Nurseinfo.in provides free Nursing Notes, Nursing Procedures, Medical MCQs, Nursing Calculators, Care Plans and exam preparation resources for BSc Nursing, GNM, P.B. BSc and MSc Nursing students. Browse subject-wise notes, previous year questions and study materials based on the latest nursing syllabus.
Nurseinfo.in provides free Nursing Notes, Nursing Procedures, Medical MCQs, Nursing Calculators, Care Plans and exam preparation resources for BSc Nursing, GNM, P.B. BSc and MSc Nursing students. Browse subject-wise notes, previous year questions and study materials based on the latest nursing syllabus.
GUILLAIN-BARRE SYNDROME OR INFECTIOUS
POLYNEURITIS – Etiology, Pathophysiology, Signs and Symptoms, Diagnostic
Evaluation and Management
Guillain-Barre Syndrome (GBS) is a
acute condition that involves progressive muscle weakness or paralysis. It is
an autoimmune disorder in which the body’s immune system attacks its own
nervous system, causing inflammation that damages the myelin sheath of the
nerve. This damage (demyleinazation) slows or stops the conduction of impulses
through the nerve. The impairment of nerve impulses to the muscles leads to
symptoms that may include muscle weakness, paralysis, spasms, numbness,
tingling or pin-and-needle sensations and tenderness.
ETIOLOGY
Camphylobacter jejuni infection:
camphylobacter infection is also the most common risk factor for
Guillain-Barre. It is often found in undercooked food, especially poultry.
Influenza
Cytomegalovirus
Epstein-Barr virus infection
Mycoplasma pneumonia
HIV or AIDS
PATHOPHYSIOLOGY
A condition
of symptoms characterized by a widespread, inappropriate inflammatory immune
response —- the syndrome progresses from the feet up and generally affects
one side more than the other —- nerve condition is interrupted as T-cells are
activated and antibodies attack the myelin sheath —- a polyneuropathies, that
include the associated neurological symptoms related to immune response —-
symptoms continually progress in severity over the course of a few hours to
several days —- symptoms initiate in lower extremities with symmetrical
paresthesia that may advance to paralysis
SIGNS AND SYMPTOMS
Loss of tendon reflexes in the arms
and legs
Tingling or numbness (mild loss of
sensation)
Muscle tenderness or pain (maybe a
cramp-like pain)
Uncoordinated movement (cannot walk
without help)
Low blood pressure or poor blood
pressure control
Abnormal heart rate
Blurred vision and double vision
Clumsiness and falling
Difficulty moving face muscles
Muscle contractions
Feeling the heartbeat
EMERGENCY SYMPTOMS
Breathing temporarily stops
Cannot take a deep breath
Difficulty breathing
Difficulty swallowing
Drooling
Fainting
Feeling light-headed when standing
DIAGNOSTIC EVALUATION
Spinal tap: this test is also
referred to as a lumbar puncture. A spinal tap involves taking a small amount
of fluid from the spine in the lower back. The fluid is then tested to detect
protein levels. People with Guillain-Barre typically have higher-than-normal
levels of protein in their cerebrospinal fluid
Electromyography: an electromyography
is a nerve function test. It reads electrical activity from the muscles and
help to learn if the muscle weakness is caused by nerve damage or muscle damage
MANAGEMENT
Physical therapy: before recovery, a caregiver may need to
manually move the arms and legs. This will help the muscles strong and mobile.
After recovery, physical therapy will helps to strengthen and flex the muscles
again. Therapy includes massages, exercises and frequent position changes.
Plasmapheresis: the immune system
produces protein called antibodies that normally attack harmful foreign
substances, such as bacteria and viruses. Guillain-Barre occurs when the immune
system mistakenly makes antibodies that attack the healthy nerves of the
nervous system. Plasmapheresis is intended to remove the antibodies attacking
the nerves from the blood. During this procedure, blood is removed from the
body by machine that removes the antibodies from the blood and then the blood
is returned to the body
Intravenous immunoglobulin: high
doses of immunoglobulin can also help to block the antibodies causing
Guillain-Barre.
NURSING MANAGEMENT
Nursing
Diagnosis
Ineffective breathing pattern and
airway clearance related to respiratory muscle weakness or paralysis, decreased
cough reflex, immobilization
Impaired physical mobility related to
paralysis, ataxia
Risk for impaired skin integrity,
pressure sores related to muscle weakness, paralysis, impaired sensation,
changes in nutrition, incontinence
Imbalanced nutrition, less than body
requirements related to difficulty chewing, swallowing, fatigue, limb paralysis
Impaired elimination: constipation,
diarrhea, related to inadequate food intake, immobilization
Impaired verbal communication related
to the VII cranial nerve paralysis, tracheostomy
Ineffective copying related to the
patient’s disease state
Interventions
Monitor respiratory status through
vital capacity measurements, rate and depth of respirations and breath sounds
Monitor level of muscle weakness as
it ascends toward respiratory muscles. watch for breathlessness while talking
which is a sign of respiratory fatigue
Monitor the patient for signs of
impending respiratory failure
Monitor gag reflex and swallowing
ability
Position patient with the head of bed
elevated to provide for maximum chest excursion
Avoid giving opioids and sedatives
that may depress respirations
Position patient correctly and
provide range-of-motion exercises
Provide good body alignment,
range-of-motion exercises, and change of position to prevent complications such
as contractness, pressure sores, and dependent edema
Ensure adequate nutrition without the
risk of aspiration
Encourage physical and occupational
therapy exercises to help the patient regain strength during rehabilitation
phase
Provide assistive devices as needed
(cane or wheelchair) to maximize independence and activity
If verbal communication is possible,
discuss the patient’s fears and concerns
Provide choices in care to give the
patient a sense of control
Teach patient about breathing
exercises or use of an incentive spirometer to re-establish normal breathing
patterns
Instruct patient to wear good
supportive and protective shoes while out of bed to prevent injuries due to
weakness and paresthesia
Instruct patient to check feet
routinely for injuries because trauma may go unnoticed due to sensory changes
Urge the patient to maintain normal
weight because additional weight will further stress monitor function
FLAIL CHEST – Characteristics,
Etiology, Signs and Symptoms and Treatment
A flail
chest is a life-threatening medical condition that occurs when a segment of the
rib cage breaks under extreme stress and becomes detached from the rest of the
chest wall. It occurs when multiple adjacent ribs are broken in multiple
places, separating a segment, so a part of the chest wall moves independently.
