotherapy, radiation, biologic therapies, and, rarely, liver transplantation. • Nutritional assessment and dietary intervention: • Small, frequent high-calorie, low-sodium meals. • Protein is titrated according to the serum ammonia levels. 11 • Lactulose for high ammonia levels; diuretics and/or albumin for ascites. • Alcohol cessation program. • Paracentesis to remove ascitic fluid, if respiratory embarrassment occurs. • Transjugular intrahepatic portosystemic shunt. Keep in Mind • Avoid hepatotoxic substances as much as possible. • Manage stress with counseling. • Teach the side effects of chemotherapy and radiation therapy. Make the Connection • Offer pain medication and antiemetics around the clock or by patient-controlled system. • Monitor laboratory values, respiratory ease, and signs of bleeding. • Intra-arterial chemotherapy is shown to be less toxic to the body. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 12 Gastrointestinal Disorders 12 Esophageal Varices (e-sof-a-je-al var-i-sez) Clue: Diagnostic or Clinical Findings Oral hemorrhage in the presence of portal hypertension. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 12 Gastrointestinal Disorders Pathophysiology • Dilation of the veins of the esophagus occurs related to portal hypertension from chronic liver disease. • The walls of the veins become thin and can spontaneously rupture and cause massive bleeding. • Ingestion of fibrous or fried foods can scratch and rupture the varices. Assessment and Diagnostic Findings • • Endoscopic examination for dilated areas of the esophagus. Portal hypertension (resistance to blood flow through the liver). 12 • Transfusion of packed red blood cells (PRBCs), • volume expanders (e.g., albumin), and fresh frozen plasma (FFP) for clotting factors (if necessary). Sclerotherapy done with an esophagogastroduodenoscopy (EGD). Keep in Mind • Avoid hard, fried, or fibrous foods if diagnosed with enlarged esophageal varices. • After sclerotherapy, chest pain may occur for 72 hours. Report worsening pain not responding to the prescribed analgesic. Complications • Hemorrhage. • Fluid and electrolyte imbalance. Make the Connection • Monitor the airway carefully when using Medical Care and Surgical Treatment • Infusion of vasopressin to stop the hemorrhage. • Tamponade (pressure) on the varices with a Sengstaken-Blakemore tube, which has three lumens. One drains the stomach contents, another inflates a balloon in the fundus of the stomach, and the last inflates a long balloon in the esophagus. The esophageal balloon pressure should be maintained between 20 and 25 mm Hg. • • • tamponade. Be ready to quickly deflate or cut the lumens of the esophageal balloon in cases of respiratory distress. Assess the complete blood count (CBC), blood pressure, and pulse for hypovolemia and anemia. Start venous access. Unrelieved pain after sclerotherapy could indicate esophageal perforation. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 13 Gastrointestinal Disorders 13 Pancreatitis (pan-kre-a-ti-tis) Clue: Diagnostic or Clinical Findings Severe midline abdominal pain that radiates to the flank, spine, and back, worsening with extension of the legs or ingestion of food. Elevated ALT and AST, amylase, lipase, and glucose. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 13 Gastrointestinal Disorders Pathophysiology • The outlet of the pancreas may become blocked • • due to inflammation, mechanically (gallstones), or by the digestive enzymes being prematurely activated while they are still in the pancreas. Protease causes dilation and permeability of the capillaries, allowing fluid to move from the pancreas to the retroperitoneal space. If fluid loss is severe, shock may occur. Protease initiates a chain reaction of inflammation that results in conversion of prothrombin to thrombin, causing DIC. Assessment and Diagnostic Findings • ↑ ALT and AST, amylase, lipase, ALP, bilirubin, LDH, potassium, and glucose. • CT scan and US to show infiltrates in the retroperitoneal and pleural spaces. • Pain in the abdomen with guarding. Pain is less• ened by drawing the knees up and worsened by extension. Low blood pressure and ↑ pulse indicate shock. Complications • Shock, respiratory distress. • Renal failure. 13 • Signs of hemorrhage: Turner’s sign (a purple discoloration in the flanks) and Cullen’s sign (a purple discoloration around the umbilicus). Medical Care and Surgical Treatment • IV infusion of fluids, volume expanders, and PRBCs. • Oxygen, IV analgesics (meperidine rather than • morphine to lessen spasm of the sphincter of Oddi), and antiemetics. NPO to avoid worsening autodigestion. Keep in Mind • Chronic alcohol ingestion is a causative factor in pancreatitis. • Cholelithiasis may cause mechanical obstruction. Make the Connection • Monitor pain level and medicate as needed. • Assess vital signs for ↑ pulse and ↓ blood pressure. • Monitor amylase and lipase levels and F and E levels. • Assess for Turner’s or Cullen’s sign. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 14 Gastrointestinal Disorders 14 Cholecystitis (ko-le-sis-ti-tis) Clue: Diagnostic or Clinical Findings Right upper quadrant pain that radiates to the right scapula. Murphy’s sign is present. ↑ Amylase and bilirubin. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 14 Gastrointestinal Disorders Pathophysiology • Presence of gallstones causes mechanical • • • obstruction of bile from the gallbladder. Stasis of bile attracts bacteria, which adds to the inflammation. Small gallstones enter the cystic duct and cause severe colicky pain as the duct’s peristaltic waves press on the stone. The gallbladder becomes fibrotic and does not release bile effectively into the duodenum. Pressure of gallstones on the gallbladder walls can cause necrosis. Assessment and Diagnostic Findings • Severe right upper quadrant (RUQ) pain (biliary • • • • colic) radiating to the right scapula, especially after a fatty meal, and lasting for 4–6 hours; nausea and vomiting. Murphy’s sign, in which the client is unable to take a deep breath when the examiner places pressure over the lower liver border. Low-grade temperature elevation, elevated WBC count. ↑ Serum amylase levels, ↑ bilirubin, jaundice. PIPIDA, DISIDA, or HIDA nuclear medicine scans. 14 • Ultrasound of the gallbladder. • Endoscopic retrograde cholangiopancreatography (ERCP) with contrast. Complications • Sepsis, gallbladder perforation, peritonitis. • Adenocarcinoma of the gallbladder. Medical Care and Surgical Treatment • Low-fat diet, meperidine for pain, antispasmodics, antiemetics, oral gallstone dissolution medications. • Laparoscopic or classic cholecystectomy. • Extracorporeal shock wave lithotripsy (ESWL). Keep in Mind • Avoid high-fat meals preoperatively. Postoperatively, reintroduce fats into the diet gradually. • A T tube may be inserted temporarily after cholecystectomy for drainage of bile if the cystic duct was explored. Make the Connection • Assess pain patterns and medicate as needed; assess for Murphy’s sign. • Monitor laboratory values and vital signs. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 15 Gastrointestinal Disorders 15 Pancreatic Cancer (pan-kre-at-ik kan-ser) Clue: Diagnostic or Clinical Findings Weight loss, anorexia; ↑ amylase, lipase, and bilirubin. ↑ vitamin D intake may be preventative. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 15 Gastrointestinal Disorders Pathophysiology • Mutation of cells in the pancreas occurs from genetic factors or chronic irritation. • Tumors are most commonly found in the head of the pancreas and are large. • Metastasis by direct extension to the stomach, gallbladder, liver, and duodenum occurs rapidly. • Tumors in the body of the pancreas metastasize rapidly via blood and lymph. Assessment and Diagnostic Findings • ↑ ALP, glucose, and bilirubin. • If the cancer causes obstruction, ↑ amylase and lipase levels are seen. • Needle biopsy guided by ultrasound revealing cancer cells. • ERCP. • CT scan and MRI. Complications • DVT and CVA are commonly associated with • pancreatic cancer. The tumor secretes substances similar to trypsin or protease that convert prothrombin to thrombin and increase clotting factors in the blood. Diabetes mellitus. 15 • • Postoperative infection, fistula formation, peritonitis, paralytic ileus, malabsorption disorder. Death: pancreatic cancer has a poor prognosis. Medical Care and Surgical Treatment • Total or partial pancreatectomy when the tumor is located in the head of the pancreas. • Whipple’s procedure, which involves removal of the head of the pancreas, the duodenum, and parts of the stomach. Chemotherapy and/or radiation. Keep in Mind • Manage pain and stress of illness. • Monitor glucose level; report bruising. • Take digestive enzymes as ordered. Make the Connection • Monitor pain level and medicate as needed. • Assess laboratory values, electrolytes, albumin, vital signs, weight and nutritional status. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 16 Gastrointestinal Disorders 16 Bowel Obstruction (bow-el ob-struk-shun) Clue: Diagnostic or Clinical Findings High-pitched bowel sounds, abdominal distention and pain. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 16 Gastrointestinal Disorders Pathophysiology • Mechanical obstruction occurs when a tumor or • • hard stool lodges in the intestine or when the bowel twists (volvulus) or telescopes within itself (intussusception). Pressure builds on the walls of the intestine, decreasing perfusion, which can lead to necrosis of the bowel. Adhesions from prior abdominal surgeries cause scar tissue causing mechanical obstruction. Paralytic obstruction results from a temporary cessation in nerve conduction. Assessment and Diagnostic Findings • Abdominal pain, thirst, and malaise. • Abdominal distention and visible loops of bowel. • Intractable vomiting, eventually of fecal material; no stools. • F and E imbalance (dehydration). • CT scan. • ↑ WBC and H&H. Complications • Necrosis and perforation of the bowel. • Peritonitis. 16 • Mental status changes or cardiovascular abnormalities related to electrolyte imbalance. Medical Care and Surgical Treatment • NPO. • Decompression with an NGT. • Bowel resection. • F and E replacement. • Antibiotics, antiemetics, and analgesics. Keep in Mind • The NGT is used until the obstruction is resolved (self-resolution or with surgery). • Report nausea immediately, because the NGT may be occluded. Make the Connection • Monitor all clients with past abdominal surgeries for signs of bowel obstruction. • Bowel sounds are more active and high pitched at the area of obstruction. • Assess vital signs, pain level, and laboratory values for infection; assess F and E status. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 17 Gastrointestinal Disorders 17 Ulcerative Colitis (ul-ser-a-tiv ko-li-tis) Clue: Diagnostic or Clinical Findings Daily passage of six or more bloody mucus stools associated with abdominal pain. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 17 Gastrointestinal Disorders Pathophysiology • Inflammation and hemorrhage in small areas of • • • • the mucosal layer of the colon cause abscesses to form (crypt abscesses). The necrotic areas slough off, causing ulcer formation that extends to the submucosal layer of the bowel. Blood in the colon causes hypertonicity of the bowel contents and acts as a laxative. Pseudopolyps (ragged edges of the mucosal layer). Incidence is greatest in the second, third, and sixth decades of life, a genetic link exists; probable autoimmune disease. Lesions begin in the rectum and spread proximally. Assessment and Diagnostic Findings • Weight loss, diarrhea with blood and mucus, cramping and abdominal pain. • F and E imbalance. • CBC, colonoscopy with bowel biopsy, presence of fissures, fistulas. • Arthritis, skin lesions, inflammatory eye disorders, altered liver function studies. • P-ANCA, ASCA, OmpC testing. Complications • Anemia. 17 • Bowel perforation, peritonitis, and CA. • Bowel cancer. Medical Care and Surgical Treatment • Antirheumatics, tumor necrosis factor (TNF) • • inhibitors, anti-inflammatory medications; corticosteroids and immunosuppressants; bulk laxatives (gel the stool, ↓ diarrhea). Partial bowel resection or colectomy. NPO during the acute phase; IV or TPN. Keep in Mind • Avoid spicy foods and high-residue foods. • Expect remissions and exacerbations; avoid stress. • Avoid persons with infections while on anti• inflammatories, antirheumatics, TNF inhibitors, or corticosteroids; teach care of ostomy. Support groups for ulcerative colitis are helpful. Make the Connection • Monitor number and characteristics of • stools; assess laboratory values for anemia and electrolyte imbalances. Assess vital signs and pain level frequently. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 18 Gastrointestinal Disorders 18 Colon Cancer (ko-lon kan-ser) Clue: Diagnostic or Clinical Findings Stool is positive for blood. A change in bowel habits has occurred. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 18 Gastrointestinal Disorders Pathophysiology • Mutation of epithelial cells of the colon from the chronic irritation of inflammatory bowel disease, familial adenomatous polyposis (FAP; early onset of polyps in the colon that become malignant), removal of the gallbladder, increased fat in the diet, and ingestion of carcinogens. 18 Medical Care and Surgical Treatment • Bowel resection with or without ostomy creation. • Chemotherapy and/or radiation. • Analgesics, antiemetics. Keep in Mind • Provide preoperative teaching concerning naso- Assessment and Diagnostic Findings • Change in bowel habits (constipation or diarrhea). • Change in shape of stool due to obstructing lesion. • Virtual colonoscopy by computed tomographic (CT) scan, colonoscopy with biopsy, barium enema revealing polyps or tumors; stool for occult blood is positive (polyps and tumors tend to bleed). Complications • Bleeding. • Obstruction, necrosis, bowel perforation with peritonitis. • Metastasis to the lymph system and liver, resulting in death. • After bowel resection, anastomotic leak, and peritonitis. • • gastric tube (NGT), deep breathing, incentive spirometer, exercise, use of antiemetics and analgesics, and early ambulation. Awareness of the side effects of chemotherapy and/or radiation and their mitigation is important. Support groups for colon cancer are helpful; teach ostomy care. Make the Connection • Monitor laboratory tests for elevated liver enzymes to detect metastasis. • Assess vital signs and pain level. • Teach ostomy care and assess ability of the client for self-care. • Assess complete blood count (CBC) for immuno- suppression related to chemotherapy or radiation. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 19 Gastrointestinal Disorders 19 Diverticulosis (di-ver-tik-u-lo-sis) Clue: Diagnostic or Clinical Findings History of constipation and poor bowel habits. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 19 Gastrointestinal Disorders Pathophysiology • Small herniations of the sigmoid and descending • • colon that occur when pressure within the bowel and abdomen is high. Related to poor bowel habits, constipation, and straining at stool. When diverticula become inflamed by seeds or other residue entering them, diverticulitis results. Assessment and Diagnostic Findings • Diverticulosis is asymptomatic. • Barium enema or computed tomographic (CT) • • scan shows multiple small pouches, usually on the sigmoid colon. Diverticulitis presents with pain in the left lower quadrant (LLQ); bleeding may be present and necessitate transfusion with packed red blood cells (PRBCs) or surgery (bowel resection). Stool for occult blood may be positive. Complications • Infection, colon perforation with peritonitis. Medical Care and Surgical Treatment • Diverticulosis: High-fiber diet; adequate fluid and exercise to encourage healthy bowel habits. 19 • Diverticulitis (acute phase): Nothing by mouth (NPO); rest the gut; intravenous fluids. • Diverticulitis (surgical intervention): Bowel resection. • Diverticulitis (convalescent phase): Increase to a soft, low-fiber, low-residue diet and avoid all foods with nondigestible seeds or shells; once healed, slowly resume normal diet, adding fiber. Keep in Mind • When the signal comes for a bowel movement, • • do not ignore it because doing so causes water loss from the stool and promotes constipation. Use bulk laxatives; eat raw vegetables and fruits, fiber-containing grain; increase fluid intake and exercise for healthy bowel habits. Do not strain at stool. Make the Connection • Assess for rebound tenderness at the LLQ if diverticulitis is suspected. • Monitor complete blood count (CBC); monitor stool for occult blood. • Teach proper dietary habits for the presenting condition. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 20 Gastrointestinal Disorders 20 Appendicitis (a-pen-di-si-tis) Clue: Diagnostic or Clinical Findings Rebound tenderness at McBurney point, ↑ WBC. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 20 Gastrointestinal Disorders Pathophysiology • Inflammation of the appendix by obstruction, usually by fecalith. The small stones may enter, causing more inflammation by exerting pressure and abrasiveness on the walls of the appendix. Assessment and Diagnostic Findings • • • • • Temperature elevation, ↑ white blood count (WBC). Guarding, limping on ambulation, rebound tenderness at McBurney point (midpoint between the umbilicus and the right iliac crest). Computed tomographic (CT) scan and ultrasound show enlargement of the appendix. Rectal examination reveals enlarged appendix. If appendix has ruptured, abdominal rigidity is evident; if appendix is abscessed, no bowel sounds are heard over the right lower quadrant (RLQ), and pain increases. Complications • Rupture and peritonitis. • Abscess. Medical Care and Surgical Treatment • Laparoscopic resection. • Drainage of abscess. • Antibiotics, analgesics. 20 Keep in Mind • A nasogastric tube (NGT) may be in place briefly • • • until bowel function returns to prevent nausea and vomiting; diet is increased once bowel function returns to normal. Pain medication should be taken only after diagnosis; no enemas should be used prior to coming to the emergency department. Take nothing by mouth (NPO). Lying in side-lying or semi-Fowler’s position will decrease pain. Make the Connection • Monitor complete blood count (CBC) for WBC elevation. • Assess pain patterns, including rebound tenderness at McBurney point. • Watch for any increase in pain and decreased bowel sounds in the RLQ. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 21 Gastrointestinal Disorders 21 Crohn’s Disease (kronz di-zez) Clue: Diagnostic or Clinical Findings Diarrhea, weight loss, cobblestone appearance in the small bowel. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 21 Gastrointestinal Disorders Pathophysiology • Inflammatory bowel disease affecting mostly • • • • • women from adolescence to the third decade of life. Cobblestone appearance of the bowel wall related to interspersed areas of inflammation and healthy tissue; also called regional enteritis. Inflammation occurs mainly in the small intestine above the cecum and spreads proximally. Affects the submucosa, causing strictures, scarring, fissures, and fistulas. Disease involves both genetic and autoimmune factors. Crohn’s disease affects the entire bowel wall. 21 Medical Care and Surgical Treatment • Antirheumatics and TNF inhibitors, • • corticosteroids, immunosuppressants, anti-inflammatories. Ileostomy or bowel resection. Surgery is not a cure; the enteritis will spread. Dietary intervention with folate, calcium, flaxseed, and fish oil. Keep in Mind • Avoid spicy foods and high-residue foods. • Expect remissions and exacerbations; avoid stress. • Avoid persons with infections. • Support groups for Crohn’s disease are helpful. Assessment and Diagnostic Findings • Cramps and diarrhea that occur with food intake. • Remissions and exacerbations. • F and E imbalance. • CBC, bowel biopsy, presence of fissures, fistulas. • P-ANCA, ASCA, OmpC testing. Complications • Anemia and malnutrition. • Fissures, fistulas, stricture/obstruction, bowel perforation with peritonitis. Make the Connection • Monitor I&O, calories, and characteristics and number of stools. • Assess laboratory values for anemia and inflammatory markers. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 22 Gastrointestinal Disorders 22 Peritonitis (per-i-ta-ni-tis) Clue: Diagnostic or Clinical Findings Rebound tenderness and rigidity over the abdominal wall. Decreased bowel sounds. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 22 Gastrointestinal Disorders Pathophysiology • Inflammation of the sterile peritoneal cavity by introduction of bacteria via invasive procedures, open bowel surgeries, or perforation of intraabdominal organs whose normal flora contain bacteria. Assessment and Diagnostic Findings • Generalized abdominal pain and rigidity. • If perforation is the cause, pain localizes to the area of the perforation and leak. • ↑ White blood count (WBC), temperature increase, tachycardia. • Absence of bowel sounds (peristalsis) over the affected area. Complications • Septicemia. • Hypovolemia with fluid shifts into the peritoneum. • Shock and death. Medical Care and Surgical Treatment • Nothing by mouth (NPO). • Exploratory surgery; abscess drainage and infiltration with antibiotic solution. 22 • Intravenous antibiotics, analgesics. • Organ repair if caused by a perforation; placement of a nasogastric tube (NGT) if bowel is perforated. Keep in Mind • Teach pre- and postoperative care and expecta• tions (early ambulation, deep breathing, leg exercises). Explain the illness and the use of antibiotic therapy. Make the Connection • Assess for return of bowel sounds. • Monitor CBC for normalization of WBC levels. • Assess function of all organ systems. • Support cardiorespiratory functions as needed. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 23 Gastrointestinal Disorders 23 Hemorrhoids (hem-o-roydz) Clue: Diagnostic or Clinical Findings History of constipation. Frank blood on the stool. Painful anal lesions. 2693_Tab01_Card_01-23.qxd 7/13/11 11:48 AM Page 23 Gastrointestinal Disorders Pathophysiology • Varicosities of the veins of the anus related to increased intra-abdominal pressure. • Occur during pregnancy as the weight of the • • fetus compresses the inferior vena cava, causing congestion of the veins in the anus (as well as the legs). Poor bowel habits and constipation contribute to the etiology. Internal hemorrhoids occur above the internal sphincter; external hemorrhoids occur below the external sphincter. Assessment and Diagnostic Findings • Frank red blood on stools. • External hemorrhoids are visible. When inflamed, they are large and red and usually encircle the anus. Careful examination should be done of these lesions to determine whether they are blue, light-colored, or black, which could indicate ischemia or necrosis of the overlying skin. Complications • Pain, bleeding, and infarction of the skin above the lesions. 23 Medical Care and Surgical Treatment • Prevent straining at stool and constipation. • Nutritional consultation. • Anti-inflammatory topical medication, analgesics. • Sitz baths, side-lying positions, ice packs. • Sclerotherapy. • Rubber-band ligation. • Laser, cryotherapy, or surgical removal. Keep in Mind • Avoid constipation by eating adequate fiber-rich foods; increase fluids and exercise. • Encourage good hygiene. Make the Connection • Monitor affected site for improvement. • Sitz baths can lower blood pressure and cause syncope, so monitor the client carefully. • Assess stools for bright red blood. • Assess hemorrhoids for color. • Postoperatively, monitor for bleeding, infection, and pain. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 2 ENDOCRINE Hyperpituitarism, 24 Hypopituitarism, 25 Diabetes Insipidus, 26 Syndrome of Inappropriate Antidiuretic Hormone, 27 Cushing’s Syndrome, 28 Addison’s Disease, 29 Hyperthyroidism, 30 Hypothyroidism, 31 Diabetes Mellitus Type 1, 32 Diabetes Mellitus Type 2, 33 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 24 Endocrine Disorders 24 Hyperpituitarism (hi-per-pi-tu-i-tar-ism) Clue: Diagnostic or Clinical Findings Excess growth hormone, abnormal lipid level, high blood glucose levels. Adults experience arthritis, visual changes, and enlarged hands and feet. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 24 Endocrine Disorders Pathophysiology • Hyperfunction of the pituitary is almost always caused by an adenoma. • GH, from the anterior pituitary, is secreted in • • • • • • large amounts, resulting in gigantism in children and acromegaly in the adult. Acromegaly is characterized by growth of bone, connective, and soft tissue. Hands and feet become enlarged; larynx enlarges; vertebral growth often results in kyphosis; teeth become displaced; enlargement and erosion of the sella turcica causes visual changes and headache. Metabolic alteration causes fats to become the initial energy burned, resulting in ketosis. GH–induced insulin resistance, along with glycogen release by the liver, causes DM. Other anterior pituitary hormones are inhibited. Fatty acid metabolism is altered causing atherosclerosis. Excess soft tissue of the soft palate cause sleep apnea. Assessment and Diagnostic Findings • ↑ GH, ↑ LDL. 24 • Enlarged feet and hands, deep voice, arthritis, insulin resistance, headache, sleep apnea. • CT scan and MRI to detect pituitary tumor. Complications • MI, CHF, DM. • Sleep apnea, dysphagia. • Arthritis, osteoporosis, and chronic bone pain. • Cancer from GH. Medical Care and Surgical Treatment • Dopamine agonists, GH inhibitors (somatostatin). • Radiation therapy or hypophysectomy. Keep in Mind • Monitor the glucose level, report excessive snoring, and report difficulty swallowing. Make the Connection • Remember: Following transsphenoidal hypophysectomy, assess all drainage for glucose, indicating CSF leak. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 25 Endocrine Disorders 25 Hypopituitarism (hi-po-pi-tu-i-ta-rizm) Clue: Diagnostic or Clinical Findings Short stature in children accompanied by weakness, low blood glucose, and delayed sexuality and stunted growth of sexual organs. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 25 Endocrine Disorders Pathophysiology • Growth hormone (somatropin) is deficient • • related to an ablative pituitary tumor or failure of the gland to develop. Dwarfism, in the child, and mental slowness. In adults, decreased GH leads to central accumulation of body fat and related problems with cardiovascular health. Assessment and Diagnostic Findings • Growth of a child well below the 25th percentile. • Developmental delay. • Weakness, hypoglycemia, “apple fat,” and skin changes in adults. • GH levels, GH stimulation test in response to induced hypoglycemia. • MRI and CT scan to detect presence of pituitary tumor. Complications • Cardiovascular disease in adults and untreated children. • Short stature, mental retardation. • Headache and visual changes in cases of pituitary tumor. 25 Medical Care and Surgical Treatment • Somatropin. • Hypophysectomy. • Hypoglycemia treated with dietary intervention. Keep in Mind • Report any bone pain or limping after starting somatropin therapy. • Growth is possible as long as the epiphyseal disks are not closed. • Adults should be under the care of a health professional if GH or secretagogues are used. Make the Connection • Monitor glucose levels, growth patterns, • sexual organ development, and thyroid function tests. Measure long-bone growth bilaterally; note any change in gait, which may be a sign of a slipped epiphyseal disk, in which growth is occurring only in one area of the disk. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 26 Endocrine Disorders 26 Diabetes Insipidus (di-a-be-tez in-si-pi-dus) Clue: Diagnostic or Clinical Findings Low specific gravity of urine <1.005. Urinary output in excess of 5–15 liters daily. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 26 Endocrine Disorders Pathophysiology • • • • ADH or AVP is secreted by the posterior pituitary gland and is responsible for reabsorption of water by the kidney. DI is caused by a deficiency of ADH and excess loss of water through urination. Urinary output can be in excess of 5–15 L daily. DI can be caused by drugs like lithium; surgical removal of the pituitary; and nephrogenic DI. Psychogenic DI (not true DI) is caused by a desire to drink large amounts of fluids (water intoxication); alcohol ingestion causes a temporary DI resulting in dehydration. Assessment and Diagnostic Findings • • • • • • Polyuria, nocturia, excessive thirst, poor skin turgor. Hypovolemia, dehydration, and electrolyte imbalance. Specific gravity of urine of <1.005; ↓ urine osmolality. ↓ ADH levels following administration of hypertonic saline solution or fluid restriction (should ↑). Water deprivation test. CT scan and MRI to detect presence of a pituitary tumor. 26 Complications • Hypovolemic shock. • Electrolyte imbalances. • Enlarged bladder. Medical Care and Surgical Treatment • Hypophysectomy in presence of pituitary tumor. • Replacement of ADH. • Hypotonic fluid replacement (0.45% sodium chloride solution). • Sulfonylureas that increase sensitivity to ADH and thiazide diuretics (slow urine output in the absence of ADH). Keep in Mind • Monitor daily weight (report an increase of • • greater than 2 lb in 1 day), and keep a diary of intake and output (I&O) after start of therapy. Take extra fluids if thirst occurs. Comply with medication regimen. Make the Connection • Monitor vital signs, I&O, urine specific gravity, and serum electrolytes. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 27 Endocrine Disorders 27 Syndrome of Inappropriate Antidiuretic Hormone (sin-drom uv in-a-pro-pree-et an-ti-di-u-ret-ik hor-mon) Clue: Diagnostic or Clinical Findings High blood pressure, low serum osmolality, bounding pulse, seizures. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 27 Endocrine Disorders Pathophysiology • SIADH occurs when ADH does not decrease in • • response to a low serum osmolality, leading to fluid overload. Frequently, SIADH is associated with cancers of the lung, pancreas, and Hodgkin’s disease. ADH may hypersecrete in the presence of head trauma or tumor or as a complication of diabetes insipidus treatment. Assessment and Diagnostic Findings • Weight gain, bounding pulse, increased blood pressure, crackles. • Dilutional hyponatremia with signs and symp• • • • toms of headache, personality changes, nausea, diarrhea, seizure, and coma (cerebral edema). Serum osmolality <275 mOsm/kg; serum ADH ↑. Lethargy, muscle cramps and weakness. History of cancer, especially oat cell cancer of the lung. Water load test. Complications • Mental status changes, weakness, lethargy, muscle cramps related to dilution of electrolytes. 27 • Seizures, coma, cerebral and pulmonary edema, and death. Medical Care and Surgical Treatment • Oral salt, hypertonic solutions, loop diuretics, and fluid restriction (1,000 mL/24 hr). • Demeclocycline. • Treatment of underlying cancer. Keep in Mind • Monitor fluid restriction adherence, monitor daily weight (report gain of >2 lb/24 hr), encourage fluids high in sodium (ice chips may satisfy thirst without adding to fluid intake), maintain diary of I&O. Make the Connection • Monitor for change in mental status • • • (Glasgow Coma Scale may be used in severe cases). Monitor serum osmolality, urine output, daily weight, and urine specific gravity. Monitor serum electrolytes (135–145 mEq/L). Auscultate lungs for crackles or diminished breath sounds in the bases. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 28 Endocrine Disorders 28 Cushing’s Syndrome (koosh-ingz sin-drom) Clue: Diagnostic or Clinical Findings Moon face, buffalo hump, truncal obesity, ↑ serum glucose, ↓ potassium (K+), ↑ serum sodium. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 28 Endocrine Disorders Pathophysiology • Hormones secreted by the adrenal cortex are • • the body’s stress hormones (glucocorticoids and mineral corticoids). Cushing’s disease is caused by excess cortisol secretion related to excess ACTH secretion, while Cushing’s “syndrome” is related to consumption of exogenous cortisol. May be caused by secreting tumor of the lungs or adrenal glands. Assessment and Diagnostic Findings • Weight gain, moon face, buffalo hump, truncal • • obesity, osteoporosis, glucose intolerance and secondary diabetes, slow wound healing, striae, bruising, bone marrow suppression and hyperpigmentation of the skin. ↑ Serum sodium and ↓ serum potassium. Plasma and urine cortisol and plasma ACTH are elevated. Complications • Masked infection, WBC activity, ↓ platelets. • Cardiac arrhythmias; atherosclerosis. • Pathologic bone fracture. • Diabetes mellitus. 28 Medical Care and Surgical Treatment • Hypophysectomy or adrenalectomy if indicated. • Treatment for secondary diabetes and insulin resistance. • Exogenous cortisol dosage change or given every other day. Keep in Mind • Teach client to monitor blood glucose; modify • dietary intake to low calorie, high protein, high K+, and low Na+. Report any signs of infection (e.g., sore throat). Make the Connection • Monitor cardiac rhythm strip, serum potassium, and serum sodium. • Monitor daily weights and I&O; administer potassium supplements, if ordered. • Encourage weight-bearing exercise. • Monitor CBC and for any signs of infection. • Monitor wound healing. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 29 Endocrine Disorders 29 Addison’s Disease (ad-i-sonz di-zez) Clue: Diagnostic or Clinical Findings Tanned appearance to skin, low blood pressure, ↓ serum glucose, ↓ serum sodium (Na+), ↑ serum potassium (K+). 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 29 Endocrine Disorders Pathophysiology • The adrenal cortex secretes hormones necessary • • • to react to stress (physical or psychological). They include glucocorticoids, aldosterone, and sex hormones (sugar, salt, and sex). In primary hypofunction of the adrenal gland, the adrenal hormones are not secreted in adequate amounts; in secondary hypofunction of the adrenal glands, insufficient pituitary secretion of ACTH occurs. Primary Addison’s disease may be autoimmune. Adrenalectomy may cause Addison’s. Assessment and Diagnostic Findings of the skin, ↓ BP, ↓ serum • Hyperpigmentation Na+, ↑ K+, ↓ serum glucose levels. • Anorexia, weight loss, confusion, psychosis. • Low urine sodium and cortisol levels; ↑ pituitary output of serum ACTH (primary); ↑ blood urea nitrogen (BUN) related to dehydration. Complications • Inability to respond to stress; Addisonian crisis. • Arrhythmias. • Coma and death from hypoglycemia. 29 Medical Care and Surgical Treatment • Replacement of corticosteroids and aldosterone given daily in divided doses in times of stress. Keep in Mind rest • Teach compliance with medication regimen; + • • as needed; and high-calorie, moderate-Na , and ↓K+ diet. Client must learn to assess his or her BP. Wear a MedicAlert bracelet. Make the Connection •+ Monitor BP, blood glucose, serum Na+, and K levels; weight, Addisonian crisis. • Monitor cardiac rhythm strip data. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 30 Endocrine Disorders 30 Hyperthyroidism (hi-per-thi-royd-izm) Clue: Diagnostic or Clinical Findings Restlessness, irritability, heat intolerance, ↓ TSH, ↑ T3 and T4. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 30 Endocrine Disorders 30 Pathophysiology • The thyroid gland hormones are responsible for • • • • carbohydrate, protein, and fat metabolism required by the body cells and for calcium regulation (in tandem with the parathyroid glands). Primary hyperthyroidism (Graves’ disease) is caused by excess thyroid hormone secretion (T3 and T4). Secondary hyperthyroidism is caused by hypersecretion of thyroid-stimulating hormone (TSH) by the pituitary gland. A thyroid tumor may also cause hypersecretion of thyroid hormones or TSH. Exposure to radiation is another causative factor. Assessment and Diagnostic Findings • • • pressure, restlessness, decreased mental acuity, and delirium. Goiter (enlargement of the thyroid gland). Hypothyroidism after treatment. Visual changes related to exophthalmos. Medical Care and Surgical Treatment • Subtotal thyroidectomy. • Radioactive iodine treatment. • Thyroid-suppressing medications. Keep in Mind • Report temperature increase, increased blood pressure, or change in mental status; manage stress, maintain nutritional status, and take rest breaks. • Weight loss despite increased appetite, heat intol• • • erance, irritability, nervousness, tremor, tachycardia, palpitations, inability to sit still or rest. ↓ Serum TSH, ↑ serum T3 and T4. Thickening of the skin on the anterior legs. Exophthalmos. Complications • Thyrotoxic crisis (thyroid storm) characterized by very high temperature, tachycardia, high blood Make the Connection • Monitor vital signs, serum TSH, and cardiac rhythm strip data. • Assess for nodules palpated on the thyroid. • In the case of radioactive iodine treatment, remind the client he or she will have to be in isolation. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 31 Endocrine Disorders 31 Hypothyroidism (hi-po-thi-royd-izm) Clue: Diagnostic or Clinical Findings Lethargy, mental slowness, heavy menstrual periods in women, ↑ TSH, ↓ T3 and T4. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 31 Endocrine Disorders Pathophysiology • The thyroid gland is responsible for metabolism • • • • of carbohydrates, fats, and protein according to body requirements. Primary hypothyroidism (myxedema) occurs when the thyroid gland does not secrete adequate thyroid hormone. Secondary hypothyroidism is related to hyposecretion of thyroid-stimulating hormone (TSH) by the pituitary gland or overtreatment of hyperthyroidism. Low levels of thyroid hormone decrease metabolism in the body. Hashimoto’s thyroiditis is an autoimmune disorder that destroys thyroid tissue. Assessment and Diagnostic Findings • Fatigue; weight gain; lethargy; mental slowness; • bradycardia and heart failure; dry skin; coarse, dry hair; feeling cold all the time; menorrhagia in women; shortness of breath; decreased sweating. ↑ TSH and ↓ T3 and T4 in primary disease. Complications • Myxedema coma triggered by physical or psychological stress and resulting in subnormal 31 temperature, decreased respiration, decreased cardiac output, renal failure, nonpitting edema of extremities, death from respiratory failure. Medical Care and Surgical Treatment • Synthetic thyroid hormone replacement therapy. Keep in Mind • Teach that full effects of the hormone replacement may take from days to a week. • Report palpitations or shortness of breath after hormone replacement therapy. Make the Connection • Monitor TSH level. • Assess cardiac rhythm strip data when beginning synthetic hormone replacement. • Teach client to report signs and symptoms of hyperthyroidism or myxedema. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 32 Endocrine Disorders 32 Diabetes Mellitus Type 1 (di-a-be-tez mel-i-tus type 1) Clue: Diagnostic or Clinical Findings Polyuria, polydipsia, polyphagia, ↑ serum glucose levels that persist. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 32 Endocrine Disorders Pathophysiology • The pancreas secretes insulin from the beta cells • • (islets of Langerhans) in response to elevated blood glucose levels. In primary diabetes mellitus type 1, the beta cells are destroyed by an autoimmune reaction. In secondary diabetes mellitus type 1, the beta cells are damaged by cancer of the pancreas or other diseases like pancreatitis and cystic fibrosis. Assessment and Diagnostic Findings • Elevated fasting blood glucose levels, elevated postprandial glucose levels. • Weight loss, polyuria, polydipsia, polyphagia. • Elevated glycohemoglobin levels, acetone breath (smells like alcohol/fermented fruit). Complications • Neuropathy, nephropathy, retinopathy. • Diabetic ketoacidosis (DKA). • Hypoglycemia (the most common complication after treatment with insulin is begun). • Infertility related to sexual dysfunction. Medical Care and Surgical Treatment • Carbohydrate counting; dietary regimen should be similar day to day with increase in calories if physical activity is increased. 32 • Synthetic or animal-derived insulin given subcutaneously. • Treatment of DKA with intravenous hypotonic • saline solution with regular insulin added. Once the glucose begins to normalize, potassium replacement is necessary. Pancreas transplant; transplantation of beta cells into the liver via the portal vein. Keep in Mind • Monitor glucose level before meals and at bed• time. Report hypoglycemia in the middle of the night (Somogyi effect) or increase in the morning (dawn phenomenon). Encourage client to carry a simple sugar or glucose at all times, wear a MedicAlert bracelet, examine his or her feet for lesions, and report visual problems or pain in arms/legs. Make the Connection • Teach the client to rotate sites for insulin administration and to follow dietary regimen. • Monitor glycosylated hemoglobin and serum glucose levels; monitor for complications. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 33 Endocrine Disorders 33 Diabetes Mellitus Type 2 (di-a-be-tez mel-i-tus type 2) Clue: Diagnostic or Clinical Findings Sedentary lifestyle. Polyuria, polyphagia, and polydipsia. Elevated serum glucose levels. 2693_Tab02_Card_24-33.qxd 7/13/11 11:49 AM Page 33 Endocrine Disorders 33 Pathophysiology • • Type 2 diabetes increases in incidence with obesity, poor diet, and sedentary lifestyle as the cells of the body become resistant to insulin. Genetic link (10 new gene variants that affect blood glucose and insulin levels have been identified); type 2 diabetes is affecting more children related to poor diet and obesity. Assessment and Diagnostic Findings • Elevated fasting blood glucose levels, elevated postprandial glucose levels. • Weight loss, polyuria, polydipsia, polyphagia. • Elevated glycohemoglobin levels. Complications • Neuropathy, nephropathy, retinopathy. • Metabolic syndrome (syndrome X), character- • ized by elevated waist circumference (apple fat), reduced high-density lipoprotein levels, elevated blood pressure, fasting glucose levels of >100 mg/dL. This syndrome is related to atherosclerosis and cardiac events. Hyperosmolar nonketotic syndrome, in which stress from illness causes extreme • increases in the blood glucose level without ketosis. Death. Medical Care and Surgical Treatment • Oral hypoglycemic agents and drugs to lower • • • insulin resistance; insulin may be required if these medications are ineffective or if the client is ill (increases glucose levels). Nutritional consult and exercise regimen. Assessment of cardiac status with stress testing, lipid profile, cardiac rhythm strip. Renal tests. Keep in Mind • Monitor blood glucose level ac and hs. Learn the • • • symptoms of low blood glucose and report if it occurs. Follow dietary, exercise, and medication regimen. Check feet for sores. Report sensation or vision changes. Make the Connection • Monitor HgbA1c and serum glucose levels; monitor for complications. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 3 UROLOGIC Urinary Tract Infection, 34 Urethritis, 35 Pyelonephritis, 36 Glomerulonephritis, 37 Nephrotic Syndrome, 38 Polycystic Kidney Disease, 39 Hydronephrosis, 40 Renal Calculus, 41 Rhabdomyolysis, 42 Acute Renal Failure, 43 Chronic Renal Failure, 44 Overactive Bladder, 45 Renal Artery Stenosis, 46 Epididymitis, 47 Benign Prostatic Hyperplasia, 48 Bladder Cancer, 49 Prostate Cancer, 50 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 34 Urologic Disorders 34 Urinary Tract Infection (u-ri-nar-e trakt in-fek-shun) Clue: Diagnostic or Clinical Findings Urinary frequency, urgency, dysuria, bacterial count of >100,000/mL of urine. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 34 Urologic Disorders Pathophysiology • Occurs more frequently in women because of anatomy and age-related structural changes. • UTIs can also occur as a result of obstructive disease, invasive therapies, and incontinence issues. • Most UTIs (95%) are caused by contamination • • • and ascension in the urethra by normal flora from the rectum. Causative agents are Escherichia coli; Staphylococcus saprophyticus; and to a lesser extent Klebsiella species, Proteus mirabilis, Staphylococcus aureus, and Pseudomonas aeruginosa. The normal mucin-surface glycosaminoglycans are overwhelmed and bacteria become adherent to bladder surfaces. Soap in bathwater causes UTIs in children. Assessment and Diagnostic Findings • Chills, temperature elevation, dysuria, frequency, • urgency, frank blood in urine, urethral spasm, and pyuria or strong ammonia smell of urine. Urine culture showing bacterial count of >100,000/mL indicates infection. The presence of RBCs, WBCs, hyaline casts, and positive leukocyte esterase and nitrite in urinalysis. 34 • Residual urine of >50 mL immediately after voiding (bladder scans). • Voiding cystourethrogram or KUB x-ray showing obstruction. Complications • Ascending infection. • Urosepsis. Medical Care and Surgical Treatment • Antibiotics and urinary analgesics. • Transurethral resection of the prostate or lithectomy for obstructions. • Complementary ingestion of cranberry capsules, which are shown to prevent adherence of bacteria. Keep in Mind • Increase fluid intake when on treatment, and complete all antibiotics as ordered. Make the Connection • Recurrent infections or those caused by unusual organisms must be investigated. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 35 Urologic Disorders 35 Urethritis (u-re-thri-tis) Clue: Diagnostic or Clinical Findings Dysuria, blood in the urine or ejaculate in a male. Discharge from the urethra. History of unprotected sex. In women, pelvic pain. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 35 Urologic Disorders Pathophysiology • More common in men but can occur in women; • also characterized by inflammation and colonization of the urethra by Escherichia coli, Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex, or cytomegalovirus. Infectious agents may ascend and affect the prostate and infiltrate the lymph nodes in the groin area. In women, these agents can ascend to infect the pelvic area and may be a cause of infertility. Assessment and Diagnostic Findings • • • • Culture and sensitivity and treatment with antiinfective to which the organism is sensitive. In males, symptoms are dysuria, blood or pus in urine and semen, swollen lymph nodes in the groin area, swollen testicles, purulent discharge from the penis, sore throat, and fever. In women, symptoms include dysuria, dyspareunia, vaginal discharge, pelvic pain, sore throat, and fever. Cervical cultures, rectal culture, penile cultures, joint fluid culture, Gram stain, and throat culture. 