CHARACTERISTICS
During normal respiration, the
diaphragm contracts and intercostals muscles push the rib cage out. Pressure in
the thorax decreases below the atmospheric pressure, and air rushes in through
the trachea. However, a flail segment will not resist the decreased pressure
and will appear to push in while the rest of the rib cage expands.
During normal expiration, the
diaphragm and intercostals muscles relax, allowing the abdominal organs to push
air upwards and out of the thorax. However, a flail segment will also be pushed
out while the rest of the rib cage contracts
ETIOLOGY
This typically occurs when three or more adjacent ribs are
fractured in two or more places, allowing that segment of the thoracic wall to
displace and move independently of the rest of the chest wall. Flail chest can
also occur when ribs are fractured proximally in conjunction with
disarticulation of costal cartilages distally. For the condition to occur, generally
there must be a significant force applied over a large surface of the thorax to
create the multiple anterior and posterior rib fractures. Rollover and crushing
injuries most commonly break ribs at only one point – for flail chest to occur,
a significant impact is required, breaking the ribs in two or more places.
SIGNS AND SYMPTOMS
Fracture is extremely painful, and
untreated, the sharp broken edges of the ribs
Puncture in the pleural sac and lung
Pneumothorax
TREATMENT
Treatment of
the flail chest initially follows the principles of advanced trauma life
support. Further treatment includes:
Good analgesia including intercostals
blocks, avoiding narcotic analgesics as much as possible. This allows much
better ventilation, with improved tidal volume, and increased blood oxygenation
Positive pressure ventilation,
meticulously adjusting the ventilator settings to avoid pulmonary barotrauma
Chest tubes as required
Adjustment of position to make the
patient most comfortable and provide relief of pain
Aggressive pulmonary toilet
SURGICAL FIXATION
Can help in significantly reducing
the duration of ventilator support and in conserving the pulmonary function
A patient may be intubated with a
double lumen tracheal tube. In a double lumen endotracheal tube, each lumen may
be connected to a different ventilator. Usually one side of the chest is
affected more than the other. So each lung may require drastically different
pressures and flows to adequately ventilate
FLAIL CHEST – Characteristics, Etiology, Signs and Symptoms and Treatment
HYPERPARATHYROIDISM – Etiology, Risk
Factors, Signs and Symptoms, Complications and Management
Hyperparathyroidism
is an excess of parathyroid hormone in the bloodstream due to over activity of
parathyroid glands. These oval, grain-of-rice-sized glands are located in your
neck. The parathyroid glands produce parathyroid hormone, which helps maintain
an appropriate balance of calcium in the bloodstream and in tissues that depend
on calcium for proper functioning.
ETIOLOGY
Primary hyperparathyroidism: it
occurs because of some problem with one or more of the four parathyroid glands:
a noncancerous growth (adenoma) on a gland is the most common cause,
enlargement (hyperplasia) of two or more parathyroid glands accounts for most
other cases. A cancerous (malignant) tumor is a rare cause of primary
hyperparathyroidism
Secondary hyperparathyroidism: it is
the result of another condition that lowers calcium levels
Severe calcium deficiency
Severe vitamin D deficiency
Chronic kidney failure: kidneys
convert vitamin D into a form that body can use. If kidneys function poorly,
useable vitamin D may decline and calcium levels drop. Chronic kidney failure
is the most common cause of secondary hyperparathyroidism
RISK FACTORS
Woman who has gone through menopause
Severe calcium or vitamin D
deficiency
Inherited disorder, such as multiple
endocrine neoplasia, type I, which usually affects multiple glands
Radiation treatment for cancer that
has exposed neck to radiation a drug most often used to treat bipolar disorder
SIGNS AND SYMPTOMS
Fragile bones that easily fracture
(osteoporosis)
Kidney stones
Excessive urination
Abdominal pain
Tiring easily or weakness
Depression or forgetfulness
Bone and joint pain
Frequent complaints of illness with
no apparent cause
Nausea, vomiting or loss of appetite
DIAGNOSTIC EVALUATION
Blood tests: if the result of a blood
test indicates elevated calcium in your blood
Bone mineral density test (bone
densitometry): the most common test to measure bone mineral density is dual
energy X-ray absorptiometry, or a DXA scan. This test uses special X-ray
devices to measure how many grams of calcium and other bone minerals are packed
into a segment of bone
Urine tests: a 24-hour collection of
urine can provide information on how well kidneys function and how much calcium
is excreted in urine. This test may help in judging the severity of
hyperparathyroidism or diagnosing a kidney disorder causing
hyperparathyroidism.
Ultrasound: ultrasound uses sound
waves to create images of your parathyroid glands and surrounding tissue. A
small device held against your skin (transducer) emits high-pitched sound waves
and records the sound wave echoes as they reflect off internal structures. A
computer converts the echoes into images on a monitor.
Sestamibi scan: sestamibi is a
specifically designed radioactive compound that is absorbed by overactive
parathyroid glands and can be detected on computerized tomography (CT) scans. A
small dose of the compound is injected into your bloodstream before the imaging
test is done
COMPLICATIONS
Osteoporosis: the loss of calcium
often results in osteoporosis, or weak, brittle bones that fracture easily.
Kidney stones: the excess of calcium
in blood may cause small, hard deposits of calcium and other substances to form
in kidneys. A kidney stone usually causes significant pain as it passes through
the urinary tract
Cardiovascular disease: although the
exact cause-and-effect link is unclear, high calcium levels are associated with
cardiovascular conditions, such as high blood pressure (hypertension) and
certain types of heart disease
Neonatal hyperparathyroidism: severe,
untreated hyperparathyroidism in pregnant women may cause dangerously low
levels of calcium in newborns
MANAGEMENT
Your doctor
may recommend no treatment and regular monitoring if:
Your calcium levels are only slightly
elevated
Your kidneys are functioning normally
Your bone density is normal or only
slightly below normal
You have no other symptoms that may
improve with treatment
If you choose this watch-and-wait
approach, you will likely need a test to check your blood-calcium levels at
least twice a year and have other monitoring tests done at least once a year
Surgical
Management
Surgery is
the most common treatment for primary hyperparathyroidism and provides a cure
in at least 90 percent of all cases. A surgeon will remove only those glands
that are enlarged or have a tumor (adenoma). If all four glands are affected, a
surgeon will likely remove only three glands and perhaps a portion of the
fourth – leaving some functioning parathyroid tissue
Complications
from surgery are not common. Risks include:
Damage to nerves controlling the
vocal cords
Long-term low calcium levels
requiring the use of calcium and vitamin D supplements
Drugs
Calcimimetics: a calcimimetic is a
drug that mimics calcium circulating in the blood. Therefore, the drug may
trick the parathyroid glands into releasing less parathyroid hormone. This drug
is solid as cinacalcet (sensipar). The Food and Drug Administration approved
cinacalcet to treat hyperparathyroidism caused by chronic kidney disease or
parathyroid cancer
Hormone replacement therapy: for
women who have gone through menopause and have signs of osteoporosis, hormone
replacement therapy may help bones retain calcium. This treatment, usually a
combination estrogen and progestin, does not address the underlying problems with
the parathyroid glands. Prolonged use of hormone replacement therapy can
increase the risk of cardiovascular disease and some cancers. Work with your
doctor to evaluate the risks and benefits to help you decide what is best for
you.
Bisphosphonates: bisphosphonates also
prevent the loss of calcium from bones and may lessen osteoporosis caused by
hyperparathyroidism
LIFESTYLE
AND HOME REMEDIES
Monitor how much calcium and vitamin
D you get in your diet. The Institute of Medicine recommends 1,000 milligrams
(mg) of calcium a day for adult’s ages 19 to 50 and men ages 51-70. That
calcium recommendation increases to 1,200 mg a day if you are a woman age 51 or
older or a man age 71 or older. The Institute of Medicine also recommends 600
international units (IUs) of vitamin D a day for adults ages 19 to 70 and 800
IUs a day for adults age 71 and older.
Drink plenty of water. Drink six to
eight glasses of water daily to lessen the risk of kidney stones
Do not smoke. Smoking may increase
bone loss as well as increase your risk of a number of serious health problems
Avoid calcium-raising drugs. Certain
medications, including some diuretics and lithium, can raise calcium levels
NURSING MANAGEMENT
Protect the patient from injury
Monitor for possible complications
Provide patient education independent
Adjust activities and reduce
intensity
Provide positive atmosphere, while
acknowledging the difficulty of situation for the client
Assist patients with
activities/monitor clients use of assistive device such as walker
Helps minimize frustration,
rechanneling of energy
To protect client from injury
To remove cause of hypersecretion of
parathormones
Loop diuretic used with normal saline
to cause diuresis and to reduce calcium levels
Obtain baseline serum potassium,
calcium, phosphate, and magnesium levels before treatment
Provide at least 3 liters of fluid
per day, including cranberry or prune juice, to increase urine acidity and help
prevent calculus formation
Take safety precaution to minimize
the risk for injury from fall
Schedule care to allow the patient
with muscle weakness as much rest as possible
Provide comfort measures to alleviate
bone pain
Administer antacids, as appropriate
to prevent pelvic ulcers
Auscultate the lungs regularly. Check
for signs of pulmonary edema in the patient receiving large amounts of normal
saline solution, especially if he has pulmonary or cardiac disease
Check for elevated serum calcium
levels if the patient is receiving cardiac glycosides
Assess the patient for parathyroid
poisoning, musculoskeletal changes, and renal impairment
Observe the patient for signs of pain
and monitor him for effectiveness of analgesics and comfort measures
HYPERPARATHYROIDISM – Etiology, Risk Factors, Signs and Symptoms, Complications and Management
Nursing
focuses on the individual’s response to potential or actual health problems.