35 Complications • Infertility. • Diffuse infection that spreads to joints, heart valves, and meninges. • Spread to other sexual partners. Medical Care and Surgical Treatment • Ceftriaxone, azithromycin, or penicillin. • Sexual counseling and reporting to public health department as indicated. • Urinary analgesics. Keep in Mind • Men may not become symptomatic for 1 month after contact with infectious agents. Make the Connection • It is important to diagnose this condition early to prevent systemic infection and infertility. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 36 Urologic Disorders 36 Pyelonephritis (pi-e-lo-ne-fri-tis) Clue: Diagnostic or Clinical Findings Chills, fever, tenderness over the costovertebral angle, dysuria, elevated WBCs. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 36 Urologic Disorders Pathophysiology • Usually an ascending urinary tract infection (UTI) • caused by a failure of the “washout” mechanism of urine and protective mucin gel. Causative agents are usually Escherichia coli and, to a lesser extent, Staphylococcus aureus. Kidney pelvis structures may be damaged by ongoing infection, leading to nephron damage and renal failure. 36 Keep in Mind • Recognize signs and symptoms of UTI so that spread to the kidneys may be avoided. • Use complementary agents, like cranberry juice or • • capsules, to prevent adherence of bacteria to bladder area (trigone is most easily breached). Take entire antibiotic prescription as directed. Ensure that urine culture is collected properly (midstream). Assessment and Diagnostic Findings • Pyuria. • Urinalysis and culture findings showing white blood cells singly, in clumps, or in casts. • Bacteria count of >100,000/mL of urine. • Low specific gravity and osmolarity. • Slightly alkaline urine pH. • Proteinuria, glycosuria, and ketonuria. Complications • Chronic renal failure. Medical Care and Surgical Treatment • Antibiotics (e.g., sulfonamides, fluoroquinolones, nitrofurantoin, penicillins) and urinary analgesics. If drugs are given intravenously (IV), hospitalization is required. Make the Connection • Monitor for dysuria. • Assess costovertebral angle for tenderness. • Assess urinalysis and urine culture. • Identify risk factors for UTI. • Remember: The kidneys are inextricably linked to the bloodstream, so infections in the kidney may quickly become overwhelming infections of the blood, and the reverse is also true. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 37 Urologic Disorders 37 Glomerulonephritis (glo-mer-u-lo-ne-fri-tis) Clue: Diagnostic or Clinical Findings Hypertension; oliguria; smoky, frothy urine. Urinalysis shows RBCs, casts, and protein. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 37 Urologic Disorders Pathophysiology • The glomerulus is formed from tufts of arteriolar • • capillaries fed by an afferent arteriole and drained by an efferent arteriole that have thin basement membrane composed of a proteinous matrix and a layer of epithelial cells with footlike outpouches. Blood plasma is forced through these thin structures by a pressure gradient into Bowman’s capsule and the renal tubule. A number of toxins, diseases, and organisms can cause inflammation and damage to this basement membrane. In poststreptococcal infection, antigens are deposited in the basement membrane of the glomerulus. When antigen/antibody complexes form, the immune system destroys them, setting up large areas of inflammation and damage to surrounding structures. 37 • High BUN, creatinine, and creatinine/BUN ratio (>20:1); elevated antistreptolysin O titer. • US of the kidney, renal biopsy, or CT scan. Complications • Renal failure. Medical Care and Surgical Treatment • Steroidal and nonsteroidal anti-inflammatory agents; antibiotics, if indicated. • Sodium and fluid restriction, antihypertensive agents, and diuretics. • Dialysis may be necessary; bedrest. Keep in Mind • All suspected streptococcal infections require culture specimen analysis, completion of treatment, and verification of negative culture. Assessment and Diagnostic Findings Make the Connection • Hypertension; smoky, frothy urine from RBCs and • protein; oliguria; edema; periorbital edema tenderness over the costovertebral angle; and flank pain. Adventitious lung sounds or absent lung sounds and generalized edema. • Monitor laboratory values, pulse oximetry, • BP urinalysis results; serum chemistry for worsening azotemia. Monitor level of consciousness and daily weights; maintain strict I&O measurements. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 38 Urologic Disorders 38 Nephrotic Syndrome (ne-frot-ik sin-drom) Clue: Diagnostic or Clinical Findings Elevated LDL cholesterol and triglycerides, proteinuria, frothy urine from protein and lipids, decreased immunoglobulins lost in urine. Massive edema. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 38 Urologic Disorders Pathophysiology • Nephrotic syndrome is an umbrella term encom- • • passing disorders that result from glomerular damage. Damage to the basement membrane results in loss of blood components that would otherwise remain in circulation. Large amounts of protein and immunoglobulins are lost in the urine. Hyperlipidemia and hypertriglyceridemia occur as the liver responds to the low protein levels. Triglycerides and LDL are also lost in the urine, to some extent adding to the frothy appearance. Protein loss causes loss of intravascular fluid into the interstitial spaces, but low glomerular filtration rate still results in hypertension. Assessment and Diagnostic Findings • Hypertension, hyperlipidemia, hypertriglyceridemia, loss of antibodies (immunoglobulins). • Foamy urine. • Azotemia (increased nitrogenous wastes). • Hypercoagulability. Complications • Thrombosis and embolism. 38 • Generalized edema, CHF, pleural effusion, and HTN. • Atherosclerosis. • Renal failure. • Infections from loss of immunoglobulins. Medical Care and Surgical Treatment • Antihypertensive agents, lipid-lowering drugs, diuretics. • Anticoagulant therapy, corticosteroids. • Sodium and water restrictions; protein is titrated • based on serum nitrogenous wastes and estimate of protein loss in the urine (low to moderate amount). Dialysis. Keep in Mind • Report sudden weight gain or change in mental or urinary status. Make the Connection • Monitor I&O, daily weights, abdominal circumference, and vital signs. • Monitor laboratory values for worsening azotemia and complications of thrombosis. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 39 Urologic Disorders 39 Polycystic Kidney Disease (pol-e-sis-tik kid-ne di-zez) Clue: Diagnostic or Clinical Findings Hypertension, headaches, and hematuria. Ultrasound shows fluid-filled cysts. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 39 Urologic Disorders Pathophysiology • Hereditary disorder causing cystic formation in the cortex or medulla of the kidney. • Cysts may develop from pressure buildup in the tubules and can progress to the entire kidney. • Glomerular filtration rate (GFR) decreases. • Stasis of fluid in the cysts predisposes to repeated urinary tract infection (UTI). • Persons with this hereditary disease are at high risk for aneurysms in the brain and diverticulosis related to body system formation during the embryonic period. Assessment and Diagnostic Findings • Elevated blood pressure, UTIs and hematuria. • Ultrasound revealing cysts in the kidney. • Subjective findings of discomfort in the flank and lower back. Complications • Urosepsis. • Hypertension. • Renal failure. 39 • Aneurysm in the brain. • Diverticulosis in the colon. • Cyst formation in other organs. Medical Care and Surgical Treatment • Antibiotic therapy and antihypertensives. • Dialysis or renal transplant. Keep in Mind • Report signs and symptoms of UTI (frequency, urgency, pyuria, and hematuria). • Report change in mental status and prolonged, severe headache. Make the Connection • Remember: Decrease in GFR will result in hypertension. • Because this disease is associated with brain aneurysm, it is important to keep hypertension under control. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 40 Urologic Disorders 40 Hydronephrosis (hi-dro-nef-ro-sis) Clue: Diagnostic or Clinical Findings Obstruction of urine outflow from the kidney related to lithiasis, tumor, outflow obstruction from the bladder. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 40 Urologic Disorders 40 Pathophysiology • Unilateral or bilateral swelling of the renal cap- • • sule from regurgitant urine related to outflow obstruction. Because the renal capsule is fibrous, internal functional structures (nephrons) are destroyed. Causes may include renal system lithiasis; tumors of the kidneys, ureters, or bladder; enlargement of the prostate; or stricture of the urethra. May occur with continuous bladder irrigation (CBI) if a clot obstructs outflow of irrigant and urine or with an obstructed Foley catheter. • • • removal of tumor, lithectomy, dilation of strictures, careful monitoring of urinary output during CBI or when an indwelling Foley catheter is in place). Nephrostomy tubes and/or stent placement. Nephrectomy, if necessary. Antibiotics for repeated UTI. Keep in Mind • Report repeated UTI symptoms to the health-care professional. • Report flank pain, especially if post-TURP. Assessment and Diagnostic Findings • Flank and back pain. • If insidious onset, urinary tract infections (UTIs) begin to occur because of urine stasis. Complications • Renal failure. • Urosepsis. Medical Care and Surgical Treatment • Removal or mitigation of the obstruction (transurethral resection of the prostate [TURP], Make the Connection • Remember: Monitor intake and output carefully during CBI. • As they grow, renal system cancers can physically obstruct kidney outflow at any point from the hilus of the kidney to the urethra. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 41 Urologic Disorders 41 Renal Calculus (re-nal kal-ku-lus) Clue: Diagnostic or Clinical Findings KUB or US shows one or more masses in the kidneys, ureters, or bladder. Renal colic in the flank that radiates downward, nausea, vomiting, and costovertebral tenderness. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 41 Urologic Disorders Pathophysiology • Men are affected more than women, and stone • • • • formation is usually unilateral. Once stones have formed, repeated formation is likely. Irritation of the epithelial cells that line the tubules. Dehydration causes more solute to be present in the urine. Persons prone to stone formation may lack inhibitor proteins and stones may recur. Small stones (<5 mm) usually are passed in the urine. Assessment and Diagnostic Findings • Repeated urinary tract infection (UTI), hematuria from stasis of urine. • Calculi, hydronephrosis, and hydroureter can be • • • diagnosed by KUB x-ray, retrograde pyelography, or ultrasound (US). Renal colic, genital pain, nausea, vomiting, and diarrhea. 24-hour urine for creatinine clearance. Urinalysis and urine pH. Complications • Hemorrhage and hypovolemic shock. • Urosepsis. 41 • Hydronephrosis and hydroureter. • Renal failure with repeated stone formation. Medical Care and Surgical Treatment • Nephrolithotomy, pyelolithotomy, lithotripsy, chemolysis, and nephrostomy tubes. • Pain medication. • Dietary changes: increase fluid intake. Acid-ash diet for calcium, struvite, and calcium oxalate stones. Calcium added to the diet binds with oxalates and is eliminated in the stool. Struvite stones are formed in the presence of infections and an alkaline environment. Alkaline-ash diet for uric acid stones. Keep in Mind • Stone formation seems to be hereditary. Alter diet as necessary and force fluids. Make the Connection • Monitor for characteristic pain, hematuria, and repeated UTI. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 42 Urologic Disorders 42 Rhabdomyolysis (rab-do-mi-ol-i-sis) Clue: Diagnostic or Clinical Findings Azotemia, edema, hypertension, hematuria, arrhythmias. Common causative drugs are cholesterollowering agents. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 42 Urologic Disorders 42 Pathophysiology • Results from crush injuries (compartment syn• drome), the toxic effect of drugs or chemicals on skeletal muscle, extremes of exertion, sepsis, shock, electric shock, and severe hyponatremia. Lipid-lowering drugs (e.g., statins, niacin, and/or fibrates) are among the commonly prescribed drugs that cause damage to skeletal muscle fibers that are released into the bloodstream and accumulate in renal tubules. Assessment and Diagnostic Findings • Elevated levels of serum or urine myoglobin or creatine kinase (CK). • Hematuria, elevated potassium levels, low calcium levels, and metabolic acidosis. • Arrhythmias related to altered electrolyte levels. • Azotemia and decreased glomerular filtration rate (GFR). Complications • Renal failure and death. Medical Care and Surgical Treatment • Hydrate to achieve urine output of between 200 and 300 mL/hr. If urine output does not increase • • • with hydration, loop and osmotic diuretics are prescribed to promote diuresis. Dialysis may be needed if renal failure develops. Urinary alkalinization with sodium bicarbonate increases myoglobin solubility in the urine and assists its elimination from the body. The patient with rhabdomyolysis should also be monitored closely for electrolyte disturbances (hypocalcemia, hyperkalemia) and dysrhythmias, with corrections being made as quickly as possible. Bedrest throughout the acute illness phase. Keep in Mind • Report any muscle tenderness immediately if taking a cholesterol-lowering drug. Make the Connection • Monitor closely for electrolyte disturbances (hypocalcemia, hyperkalemia) and dysrhythmias. • Remember: Crush injuries may cause renal failure. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 43 Urologic Disorders 43 Acute Renal Failure (a-kut re-nal fal-yer) Clue: Diagnostic or Clinical Findings Azotemia, anuria, or oliguria. Precipitated by severe hypotension, use of diagnostic contrast dyes, or structural damage to nephrons. Elevated K+ and decreased Na+ in serum. Elevated creatinine and BUN. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 43 Urologic Disorders Pathophysiology • Acute damage to nephrons associated with severe • • • hypotension, use of contrast dyes, or damage to skeletal muscle fibers that accumulate in the nephron tubules. Three stages: The oliguric stage (less than 400 mL/ 24 hr), lasting 2 weeks (better prognosis) to several months (poor prognosis). The diuretic phase, characterized by a normal output of low-quality urine lasting up to a month. The recovery phase, which may last up to 1 year. The quality of urine in this phase improves, but full recovery is not guaranteed. Prerenal conditions are those that decrease perfusion of the kidneys. Intrarenal failure includes incidents that damage the nephrons. Postrenal failure is caused by obstruction, resulting in hydronephrosis. Assessment and Diagnostic Findings • Hypertension, azotemia, change in LOC, nausea, vomiting, fatigue, anemia. • Low urine sodium level (<10 mEq/L). • CBC showing anemia and platelet dysfunction, azotemic pericarditis, and acidosis. 43 Complications • Azotemic encephalopathy; acute renal failure becomes chronic renal failure. • Hypertension, CHF, anemia, osteomalacia or osteoporosis with spontaneous fracture, and pulmonary edema. Medical Care and Surgical Treatment • Bedrest; treatment of the underlying cause. • Restriction of protein intake, fluid, sodium, • • potassium, and phosphorus while in renal failure. Erythropoietin injections, antihypertensives, diuretics, vitamin D supplementation, and calcium supplements with meals. Dialysis or transplant. Keep in Mind • Hydrate well prior to and following studies using contrast dyes; report changes in voiding. Make the Connection • Renal failure carries with it the 3 Ds—dialysis, donor, or death. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 44 Urologic Disorders 44 Chronic Renal Failure (kron-ik re-nal fal-yer) Clue: Diagnostic or Clinical Findings History of diabetic nephropathy, hypertension, glomerulonephritis, or an autoimmune disease (systemic lupus erythematosus [SLE]). 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 44 Urologic Disorders 44 frost, sexual dysfunction, and accumulation of drugs in the body. Pathophysiology • Gradual destruction of the nephrons and reduction of GFR. Acute renal failure, diabetic nephropathy, and hypertension are the most common causes, but abnormalities of the kidney, autoimmune disorders, and chronic infection or cancer are also causes. Assessment and Diagnostic Findings • Hypertension, worsening azotemia, change in • • LOC, nausea, vomiting, fatigue, anemia, electrolyte imbalances, and abnormal DEXA scan. Low urine sodium level (<10 mEq/L). CBC showing anemia and platelet dysfunction, azotemic pericarditis, and acidosis. Complications • Increasing azotemia, ESRD, uremic • • • encephalopathy, and sites for hemodialysis becoming exhausted. Infection from peritoneal dialysis (PD) from peritoneal catheter access (peritonitis). Infected or clotted hemodialysis shunt or graft. HTN, arrhythmias, azotemic pericarditis, peptic ulcers, change in LOC/coma, pruritus, uremic Medical Care and Surgical Treatment • Diet+ high in calories+and ++low in phosphorus, • • • • Na , protein, and K ; Ca supplements (PhosLo) with meals, vitamin D; fluid restriction (titrated). Hemodialysis or PD-insertion of peritoneal catheter. Erythropoietin injections, iron supplements. Antihypertensives and diuretics. Kidney transplant. Keep in Mind • It is important to know the blood glucose level and blood pressure to avoid renal complications. Make the Connection • Monitor laboratory results; monitor for peritonitis (cloudy peritoneal return). Check graft for bruit/thrill. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 45 Urologic Disorders 45 Overactive Bladder (o-ver-ak-tiv blad-der) Clue: Diagnostic or Clinical Findings Urgency, frequency, and stress incontinence related to autonomic and structural anomalies of the bladder. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 45 Urologic Disorders Pathophysiology • Overactive bladder is thought to be caused by • • excessive parasympathetic impulses to the detrusor muscle of the bladder, initiating the micturition response. Also, structural anomalies resulting from pelvic relaxation syndrome decrease the angle of the bladder, causing undue pressure on the neck of the bladder and abnormal stretch of the transitional cells, which again triggers the micturition response. Neurogenic causes may include chronic neurologic illnesses (e.g., multiple sclerosis) that unintentionally stimulate motor function and the micturition reflex arc, making the bladder more active. Assessment and Diagnostic Findings • Ultrasound (US) examination of the bladder for residual urine. • Endoscopic examination of the bladder. • Subjective history of stress incontinence, frequency, and urgency. Complications • Incontinence and social inhibition. • Urinary tract infections, especially if the bladder is at an abnormal angle due to pelvic relaxation. 45 Medical Care and Surgical Treatment • Anticholinergics to block parasympathetic impulses. • Behavioral modification exercises for bladder retraining and Kegel exercises. • Dietary changes to reduce fluids that cause diuresis; decreased fluid intake prior to bed. Keep in Mind • Anticholinergic medications may cause drowsi- • • ness; dry mouth; warm, flushed skin; changes in vision; and, in some clients, changes in mental status. Troublesome side effects should be reported. Side effects may diminish with time. Behavioral modification exercises and Kegel exercises are very effective for this condition. Make the Connection • Monitor frequency and urgency. • Monitor for side effects of anticholinergic medications (blind as a bat, mad as a hatter, dry as a bone, red as a beet, and hot as a hen). 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 46 Urologic Disorders 46 Renal Artery Stenosis (re-nal ar-ter-e ste-no-sis) Clue: Diagnostic or Clinical Findings Onset of severe hypertension in the absence of glomerular disease, renal failure, or pheochromocytoma. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 46 Urologic Disorders Pathophysiology • Hypertension occurs when the renal artery • becomes narrowed and incapable of transmitting blood to the kidney. The response is activation of the renin-angiotensin-aldosterone mechanism to increase vasoconstriction, further increasing the blood pressure. Young women usually develop renal stenosis from fibromuscular dysplasia; older adults develop it from chronic atherosclerotic disease. Assessment and Diagnostic Findings • Computed tomography (CT) scan or magnetic • • resonance imaging (MRI) of the kidney with contrast. Duplex ultrasound of the kidney. Renal artery angiography. Complications • Cerebrovascular accident (CVA), retinopathy, heart disease, vascular disease, and nephropathy of the uninvolved kidney (if unilateral). 46 Medical Care and Surgical Treatment • Renal artery angioplasty. • Medications, especially angiotensin-converting enzyme (ACE) inhibitors. Keep in Mind • Report headache or changes in vision immediately. • Have blood pressure assessed at every health-care visit. Make the Connection • Structural anomalies must be ruled out before standard treatment with antihypertensive agents is begun. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 47 Urologic Disorders 47 Epididymitis (ep-i-did-i-mi-tis) Clue: Diagnostic or Clinical Findings Painful inflammation of the back of the testes. The scrotum is erythematous. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 47 Urologic Disorders Pathophysiology • Infection and inflammation of the epididymis, the • • • • tube along the back side of the testes in which sperm mature and are stored, can be the result of several events. In older men, regurgitation of urine from excessive bladder pressure when trying to urinate in the presence of an enlarged prostate can force urine into the vas deferens to the epididymis, causing infections with bacteria such as Escherichia coli. Infections with sexually transmitted organisms occur with frequency in young, sexually active males. Congenital structural abnormalities in young children predispose them to infection. Trauma results from excessive pressure exerted on the epididymis. 47 Complications • Sexually transmitted diseases (STDs) may persist and cause infertility and abnormalities in other organ systems (valvular disease, neurologic deficits). Medical Care and Surgical Treatment • Antibiotic therapy. • Bedrest, scrotal elevation, and ice pack application. • Oral analgesics and antipyretics. • Sexual counseling. Keep in Mind • Appropriate protection from STD must be used (condoms). • Difficulty urinating must be reported to the health-care provider. • Scrotal protection should be worn when strenuous activity resulting in scrotal pressure is planned. Assessment and Diagnostic Findings • Scrotum is painful to touch; usually unilateral involvement. Ambulation is difficult. • Urinalysis, Gram stain, and urine culture showing infection. • Possible pyuria and penile discharge. Make the Connection • Assess laboratory results. • Maintain bedrest in the acute phase, with scrotal elevation and intermittent use of ice packs. • Counsel the person with an STD that the sexual partner must be treated as well. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 48 Urologic Disorders 48 Benign Prostatic Hyperplasia (be-nin pros-tat-ik hi-per-pla-ze-a) Clue: Diagnostic or Clinical Findings Difficulty starting or maintaining urinary stream, dribbling of urine, urgency and frequency in men approaching or in the fifth decade of life. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 48 Urologic Disorders Pathophysiology • Enlargement of glandular tissue in the periurethral • • area of the prostate under the influence of testosterone, particularly DHT. Estrogen is also implicated, as it makes the gland more susceptible to DHT. The prostatic urethra narrows as the prostate gland enlarges, causing partial, or eventually total, obstruction of urine outflow from the bladder. Assessment and Diagnostic Findings • Decrease in urinary stream, difficulty starting the • • flow of urine, frequency and urgency, incomplete emptying of the bladder, dribbling of urine, overflow incontinence, and nocturia. Urinary tract infections from urine stasis; epididymitis from pressure in the bladder forcing urine into the ejaculatory ducts. Digital rectal examination for assessment of enlargement, urinalysis, prostate-specific antigen (PSA), and serum creatinine level to determine the level of obstruction. Complications • Hydronephrosis, hydroureter, and diverticular lesions of the bladder from pressure of attempted voidings. 48 Medical Care and Surgical Treatment • Alpha-adrenergic antagonists. • DHT- and testosterone-blocking medications. • Herbals like saw palmetto. • TUMA. • Prostatic balloon dilation. • Transurethral resection of the prostate (TURP). Keep in Mind • Report difficulty passing urine to the health-care provider. • Medications used for benign prostatic hyperplasia (BPH) can cause significant side effects like ↓ BP or feminization (DHT blockers). Make the Connection • If untreated, prostatic enlargement can cause hydronephrosis and renal failure. • The PSA test is done serially from age 40. • If a TURP is done, monitor I&O from the CBI carefully to prevent postoperative hydronephrosis; output should exceed instillation amount. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 49 Urologic Disorders 49 Bladder Cancer (blad-der kan-ser) Clue: Diagnostic or Clinical Findings Painless hematuria, pelvic pain, lower back discomfort, and changes in voiding patterns. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 49 Urologic Disorders Pathophysiology • More common in middle-aged males than in females. • Strong association with cigarette smoking. • Exposure to industrial pollutants (e.g., aniline dyes). • The tumor-node-metastasis (TNM) method of staging the cancer determines prognosis and treatment. • Over time, dysplastic changes occur in the urothelium. With chronic irritation, these areas of dysplasia are replaced by malignant cells. The cells may form small cancers that remain in the urothelium or may become invasive and metastatic to the liver, lungs, and bones. Assessment and Diagnostic Findings • Urine for cytology; urine culture. • Intravenous pyelogram (IVP) to assess invasion of other urinary structures. • Cystoscopy with biopsy is the only definitive diagnostic method. Complications • Hydronephrosis, hydroureter, renal failure, and hemorrhage. • Removal of the bladder with urinary diversion may result in urinary tract infection or sepsis if not cared for properly. 49 • Metastasis and death. Medical Care and Surgical Treatment • Surgery, radiation, chemotherapy, bacille • Calmette-Guérin (BCG) bladder instillations to prevent return of cancer cells. Surgeries after cystectomy include incontinent urinary diversion, continent urinary diversion using a Kock pouch, or formation of a neobladder (or new bladder) using a part of the intestines. Keep in Mind • Report blood in the urine immediately. • If surgery for bladder cancer has been performed and a urinary diversion is done, care for area aseptically. Make the Connection • Monitor laboratory and urinalysis results for infections and nitrogenous waste levels. • Teach client how to care for urinary diversions. • Explain that incontinence is sometimes a problem with orthotopic or neobladder formation. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 50 Urologic Disorders 50 Prostate Cancer (pros-tat kan-ser) Clue: Diagnostic or Clinical Findings Late symptoms include signs of urinary obstruction, pain in the lumbar or hip area, weight loss, and weakness. Urine outflow may be impaired. 2693_Tab03_Card_34-50.qxd 7/13/11 11:50 AM Page 50 Urologic Disorders Pathophysiology • Prostatic glandular cells mutate and grow under the influence of testosterone and DHT. • Prostate cancer late in life is usually slow growing (↓ testosterone levels). • Metastatic spread into other urinary and repro• ductive structures is through lymph and blood vessels. The TNM system is used to grade the cancer and make a prognosis. Assessment and Diagnostic Findings • Symptoms are usually late in the disease, so PSA and DRE should be done in males older than 40. • Elevated prostatic acid phosphatase. • Late symptoms include hematuria, signs of • urinary obstruction, weight loss, anemia, and pain in the boney structures of the pelvic girdle. Definitive diagnosis is made by a transrectal ultrasound-guided prostatic biopsy. Complications • Complications of chemotherapy include nausea, vomiting, alopecia, hyperuricemia, and bone marrow suppression; radiation causes burns, skin breakdown, and scarring of internal tissue. 50 • Metastatic disease. • Tumors that obstruct urinary outflow and may result in hydronephrosis and renal failure. Medical Care and Surgical Treatment • Testosterone-suppressing medications. • Radiation therapy (external beam or implanted radioactive seeds) and/or chemotherapy. • Radical prostatectomy; TURP. • Orchiectomy to decrease testosterone levels. Keep in Mind • Early detection is key. • Medications and surgeries may cause feminization and permanent erectile dysfunction. Make the Connection • Monitor I&O, calorie count, and stool characteristics. • Assess for development of vesicular rash on knees, elbows, and buttocks. • Monitor for anemia and bleeding tendencies. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 4 IMMUNE SYSTEM Anaphylaxis, 51 Scleroderma, 52 Systemic Lupus Erythematosus, 53 Hashimoto’s Thyroiditism, 54 Sjögren’s Syndrome, 55 Acquired Immunodeficiency Disease, 56 Kaposi’s Sarcoma, 57 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 51 Immune Disorders 51 Anaphylaxis (an-a-fi-lak-sis) Clue: Diagnostic or Clinical Findings Sudden onset of wheezing, edema of airway, hypotension, tachycardia, feeling of impending doom and anxiety. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 51 Immune Disorders Pathophysiology • Severe type I hypersensitivity reaction in which • IgG antibodies attached to mast cells, previously sensitized to an antigen, are reactivated. The most common antigenic material is derived from foods or insect stings. Chemical mediators are released, the most common of which are histamine, proteases, chemotactic factors, leukotrienes, prostaglandin D, cytokines, and interleukins 1, 3, 4, 5, and 6). These mediators cause vasodilation and fluid shift from the intravascular to the interstitium. Assessment and Diagnostic Findings • • Erythema, angioedema, urticaria (hives), stridor, wheezing, decrease in BP, and increase in pulse. Change in level of consciousness, drowsiness. Complications • Shock, respiratory and cardiac failure. • Renal ischemia. 51 Medical Care and Surgical Treatment • Emergency care includes use of an EpiPen. • IV fluids, IV vasopressors, corticosteroids, • • epinephrine, antihistamines, and histamine 1 (H1)-receptor and H2-receptor blockers. Supplemental oxygen will be needed and airway support. Electrocardiogram (ECG) monitoring. Keep in Mind • Teach that severe allergy an occur at any time after first occurance. • Families with a member who has food or other allergies should have an EpiPen on hand. Make the Connection • Anaphylaxis causes shock. Remember: shock = ↓ BP, ↑ pulse. • Remember: ↓ HOB, ↑ legs. Keep client warm. • Start an IV for fluid and drug administration. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 52 Immune Disorders 52 Scleroderma (skler-a-der-ma) Clue: Diagnostic or Clinical Findings Taut face without wrinkles. Calcium deposits. + ELISA for ANA and other antibodies. Raynaud’s phenomenon. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 52 Immune Disorders Pathophysiology • An autoimmune disease. • Women are affected more often than men; • • disorder often has periods of exacerbation and remission. The skin, connective tissue, and internal organs are affected. Insoluble collagen is overproduced and deposited in the skin and other organs, causing inflammation. Inelastic rather than supple edema results. A common finding is “stone face,” which is the result of this hardening of the skin. There is a strong association (95%) with Raynaud’s phenomenon. Assessment and Diagnostic Findings • Pitting edema of the upper extremities followed by tightening of the tissue. • The face will have no wrinkles. • Arthritis and decreased range of motion occur. • The kidneys, lungs, heart, and gastrointestinal tract are also affected. • Skin biopsies and ELISA testing for anti-Scl-70 and anticentromere antibodies. • Kidney function tests, pulmonary function tests, electrocardiogram, and x-ray studies. 52 Complications • CREST syndrome: calcinosis (calcium deposits), • Raynaud’s phenomenon, esophageal immotility, sclerodactyly, and telangiectasia. Dysphagia and aspiration risk; pneumonia and desaturation of blood from lung noncompliance; arrhythmias; and necrosis of fingertips, toes, and nose from Raynaud’s vasculitis. Medical Care and Surgical Treatment • Immunosuppressants. • Vasodilating agents. • Careful and consistent physical therapy and occupational therapy. • Extremities must be kept warm. Keep in Mind • Report any signs of illness (e.g., sore throat) immediately. • Physical activity helps to keep the body supple. Be as independent as possible. Make the Connection • Scleroderma presents a body image problem, so psychological counseling is essential. • Monitor lung, renal, and cardiac function. • Passive and active ROM. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 53 Immune Disorders 53 Systemic Lupus Erythematosus (sis-tem-ik lu-pus er-i-the-ma-to-sis) Clue: Diagnostic or Clinical Findings Butterfly rash, arthritis, malaise, Raynaud’s phenomenon, peripheral neuropathy, change in vision and renal status; round lesions on head cause hair loss. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 53 Immune Disorders Pathophysiology • Immune system antibodies attack “self.” Females • • are affected more than males. A hereditary predisposition exists. Discoid lupus causes skin plaques that tend to occur on the face, ears, and hair. Wherever they appear, the area is inflamed and becomes scarred. Alopecia results in affected areas in the hair. Systemic lupus erythematosus (SLE) causes changes in the dermatologic, cardiovascular, musculoskeletal, hematologic, gastrointestinal, renal, and ophthalmologic systems—all related to inflammation from overreaction of the immune system. 53 • Peritonitis from chronic inflammation and scarring of abdominal and intestinal vasculature. • Visual changes or blindness. • Severe arthritic changes. Medical Care and Surgical Treatment • Antirheumatics and tumor necrosis factor inhibitors. • Corticosteroids and other immunosuppressants. Keep in Mind • Teach signs of heart disease, like SOB. • Teach signs of kidney inflammation. • Eat a healthy diet, stay active, get adequate rest, and wear a MedicAlert bracelet. Assessment and Diagnostic Findings • ELISA for SLE-specific antibodies; antinuclear antibody (ANA); and nonspecific inflammatory studies, like complete blood count with differential (CBC with diff), erythrocyte sedimentation rate, and kidney function tests. Complications • • • Myocarditis, myocardial infarction, and pericarditis. Renal failure. Thrombocytopenia, anemia. Make the Connection • Monitor laboratory results and clinical • condition. Refer to a rheumatologist if butterfly rash and arthritis occur. Immunosuppressant therapy puts the client at risk for infection and pseudodiabetes. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 54 Immune Disorders 54 Hashimoto’s Thyroiditis (ha-she-mo-toz thi-royd-i-tis) Clue: Diagnostic or Clinical Findings Goiter, periods of insomnia, anxiety, muscle and joint aches, weight changes, hair loss, and fertility problems that are mixed symptoms of hyper- and hypothyroidism. TSH may be normal or elevated. T3 and T4 are low. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 54 Immune Disorders Pathophysiology • Usually a disease of older women with a history of autoimmune disease. • Autoantibodies are produced to fight TSH. TSH • • is not destroyed and instead binds with its receptors in the thyroid gland, causing symptoms of hyperthyroidism. As the thyroid gland becomes infiltrated with lymphoid tissue and plasma cells it enlarges and hypothyroidism occurs. Episodic hyperthyroidism can occur, so symptoms may swing back and forth from hyperthyroidism to hypothyroidism. Assessment and Diagnostic Findings • Elevated levels of serum TG antibodies and TPO • • • 54 • Fatigue, depressive illness, and mental dullness. • Anorexia, constipation, facial puffiness, and dry skin. Medical Care and Surgical Treatment • Evidence shows that low-dose thyroid hormone therapy may reduce destruction of the thyroid gland. Keep in Mind • Report any signs of chest pain when therapy • • using immunofluorescent assay. TSH may be elevated or normal. T3 and T4 levels ↓. Needle biopsy of the thyroid. ↑ RAIU. Visible goiter or enlarged thyroid gland on US. Complications • Atherosclerosis, bradycardia, hypotension, and chest pain. begins. It takes a few weeks for the drug to reduce symptoms. Report any thoughts of suicide. Stay active and follow a low saturated-fat diet. Make the Connection • Remember: Starting thyroid replacement • hormones with a sluggish heart can precipitate an angina attack or myocardial infarction. Monitor the client’s electrocardiogram. Adjust dietary regimen as condition changes. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 55 Immune Disorders 55 Sjögren’s Syndrome (sho-grenz sin-drom) Clue: Diagnostic or Clinical Findings Blurred vision, thick secretions, decreased sense of taste, dysphagia, xerostomia, and dry nasal membranes. Antiribonucleoprotein serum antibodies and + rheumatoid factor in the absence of rheumatoid arthritis. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 55 Immune Disorders Pathophysiology • Autoimmune illness in which the lacrimal and • • • salivary glands are attacked by autoantibodies and T lymphocytes. Can occur alone or with other autoimmune diseases. Occurrence is mainly seen in older women. Sjögren’s syndrome is associated with a 40%–60% increase in the chance of developing non-Hodgkin’s lymphoma. Assessment and Diagnostic Findings • Blurred vision, burning and itching of the eyes, • • • • Schirmer’s test (ability to wet a test strip placed under the eyelid). Decreased sense of taste; thick secretions; dysphagia; dry, cracked oral mucous membranes; enlarged parotid glands; lower lip salivary biopsy. Dry nasal membranes, thick secretions in the bronchi and lungs. Synovitis, vaginal dryness with frequent Candida infection, and vasculitis. Anemia, leukopenia, and elevated ESR. 55 Complications • Corneal abrasion, choking, pneumonia, anorexia, non-Hodgkin’s lymphoma, dyspareunia, tachycardia, and primary biliary cirrhosis. Medical Care and Surgical Treatment • Artificial tears, cyclosporine eye drops, effective • and thorough mouth care, sugarless gum or candies, sips of water, a cholinergic preparation to induce salivation, and artificial saliva. Antimalarials and immunosuppressants. Keep in Mind • Report xerostomia, dysphagia, and chronic dry eye. Make the Connection • Observe ability to swallow. • Protect eyes from excessive dryness to prevent corneal abrasion. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 56 Immune Disorders 56 Acquired Immunodeficiency Disease (a-kwird im-u-no-de-fish-en-se di-zez) Clue: Diagnostic or Clinical Findings Lymphadenopathy, night sweats, and presence of rare opportunistic illness. T-helper (CD4) cells <500 cells/mm3, T-killer (cytotoxic) (CD8) cells <375 cells/mm3, change in the CD4/CD8 ratio (normal 0.9–1.9), and measurable viral load. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 56 Immune Disorders Pathophysiology • Macrophages process foreign antigens and present antigenic material to the T-helper cells (CD4). • The CD4 transfer this information to the T and • B lymphocytes. In HIV, a retroviral particle (RNA strand) wrapped in a glycoprotein coat (gp120 receptor) with p24 viral protein invades the CD4 cell. The CD4 cell and macrophage are the immune cells affected and destroyed. Once the CD4 cell count drops below 200 cells/mm3, the client is diagnosed with AIDS. Other diagnostic criteria include the presence of an opportunistic infection. Assessment and Diagnostic Findings • CD4 and CD8 counts, CD4/CD8 ratio abnormality, and viral load. • GI wasting through opportunistic diarrheal • • infection and by alterations in enteral epithelial function by the viral particles. AIDS dementia complex. Opportunistic disease; ELISA is repeated after one positive result and confirmed by Western blot analysis. 56 Complications • Kaposi’s sarcoma and lymphomas, AIDS dementia, fungal meningitis, and tuberculosis. • Pneumocystis carinii pneumonia, Mycobacterium avium complex, and other pneumonias. • Septicemia, toxoplasmosis, cytomegalovirus retinitis, cervical cancer and Candida infections, GI infections, and wasting. Medical Care and Surgical Treatment • HAART, fusion inhibitors (injectable only), and • integrase inhibitors. Monotherapy with a nucleoside transcriptase inhibitor is administered only during pregnancy and the neonatal period. Once an opportunistic infection occurs, prophylactic treatment is added to the daily medical regimen. Keep in Mind • Avoid smoking, unprotected sex, and organic foods, and take medications as ordered. Make the Connection • Monitor CD4/CD8 ratios, viral load, and presence of opportunistic infection. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 57 Immune Disorders 57 Kaposi’s Sarcoma (kap-o-sez sar-ko-ma) Clue: Diagnostic or Clinical Findings Red-to-purple macules, papules, and nodules seen in persons with AIDS. First seen usually on the mucous membranes. 2693_Tab04_Card_51-57.qxd 7/13/11 11:53 AM Page 57 Immune Disorders Pathophysiology • A rare lymphatic malignancy of the endothelial, • • • rather than connective, tissue characterized by red-to-purple macules, papules, or nodules. Lesions are first seen on the skin or mucous membranes but may involve the internal organs. A rare cancer commonly related to AIDS. In patients with AIDS, KS is believed to be sexually acquired by infection with the human herpesvirus 8. 57 Medical Care and Surgical Treatment • Chemotherapy and radiation treatment, biotherapy • Keep in Mind • Do not have unprotected sex, as this cancer may • Assessment and Diagnostic Findings • Classic form is found on the lower extremities • and dorsal area of the feet. The type associated with AIDS is found on the upper extremities and on the mucous membranes. Biopsy provides the only definitive diagnosis. Complications • Damage to organ systems by metastasis. • Overgrowth and blockage of lymph, blood vessels, gastrointestinal and accessory tract, and organ exocrine function. (interferon alfa-2b), cryotherapy, and hormone therapy. Treatment with HAART. be spread in this way and there are many strains of human immunodeficiency virus that can be spread. Do not smoke, as many infective organisms can be present in cigarette paper. Make the Connection • Monitor complete blood cell count and • • • uric acid level during chemotherapy to assess for bone marrow suppression and hyperuricemia. Assess the skin (portal of entry and portal of exit) during radiation therapy. Provide reverse isolation if leukopenic; avoid fresh flowers and organic foods. Counseling. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 5 MUSCULOSKELETAL Osteoarthritis, 58 Gouty Arthritis, 59 Rheumatoid Arthritis, 60 Osteoporosis, 61 Osteomalacia, 62 Osteomyelitis, 63 Paget’s Disease, 64 Sprain, 65 Fracture, 66 Compartment Syndrome, 67 Total Joint Replacement, 68 Herniated Nucleus Pulposus, 69 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 58 Musculoskeletal Disorders 58 Osteoarthritis (os-te-o-ar-thri-tis) Clue: Diagnostic or Clinical Findings Pain and stiffness in the weightbearing joints and the vertebral column due to wear and tear or obesity. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 58 Musculoskeletal Disorders Pathophysiology • The matrix of cartilage is composed of chondro• cytes imbedded in proteoglycan molecules, which are large and osmotic, drawing fresh synovial fluid into the joint. With excess wear and tear, the chondrocytes become inflamed and release inflammatory mediators (cytokines), causing a cascade of events that includes formation of protease, which break down the proteoglycan molecules. Eventually, the cartilage becomes worn and misshaped. Streaks and dents in the cartilage become cracks. Synovial fluid leaks into the underlying bone, causing cysts. The underlying layer of the cartilage can no longer be an effective shock absorber. Bone spurs form. Assessment and Diagnostic Findings • Pain with or following activity that subsides with rest. More likely to occur after age 40. • CT scan or MRI scan are diagnostic. • Arthroscopy may be done to both diagnose and treat articular and bony malformations. Complications • Ankylosis of joints, with resulting immobility and chronic pain. 58 • Heberden’s and Bouchard’s nodes, which are painful nodes in the fingers. • Vertebral osteoarthritis can result in muscle spasm and pressure on nerves. Medical Care and Surgical Treatment • Anti-inflammatory and immunosuppressants like DMARDs and TNF-I. • Muscle relaxants and application of cold and heat therapy. • Joint replacement surgery, if necessary. Keep in Mind • Walking and swimming can replace high-impact exercise. Weight loss is necessary if obese. • Take anti-inflammatory agents with food, and report any signs of infection immediately. Make the Connection • Inactivity should never be advocated. Clients should know that if you don’t use it, you lose it. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 59 Musculoskeletal Disorders 59 Gouty Arthritis (gowt-e ar-thri-tis) Clue: Diagnostic or Clinical Findings Acute pain and swelling in a joint, usually the great toe (unilaterally). High serum uric acid levels. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 59 Musculoskeletal Disorders Pathophysiology • In gouty arthritis, uric acid crystals are deposited in the joints and other connective tissues. The concentration in synovial fluid is higher than in plasma, so the crystals cause excessive inflammation in the joint. Joints affected are usually those at the distal area of the body, as uric acid crystals are affected by gravity. Called “the rich man’s disease” because many of the foods that contain purines are considered those consumed by the wealthy. Assessment and Diagnostic Findings • Hyperuricemia, high-purine diet, painful joints, and possible gouty lesions near joints. • Attacks of gout precipitated by excessive alcohol • ingestion, dehydration, illness/stress, and medications like diuretics, aspirins, cyclosporine, levodopa, aminophylline, niacin, and antibiotics used to treat tuberculosis. Arthroscopy with joint fluid aspiration for uric acid crystals and white blood cells. Complications • Pain and immobility during acute attacks. 