Under the nursing model, human behavior is viewed from a holistic perspective.
Nursing View of Behavioral Deviations
Behavior is viewed on a continuum
from healthy adaptive responses to maladaptive responses that indicate illness.
Each individual is predisposed to
respond to life events in unique ways. These predispositions are biological,
psychological, socio cultural, and the sum of the person’s heritage and past
experiences.
Behavior is the result of combining
the predisposing factors with precipitating stressors. Stressors are life
events that the individual perceives as challenging, threatening or demanding.
The nature of the behavioral response depends on the person’s primary appraisal
of the stressor and his secondary appraisal of the coping resources available
to him.
A stressor that has primary impact on
physiological functioning also affects the person’s psychological and
socio-cultural behavior. For instance, a man who has a myocardial infarction
may also become severely depressed, because he fears he will lose his ability
to work. On the other hand, the patient who enters the psychiatric inpatient
unit with major depression may be suffering from malnutrition and dehydration
because of his refusal to eat or drink. The holistic nature of nursing
encompasses all of these facets of behavior and incorporated them into patient
care planning.
Nursing Process
Nursing intervention may take place at any point on the
continuum. Nursing diagnosis may focus on behavior associated with a medical
diagnosis or other health behavior that the patient wishes to change.
A nurse may practice primary prevention by intervening in a
potential health problem, secondary prevention by intervening in an actual
acute health problem or tertiary prevention by intervening to limit the
disability caused by actual chronic health problem. The nursing assessment of
the patient includes presenting complaints, past history, family history, personal
history, occupational history, sexual history, physical examination and mental
status examination. Additional data may be collected for significant others and
by reviewing the systems. A nursing diagnosis is then formulated and based on
this diagnosis; planning and interventions are carried out. Finally, evaluation
will be done to find out the effectiveness of nursing interventions.
Providing nursing care is a collaborative effort, with both
the nurse and the patient contributing ideas and energy to the therapeutic
process.
Summary of Selected Nursing Theories
Peplau’s Theory
Peplau proposed an interpersonal theory applicable to nursing
practice in general and to psychiatric-mental health nursing in particular. It
focuses primarily on the nurse-patient relationship. Peplau’s theory describes,
explains, predicts and to some extent, permits control of the sequence of
events occurring in the nurse-patient relationship.
Peplau describes the interpersonal aspects of nursing as a
process consisting of four phases. These are orientation, identification,
exploitation and resolution phases.
While working with the patient through these phases, the
nurse assumes six roles: resource person, technical expert, teacher, leader,
surrogate parent and a counselor.
Peplau’s theory continues to apply to today’s nursing scene,
especially with respect to long-term psychiatric care in outpatient and home
health settings.
Orem’s Theory
Dorothea E Orem’s theory is based on the premise that people
need a composite of self-care actions to survive. Self-care actions consist of
all behaviors performed by people to maintain life and health. The capacity of
the patient and the patient’s family to perform self-care is called self-care
agency. Orem states that a need for nursing care exists if the patient’s self
–care demand exceeds the patient’s self-care agency. Thus, the goal of nursing
is to meet the patient’s self-care demands until the patient and his family are
able to do so.
Orem’s theory describes three types of self-care:
Universal self-care behaviors,
required to meet physiological and psychosocial needs.
Developmental self-care behaviors,
required to undergo normal human development.
Health deviation self-care behaviors,
required to meet patient’s needs during health deviations.
The classification of self-care behaviors in this manner
helps to ensure complete assessment of the patient’s self-care agency.
Assessment focuses on the patient’s self-care demand,
self-care agency and self-care deficits. A plan is formulated from the
information obtained in the assessment that indicates the nursing approach
needed to meet the patient’s needs. It can be categorized as follows:
Wholly compensatory, in which the
patient does not participate behaviorally in self- care.
Partially compensatory, in which the
patient and nurse participate behaviorally in meeting the patient’s self-care
needs.
Educative-developmental, in which the
patient meets self-care needs with minimal nursing assistance.
To implement the required nursing
approach, the nurse uses one of the five behaviors: acting or doing for the
patient, guiding, supporting, providing and teaching.
Roger’s Theory
Roger’s
model focuses on the individual as a unified whole in constant interaction with
the environment. The unitary person is viewed as an energy field that is more
than as well as different from the sum of the biological, physical, social and
psychological parts. In Roger’s model, nursing is concerned with the unitary
person as a synergistic phenomenon.
Nursing
science is devoted to the study of nature and direction of unitary human
development. Nursing practice helps individuals achieve maximum well-being
within their potential.
Roy’s Theory
According to
Callista Roy’s theory, the goal of nursing is to promote the patient’s adaptation
in health and illness. This goal is achieved through the nurse’s efforts to
change, manipulate or block stress-producing stimuli that may impinge on the
patient. The theory assumes that this kind of nursing intervention assists the
patient to cope more effectively through reducing stress.
Roy’s theory
assumes that all human beings have adaptive systems and change in response to
stimuli. If the change does not promote the person’s integrity then the change
can be considered maladaptive.
The nursing
process used in Roy’s theory involves two levels of assessment. The first level
includes observation of behavior related to the four adaptive modes:
Physiologic, self-concept, role function and interdependence. These four modes
represent methods used by the patient to adapt. The second level of assessment
consists of identifying focal, contextual and residual stimuli. The focal
stimulus represents the immediate dominant stimulus affecting the patient, such
as injury, stress or illness. Contextual stimuli include the environment, the
patient’s family and all other background factors related to the focal
stimulus. Residual stimuli consist of the patient’s previous background,
beliefs, attitudes and traits.
According to Roy’s theory, a person’s adaptation level is a function of focal, contextual and residual stimuli. When a person encounters stresses form these stimuli that surpassinnate and acquired mechanisms to cope effectively, the person behaves ineffectively as demonstrated by one or more of the adaptive modes. At this point, nursing intervention is required. This emphasizes on the patient’s behavior, stimuli determining the patient’s behavior, stimuli determining the patient’s behavior, and the nurse intervening in some way to interfere with the stimuli.
Investigations
are useful to detect alteration in biologic function and to screen for medical
disorders causing psychiatric symptoms.
Routine Investigations
A complete hemogram (total and
differential blood count, hemoglobin, ESR) and urinalysis are the basic routine
tests. Leucopenia and agranulocytosis are associated with certain medications
(Clozapine). Treatment with lithium and neuroleptic malignant syndrome are
often associated with leukocytosis.
Renal function tests: Treatment with
lithium
Liver function tests: For all
alcoholic patients treatment with carbamazepine, valproate and benzodiazepines
Serum electrolytes: Dehydration,
treatment with carbamazepine,
antipsychotics, lithium
Blood glucose: Routine screen above
35 years age
Thyroid function test: Depression,
treatment with lithium and carbamazepine
Electrocardiogram (ECG): Above 35
years of age, treatment with lithium, antidepressants, ECT, antipsychotics
HIV testing: IV drug users suggestive
sexual history, AIDS, dementia
Drug level estimation: Drug levels
are indicated to test for therapeutic blood levels, for toxic blood levels and
for testing drug compliance. Examples are lithium (0.6 – 1.6 mEq/L),
carbamazepine (6-12 mg/mL), valproate (50-100 mg/mL), haloperidol (8-18 ng/mL),
tricyclic antidepressants (Imipramine 200-250 ng/mL, nortriptyline 50-150
ng/mL), benzodiazepines, barbiturates.
Electrophysiological Tests
Electroencephalogram
(EEG): Measures brain electrical activity, identifies dysrhythmias and
asymmetries, used in the diagnosis of seizures, dementia, neoplasm, stroke,
metabolic or degenerative disease.
Polysomnography/sleep studies: Used in
the diagnosis of sleep disorders and seizures.
Brain Imaging Tests (Cranial)
Computed tomography (CT) scan:
Measures accuracy of brain structure to detect possible lesions, abscesses,
areas of infarction or aneurysm. CT scan also identifies various anatomic
differences in patients with schizophrenia, organic mental disorder and bipolar
disorder.
Magnetic resonance imaging (MRI)
scan: Measures the anatomic and biochemical status of various segments of the
brain; detects brain edema, ischemia, infection, neoplasm, trauma and other
changes such as demyelination used in the diagnosis of dementia, to detect
morphological changes in schizophrenia patients.
Other tests are positron emission
tomography (PET).
Neuroendocrine Tests
Commonly used
neuroendocrine tests are dexamethasone suppression test, TRH stimulation test,
serum prolactin levels, serum 17-hydroxycorticosteriod, serum melatonin levels.
Genetic
tests
Cytogenetic work-up is advised in some cases of mental retardation.
The holistic
view of the patient, with the body and soul seen as inseparable, and the
patient viewed as a member of a family and community was central to
Nightingale’s view of nursing. The primary goal of nursing is to help patients
develop strategies to achieve harmony within themselves and with others, nature
and the world. Integrative functioning of the patient is physical, emotional,
intellectual, social and spiritual dimensions are emphasized. Each person is
considered as a whole, with many factors contributing to health and illness.
Major
Concepts
Five major
concepts are generally accepted as premises of holistic health care philosophy:
First, each person is
multidimensional; one’s physical, emotional, intellectual, social and spiritual
dimensions are in constant interaction with each other:
The
physical dimension involves everything associated with one’s body, both
internal and external.
The
emotional dimension consists of affective states and feelings, including motor
behavior associated with emotion, the experienced aspect of emotion, and the
physiological mechanisms that underlie emotion
The
intellectual dimension includes receptive functions, memory and learning,
cognition and expressive functions.
The
social dimension is based on social intersection and relationships, more so the
global concept of culture.
The
spiritual dimension is that aspect of a person from which meaning in life is
determined; through which transcendence over the ordinary is possible.
The second premise of holistic care
philosophy is that the environment makes significant contributions to the
nature of one’s existence. Each person’s environment consists of many factors
that are influential in that person’s quality of life. Consequently, people
cannot be fully understood without consideration of environmental factors such
as family relationships, culture, and physical surroundings. Individuals interact with their unique
environments through all dimensions, based on subjective experience as well as
external stimuli.
The third premise is that each person
experiences development across his life cycle; in each stage of life, the
individual experiences and confronts different issues or similar issues in
different ways. One’s experience of each stage of life, forms the basis for
further development as one moves through the life cycle.