59 • Soft nontender tophi can occur on the extremities • near joints. These may become open sores (ulcers) if the skin is not cared for properly. Possible uric acid kidney stone formation. Medical Care and Surgical Treatment • Anti-inflammatory agents, uricosuric agents, and probenecid; increasing daily fluid intake to 2,000–3,000 mL. Keep in Mind • Avoid aspirin and diuretics as well as high-purine foods. • Consume alcohol in small amounts, if at all. • Find healthy outlets for stress. Make the Connection • Remember: Gouty arthritis is very painful. Give anti-inflammatory drugs, such as colchicine. • Force fluids, and teach the client the importance of remaining hydrated. • Monitor uric acid levels, and assist the client in choosing low-purine foods and drugs. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 60 Musculoskeletal Disorders 60 Rheumatoid Arthritis (roo-ma-toyd ar-thri-tis) Clue: Diagnostic or Clinical Findings Swan neck deformity or ulnar deviation of the metacarpophalangeal joints. Fatigue, flu-like symptoms may accompany exacerbations of the disease. Elevated ESR; RF and CCP antibodies present. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 60 Musculoskeletal Disorders Pathophysiology • Rheumatoid arthritis is a systemic disease known • • • • to be genetic and autoimmune in nature. Women are affected more than men. Rheumatoid factor (RF) antibodies react with IgG, forming immune complexes in the body and in the synovial joints. Granulocytes phagocytize the immune complexes and release toxins into the tissue and into the joints. Synovitis occurs as well as increased formation of blood vessels in the synovial walls, which contributes to production of vascular pannus. The area of inflammation is “walled off” in an attempt to heal injured tissue causing more immobility and destruction. Assessment and Diagnostic Findings • Presence of RF, anti-CCP antibodies, WBC elevation, and ↑ ESR. • Synovial fluid examination reveals a significant number of neutrophils. • Low-grade temperature, flu-like symptoms, bilateral joint inflammation, joint deformities like swan neck deformity, and nodal formation. 60 Complications • Pain, joint deformity, ankylosis, and immobility. • Vasculitis, scleritis, pulmonary and cardiac inflammation, and leukopenia. Medical Care and Surgical Treatment • Salicylates, NSAIDs, gold salts, TNF inhibitors, DMARDs, and corticosteroids. • Surgery for joint replacement. • Physical and occupational therapy to maintain function. Keep in Mind • Take all anti-inflammatory agents with food. Report any signs of infection immediately. Make the Connection • Monitor CBC for signs of infection while on anti-inflammatory agents. • Assist with ROM exercises to maintain function. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 61 Musculoskeletal Disorders 61 Osteoporosis (os-te-o-por-o-sis) Clue: Diagnostic or Clinical Findings Loss of bone density (by DEXA scan) seen mainly in females who weigh less than 140 lb at menopause and have never used estrogen-replacement therapy. The mnemonic is ABONE (A = age, B = bulk, ONE = one never on estrogen). 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 61 Musculoskeletal Disorders Pathophysiology • Healthy bone is living tissue that is dynamic in • • nature. Osteoclasts resorb bone, while osteoblasts lay down new bone. In this way, healthy bone is always remodeled. Bone remodeling occurs under the influence of hormones and from normal body movement and weight-bearing activities. At menopause, estrogen withdrawal causes inflammatory mediators and immune cells that encourage the differentiation of osteoclasts and increase their life span. Osteoblasts, or bone creators, are less active. As osteoporosis progresses, this trabecular framework is diminished and may be totally resorbed. Bone density decreases. 61 and prolonged immobility. • DEXA scan of the hip, spine, and first four vertebrae; serial heights; US of bone; and CT scan. Complications • Falls resulting in hip fracture. • Pathologic fractures. Medical Care and Surgical Treatment • SERMs, biphosphonates, calcitonin hormone, and recombinant human parathyroid hormone. • HRT Weight-bearing exercise. • Calcium and vitamin D supplements. Keep in Mind • The client with confirmed osteoporosis should Assessment and Diagnostic Findings • Risk factors include Caucasian or Asian ancestry, postmenopausal status, weight of less than 140 lb at menopause, sedentary lifestyle, history of rheumatoid arthritis, low calcium and vitamin D consumption, excessive alcohol consumption, smoking and caffeine intake. Secondary risks are associated with endocrine imbalance, steroid use, sleeping tablets, cancer treatment, kidney disease, • • wear well-fitting shoes (no slip-ons) and clear all clutter (e.g., throw rugs) from walking areas. Assistive devices (e.g., walkers) may decrease the chance of falls and fractures. Teach importance of DEXA scan. Make the Connection • Give calcium with meals. Observe for esophagitis related to SERM therapy. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 62 Musculoskeletal Disorders 62 Osteomalacia (os-te-o-mal-a-she-a) Clue: Diagnostic or Clinical Findings Softening of bone causing bowed legs in children and soft or brittle bones in adults. Bone pain is often present with muscle weakness. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 62 Musculoskeletal Disorders Pathophysiology • Bone mineralization is diminished because of lack of calcium or vitamin D. • Vitamin D absorbed by exposure of the skin to • • sunlight must be activated by two organs, first the liver and then the kidney. Any disorders of these organs decreases vitamin D availability. The disease is more prevalent in women because of their increased need for calcium. Osteomalacia is seen more frequently in persons with low sun exposure. Assessment and Diagnostic Findings • X-ray (sometimes showing transverse pseudo- fractures believed to be stress fractures that have not been remodeled), laboratory tests for serum calcium and phosphorus, bone scan, and bone biopsy. Complications • Deformity of bone and teeth. • Change or closure of the epiphyseal growth plate in children, resulting in stunted growth. • Muscle weakness. 62 Medical Care and Surgical Treatment • Treatment of the underlying condition. • Biliary disease may require that pancreatic • enzymes be given to absorb vitamin D and calcium from the diet. In renal disease, supplemental calcium, phosphate binders, and vitamin D supplements are used. Keep in Mind • Moderate exposure to the sun with skin SPF 15 sunscreen. • Dietary intake of supplemented foods, like dairy products and dark green leafy vegetables. Visit choosemyplate.gov Make the Connection • Monitor laboratory values; do serial height and gait assessment. • Bracing of upper and lower extremities may be necessary in severe cases. • Monitor for scoliosis and other vertebral abnormalities. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 63 Musculoskeletal Disorders 63 Osteomyelitis (os-te-o-mi-el-i-tis) Clue: Diagnostic or Clinical Findings Increased temperature with pain and inflammation over the affected bone; elevated WBC and ESR. Bone biopsy positive for infection. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 63 Musculoskeletal Disorders Pathophysiology • Bone infection with microorganisms that can • • occur in compound fracture as well as in surgical intervention (direct inoculation), spread from surrounding tissue (e.g., cellulitis [contiguous spread]), and infection of the bone from sepsis (hematogenesis). When the bone becomes infected, the inflamed area forms an abscess that impairs blood flow to the intramedullary area. Bone death occurs, the periosteum peels away from the ostium, and dead bone (sequestrum) forms. The sequestrum can fall from the bone, causing more pressure and decreased blood flow to other boney areas. Sinuses commonly form that allow pus and debris to escape from the bone to the outer skin. Assessment and Diagnostic Findings 63 Complications • Amputation of the affected limb to decrease the chance of death from septic shock. • Repeated surgical procedures to remove diseased bone (sequestrectomy). Medical Care and Surgical Treatment • IV and oral antibiotic therapy for long periods of time. • Sterile wound dressing changes. • Sequestrectomy. Keep in Mind • Avoid osteomyelitis by carefully controlling blood • glucose levels and checking the feet each evening for pressure areas. Report any sore areas where a soft tissue injury has occurred. • History and physical, x-ray, complete blood count • (CBC), elevated erythrocyte sedimentation rate (ESR), positive bone biopsy for infection, positive blood culture, magnetic resonance imaging (MRI), and computed tomography (CT) scan. A history of diabetic foot ulcers and cellulitis is considered a risk factor. Make the Connection • Teach clients the importance of tight • glycemic control and to check for ill-fitting shoes, dentures, and other prosthetics. Assess sites of infection carefully; monitor CBC and ESR. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 64 Musculoskeletal Disorders 64 Paget’s Disease (paj-ets di-zez) Clue: Diagnostic or Clinical Findings Enlarged bone mass and deformity of the femur, skull, vertebrae, or pelvis, usually in older adults. Increased serum ALP, increased urine hydroxyproline (measured by Pyrilinks and Osteomark), increased urine and serum calcium. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 64 Musculoskeletal Disorders Pathophysiology • A disease of older adults in which osteoclastic • • • activity is followed by an exaggerated response by osteoblasts resulting in enlargement of bone. There are three phases: (1) the active phase (reabsorption); (2) the mixed phase (osteoblast activity); and (3) the inactive phase, in which the osteoblastic phase has exceeded the osteoclastic activity. Increased vasculature around the bones. The femur, skull, vertebrae, and pelvis are most often affected. Assessment and Diagnostic Findings • X-ray showing enlargement and deformity of bone. • Nuclear bone scans showing “hot spots” of abnormally rapid bone cell turnover that appear overgrown or have a mosaic pattern; increased ALP. Pyrilinks and Osteomark urine tests, which measure markers of bone resorption, are elevated in Paget’s disease. Complications • ↓ cardiac output related to vasodilation. • Pain and deformities. 64 • Nerve palsies. • Calcified aortic stenosis. • Decreased rib cage compliance and pneumonia. Medical Care and Surgical Treatment • Calcitonin, biphosphonates, and • • anticancer/antibiotic agents (e.g., plicamycin) to suppress osteoclasts and osteoblasts. Anti-inflammatory agents. Analgesics. Keep in Mind • Report pain level on a 0–10 scale and any dizziness or dyspnea. • Report any bleeding of the gums or from any orifice while under treatment. Make the Connection • Monitor CBC for low platelet level with plicamycin therapy. • Titrate analgesic levels to keep pain level <3. • Monitor serum and urine studies to assess effectiveness of therapy. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 65 Musculoskeletal Disorders 65 Sprain (sprane) Clue: Diagnostic or Clinical Findings Pain, swelling, and heat around a recently injured joint, usually the ankle. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 65 Musculoskeletal Disorders 65 Pathophysiology • The ligaments, the strong connective tissue bands • that secure bone to bone, are affected. The most likely joint is the ankle. The ligaments may be slightly torn or completely torn with disconnection from and a piece of the bone attached to the torn ligament. Assessment and Diagnostic Findings • Rapid swelling and pain of the joint. • Limited ability to function. • X-ray, necessary to differentiate a sprain from a fracture, is done usually after the extremity swelling has diminished. Complications • Poor healing with change in range of motion. Medical Care and Surgical Treatment • RICE method: rest the extremity; apply ice to decrease swelling; confine or compress the • • extremity by using an ACE wrap, cast, or brace; and elevate the extremity to decrease tissue edema. Assistive devices are necessary for mobility. Muscle relaxants or anti-inflammatory agents may be used. Keep in Mind • Keep the injured area elevated as much as possible and avoid weight bearing. • Allow time for adequate repair. Make the Connection • Sprains have to be assessed for a fracture being present. • Remember: Ligaments hold bone to bone; tendons hold muscle to bone (more involved in strains). 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 66 Musculoskeletal Disorders 66 Fracture (frak-chur) Clue: Diagnostic or Clinical Findings Tenderness, pain, or deformity over an area of injury. Crepitation may be heard or felt; range of motion is decreased. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 66 Musculoskeletal Disorders Pathophysiology • Healthy bone is living tissue that is dynamic in • • • • nature. Osteoclasts resorb bone, while osteoblasts lay down new bone. In this way, healthy bone is always remodeled. A fracture is a disruption in the bone structure caused by trauma or pathology. Closed fractures do not disrupt the integrity of the skin; open fractures are called compound because they break through the skin as well as disrupt the integrity of the bone. Fracture types are comminuted, impacted, greenstick, oblique, longitudinal, and transverse. Fractures heal by forming a blood clot at the site and attracting cells to the site. The fracture site is known as a callus at week 1, and by week 6, osteoclasts have resorbed dead bone and osteoblasts have remodeled the site. Complete healing is usually in 1 year. Assessment and Diagnostic Findings • X-ray, CT scan, and MRI. • CBC++ to assess blood loss internally or externally. • CA and ESR to assess tissue damage. Complications • Fat embolism. 66 • Infection, neurologic damage, compartment syndrome, and thrombophlebitis. Medical Care and Surgical Treatment • Analgesics, skin traction using balanced traction or an external fixator. • ORIF. • Closed reduction. • Electrical stimulation and bone grafting in cases in which the bone does not mend. Keep in Mind • If a fall involves the hip, report deep groin pain in the absence of x-ray data (a positive sign). • Report any unusual smells from a cast; do not scratch under the cast. Make the Connection • Monitor vital signs for signs of infection, petechial hemorrhage, or dyspnea. • Watch for color, motion, and sensitivity and “palm” cast. • Encourage mobility exercises for the unaffected side to combat thromboembolism. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 67 Musculoskeletal Disorders 67 Compartment Syndrome (com-part-ment sin-drom) Clue: Diagnostic or Clinical Findings Neurovascular assessment of injured area, usually by crush injury or fracture, includes severe pain, pallor, pulselessness, paresthesia, paralysis, and coolness to the touch. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 67 Musculoskeletal Disorders Pathophysiology • In a traumatic injury (e.g., fractures caused by • • automobile accident or crush injury), soft tissue swelling occurs. The soft tissue in this case is the muscle. Every muscle compartment is surrounded by connective tissue called fascia. Fascia compresses the swelling tissue, causing loss of vascularity to tissue and nerves. The muscle tissue is essentially being strangled in its own covering. Less problematic compartment syndrome is seen in exertional compartment syndrome and stress fracture. 67 • Rhabdomyolysis and renal failure. • Infection. Medical Care and Surgical Treatment • Restoring blood flow by performing a fasciotomy. Once pressure is relieved and the swelling goes down, the fascia and skin are closed. Skin grafting may be required. Keep in Mind • Report excessive pain after any sports injury. • Report skin that is cool to the touch distal to any wrap or cast. Assessment and Diagnostic Findings Make the Connection • Neurovascular assessment of injured area, usually • by crush injury or fracture, includes severe pain, pallor, pulselessness, paresthesia, paralysis, and coolness to the touch. Excessive pain is the first clue. • Time is muscle. Is it important to • Complications • Necrosis of the affected tissue. • Paralysis of the extremity. • Volkmann’s contracture. • recognize compartment syndrome to prevent complications and deformity. Remember: When muscle fibers are injured, they may gain access to the bloodstream and filter into the nephrons, causing renal failure. Watch for signs of infection in the area of the fasciotomy or graft. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 68 Musculoskeletal Disorders 68 Total Joint Replacement (to-tal joint re-plas-ment) Clue: Diagnostic or Clinical Findings Replacement of the femoral head and placement of an acetabular cup (THR) (hip), or replacement of the femoral and tibial ends of the knee by metal and the knee cap by a button (TKR). 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 68 Musculoskeletal Disorders Pathophysiology • Persons with problems like chronic osteoarthritis pain, avascular necrosis of the femoral head, or systemic lupus erythematosus (SLE) cannot perform activities of daily living (ADLs) and require the joint be replaced by prosthetic devices. Assessment and Diagnostic Findings • Preoperatively, the client exhibits severe decrease in range of motion and increased pain with ADLs. • Baseline neurovascular assessment is performed. • Postoperatively, the complete blood count (CBC) • is monitored for blood loss and infection; neurovascular assessments are done every 4 hours. Total hip replacement (THR) clients have legs abducted and may not sit with hips flexed at greater than a 90-degree angle. Total knee replacement (TKR) clients have the affected leg (legs) in continuous passive motion (CPM) machines, which move the knee to greater angles as directed by the orthopedist. Complications • Thrombophlebitis and embolism. • Infection. • Hip or knee dislocation. 68 • Sepsis in the joint or blood. • Skin breakdown. • Hemorrhage. Medical Care and Surgical Treatment • Prophylactic antibiotics. • Blood transfusion if necessary (autologous replacement if possible). • Analgesia. • Assessment of neurovascular status. • Assessment of neurologic status in the elder adult. • Flowtron boots or compression stockings; early ambulation (non–weight-bearing). Keep in Mind • Teach THR clients to not cross their legs or sit at greater than a 90-degree angle. • Report pain or chills immediately. Make the Connection • Monitor CBC for hemorrhage and infection. • Monitor and report the neurovascular status of the affected leg distal to the surgery. • Remember that orthopedic surgery is very bloody, so the need for transfusion exists. 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 69 Musculoskeletal Disorders 69 Herniated Nucleus Pulposus (her-ne-at-ed nu-kle-us pul-po-sis) Clue: Diagnostic or Clinical Findings Pain and numbness in the arm or headaches on the affected side (cervical), or pain and numbness radiating down the sciatic nerve in the leg (lumbar). 2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 69 Musculoskeletal Disorders Pathophysiology • The vertebrae have cushions or intervertebral • • disks between them to absorb shock and to keep the nerve roots away from the boney areas. Disks can herniate out of the normal position, and the annulus fibrosus tears. The inner portion (nucleus pulposus) pushes outward and places pressure on a nerve root. The most common sites are the cervical and lumbar areas. Assessment and Diagnostic Findings • Cervical disk herniation causes numbness and tin• • gling in the affected arm, neck spasm, pain, and (in some cases) migraine headache. Lumbar disk herniation causes numbness, pain, and tingling in the affected leg. Muscle spasm is common. Heel-toe walking is not possible because of discomfort. Severe herniation is the only type that would cause incontinence. MRI, with and without contrast, will show herniation of the disk. Complications • Hemorrhage, nerve root damage, and reherniation, and altered mobility after surgery. 69 • Infection after surgery. Medical Care and Surgical Treatment • Analgesics, muscle relaxants, physical therapy, • minimally invasive balloon vertebroplasty, TENS unit, skin traction, and corticosteroid injections directly into the disk area. Surgical laminectomy (frontal approach for cervical, posterior approach for lumbar). Keep in Mind • Report any numbness or problems with mobility after surgery. • Report chills or other signs of infection. • Spinal fusions will limit range of motion. Make the Connection • Monitor neurovascular status of the • • arms (cervical surgery) or of the legs, bladder, and bowel (lumbar surgery). Log-roll the client after surgery. Monitor CBC and ability to perform ADLs without pain. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 6 NERVOUS SYSTEM Meningitis, 70 Concussion, 71 Skull Fracture, 72 Epidural and Subdural Hematoma, 73 Huntington’s Disease, 74 Spinal Cord Injury, 75 Autonomic Dysreflexia, 76 Spinal Shock, 77 Cerebral Aneurysm, 78 Tonic-Clonic Seizures, 79 Absence Seizures, 80 Myoclonic Seizures, 81 Atonic Seizures, 82 Simple Partial Seizures, 83 Complex Partial Seizures, 84 Cerebrovascular Accident, 85 Multiple Sclerosis, 86 Myasthenia Gravis, 87 Trigeminal Neuralgia, 88 Parkinson’s Disease, 89 Alzheimer’s Disease, 90 Bell’s Palsy, 91 Amyotrophic L ateral Sclerosis, 92 Guillain-Barré Syndrome, 93 Encephalitis, 94 Malignant Hyperthermia, 95 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 70 Nervous System Disorders 70 Meningitis (men-in-ji-tis) Clue: Diagnostic or Clinical Findings Nuchal rigidity and pain as the meninges are stretched by moving the legs or flexing the neck to the chin. Turbid CSF with low glucose and high protein. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 70 Nervous System Disorders Pathophysiology • The meninges include the dura matter, arachnoid • • • • layer, and pia matter; and surround the brain and spinal cord. Causative agents include bacteria, viruses, mycobacteria, fungi, amebas, cancer, and noninfectious sources. Entrance via the respiratory system is most common. Infections that occur close to the CNS, basilar fracture, CNS surgery or presence of an indwelling shunt, and blood-borne illnesses cause meningitis. TNF-α and IL-1 are major mediators of inflammation that increase permeability and transit of the causative agent through the blood–brain barrier. Inflammation causes ↑ ICP in meningitis. Assessment and Diagnostic Findings • Fever and symptoms of ICP, including change in • LOC, headache, nausea, vomiting, nuchal rigidity (positive Kernig’s and Brudzinski’s signs), lethargy, photophobia, seizures, pupil dilation, decorticate or decerebrate posturing, and pulse pressure changes. LP shows turbid CSF, and ↓ glucose and ↑ protein levels. Infectious cell count, Gram stain or C&S. 70 • CBC, procalcitonin testing, MRI. • Eye fundus examination showing papilledema. Complications • Seizures; residual hearing, vision, or cognitive defects; and death. Medical Care and Surgical Treatment • Quiet, darkened, nonstimulating environment. Cooling blanket for high temperature. • Antimicrobials, antipyretics, steroids, pain medication, and (rarely) surgical drainage of abscesses. Keep in Mind • Vaccines are recommended for the most common forms of bacterial meningitis (Haemophilus influenzae type b in infants and children, and Neisseria meningitidis in college-aged children). Make the Connection • Change in LOC is often the first sign. • Monitor CBC and Glasgow Coma Scale assessments; elevate the head with neck straight. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 71 Nervous System Disorders 71 Concussion (kon-kush-un) Clue: Diagnostic or Clinical Findings A blow to the head resulting in changes in LOC. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 71 Nervous System Disorders Pathophysiology • Also known as traumatic brain injury, concussion • is caused by a nonpenetrating, or closed, head injury. Mechanisms of injury include acceleration injury, deceleration injury, or a combination of both. Rotational injuries cause traumatic shearing of the brain tissue. Most injuries are related to automobile accidents, but playing contact sports and falls are also frequent causes. After injury, the compromised cells require increased glucose in order to remain alive. However, with the onset of cerebral edema, the capillary bed may become displaced from the cells by fluid. With decreased blood flow, neuronal loss can continue to occur. Assessment and Diagnostic Findings • Change in LOC that may include confusion, • difficulty concentrating, amnesia, brief loss of conciousness, ICP (direct or MRI measurement of ≥15 mmHg), widening pulse pressure, and decorticate or decerebrate posturing. CT scan, MRI ICP measurement >15 mm Hg, and PET. 71 Complications • ICP, brain herniation, diabetes insipidus, and vital sign instability. • Posttraumatic syndrome characterized by a permanent impairment of cognitive or motor function. Medical Care and Surgical Treatment • Control ICP by pharmacologic means or by • mechanical hyperventilation with barbiturateinduced coma and temperature control. Initiate invasive ICP monitoring and ventricular drainage; elevate head and keep neck straight. Keep in Mind • Head trauma is cumulative, so repeated blows to the head can cause irreversible damage. • Teach clients that prevention is the best approach. Wear appropriate headgear when engaging in activities such as bike riding, skating, skiing, or playing contact sports. Helmet use does not guarantee that brain trauma will not occur. Make the Connection • Any change in LOC after head injury warrants medical care and monitoring. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 72 Nervous System Disorders 72 Skull Fracture (skul frak-chur) Clue: Diagnostic or Clinical Findings Severe head trauma resulting in an area of open-skull injury that presents as crepitus, CSF leak, or a depressed area in the skull. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 72 Nervous System Disorders Pathophysiology • Loss of integrity of the cranial bones and/or • • meninges causing damage to the underlying brain tissue and creation of an avenue of infection to the CNS. Types include linear, comminuted, depressed, compound, and basilar. Acute cerebral edema and ICP occur from neuronal damage, hemorrhage, inflammation, infection, potassium leaking to the extracellular space, and lactate buildup from glycolysis. Assessment and Diagnostic Findings • Amnesia, brief loss of consciousness, or signs of increased ICP. • CT scan, or skull x-ray to detect fracture, MRI ICP reading. • Leakage of CSF from cranial orifices. • Battle’s sign or raccoon sign. Complications • ICP, brain herniation, diabetes insipidus, and vital sign instability. • Permanent impairment of cognitive or motor function. 72 Medical Care and Surgical Treatment • Control ICP by pharmacologic means or by • • mechanical hyperventilation with barbiturateinduced coma and temperature control. Initiate invasive ICP monitoring and ventricular drainage; elevate head and keep neck straight. Reduction of fracture, including removal of penetrating bone. Keep in Mind • After head trauma, an area that is depressed rather than swollen requires immediate care. Make the Connection • Monitor CT, MRI, or PET imaging. • Maintain a record of vital signs and Glasgow Coma Scale readings. • Monitor ICP reading. • Check any clear drainage for glucose or concentric circles forming on a dressing. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 73 Nervous System Disorders Epidural and Subdural Hematoma (ep-i-dur-al and sub-du-ral he-ma-to-ma) Clue: Diagnostic or Clinical Findings Head injuries that may be arterial or venous in nature, causing ICP and change in LOC. May cause rapid ICP or be insidious, chronic, or become fatal. 73 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 73 Nervous System Disorders Pathophysiology • Traumatic brain injury that is nonpenetrating and • • • caused by rotational injury, acceleration injury, deceleration injury, or both. Epidural hematomas are arterial, so symptoms are more severe due to rapid accumulation of blood above the dural layer. Subdural hematomas are venous, so symptoms may be more insidious. These hematomas may occur together. Assessment and Diagnostic Findings • CT scan, MRI scan, and x-ray of the skull. • Increased ICP with decreased LOC, headache, dizziness, nausea, vomiting, vital sign changes like temperature increase, hemiparesis, unequal pupil dilation, decorticate or decerebrate posturing, ICP measurement by invasive or noninvasive MRI measurement of ≥15 mm Hg. Complications • ICP, brain herniation, diabetes insipidus, and vital sign instability. • Hemiparesis, chronic neurologic injury, or death. 73 Medical Care and Surgical Treatment • Control ICP by pharmacologic means, steroids, or • • by mechanical hyperventilation with barbiturateinduced coma and temperature control. Initiate invasive ICP monitoring and ventricular drainage; elevate head and keep neck straight. Surgical evacuation of hematoma and repair of bleeding vessels. Keep in Mind • Teach clients that prevention is best approach. Wear appropriate headgear when engaging in activities such as bike riding, skating, skiing, or playing contact sports. Helmet use does not guarantee that brain trauma will not occur. Make the Connection • Monitor CT, MRI, and ICP measurements. Maintain Glasgow Coma Scale assessments. • Monitor vital signs; keep head elevated and neck straight to lessen ICP. • Elderly clients and alcoholics may develop insidious subdural hematoma. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 74 Nervous System Disorders 74 Huntington’s Disease (se-le-ak di-zez) Clue: Diagnostic or Clinical Findings Onset of jerking movements of the upper extremities, face, and neck progressing to the rest of the body accompanied by progressive psychotic behavior. Genetic testing reveals mutation of the IT15 gene resulting in huntingtin protein. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 74 Nervous System Disorders Pathophysiology • A disorder that causes a mutation in the IT15 • • gene that results in transcription of an abnormal protein called huntingtin protein. Abnormalities in DNA trigger cellular death. Cells affected are those that control motor and cognitive function. An autosomal dominant disorder; each offspring of an affected parent has a 50% chance of inheriting the disorder. Onset may be in childhood or in midlife. Assessment and Diagnostic Findings 74 Medical Care and Surgical Treatment • Antipsychotic medications, antidepressants, and antichoreic medications. • Research is ongoing regarding fetal nerve tissue transplant, but there is no cure. Keep in Mind • Teach clients and caregivers that soft foods and • • Personality changes, inappropriate behaviors, • • • labile moods, depression, and suicidal tendencies. Paranoia with irritability, anxiety, and aggressive behavior. Choreiform movements. Video swallowing test for dysphagia. Complications • Aspiration pneumonia. • Choking. • Progressive loss of social and physical skills, leading to debilitation and death. thickened liquids will be substituted in the diet to assist in swallowing effectively. Teach caregivers that jerking movements are not a sign of aggression but that aggression can occur. Make the Connection • The client with Huntington’s disease must • • make end-of-life decisions at the onset of symptoms. Genetic counseling and testing must be available to anyone with a history of Huntington’s disease. Assess respiratory function, breath sounds, and ability to swallow. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 75 Nervous System Disorders 75 Spinal Cord Injury (spi-nal kord in-jur-e) Clue: Diagnostic or Clinical Findings Loss of sensation, movement, or both after trauma to the neck, thorax, lumbar, or sacral area. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 75 Nervous System Disorders 75 substance abuse, skin breakdown, and autonomic dysreflexia. Pathophysiology • Nerve fibers of the spinal cord are nonregenerative. • Central cord syndrome results in weakness or • • • • paralysis that affects the upper extremities more than the lower extremities. Anterior cord syndrome, caused by trauma or ischemia results in weakness and decreased pain and temperature sensation below the damaged area. Posterior cord syndrome causes ataxia, but strength and sensation are preserved. Brown-Séquard syndrome results in paralysis on the affected side and sensation loss on the opposite side of injury. Cauda equina syndrome results in bowel and bladder dysfunction and some leg paresthesia. Medical Care and Surgical Treatment • Immobilize the client, apply traction, and support • • the respiratory and vital functions. IV access required for fluids and medications. Injuries above C4 will result in respiratory depression. Support bowel and bladder function. Surgically stabilize the vertebrae. Keep in Mind • Teach clients that they must remain immobile. • Clients need to know that there is a “wait and see” time frame for some types of injuries, but they must be kept apprised and participate in the plan of care. Assessment and Diagnostic Findings • Abnormalities in sensation, temperature sense, • or motor function that occur in patterns that suggest the type of injury. MRI scan. Complications • Infection, deep vein thrombosis, orthostatic hypotension, spinal shock, depression and/or Make the Connection • Monitor all vital functions and oxygenation; assess CBC. • Maintain immobilization; check sensation/motor function; assess skin, bowel, and bladder. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 76 Nervous System Disorders 76 Autonomic Dysreflexia (aw-to-nom-ik dis-re-flek-se-a) Clue: Diagnostic or Clinical Findings In spinal cord injuries above T6, sudden onset of headache, nasal stuffiness, high BP, and flushed skin above the level of injury. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 76 Nervous System Disorders Pathophysiology • SCI above T6 receive peripheral sensory impulses • • from below the injury via the spinothalamic tract that stimulates a large sympathetic release of norepinephrine, dopamine β-hydroxylase, and dopamine. These neurotransmitters cause vasoconstriction (↑ BP) and skin pallor below the area of injury. The brainstem reacts to the ↑ BP by parasympathetic nervous innervation above the level of injury. Relieving the noxious stimuli stops the sensory signal and therefore the sympathetic response. 76 Complications • Cerebrovascular accident or hemorrhage; retinal hemorrhage. • Myocardial infarction. Medical Care and Surgical Treatment • Antihypertensive medications as needed. • Remove the noxious stimuli to stop the dysreflexia. Keep in Mind • Teach clients with SCI above T6 about symptoms and to report them immediately. • If clients are capable, they should self-catheterize if symptoms begin. Assessment and Diagnostic Findings • Blood pressure elevation that can be as high as 300 mm Hg systolic. • Flushing of skin above the thoracic SCI, nasal stuffiness, headache, and bradycardia. • Pallor of the skin below the thoracic SCI with piloerection. • Bladder distention, bowel impaction, UTI, ingrown toenail, pressure sores, wrinkled bed linen, or pain below the level of the SCI are causes. Make the Connection • Monitor vital signs. • Assess for full bladder or rectal impaction first, and then conduct systematic assessment for stimuli. • Monitor CBC, I&O, and urine C&S. • Turn client every 2 hours. • Teach and assess bladder and bowel training activities. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 77 Nervous System Disorders 77 Spinal Shock (spi-nal shok) Clue: Diagnostic or Clinical Findings Period of time after SCI in which there is no motor or sensory transmission. Can last a day to several months. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 77 Nervous System Disorders Pathophysiology • SCI causes a concussion-like injury to neurons • • • • known as spinal shock in which neurons below the level of the SCI are incapable of any sensory or motor transmission. Cytokines cause an inflammatory condition in the affected neurons. Phase 1 spinal shock is characterized by the absence of all reflex arcs below the SCI. Phase 2 spinal shock is characterized by the return of some of the reflex arcs, which signals the beginning of the end of spinal shock. Phase 3 and 4 are characterized by strong reflexes that occur with minor stimulation and may be followed by autonomic dysreflexia, hyperreflexia, and clonus. Assessment and Diagnostic Findings • Hypotonia, areflexia, and paralysis below the level of SCI. • Bulbocavernosus reflex elicitation and assessing for anal sphincter contraction. Complications • Skin breakdown; osteoporosis. 77 • Depression of the client with spinal shock waiting to know the extent of injuries. • Respiratory infection; hemodynamic fluctuation. • Spasticity; autonomic dysreflexia. Medical Care and Surgical Treatment • Immobilization to prevent any further injury. • Steroids and other anti-inflammatory agents. Keep in Mind • Teach clients that the extent of their injuries cannot be assessed until spinal shock ends. Make the Connection • Monitor for return of reflexes, spasticity, or clonus. • Assess breath sounds and institute a respiratory care program. • Monitor blood chemistry for F&E and CBC for infection. • Assess skin and utilize pressure-relieving methods while maintaining immobilization for SCI. • Support the client psychologically. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 78 Nervous System Disorders 78 Cerebral Aneurysm (ser-a-bril an-u-rizm) Clue: Diagnostic or Clinical Findings Sudden onset of a severe headache, ICP, change in LOC, and motor dysfunction and dilation of pupil on affected side. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 78 Nervous System Disorders Pathophysiology • • The endothelial lining of vessel walls become damaged, lose elasticity, and become vulnerable to rupture. Contributing conditions include HTN, atherosclerosis, natural presence of arterial bifurcation, and congenital high-pressure areas such as AVMs. Ruptured aneurysms have abnormally high levels of inflammatory cell infiltration. Assessment and Diagnostic Findings • Cerebral angiography can precisely diagnose an • • • • • aneurysm by outlining the abnormal dilation or outpouching of vessels. MRI with contrast is diagnostic and shows abnormal outpouching of vessels. Dilation of the pupil on the affected side, headache, nausea and vomiting, change in LOC, and other signs of ICP. Motor dysfunction of cranial nerve VI resulting in abnormal gaze. Motor dysfunction of one or both limbs on the side opposite the ruptured aneurysm. Abnormal Glasgow Coma Scale score. 78 Complications • Rebleeding after surgical repair. • Vasospasm leading to widespread ischemia. • Hydrocephalus. Medical Care and Surgical Treatment • Antihypertensives. • Smoking cessation program. • Catheterization and placement of a coil or other material to fill a small aneurysm. • The stalk of a berry aneurysm can be clipped surgically; others may be wrapped to prevent rupture; some are resected and reanastomed. Keep in Mind • Teach clients to report severe headaches, especially accompanied by nausea/vomiting; have yearly physicals; stop smoking; and limit alcohol consumption. Make the Connection • Monitor ICP, Glasgow Coma Scale score, and vital signs. • Assess psychological status. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 79 Nervous System Disorders 79 Tonic-Clonic Seizures (ton-ik klon-ik se-zhurz) Clue: Diagnostic or Clinical Findings Presence of an aura followed by loss of consciousness with alternating cycles of stiffness and jerking movements lasting 1–2 minutes. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 79 Nervous System Disorders Pathophysiology • Tonic-clonic seizures are generalized seizures. • Pathology includes an area of hyperexcitable neurons. This is the epileptogenic focus. Assessment and Diagnostic Findings • EEG identifies the epileptogenic focus and seizure threshold. • Client reports having a sensory warning prior to onset of a seizure (aura). • The tonic phase is accompanied by laryngeal • • • spasm, autonomic reaction with increase in pulse and BP, and increased mucus secretion. This phase lasts approximately 20 seconds. The clonic phase is characterized by alternating atonia and spasm and lasts approximately 30 seconds; the client may be incontinent as the urinary sphincter relaxes. The entire seizure usually does not exceed 1–2 minutes. The postictal phase follows the seizure and is characterized by amnesia of the seizure, confusion, lethargy, muscle pain, and embarrassment. 79 Complications • Status epilepticus and death. • Injury to the head or body, biting of the lips or tongue, vertebral compression fractures. • Interpersonal relationship interruption. Medical Care and Surgical Treatment • AEDs; ketogenic diet. • Resection or ablation of the epileptogenic focus. • Vagal nerve stimulation; corpus callosotomy. Keep in Mind • Teach clients they may drive again when seizures are certified as being controlled. • Stress may increase the need for AEDs. • Comply with serum AED levels. Make the Connection • Protect the client from injury; never insert anything into the mouth during the seizure. • Time the seizure; monitor serum level of AEDs; monitor CBC for ↓ WBC. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 80 Nervous System Disorders 80 Absence Seizures (ab-sens se-zhurz) Clue: Diagnostic or Clinical Findings Usually a disease of children; the child appears to be daydreaming and has no recall of the event. Abnormal EEG. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 80 Nervous System Disorders Pathophysiology • Generalized seizures that may be due to alternat• ing gamma-aminobutyric acid type B (GABAB) receptor–mediated inhibition alternating with glutamate-mediated excitation. Calcium channel abnormalities are also implicated in the genesis of absence seizures. Assessment and Diagnostic Findings • Electroencephalogram (EEG) showing abnormal spikes alternating with slow-wave patterns. • Staring episodes that look like daydreaming. • Mutation in the GABAA receptor gene (GABRB3). Complications • Educational and behavioral problems related to unrecognized seizures. Medical Care and Surgical Treatment • Antiepileptic drugs (AEDs). 80 Keep in Mind • Teach clients, caregivers, and teachers about the illness. • Medication regimens must be followed to prevent further seizures. • Teach that serum blood levels of AEDs will be measured. • Teach side effects (lethargy, sleepiness) of AEDs. • The need for AEDs increases with stress. Make the Connection • Monitor serum AED levels. • Monitor vital signs. • Provide emotional support to the family; impress upon the family that this illness can be controlled with little risk to or interruption of the development of the child. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 81 Nervous System Disorders 81 Myoclonic Seizures (mi-o-klon-ik se-zhurz) Clue: Diagnostic or Clinical Findings Brief, sudden jerking motion bilaterally, with EEG showing abnormal waveforms. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 81 Nervous System Disorders Pathophysiology • A generalized seizure with juvenile onset. The • • cerebral cortex, subcortical, and spinal areas are believed to be involved in the development of myoclonic seizures. The electrical discharge from the cortex produces stimulation of the muscles through the motor centers. Acetycholine (excitatory), serotonin (inhibitory), and GABA (inhibitory) neurotransmitters are present in mismatched amounts in this disorder. The mechanism of myoclonic seizure disorder is related to restless leg syndrome. Assessment and Diagnostic Findings • Involuntary jerking motion of limbs, soft palate, and other areas that occurs bilaterally. • CT scan and MRI to rule out physiologic abnormalities of the brain. • EEG identifies the epileptogenic focus. • Loss of consciousness cannot be determined due to the brevity of the seizure; however, myoclonic seizures can progress to tonic-clonic seizures. Complications • Falls and injury from tripping. • May progress to tonic-clonic seizures. 81 • Some forms of myoclonic seizure can be associated with cognitive delay and progressive brain dysfunction. Medical Care and Surgical Treatment • AEDs; ketoginec diet. • Vagal nerve stimulation. • Focal resection; corpus callosotomy. Keep in Mind • Teach clients and family members that myoclonic • seizure activity can occur during sleep or immediately after awakening. Loss of consciousness is rare, but a period of confusion may occur. Make the Connection • Monitor serum concentrations of AEDs to assure therapeutic levels. • Monitor CBC to assess for BMS. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 82 Nervous System Disorders 82 Atonic Seizures (a-ton-ik se-zhurz) Clue: Diagnostic or Clinical Findings Sudden loss of muscle tone causing a “drop attack.” 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 82 Nervous System Disorders Pathophysiology • Classified as a generalized seizure, with juvenile • onset lasting into adulthood. The cerebral cortex, subcortical, and spinal areas are believed to be involved in the development of generalized seizures. The electrical discharge from the cortex produces stimulation of the muscles through the motor centers. Evidence indicates that an abnormality exists among neurotransmitters (e.g., gammaaminobutyric acid [GABA]) or in calcium, potassium, or sodium channel activity. Assessment and Diagnostic Findings • May experience an aura and have sweating and piloerection. • Electroencephalogram (EEG) showing abnormal wave patterns. • Computed tomography (CT) scan and magnetic resonance imaging (MRI) to rule out other brain pathology. Complications • Injury related to loss of tone and falls. 82 Medical Care and Surgical Treatment • Antiepileptic drugs (AEDs). • Vagal nerve stimulation. • Focal resection; corpus callosotomy. • Ketogenic diet. Keep in Mind • Teach clients and family members about the nature of the disorder and its treatments. • Blood tests will be done to monitor serum AED levels. Make the Connection • Monitor serum concentrations of AEDs to assure therapeutic levels. • Monitor complete blood count (CBC) to assess for bone marrow suppression. • Assess CT scan and MRI for abnormalities in brain structure. • Provide emotional support; refer to support group. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 83 Nervous System Disorders 83 Simple Partial Seizures (Focal) (sim-pl par-shul se-zhurz fo-kal) Clue: Diagnostic or Clinical Findings Lip smacking, picking at clothing, or chewing behaviors of which the client is unaware. Consciousness is not lost. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 83 Nervous System Disorders Pathophysiology • Simple partial seizures, or focal seizures, arise • • • from one hemisphere of the brain, usually in the temporal lobe. May spread to the parietal lobe, causing transient paresthesias of the body on the opposite side of the epileptogenic focus, usually beginning in the finger, arm, and hand and then spreading to the leg and face. Neurotransmitter abnormalities, especially in gamma-aminobutyric acid (GABA), as well as calcium, potassium, or sodium channel abnormalities, may produce the abnormal electrical charge. Simple partial seizures may spread and become a generalized seizure. Assessment and Diagnostic Findings • Juvenile onset lasting into late adulthood. • Electroencephalogram (EEG) showing abnormal wave patterns. • Computed tomography (CT) scan and magnetic • resonance imaging (MRI) to rule out other brain pathology. Automatisms (e.g., fondling oneself, chewing, lip smacking). 83 Complications • Psychosocial implications if automatisms are present. • May spread and become a generalized seizure. Medical Care and Surgical Treatment • Antiepileptic drugs (AEDs). • Vagal nerve stimulation. • Focal resection. • Corpus callosotomy is controversial. • Ketogenic diet. Keep in Mind • Teach clients and family members about the nature of the disorder and its treatments. • Blood tests are done to monitor serum AED levels. Make the Connection • Monitor serum concentrations of AEDs to assure therapeutic levels. • Monitor complete blood count (CBC) to assess for bone marrow suppression. • Assess CT scan and MRI for abnormalities in brain structure. • Provide emotional support; refer to support group. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 84 Nervous System Disorders Complex Partial Seizures (Psychomotor) (kom-pleks par-shul se-zhurz si-ko-mo-tor) Clue: Diagnostic or Clinical Findings Staring, running away, picking at clothing, or standing still with lip smacking or other socially awkward behavior. May lose consciousness. 84 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 84 Nervous System Disorders Pathophysiology • Complex partial seizures arise from one hemisphere of the brain, usually in the temporal lobe. • May spread and become a generalized seizure. • Neurotransmitter abnormalities, especially in • gamma-aminobutyric acid (GABA), as well as calcium, potassium, or sodium channel abnormalities, may produce the abnormal electrical charge. Loss of consciousness occurs and may last 2–15 minutes. Assessment and Diagnostic Findings • Electroencephalogram (EEG) showing abnormal wave patterns. • Computed tomography (CT) scan and magnetic • resonance imaging (MRI) to rule out other brain pathology. Automatisms (e.g., fondling oneself, chewing, lip smacking, running away, screaming, masturbating). Complications • Psychosocial implications if automatisms are present. • May spread and become a generalized seizure. 84 Medical Care and Surgical Treatment • Antiepileptic drugs (AEDs). • Vagal nerve stimulation. • Focal resection. • Corpus callosotomy is controversial. • Ketogenic diet. Keep in Mind • Teach clients and caregivers the nature of these seizures and that they may spread. • Teach caregivers not to yell at the client or tell the client to stop the behavior because doing so is not helpful; rather, keep the client safe. Make the Connection • Monitor serum concentrations of AEDs to assure therapeutic levels. • Monitor complete blood count (CBC) to assess for bone marrow suppression. • Assess CT scan and MRI for abnormalities in brain structure. • Provide emotional support; refer to support group. • Do not attempt to restrain the client unless he or she is in danger. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 85 Nervous System Disorders 85 Cerebrovascular Accident (ser-e-bro-vas-ku-lar ak-si-dent) Clue: Diagnostic or Clinical Findings Inability to form words, drooping of the face, or inability to see out of one eye. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 85 Nervous System Disorders Pathophysiology • Result of a thrombotic block to blood flow or • • • bleeding into the brain that drastically diminishes blood flow to the neurons, causing the cerebrovascular accident (CVA). Injured cells fill up with free zinc ions that are believed to hasten their demise. Production of glutamate increases the metabolic needs of the already depleted neurons. Inflammation causes cerebral edema. Assessment and Diagnostic Findings • CT scan (first) and MRI to determine if the CVA • • • • is a result of ischemia related to a thrombus or a hemorrhage. Hemianopsia and facial droop on affected side, aphasia or dysphasia, and paresthesia or paralysis on the opposite side of the CVA. The CPHSS is performed, and if any one of the three criteria is positive, the client is brought to the hospital for assessment. ECG to rule out atrial fibrillation; ↑ BP. A severe headache will be present in hemorrhagic stroke. 85 Complications • Death. • Permanent loss of function; unilateral neglect. • Depression, poor judgment, seizures, and PE. • Increased ICP and respiratory insufficiency. Medical Care and Surgical Treatment • Thrombolytic therapy. • Antiplatelet therapy; antidysrhythmic medications; oxygenation; cardiac monitor. • Suction as necessary; liquids are thickened. • Surgical intervention for hemorrhagic stroke. Keep in Mind • Teach clients to have their BP and blood lipids checked and to report any CVA signs. Make the Connection • Closely monitor laboratory tests and hemodynamic status in the acute phase. • Provide physical and occupational therapy; assess ability to swallow effectively. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 86 Nervous System Disorders 86 Multiple Sclerosis (mul-ti-pl skle-ro-sis) Clue: Diagnostic or Clinical Findings Exacerbating and remitting periods of degenerating motor function. The MRI shows demyelination of the white matter of the brain. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 86 Nervous System Disorders Pathophysiology • Exacerbating and remitting disease characterized • • by demyelination of brain white matter, damage to axons, and decreased number of oligodendrocytes in the CNS affecting young adults (ages 20–40) and women more than men. Autoimmune inflammatory disease involving cell-mediated (T-cell) and antibody (B-cell) activity. Exacerbation of symptoms can be caused by extreme heat or cold, fatigue, infection, stress, or pregnancy. Assessment and Diagnostic Findings • Visual problems (one eye at a time), with eye pain • • • • during eye movement; diplopia; slurred speech and dysarthria; vertigo; tinnitus; nystagmus; ataxia; and dysphagia. Numbness and weakness of limbs, spastic or flaccid bladder, urinary incontinence, constipation, and sexual dysfunction. Mood lability. CSF assessment for oligoclonal IgG. Magnetic resonance imaging (MRI) reveals sclerotic plaques. 86 Complications • Immobility issues. • Accidents and risk for falls; decreased cognitive function; alteration in family relationships. • Respiratory infections; death. Medical Care and Surgical Treatment • Beta-interferons, corticosteroids, or adrenocorticotropic hormone. • Antidepressants, antispasmodics, and anticholinergics. • Plasmapheresis. • Physical therapy and rest periods. Keep in Mind • Teach clients to avoid stress and extremes of temperature and to report respiratory infections. Make the Connection • Evaluate respiratory status; have client use incentive spirometry. • Encourage self-care and stress reduction; provide emotional support. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 87 Nervous System Disorders 87 Myasthenia Gravis (mi-as-the-ne-a gra-vis) Clue: Diagnostic or Clinical Findings Ptosis of one eyelid. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 87 Nervous System Disorders Pathophysiology • Meaning “grave muscle weakness,” MG is an • • autoimmune disease that produces antibodies that attack AChR in the NMJ of skeletal muscles. ACh molecules are inactivated by the enzyme AChE, which is abundantly present at the NMJ. The disease involves periods of exacerbation and remission. 87 Medical Care and Surgical Treatment • Cholinesterase-inhibiting drugs; steroids; plasmapheresis. Keep in Mind • Teach clients to take their medication on arising and before eating breakfast. • Report excessive weakness, nausea, vomiting, constriction of pupils, and dyspnea. Assessment and Diagnostic Findings • Antibodies to muscle striations in serum. • Weakness with activity and return of muscle strength after rest. • Ptosis of eyelids when asked to gaze upward for • • • • 2 minutes; weakness in chewing and swallowing, speaking, and breathing. Exacerbations caused by stress. EMG to rule out nerve damage. Tensilon test. Respiratory function tests. Complications • Cholinergic crisis; myasthenic crisis. • Aspiration and choking. • Respiratory failure; death. Make the Connection • Avoid medications that interfere with therapy. • Monitor clients on calcium channel blockers, • beta blockers, antibiotics, and antidysrhythmics, as these may interfere with muscle contraction. Assess muscle function; auscultate lungs and review pulmonary function tests. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 88 Nervous System Disorders 88 Trigeminal Neuralgia (tri-jem-in-al nu-ral-je-a) Clue: Diagnostic or Clinical Findings Severe knife-like facial pain unilaterally in response to movement of the musculature of the face, a touch, or cool breeze. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 88 Nervous System Disorders Pathophysiology • Vascular compression or other structural disor• • ders of the vasculature cause inflammation of the fifth cranial nerve, or TN. Inflammation and compression cause demyelination and remyelination of the nerve. This abnormal myelination causes abnormal sensory discharge, felt by the client as intense pain. Trigger zones include the lips, upper or lower gums, cheeks, forehead, and side of the nose. Assessment and Diagnostic Findings • Burning, jabbing or knife-like pain in the face on one side. • Triggers include a slight touch, a cold breeze, • • • chewing, talking, face washing, teeth brushing, shaving, and eating. Tearing and frequent blinking on the affected side. Attacks are rare during sleep. CT scan and MRI to rule out other disorders. Complications • Avoidance behaviors. • Bone marrow suppression from drugs to treat TN; loss of corneal sensation from nerve blocks and ablative therapies. 88 Medical Care and Surgical Treatment • Anticonvulsants and benzodiazepines. • Nerve block with a local anesthetic. • Radiofrequency ablation to destroy some of the nerve branches. • Gamma knife therapy. Keep in Mind • Teach clients to protect their eyes if corneal sensation is lost as a result of treatment. Artificial tears and an eye patch should be used (eye patch during sleep). Make the Connection • Encourage normal activity. • Report attacks and implement pharmacologic intervention as necessary. • Assess corneal sensation after ablative therapies. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 89 Nervous System Disorders 89 Parkinson’s Disease (par-kin-sonz di-zez) Clue: Diagnostic or Clinical Findings Mask-like facial expression, soft and monotonous voice, drooling, dysphagia, and shuffling gait. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 89 Nervous System Disorders Pathophysiology • Under the cerebral cortex are interconnected • areas of gray matter (basal ganglia), which are involved in controlling voluntary movement. Adjacent to the basal ganglia are cells of the substantia nigra that produce the neurotransmitter dopamine necessary to produce smooth and coordinated muscle movement. Death of cells in the substantia nigra leads to decreased levels of dopamine production, and impairment of EP tract. As dopamine levels decrease, acetylcholine levels increase. Assessment and Diagnostic Findings • MRI to rule out other conditions. • Lewy bodies, found in the cortex. • TRAP criteria. Complications • Orthostatic hypotension, falls, constipation, • painful joints from stiffness and tremor, and communication problems. Loss of quality of life, depression, swallowing difficulty, and dementia in later stages related to the disease or treatment. 89 • Parkinsonian crisis triggered by physical or emotional stress. Medical Care and Surgical Treatment • Dopamine agonists, MAO-B inhibitors, COMT inhibitors, and anticholinergics. • Pallidotomy; embryonic stem cell therapy. Keep in Mind • Teach clients tricks to overcome “freezing”; add • fiber and liquids to the diet; report any psychological problems (hallucinations or depression). Avoid tyramine-containing foods. Make the Connection • Monitor side effects of medication. • Avoid meperidine (fatal interaction with MAO-B inhibitors). • Assess ability to chew and swallow. • Assess for worsening of symptoms. • Provide emotional support, assess for pain. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 90 Nervous System Disorders 90 Alzheimer’s Disease (alts-hi-merz di-zez) Clue: Diagnostic or Clinical Findings Short-term memory loss, forgetfulness, confusion, and inability to recognize loved ones or self. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 90 Nervous System Disorders 90 Pathophysiology • Neuropathologic findings in SDAT include amy• • • loid plaques, neurofibrillary tangles, and synaptic and neuronal cell death. Degeneration occurs first in the hippocampus, (short-term memory), then damage spreads to the temporal area. Frontal damage causes personality changes and incontinence. Acetylcholine levels in the cerebral cortex become deficient. Ventricles of the brain become larger as the brain tissue is destroyed. The brain shrinks in size. Assessment and Diagnostic Findings • Stage 1 (the forgetfulness stage) is characterized • • by episodes of losing personal items, forgetting appointments, and jealousy. Stage 2 (the confusional stage) is characterized by transient loss of recognition of loved ones and self, inability to do simple mathematic calculations, depression, anxiety, and hyperorality. Stage 3 (the dementia stage) is characterized by psychosis, permanent loss of memories of loved ones, severe sleep disorders and “sundowning,” • incontinence, decreased appetite, and respiratory compromise. MRI, PET scan, and SPECT scans may reveal areas of tangles, plaques, and decreased cell metabolism respectively. Complications • Inability to achieve caloric needs. • Respiratory compromise leading to pneumonia. • Incontinence and skin breakdown. • Immobility resulting in death. Medical Care and Surgical Treatment • Acetylcholinesterase inhibitors; NMDA receptor antagonists. • Cognitive therapy, reality orientation, pet therapy, validation therapy, reminiscence therapy. Keep in Mind • Teach family to assist clients with ADLs. • Arrange for respite care services. Make the Connection • Utilize recall of past events in order to communicate with those with severe dementia; monitor I&O and dietary intake. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 91 Nervous System Disorders 91 Bell’s Palsy (bellz pawl-ze) Clue: Diagnostic or Clinical Findings Unilateral drooping of the face; inability to blink the eye. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 91 Nervous System Disorders Pathophysiology • Inflammation thought to be caused by autoim• • mune, viral, bacterial, or traumatic processes of the seventh cranial nerve (facial nerve), causing interruption of nerve transmission. Motor control is lost usually on one side of the face, although it can occur bilaterally (1%). More likely to occur in pregnancy, immune dysfunction (e.g., human immunodeficiency virus), or diabetes. Assessment and Diagnostic Findings • Drooping of the face unilaterally; inability to blink the eye. • Electromyogram (EMG) may be done to confirm nerve dysfunction. • Computed tomography (CT) scan to rule out cerebrovascular accident. Complications • Damage to the cornea of the eye through drying or rubbing against the pillow during sleep. Pain described as burning or “cold” in the eye and facial area. 91 Medical Care and Surgical Treatment • Steroids, antibiotics, antiviral medications, and B-vitamin supplements. • Eye patch and frequent application of artificial tears. Keep in Mind • Teach the client to gently massage the face and ear to ease pain. • Teach the client to use analgesics as needed and as prescribed. • Disorder may be self-limiting or become a chronic condition. Make the Connection • Medicate the client for pain based on a scale of 0–10 when pain level is at 4 or above. • Assess the affected eye for inflammation, which could be a sign of corneal irritation. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 92 Nervous System Disorders 92 Amyotrophic Lateral Sclerosis (a-mi-o-tro-fik lat-er-al skle-ro-sis) Clue: Diagnostic or Clinical Findings Fasciculations and atrophy of muscle groups with progressive weakness; a degenerative neuromuscular disease. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 92 Nervous System Disorders Pathophysiology • Also known as Lou Gehrig’s disease, ALS is a progressive neurodegenerative disease. • The upper and lower motor neurons degenerate • • and form scar tissue, disrupting nerve transmission and leading to muscle atrophy. Results in swallowing and breathing difficulty. A genetic link is suspected as the cause. Onset is usually between ages 40 and 70 years and more prevalent in men than in women; survival varies from 3–10 years or more. Assessment and Diagnostic Findings • Fasciculation and atrophy of muscle, with progressive weakness. • Intellect is intact. • Difficulty chewing and swallowing. • Difficulty clearing respiratory secretions. • CSF analysis, EEG, nerve biopsy, and EMG may be done to rule out other disorders. • Blood enzymes may be increased due to muscle atrophy. Complications • Aspiration; respiratory compromise. 92 • Incontinence. • Immobility issues; death. Medical Care and Surgical Treatment • Muscle relaxants and benzodiazepines for spasticity. • Quinine for muscle cramps. • Riluzole to reduce motor neuron destruction. • Physical and occupational therapy, massage, mobility aids, and enteral feedings. • Air mattresses to reduce skin breakdown. • Respiratory suctioning and supplemental oxygen. Keep in Mind • Teach the client and caregivers how to preserve the skin, respiratory function, and activity level. • Provide information regarding mobility devices and computer-assisted communication devices. Make the Connection • Assess respiratory function and ability to clear secretions. • Provide a method of communication. • Monitor for skin breakdown; institute a turning schedule. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 93 Nervous System Disorders 93 Guillain-Barré Syndrome (ge-yan ba-ra sin-drom) Clue: Diagnostic or Clinical Findings Paralysis of the legs, ascending to the upper body. May affect the ability to breathe on one’s own. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 93 Nervous System Disorders Pathophysiology • GB syndrome (inflammatory polyneuritis), is an • • • inflammatory disorder characterized by a distinct progression of paralysis. GB often follows a viral infection. Occurs in those older than age 45 years and with higher frequency in Caucasians than in African Americans. Peripheral nerves are infiltrated by immune cells that lead to inflammation and demyelination of the axon. Paralysis begins in the legs and ascends. If the disease reaches the lungs, respiratory support is required. The plateau stage is the most severe, but it signals the end of the progression; remyelination occurs and the symptoms regress. A descending form of the disease exists. Miller-Fisher syndrome causes ataxia and extra ocular paralysis but no respiratory or sensory loss. Assessment and Diagnostic Findings • • • LP for CSF. Shows ↑ protein. EMG and nerve conduction velocity tests. Pulmonary function tests. Complications • Respiratory failure, infections, depression, and anxiety. 93 • Immobility, skin breakdown, PE, muscle atrophy, and DVT. Medical Care and Surgical Treatment • Plasmapheresis. • Ventilation and supplemental oxygen. • Steroids. Keep in Mind • Teach clients and caregivers measures will be • taken to mitigate symptoms; temporary ventilator support may be needed. Teach about the normal progression of the disease. Make the Connection • Provide emotional support and diversion. • Manage pain; assess for skin integrity, nutritional status. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 94 Nervous System Disorders 94 Encephalitis (en-sef-a-li-tis) Clue: Diagnostic or Clinical Findings Inflammation of the brain leading to ICP, most frequently caused by viruses (e.g., West Nile virus), parasites, toxins, bacteria, vaccines, or fungi. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 94 Nervous System Disorders Pathophysiology • Neurons are damaged and inflamed, leading to cerebral edema and increased ICP. • Causative agents are viruses, ticks, mosquitoes, • parasites, toxins, bacteria, vaccines, or fungi. Those with a compromised immune system, the very young, and the very old are especially at risk. Herpes simplex virus may be the most common non-insect-borne cause of the disease. Assessment and Diagnostic Findings • Elevated temperature, headache, nausea, vomiting, and general malaise. • Ataxia, altered sleep patterns, tremors, and hemiparesis. • CT scan, MRI, and LP to assess CSF. CT scan and MRI diagnose cerebral edema. CSF shows an increased WBC and protein level, and normal glucose levels. Complications • Seizures, motor deficits, personality changes, blindness, and cognitive deficits. • Brain herniation and death. 94 Medical Care and Surgical Treatment • AEDs, antipyretics, analgesics, sedatives, and corticosteroids. • ICP monitoring through invasive methods or noninvasive MRI. • Antiviral medications IV. Keep in Mind • Teach client and family members about the disorder. • To decrease cerebral edema, maintain a calm environment with little stimuli. • Teach that the goal of ventilator and medication therapy is to reduce ICP. Make the Connection • ICP is made worse by noxious stimuli; keep the client calm and the environment quiet. • Monitor CBC, ABGs, and ICP measures. • Assess for skin breakdown. • Monitor ventilation; clear respiratory passages only when needed to reduce ICP increases. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 95 Nervous System Disorders 95 Malignant Hyperthermia (ma-lig-nant hi-per-ther-me-a) Clue: Diagnostic or Clinical Findings Temperature increase and muscle rigidity following exposure to anesthetics. Creatinine and BUN levels increase. Urine is brown in color. 2693_Tab06_Card_70-95.qxd 7/13/11 12:07 PM Page 95 Nervous System Disorders Pathophysiology • Autosomal dominant disorder in which exposure • • to a certain anesthetic agent causes temperature increase and muscle rigidity. Affects skeletal muscle tissue primarily. Free ionized calcium concentration can increase to damaging levels and cause multiple contractions of skeletal muscle. The temperature may rise to over 105°F from repeated contractions. The hypermetabolic state causes lactate formation, resulting in acidosis. 95 Medical Care and Surgical Treatment • Discontinue the anesthetic immediately. • Cooled intravenous dantrolene and IV fluids to clear myoglobin from the kidneys. • Cooling blanket; antipyretics. Keep in Mind • Teach client to report any personal or family history of side effects with anesthesia. Make the Connection Assessment and Diagnostic Findings • Familial link. • Temperature increase following exposure to an anesthetic. • Muscle rigidity and sore muscles. • Dark brown urine (myoglobin in urine); renal insufficiency due to rhabdomyolysis. • Blood chemistry. Complications • Arrhythmia; death. • Renal failure. • Destruction of brain tissue; seizure. • Muscle tissue is destroyed by rapid • • contraction due to excess calcium. As muscle is destroyed, myoglobin is released and flows via the bloodstream to the kidneys, which may cause acute tubular necrosis; adequate hydration is necessary to flush the kidneys. Monitor blood chemistry for elevated levels of enzymes, creatinine, and BUN. Temperature must be reduced to normal by antipyretics and cooled intravenous fluid. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 7 CARDIOVASCULAR Coronary Artery Disease, 96 Angina Pectoris, 97 Myocardial Infarction, 98 Congestive Heart Failure, 99 Cardiogenic Shock, 100 Atrial Fibrillation, 101 Ventricular Tachycardia, 102 Ventricular Fibrillation, 103 Pericarditis, 104 Myocarditis, 105 Rheumatic Endocarditis, 106 Cardiomyopathy, 107 Deep Vein Thrombosis, 108 Aortic Stenosis, 109 Venous Stasis Ulcer, 110 Varicose Veins, 111 Peripheral Artery Disease, 112 Buerger’s Disease, 113 Raynaud’s Disease, 114 Aortic Aneurysm, 115 Hypertension, 116 Leukemia, 117 Multiple Myeloma, 118 Graft-Versus-Host Disease, 119 Metabolic Acidosis, 120 Metabolic Alkalosis, 121 Respiratory Acidosis, 122 Respiratory Alkalosis, 123 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 96 Cardiovascular System Disorders Coronary Artery Disease (kor-o-na-re ar-ter-e di-zez) Clue: Diagnostic or Clinical Findings Shortness of breath with activity in a client with risk factors for heart disease such as a history of elevated blood lipids, smoking, poor dietary habits, sedentary lifestyle, and obesity. 96 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 96 Cardiovascular System Disorders Pathophysiology • CAD results in interruption of blood flow that • • • can cause ischemia or infarction as a result of atherosclerosis. The inflammation attracts low-density lipoproteins (LDL) and binds them to the site. The triglyceride core of the LDLs is spilled into the underlayer of the intima. Macrophages envelop these fats and are now termed “foam cells.” This is the “fatty streak” seen in early stages of atherosclerosis. As the area enlarges, more LDL, macrophages, platelets, and smooth muscle fibers are drawn to the site and accumulate under the intima, narrowing the vessel. This causes reduced blood flow and higher blood pressure in the small coronary vessels. Assessment and Diagnostic Findings • Crp to diagnose inflammation in the body; serum lipid profile to assess cholesterol and LDL. • Stress test with thallium nuclear imaging (areas not well perfused are seen as “cold spots”). • Stress echocardiography; ECG abnormalities. • Ultrafast CT scan to detect calcium deposits in the arteries. 96 • Cardiac catheterization is the gold standard for diagnosis. Complications • Activity intolerance with angina pectoris; myocar• dial infarction that can result in permanent heart muscle damage and heart failure. Arrhythmias because of loss of perfusion to the conduction system. Medical Care and Surgical Treatment • Dietary changes; lipid-lowering drugs. • Cardiac catheterization with balloon angiography and stent placement, depending on severity. • CABG. Keep in Mind • Teach clients that CAD may be genetic, but there are modifiable risk factors (e.g., cessation of smoking, healthy diet, exercising). Make the Connection • Lifestyle changes can reverse CAD. Assess shortness of breath with activity. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 97 Cardiovascular System Disorders 97 Angina Pectoris (an-ji-na pek-tor-is) Clue: Diagnostic or Clinical Findings Chest pain referred to the jaw, neck, upper arms, and scapulae that is usually associated with activity, cold weather exercise, or smoking. Usually subsides with rest. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 97 Cardiovascular System Disorders Pathophysiology • The coronary arteries that feed the heart muscle • • become occluded with atherosclerotic plaque. Increased oxygen demands cannot be met because of narrowing and noncompliance to dilation. Ischemic pain results and is referred to the jaw, inner upper arms, sternum, and between the scapulae. Causative events include the 4 Es—eating a large meal, excitement, environment (very cold or very hot), and exercise—as well as smoking. Types include stable angina; variant angina (Prinzmetal’s), unstable angina, which can easily lead to MI; and silent ischemia, usually experienced by older adults, that damages the heart without pain. Assessment and Diagnostic Findings • ECG, exercise ECG, graded testing exercise, and • • chemical stress testing with radioisotope imaging (showing “cold spots” or areas of diminished cellular metabolism). Stress ECHO. Crp ↑; cardiac enzymes. 97 Complications • MI; permanent heart muscle damage leading to heart failure. Medical Care and Surgical Treatment • Cardiac catheterization with balloon angioplasty and stent placement. • CABG. • Vasodilators, calcium channel blockers, beta- adrenergic blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, lipid-lowering drugs, and antiplatelet drugs. Keep in Mind • Teach the client about healthy diet, exercise, and avoiding triggers of angina. • Teach the client about use of nitroglycerin. Make the Connection • Anginal attacks and MI must be differentiated. Cardiac enzymes and ECG assist in diagnosis. Until an MI is ruled out, angina should be treated as an MI. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 98 Cardiovascular System Disorders Myocardial Infarction (mi-o-kar-de-al in-fark-shun) Clue: Diagnostic or Clinical Findings Severe chest pain that refers to the jaw, upper arms, neck, and scapula and is described as “crushing.” Accompanied by shortness of breath, elevated BP, and sweating. 98 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 98 Cardiovascular System Disorders Pathophysiology • When blood flow diminishes to the heart muscle, • • • the sympathetic nervous system is activated, raising the blood pressure and heart rate. This increases the oxygen and glucose needs of the cardiac cells. Cardiac necrosis from lack of perfusion occurs centrally, surrounded by varying levels of ischemic tissue radiating outward from the site. Necrotic cardiac tissue will never resume its prior ability to contract but rather will form scar tissue. Damage can occur to the pacing system of the heart, causing lethal arrhythmias. 98 Medical Care and Surgical Treatment • Thrombolytics, antiplatelet drugs, antidysrhyth• mic agents, oxygen, morphine sulfate, nitrates, vasodilators, beta blockers, and angiotensinconverting enzyme inhibitors. Cardiac catheterization with stent placement; CABG. Keep in Mind • Prevention of atherosclerosis by healthy lifestyle is best; some people are genetically predisposed. • Teach clients the signs and symptoms of MI so they will seek treatment in time. Assessment and Diagnostic Findings • ECG changes (ST segment elevation). • Abnormalities in a 12-lead ECG. • Elevation of cardiac enzymes. • Elevated pulse and blood pressure; decreased oxygen saturation. • CBC showing an elevation of white blood cells; electrolyte abnormalities. Complications • Lethal dysrhythmias, cardiogenic shock, valvular insufficiency, heart failure, and sudden death. Make the Connection • Women have atypical signs and symptoms • • (nausea, indigestion, and maybe no pain), but if they present with shortness of breath or other symptoms, diagnostic tests should be performed. There is a 6-hour window for thrombolytic therapy, but following “60 minutes to treatment” guideline is best. “Time is muscle.” Defibrillator access in public areas saves lives of those with arrhythmia. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 99 Cardiovascular System Disorders 99 Congestive Heart Failure (kon-jes-tiv hart fal-yer) Clue: Diagnostic or Clinical Findings Elevated BNP, edema in the extremities, shortness of breath, crackles and pleural effusion, jugular vein distention, hepatomegaly, and splenomegaly. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 99 Cardiovascular System Disorders Pathophysiology • The heart is a double pump. Any structural damage to the pump will cause heart failure. • Left-sided heart failure causes backup of fluid in the lungs. • Right-sided heart failure causes backup of fluid in the inferior and superior venae cavae. • Preload becomes extensive and afterload is difficult to overcome because of ↑ PVR. Assessment and Diagnostic Findings • SOB; crackles or diminished breath sounds at the • • lung bases; presence of third and fourth heart sounds; orthopnea; cough; pale, clammy skin; anxiety; and restlessness. CXR revealing pleural effusion and/or atelectasis, increased pulmonary wedge pressures, transesophageal echocardiogram (TEE) showing decreased ejection fraction and low cardiac output, exercise or pharmacologic stress test demonstrating poor myocardial perfusion pattern, ECG abnormalities. ABG showing a decreased PaO2; elevation of endothelin 1 (ET-1), a vasoconstrictor, and ANP and BNP elevation. 99 Complications • PND related to pleural effusion, hepatomegaly and splenomegaly, left ventricular thrombus/ embolus, and cardiogenic shock. Medical Care and Surgical Treatment • Oxygen, high Fowler’s position, bedrest, IV opioids, IV inotropic agents, IV vasodilators, IV human B-type natriuretic peptide, ventricular assist device, hemodynamic monitoring, and daily weights. Keep in Mind • Yearly physical examinations, proper diet, exercise, and medications can prevent heart failure. Make the Connection • Monitor daily weights, urinary output, breath sounds, and BNP for improvement. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 100 Cardiovascular System Disorders 100 Cardiogenic Shock (kar-de-o-jen-ik shok) Clue: Diagnostic or Clinical Findings Following MI, sudden onset of low BP, poor perfusion, tachycardia, and arrhythmias. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 100 Cardiovascular System Disorders Pathophysiology • AMI leads to decreased contractility of either the • • • right or left ventricle, decreasing cardiac output to all body organ systems. CS may be caused by pericarditis and resulting cardiac tamponade. Stenosis of heart valves or sustained arrhythmia can cause CS. Drugs, used for preexisting hypertension, angina, or arrhythmias, may reach toxic levels and cause CS. Assessment and Diagnostic Findings • • • • • • Jugular venous distention, cyanosis, muffled heart sounds, crackles and wheezes in the lung bases, and extra heart sounds. BP of less than 90 mm Hg lasting more than 30 minutes; ECG showing ST-segment elevation that indicates AMI. Cold extremities; change in mental status. Urine output of less than 20–30 mL/hr. Increased cardiac enzymes. CBC indicating inflammation, electrolyte levels, ABG for acidosis, BNP, and coagulation studies. 100 Complications • Cardiopulmonary arrest, fatal arrhythmias, renal failure, thromboembolus, and stroke. Medical Care and Surgical Treatment • Inotropic agents, phosphodiesterase enzyme • • inhibitors, platelet aggregation inhibitors, vasodilators, natriuretic peptides, vasopressors, and opioid analgesics. Hemodynamic monitoring. LVAD; intra-aorta balloon pump. Keep in Mind • Teach clients the early signs and symptoms of AMI and to seek care immediately. Make the Connection • Monitor urine output, BP, cardiac output, pulse oximetry, and ECG. • Keep the environment calm; reassure the client to decrease sympathetic outflow. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 101 Cardiovascular System Disorders 101 Atrial Fibrillation (a-tre-al fi-bril-a-shun) Clue: Diagnostic or Clinical Findings Irregular R-R intervals Palpitations, skipping heartbeats, or vertigo perceived. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 101 Cardiovascular System Disorders Pathophysiology • Atrial fibrillation (AF), or quivering of the atria, • • • is caused by repeated reentry of stimuli to the atrioventricular (AV) node. Loss of atrial kick. Stimulation of the sympathetic nervous system, as well as increasing age, illness (e.g., hyperthyroidism), and the stress of surgery may initiate AF. Types of AF include paroxysmal, persistent, permanent, and lone. Assessment and Diagnostic Findings • ECG shows no P waves, and the rhythm is irregu• • • larly irregular with shortened QRS complex. PR interval cannot be measured. Client may complain of palpitations, skipped heartbeats, and anxiety. CBC, cardiac enzymes, thyroid function tests, serum drug levels, serum toxicology, and blood chemistry to assess for infection, MI, thyrotoxicosis, toxicity of prescribed cardiac drugs or side effects of over-the-counter or street drugs, renal failure, or abnormalities of electrolytes. CXR or TEE to evaluate for structural or inflammatory disease. 101 Complications • Stasis of blood causes formation of thrombi, • which can lead to CVA, MI, or pulmonary embolism (PE). Left ventricular failure. Medical Care and Surgical Treatment • Intravenous anticoagulants, antiarrhythmic • agents, cardiac glycosides, beta-adrenergic blockers, and calcium channel blockers. Electrical cardioversion, pacemaker, implantable cardioverter defibrillator (ICD), ablation or maze procedure (cardiac catheterization approach), or open-heart maze procedure. Keep in Mind • Teach clients, especially those with preexisting cardiac conditions, to report palpitations. • Teach clients the importance of monitoring laboratory values. Make the Connection • Monitor ECG and INR and PT levels carefully. Report any SOB that may indicate PE. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 102 Cardiovascular System Disorders Ventricular Tachycardia (ven-trik-u-lar tak-e-kar-de-a) Clue: Diagnostic or Clinical Findings Client may be lightheaded or unconscious and pulseless. 102 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 102 Cardiovascular System Disorders Pathophysiology • In ventricular tachycardia (VT), the ventricles • • • • replace the sinoatrial (SA) node as the pacemaker of the heart. PVCs often precede VT. VT may be caused by MI, myocardial irritability, and cardiomyopathy. Abnormally low levels of K+, Ca++, and Mg+; digoxin toxicity; RA, SLE, and respiratory acidosis. Cardiac catheterization and pacing wires. 102 Medical Care and Surgical Treatment • Defibrillation; administration of antiarrhythmics, • Keep in Mind • Teach clients to seek emergency medical services for any incidence of chest pain, dizziness, or syncope because prehospital stabilization can increase chances of survival. Assessment and Diagnostic Findings • ECG shows rapid ventricular rhythm, absent • • P waves, no PR interval, and QRS complex greater than 0.11 seconds. Client may become diaphoretic and report sudden dyspnea, palpitations, lightheadedness, nausea, and chest pain. The client may lose consciousness and become pulseless. Blood chemistry, cardiac enzymes, ABGs, and serum digoxin levels are assessed. Complications • Sustained VT can progress to ventricular fibrillation and death. • CHF following repeated episodes. vasopressors, and oxygen according to ACLS protocol. Replacement of electrolytes; magnesium administration to relax ventricular myocardium. Make the Connection • Clients with severe preexisting cardiac • • conditions may have VT and should be on telemetry. Remember: check the client not only the ECG. Monitor electrolyte levels, serum drug levels, and cardiac enzymes. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 103 Cardiovascular System Disorders Ventricular Fibrillation (ven-trik-u-lar fi-bril-a-shun) Clue: Diagnostic or Clinical Findings Loss of consciousness, no peripheral pulses or blood pressure. 103 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 103 Cardiovascular System Disorders Pathophysiology • VF is associated with CAD, MI, and structural or • • inflammatory cardiac conditions. It may be precipitated by antiarrhythmic drug administration, atrial fibrillation, cardioversion, and hypoxic states. VF causes include hyperkalemia and hypomagnesemia, cardiac catheterization and placement of pacemaker wires. Congenital conditions that predispose to VF include Marfan’s syndrome, tetralogy of Fallot, Kawasaki’s disease, long QT syndrome, and Wolff-Parkinson-White syndrome also predispose to VF. Assessment and Diagnostic Findings • ECG shows an irregular rhythm with no P wave, PR interval, or QRS complex. • Clients lose consciousness immediately, are pulseless, and have no BP. • Cyanosis, respiratory arrest, circulatory collapse, and pupil dilation occur. Complications • Death. • Cerebral anoxia, aspiration pneumonia, defibrillation injury, and repeated VF episodes. 103 Medical Care and Surgical Treatment • Immediate defibrillation, oxygen therapy, intuba• • tion, and administration of antiarrhythmics, anticholinergics, and vasopressors according to ACLS protocol. CABG for perfusion problems. ICD for those with known risk. Keep in Mind • Encourage all clients and family members to learn • CPR and to use AEDs for personal safety and promotion of public health. Teach clients to activate emergency services if experiencing any chest pain. Make the Connection • Follow ACLS protocols and algorithms to increase the likelihood of client survival. • Defibrillate immediately; monitor oxygen saturation, ECG, and vital signs continuously. • Follow safety protocols for use of defibrillators. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 104 Cardiovascular System Disorders 104 Pericarditis (per-i-kar-di-tis) Clue: Diagnostic or Clinical Findings Pericardial friction rub. Substernal radiating chest pain that increases in intensity with deep inspiration or lying flat. Pain is somewhat relieved by sitting upright and leaning forward. CBC and ESR may indicate inflammation or infection is present. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 104 Cardiovascular System Disorders Pathophysiology • Pericarditis is an inflammation of the pericardial • • sac. The pericardial sac is a fibrous tissue layer that surrounds the heart. Under normal circumstances, it contains and is bathed with approximately 25–50 mL of serous fluid. In pericarditis, the volume may increase to 1,500 mL. Many diseases, conditions, and drugs can inflame the pericardial sac. Hemopericardium may be caused by trauma and in-hospital procedures. Assessment and Diagnostic Findings • Radiating substernal chest pain that increases • with deep inspiration or lying flat and is somewhat relieved by sitting upright and leaning forward, dyspnea, low-grade fever, cough, and pericardial friction rub. CBC and ESR to detect infection and inflammation; ECG shows ST-T wave elevation; echocardiogram shows pericardial effusions; CT scans and MRI can show the status of the pericardial tissue and effusions; blood chemistries to detect uremia; pericardiocentesis fluid analysis to determine the causative agent. 104 Complications • Pericardial effusion (an accumulation of fluid in the pericardium). • A large pericardial effusion impairs cardiac filling, causing shock or death. • Constrictive pericarditis leads to heart failure. Medical Care and Surgical Treatment • Drug therapy depends on the causative factor. • Pericardiocentesis; creation of a pericardial window or use of a balloon pericardiotomy for chronic or persistent pericarditis. Keep in Mind • Teach clients to seek emergency medical care if experiencing dyspnea or chest pain. Make the Connection • Monitor ECG, oxygen saturation, and ease of breathing after pericardiocentesis. • Assess clients undergoing invasive cardiac procedures for postprocedure pericarditis. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 105 Cardiovascular System Disorders 105 Myocarditis (mi-o-kar-di-tis) Clue: Diagnostic or Clinical Findings Fever, chest pain, and activity intolerance. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 105 Cardiovascular System Disorders Pathophysiology • The myocardium is infiltrated by inflammatory cells leading to necrosis of muscle cells and fibrosis. • Causes include viral, bacterial, protozoan, and fungal infections. • Inflammatory and autoimmune causes or • exposure to chemicals or toxins, and radiation therapy. Women who are pregnant, those undergoing radiation therapy to the chest area, and the elderly are also at risk. Assessment and Diagnostic Findings • • • • • • CBC and ESR to detect infection and inflammation; cardiac troponin I is elevated; ECG shows ST-segment elevation and Q-wave development, and may show complete heart block and BBB; ECHO shows ↓ CO and ↓ EF. MRI shows areas of inflammation. Temperature elevation and chest pain. Signs of heart failure. Endomyocardial biopsy to examine the cells of the myocardium for damage and causative agent. PCR identification of a viral infection in myocardial biopsy tissue. 105 Complications • Pericarditis, arrhythmias, chronic dilated cardiomyopathy, and heart failure. Medical Care and Surgical Treatment • Anticoagulants for thromboembolus development. • Angiotensin-converting enzyme inhibitors, • beta-adrenergic blockers, loop diuretics, and cardiac glycosides. Temporary pacemaker or heart transplant. Keep in Mind • Teach clients to report new onset of dyspnea or swelling of ankles immediately. • Activity will be limited after diagnosis, maybe permanently. • Teach about heart transplantation. Make the Connection • Monitor for worsening signs of heart failure and for pericarditis (pericardial friction rub) and chest pain. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 106 Cardiovascular System Disorders Rheumatic Endocarditis (roo-mat-ik en-do-kar-di-tis) Clue: Diagnostic or Clinical Findings Fever, chest pain, dyspnea, cough, arthritic symptoms, chorea, and ankle edema develop 2–3 weeks after strep throat (beta-hemolytic streptococci). 106 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 106 Cardiovascular System Disorders Pathophysiology • BHS that cause throat infection or impetigo travel • • • to the bloodstream, causing bacteremia. The BHS infect the heart typically 2–3 weeks after the initial infection. May occur in clients in childhood and recur as rheumatic endocarditis at any age. All layers of the heart are affected, with generalized inflammation of all heart structures. The endocardium is affected by vegetation deposited on the valves. The end result of cardiac structural anomalies is CHF. Assessment and Diagnostic Findings • Tachycardia, heart murmur, pericardial friction • • • rub, chest pain, fever, polyarthritis, subcutaneous nodules, arthralgia, dyspnea, cough, and abdominal pain. ECG shows PR interval lengthening. ECHO shows abnormal movement of the mitral valve. Antistreptolysin O titer greater than 250 IU/mL and throat culture positive for BHS; CBC and ESR indicating infection and inflammation. 106 Complications • Thromboemboli. • Mitral or aortic valve stenosis; CHF. Medical Care and Surgical Treatment • Antipyretics as needed and long-term antibiotic therapy. • Treatment of heart failure. • Mitral valvulotomy, percutaneous balloon valvuloplasty, or mitral valve replacement. Keep in Mind • Teach clients that any sore throat or outbreak of impetigo must be examined by culture, treated, and reexamined by culture to ensure the infection has been cured. Make the Connection • Monitor CBC for improvement. • Monitor client for pericardial friction rub and symptoms of heart failure. • Monitor oxygen saturation and activity tolerance; offer restful activities. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 107 Cardiovascular System Disorders 107 Cardiomyopathy (kar-de-o-mi-op-a-the) Clue: Diagnostic or Clinical Findings Dyspnea, fatigue, edema of the ankles, and possible atypical chest pain occurring with rest and not relieved with nitrates. MRI shows enlargement of the heart muscle or chambers. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 107 Cardiovascular System Disorders Pathophysiology • Enlargement of the heart muscle or chambers of the heart that causes heart failure. • Major types: dilated and restrictive. • Causes: Heredity, myocarditis, chronic alcohol or cocaine use, HIV, thiamine or zinc deficiencies, infections; or autoimmune disease. 107 Medical Care and Surgical Treatment • Anticoagulants and antiarrhythmias. • Medications and procedures are related to type. Keep in Mind • Teach family members how to perform CPR and to seek emergency medical care if the client experiences dyspnea, chest pain, or syncope. Assessment and Diagnostic Findings • Angina, arrhythmias, dyspnea, fatigue, syncope, and S3 gallop rhythm. • ECHO, shows abnormal myocardial thickness or large chamber size. • ECG shows arrhythmias. • Cardiac catheterization to visualize chamber size and contractility. • Cardiac MRI to visualize heart wall and chamber size. Complications • Congestive heart failure. • Hypertrophic type may cause enlargement of the • septum that blocks the aortic valve resulting in abnormal heart rhythms and sudden death. Thromboemboli. Make the Connection • Monitor vital signs, oxygen saturation, • and for worsening signs of congestive heart failure and monitor ECG for arrhythmias. Remember: PE, MI, or CVA can occur if thromboemboli are produced. Monitor INR and PT. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 108 Cardiovascular System Disorders 108 Deep Vein Thrombosis (dep van throm-bo-sis) Clue: Diagnostic or Clinical Findings Positive Homans’ sign, redness or warmth in an area of pain in the leg, and edema unilaterally in the arm or leg. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 108 Cardiovascular System Disorders Pathophysiology • Causes of DVT include venous stasis, vessel wall • • • injury, and hypercoagulability. Perinatally, women are at increased risk because of excess clotting factors. Areas where blood flows more slowly, usually where veins are bending are more prone to DVT. Postsurgery clients are at greater risk due to ↓ activity. Septicemia resulting in hemolysis and dehydration can contribute to DVT. Assessment and Diagnostic Findings • Unilateral pitting edema in the affected extremity, with pain and erythema over the site. • Positive Homans’ sign. • D-dimer test showing fibrin degradation products. • Duplex ultrasonography detects the occlusion and changes in venous flow. • Impedance plethysmography shows slowed venous outflow from the affected area. • MRI to image iliac or inferior vena caval sites. • CT venography shows DVT. 108 Complications • Massive PE, MI, or CVA from thromboembolus. Medical Care and Surgical Treatment • Anticoagulants and thrombolytics, followed by outpatient warfarin treatment. • Compression stockings and early ambulation. • Thrombectomy; vena caval filter placement. Keep in Mind • Teach the client to report swelling, pain, or warmth in an extremity. • Seek immediate medical attention if sudden dyspnea occurs. • Teach the client to move about on airplanes and long car rides. Make the Connection • Never repeat a positive Homans’ assessment. • Monitor platelets and clotting time. • Have client maintain bedrest; as ordered. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 109 Cardiovascular System Disorders 109 Aortic Stenosis (a-or-tik ste-no-sis) Clue: Diagnostic or Clinical Findings Presence of a loud, harsh midsystolic, crescendo–decrescendo murmur that radiates to the side of the neck and down the left sternal border or apex. Heard loudest at the second right ICS. Low BP, fatigue, dizziness, and chest pain. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 109 Cardiovascular System Disorders Pathophysiology • AS develops from thickening, scarring, calcification, vegetation, or fusing of the flaps of the valve. • Left ventricular hypertrophy occurs as the sympathetic nervous system is activated to compensate for low cardiac output. When compensatory mechanisms fail, heart failure results. Assessment and Diagnostic Findings • Presence of a loud, harsh midsystolic, crescendo– • • • • decrescendo murmur that radiates to the side of the neck and down the left sternal border or apex. Heard loudest at the second right ICS. Low BP, fatigue, vertigo or syncope, palpitations, and angina chest pain. CXR and ECG show enlargement of the left atrium and ventricle. Two-dimensional and Doppler echocardiography show impaired movement of the aortic valve, decreased cardiac output, and lowered ejection fraction. Cardiac catheterization shows increased ventricular pressure and decreased cardiac output. Complications • CHF; pulmonary edema. 109 Medical Care and Surgical Treatment • Prophylactic antibiotic therapy; anticoagulant therapy. • Valvotomy for young adults; valve replacement in older adults. Keep in Mind • Teach clients to report any episodes of chest pain, vertigo, or syncope immediately. • Teach clients to seek immediate medical care for chest pain. • If a valve replacement is performed, teach the client the importance of maintaining anticoagulant therapy and keeping laboratory appointments to assess effectiveness of therapy. Make the Connection • Monitor the INR and PT in clients with valve replacement and on warfarin therapy. • Assess for bleeding, assess platelet count, and assess CBC for anemia. • Remember: Microorganisms can grow on the valves, forming vegetation that can embolize. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 110 Cardiovascular System Disorders 110 Venous Stasis Ulcer (ve-nus sta-sis ul-ser) Clue: Diagnostic or Clinical Findings Ulcer that occurs on the lower extremities in the presence of edema and brown, leathery skin. Described as “wet” and exudes a large amount of serous fluid. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 110 Cardiovascular System Disorders Pathophysiology • Blood is not returned efficiently to the heart and • • venous pressure ↑ in the lower extremities. The ↑ venous pressures cause backflow of blood into the capillary exchange beds and leakage of serous fluid containing wastes into the interstitial space. Edema in the interstitial space prevents capillary access for all cells and can be severe. Increased pressure in a vein causes a small rupture that becomes a deeper wound that cannot heal because of poor capillary access to inflammatory agents, oxygen, and glucose. The wound ulcerates because of inflammatory substances trapped in the subcutaneous tissue, damaging the valves in the veins and exuding serous fluid. Assessment and Diagnostic Findings • Edema of the extremities, with brown, leathery skin. • Culture of the ulcer obtained. • CBC to R/O infection. Complications • Infection, nonhealing chronic ulcerations that affect the client’s quality of life; reulceration. • Permanent damage to the valves in the veins. 110 Medical Care and Surgical Treatment • Unna’s boot compression bandage is wrapped with the leg elevated. • Pentoxifylline therapy. • Skin grafts and artificial cultured skin. • Clients are instructed to walk, as tolerated. Keep in Mind • Teach the importance of elevating the legs; walking as tolerated to ↑ use of skeletal muscle pump. Make the Connection • Assess for healing when the compression boots are removed (every 2–7 days). • If skin grafts are used, the area should not be disturbed until skin buds are seen. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 111 Cardiovascular System Disorders 111 Varicose Veins (var-i-kos vanz) Clue: Diagnostic or Clinical Findings Visible, tortuous, bulging veins that cause discomfort in the leg and changes in body image. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 111 Cardiovascular System Disorders Pathophysiology • Venous return in the body is dependent on the • • muscular contractions of the skeletal muscle pump. Competency of the valves within the veins cause forward flow that is eventually returned to the heart. In pregnancy, the pressure of the fetus causes venous hypertension, and hormones make the valves less competent, which ↑ incidence of varicose veins of the legs and anus to occur. Superficial varicosities are more visible than more deeply located varicosities. Assessment and Diagnostic Findings • Visible tortuous veins seen on the legs or hemor• • rhoids seen around the anus. Varicosities can also occur in the esophagus because of portal hypertension. Contrast venography, MRI, and color-flow duplex US that show blood pooling. Clients complain of pain, pressure, or a dragging sensation in the legs. Complications • Thromboembolisms, venous ulcerations, and bleeding varicosities. 111 Medical Care and Surgical Treatment • Sclerosing agents. • Endovenous laser therapy, radiofrequency abla• tion, ambulatory phlebectomy, and the traditional saphenectomy with saphenofemoral ligation. Corticosteroids and other immunosuppressants. Keep in Mind • Teach clients to utilize compression stockings if • they stand in one place for a prolonged period of time; teach them to plantar flex and dorsiflex the foot and ankle, and shift their weight from leg to leg. Teach pregnant clients to elevate the legs frequently. Make the Connection • Assess whether the client who has undergone treatment is using compression stockings. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 112 Cardiovascular System Disorders Peripheral Arterial Disease (per-if-er-al ar-te-re-al di-zez) Clue: Diagnostic or Clinical Findings Symptoms occur late in the disease and include intermittent claudication in the calves associated with activity. Color changes in the legs, with hair loss and dry, flaky skin, may occur. 112 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 112 Cardiovascular System Disorders Pathophysiology • PAD is caused by progressive narrowing of the lumen of the arteries by atherosclerotic plaque buildup. • If arteries are totally occluded, necrosis and ulceration (gangrene) develop, and the limb is no longer viable. Assessment and Diagnostic Findings • The 5 Ps: pulselessness, paralysis, paresthesia, pain, and pallor. • Heaviness and pain in the legs after a short period of exertion that are relieved by rest. • ABI measures BP in the upper and lower extremi• • • • • ties. The BP taken after a brief period of exercise in the client with PAD shows a drop in the ankle BP, indicating constriction and decreased perfusion. Doppler US measures the velocity of blood flow. MRI shows images of plaque in arteries. Plethysmography and angiography to visualize blood flow through the extremity. Lipid panel and a total blood chemistry to assess electrolytes and nitrogenous wastes. D-dimer test to assess for fibrin degradation products; Crp and interleukin 6 to assess for inflammatory markers. 112 Complications • Thromboembolism, CVA, and MI. • Necrosis, arterial ulcerations, gangrene, and amputation. Medical Care and Surgical Treatment • Anticoagulants; pentoxifylline. • Vasodilators and calcium channel blockers. • Amputation. Keep in Mind • Teach client to have yearly physicals and blood work to detect risks for atherosclerosis. • Eat a healthy diet and exercise daily. Make the Connection • Monitor dependent and elevated extremities • in the client with PAD. Palpate for pulses; report loss of pulse, mottling, or cold extremities. Monitor anticoagulant therapy and glucose levels. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 113 Cardiovascular System Disorders 113 Buerger’s Disease (burg-erz di-zez) Clue: Diagnostic or Clinical Findings A disease of young men who smoke. Thrombi develop in the legs, occluding circulation. “Your cigarettes or your legs” is often the choice. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 113 Cardiovascular System Disorders Pathophysiology • BD also known as thromboangiitis obliterans is a • disease of recurrent inflammation of the small and medium arteries of the legs that results in thrombus formation. Young men (aged 25–40) who smoke are affected. It is thought that substances in the tobacco products trigger an autoimmune response in these young men. Vasospasm and loss of arterial blood flow occurs. Assessment and Diagnostic Findings • The 5 Ps: pulselessness, paralysis, paresthesia, pain, and pallor. • Heaviness and pain in the legs after a short period of exertion that are relieved by rest. • ABI measures BP in the upper and lower extremi- • • • ties. The BP taken after a brief period of exercise in the client with PAD shows a drop in the ankle BP, indicating constriction and decreased perfusion. Doppler US measures the velocity of blood flow. MRI shows images of plaque in arteries. Plethysmography and angiography to visualize blood flow through the extremity. 113 Complications • Necrosis, arterial ulcerations, gangrene, and amputation. Medical Care and Surgical Treatment • Anticoagulants; pentoxifylline to increase red blood cell flow. • Vasodilators and calcium channel blockers. • Amputation. • Smoking cessation program. Keep in Mind • Teach the client the importance of smoking cessation. • Refer client to a support group for those with Buerger’s disease. Make the Connection • The legs will be purple-red when • • dependent and show pallor when elevated; palpate for pulses. Maintain anticoagulant and vasodilator therapy. Assess the effectiveness of smoking cessation program and support group interactions. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 114 Cardiovascular System Disorders 114 Raynaud’s Disease (re-noz di-zez) Clue: Diagnostic or Clinical Findings Vasospasm and vasoconstrictive ischemia of the tips of the nose, fingers, hands, feet, and toes when in contact with cold objects or cold temperatures. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 114 Cardiovascular System Disorders Pathophysiology • A disease of women, RD causes vasospasm and • • vasoconstrictive ischemia of the tips of the nose, fingers, hands, feet, and toes when in contact with cold objects or cold temperatures. Ischemia is followed by a period of hyperemia. Diagnosis is made when the ischemic attacks occur for 2 or more years. Endothelin 1 and angiotensin may be causative agents. Secondary RD is associated with autoimmune/ collagen disorders and persons with occupations that involve vibratory tools like jackhammers. Assessment and Diagnostic Findings • CBC to assess for blood disorder, BUN and • • creatinine to assess renal and hydration status, PT and aPTT to assess the clotting cascade; serum glucose; and thyroid panel to assess for metabolic disorders. Diagnostics for autoimmune and collagen disorders are also ordered. Calcitonin gene-related peptide, which is a vasodilator, is found to be decreased in RD. Neuropeptide Y, a vasoconstrictor, is found in high levels in secondary RD. 114 Complications • Digital ulceration, tissue loss, and gangrene. Medical Care and Surgical Treatment • ACE inhibitors, angiotensin-receptor antagonists, • • • vasodilators, SSRI, analgesics, and local infiltration with lidocaine. Digital sympathectomy. Pharmaceutical-grade omega-3 fatty acid. Biofeedback; avoiding contact with cold; smoking cessation. Keep in Mind • Teach the client to insulate the hands, feet, and face from cold temperatures and to never smoke. • Report ischemic events immediately. Make the Connection • Assess color, sensation, and temperature in digits and nose; smoking cessation program. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 115 Cardiovascular System Disorders 115 Aortic Aneurysm (a-or-tik an-u-rizm) Clue: Diagnostic or Clinical Findings Abdominal pain, nausea, or fullness relieved by position change. Pulsating mass in the abdomen. Auscultation with the bell of the stethoscope for a bruit adjacent to the umbilicus. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 115 Cardiovascular System Disorders Pathophysiology • Bulging or ballooning of the aorta due to athero- • • sclerosis, hypertension, chronic obstructive pulmonary disease, smoking, trauma, or congenital anomaly. Commonly found in the abdominal aorta (abdominal aortic aneurysm [AAA]). Tends to run in families with Marfan’s syndrome. Types include fusiform, saccular, and dissecting. May be completely asymptomatic until it ruptures. Assessment and Diagnostic Findings • Abdominal pain, nausea, or fullness relieved by position change. Pulsating mass in the abdomen. • Auscultation with the bell of the stethoscope for a bruit adjacent to the umbilicus. • US screening for men aged 50 or older or those with a family history. • MRI showing a enlarged black mass; aortography showing the outline of the aortic abnormality. • Spiral CT scan with contrast revealing the calcified rim of the aneurysm. Complications • Rupture of the aneurysm, cardiac arrest, hemorrhage, shock, and death. 115 Medical Care and Surgical Treatment • Monitoring of the size of the aneurysm. • Antihypertensive agents for BP management. • Smoking cessation program. • Surgical intervention with open surgical repair or endovascular grafting. Keep in Mind • Teach clients with a first-degree relative with AAA • the risk factors and symptoms to report, and encourage screening by ultrasound. Teach clients at risk to maintain therapy with antihypertensive agents, avoid smoking, and have yearly examinations. Make the Connection • The rate of rupture increases with age or surgery. • Assess BP and advise clients undergoing surgical repair to avoid lifting heavy objects. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 116 Cardiovascular System Disorders 116 Hypertension (hi-per-ten-shun) Clue: Diagnostic or Clinical Findings BP readings of greater than 119 mm Hg systolic or greater than 79 mm Hg diastolic classify the client as prehypertensive. The client may have no symptoms or, in severe cases, headache and nosebleed. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 116 Cardiovascular System Disorders Pathophysiology • BP is determined by CO, which is determined by • heart rate multiplied by the stroke volume. The heart rate can be affected by stimulation of the SNS responding to arterial baroreceptors that measure BP and by chemoreceptors that measure CO2 levels. Other mechanisms that alter BP include the renin-angiotensin-aldosterone system, exercise, emotions, and taking medications that cause vasoconstriction. High blood pressure damages the intima of arteries, making way for infiltration of macrophages, muscle fibers, cholesterol, and fatty acids that form atherosclerotic plaque. PVR is the resistance to blood flow through arterioles creating a high afterload. Assessment and Diagnostic Findings 116 Complications • Atherosclerosis and vessel damage; cerebrovascu• lar accident (CVA) and myocardial infarction (MI), and resulting congestive heart failure (CHF). Nephropathy and retinopathy due to poor perfusion. Medical Care and Surgical Treatment • Diuretics, antihypertensives, and lifestyle changes. • Smoking cessation program. Keep in Mind • Teach clients to change modifiable risk factors, avoid added salt, decrease caffeine intake, drink alcohol modestly, take prescribed medications regularly, and manage stress through exercise or meditative means. • Systolic BP should ideally be less than 120 mm Hg • and diastolic BP should be less than 79 mm Hg (JNC 7). Hypertension is diagnosed if the average BP readings taken on two separate occasions is greater than 139 mm Hg systolic and greater than 89 mm Hg diastolic. Make the Connection • Assess BP carefully in the correct way with the correctly sized cuff, the client seated, and the sphygmomanometer at heart level. Take the BP after 5 minutes of rest. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 117 Cardiovascular System Disorders 117 Leukemia (loo-ke-me-a) Clue: Diagnostic or Clinical Findings Low-grade fever, lymphadenopathy, bleeding tendency, infections, and anemia. Bone marrow biopsy shows many immature WBCs. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 117 Cardiovascular System Disorders Pathophysiology • Leukemia can be acute or chronic and affect • lymphocytes, monocytes, granulocytes, erythrocytes, and platelets. Due to a mutation in the stem cells of the bone marrow, immature WBCs (blasts), proliferate uncontrollably in the bone marrow, lymph tissue, and spleen. In the bone marrow, the immature and ineffective WBCs crowd the normal WBCs, RBCs, and platelets, greatly reducing their number. Types include ALL, AML, CLL, CML. Assessment and Diagnostic Findings • • • • • CBC showing many immature WBCs, low RBC count, and low platelet count. Bone marrow aspiration, with cell count showing many immature blasts. Genetic testing for the Philadelphia chromosome (CML). LP for identification of blasts in CSF to determine CNS involvement. Low-grade fever, pallor, weakness, SOB, bone pain, headache, and confusion. 117 Complications • Thrombocytopenia, petechiae and bleeding, infection, GVHD, and severe anemia. Medical Care and Surgical Treatment • Chemotherapy, radiation therapy, stem cell transplant, and bone marrow transplant. Keep in Mind • Teach clients that ALL in children has a high cure rate (cancer-free for 5 years or more). • Clients with leukemia should use soft toothbrushes, eat foods of moderate temperature, avoid organic vegetables, take frequent rest periods, and report fever immediately. Make the Connection • Monitor the CBC, vital signs, and oxygen saturation levels frequently. • Maintain reverse isolation in the client undergoing BMT. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 118 Cardiovascular System Disorders 118 Multiple Myeloma (mul-ti-pl mi-e-lo-ma) Clue: Diagnostic or Clinical Findings Pathologic fractures from severe osteoporosis, bleeding tendency, infections, and anemia affecting those in the fifth to seventh decades of life. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 118 Cardiovascular System Disorders Pathophysiology • Mutation of plasma cells (type of B-lymphocyte) • that infiltrate the bone marrow, bone tissue, liver, spleen, lymph nodes, lungs, adrenal glands, kidneys, skin, and GI tract. MM has a poor prognosis. Assessment and Diagnostic Findings • Bone pain, especially in the back or ribs, joint pain, low-grade fever, and general malaise. • Pathologic fractures and spinal cord compression, hypercalcemia, and pneumonia. • CBC shows anemia, WBC fluctuation, and decreased platelets. • X-ray, CT scan, bone scans, and MRI show severe osteoporosis. • Urine is positive for M-type gamma globulins known as Bence-Jones protein (24-hour urine). • Bone marrow biopsy confirms the presence of immature plasma cells. Complications • Bone destruction, pathologic fracture, spinal cord • compression with loss of bowel and bladder control, and renal calculi from hypercalcemia; GVHD. Recurrent infections, pneumonia, and sepsis. 118 Medical Care and Surgical Treatment • High-dose steroids, IV biphosphonates, thalidomide, and analgesics. • Treatment of hypercalcemia, hyperuricemia, dehydration, respiratory infection, renal calculi. • High-dose chemotherapy with stem cell transplant and external beam radiation therapy. Keep in Mind • Teach the client to drink plenty of fluids, walk as tolerated, and avoid injury. • Report fever, pain, or paresthesias immediately. Make the Connection • Monitor the CBC, vital signs, oxygen saturation, and breath sounds frequently. • Ambulation as tolerated. • Lift the client with a lift sheet gently; provide passive and active range of motion. • Encourage fluid intake of up to 4 liters daily; medicate for pain as needed. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 119 Cardiovascular System Disorders 119 Graft-Versus-Host Disease (graft vur-sus host di-zez) Clue: Diagnostic or Clinical Findings Approximately 31/2 months following solid organ, bone marrow, or stem cell transplant, damage to the epithelial cells of the skin, GI tract, and hepatocytes occurs from an immune attack initiated by the transplanted tissue. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 119 Cardiovascular System Disorders Pathophysiology • GVHD can occur following solid organ, bone • • • marrow, or stem cell transplant. The graft cells recognize the host cells as foreign. Phase 1 of GVHD involves the host tissue that has been prepared for transplant by use of chemotherapy and radiation therapy. The injured tissue releases cytokines, which stimulate the host’s CD4+ cells. In phase 2 of GVHD, activated CD4+ cells cause the graft to activate T killer cells and NK cells that mount an immune response against susceptible tissues of the host (epithelial tissue, GI tract, and hepatocytes). In phase 3 of GVHD, immune cells and cytokines begin to damage host tissues. Assessment and Diagnostic Findings • CBC shows anemia, thrombocytopenia, and an • • elevation in eosinophils; Howell-Jolly bodies are identified in the peripheral blood smear. Elevated serum levels of IL-2 receptor alpha, TNF receptor 1, IL-8, and hepatocyte growth factor; elevated LE and liver biopsy. US, CT scan, and Doppler studies to assess the liver. 119 • Endoscopic examination of the GI tract. Complications • Graft failure, hemorrhage, infection, and liver failure that may lead to death. • Permanent scarring of epithelium of skin and GI tract. Medical Care and Surgical Treatment • Removal of graft T cells. • Immunosuppressive agents, DMARDs, and anti-TNF agents. • Plasmapheresis of host CD4+ cells. Keep in Mind • Teach the client that prior to bone marrow or stem cell transplant, immunosuppressive and steroid drugs may be given. Make the Connection • Monitor serial CBC, liver enzymes, and blood chemistries. Remember: This disease occurs 3 1/2 months after graft. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 120 Cardiovascular System Disorders 120 Metabolic Acidosis (met-a-bol-ik as-i-do-sis) Clue: Diagnostic or Clinical Findings ABG shows pH of less than 7.35, PCO2 in the range of 35–45 mm Hg or decreasing to compensate, and _ HCO3 of less than 22 mEq/L. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 120 Cardiovascular System Disorders Pathophysiology • Normal pH of the body is 7.35–7.45. ABG analy• • • • sis diagnoses metabolic acidosis; pH is low, CO2 is within normal_range or decreasing to compensate, and HCO3 is low. Buffering systems are initiated by the body when the pH goes out of range. The first to react are cellular buffers. In metabolic acidosis, H+ are absorbed into the cells, causing a shift of K+ into the extracellular area. The lungs are the second buffering system to activate. When pH is low, CO2 is released through rapid and deep respirations. The kidneys are the last buffering system to activate; and it may take as long as 1–2 days for them to begin to affect pH. In metabolic acidosis, the kidneys secrete H+. Causes include diarrhea (loss below the waistlose base), CRF, lactic acidosis, salicylate poisoning, methanol and alcohol poisoning, paraldehyde poisoning, and diabetic ketoacidosis. Assessment and Diagnostic Findings _ • Low pH and low HCO3 . The value of the anion gap may be high, low, or normal; guides further testing. 120 • Serum osmolality; blood chemistry analysis for azotemia, electrolytes, and high fasting glucose levels; Kussmaul’s respirations; change in mental status; ECG changes. Complications • Prolonged acid-base imbalance will lead to death. Medical Care and Surgical Treatment • IV administration of sodium bicarbonate; correction of electrolytes. Keep in Mind • Teach the client about toxic materials in the environment. • Teach the client the signs and symptoms of diabetes mellitus and the importance of maintaining a normal blood glucose level. Make the Connection • Monitor laboratory values, mentation, acetone breath, and ECG. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 121 Cardiovascular System Disorders 121 Metabolic Alkalosis (met-a-bol-ik al-ka-lo-sis) Clue: Diagnostic or Clinical Findings ABG shows pH of greater than 7.45, PCO2 in the range of 35–45 mm Hg or rising to compensate, and _ HCO3 of greater than 26 mEq/L. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 121 Cardiovascular System Disorders Pathophysiology • Normal pH of the body is 7.35–7.45. The ABG • • • • diagnoses metabolic alkalosis, pH is high, CO2 is within normal range or increasing to compensate, _ and HCO3 is high. Buffering systems are initiated by the body when the pH goes out of range. The first to react are cellular buffers. In metabolic alkalosis, H+ are released from the cells, causing a shift of potassium ions (K+) into the cells. The lungs are the second buffering system to activate. When pH is high, CO2 is held by slow, shallow respirations. The kidneys are the last buffering system to activate, and it may take as long as 1–2 days for them to begin to affect pH. In metabolic alkalosis, the kidneys hold H+. Causes include persistent vomiting; gastrointestinal suction; diarrhea; and use of loop diuretics, antacids, licorice, glucocorticoids, and mineralocorticoids. Assessment and Diagnostic Findings • Urine chloride less than 20 mEq/L; hypocalcemia and hypokalemia; ABG analysis. 121 • Abnormalities on electrocardiogram (ECG). Complications • Prolonged changes in pH level of the body. • Tetany, seizures, change in mentation, hypoventila+ tion and hypoxemia, and lethal arrhythmias (K ). Medical Care and Surgical Treatment • Carbonic anhydrase inhibitors, IV hydrochloric acid preparations, potassium-sparing diuretics, ACE inhibitors, K+ and Ca supplements, corticosteroids, nonsteroidal fluid replacement, and fluid replacement. Keep in Mind • Teach clients about metabolic alkalosis, especially in the case of vomiting for prolonged periods, and to seek medical care if mental status changes occur or if they have tremors. Make the Connection • Monitor ABGs and other laboratory values. Check both Chvostek’s and Trousseau’s signs to detect low calcium levels and ECG for arrhythmias related to low K+ levels. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 122 Cardiovascular System Disorders Respiratory Acidosis (res-pir-a-to-re as-i-do-sis) Clue: Diagnostic or Clinical Findings ABG shows pH of less than 7.45, than 45 mm Hg, PCO2 of greater _ and HCO3 within range or rising to compensate. 122 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 122 Cardiovascular System Disorders Pathophysiology • Normal pH of the body is 7.35–7.45. The ABG • • • • analysis diagnoses respiratory acidosis; pH is low, _ CO2 is high, and HCO3 is within normal range or rising to compensate. Buffering systems are initiated by the body when the pH goes out of range. The first to react are cellular buffers. In respiratory acidosis, H+ are absorbed into the cells, causing a shift of K+ out of the cells. The lungs are the second buffering system to activate. When pH is low, CO2 is released through rapid and deep respirations. The kidneys are the last buffering system, and it may take as long as 1–2 days for them to begin to affect pH. In respiratory acidosis, the kidneys secrete H+. Causes include COPD, hypoventilation, sleep apnea, and drug use that suppresses respiratory function. Assessment and Diagnostic Findings • ABG analysis, CBC for polycythemia, drug screens, and CXR. 122 Complications • Chronic hypoxemia leading to polycythemia, pulmonary hypertension, and cor pulmonale; mental status changes; cerebral edema; and papilledema. Death may occur. Medical Care and Surgical Treatment • Bronchodilators, ventilation support, mechanical • or, naloxone or flumazenil for opioid and benzodiazepine overdosages, and theophylline. Surgical interventions for obesity and sleep apnea. Keep in Mind • Teach the client to avoid smoking, use oxygen as directed, and maintain a healthy weight. • Teach the client about sleep study programs. Make the Connection • Monitor ABGs, ventilation status, and CBC for polycythemia. • Assess Glasgow Coma Scale score for cerebral edema; assess for papilledema. 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 123 Cardiovascular System Disorders Respiratory Alkalosis (res-pir-a-to-re al-ka-lo-sis) Clue: Diagnostic or Clinical Findings ABG shows pH of greater than 7.45, PCO2 of_ less than 35 mm Hg, and HCO3 within the range of 22–26 mEq/L or decreasing to compensate. 123 2693_Tab07_Card_96-123.qxd 7/14/11 7:36 PM Page 123 Cardiovascular System Disorders Pathophysiology • Normal pH of the body is 7.35–7.45. The ABG • • • • analysis diagnoses respiratory alkalosis; pH is _ high, CO2 is low, and HCO3 is within normal range or decreasing to compensate. Buffering systems are initiated by the body when the pH goes out of range. The first to react are cellular buffers. In respiratory alkalosis, H+ are released from the cells, causing a shift of K+ into the cells. The lungs are the second buffering system to activate. When pH is high, CO2 is held by slow, shallow respirations. The kidneys are the last buffering system to activate, and it may take as long as 1–2 days for them to begin to affect pH. In respiratory alkalosis, the kidneys hold H+. Causes include pain, anxiety, fever, CVA, tumor, and trauma. Assessment and Diagnostic Findings serum chemistries for intracellular • ABG analysis; + + • shifts of Na , K , and phosphates; and LFT, as respiratory alkalosis may be caused by liver failure. CBC showing a reduced hematocrit. 123 • CXR and VQ scans to identify pulmonary infection, pneumothorax, or PE. • Brain MRI to R/O tumor. Complications • Cerebral vasoconstriction leading to seizures. • Hyperventilation causing paresthesias, dyspnea, and chest pain. • ECG changes related to hypocapnia; BP changes. Medical Care and Surgical Treatment • Rebreathing of CO2 and treatment of underlying conditions. Keep in Mind • Teach the client methods for relieving hyperventilation. Make the Connection • Monitor ABG; assist to calm the client; monitor CBC and imaging studies. • Institute seizure precautions if necessary; monitor the ECG and vital signs. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 8 RESPIRATORY Bronchiectasis, 124 Asthma, 125 Emphysema, 126 Chronic Bronchitis, 127 Pneumothorax, 128 Cystic Fibrosis, 129 Acute Respiratory Distress Syndrome (ARDS), 130 Severe Acute Respiratory Syndrome (SARS), 131 Pulmonary Embolism, 132 Pneumonia, 133 Pleural Effusion, 134 Influenza, 135 Legionnaires’ Disease, 136 Lung Cancer, 137 Histoplasmosis, 138 Sarcoidosis, 139 Mesothelioma, 140 Tuberculosis (TB), 141 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 124 Respiratory Disorders 124 Bronchiectasis (brong-ke-ek-ta-sis) Clue: Diagnostic or Clinical Findings Dyspnea, cyanosis, expectoration of large amounts of foul-smelling mucus. ↓ RBC, weight loss. Rhonchi heard on auscultation. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 124 Respiratory Disorders Pathophysiology • Chronic dilation of the bronchi and bronchioles due to inflammation. • Inflammatory process destroys elasticity of smooth muscle in the airways. • Chronic infections occur in dilated areas that retain mucus and obstruct airways. • Can be localized or diffuse; associated with childhood diseases (e.g., measles), influenza, or tuberculosis. Assessment and Diagnostic Findings • Recurrent respiratory infections, foul-smelling • • mucus from accumulation of infected secretions, rhonchi over bronchi and diminished breath sounds in the lung bases. High-resolution CT scan, CBC with differential, ABG, oxygen saturation. Bronchoscopy for diagnosis and palliative treatment. Complications • Anemia due to poor dietary intake (dyspnea). • Respiratory acidosis; atelectasis, pneumonia. • Chronic obstructive disease. • Necrosis of bronchi and bronchioles. 124 Medical Care and Surgical Treatment • Antibiotics, bronchodilators, mucolytics, expectorants, supplemental oxygen, leukotriene inhibitors. • Postural drainage; limiting of activity level. • Bronchoscopy for palliative treatment. • Segmental lobectomy. Keep in Mind • Teach importance of influenza and pneumonia vaccination. • Postural drainage must be continued on an outpatient basis; discontinue smoking. Make the Connection • Assess for oxygen saturation by pulse oximetry as well as for worsening dyspnea. • Auscultate lungs every 4 hours, and perform postural drainage. • Assess characteristics of cough and mucus. • Remember: When there is collection and stasis of mucus, viruses and bacteria have a perfect medium in which to grow and cause infection. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 125 Respiratory Disorders 125 Asthma (az-ma) Clue: Diagnostic or Clinical Findings Expiratory wheeze on auscultation, rapid onset, difficult expiration, nonproductive cough, “chest is tight,” and ↓ O2 saturation. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 125 Respiratory Disorders Pathophysiology 125 aminophylline drip. • Reactive inflammatory disorder associated with • Small, frequent high-calorie, high-protein meals. • Limiting of activity level. • Keep in Mind • exposure to allergens, viral infection, pollution, smoking, or extremes of temperature. Chronic inflammation results in fibrosis and narrowing of bronchiole passageways, leading to air trapping, bronchospasm, and increased dead air space. Mast cells, active in inflammation, release histamine, prostaglandins, leukotrienes, and bradykinin. Assessment and Diagnostic Findings • Sudden onset of nonproductive cough, expiratory • wheeze, dyspnea, “tight chest,” ↑ expiratory effort and prolonged expiratory cycle, diaphoresis, and tachycardia. ABG (acidosis), blood and sputum for eosinophils, ↑ serum IgE, abnormal PFTs, and CXR, allergy skin testing. Complications • Status asthmaticus; acute respiratory failure. Medical Care and Surgical Treatment • Beta2-agonist bronchodilators, leukotriene inhibitors, supplemental O2, corticosteroids, IV • Environment should be free of allergen-laden materials like carpets and drapes. • Stop smoking; have a rescue inhaler available at all times (beta2-agonist). • Increase fluid intake; maintain a healthy diet. • Monitor asthma with a peak flowmeter. • Avoid temperature extremes. • Vaccinate for influenza and pneumonia. Make the Connection • Monitor for exacerbation of condition, respiratory failure, and status asthmaticus. • Monitor breathing pattern, auscultate lungs every 4 hours, and monitor with pulse oximetry. • Remember: Daily assessment with the peak flowmeter is integral to treating exacerbations early. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 126 Respiratory Disorders 126 Emphysema (em-fi-se-ma) Clue: Diagnostic or Clinical Findings Barrel or pigeon chest, dyspnea, the “pink puffer,” ↑ PaCO2, chronic respiratory acidosis, and hypoxic respiratory drive. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 126 Respiratory Disorders Pathophysiology • A chronic disorder in which the alveolar struc- • tures distend, lose elasticity, rupture, or coalesce, resulting in damage and destruction to the pulmonary capillary bed, air trapping, and increased dead air space. Cigarette smoking and an inherited deficiency of α1-antitrypsin are cocontributors to the disease. ↓ α1-antitrypsin results in elastase secreted from neutrophils that can digest elastin and other alveolar structures. Assessment and Diagnostic Findings • Pursed lip breathing, a prolonged expiratory • • respiratory cycle, barrel or pigeon chest, and use of accessory muscles to breathe; difficult inspiration and chronic cough with thick sputum. Abnormal CXR, and PFTs, sputum analysis, ABG. Clubbing of fingers, diminished breath sounds, orthopnea, dyspnea on exertion. Complications • Cor pulmonale, recurrent respiratory infections, and respiratory failure. • Hypoxia and confusion. 126 Medical Care and Surgical Treatment • Bronchodilators, expectorants, mucolytics, supplemental O2, corticosteroids, antibiotics. • Lung volume reduction surgery. • Limiting of activity level. Keep in Mind • Teach pursed lip breathing. O2 may be needed at home. • Vaccinate for influenza and pneumonia. • Suggest small, frequent nutrient-dense meals. ↑ fluids. Make the Connection • Monitor I&O, calorie count; offer small high-calorie, high-protein meals frequently. • Assess O2 saturation, ABG, breathing pattern; clients may like a fan blowing on them. • Remember: Keep O2 at low levels; hypoxic respiratory drive. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 127 Respiratory Disorders 127 Chronic Bronchitis (kron-ik brong-ki-tis) Clue: Diagnostic or Clinical Findings A history of a chronic productive cough of more than 3 months’ duration for more than 2 consecutive years; the “blue bloater.” 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 127 Respiratory Disorders Pathophysiology • Chronic Inflammation by IL-8 and cytokines of • the mucous membrane lining the bronchi and bronchioles. Excess mucus is produced, and the mucociliary pump ceases to function properly, causing chronic congestion. Common in smokers. Chronic bronchitis results in a fibrotic, noncompliant airway and pulmonary hypertension. Assessment and Diagnostic Findings • Cough with expectoration for at least 3 months • • • for more than 2 consecutive years, with dyspnea and cyanosis. The “blue bloater” related to cor pulmonale; clubbing of the fingernails. Fever, headache, fatigue, and nausea. Along with clinical findings, abnormal, CXR scans, MRI, ABGs, and abnormal PFTs. Complications • Worsening right-sided CHF. • Chronic bouts of pneumonia and hospitalization. • Colonization of antibiotic-resistant organisms. • Development of oxygen dependency as pulmonary function worsens. • Death from pneumonia and/or heart failure. 127 Medical Care and Surgical Treatment • Bronchodilators, mucolytics, diuretics, oxygen • • supplementation, anti-infective drugs, nebulizer treatments, incentive spirometry, antihypertensives, ACE inhibitors, and inotropic drugs and betaadrenergic blockers. Smoking cessation program. Lung-reduction surgery. Keep in Mind • Teach clients that the effects of smoking. • Teach clients that vaccination against influenza and pneumonia are necessary. • Teach clients to report SOB, symptoms of infection, or sudden weight gain immediately. Make the Connection • Monitor diagnostic chest x-rays, CT scan, or MRI for improvement. • Monitor ABGs and pulse oximetry. • Weigh the client daily during acute episodes of right-sided CHF. • Plan care according to activity tolerance. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 128 Respiratory Disorders 128 Pneumothorax (nu-mo-tho-raks) Clue: Diagnostic or Clinical Findings Sudden sharp pain in the chest area, SOB, ↓ O2 saturation, absent breath sounds in the affected lung. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 128 Respiratory Disorders Pathophysiology • Potential space created by the visceral and pari- • etal pleura creates negative pressure in that area. Once breached by trauma or a pathologic event, negativity is lost and the potential space becomes an actual space that fills with air (pneumothorax) or blood (hemothorax). Positive pressure in the pleural space presses against the lung tissue, causing atelectasis ↓ gas exchange. 128 • For lung collapse related to pathology (injury • to the pleura from disease), a thoracotomy with evacuation of accumulated fluid offers relief. Recurrent pneumothorax may require pleurodesis. Keep in Mind • The chest tube may be in place for several days. • Bronchodilators, coughing and deep breathing exercises, and frequent x-rays are needed. Assessment and Diagnostic Findings • Sudden, sharp pleural pain; dyspnea; anxiety; SOB. • Absent breath sounds in affected lung field, uneven chest movement, ↓O2 saturation, hemoptysis. • ABG abnormalities and CXR showing atelectasis. Complications • Mediastinal shift with respiratory distress. • Respiratory acidosis. • Subcutaneous emphysema. Medical Care and Surgical Treatment • Depending on the size of the pneumothorax (>30%), placement of a chest tube exerts suction in the pleural space, restoring negative pressure. Make the Connection • Monitor O2 saturation, auscultate lungs • • every 4 hours, and palpate thorax for subcutaneous emphysema. Remind client to ask for pain medication as needed, especially if the chest tube is being removed. Remember: Monitor the blood pressure carefully for hypotension following evacuation of a large amount of fluid from the pleural space. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 129 Respiratory Disorders 129 Cystic Fibrosis (sis-tik fi-bro-sis) Clue: Diagnostic or Clinical Findings Meconium ileus at birth is the earliest sign. Later, respiratory, gastrointestinal, and reproductive dysfunction. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 129 Respiratory Disorders Pathophysiology • Autosomal recessive disorder that affects chro• • mosome 7, which normally produces a protein CFTR that affects movement of Na+ and Cl– ions. All secretions of exocrine glands of the respiratory, gastrointestinal, and reproductive tracts become thick and obstruct normal flow. Sweat glands do not reabsorb sodium, so salt depletion in sweat can occur. Assessment and Diagnostic Findings • CXR, testing of sweat electrolytes, PFTs, fat absorp• tion; pancreatic enzymes for infants who present with a meconium ileus and children with repeated or severe pulmonary disease. Genotype testing of the parents and child. Complications • Obstruction to pancreatic exocrine function. Chronic pancreatitis and secondary type 1 DM. • Potentially fatal recurrent respiratory episodes of • • infections and atelectasis; thorax may become barrel-shaped due to respiratory effort. Steatorrheic stools, malnutrition, hypovitaminosis; and bowel obstruction. Sterility. 129 Medical Care and Surgical Treatment • Pancreatic enzymes. • Antibiotics for respiratory episodes, chest percussion, supplemental O2, ABG, CXR, CBC. • Lung transplant. • Genetic counseling. Keep in Mind • The disease is chronic, and clients usually have shortened life spans (3 or 4 decades). • Chest percussion and pancreatic enzyme replacement must be continued. • Vaccination for influenza and pneumonia are recommended for high-risk individuals. Make the Connection • Monitor PFTs and O2 saturation; auscultate lungs sounds every 4 hours. • Monitor stools; assess for small-bowel obstruction. • Assess labs for hypovitaminosis and low total protein. • Remember: Help families emotionally. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 130 Respiratory Disorders 130 Acute Respiratory Distress Syndrome (ARDS) (a-kut res-pir-a-to-re dis-tres sin-drom) Clue: Diagnostic or Clinical Findings Rhonchi and crackles on auscultation, ↓ O2 saturation after sepsis, near-drowning, or aspiration of gastric contents. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 130 Respiratory Disorders Pathophysiology • Destruction of alveolar walls and capillary beds • caused by stimulation of immune mediators that ↓O2 exchange by fibrosis and edema. Immune mediators are also stimulated by traumatic events. Assessment and Diagnostic Findings • Rapid breathing; air hunger. • CXR showing consolidation to complete “white • • • out”; symptoms of noncardiogenic right-sided CHF. ABG and pulse oximetry showing decreased oxygenation. Auscultation revealing rhonchi, crackles, and areas of absent breath sounds over areas of consolidation. Cool skin, cyanosis, peripheral edema. Complications • Acute respiratory failure with a 50% or greater mortality rate. • Respiratory acidosis. • Multisystem organ failure; shock. 