Fourth, the holistic healthcare model
maintains that stress is a primary factor in health and illness. Any event or
circumstance can act as a stressor. Regardless of the source, stress has an
impact on the whole person. Examples of stressors directly affecting the
physical dimension include stressors associated with genetic factors,
physiological processes, and body image. Emotional stress may result from any
experience or situation. Examples include poor physical conditions, perceived
social inequities, a significant loss, intellectual incompetence, and a sense
of meaninglessness. Stressors affecting the intellectual dimension may include
factors that interfere with receptive functions, memory and learning, cognitive
functions, and expressive functions. Social stressors may arise from
interactions and relationships with other people, as well as from more general
societal and cultural factors. Stressors affecting the spiritual dimension
include all such factors that interfere with one’s ability to meet spiritual
needs.
Fifth, people are ultimately
responsible for the directions their lives take and the lifestyles they choose.
Within a holistic framework, people are viewed as active participants in and
contributors to their health status; they are willing to learn from illness and
strive towards healthier choices.
Recognizing all human dimensions encourages a balanced and whole view of a person. Each facet of an individual is important and contributes to the quality of life experience. All dimensions are intricately interwoven, and the person as a whole functioning organism is more than the simple combination of dimensions. The holistic model emphasizes that all the dimensions of the individual should be considered when planning and instituting care.
Hyperthyroidism
is a condition in which thyroid gland produces too much of the hormone
thyroxine, characteristic by elevated T3 and T4 level that result in
accelerate body’s metabolism, causing sudden weight loss, a rapid or irregular
heartbeat, sweating, and nervousness or irritability.
ETIOLOGY
Grave’s disease: Grave’s disease, an
autoimmune disorder in which antibodies produced by immune system stimulate
thyroid to produce too much T4, is the most common cause of
hyperthyroidism. It may lead to graves ophthalmopathy and graves dermopathy.
Hyper functioning thyroid nodules
(toxic adenoma, toxic multinodular goiter, Plummer’s disease): hyperthyroidism
occurs when one or more adenomas of thyroid produce too much T4.
Thyroiditis: thyroid gland can become
inflamed for unknown reasons. The inflammation can cause excess thyroid hormone
stored in the gland to leak into bloodstream. It may be subacute thyroiditis or
postpartum thyroiditis.
Pathophysiology
Any
disturbance in the normal homeostatic mechanism at hypothalamus and pituitary
gland leads to hypersecretion of thyroid hormone. It may occur due to certain
tumor or a defect of thyroid gland that may lead to hypersecretion of T3 and
T4. Hypersecretion of T3
and T4 lead to hypermetabolism state.
Hypersecretion
of T3 and T4 —- increase degradation of protein,
carbohydrate and fat —- increase fuel consumption —- increase BMR —-
increasing rate of catabolism —- weight loss and excess heat production —-
heat intolerance —- palpitation and excessive sweating
SYMPTOMS
Hyperthyroidism
can mimic other health problems, which may make it difficult to diagnose. It
can also cause a wide variety of signs and symptoms.
Sudden weight loss
Rapid heartbeat (tachycardia)
Increased appetite
Nervousness anxiety and irritability
Tremor
Sweating
Changes in menstrual patterns
Increased senstitivity to heat
Changes in bowel patterns
An enlarged thyroid gland (goiter)
Fatigue, muscle weakness
Difficulty sleeping
Skin thinning
Fine, brittle hair
Exophthalamus
Fast tendon reflex
Reduce eye movement
COMPLICATIONS
Heart problems: these include a rapid
heart rate, a heart rhythm disorder called atrial fibrillation and congestive
heart failure
Brittle bones: untreated
hyperthyroidism can also lead to weak, brittle bones (osteoporosis) because of
over secretion of calcitonine
Eye
problems: Grave’s ophthamlopathy characterized by bulging, red or swollen eyes,
sensitivity to light, and blurring or double vision.
CLINICAL FEATURES
The
characteristic symptoms of Graves’ eye disease feature the inflammation of the
eye tissues. The eyes are painful, red and watery – particularly in sunshine or
wind. The covering of the eye is inflamed and swollen. The lids and tissues
around the eyes are swollen with fluid. The eyeballs bulge out of their
sockets. Because of eye muscle swelling, the eyes are unable to move normally
and there may be blurred or double vision. Some patients have decreased color
vision as well.
Red, swollen skin: people with
Graves’ disease develop Graves’ dermopathy, which affects the skin, causing
redness and swelling, often on the shins and feet
Thyrotoxic crisis: this leads to a
fever, a rapid pulse and even delirium
DIAGNOSTIC EVALUATION
Radioactive iodine (RAI) uptake test:
High in Graves’ disease and toxic nodular goiter, low in thyroiditis
Serum T4 and T3: increased in
hyperthyroidism. Normal T4 with elevated T3 indicates
thyrotoxicosis
Thyroid-stimulating hormone (TSH):
Suppressed
Thyroglobulin: increased
TRH stimulation: hyperthyroidism is
indicated if TSH fails to rise after administration of TRH
Thyroid T3 uptake: normal
to high
Protein-bound iodine: increased
Serum glucose: elevated (related to
adrenal involvement)
Electrolytes: hyponatremia may
reflect adrenal response or dilutional effect in fluid replacement therapy.