130 Medical Care and Surgical Treatment • Intubation and ventilation with PEEP. • Hemodynamic monitoring for CO; daily weigh• • ing to assess fluid retention; use of diuretics, antibiotics, and inotropic agents; ECG monitoring. Intravenous support; transfusion of PRBC for oxygen transport. Enteral feedings; intermittent prone positioning for increased oxygenation. Keep in Mind • Teach clients about mechanical ventilation. • Will require serial x-rays, laboratory tests, and central IV catheters. Make the Connection • Monitor central venous pressure, lung sounds, ABG, pulse oximetry, and ECG. • Monitor I&O strictly. • Monitor for signs of shock, assess serial CXR, and provide aseptic ventilator care. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 131 Respiratory Disorders 131 Severe Acute Respiratory Syndrome (SARS) (se-ver a-kut res-pir-a-to-re dis-tres sin-drom; sarz) Clue: Diagnostic or Clinical Findings Cough, rhonchi, crackles, and worsening respiratory symptoms after exposure to the coronavirus. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 131 Respiratory Disorders Pathophysiology • Exposure to the coronavirus by droplet inhalation • or contact. The SARS virus can live 6 hours on the hands. After contact with the SARS coronavirus, immune mediators cause inflammation, edema, and pneumonia by blocking gas exchange and resulting in filling of the alveoli with fluid. Assessment and Diagnostic Findings • Auscultation revealing rhonchi, crackles, and • • diminished lung sounds in areas of consolidation; fever; myalgia; cough. Liver function tests (LFTs) showing elevation; complete blood count (CBC) for low white blood cell (WBC) and platelet counts; chest x-ray and chest computed tomography (CT) for areas of consolidation; electrolyte panel for low potassium and low sodium; polymerase chain reaction (PCR) and antibody test for SARS. Recent trips to countries with SARS. 131 • Intubation and ventilation possibly required if the client’s status worsens. • Hemodynamic monitoring for cardiac output; • Keep in Mind • Teach ventilator-dependent clients about intense physical and psychosocial care they will receive. • Serial x-rays, arterial blood gas (ABG), blood transfusion, central venous catheters, and intensive care are needed. Make the Connection • Strict infection control must be followed. • Monitor central venous pressure, lung sounds, Complications • Acute respiratory failure and death. Medical Care and Surgical Treatment • Antivirals, antibiotics, steroids, supplemental O2. daily weighing to assess fluid retention; use of diuretics, antibiotics, and inotropic agents; continuous electrocardiogram (ECG) monitoring. Intravenous support; transfusion of packed red blood cells (RBCs) for oxygen transport. • • ABG, pulse oximetry, and electrocardiogram (ECG). Monitor intake and output (I&O) strictly. Monitor for signs of shock, assess serial chest x-rays, and provide aseptic ventilator care. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 132 Respiratory Disorders 132 Pulmonary Embolism (pul-mo-ne-re em-bo-lizm) Clue: Diagnostic or Clinical Findings Rapid onset of dyspnea, chest pain, anxiety, feeling of impending doom, and hemoptysis. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 132 Respiratory Disorders Pathophysiology • Thrombus formation in the deep veins from an • • ineffective cardiac pump; atrial fibrillation; the presence of increased clotting factors; or lack of movement of the musculoskeletal pump, delaying blood movement back to the heart. Emboli may also consist of air, fat, amniotic fluid, and bacteria. The thrombus occludes pulmonary circulation, impairing gas exchange. Assessment and Diagnostic Findings • • Anxiety, dyspnea, diaphoresis, fear, feeling of impending doom, chest pain, abnormal auscultatory findings, hemoptysis, syncope, and hypotension. CXR for obstruction, ECG for arrhythmias or signs of right ventricular hypertrophy, ABG showing decreased oxygenation, V/Q scan abnormality, peripheral Doppler studies for DVT, spiral CT scan of the lung to visualize PE, D-dimer test, and pulmonary angiography. 132 Complications • Right-sided CHF, shock, and sudden death. Medical Care and Surgical Treatment • Supplemental O2, suctioning, frequent auscultation of the lungs, hemodynamic support. • Anticoagulants, thrombolytics, inotropics, diuretics, antiarrhythmics, IV morphine. • Embolectomy. Keep in Mind • Identify and decrease risk factors for PE. • Prophylaxis of atrial fibrillation with warfarin. Make the Connection • Remember: Assess extremities of • bed-bound clients every shift. Look for unilateral edema of the arms or legs to identify DVT formation. Assess vital signs for shock; support the anxious client; be ready to support ventilation and hemodynamic state. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 133 Respiratory Disorders 133 Pneumonia (nu-mo-ne-a) Clue: Diagnostic or Clinical Findings Productive cough, chills, dyspnea, pain on inspiration. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 133 Respiratory Disorders Pathophysiology • Acute inflammation of lung tissue by inhalation • of droplets containing viral particles, bacteria, fungi, parasites, or irritating chemicals. Inflammatory mediators in lung tissue cause edema and filling of alveoli with serous fluid and mucus. Assessment and Diagnostic Findings 133 Medical Care and Surgical Treatment • Antibiotics, bronchodilators, expectorants, antipyretics, pulse oximetry. Keep in Mind • Vaccination for influenza and pneumonia reduces risk of pneumonia. • Respiratory toileting and infection control measures are necessary. • Rhonchi, crackles, and wheezes on auscultation. • Auscultation over areas of consolidation are diminished; over these areas, the spoken word is clearly heard (not the case in air-filled areas). Temperature elevation; productive cough characterized by green, yellow, or rusty sputum. Chest x-ray or computed tomography (CT) for consolidation, complete blood count (CBC) for elevated white blood count (WBC), arterial blood gas (ABG) for ↓ O2 level, sputum analysis for causative agent with culture and sensitivity (C&S) test and Gram stain. Complications • Pulmonary edema. • Respiratory failure and death. Make the Connection • Auscultate lungs every 4 hours; assess • • vital signs; monitor intake and output (I&O); position in semi-Fowler’s to high Fowler’s position; assess pulse oximetry reading every 4 hours. Assess breathing patterns; give supplemental O2 (humidified if necessary). Teach infection control measures. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 134 Respiratory Disorders 134 Pleural Effusion (ploo-ral e-fu-zhun) Clue: Diagnostic or Clinical Findings Dyspnea, diminished breath sounds over affected area, pleural friction rub. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 134 Respiratory Disorders Pathophysiology • The pleural space is the visceral and parietal • lining of the outer lungs. Negative pressure or a vacuum exists in this space. If the lining becomes damaged or diseased, or experiences oncotic pressure changes (lung cancer, pulmonary tuberculosis [TB], lung abscess, congestive heart failure, ascites, chronic renal disease, chest trauma), the space loses its negative pressure and expands into a space that presses on the lung in that cavity. 134 Medical Care and Surgical Treatment • Thoracentesis or placement of chest tube. • Antibiotics, steroids, and analgesics. • Cancer-causing pleural effusions are assessed by • Keep in Mind • Shortness of breath (SOB) should be reported Assessment and Diagnostic Findings • Cough, dyspnea, diminished breath sounds • over the affected area, asymmetric expansion of the chest, presence of pleural friction rub on inspiration. Complete blood count (CBC) with differential showing an increase in white blood count (WBC) (infection); chest x-ray; thoracentesis and cytology to find the cause of the effusion; client history. • • immediately, especially if diagnosed with chronic lung disorders. Vaccination for influenza and pneumonia is recommended for high-risk clients. Infection control and splinting the chest for effective coughing are important. Make the Connection • Remember: Carefully assess blood pressure Complications • Mediastinal shift with pressure on unaffected lung. • Respiratory distress. the oncologist to determine the most efficacious treatment. Pleurodesis (talc placed in pleural space to cause a scar to prevent further effusion). • • (BP) after thoracentesis, as removal of fluid depletes total circulating volume. Place client in high-Fowler’s position, medicate before chest tube removal, and limit activities. Monitor for SOB and poor pulse oximetry. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 135 Respiratory Disorders 135 Influenza (in-floo-en-za) Clue: Diagnostic or Clinical Findings Fever, myalgia, respiratory and gastrointestinal symptoms. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 135 Respiratory Disorders Pathophysiology • A viral syndrome that is spread as aerosolized • • • particles (airborne) and causes systemic inflammatory reactions of myalgia, fever, respiratory symptoms, and gastrointestinal symptoms. Strains are varied, and influenza vaccine is developed anew each season on the basis of identified strains. H1N1 influenza (swine flu) and H5N1 (bird flu) are relatively new strains causing concern. Influenza can easily become pandemic without vaccination. The very young, very old, and those with chronic disease are at most risk for death from complications. 135 Medical Care and Surgical Treatment • Antiviral medications, which must be started • Keep in Mind • Vaccination for influenza strains is essential in high-risk populations but contraindicated in persons allergic to eggs. Make the Connection Assessment and Diagnostic Findings • History of contact with an infected person. • Complete blood count (CBC) with differential, vital signs, culture for strain (if necessary), breath sounds, visualization of postnasal drip by oropharyngeal examination. Complications • Pneumonia. within 48 hours of onset of symptoms to be most effective. Analgesics, bronchodilators (if necessary), culture, antibiotics for secondary infection, electrolyte solutions for gastrointestinal symptoms, and resting of the gut. • Monitor intake and output (I&O), vital signs, and breath sounds. • Teach clients that vaccines are in forms with • either killed or weakened virus; therefore, they are unable to cause influenza. Vaccination may result in a low-grade temperature or soreness at injection site related to local and systemic inflammation and production of antibodies. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 136 Respiratory Disorders 136 Legionnaires’ Disease (le-ju-nerz di-zez) Clue: Diagnostic or Clinical Findings Dry cough, myalgia, abnormal lung sounds. Exposure to contaminated water droplets. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 136 Respiratory Disorders Pathophysiology • Legionella bacteria is inhaled from contaminated • • water supplies (e.g., from air conditioner vents, spas, respiratory equipment), causing pneumonialike symptoms. Thrives at temperatures from 90°–105° F. Headache, myalgia, fever, diarrhea. Incubation period of 2–10 days. Results in Legionnaire’s disease or a lesser influenza-like illness known as Pontiac fever. Assessment and Diagnostic Findings • Persons at risk include middle-aged or older • adults who smoke cigarettes or have chronic lung disease and those whose immune systems are compromised by diabetes, renal failure, organ transplantation, cancer, or AIDS. Sputum culture, bronchial washings, blood serology for antibody titer; or antigen testing of urine. 136 Medical Care and Surgical Treatment • Erythromycin given early and throughout the course of the disease is the treatment of choice. • Rifampin (used only with other antibiotics). • Macrolides and fluoroquinolones are effective. • Penicillin, cephalosporins, and aminoglycosides. • Antiemetics for vomiting. • CBC, ABG, CXR. Keep in Mind • Maintain infection control practices. • Encourage coughing and deep breathing exercises; use incentive spirometer. Make the Connection • Monitor intake and output (I&O) and character of stools; assess and treat emesis. • Assess breath sounds every 4 hours; monitor ease Complications • Pneumonia. • Respiratory failure leading to death. • • of respiration, pulse oximetry, ABGs, and vital signs; perform chest percussion; and provide frequent oral hygiene care. Assess for neurologic deterioration. Use sterile water for humidification. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 137 Respiratory Disorders 137 Lung Cancer (lung kan-ser) Clue: Diagnostic or Clinical Findings Persistent cough, weight loss, history of or current cigarette smoking. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 137 Respiratory Disorders Pathophysiology • Exposure to chronic irritants or carcinogens cause • • • • cell mutation, resulting in oncogene stimulation and loss of genetic material from chromosome 3. Cells in early differentiation that mutate are more aggressive than more mature cells. Cancers are evaluated using the TNM method. Cancer cells divide more rapidly and are more metabolic than normal body cells. Secreting cancers cause damage to the body by hypersecretion. Cancer in the lung may be the primary site or a metastatic secondary site from a distant body area. 137 • Hyperuricemia as a side effect of cancer treatment and cancer cells killed. Medical Care and Surgical Treatment • Radiation, chemotherapy, immunotherapy, corticosteroids, TomoTherapy. • Lobectomy or pneumonectomy. • CBC, electrolytes, serial CXRs or other imaging. Keep in Mind • Encourage smoking cessation, yearly checkups, and learning the warning signs of cancer. Make the Connection Assessment and Diagnostic Findings • • Persistent cough, wheezing, dyspnea, fever, weight loss, anorexia, pleural friction rub, hoarseness. CXR, bronchoscopy and biopsy, sputum for cytology, MRI, CT scan, PET scan, US. Complications • Superior vena cava syndrome. • Pleural effusions. • Cardiac tamponade. • Monitor F and E, skin and underlying • • structures (radiation); provide antiemetics (chemotherapy). Monitor CBC for ↓ RBC, and ↓ WBC. Support the psychosocial needs of the client and family; medicate for pain as needed. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 138 Respiratory Disorders 138 Histoplasmosis (his-to-plaz-mo-sis) Clue: Diagnostic or Clinical Findings Cough, fever. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 138 Respiratory Disorders Pathophysiology • Systemic fungal disease caused by dimorphic fungus Histoplasma capsulatum. • Organism grows in soil enriched with bird droppings. Fungal spores form that are then inhaled. • Once at body temperature, fungal spores change to the yeast form in the alveoli. The yeast is then absorbed through the regional lymphatics and into the bloodstream. Cellular immunity occurs 2–3 weeks after infection. 138 • Decreasing neurologic status. Medical Care and Surgical Treatment • Intravenous amphotericin B, ketoconazole, itraconazole. • Immunosuppressed clients will be on fluconazole for life. Keep in Mind • Immunosuppressed clients who are human Assessment and Diagnostic Findings • Fever, cough. • Fever, anemia, enlargement of the spleen and liver, • leukopenia, pneumonia, adrenal necrosis, and gastrointestinal tract ulcers in disseminated disease. Chronic pulmonary histoplasmosis produces lung cavitations similar to those in tuberculosis. Positive histoplasmin skin test or urine antigen test, and rising complement fixation and agglutination titers. Confirmed by stained tissue biopsy or culture of H. capsulatum from sputum, blood, lymph nodes, or bone marrow. Complications • Pleural effusion, cardiac tamponade. • immunodeficiency virus (HIV) positive or are undergoing chemotherapy or radiation should avoid exposure to soil that may be contaminated with bird droppings. Encourage client to report cough or fever immediately. Make the Connection • Monitor breath sounds every 4 hours, • vital signs, liver function tests (LFTs), and gastrointestinal pain indicating ulceration. Monitor chest x-ray for tuberculosis-like cavitations; complete blood count (CBC) for anemia and blood chemistry for catecholamines. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 139 Respiratory Disorders 139 Sarcoidosis (sar-koyd-o-sis) Clue: Diagnostic or Clinical Findings Fever, myalgia, night sweats, anorexia, weight loss, fatigue, with progressive lung noncompliance and SOB. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 139 Respiratory Disorders Pathophysiology • Granulomatous disorder primarily of the lungs, • • • • skin, eyes, and lymphatics thought to have a genetic link. Other organs affected are the heart, bones, joints, liver, and kidneys. Genetic clusters include mainly African Americans and Scandinavians. Environmental influences are considered as genetic triggers. Affects those 40 years of age and younger. Hilar lymphadenopathy occurs, then progresses to lymphocytic alveolitis. Skin lesions, peripheral lymphadenopathy, interstitial nephritis, iritis, hepatomegaly and splenomegaly can also occur. Symptoms and complications are related to malabsorption. Can result in pulmonary fibrosis or associated right-sided heart failure (cor pulmonale). 139 • Abnormalities on chest x-ray, electrocardiogram (ECG), histology; rule out histoplasmosis and tuberculosis (TB). Complications • Cor pulmonale and progressive pulmonary fibrosis leading to death. • Kidney, liver, and eye damage. Medical Care and Surgical Treatment • Corticosteroids and other immunosuppressants. Keep in Mind • Report dry cough that does not remit, night sweats, and shortness of breath (SOB). • Teach client about the nature of the illness, its low mortality rate, and the use of corticosteroids. Assessment and Diagnostic Findings • Signs of inflammation, such as temperature elevation, and other flu-like symptoms. • History of night sweats. • T-cell lymphocytopenia, increased monocyte count, allergy panel testing for common allergens. Make the Connection • Monitor pulse oximetry reading, chest • x-rays, ease of respiration, and signs of rightsided heart failure. Assess for symptoms associated with corticosteroid therapy and intervene when noted. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 140 Respiratory Disorders 140 Mesothelioma (mes-o-the-le-o-ma) Clue: Diagnostic or Clinical Findings Cough, SOB, history of asbestos exposure. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 140 Respiratory Disorders Pathophysiology • Mesothelia is a single layer of flat cells that line • the pleural, peritoneal, and pericardial cavities. Exposure to asbestos through inhalation causes infiltration by the short asbestos fibers into these cells. Peritoneal infiltration is thought to occur by coughing up and swallowing the asbestos fibers. Cells mutate causing changing DNA, and activating oncogenes. 140 Medical Care and Surgical Treatment • Chemotherapy, radiation (external beam and implanted). • Lobectomy and pneumonectomy. • Pleurodesis for repeated pleural effusion. Keep in Mind • Follow the OSHA guidelines for working with asbestos products. • Those with history of asbestos exposure should have frequent health screenings. Assessment and Diagnostic Findings • A good history assists with diagnosis. • CT scan, CXR, MRI, bronchoscopy or thoracoscopy with biopsy. • Genotypes show abnormalities in chromosome 22 and rearrangement of the arms of chromosomes 1, 3, 6, and 9. Complications Make the Connection • Monitor for SOB, vital signs, pulse • • Spread to the peritoneal cavity, chest wall, and lymph nodes. • Pleural effusion, dysphagia, superior vena cava syndrome. • oximetry, electrolytes, CBC, and pleural effusions. Auscultate the breath sounds every 4 hours. Remember: If the client has had a pneumonectomy, there is no chest tube, and the affected lung is placed down or in semi- to high-Fowler’s position. In the case of a lobectomy, a chest tube is in place. The client is placed in semi- to highFowler’s position. Radiation may cause dysphagia, candidiasis of the esophagus. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 141 Respiratory Disorders 141 Tuberculosis (TB) (tu-ber-ku-lo-sis) Clue: Diagnostic or Clinical Findings Fatigue, weight loss, anorexia, night sweats, low-grade fever, productive cough, hemoptysis, chest pain, anxiety. 2693_Tab08_Card_124-141.qxd 7/13/11 12:15 PM Page 141 Respiratory Disorders Pathophysiology • Mode of transmission: The tubercle bacilli are • spread by the airborne route. The mycobacteriumcontaining droplet nuclei circulate in the air. A T-cell–mediated response occurs, walling off the lesion (Ghon tubercle), inactivating the disease. The Ghon tubercle affects the hilar region first. If the client becomes immunosuppressed, the Ghon necrose cavitates then may release the organism into the lung. Assessment and Diagnostic Findings 141 Medical Care and Surgical Treatment • Combination of four antibiotics. Based on immu• • Keep in Mind • After exposure or vaccination with BCG, the • History; chest x-ray (lesions more likely in the • • upper lobes); Mantoux test revealing TB or induration of >15 mm in clients with normal immune system function; sputum smears and culture for AFB. NAA; QFT-G test done on blood specimen with results given in 24 hours. The QFT-G test result is unaffected by having received the BCG vaccine. Auscultation of chest reveals adventitious breath sounds. Complications • Obstructive respiratory disease, respiratory failure, and death. nity, 6–9 or more months of antibiotic therapy may be needed. Monthly AFB sputum test until two tests are negative in a row. Adequate nutrition, weekly weights, bronchodilators, chest percussion. Airborne isolation in a negative pressure room. • • Mantoux test will always be positive, so CXR will have to be done. Expect health-care providers wear special masks while in the room. Compliance with the medical regimen is essential for personal and public health. Teach about the side effects. Make the Connection • Monitor for SOB, poor pulse oximetry, presence of lymphadenopathy, vital signs, and night sweats, wear fit-tested HEPA mask. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 9 SENSORY Cataracts, 142 Acute Angle-Closure Glaucoma, 143 Primary Open-Angle Glaucoma, 144 Retinal Detachment, 145 Macular Degeneration, 146 Diabetic Retinopathy, 147 Conductive and Sensorineural Hearing Loss, 148 Otitis Media, 149 Otitis Externa, 150 Mastoiditis, 151 Otosclerosis, 152 Labyrinthitis, 153 Ménière’s Disease, 154 Acoustic Neuroma, 155 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 142 Sensory Disorders 142 Cataracts (kat-a-rakts) Clue: Diagnostic or Clinical Findings Difficulty driving at night because of excessive glare. Opacity of the lens on ophthalmologic examination. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 142 Sensory Disorders Pathophysiology • Opacity of the lens can occur at any age, including • • • congenitally. However, most cataract formation occurs over age 40 years and most commonly in the elderly. Types include subcapsular; nuclear; and cortical. In nuclear (age-related) cataract formation, the center and outer areas of the lens start to produce more protein strands that begin to aggregate in the center portion of the lens and form strata by folding. As strata forms, the center portion of the lens opacifies and yellows as the protein fibers accumulate. Women who take HRT are at a greater risk, and women who take HRT and consume significant amounts of alcohol are at an even greater risk. Exposure to UV light is another risk factor. Assessment and Diagnostic Findings • Ophthalmoscope and slit lamp microscope exams reveal opacity of the lens. • Subjective reports include difficulty reading small print, difficulty seeing in bright light, seeing halos around objects, and difficulty driving at night because of glare. 142 Complications • Intraoperative floppy iris syndrome (α-blocker • therapy), which can cause the iris to suddenly constrict during surgery. Retinal detachment, macular edema, IOP, hemorrhage; IOL implant dislocation. Medical Care and Surgical Treatment • Phacoemulsification of the old lens, with insertion of an IOL. Keep in Mind • Discuss all daily medications with the surgeon, especially α-adrenergic blockers. • Recovery time is very fast. Make the Connection • Monitor vital signs and visual acuity pre- and postoperatively. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 143 Sensory Disorders 143 Acute Angle-Closure Glaucoma (a-kut ang-gl klo-shur glaw-ko-ma) Clue: Diagnostic or Clinical Findings Unilateral redness and pain in the eye, headache, nausea, and vomiting. Client may see halos in the visual field around lights. Tonometry measurement may exceed 50 mm Hg. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 143 Sensory Disorders Pathophysiology • Highest risk group is Asian or Inuit women over age 45 years or persons with nearsightedness. • In glaucoma, the anterior chamber experiences • • outflow problems, with fluid and pressure increases. Because it is an enclosed fibrous capsule, the eye is unable to swell without causing pressure on important structures like the choroid retina and optic nerve. Causes the outflow area of the iris/corneal angle to become narrow because of bunching of the iris as the pupil dilates. Prolonged pupil dilation, can cause an episode of mild or emergent severity. A mild episode may be relieved by sleep and relaxation. Trauma to the eye can also produce the same type of symptoms, which create a medical and surgical emergency. Assessment and Diagnostic Findings • Tonometry that measures IOP. Gonioscopy that visualizes and assesses the angle of the anterior chamber during eye exam. 143 Complications • Partial or total blindness. • Systemic effects of eye drops. • Postsurgical infection. Medical Care and Surgical Treatment • Laser surgery that creates an opening from the • • anterior chamber to posterior chamber; may be done on the unaffected eye as prophylaxis. Miotic agents, carbonic anhydrase inhibitors, adrenergic agonists, or beta-adrenergic blockers. In acute episodes, corticosteroids to reduce inflammation, osmotic diuretics, analgesics, antiemetics, and bedrest. Keep in Mind • Avoid long periods of time in the dark, stress, and any medication that may produce mydriasis. Make the Connection • Assess for eye redness, nausea, vomiting, and seeing rainbows around objects. • Remember: This is a medical and surgical emergency. Time is vision. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 144 Sensory Disorders 144 Primary Open-Angle Glaucoma (pri-ma-re o-pen ang-gl glaw-ko-ma) Clue: Diagnostic or Clinical Findings Bilateral, usually painless loss of vision. May see halos around objects and experience mild aching in the eyes or headaches. Tonometry measurement ⬎20 mm Hg. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 144 Sensory Disorders Pathophysiology • This is the most common type of glaucoma, with • • insidious onset in persons older than 35 years of age. The only risk factors are black race, trauma to the eye, and chronic use of corticosteroids by any route. In glaucoma, the anterior chamber experiences outflow problems, with fluid and pressure increases on the choroid layer, the retina, and optic nerve. In the darkly pigmented eye, iris pigment may flake off and occlude the iridocorneal angle. Assessment and Diagnostic Findings • Tonometry measurements exceed 12–20 mm Hg. • Gonioscopy to assess the anterior angle. • Ophthalmoscopic examination with pupil dilation. • GDx Access device scan, which utilizes an infrared laser to assess damage to retinal fibers. Complications • Gradual visual loss and blindness. • Systemic effects of eye drops. • Postsurgical infection. 144 Medical Care and Surgical Treatment • Miotic agents, carbonic anhydrase inhibitors, adrenergic agonists, or beta-adrenergic blockers. • Argon laser trabeculoplasty, trabeculectomy, or cyclocryotherapy. Keep in Mind • Eye examinations with tonometry must be continued on a regular basis. • Eye drops must be continued for life; wear a MedicAlert bracelet and always carry medications. • Occlude the lacrimal duct for 1 full minute after administration of eye drops to prevent systemic effects. Make the Connection • Tonometry is the most important aspect of diagnosis for most clients. • Monitor for systemic effects of eye drops, especially in the elderly. • Administration of eye drops is done with sterile technique; the applicator does not touch the eye. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 145 Sensory Disorders 145 Retinal Detachment (ret-i-nal de-tach-ment) Clue: Diagnostic or Clinical Findings Visual abnormalities of seeing flashing lights or sparks, floaters, loss of peripheral vision, and eventually nothing, like a curtain falling over the visual field. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 145 Sensory Disorders Pathophysiology • Disorders in vision, like myopia, may predispose • • the peripheral retina to come away (traction) from the choroid layer. Rhegmatogenous detachment can occur during intraocular surgery if traction is applied to the retina, causing vitreous fluid to flow into a hole between the retina and choroid layer, resulting in detachment. Trauma to the head and eyes may cause this type of detachment. Exudative or serous detachment occurs in persons with hypertension or intraocular tumors in which serous fluid leaks between the retina and choroid. 145 Medical Care and Surgical Treatment • Argon laser reattachment. • Cryosurgery. • Scleral buckling. • Less common procedures include pneumatic retinopexy. • Electrodiathermy uses heat to drain fluid from the area between the choroid and retina. Keep in Mind • Report any sudden changes in vision, especially after trauma. • Be aware of the signs and symptoms of retinal detachment after cataract surgery. Assessment and Diagnostic Findings • Loss of peripheral vision, flashing lights, floaters, or total loss of part of the visual field. • Indirect ophthalmoscopic visualization of the Make the Connection • Retinal detachment will cause death of retina. Complications • Permanent visual loss in the area of detachment. • IOP. • Recurrent detachment. • rods and cones in the area of detachment unless interventions are initiated quickly. The client must comply with postsurgical limitations on activity in order to allow the procedure to correct the detachment. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 146 Sensory Disorders 146 Macular Degeneration (mak-yoo-ler de-jen-er-a-shun) Clue: Diagnostic or Clinical Findings Most commonly, a gradual, age-related loss of central, near, or color vision. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 146 Sensory Disorders Pathophysiology • The central fovea of the retina is rich in cones • • • (color vision) and is responsible for clear central vision. Risk factors include being an older (⬎75 years) female, white, a smoker; having hyperlipidemia; and consuming little antioxidant-containing foods. Dry or atrophic age-related macular degeneration causes pigmental changes in the fovea, which can be visualized on examination. Drusen (pale yellow spots) appear on the macula, showing areas that no longer function. This is the most common type. Wet or exudative age-related macular degeneration occurs when vitreous fluid and/or blood leak under the macula. The onset of this type is sudden, and it may be treated with an argon laser, as in retinal detachment. Assessment and Diagnostic Findings • Progressive loss of central and near vision in the dry type; sudden onset in the wet type. • Visual acuity tests. 146 • Color vision test. • IV fluorescein angiography. • Amsler grid for initial and ongoing self-diagnosis. Complications • Central blindness. Medical Care and Surgical Treatment • Dry type: few options other than low-vision lenses. • Wet type: argon laser therapy, vascular endothelial growth factor inhibitors. Keep in Mind • Teach coping skills for clients with loss of central vision. Make the Connection • Monitor Amsler grid findings to assess visual stability or loss. • Monitor IOP and for infection following argon laser therapy. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 147 Sensory Disorders 147 Diabetic Retinopathy (di-a-bet-ik ret-in-op-a-the) Clue: Diagnostic or Clinical Findings Those with a history of poorly controlled diabetes experience gradual central visual field changes that can progress to flashing lights and cessation of vision (retinal detachment). On ophthalmoscopic examination, cotton-wool spots and tortuous, dilated vessels are seen. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 147 Sensory Disorders Pathophysiology • Background retinopathy is caused by microa• • • neurysms that form on the retinal capillaries and leak blood. The client may experience visual changes caused by inflammation. The preproliferative stage of retinopathy is characterized by edema of the retina with blocked and infarcted blood flow. The proliferative stage of retinopathy is characterized by twisting of vessels, with neovasculature growing into the optic disk and obscuring the retina. The neovasculature leaks easily. Traction may occur as a result of the twisting and leaking of these vessels and cause retinal detachment. Disorder has a genetic link. 147 Medical Care and Surgical Treatment • Tight blood glucose control, especially during the first 5 years following diagnosis of diabetes. • Vitrectomy is done if leakage of blood has • Keep in Mind • Retinopathy can be avoided with tight control of blood glucose levels through diet, lifestyle changes, and medication. Make the Connection • Teach diabetic clients how to keep their Assessment and Diagnostic Findings • Change in visual acuity testing. • Ophthalmoscopic examination with dilation of the pupil. • Retinoangiography. Complications • Visual loss. • Retinal detachment. occurred under the retina. The vitreous humor is drained and replaced with saline or silicon oil. Argon laser therapy or sclera buckling is needed if retinal detachment occurs. blood glucose levels in the normal range. • Teach diabetic clients to undergo a complete • • visual examination with pupil dilation at least yearly. Monitor blood glucose level and provide periodic visual acuity tests. Listen to subjective complaints of the client or family about visual changes. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 148 Sensory Disorders 148 Conductive and Sensorineural Hearing Loss (kon-duk-tiv and sen-so-re-nu-ral her-ing los) Clue: Diagnostic or Clinical Findings Acquired or congenital inability to discriminate sound, resulting in impaired hearing. History of ototoxic drug use. Weber’s and Rinne’s tests are abnormal. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 148 Sensory Disorders Pathophysiology • Hearing loss is a common problem in the elderly, but it may occur at any age. • Efficient hearing is accomplished by appropriate • • conduction of sound into the inner ear. Conduction of sound is accomplished by vibration of the tympanic membrane that is connected to the malleus. The malleus, incus, and stapes transmit the vibration to the oval window of the inner ear. The oval window vibrates and causes movement of endolymph within the cochlea that stimulates sensorineural receptors within the cochlea. Transmission to the acoustic nerve sends information to the brain for interpretation. Conductive hearing loss can result from increased cerumen, foreign bodies in the ear canal, cysts, tumors, otosclerosis, or stiffened or scarred tympanic membrane. Sensorineural hearing loss occurs through damage to sensory nerves caused by complications of infections, use of ototoxic drugs, neuromas, arteriosclerosis, chronic exposure to noise, and aging. 148 Assessment and Diagnostic Findings • Abnormal Weber’s and Rinne’s tests. • Hearing loss indicated by subjective methods as well as audiometric testing. Complications • Changes in family processes and relationships with friends; safety issues. Medical Care and Surgical Treatment • Use of cerumen-reducing topical solutions. • Anti-infectives and anti-inflammatories. • Hearing aids, cochlear implants. • Stapedectomy for otosclerosis. Keep in Mind • Lipreading can assist in hearing. • Clean hearing aid and replace batteries as directed. Make the Connection • Face the person with hearing loss while speaking; use gestures or word boards. • Assess if the client has heard you by writing a question about the conversation. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 149 Sensory Disorders 149 Otitis Media (o-ti-tis me-de-a) Clue: Diagnostic or Clinical Findings Fever and pain in the ear. Otoscopic examination reveals a reddened and swollen tympanic membrane. Usually associated with colds and allergies. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 149 Sensory Disorders Pathophysiology • Otitis media is common in infants and children • • and results in accumulation of fluid in the middle ear because their short, horizontal eustachian tubes allow exudates from colds and allergens access to the inner ear. Causative microorganisms are viruses and bacteria. Other risks include respiratory infections, daycare attendance, lower socioeconomic status, exposure to secondhand smoke or wood-burning stoves, allergies, excessive use of a pacifier, and feeding with a propped bottle. Assessment and Diagnostic Findings • Ear pain, drainage of fluid from the ear canal, ear tugging, and hearing loss. • Elevated temperature, irritability, headache, lethargy, anorexia, and vomiting. • History of a recent upper respiratory infection or allergies. • Elevated WBC count, altered Weber’s and Rinne’s tests. 149 Complications • Tympanosclerosis. • Cholesteatoma. • Mastoiditis. • Hearing loss. Medical Care and Surgical Treatment • Vaccination against Streptococcus pneumoniae. • Antibiotics, decongestants, analgesics, antipyretics, and heat or cold application. • Low-dose antibiotics. • Myringotomy with ventilation tubes. Keep in Mind • Do not smoke around children. • Vaccination can reduce the number and severity of inner ear infections. • Breastfeeding for at least 3 months ↓ incidence. Make the Connection • Assess the tympanic membrane and ability to hear (bilaterally). Assess tympanic membrane for redness and swelling. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 150 Sensory Disorders 150 Otitis Externa (o-ti-tis eks-tur-na) Clue: Diagnostic or Clinical Findings Pain in the external auditory canal. The canal may swell shut. Pain is elicited by pressure on the tragus. Often called “swimmer’s ear.” 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 150 Sensory Disorders Pathophysiology • Infection or inflammation of the external auditory • canal caused by a contact allergy, an acute bacterial infection, or a fungal infection. Diabetics and immunosuppressed clients may experience invasion of the infection into the base of the skull, resulting in deep bone infection. 150 Keep in Mind • Use a mild alcohol solution or an over-the-counter • Assessment and Diagnostic Findings Make the Connection • Pain in the auditory canal (elicited by pushing on the tragus of the ear), fever. • Otoscopic examination reveals a reddened, • swollen ear canal. This infection may exist by itself or with otitis media. Elevated white blood cell (WBC) count shown on complete blood count (CBC); altered Weber’s and Rinne’s test. Complications • Otitis media. • Mastoiditis. • Hearing loss. Medical Care and Surgical Treatment • Antibiotics, corticosteroid given by mouth or as drops, and analgesics. drying agent to dry water in the ear canal after swimming. Report ear pain immediately to prevent otitis media and severity of infection. • Bacteria and other organisms like to grow • • in moist, warm, dark environments like the ear canal. Assess the ears carefully in the adolescent or adult who swims frequently. Teach the client to hold the head to one side to drain water from ears completely and to follow up with a drying agent. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 151 Sensory Disorders 151 Mastoiditis (mas-toyd-i-tis) Clue: Diagnostic or Clinical Findings Pain behind the ear, with fever and chills, usually after ear or sinus infection. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 151 Sensory Disorders Pathophysiology • Inflammation of the mastoid sinuses, usually as a • • • result of the spread of infection from acute otitis media. Occurs rarely because of the availability of antibiotics for otitis media. Causative organisms usually are the same as those causing otitis media (e.g., Streptococcus species, Haemophilus influenzae, Staphylococcus aureus), although on some occasions, mycobacteria or fungi may cause the disease. Chronic infection of the frontal sinuses may cause this secondary infection. Assessment and Diagnostic Findings • • • Pain behind the ear and sometimes fever and systemic symptoms (e.g., malaise, chills). Physical examination may reveal redness and tenderness behind the affected ear, with swelling of the external auditory canal. Magnetic resonance imaging (MRI) or computed tomography (CT) scan showing inflammation or abscess of the mastoid bone. 151 Complications • Brain abscess. • Meningitis. Medical Care and Surgical Treatment • Intravenous (IV) antibiotics followed by PO outpatient medications and close follow-up. • Mastoidectomy or other neurosurgical procedures if infection has spread to beneath the periosteum or if intracranial infection or thrombosis of neighboring veins develops. Keep in Mind • Treat sinus and ear infections when symptoms occur to prevent complications and secondary infection. Make the Connection • Monitor level of consciousness in the context of a comprehensive neurologic assessment. • Gain IV access and watch for irritability of the neurologic system. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 152 Sensory Disorders 152 Otosclerosis (o-to-skle-ro-sis) Clue: Diagnostic or Clinical Findings Progressive hearing loss, especially with low or soft tones. Rinne’s test for bone conduction is normal, but Weber’s test shows lateralization to the most affected ear. Tinnitus may be evident. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 152 Sensory Disorders Pathophysiology • The cause of this condition is unknown, and is more common in women (worsens in pregnancy). • The condition may begin in the adolescent years and occurs bilaterally. • Due to chronic inflammation in the inner ear, bone remodeling by the osteoclasts and osteoblasts occurs, causing excessive spongy bone growth around the stapes and the oval window, resulting in ankylosis and conductive hearing loss. Assessment and Diagnostic Findings • Whispered voice test shows decreased hearing; low-tone deafness, tinnitus. • Rinne’s test is normal for bone conduction, • but Weber’s test shows lateralization to the most affected ear. Audiometric tests and CT scan and MRI determine the extent of sclerosis. Complications • Progressive hearing loss. • Postsurgical brain infection, dizziness, nausea, vomiting, and movement of prosthetic inserted after stapedectomy. 152 Medical Care and Surgical Treatment • Stapedectomy with prosthetic. • Postoperatively, the client is positioned with the • operative ear upward, perhaps with a plug or dressing to prevent infection that could travel to the brain. Antiemetics are given as well as instructions not to cough, sneeze, vomit, or travel by air for a given time. Keep in Mind • Teach to notify the surgeon immediately if the client develops a cold postoperatively. Make the Connection • Conduct neurologic examinations periodically. • Monitor vital signs frequently. • Position the client on the unaffected side. • Give antiemetics or other medications necessary to prevent loss of prosthetic. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 153 Sensory Disorders 153 Labyrinthitis (lab-i-rin-thi-tis) Clue: Diagnostic or Clinical Findings Vertigo, tinnitus. Weber’s and Rinne’s tests indicate conductive or sensorineural hearing loss. Fever, elevation in WBCs, nausea, and vomiting may occur. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 153 Sensory Disorders Pathophysiology • Inflammation of the inner ear caused by bacterial • • or viral microorganisms that enter the inner ear from the middle ear, meninges, or bloodstream. Serous labyrinthitis can occur after toxic intake of alcohol or drugs. Diffuse suppurative labyrinthitis is caused by acute or chronic otitis media, mastoiditis, or mastoid surgery. 153 Medical Care and Surgical Treatment • Antibiotics or antiviral agents. • Mild sedatives, antiemetics, and antihistamines. • Bedrest. Keep in Mind • Ringing in the ears should always be investigated by the health-care provider. Assessment and Diagnostic Findings • Complete blood count (CBC) to diagnose infection (increased WBC count or shift to the left). • Nystagmus on the affected side. • Weber’s and Rinne’s tests to assess for conductive or sensorineural hearing loss. • Presence of tinnitus. Complications • Loss of cochlear function and hearing loss. • Spread of infection to neurologic structures. Make the Connection • Counsel clients with tinnitus and hearing • loss on methods to mitigate problems that will be encountered. Assess for dizziness, as this may be a safety issue for the client and his or her family. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 154 Sensory Disorders 154 Ménière’s Disease (man-e-arz di-zez) Clue: Diagnostic or Clinical Findings Ear fullness, tinnitus, and vertigo. Sweating, nausea, and vomiting may occur. Movement of the head makes symptoms worse. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 154 Sensory Disorders Pathophysiology • Excessive endolymph in the compartment of the • • • • inner ear, possibly from a blockage of endolymph reabsorption. Recurring episodes of hearing loss, tinnitus, vertigo, and aural fullness, often resulting in gradually progressive hearing loss. Exacerbations may occur suddenly and last for as long as 24 hours. When one ear is affected, the other ear will become involved in approximately 50% of cases. Injury, infections, endocrine disorders, and vascular disorders may be causative. 154 Medical Care and Surgical Treatment • Bedrest and keeping the head still during acute episodes is the most effective treatment. • Antihistamines, sedatives, corticosteroids, and diuretics. • A low-sodium diet. • Endolymphatic shunt. • Balance training exercises. • Discontinue smoking. Keep in Mind • Report dizziness and tinnitus to the health-care provider. Assessment and Diagnostic Findings • Electronystagmography, caloric stimulation, rotational tests, and Romberg’s test. • Auditory assessment, x-rays, CT scan, and MRI studies are performed to assess quantity of endolymph in the inner ear and extent of hearing loss accompanying the disorder. Complications • Postoperative brain infection. • Hearing loss. Make the Connection • Monitor for balance and hearing problems. • Neurologic assessments, and monitor CBC. • Counsel the client concerning balance training exercises, safety, and adherence to low-sodium diet. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 155 Sensory Disorders 155 Acoustic Neuroma (a-koos-tik nu-ro-ma) Clue: Diagnostic or Clinical Findings Hearing loss, headache (wakes the client or is worse with sneezing or coughing), facial numbness, balance problems, and tinnitus. 2693_Tab09_Card_142-155.qxd 7/14/11 11:49 AM Page 155 Sensory Disorders Pathophysiology • Benign tumor of the Schwann cells of cranial nerve VIII. • Linked with neurofibromatosis type 2. Assessment and Diagnostic Findings • Drooling, facial drooping, and dilation of pupil on affected side. • Computed tomography (CT) scan, magnetic • • • resonance imaging (MRI) to assess size and location of lesion. Electronystagmography to assess extent of vertigo. Test of hearing and brainstem function (brainstem auditory evoked response). Caloric stimulation test. Complications • Postoperative brain infection. • Radiation therapy after radiosurgery can result in nerve damage and hearing loss. • Without treatment, the tumor can continue to • press on structures, causing increasing discomfort and loss of function. Hydrocephalus. 155 Medical Care and Surgical Treatment • Surgery. • Stereotactic radiosurgery. • Treatment of inflammation with corticosteroids. • Antihistamines for dizziness; analgesics for headache. Keep in Mind • Benign tumors will not metastasize but will grow and cause pressure on other structures, possibly resulting in serious problems (e.g., hydrocephalus, hearing loss, and progressive pain and dizziness). Make the Connection • Monitor postsurgically for infection by watching the complete blood count (CBC). • Assess hearing and facial movement after surgical or radiosurgery procedures. • Monitor neurologic status. • Counsel client on what to expect from treatment or choosing not to have treatment. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 10 DERMATOLOGIC Skin Cancer, 156 Contact Dermatitis, 157 Eczema, 158 Cellulitis, 159 Psoriasis, 160 Herpes Zoster, 161 Herpes Simplex, 162 Paronychia, 163 Impetigo, 164 Scabies, 165 Pediculosis Capitis, 166 Acne Vulgaris, 167 Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis, 168 Tinea, 169 Verruca, 170 Superficial and Partial-Thickness Burns, 171 Full-Thickness Burns, 172 Rosacea, 173 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 156 Dermatologic Disorders 156 Skin Cancer (skin kan-ser) Clue: Diagnostic or Clinical Findings Skin lesion with asymmetry, irregular borders, color changes, and >6 mm diameter. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 156 Dermatologic Disorders Pathophysiology • Mutation of cells of the skin that occurs from chronic exposure to the sun or other irritants. • Basal cell cancer (the most common; cells in the • lowest layer of the epidermis), squamous cell (cells of the middle layer of the epidermis), or melanoma (the most deadly form; melanocytes in the bottom layer of the epidermis). Cells lose normal functional properties and can metastasize to other organs (melanoma). Assessment and Diagnostic Findings • Unusual lesion or change in a mole. • ABCD criteria: Is it asymmetric? Are the borders • irregular? Is the color unusual (ranges from tan, black, and brown to white, blue, and red). Is the diameter greater than 6 mm? • Basal cell lesions are curled; squamous cell lesions reveal underlayer of tissue and are red, scaly, or have drainage; melanomas are darkly pigmented. Diagnosis made by excision and biopsy of the melanoma or Mohs’ chemosurgery technique, in which thin layers of skin are shaved and examined for cancerous cells (basal and squamous). 156 Complications • Metastasis to internal organs and death. Medical Care and Surgical Treatment • Excision and biopsy; Mohs’ chemosurgery for basal and squamous cell cancers. • Chemotherapy, radiation, TomoTherapy, interleukin, interferon. Keep in Mind • Avoid prolonged sun exposure; wear SPF 30 or greater sun block. • Maintain yearly skin checks with the dermatologist. Make the Connection • Monitor skin lesions and apply ABCD criteria. • If client is undergoing cancer treatment, assess for nausea, vomiting, CBC, electrolytes, site of radiation, and problems with underlying structures. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 157 Dermatologic Disorders 157 Contact Dermatitis (kon-takt der-ma-ti-tis) Clue: Diagnostic or Clinical Findings Patterned skin eruption after contact with an irritant or allergen. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 157 Dermatologic Disorders Pathophysiology • Irritant contact dermatitis is caused by chemicals • like detergents; allergic contact dermatitis is a cell-mediated type IV hypersensitivity reaction to an allergen (poison ivy, tape, and jewelry are some examples). Areas affected may show mild erythema or vesicles and bullae and are referred to as eczema. Assessment and Diagnostic Findings • Areas of erythema, vesicles, or bullae that appear in a pattern. • Allergy to the metal in a client’s watch will result in a rash localized in that area. • Exceptions: poison ivy leaves, in which the sap may aerosolize if leaves are burnt, or photosensitivity, which is a reaction to exposure to the sun, usually caused by use of drugs like diuretics, antipsychotics, or antibiotics, producing a more extensive rash not occurring in area of clothing. Complications • Infection. • Rash occurring in the eye. 157 • Respiratory distress, as in cases of severe latex allergy. Medical Care and Surgical Treatment • Corticosteroids topically, orally, or intraocularly. • Lesions should be lightly wrapped. Keep in Mind • Allergy testing should be done to prevent further outbreaks. • Avoid the allergen. Make the Connection • Take a good history; look to see if the lesions have a distinct pattern. • Apply corticosteroids; watch for adrenal insufficiency (↓ Na, ↑ K, ↓ BP). 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 158 Dermatologic Disorders 158 Eczema (ek-ze-ma) Clue: Diagnostic or Clinical Findings Presence of a vesicular rash that may occur on any skin surface, including under the eyes. Asthma is often a comorbid illness. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 158 Dermatologic Disorders 158 than steroid creams except in severe outbreaks. Tacrolimus and pimecrolimus inhibit the actions of T lymphocytes, mast cells, dendritic cells, and keratinocytes. Ointment forms are preferable. Pathophysiology • Type I hypersensitivity disorder, genetically linked, • • with a family history of hay fever, asthma, or atopic dermatitis. Infantile forms are vesicular, cheeks are pale, and Dennie-Morgan folds may be present under the eyes. Adults usually have dry leathery areas that are either more or less pigmented than surrounding tissue and appear in the antecubital and popliteal areas. The pruritic lichenified (dry, leathery) lesions can spread to the hands, feet, eyelids, and neck. Keep in Mind • Family histories of asthma or hay fever place other family members at greater risk. • Allergy skin testing should be done so contact with allergens can be avoided. • Scratching the skin should be avoided to decrease the chance of secondary infection. Assessment and Diagnostic Findings • Areas of vesicular eruption in infants; dry, leathery Make the Connection • Assess skin care habits and take a good areas in adolescents and adults. Complications • Secondary infection. family history. • Assess discomfort and medicate with antihista- Medical Care and Surgical Treatment • Warm water baths with a hypoallergenic soap or colloidal substances like oatmeal. • Moisturizers. • Antihistamines for itching, topical immune modulators (tacrolimus and pimecrolimus) rather • mines to prevent scratching of the skin. Show how to lightly tap the area rather than scratch for relief. Assess for adrenal insufficiency if topical or oral steroids are used. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 159 Dermatologic Disorders 159 Cellulitis (sel-u-li-tis) Clue: Diagnostic or Clinical Findings Patchy erythema and edema in the extremities in the absence of DVT. May be more prevalent in those with diabetes or peripheral vascular disease. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 159 Dermatologic Disorders Pathophysiology • Bacteria infiltrate skin, bypassing normal skin barriers, and release toxins in the subcutaneous tissue. Comorbid illnesses like diabetes and peripheral vascular disease increase the incidence. Assessment and Diagnostic Findings 159 Keep in Mind • Educate clients at risk about proper skin and foot care. • Clients should not use heating pads if they have decreased sensation in the extremities as they may be burned. • Acute onset of edema, patchy erythema, sometimes vesicles and pain with systemic signs and symptoms of inflammation, like fever, pain, and sweating. Lymph nodes in the region may be swollen. Complications • Possible deep vein thrombosis (DVT) forming due to inactivity. • Spreading infection and possible necrosis of tissue. Medical Care and Surgical Treatment • Antibiotics. • Elevate the limb. • Warm, moist soaks. Make the Connection • Monitor the skin if client is using warm, moist soaks, to prevent maceration. • Assess for allergy to antibiotics. • Teach clients that any injury (bruising, ulcerations, ingrown toenails, and hangnails) can result in cellulitis. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 160 Dermatologic Disorders 160 Psoriasis (so-ri-a-sis) Clue: Diagnostic or Clinical Findings Patches of papules or plaques with silvery scale. The underlying skin is erythematous. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 160 Dermatologic Disorders Pathophysiology • T cell–mediated autoimmune disorder characterized by silvery scale on an erythematous base. • Abnormal growth of keratinocytes and dermal blood vessels. • Precipitating factors may be any that stimulate • the T-cell lymphocytes (e.g., trauma, stress, infections, and medications). Histologic studies show increased epidermal cell turnover; white blood cells (WBCs) are found in the stratum corneum. Assessment and Diagnostic Findings • History, presence of typical lesions. Client may report improvement with sun exposure. • Histologic studies showing defects in keratinocyte differentiation (filaggrin and involucrin gene mutation), increased presence of plasma proteins and Ig G. Complications • Secondary infections to skin shedding. • Adrenal insufficiency from corticosteroid use. 160 Medical Care and Surgical Treatment • Topical moisturizers, keratolytic agents, retinoids; • • coal tar products; anthralin; corticosteroids (topical or PO); calcipotriene; and antihistamines. Psoralenscoupled with PUVA phototherapy. Disease-modifying antirheumatic drugs (DMARDs; e.g., methotrexate), biologic agents (e.g., etanercept), and intralesional cyclosporine. Keep in Mind • Support groups are in place because psoriasis can be psychosocially disruptive. • Sun exposure and swimming in salt water will help clear or reduce the severity of lesions, but excess sun exposure increases risk for skin cancer. Make the Connection • Monitor the extent of the lesions. • Watch for bleeding or secondary infection. • Watch for signs of adrenal insufficiency (↓ Na, ↑ K, ↓ BP). 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 161 Dermatologic Disorders 161 Herpes Zoster (her-pez zos-ter) Clue: Diagnostic or Clinical Findings “Dew drops on a red leaf.” Painful vesicular lesions unilaterally occurring along sensory nerve pathways. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 161 Dermatologic Disorders Pathophysiology • Caused by varicella zoster virus, identical to that which causes chickenpox. • The herpes virus lies latent in the nerve tissue and • • reactivates with stress or decreased immunity or in clients with a malignancy or an injury to the spine or cranial nerve. Breakouts follow the course of sensory nerves, dermatomes, or cranial nerves and occur unilaterally. Eruptions last may last from 5 days to 5 weeks. Even when the lesions are gone, a postherpetic neuralgia exists and persists. Assessment and Diagnostic Findings • Painful unilateral vesicular lesions following a sensory nerve, dermatome, or cranial nerve. • Vesicles cause an erythema on the skin because of 161 • Scarring. • Systemic infection. Medical Care and Surgical Treatment • Antivirals orally, topically, or intravenously. • Analgesics, corticosteroids if no systemic infection occurs. • Antibiotics for secondary infection. Keep in Mind • Persons with risk factors should avoid persons with varicella zoster infection. • Antiviral medications will shorten the course of the illness. • Lesions should not be scratched. • The infectious period is 1–2 days prior to the lesions erupting to when the lesions are dry. the acute inflammation. Complications • Postherpetic neuralgia, persistent dermatomal • • pain, and hyperesthesia, which can last for weeks or months. Ophthalmic herpes zoster can affect eyesight. Hearing loss, tinnitus, paralysis, and vertigo as postherpetic cranial nerve problems. Make the Connection • Clients with herpes zoster in the hospital setting should be isolated for infection control. • Monitor vital signs and skin for secondary infection. • Assess pain level and medicate as necessary. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 162 Dermatologic Disorders 162 Herpes Simplex (her-pez sim-plex) Clue: Diagnostic or Clinical Findings Painful, itchy, vesicular lesion on the lips or in the nose. May also occur in the genital area. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 162 Dermatologic Disorders Pathophysiology • Caused by the herpes simplex virus (HSV). There • are two types: HSV-I occurs above the waist, and HSV-II occurs below the waist. Occurs through direct contact, respiratory droplet, or fluid exposure. After exposure, the virus lies dormant in the nerve ganglia where the immune system cannot destroy it. Stress of any kind can cause the virus to reactivate. 162 • Daily antiviral medication is given orally for prevention of genital herpes outbreak. Keep in Mind • Lesions are infectious a couple of days prior to outbreak to the time the lesions are crusted. • Herpes I and II cannot be cured, only suppressed. • Genital herpes is spread most commonly by sexual contact. Assessment and Diagnostic Findings • Tingling sensation or itching as the vesicle erupts. • Area is swollen and erythematous. Complications • Type II (genital herpes), if present during vaginal • birth, can cause blindness or acute neurologic problems in the newborn such as herpes encephalitis. A herpetic lesion on the eye requires ophthalmologic care. Medical Care and Surgical Treatment • Antiviral medication topically or orally, which will shorten the duration of the outbreak. Make the Connection • Teach the client about type I and type II HSV. • Avoid contact with lesions; wear appropriate protective gear. • Teach about antiviral medication and its side effects and action. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 163 Dermatologic Disorders 163 Paronychia (par-o-nik-e-a) Clue: Diagnostic or Clinical Findings Erythema around the base of the nailbed in persons who frequently, as a result of employment, have their hands in water or are nailbiters or thumb suckers. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 163 Dermatologic Disorders Pathophysiology • Acute or chronic condition in which the protec• tive barrier between the nail and the nail fold is breached by bacteria or fungus, causing erythema and pain. Can occur in persons whose hands are often in water and in those who engage in thumb sucking or nail/cuticle biting. 163 Keep in Mind • Keep nails moisturized, and care for cuticles carefully. • Dry hands after thoroughly washing them. • Do not bite the nails or cuticles. Make the Connection • Assess the site carefully; look for the nail Assessment and Diagnostic Findings • Erythema and pain around and at the nail fold, which can spread. • Antiretroviral drug use (indinavir) predisposes to this illness in HIV+ persons. • Potassium hydroxide 5% smears; potassium hydroxide (KOH) wet mounts from scrapings or discharge (hyphae). Complications • A run-around infection of the nail. • Loss of the nail. Medical Care and Surgical Treatment • Warm soaks; a drain if necessary; antibiotics or antiviral medications orally or topically. lifting from the nailbed. • Apply warm soaks and give medications as ordered. • Teach the client to stop nail biting and use anti• bacterial hand sanitizers as needed at places of employment. Apply antibacterial moisturizers. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 164 Dermatologic Disorders 164 Impetigo (im-pe-ti-go) Clue: Diagnostic or Clinical Findings Honey-colored crusts on the lips mouth, nose, hands, or perineum; usually in children. Shallow vesicles that rupture easily. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 164 Dermatologic Disorders Pathophysiology • Superficial bacterial infection of the skin caused by staphylococci, streptococci, or both. • Vesicles or bullae are preceded by discolored spots. • Vesicles or bullae rupture, leaving honey-colored crusts. • Infection spreads outward. 164 Keep in Mind • Teach that the lesions are a bacterial infection, so medical regimen should be followed. • Parents should teach their child not to scratch the lesions because the infection can spread. • Child should not come in contact with other children until crusts are dry and antibiotics have been taken for 24 hours. Assessment and Diagnostic Findings • Pruritus, weeping vesicles, bullae, and crusts. • Cultures can be taken for confirmation. Complications • Systemic infection, rarely necrotizing fasciitis, or toxic shock syndrome. Medical Care and Surgical Treatment • Antibacterial soap; topical and systemic antibiotics. Make the Connection • Clean the area carefully. • Administer antibiotics and antibiotic ointment as ordered. • Assess for diminution of lesions. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 165 Dermatologic Disorders 165 Scabies (ska-bez) Clue: Diagnostic or Clinical Findings Grayish brown pruritic threadlike lesions with black dot at the end between fingers, toes, axillae, groin, buttocks, and abdominal areas. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 165 Dermatologic Disorders Pathophysiology • Impregnated female scabies mite burrows under the skin and lays eggs. An inflammatory response occurs 30–60 days after initial contact. 165 Keep in Mind • Scabicides do not have to be applied above the neck; keep on only for prescribed time, no longer. • Teach that infestations like scabies are common- Assessment and Diagnostic Findings • • • Grayish brown threadlike lesions with black dot at the end found between fingers, toes, axillae, groin, buttocks, and abdominal areas. Pruritus. Skin scraping shows mite under microscope. Complications • Secondary infection from scratching. • Spreads from person to person easily, so it can become epidemic in school-aged children and their families. Medical Care and Surgical Treatment • Application of a scabicide (e.g., Permethrin topical cream or Lindane lotion). • Wash clothing and other items with which the infected person came into contact. • place among schoolchildren and discourage from feeling judged. Scabies are easily passed person to person, so all persons in contact with the infected person are to be treated. Make the Connection • Monitor lesions; wear protective gear. • Advise the infected person not to scratch the lesions. • Support the family’s psychosocial needs. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 166 Dermatologic Disorders 166 Pediculosis Capitis (pe-dik-u-lo-sis ka-pi-tis) Clue: Diagnostic or Clinical Findings Itching of the scalp. Magnifying glass assessment reveals white or translucent eggs adhered to hair shaft near the skin or movement of insects in the hair. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 166 Dermatologic Disorders Pathophysiology • Infestation of the head by Pediculus humanus capitis (head louse). • Female louse lays eggs at night on a hair shaft close to the skin; eggs appear white or clear. • Eggs hatch 7–10 days later. • Itching of the scalp is produced by the insects crawling and by their saliva on the scalp. Lice bite and feed on human blood. They are approximately 2 mm in length. Assessment and Diagnostic Findings • Itching. • Nits observable on hair shaft by magnifying glass. • Usually found in the hair at the occipital area and nape of the neck, but can spread anywhere, even to eyebrows and eyelashes. Complications • Secondary infection from itching and scratching the skin on the scalp. • Spreads easily, so anyone with contact can become infected. Medical Care and Surgical Treatment • Shampoos and conditioners that contain pediculicidal agents (e.g., Lindane, RID, NIX). 166 • Small-tooth comb to remove nits. Keep in Mind • Wash all clothing, hats, and bedding in hot water. • Pediculicidal spray can be used on items that cannot be laundered, like carpet or large pillows. • Vacuum carpets and other surfaces. • Soak combs and other hair management items in the pediculicidal solution. • Do not leave shampoo on longer than directed, as it is a toxic agent meant to kill insects. • In the case of a child, report the infestation to • the school nurse so anyone in contact can be treated. Support the child to prevent feelings of embarrassment. Make the Connection • Use gloves and tongue blades when looking for lice or nits. • Nits are difficult to remove and are adhered tightly to the hair shaft. 2693_Tab10_Card_156-173.qxd 7/14/11 7:30 PM Page 167 Dermatologic Disorders 167 Acne Vulgaris (ak-ne vul-ga-ris) Clue: Diagnostic or Clinical Findings Whitehead, blackheads, or cysts on the face, neck, upper back, chest, and shoulders, usually in adolescents, but can occur in adults. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 167 Dermatologic Disorders Pathophysiology • Skin disorder of the sebaceous glands and their hair follicles. • Androgens, stress, strong soaps or cosmetics, • • or genetic factors cause an increase in sebum secretion. Pilosebaceous ducts are blocked with accumulated debris causing inflammation and bacterial infiltration. Lesions may be on face, neck, chest, upper back, and shoulders. Assessment and Diagnostic Findings • Erythematous areas with open comedones (whiteheads) or closed (blackheads). • Presence of papules, pustules, nodules, and in severe cases, cysts. Complications • Scarring, especially if the acne is cystic. • Psychosocial implications. Medical Care and Surgical Treatment • • Topical antibiotics in combination with desquamation agents. Oral antibiotics in combination with desquamation agents or retinoids. 167 • Oral retinoids. • Intralesional injections with corticosteroids. • Comedones extraction. • Chemical peels or collagen injections for scars. Keep in Mind • Lesions should not be manipulated or “squeezed.” • Oral retinoids require that females use a reli- able method of birth control and produce a negative pregnancy test prior to the start of therapy. Monthly LFTs will be performed. Skin structures will be very dry and will require a moisturizer. Report depressive symptoms. Make the Connection • Acne causes psychosocial effects. • Assess for improvement once therapy is begun. • If using oral retinoids, make certain adequate teaching is done about prevention of pregnancy and monthly LFTs. Assess for signs of depression in the client on these medications. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 168 Dermatologic Disorders 168 Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (ste-venz-jon-son sin-drom; toks-ik ep-i-der-mal ne-krol-i-sis) Clue: Diagnostic or Clinical Findings Flu-like symptoms or macular rash after starting sulfa drugs, antibiotics, or antiepileptics. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 168 Dermatologic Disorders Pathophysiology • Altered drug metabolism causes a T cell–mediated reaction in the keratocytes. • A macular rash spreads rapidly and forms vesicles • and bullae in the epidermis and in the mucous membranes, which necrose and slough. Stevens-Johnson syndrome (SJS) involves 10% of body surface area, while toxic epidermal necrolysis (TEN) involves 30%. Assessment and Diagnostic Findings • About 1–3 weeks after a drug is started, flu-like symptoms and conjunctivitis occur. • Large bullae that are easily broken will slough • • • • over a period of 1–3 days. Nails, eyebrows, and internal mucosal structures may be lost. Nikolsky’s sign. Painful oral crusts, erosions, and genital problems exist in most cases. Cough, pulmonary edema, and hypoxemia. Glomerulonephritis and hepatitis may develop. Histology shows necrotic epithelial tissue. 168 Complications • Fluid loss and electrolyte imbalance. • Respiratory failure. • Acute renal and hepatic failure. Medical Care and Surgical Treatment • Transfer to a burn unit. • F & E replacement. • Prophylaxis for infection. • Corticosteroids. Keep in Mind • Report any flu-like symptoms or rash after starting therapy with any medication, seek immediate medical care. Make the Connection • Maintain strict monitoring of I&O; provide fluid replacement based on total surface area. • Monitor pulse oximetry, CBC, LFTs, RFTs, and electrolyte panel. • If client is placed on a ventilator, provide aseptic ventilator care and suctioning. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 169 Dermatologic Disorders 169 Tinea (tin-e-a) Clue: Diagnostic or Clinical Findings Reddened lesions that have a scaly appearance. Lesions may form circular areas, reddened raised areas, or, between toes, crevasses that can be deep and bloodless. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 169 Dermatologic Disorders Pathophysiology • Tinea infections or dermatophytoses occur • • when skin is impaired by exposure to a moist environment. Infections may occur through direct contact with infected humans, animals, or objects. Superficial mycotic infections include: Tinea pedis. Tinea capitis. Tinea corporis. Tinea versicolor. Tinea cruris. Tinea unguium. Tinea barbae. Assessment and Diagnostic Findings 169 Complications • Secondary infection from altered skin integrity. • Alopecia. Medical Care and Surgical Treatment • Topical and oral antifungal agents. • Corticosteroids for severe hypersensitivity reactions (kerion). Keep in Mind • Teach clients to keep area clean and dry. • Tinea capitis and tinea pedis are easily spread • • Superficial types are characterized by scaling, • slight itching, reddish or grayish patches, and dry brittle hair that is easily extracted with the hair shaft. Deep lesions are flat, reddish, kerion-like areas studded with dead or broken hairs. Permanent alopecia may occur in these areas. by direct contact; tinea capitis is also spread by animals. Nonsynthetic or cotton socks and underwear help decrease the incidence or severity of tinea infections. Make the Connection • Assess for sites in moist areas that are • reddened, have a scaly appearance, or form a circular lesion. Assess effectiveness of topical antifungals. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 170 Dermatologic Disorders 170 Verruca (ver-roo-ka) Clue: Diagnostic or Clinical Findings Pink or light pink growths that cluster on skin structures. Occasionally, these lesions are flattened and found on the facial area. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 170 Dermatologic Disorders Pathophysiology • Benign papillomas, or warts, are caused by • • human papillomaviruses (HPVs) that are spread through cracks in the skin; genital warts are spread by sexual contact. Various types are commonly seen: Verruca vulgaris (common warts). Verruca filiformis are found on the eyelids, face, and neck and project from the skin. Verruca plana (flat warts). Verruca plantaris (plantar warts). Condyloma acuminata (genital warts). These growths usually clear in time, but the immune system reacts very slowly to their presence. 170 Medical Care and Surgical Treatment • Keratolytic agents, plaster that breaks down the verruca, and freezing with liquid nitrogen. • Intralesional bleomycin injections. • Laser surgery and electrosurgery. • Antiviral therapy. • Duct tape (on for 6–7 days, off for 12 hours, and repeat). Keep in Mind • Teach females the connection between genital warts and cervical cancer. • Warts can be self-limiting, but removal methods do exist. • Wart removal can cause scarring. Assessment and Diagnostic Findings • Irregular thickening of the skin layers (stratum spinosum and stratum corneum) in typical areas. • Differentiated from other growths by biopsy. Complications • Scarring. • Cervical cancer from condyloma acuminata. Make the Connection • Assess areas affected by verrucae and apply topical removal agents as ordered. • Assess effectiveness. • Refer to dermatologist or gynecologist for verrucae removal. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 171 Dermatologic Disorders Superficial and Partial-Thickness Burns (soo-per-fish-al and par-shal thik-nes birns) Clue: Diagnostic or Clinical Findings Redness of the skin resembling sunburn or redness and mottling of the skin with blister formation after contact with a thermal source. 171 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 171 Dermatologic Disorders Pathophysiology • Thermal or chemical injury to skin, the extent of which is expressed as body surface area. • Superficial (first-degree) burns are likened to • • sunburn and affect only the epidermis. Partialthickness (second-degree) burns involve the epidermis and some portion of the dermis. Second-degree burns are characterized by blister formation. Deep second-degree burns take longer to heal and may cause scarring. First- and second-degree burns are painful because of intact free nerve endings for sensory pain transmission. Assessment and Diagnostic Findings • Redness of the skin resembling sunburn that is very painful. • Red, mottled skin with blisters that blanch on 171 the hand, the client will require referral to a burn center for treatment, especially if the burn is a deep second-degree burn. Medical Care and Surgical Treatment • Silvadene or other antibiotic creams; analgesics (usually morphine sulfate for severe pain). • Original Biobrane or Integra Artificial Skin for deep second-degree burns of the hands. • Assess respiratory status if the client was exposed to smoke and heat. Keep in Mind • Teach the client about the extent of the burn and what kind of treatment to expect. • The client must maintain adequate fluid intake and a nutritious diet. • Any treatment regimen, like creams or occlusive dressings, must be maintained. pressure and then refill; very painful. Complications • Edema, pain, and secondary infection with second-degree burns. • If burn occurs in the perineal area, over a large surface area, or involves the entire surface of Make the Connection • Monitor I&O, pain level, electrolytes, and nutritional status. • Assess for healing or infection. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 172 Dermatologic Disorders 172 Full-Thickness Burns (ful thik-nes birns) Clue: Diagnostic or Clinical Findings Tough, leathery, or charred skin surface that is brown, tan, red, or black. The skin does not blanch and is painless. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 172 Dermatologic Disorders Pathophysiology • Thermal, chemical, or electrical source destroys all layers of the skin (third-degree burns). • Severe edema from protein loss and increased capillary permeability. Assessment and Diagnostic Findings • Tough, leathery, or charred skin that is brown, • • • • tan, red, or black; does not blanch; and is painless. Progressive dyspnea from hot air burns. Progressive edema, ↓ BP, ↑ HR; rule of nines to assess BSA burned. CBC shows decreased RBCs. Decreased renal output or hemoglobin in the urine. Complications • Shock from massive fluid loss to death. • Respiratory distress. • Secondary infection. Medical Care and Surgical Treatment • LR IV for fluid resuscitation with albumin infusion based on BSA burned; transfer to burn center; fluids must be sufficient to keep urine clear of hemoglobin. 172 • Respiratory support. • Allograft, autograft, xenograft or cultured skin that must not be disturbed. • Antibiotics, morphine sulfate, TPN, and pressure suits to reduce scarring. Keep in Mind • Client and family must be kept apprised of the situation to reduce anxiety. • Client will require reverse isolation when stable; débridement is done with anesthesia. Make the Connection • Assess BSA affected by using the rule of nines for adults and children. • Prepare to infuse a large volume of LR in the first 24 hours. • Monitor vital signs for shock; monitor I&O; and monitor urine for color (must not be maroon). • Medicate with morphine sulfate IV as needed. • Support the family and client. • Apply splints or pressure suits as needed. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 173 Dermatologic Disorders 173 Rosacea (ro-za-se-a) Clue: Diagnostic or Clinical Findings Client’s skin appears flushed. States that sun exposure, eating or drinking hot foods or liquids, and alcohol make the condition worse. 2693_Tab10_Card_156-173.qxd 7/14/11 7:31 PM Page 173 Dermatologic Disorders Pathophysiology • Chronic inflammatory process that often coexists with acne that looks like blushing. • Thought to be caused by leakage of fluid and • • • inflammatory mediators into the dermis. Inflammation may persist because of bacterial infiltration in the area. The main types of rosacea are the following: • Telangiectatic (marked by the appearance of spidery blood vessels on affected skin). • Papulopustular (bumpy/pustular lesions). • Phymatous (nasal scarring and deformity). • Ocular (involving the lids, lashes, or conjunctiva). The condition is common, especially in persons of Northern European ancestry. It usually is noted first between the ages of 30 and 50. Women are affected more often than men. Assessment and Diagnostic Findings • Blushing or redness of the cheeks, nose, and eyelids, with acne-like outbreaks that are worsened by sun exposure, ingestion of hot liquids or foods, and alcohol (especially wine). 173 Complications • Rhinophyma (thickening and bumpy deformity of the nose and cheeks). Medical Care and Surgical Treatment • Metronidazole or azelaic acid topically. • Oral antibiotics. • Rhinophyma requires laser treatment, dermabra- sion, cryosurgery, or excision of excess tissue by a plastic surgeon. Keep in Mind • Clients with rosacea must be treated to prevent worsening. • Teach clients to avoid hot foods and liquids, exposure to the sun, and alcohol. Make the Connection • Monitor skin for improvement during treatment. • Reinforce teaching about foods, alcohol, and sun exposure. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 11 MENTAL HEALTH Generalized Anxiety Disorder, 174 Posttraumatic Stress Disorder, 175 Panic Disorder, 176 Phobias, 177 Obsessive-Compulsive Disorder, 178 Conversion Disorder, 179 Dissociative Amnesia, 180 Mania, 181 Depression, 182 Bipolar Disease, 183 Schizophrenia, 184 Attention Deficit-Hyperactivity Disorder (ADHD), 185 Alcoholism, 186 Borderline Personality Disorder, 187 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 174 Mental Health Disorders 174 Generalized Anxiety Disorder (jen-er-al-ized ang-zi-e-te dis-or-der) Clue: Diagnostic or Clinical Findings Excessive worry or anxiety that cannot be controlled, causing interference with normal activities of daily living. Symptoms must have occurred for at least 6 months. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 174 Mental Health Disorders Pathophysiology • Anxiety is produced by stimulation of the autonomic nervous system. Neurotransmitters involved in the anxiety response include gammaaminobutyric acid (GABA), serotonin, epinephrine, and norepinephrine. A prolonged, abnormal fight-or-flight response occurs to normal stimuli. Assessment and Diagnostic Findings • According to the Diagnostic and Statistical Manual • • of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), symptoms must be associated with the following: feeling easily fatigued, irritability, sleep disturbances, difficulty concentrating, restlessness, and muscle tension. Autonomic activity causes cold sweats, sweaty palms, dry mouth, nausea or diarrhea, urinary frequency, difficulty swallowing and eating, an exaggerated startle response, and depressive symptoms. PET and SPECT scans reveal increases in metabolism in the brain. Complications • Panic disorder and phobia development. 174 • Disturbances in family processes. • Loss of ability to function in society. • Depression that can lead to psychosis or suicide. Medical Care and Surgical Treatment • Cognitive behavioral therapy, along with anxiolytic and antidepressive agents. • Electroconvulsive therapy (ECT). • Group therapy. Keep in Mind • Exercise, diet, and social activity are part of therapy. Make the Connection • “Offer yourself” to the client (“I will stay • • with you until you feel better”) and use empathy. Walk along with clients who need to pace. Use open-ended questions (“Tell me about . . .”). Be aware of the defense mechanisms. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 175 Mental Health Disorders 175 Posttraumatic Stress Disorder (post-traw-mat-ik stres dis-or-der) Clue: Diagnostic or Clinical Findings Acute anxiety and distress related to flashbacks or memories of a traumatic event. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 175 Mental Health Disorders Pathophysiology • Severe psychological distress after traumatic • • • events (e.g., war, criminal assault, accidents, natural disasters, rape). The amygdala of the brain is hyperactive in PTSD. Activation of the amygdala causes activation of the autonomic nervous system, and the adrenal system. The sympathetic nervous system produces many of the symptoms of PTSD, which are prolonged by the adrenal hormones. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), symptoms must last at least 1 month. Onset may occur at any time after the traumatic event. 175 Complications • Depression, suicide, and homicide. • Loss of family processes and social withdrawal. Medical Care and Surgical Treatment • Treatment of substance abuse. • Anxiolytic and antidepressant agents. • ECT. • Group therapy and cognitive behavioral therapy. Keep in Mind • Family therapy will help enlist assistance for the client at home. Make the Connection Assessment and Diagnostic Findings • “Offer yourself” to the client • Flashbacks or reexperiencing the horrifying event. • Avoidance behavior: • • Memory disturbances. Irritability. Sleep disturbances. Psychological or social withdrawal and substance abuse. EEG changes, and PET scan showing ↑ in brain metabolism. • • • • (“I will stay with you until you feel better”) and use empathy. Walk along with anxious clients who need to pace and ensure they are safe. Use open-ended questions (“Tell me about....”). Be aware of the defense mechanisms. Reexperiencing traumatic events can be very disturbing to the client. Use crisis management theory. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 176 Mental Health Disorders 176 Panic Disorder (pan-ik dis-or-der) Clue: Diagnostic or Clinical Findings Sudden feeling of impending doom, going crazy, unreality, and fear accompanied by palpitations, numbness of the arms, chest discomfort, and dizziness. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 176 Mental Health Disorders Pathophysiology • Symptoms are recurrent. • The cycle of panic is attributable to “fear of the fear.” Dreading an attack brings one on. • Physical symptoms are related to the sympathetic and adrenal systems. • Several hypotheses exist as to cause: a disorder in serotonin sensitivity, hypersensitivity to catecholamines, sensitivity to lactate, decreased inhibition to GABA, hypersensitivity in neuroanatomy producing abnormal signals for fight or flight, and genetics. Assessment and Diagnostic Findings • Differential diagnosis must be made, especially to rule out hypoglycemia and mitral valve prolapse. • PET scan shows abnormalities of brain metabo• lism. Lactate infusion can precipitate a panic attack. Chest discomfort, palpitations, dyspnea, numbness and tingling of extremities, depersonalization and dizziness, feelings of impending doom, nausea, choking, chills, cold sweats, and hot flashes. 176 Complications • Development of phobias,↑ functioning socially. • Disturbances in family processes. • Loss of ability to function in society. • Depression and substance abuse. Medical Care and Surgical Treatment • Anxiolytic and/or antidepressant agents along with cognitive behavioral therapy. • Electroconvulsive therapy (ECT) for severe depression. • Group therapy; treatment of substance abuse. Keep in Mind • Once stable, the client can use therapeutic techniques to recognize the self-limiting nature of a panic attack. Make the Connection • Offer yourself to the client (“I will stay • with you”). Walk along with clients who need to pace. Use crisis theory to assure that the client knows he or she is safe. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 177 Mental Health Disorders 177 Phobias (fo-be-az) Clue: Diagnostic or Clinical Findings Irrational fear of an object, place, situation, thing, or person that causes avoidance behaviors. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 177 Mental Health Disorders Pathophysiology • According to the Diagnostic and Statistical Manual • • of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), phobia development is strongly associated with anxiety disorders. A phobia occurs when an object, place, situation, thing, or person causes a sympathetic nervous system (autonomic) response that results in anxiety. The trigger of anxiety becomes a phobia. A phobia can become so severe that all social contact is lost. A simple phobia is one associated with fear of common things (e.g., spiders, heights). 177 Medical Care and Surgical Treatment • Cognitive behavioral therapy; group therapy. • Desensitization therapy (a long process). • Anxiolytic and antidepressant agents. Keep in Mind • Once stabilized, the client can gradually be intro• Make the Connection • It is crucial to offer yourself to the client Assessment and Diagnostic Findings • Fear, anxiety, and panic when faced with the object of the phobia. • Tachycardia and dyspnea. • An intense desire to escape. Complications • Social phobia and agoraphobia result in loss of social contacts and isolation. • Phobias are associated with anxiety and depression, so suicide can be a complication. duced to the phobic object or situation in a therapeutic setting. Phobias can be overcome. • • • • (“I will stay with you until you feel better”) and use empathy (“I understand your discomfort”). Walk along with anxious clients who need to pace. Use open-ended questions (“Tell me about....”). Be aware of the defense mechanisms that clients will use to ease their discomfort. Use crisis management theory. Make certain the client knows he or she is safe, especially if using desensitization therapy. Utilize appropriate medication therapy to decrease the client’s anxiety. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 178 Mental Health Disorders 178 Obsessive-Compulsive Disorder (ob-sess-iv kom-pul-siv dis-or-der) Clue: Diagnostic or Clinical Findings Rituals are performed a specific number of times and in a specific sequence to decrease unpleasant thoughts. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 178 Mental Health Disorders Pathophysiology • • • • According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), an obsession involves recurrent, intrusive, and persistent thoughts, impulses, or images that cause excessive anxiety. The obsession is known to be irrational yet cannot be ignored. Attempts to suppress the obsession become rituals known as compulsions. The DSM-IV-TR defines a compulsion as a repetitive act or ritual. The client with obsessive-compulsive disorder (OCD) spends a great deal of time on the ritualistic behavior. There is a genetic predisposition for OCD. 178 Complications • Severe interruption in social and family processes. • Depression, suicide, or homicide. Medical Care and Surgical Treatment • Selective serotonin reuptake inhibitors and anxiolytic agents. • Cognitive behavioral therapy. Keep in Mind • If behaviors are interfering with activities of daily living, it is time to seek help. • An obsession can be controlled with medication. Make the Connection • “Offer yourself” to the client (“I will stay Assessment and Diagnostic Findings • • • • Ritualistic hand washing, “checking for” safety, opening and closing drawers a certain number of times, and other repetitive, time-consuming behaviors. Severe anxiety is experienced if the compulsion is not completed. Some obsessions and compulsions are violent or sexual in nature. MRI may show increase in size of caudate nucleus. • • • • with you until you feel better”) and use empathy. Walk along with anxious clients who need to pace. Use open-ended questions (“Tell me about....”). Be aware of the defense mechanisms. Use crisis management theory. Monitor LFTs during antidepressant drug therapy. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 179 Mental Health Disorders 179 Conversion Disorder (kon-ver-zhun dis-or-der) Clue: Diagnostic or Clinical Findings Somatization of anxiety that results in paralysis, blindness, or other physical symptoms for which no medical explanation can be found. The client seems indifferent to the loss of function. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 179 Mental Health Disorders Pathophysiology • A somatoform disorder in which neurologic • • symptoms (e.g., blindness, paralysis, loss of touch) may occur as a result of anxiety. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), symptoms cannot be intentional or explained by any medical tests. Impulses to the brain are misinterpreted or rerouted by an anxiety response, resulting in perceptual abnormalities. An anxiety- or stressproducing event precedes onset of the conversion disorder. Women are affected more than men. Neurotransmitters affected in this disorder are serotonin and norepinephrine. Assessment and Diagnostic Findings • Neurologic deficit with no medical explanation. • MRI, CT scan, and other symptom-specific • • examinations are performed to rule out physical causes. “La belle indifference.” Primary gain (avoidance behavior) and secondary gain (attention). 179 Complications • Comorbid depression and risk of suicide. • Deterioration of the personality. • Failure to diagnose actual neurologic conditions. Medical Care and Surgical Treatment • Anxiolytic and antidepressive agents. • Cognitive behavioral therapy. Keep in Mind • Teach clients methods for keeping stress under control. Make the Connection • “Offer yourself” to the client (“I will stay with you”) and use empathy (“I understand your discomfort”). • Never reveal doubt that the illness is real. • Use open-ended questions (“Tell me about....”). • Be aware of the defense mechanisms. • Use crisis management theory. • Monitor LFTs during antidepressant therapy. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 180 Mental Health Disorders 180 Dissociative Amnesia (dis-o-shi-a-tiv am-ne-ze-a) Clue: Diagnostic or Clinical Findings Inability to remember stressful events. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 180 Mental Health Disorders Pathophysiology • • • A dissociative disorder is caused by a traumatic occurrence. The areas of the brain associated with memory recall and storage (the limbic and hippocampal areas) may be traumatized by childhood events or by unbearable events later in life. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), the client must have experienced at least two occurrences of amnesia for an event as well as impaired social or familial processes. Repression. Assessment and Diagnostic Findings • After a traumatic event, the client cannot recall • • any details of the event. This may be a temporary or permanent loss of recall. Early-life trauma may not be recalled later in life. Imaging studies conducted to rule out physical cause. Complications • Overuse of repression; poor coping skills. • Recall can cause severe trauma. 180 • Loss of family or social contacts. • Suicide or homicide. • Self-medication (substance abuse). Medical Care and Surgical Treatment • Cognitive behavioral therapy. • Crisis management. • Anxiolytic and antidepressant agents. Keep in Mind • Teach coping skills once the client is stabilized. Make the Connection • Clients may become assaultive when memory returns. • If client is pacing, walk along with him or her to communicate and provide company. • “Offer yourself” to the client (“I will stay with you”) and use empathy. • Use crisis theory and assure safety. • Monitor LFTs during antidepressant therapy. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 181 Mental Health Disorders 181 Mania (ma-ne-a) Clue: Diagnostic or Clinical Findings Mental disorder characterized by excessive excitement, restlessness, delusions of grandeur, and poor judgment. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 181 Mental Health Disorders Pathophysiology • According to the Diagnostic and Statistical Manual • of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), the client must have experienced at least three persistent episodes of grandiose thoughts, excessive need to speak characterized by flight of ideas, decreased need for sleep, poor judgment, and irritability. Imbalance in levels of norepinephrine, serotonin, dopamine, and hormones. Assessment and Diagnostic Findings • Hyperactivity, hypersexuality, hyperreligiosity, • • impulsiveness, poor nutritional status, substance abuse, and sleep disturbances. MRI and PET scan may show disturbances in metabolic function of the brain (prefrontal and temporal). Cortisol levels may be abnormal. Complications • Severe interference with societal, familial, and legal processes. • Worsening substance abuse and decline of nutritional status. • Sexually transmitted disease. 181 Medical Care and Surgical Treatment • Long-term treatment with mood stabilizers, anti• depressant agents, anticonvulsants, antipsychotic agents, and calcium channel blockers. Cognitive behavioral therapy. Keep in Mind • Compliance with therapy is important to success. Make the Connection • “Offer yourself” to the client (“I will stay with you”) and use empathy. • If the client is pacing, walk along with him or her. • Offer finger foods so the active client can walk and eat. • A one-on-one therapeutic setting is more effective. • Monitor CBC for low WBC, and monitor drug levels and LFTs during mood stabilizer, antidepressant, and anticonvulsant therapy. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 182 Mental Health Disorders 182 Depression (de-presh-un) Clue: Diagnostic or Clinical Findings Persistent sadness, hopelessness, feelings of guilt, inability to concentrate, decreased interest in daily activities, changes in appetite, insomnia or excessive sleep, and recurrent thoughts of death or suicide. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 182 Mental Health Disorders Pathophysiology • Changes in brain tissue metabolism and blood • • flow, particularly in the prefrontal cortex (decreased) and the amygdala (increased). Changes in the ability of receptors to bind with neurotransmitters (e.g., serotonin, norepinephrine); increase in reuptake of neurotransmitters before they can bind with receptors and increased destruction of neurotransmitters by monoamine oxidase, which deaminates serotonin and norepinephrine. Less ability to handle stress related to altered hypothalamus-pituitary-adrenal system. Assessment and Diagnostic Findings • MRI and PET scan abnormalities. ↓ blood flow • • • and metabolism in the prefrontal cortex but ↑ in the amygdala. Low serum cortisol levels. Sleep study abnormalities. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), symptoms of depression must represent a significant deviance from normal activity that is present for greater than 2 weeks. 182 Complications • Psychosis, suicide attempts, and death. • Severe interference with family and societal processes; self-medication (substance abuse). Medical Care and Surgical Treatment • Anxiolytic, mood stabilizing, antipsychotic, and antidepressant agents. • ECT; light therapy (if associated with SAD). • Cognitive behavioral therapy with a one-on-one structured therapeutic setting (until stable). Keep in Mind • Teach clients that side effects will lessen with time, and some require dietary restrictions. • Persons with major depression can recover completely. Make the Connection • “Offer yourself” to the client (“I will stay with you until you feel better”) and use empathy. • Use open-ended questions (“Tell me about....”). • Be aware of the defense mechanisms. • Monitor LFTs during antidepressant therapy. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 183 Mental Health Disorders 183 Bipolar Disorder (bi-pol-ar dis-or-der) Clue: Diagnostic or Clinical Findings Cycling through periods of depression and mania. Rapid cycling (four episodes per year) indicates a more severe illness. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 183 Mental Health Disorders 183 poor nutritional status, substance abuse, and sleep disturbances. Pathophysiology • Changes in brain tissue metabolism and blood flow, • • • particularly in the prefrontal cortex (decreased) and the amygdala (increased). Strong genetic link, and women are affected more than men. Imbalance in neurotransmitters. Epinephrine and norepinephrine are increased in the manic phase, and serotonin and norepinephrine are decreased in the depressive phase. Less ability to handle stress (hypothalamuspituitary-adrenal system). Sleep disturbances related to neurotransmitter imbalances. Assessment and Diagnostic Findings • MRI and PET scan. • Sleep study abnormalities. • According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IVTR), symptoms of bipolar disorder such as persistent sadness, hopelessness, feelings of guilt, inability to concentrate, decreased interest in daily activities, changes in appetite, insomnia or excessive sleep, and recurrent thoughts of death or suicide alternate with periods of hyperactivity, hypersexuality, hyperreligiosity, impulsiveness, Complications • Psychosis, suicide attempts, and death. • Severe interference with family and societal processes, self-medication, and substance abuse. Medical Care and Surgical Treatment • Anxiolytic, mood stabilizing, antidepressant, and antipsychotic agents. • ECT; light therapy (if associated with SAD). • CBT with a one-on-one structured therapeutic milieu. Keep in Mind • Teach the client about the disorder and the need for periodic blood tests. Make the Connection • “Offer yourself” to the client (“I will stay • with you”) and use empathy (“I understand your discomfort”). A one-on-one therapeutic setting is most effective. Offer nutrient-dense finger foods during the manic phase. If the client is pacing, walk along with him or her. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 184 Mental Health Disorders 184 Schizophrenia (skiz-o-fren-e-a) Clue: Diagnostic or Clinical Findings Often described by the 4 As (autism, avolition, anhedonia, and associative looseness). Schizophrenia means “split mind,” with a chasm occurring between the client and the environment. High dopamine levels are present. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 184 Mental Health Disorders Pathophysiology • The neurotransmitter dopamine is excessively abundant. Changes in brain metabolism. • Genetic links are not as strong as once thought • • but still place relatives at greater risk of developing schizophrenia (onset adolescense; early adulthood). Alterations in perception and thought, including delusions (fixed thoughts) and hallucinations (auditory is the most common but can involve all the senses). Difficulty with expression of thought. Assessment and Diagnostic Findings • PET scans. • High dopamine levels. • The 4 As: autism, avolition, anhedonia, and associative looseness. • Delusions, hallucinations, difficulty expressing • • oneself (associative looseness, neologisms, echolalia, and word salad). Depersonalization. Behavioral problems. 184 Complications • Increasing anxiety, depression, and suicide. • Severe interference with social and family processes. • Substance abuse. Medical Care and Surgical Treatment • Anxiolytic, mood stabilizing, antidepressant, and antipsychotic agents; ECT with CBT. Keep in Mind • Teach the client to report return of hallucinations and types and how to cope. • Teach the client about side effects of medications and to report movement problems. Make the Connection • Monitor CBC for low WBC count. • Check the blood glucose levels (atypical antipsychotics). • Assess the effectiveness of medication and CBT. • Ensure the client’s safety by providing structure. • Watch carefully for signs of tardive dyskinesia, akathisia, and pseudoparkinsonism. Clients with movement disorders should be referred to a movement specialist immediately. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 185 Mental Health Disorders 185 Attention Deficit-Hyperactivity Disorder (ADHD) (a-ten-shun def-i-sit hi-per-ak-tiv-i-te dis-or-der) Clue: Diagnostic or Clinical Findings Child or adult with difficulty focusing, finishing projects, listening to instructions, and sitting still who also shows emotional lability. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 185 Mental Health Disorders Pathophysiology • PET scans show decreased metabolic activity in the • • • frontal lobes and basal ganglia; EEG readings show ↓ wave activity in the same area. PET scans show ↑ metabolism in the primary sensory and sensorimotor areas. There is no specific lesion. ADHD is believed to be an error in myelination. Affects boys and men more than girls and women. Inability to wait, impatience, bursts of anger, and an inability to sit still; difficulty finishing projects, focusing, and following directions and often appears to be staring off into space. Assessment and Diagnostic Findings • Abnormal PET scan and EEG showing ↓ activity, • • • particularly in the right frontal lobe, and increased activity in the thalamus and sensorimotor areas. Diagnosis is often made by complaints of parents and teachers about behaviors. Developmental assessment. CRS-R are administered along with intelligence and psychological tests to differentiate behavioral problems from other mental or physical disorders. 185 Complications • Poor self-esteem, difficulty with school work. • Substance abuse (self-medication). Medical Care and Surgical Treatment • Psychostimulants. • Cognitive behavioral therapy. • Social skills training. Keep in Mind • Clients with ADHD may benefit from activities • like massage, music therapy, yoga, and chiropractic manipulation. Dietary management is important. Make the Connection • Monitor weight and sleep habits of clients on medications. • Interview parents to assess the degree of improvement seen in their child. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 186 Mental Health Disorders 186 Alcoholism (al-ko-hol-izm) Clue: Diagnostic or Clinical Findings Smell of alcohol on breath, ataxia, slurred speech, and inappropriate affect; or shaking if abstinent. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 186 Mental Health Disorders Pathophysiology • Alcoholism is genetically linked. • Alcohol is very lipid-soluble and enters the brain easily. Once there, it acts on GABA receptors, promoting a depressant and pleasurable effect. The action of other drugs (e.g., heroin) on the opioid and dopaminergic centers is similar to that of alcohol, cross-addictions occur. 186 • Dietary intervention. • CBT with social coping skills and group session with community follow-up. Keep in Mind • Teach that alcoholism adversely affects social, intimate, and financial aspects of an entire family. • Alcohol adversely affects physiology, resulting in many health problems. Assessment and Diagnostic Findings • Changes in mood, judgment, and sexual practices. • May exhibit ataxic gait, slurred speech, and Make the Connection • Watch for DTs from several hours to nystagmus; ETOH smell on breath. Complications • Addiction. • Severe interference with family and social processes. • Withdrawal, Wernicke-Korsakoff syndrome, cirrhosis of the liver, diabetes, metabolic syndrome, and increased blood lipid levels. Medical Care and Surgical Treatment • Antidepressant agents (tricyclic), opioid-receptor inhibitors, acamprosate, disulfiram, folic acid, thiamine, anticonvulsants, magnesium sulfate, and sedatives. several days after the last drink. • Monitor LOC and for seizure activity during acute withdrawal. • Monitor blood chemistries for LFTs nutritional • • assessment, GGT, and blood ETOH level. Check for cross-addictions. Monitor the effectiveness of drug therapy. Check compliance with therapy. Most inpatient facilities provide 28 days of treatment for alcohol withdrawal and then facilitate follow-up with Alcoholics Anonymous in the community. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 187 Mental Health Disorders 187 Borderline Personality Disorder (bor-der-lin per-sun-al-i-te dis-or-der) Clue: Diagnostic or Clinical Findings Substance abuse; impulsive, “needy” behavior. Self-destructive behavior (suicide attempts) for attention. 2693_Tab11_Card_174-187.qxd 7/14/11 2:11 PM Page 187 Mental Health Disorders Pathophysiology • The personality develops as a normal part of • neurophysiology, coupled with environmental factors. Components of the client’s genetic framework react to what is external, creating the outer and inner persona. Changes in the prefrontal cortex may be responsible for the personality changes exhibited by those with personality disorders. Affects women more than men. Assessment and Diagnostic Findings • MRI may show reduction in size of the prefrontal cortex. • Splitting. • Self-destructiveness, inappropriate affect, attention seeking; difficulty maintaining relationship, manipulation, and impulsiveness with angry outbursts. Complications • Substance abuse. • Psychosis with paranoia. • Depression. • Suicide attempts and death. 187 Medical Care and Surgical Treatment • Antidepressant, antipsychotic, and mood stabilizing agents. • CBT with clearly delineated boundaries. Keep in Mind • Teach the client about the importance of medications and about possible side effects. • Develop a contract with the client to report any thoughts of suicide. • Tell the client of the boundaries of the therapeutic relationship. Make the Connection • Monitor the CBC for WBC depletion during anticonvulsive therapy. • Monitor the drug levels of mood stabilizers and anticonvulsants. • Monitor the LFTs during antidepressant therapy. • Set limits and restate them frequently. • Realize that the client will show desired behaviors in order to attain favors. 2693_Leek_Divider Tab.qxd 7/14/11 3:32 PM Page 12 WOMEN’S HEALTH Leiomyomas, 188 Cervical Cancer, 189 Polycystic Ovarian Syndrome, 190 Breast Cancer, 191 Pregnancy-Induced Hypertension, 192 Placenta Previa, 193 Placenta Abruption, 194 Persistent Fetal Circulation, 195 Patient Ductus Arteriosus, 196 Neonatal Sepsis, 197 ABO Blood Type Incompatibility, 198 Rh Incompatibility, 199 Meconium Aspiration Syndrome, 200 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 188 Women’s Health and Perinatal Disorders Leiomyomas (li-o-mi-o-maz) Clue: Diagnostic or Clinical Findings Heavy menstrual periods with resulting low H&H. May feel pressure, heaviness, or pain in the pelvis. 188 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 188 Women’s Health and Perinatal Disorders Pathophysiology • Estrogen is dominant in the proliferative phase • • of the menstrual cycle and acts on the endometrial layer and is also responsible for proliferation of abnormal uterine cells that grow under its influence. Benign tumors or growths that usually occur in the corpus of the uterus. Subserosal myoma (forms under the outer serous layer of the uterus and may become pedunculated); intramural myomas (grow within the myometrium) and submucosal myomas (endometrial layer and may cause excessive menstrual bleeding). Fibrous connective tissue surrounds the body of the tumor. Assessment and Diagnostic Findings • • • • Pelvic examination showing enlargement of the uterus, or the mass may be felt. Ultrasound, CT scans, and MRI. Menorrhagia, which may lower the H&H significantly. Uterine fundus examination after childbirth may reveal irregular and bumpy feel of the uterine fundus. 188 Complications • Torsion and ischemia of pedunculated tumors. • Hypermenorrhea with chronic anemia. • Dyspareunia, infertility. • Pain on voiding or defecation. Medical Care and Surgical Treatment • Antiestrogen medications, GnRH agonist. • Hysterectomy; myomectomy. • MRgFUS. • Uterine artery embolization. Keep in Mind • Teach clients that uterine fibroids rarely become cancerous and will shrink in menopause. • Report excessively heavy periods, dyspnea, fatigue, or pain. Make the Connection • Monitor CBC for anemia, as well as US, CT scan, and MRI results. • Pelvic examination. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 189 Women’s Health and Perinatal Disorders Cervical Cancer (ser-vi-kal kan-ser) Clue: Diagnostic or Clinical Findings History of recurrent STD, especially HPV infection. Abnormal Pap smear. Late signs are vaginal bleeding, dyspareunia, and pelvic pain. 189 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 189 Women’s Health and Perinatal Disorders Pathophysiology • Squamous cells on the outer cervix, chronically • • irritated, undergo dysplasia from antigenic or infectious material from STD, especially HPV, or multiple sexual partners. Glandular cells on the uterine side of the cervix can undergo dysplasia from chronic irritation of smoking, infection with HIV that lowers immunity, or having several pregnancies. LSIL, and HSIL are squamous cells (afffected by HPV) that are likely to progress to cancer. CIN followed by the numbers 1, 2, or 3 describes the thickness of the lining of the cervix that contains abnormal cell growth. Pap smear results and grade (low or high) guide treatment regimen. Assessment and Diagnostic Findings • Pap smear reports are classified as negative, intraepithelial lesions, or malignancies. • Possible reports of serosanguineous bleeding or pelvic pain during or after sex. • Presence of risk factors, e.g., HPV. 189 Complications • Infertility after treatment. • Metastasis and death. Medical Care and Surgical Treatment • Gardasil, a vaccine that prevents infection with • four types of HPV that cause the majority of cervical cancers and HPV outbreaks. LEEP cryotherapy, laser therapy, conization of the cervix, and hysterectomy. Keep in Mind • • Gynecologic visits are advised in the early teenage years. Pap smears and vaccination against HPV can prevent cervical cancer. Teach client to use barrier methods to prevent pregnancy and STDs. Do not start smoking, or try to quit. Make the Connection • Early detection is essential for favorable outcome. • Remember: High-grade lesions contain less differentiated cells and are more likely to be cancerous. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 190 Women’s Health and Perinatal Disorders Polycystic Ovarian Syndrome (pol-e-sis-tik o-va-re-an sin-drom) Clue: Diagnostic or Clinical Findings US or CT scan shows multiple ovarian cysts. Clinically irregular menstrual periods, hirsutism, high FBS, and infertility. 190 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 190 Women’s Health and Perinatal Disorders Pathophysiology • 190 Medical Care and Surgical Treatment PCOS is a genetically linked female endocrine disorder that results in chronic anovulation, hyperinsulinemia that triggers androgen hormone release, type 2 DM, lipid abnormalities, hirsutism and thinning scalp hair, infertility, and ovarian cysts. • Etiology is unknown. Also known as SteinLeventhal syndrome. • Insulin sensitivity drugs and oral hypoglycemic agents. • Lipid-lowering agents, along with diet and weight reduction regimens. • Calcium and vitamin D for oocyte maturation and prevention of osteoporosis. • BCP and GnRH agonists. Assessment and Diagnostic Findings • Teach the client not to smoke. • Teach how to manage type 2 DM. • Although it is more difficult, it is possible to • Irregular menstrual periods, anovulation, and infertility. • High FBS; type 2 DM; elevated LDL and ↓ HDL; • ↑ testosterone levels; and ovarian cysts on US or CT scan. Obesity, acne, hirsutism, and male-pattern baldness. Complications • Metabolic syndrome and heart disease. • Endometrial cancer. • Complications of diabetes. • Infertility; osteoperosis. Keep in Mind become pregnant with medical assistance. Make the Connection • Monitor FBS, lipid panel, bone density scans, hormone levels, and weight. • Assess effectiveness of insulin sensitivity drug. • Assess effectiveness of BCP. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 191 Women’s Health and Perinatal Disorders Breast Cancer (brest kan-ser) Clue: Diagnostic or Clinical Findings Firm, painless, fixed, irregularly shaped lump usually found in the upper outer quadrant of the breast. Mammogram reveals a mass, usually with calcification. 191 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 191 Women’s Health and Perinatal Disorders Pathophysiology • Overstimulation of estrogen. • TP53 mutation, (protection against tumor growth). • Genetic anomalies (e.g., BRCA1, BRCA2, TP53) • • increase the risks of developing breast cancer and ovarian cancer. Women develop cancer more than men. Risk factors are ↑ age, ↓ immunity, HRT, personal or family history of breast cancer, high-fat diet, alcohol intake, early menarche, late menopause, no pregnancy or late pregnancy, and no or short breastfeeding. Assessment and Diagnostic Findings • • • • • Breast examinations done by a professional. Mammograms, US, MRI, and PET scans. Fine-needle biopsy, surgical excision and BX, ductal lavage, and sentinel lymph node examination. Tumor markers: CA 15.3, TRUQUANT, CA 27.29, CA 125, and CEA. FISH testing for excessive HER2-positive receptors. 191 Complications • Metastasis to bone, lungs, liver, and other distant sites. • Side effects of radiation, chemotherapy, SERMs, and BRMs. • Body image disturbances as a result of surgery. Medical Care and Surgical Treatment • Surgery (curative, palliative, or prophylactic). • Radiation, chemotherapy, BMT. • Trastuzumab (Herceptin), which blocks HER2 receptors, aromatase inhibitors, and SERMs. Keep in Mind • BSE monthly, yearly professional examinations, and mammograms as directed. Make the Connection • Early detection increases survival rate. • Monitor blood chemistries, tumor markers, and CBC for anomalies. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 192 Women’s Health and Perinatal Disorders Pregnancy-Induced Hypertension (preg-nan-se in-dusd hi-per-ten-shun) Clue: Diagnostic or Clinical Findings Hallmark signs include elevated blood pressure, nondependent edema, and proteinuria in the second or third trimester of pregnancy. 192 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 192 Women’s Health and Perinatal Disorders Pathophysiology • PIH, also known as preeclampsia, may be caused • • • • by a vasospastic disorder of the placenta leading to a endothelial dysfunction and placental release of factors such as sFlt-1. Endothelial dysfunction leads to capillary permeability, resulting in nondependent edema, weight gain, pulmonary edema, hemoconcentration, edema in the retina, and edema in the brain tissue. BP ↑ is caused by an abnormal response to angiotensin II and epinephrine, and an imbalance among prostaglandins, prostacyclin, and thromboxane A2, resulting in vasoconstriction and vasospasm. Proteinuria is the result of HTN and subsequent damage to vessel walls. Severe PIH is characterized by HELLP syndrome. 192 • SBP ↑ of 30 mm Hg or DBP ↑ of 15 mm Hg, the • presence of protein in the urine (5 g/24 hr or more), retinal changes, and oliguria. Oligohydramnios (by US), nonreassuring fetal heart tones, or small-for-dates fetus. Complications • HELLP syndrome. • Renal failure, coma, and seizures. • Placental insufficiency leads to a SGA neonate. Medical Care and Surgical Treatment • Delivery of the fetus; continued treatment with IV Mg SO4; environmental control; and blood work for LFT, platelets, and RBCs. Keep in Mind • Teach clients the importance of prenatal visits and that PIH may require hospitalization. Assessment and Diagnostic Findings • The risk of PIH is increased in adolescence and primigravidas older than 35, diabetics, and women with preexisting vascular problems or multiple pregnancies. Make the Connection • Continuous monitoring of DTR, blood pressure, and FHR are necessary while on MgSO4. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 193 Women’s Health and Perinatal Disorders Placenta Previa (pla-sen-ta pre-ve-a) Clue: Diagnostic or Clinical Findings Painless, frank red vaginal bleeding at or after 20 weeks’ gestation. 193 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 193 Women’s Health and Perinatal Disorders Pathophysiology • In PP, the placenta implants in the lower rather • • than the upper uterine area. When the cervix begins to dilate and move up the uterine wall in preparation for delivery of the fetus, the placenta may dislodge due to traction, causing bleeding and decreased oxygen delivery to the fetus. There are three types: PP centralis (total or complete PP) in which the placenta has been implanted in the lower uterine segment and completely covers the internal cervical os; PP lateralis (low marginal implantation) and PP marginalis (partial or incomplete PP). Risk factors include uterine scarring, previous pregnancy or cesarean section, Asian ethnicity, smoking, and age over 35 years. 193 • Premature delivery or cesarean section. • Placenta accreta. Medical Care and Surgical Treatment • Less extensive previa may require conservative • • treatment (e.g., rest, avoidance of sexual intercourse, no vaginal examinations). Severe vaginal bleeding necessitates hospitalization, blood replacement, cesarean section, and monitoring of fetal well-being. Double setup operating room. Keep in Mind • Teach clients to report any vaginal drainage. • Encourage clients to attend all prenatal and US examinations. Assessment and Diagnostic Findings • Transabdominal and intravaginal US. • Painless vaginal bleeding around the time of delivery. Complications • Placenta abruption or vasa previa. • Hemorrhage. Make the Connection • Vaginal bleeding can result in both maternal shock and fetal/neonatal hypoxia. • Monitor FHR and scalp potential of hydrogen (pH). 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 194 Women’s Health and Perinatal Disorders Placenta Abruption (pla-sen-ta a-brup-shun) Clue: Diagnostic or Clinical Findings Rigid, painful abdomen. Nonreassuring fetal heart tones with late decelerations. Maternal signs of shock or DIC. 194 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 194 Women’s Health and Perinatal Disorders Pathophysiology • Placenta abruption (PA), the sudden dislodgment of the placenta from the uterine wall, is classified according to type and severity: • Grade 1 PA (vaginal bleeding with mild uterine tenderness and mild uterine tetany, where only 10%–20% of the placenta is detached). • Grade 2 PA (uterine tenderness and uterine tetany, with or without uterine bleeding, fetal distress, or maternal shock where 20%–50% of the placenta is detached). • Grade 3 PA (severe uterine tetany and maternal shock, fetal demise is imminent or has occurred, maternal or fetal DIC, and more than 50% of the placental surface is detached). Assessment and Diagnostic Findings • A history of PIH, cocaine use, automobile accident, or domestic violence. • Painful, rigid abdomen with or without visible vaginal bleeding. • Signs of maternal shock. • Nonreassuring FHTs, with prolonged late decelerations of the fetal heart rate and low scalp pH. 194 Complications • Maternal and/or fetal death. • Maternal shock; DIC. • Possible hysterectomy. Medical Care and Surgical Treatment • Delivery may be vaginal or by emergency CS. • Blood replacement. • Treatment of DIC. Keep in Mind • Teach client to report any vaginal drainage, pain, dizziness, or shortness of breath. • Report absence of fetal movement. Make the Connection • Remember: PA can be present without visible bleeding if the abruption is central. • Monitor the FHT tracing, fetal scalp pH, and maternal vital signs. • IV to replace fluids and/or blood, administer oxygen, and assist in cesarean delivery. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 195 Women’s Health and Perinatal Disorders Persistent Fetal Circulation (per-sis-tint fe-tal sir-ku-la-shun) Clue: Diagnostic or Clinical Findings Shunting of blood from the right to the left side of the heart through the foramen ovale and ductus arteriosus after birth, causing hypoxemia. 195 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 195 Women’s Health and Perinatal Disorders Pathophysiology • Antenatal blood circulation includes three shunts. • • The lungs are bypassed by two shunts, the foramen ovale, and the ductus arteriosus. The last is the ductus venosus that bypasses the liver. Following birth and adequate ventilation pressures, the foramen ovale closes and the ducts collapse. Hypoxia and high carbon dioxide levels increase vasoconstriction in the lungs causing pulmonary hypertension that interferes with closure of the shunts and PFC occurs in small-for-gestationalage (SGA) neonates, infants of diabetic mothers (IDM), and those with a traumatic delivery. 195 Complications • Without intensive care, the neonate will not survive. Medical Care and Surgical Treatment • • • Keep in Mind • Apprise the parents tactfully of the neonate’s Assessment and Diagnostic Findings • • • • Onset of respiratory distress at or shortly following delivery, with cyanosis, tachypnea, tachycardia, and low oxygen saturation levels with administration of 100% oxygen. Meconium aspiration syndrome. Abnormal chest x-ray. Diaphragmatic hernia. Supplemental 100% oxygen by endotracheal tube and ventilator. May use a high-frequency ventilator. Neuromuscular paralyzing agents and nitric oxide inhalation. ECMO. • condition, the causes, and the required equipment. Encourage visits to the neonatal intensive care unit. Teach parents that diaphragmatic hernia requires surgical intervention. Make the Connection • Carefully monitor the bilateral breath sounds, CXR (should reveal 9–10 “ribs of air”), ABG, pulse oximetry, pulse, respiration, and blood pressure. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 196 Women’s Health and Perinatal Disorders Patent Ductus Arteriosus (pat-ent duk-tus ar-ter-e-o-sis) Clue: Diagnostic or Clinical Findings Persistent murmur. Weight loss, difficulty with feedings, and desaturation of oxygen with activity. 196 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 196 Women’s Health and Perinatal Disorders Pathophysiology • Antenatal blood circulation includes three shunts • • one of which is ductus arteriosus, which shunts oxygenated blood from the pulmonary artery to the aorta (a right-to-left shunt). A PDA following birth will become a left-to-right shunt related to pulmonary vascular resistance causing excessive blood flow to the pulmonary area and left atria, as well as left ventricle congestion and decreased systemic flow via the aorta. Occurs in preterm infants; girls are affected more often than boys; more likely to occur in neonates with Downs syndrome or those exposed to rubella during gestation. 196 Medical Care and Surgical Treatment • Prostaglandin therapy. • Transcatheter device closure. • Direct surgical ligation. Keep in Mind • Reinforce teaching about PDA repair. • Teach clients that the child with PDA repair will be able to resume normal activity levels. • Preterm children will “catch up” developmentally based on the level of prematurity at birth. Make the Connection • Assess for murmurs in neonates carefully. Assessment and Diagnostic Findings • Murmur on auscultation. • Echocardiogram shows left-to-right shunt. • Tachypnea, difficulty feeding, sweating, and weight loss. Complications • Ventilator assistance for breathing. • Pulmonary hypertension. • Infective endocarditis. • • Perform a four-extremity blood pressure assessment and carefully grade and report to the neonatal cardiologist. Provide continuous monitoring of vital signs and oxygen saturation levels. Monitor weight daily. Assess feeding problems and sweating. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 197 Women’s Health and Perinatal Disorders Neonatal Sepsis (ne-o-na-tal sep-sis) Clue: Diagnostic or Clinical Findings Temperature instability, tachypnea, and cyanosis. Amniotic fluid may have an abnormal odor. 197 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 197 Women’s Health and Perinatal Disorders Pathophysiology • Usually an ascending infection caused by • Escherichia coli, Listeria monocytogenes, or group B streptococci related to premature rupture of membranes, maternal chorioamnionitis, or premature birth in which immunity is severely limited. Sepsis may occur as a result of invasive therapies (e.g., umbilical catheters; fetal surgery). Assessment and Diagnostic Findings • Amniotic fluid may have a foul odor. • CBC may show a high WBC count and the presence of bands (immature WBC). • Gastric fluid analysis shows a high neutrophil count. • Blood and urine cultures are positive. • CSF may be cloudy or have a high protein and low glucose level and culture positive for bacteria. • Possible temperature instability (subnormal tem• • peratures), tachypnea, tachycardia, and possible need for supplemental oxygen administration. CXR may show infiltrates. ↑ CRP; erythrocyte sedimentation rate is high. 197 Complications • Neonatal death. Medical Care and Surgical Treatment • Sepsis work-up. • Temperature, respiratory, and nutritional support (IV TPN). Keep in Mind • Clients must report any vaginal drainage and be assessed for rupture of membranes. • Comply with recommendations regarding neonatal visits and testing for infection with group B streptococci and other infectious organisms. Make the Connection • Subnormal temperature, bulging fontanel, abnormal flexion or limpness, tachypnea, cyanosis, or other signs and symptoms must be reported and acted upon immediately. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 198 Women’s Health and Perinatal Disorders ABO Blood Type Incompatibility (a-b-o in-kom-pa-ti-bil-i-te) Clue: Diagnostic or Clinical Findings Jaundice that occurs in the first 24 hours of life. Maternal blood type is type O. 198 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 198 Women’s Health and Perinatal Disorders Pathophysiology • Mothers with type O blood carrying fetuses with • • type A, B, or AB blood are at risk for having a neonate with an ABO incompatibility problem if their antibodies are IgG antibodies. IgG antibodies readily cross the placenta and begin to hemolyze the fetal red blood cells (RBCs). The fetal/neonatal liver is too immature to process the bilirubin produced from the RBC breakdown, and this results in early-onset jaundice. Assessment and Diagnostic Findings 198 Medical Care and Surgical Treatment • Phototherapy. • Exchange transfusion. Keep in Mind • Keep prenatal appointments and comply with all laboratory testing. • Explain the work-up associated with early-onset jaundice. • Teach parents about phototherapy and exchange transfusion. • Teach parents how to care for the neonate during treatment. • Yellow/orange coloration to the sclera and skin. • Serum bilirubin levels are elevated within the first 12–24 hours. • Indirect Coombs’ test on maternal blood detects antibodies to the fetus’s blood type. • Fetal anemia can be monitored noninvasively by Doppler flow velocimetry (DFV), which measures the peak systolic velocity (PSV) in the middle cerebral artery. Complications • Kernicterus. • Anemia. Make the Connection • Early onset of jaundice requires a • differential diagnosis of blood incompatibilities, neonatal sepsis, or trauma at birth with hematoma formation. Serial bilirubin levels are measured by heel-stick method approximately every 6–8 hours to assess effectiveness of treatment. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 199 Women’s Health and Perinatal Disorders Rh Incompatibility (r-h in-kom-pa-ti-bil-i-te) Clue: Diagnostic or Clinical Findings Rh-negative woman carrying an Rh-positive fetus. 199 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 199 Women’s Health and Perinatal Disorders Pathophysiology • A pregnant woman with no Rh antigen, known as Rh0(D), on her RBCs is Rh negative. Additionally, there are no antibodies against the Rh antigen in her serum. If the fetus she is carrying is Rh positive, there should not be antibodies produced that cross the placenta. However, at delivery of the fetus, when maternal and fetal bloods finally mix, the maternal immune system is activated to produce anti-Rh antibodies. If no treatment is provided, the next Rh-positive fetus the woman carries will have its RBCs attacked by the anti-Rh antibodies, producing a condition called erythroblastosis fetalis, a potentially fatal condition in which most or all of the fetal RBCs are destroyed. Assessment and Diagnostic Findings • Blood and Rh factor typing, along with a screen • • for antibodies, are done at the first prenatal visit. The antibody screen is performed again at 28 weeks. Rh0(D) immune globulin (RhoGAM) is given to prevent sensitization. PUBS may be done to assess the fetal blood type, degree of hemolysis, and bilirubin levels. Amniocentesis. 199 • Direct Coombs’ testing will indicate that antibodies are attached to RBCs, destroying them. Complications • Neonatal heart failure, high bilirubin levels, kernicterus, edema (hydrops), and renal failure. Medical Care and Surgical Treatment • RhoGAM must be given to the woman within • 72 hours after delivery to prevent sensitization problems with subsequent pregnancies. If the neonate survives, aggressive therapy with phototherapy, hydration, and other symptomatic treatment in an intensive care nursery is necessary. Keep in Mind • Teach clients to keep all prenatal appointments. • Explain the significance of being Rh negative. Make the Connection • There will be no problem with this disorder if the fetus is also Rh negative; the mother must be Rh negative and the fetus Rh positive for this disorder to occur. 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 200 Women’s Health and Perinatal Disorders Meconium Aspiration Syndrome (me-ko-ne-um as-pi-ra-shun sin-drom) Clue: Diagnostic or Clinical Findings Amniotic fluid, stained with meconium, is aspirated by the fetus/neonate, causing acute respiratory distress. 200 2693_Tab12_Card_188-200.qxd 7/14/11 7:32 PM Page 200 Women’s Health and Perinatal Disorders Pathophysiology • Causes include intrauterine stress, such as PIH, • • • postmaturity (aging placenta), intrauterine hypoxia and asphyxia, and infection. Fetal stress may produce increased intestinal peristalsis, anal sphincter relaxation, and expulsion of meconium into the amniotic fluid. Fetus breathing in utero, or with the first few breaths of air after delivery, causes aspirated meconium-stained fluid to enter the lungs. Alveoli of the lungs can be infiltrated by the meconium, causing atelectasis or the blockage of bronchiolar passages. Assessment and Diagnostic Findings • Rupture of membranes reveals meconium-stained fluid. • Often meconium-stained fluid is accompanied by nonreassuring FHTs. • Laryngoscopic examination reveals meconium below the level of the vocal cords. • Acute respiratory distress develops. Complications • Low oxygen saturation levels. • Respiratory acidosis, atelectasis. • Death. 200 Medical Care and Surgical Treatment • Immediate suction when the fetal head is delivered. • Suction of meconium below the vocal cords. • Ventilator, high-frequency ventilator, or ECMO therapy. • Nitric oxide inhalation therapy and surfactant therapy. • Administration of prophylactic antibiotic therapy, IV TPN. Keep in Mind • Teach client to report rupture of membranes and the color and character of the fluid. • Apprise the client of the condition of the neonate and encourage visitation to the nursery. Make the Connection • Nonreassuring FHTs (late decelerations • and variable decelerations) are signs of fetal distress. Staff present at deliveries must be trained to suction and visualize vocal cords and to begin respiratory support in cases of meconium-stained fluid. 2693_Leek_Divider Tab.qxd INDEX References Index 7/14/11 3:32 PM Page 13 Leek_Ref_201-204.qxd 7/14/11 2:17 PM Page 201 201 References Texts Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s Drug Guide for Nurses (12th ed.). Philadelphia: F.A. Davis. DeSevo, M. (2009). Maternity and Newborn Success: A Course Review Applying Critical Thinking to Test-Taking. Philadelphia: F.A. Davis. Gylys, B. A., & Wedding, M.E. (2009). Medical Terminology Systems: A Body Systems Approach (6th ed.). Philadelphia: F.A. Davis. Leek, V. I. 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Journal of Nursing Research, 15(4), 275–283. 2693_Index_205-207.qxd 7/14/11 2:16 PM Page 205 205 Index A Abdominal hernias, 9 ABO blood type incompatibility, 198 Absence seizures, 80 Acne vulgaris, 167 Acoustic neuroma, 155 Acquired immunodeficiency syndrome, 56 Acute angle-closure glaucoma, 143 Acute renal failure, 43 Acute respiratory distress syndrome (ARDS), 130 Addison’s disease, 29 Alcoholism, 186 Alzheimer’s disease, 90 Amyotrophic lateral sclerosis, 92 Anaphylaxis, 51 Angina pectoris, 97 Aortic aneurysm, 115 Aortic stenosis, 109 Appendicitis, 20 Asthma, 125 Atonic seizures, 82 Atrial fibrillation, 101 Attention deficit-hyperactivity disorder (ADHD), 185 Autonomic dysreflexia, 76 B Bell’s palsy, 91 Benign prostatic hyperplasia, 48 Bipolar disorder, 183 Bladder cancer, 49 Borderline personality disorder, 187 Bowel obstruction, 16 Breast cancer, 191 Bronchiectasis, 124 Buerger’s disease, 113 C Cardiogenic shock, 100 Cardiomyopathy, 107 Cataracts, 142 Celiac disease, 1 Cellulitis, 159 Cerebral aneurysm, 78 Cerebrovascular accident, 85 Cervical cancer, 189 Cholecystitis, 14 Chronic bronchitis, 127 Chronic renal failure, 44 Colon cancer, 18 Compartment syndrome, 67 Complex partial seizures, 84 Concussion, 71 Conductive hearing loss, 148 Congestive heart failure, 99 Contact dermatitis, 157 Conversion disorder, 179 Coronary artery disease, 96 Crohn’s disease, 21 Cushing’s syndrome, 28 Cystic fibrosis, 129 D Deep vein thrombosis, 108 Depression, 182 Diabetes insipidus, 26 Diabetes mellitus type 1, 32 type 2, 33 Diabetic retinopathy, 147 Dissociative amnesia, 180 Diverticulosis, 19 E Eczema, 158 Emphysema, 126 Encephalitis, 94 Epididymitis, 47 Epidural hematoma, 73 Esophageal varices, 12 F Fracture, 66 Full-thickness burns, 172 G Gastric cancer, 6 Gastritis, 2 Gastroesophageal reflux disease, 3 Generalized anxiety disorder, 174 Glomerulonephritis, 37 Gouty arthritis, 59 Graft-versus-host disease, 119 Guillain-Barré syndrome, 93 H Hashimoto’s thyroiditis, 54 Hemorrhoids, 23 Hepatitis, 8 Herniated nucleus pulposus, 69 Herpes simplex, 162 Herpes zoster, 161 2693_Index_205-207.qxd 7/14/11 2:16 PM Page 206 206 Hiatal hernia, 4 Histoplasmosis, 138 Huntington’s disease, 74 Hydronephrosis, 40 Hyperpituitarism, 24 Hypertension, 116 Hyperthyroidism, 30 Hypopituitarism, 25 Hypothyroidism, 31 I Impetigo, 164 Influenza, 135 K Kaposi’s sarcoma, 57 L Labyrinthitis, 153 Laënnec’s cirrhosis, 10 Legionnaires’ disease, 136 Leiomyomas, 188 Leukemia, 117 Liver cancer, 11 Lung cancer, 137 M Macular degeneration, 146 Malignant hyperthermia, 95 Mania, 181 Mastoiditis, 151 Meconium aspiration syndrome, 200 Ménière’s disease, 154 Meningitis, 70 Mesothelioma, 140 Metabolic acidosis, 120 Metabolic alkalosis, 121 Multiple myeloma, 118 Multiple sclerosis, 86 Myasthenia gravis, 87 Myocardial infarction, 98 Myocarditis, 105 Myoclonic seizures, 81 N Neonatal sepsis, 197 Nephrotic syndrome, 38 O Obesity, 7 Obsessive-compulsive disorder, 178 Osteoarthritis, 58 Osteomalacia, 62 Osteomyelitis, 63 Osteoporosis, 61 Otitis externa, 150 Otitis media, 149 Otosclerosis, 152 Overactive bladder, 45 P Paget’s disease, 64 Pain disorder, 176 Pancreatic cancer, 15 Pancreatitis, 13 Parkinson’s disease, 89 Paronychia, 163 Partial-thickness burns, 171 Patent ductus arteriosus, 196 Pediculosis capitis, 166 Peptic ulcer disease, 5 Pericarditis, 104 Peripheral arterial disease, 112 Peritonitis, 22 Persistent fetal circulation, 195 Phobias, 177 Placenta abruption, 194 Placenta previa, 193 Pleural effusion, 134 Pneumonia, 133 Pneumothorax, 128 Polycystic kidney disease, 39 Polycystic ovarian syndrome, 190 Posttraumatic stress disorder, 175 Pregnancy-induced hypertension, 192 Primary open-angle glaucoma, 144 Prostate cancer, 50 Psoriasis, 160 Pulmonary embolism, 132 Pyelonephritis, 36 R Raynaud’s disease, 114 Renal artery stenosis, 46 Renal calculus, 41 Respiratory acidosis, 122 Respiratory alkalosis, 123 Retinal detachment, 145 Rh incompatibility, 199 Rhabdomyolysis, 42 Rheumatoid arthritis, 60 Rheumatoid endocarditis, 106 Rosacea, 173 S Sarcoidosis, 139 Scabies, 165 Schizophrenia, 184 Scleroderma, 52 Sensorineural hearing loss, 148 Severe acute respiratory syndrome (SARS), 131 2693_Index_205-207.qxd 7/14/11 2:16 PM Page 207 207 Simple partial seizures, 83 Sjögren’s syndrome, 55 Skin cancer, 156 Skull fracture, 72 Spinal cord injury, 75 Spinal shock, 77 Sprain, 65 Stevens-Johnson syndrome, 168 Subdural hematoma, 73 Superficial burns, 171 Syndrome of inappropriate antidiuretic hormone, 27 Systemic lupus erythematosus, 53 T Tinea, 169 Tonic-clonic seizures, 79 Total joint replacement, 68 Toxic epidermal necrolysis, 168 Trigeminal neuralgia, 88 Tuberculosis (TB), 141 U Ulcerative colitis, 17 Urethritis, 35 Urinary tract infection, 34 V Varicose veins, 111 Venous stasis ulcer, 110 Ventricular fibrillation, 103 Ventricular tachycardia, 102 Verruca, 170

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