Hypokalemia occurs because of GI losses and diuresis
Serum catecholamines: decreased
Urine creatinine: increased
ECG: atrial fibrillations, shorter
systole time, cardiomegaly, heart enlarged with fibrosis and necrosis
Needle or open biopsy: may be done to
determine cause hyperthyroidism, differentiate cysts or tumors, diagnose
enlargement of thyroid gland
Thyroid scan: differentiates between
Graves’ disease and Plummer’s disease, both of which result in hyperthyroidism
Physiologic state – hyperthyroidism,
untreated
Serum
TSH low
Serum free T4
high
Serum T3 high
24-h
radioiodine high
Uptake
Physiologic state – hyperthyroidism,
T3 toxicosis
Serum TSH low
Serum free T4
normal
Serum T3 high
24-h
radioiodine Normal or high
Uptake
Physiologic state – Primary
hypothyroidism, untreated
Serum
TSH low or normal
Serum free T4
low
Serum T3 low or normal
24-h
radioiodine low or normal
Uptake
Physiologic state – Hypothyroidism,
secondary to pituitary disease
Serum
TSH low or normal
Serum free T4
low
Serum T3 low or normal
24-h
radioiodine low or normal
Uptake
Physiologic state – Euthyroid, on
exogenous thyroid hormone
Serum
TSH normal
Serum free T4
normal on T4,
low on T3
Serum T3 high on T3, normal
on T4
24-h
radioiodine low
Uptake
MANAGEMENT
Beta
blockers
Beta
blockers offer prompt relief of the adrenergic symptoms of hyperthyroidism such
as tremor, palpitations, heat intolerance, and nervousness. Propranolol has
been used most widely, but other beta blockers can be used. Nonselective beta
blockers such as propranolol are preferred because they have a more direct
effect on hypermetabolism. Therapy with propranolol should be initiated at 10
to 20 mg every six hours. The dose should be increased progressively until
symptoms are controlled. Calcium channel blockers such as diltiazem can be used
to reduce heart rate in patiens who cannot tolerate beta blockers
Iodides
Iodides
block the peripheral conversion of thyroxine (T4) to
triiodothyronine (T3) and inhibit hormone release. Iodides also are
used as adjunctive therapy before emergency nonthyroid surgery, if beta
blockers are unable to control the hyperthyroidism, and to reduce gland
vascularity before surgery for Graves’ disease. Iodides are not used in the
routine treatment of hyperthyroidism because of paradoxical increases in
hormone release that can occur with prolonged use. Organic iodide radiographic
contrast agents (e.g. iopanoic acid or ipodate sodium) are used more commonly
than the inorganic iodides (e.g. potassium iodide). The dosage of either agent
is 1 g per day for up to 12 weeks.
Antithyroid
Drugs
Antithyroid
drugs act principally by interfering with the organification of iodine, thereby
suppressing thyroid hormone levels. Methimazole and propylthiouracil are the
two agents available which are commonly used.
Methimazole
Methimazole
usually is the drug of choice in nonpregnant patients because of its lower
cost, longer half-life, and lower incidence of hematologic side effects. The
starting dosage is 15 to 30 mg per day, and it can give in conjunction with a
beta blocker. The beta blockade can be tapered after four to eight weeks and
the methimazole adjusted. Maintenance dosage of 5 to 10 mg per day
Propyithiouracil
PTU is
preferred for pregnant women because methimazole has been associated with rare
congenital abnormalities. The starting dosage of PTU is 100 mg three times per
day with a maintenance dosage of 100 to 200 mg daily
Radioactive
Iodine
Radioactive
iodine is the treatment of choice for most patients with Graves’ disease and
toxic nodular goiter. It is inexpensive, highly effective, easy to administer,
and safe. There has been reluctance to use radioactive iodine in women of
childbearing years because of the theoretical risk of cancer of the thyroid,
leukemia, or genetic damage in future offspring
Potential
side effects from treatments for hypothyroidism
Most people
who are treated with radioactive iodine will eventually develop hypothyroidism
Transiently
sore thyroid gland
Anti-thyroid
pills – rash, usually requiring stopping the drug (one in twenty risk)
Agranulocytosis:
low white blood cells leading to infection risk (one in five hundred risks)
Surgery –
underactive thyroid (hypothyroidism) requiring lifelong thyroid hormone
replacement
Damage to
nerves controlling vocal chords
Damage to
parathyroid glands (glands responsible for maintaining calcium in the blood)
Surgical
risks (Typically less than 1% with experienced surgeons)
Thyroidectomy:
removal of thyroid gland, it may be subtotal thyroidectomy, hemithyroidectomy
or total thyroidectomy
NURSING MANAGEMENT
Decrease cardiac output related to
uncontrolled hyperthyroidism and hypermetabolic state
Interventions
Monitor BP lying, sitting, and
standing, if able. Note widened pulse pressure
Monitor central venous pressure
(CVP), if available
Investigate reports of chest pain or
angina
Assess pulse and heart rate while
patient is sleeping
Monitor ECG, noting rate and rhythm.
Document dysrhythmias
Auscultate heart sounds, note extra
heart sounds, development of gallops and systolic murmurs
Monitor temperature, provide cool
environment, limit bed linens or clothes, administer tepid sponge baths
Observe signs and symptoms of severe
thirst, dry mucous membranes, weak or thready pulse, poor capillary refill,
decreased urinary output, and hypotension
Weigh daily. Encourage chair-rest or
bedrest. Limit unnecessary activities
Fatigueness related to hypermetabolic
state or altered body chemistry
Intervention
Monitor vital signs, noting pulse
rate at rest and when active
Note development of tachypnea,
dyspnea, pallor, and cyanosis
Encourage patient to restrict
activity and rest in bed as much as possible
Provide for quiet environment, cool
room, decreased sensory stimuli, soothing colors, quiet music
Encourage patient to restrict
activity and rest in bed as much as possible
Provide comfort measures: touch
therapy or massage, cool showers. Patient with dyspnea will be most comfortable
sitting in high Fowler’s position
Provide for diversional activities
that are calming, e.g. reading, radio, television
Avoid topics that irritate or upset
patient. Discuss ways to respond to these feelings
Disturbed thought processes related
to altered sleep pattern
Intervention
Assess thinking process. Determine
attention span, orientation to place, person, or time.
Note changes in behavior
Assess level of anxiety
Reorient to person, place, or time as
indicated
Provide quiet environment; decreased
stimuli, cool room, dim lights
Reorient to person, place, or time as
indicated
Provide, calendar, room with outside
window, alter level of lighting to simulate day or night
Present reality concisely and briefly
without challenging illogical thinking
Administer medication as indicated:
sedatives, antianxiety agents, antipsychotic drugs
Provide safety measures. Pad side
rails, close supervision, applying soft restraints as last resorts as necessary
Risk for imbalanced nutrition: less
than body requirements related to nausea, vomiting, diarrhea
Intervention
Monitor daily food intake. Weigh
daily and report losses
Encourage patient to eat and increase
number of meals and snacks. Give or suggest high-calorie foods that are easily
digested
Provide a balance diet, with six
meals per day
Avoid foods that increase peristalsis
and fluids that cause diarrhea
Administer medications as indicated:
glucose, vitamin B complex, insulin
Consult with dietitian to provide
diet high in calories, protein, carbohydrate and vitamins
Anxiety related to CNS stimulation
(hypermetabolic state)
Intervention
Observe behavior indicative of level
of anxiety
Monitor physical responses, noting
palpitations, repetitive movements, hyperventilation, and insomnia
Stay with patient, maintaining calm
manner. Acknowledge fear and allow patient’s behavior to belong to patient
Describe and explain procedures,
surrounding environment, or sounds that may be heard by patient
Speak in brief statements. Use simple
words
Discuss with patient reasons for
emotional liability and psychotic reaction
Reduce external stimuli: place in
quiet room, provide soft, soothing music; reduce bright lights, reduce number
of persons contacting patient
Reinforce expectation that emotional
control should return as drug therapy progresses
Administer antianxiety agents or
sedatives and monitor effects
Impaired tissue integrity related to
alternation in protective mechanism of eye
Intervention
Encourage use of dark glasses when
awake and taping the eyelids shut during sleep as needed. Suggest use of
sunglasses or eye patch. Moisten conjunctiva often with isotonic eye drops
Elevate the head of the bed and
restrict salt intake if indicated
Instruct patient in extraocular
muscle exercises if appropriate
Provide opportunity for patient to
discuss feelings about altered appearance and measures to enhance self-image
Administer medications as indicated:
adrenocorticotropic hormone (ACTH), prednisone, methylcellulose drops
Knowledge deficit regarding
condition, prognosis, treatment, self-care and discharge needs
Intervention
Provide information appropriate to
individual situation
Provide information about signs and
symptoms of hypothyroidism and the need for continuing follow-up care
Identify stressors and discuss
precipitators to thyroid crises: personal or social and job concerns,
infection, pregnancy
Monitor CBC periodically
Identify signs and symptoms requiring
medical evaluation: fever, sore throat, and skin eruptions
Discuss drug therapy, including need
for adhering to regimen, and expected therapeutic and side effects
Explain need to check with physician
before taking other prescribed or OTC drugs
Review need for nutritious diet and
periodic review of nutrient needs. Tell patient to avoid caffeine, artificial
preservatives
Emphasize importance of planned rest
periods
Other
Possible Nursing Diagnosis
Imbalanced nutrition less than body
requirements related intake less than metabolic needs secondary to excessive
metabolic rate
Risk for injury related to tremors
Risk for hyperthermia related to lack
of metabolic compensatory mechanisms secondary to hyperthyroidism
Activity intolerance related to
fatigue, exhaustion secondary to excessive metabolic rate
Diarrhea related to increased
peristalsis secondary to excessive metabolic rate
Impaired comfort related to heat
intolerance and profuse diaphoresis
HYPOPARATHYROIDISM – Etiology, Risk
Factors, Diagnostic Evaluation, Complication and Management
Hypoparathyroidism
is decreased function of the parathyroid glands with under production of
parathyroid hormone. This can lead to low levels of calcium in the blood, often
causing cramping and twitching of muscles or tetany (involuntary muscle
contraction), and several other symptoms.
Hypoparathyroidism
is a condition in which body secretes abnormally low levels of parathyroid
hormone (parathormone). This hormone plays a key role in regulating and
maintaining a balance of body’s levels of two minerals, calcium and phosphorous.
This leads to abnormally low ionized calcium levels in blood and bones and to
an increased amount of phosphorus.
ETIOLOGY
Acquired hypoparathyroidism: this is
most common cause of hypoparathyroidism develops after accidental damage to or
removal of the parathyroid glands during surgery. Surgery maybe a treatment for
diseases of the nearby thyroid gland, or for throat cancer or neck cancer.
Hereditary hypoparathyroidism
(DeGeorge syndrome): in this form, either the parathyroid glands are not
present at birth, or they do not work properly.
Autoimmune disease: in this condition
in which immune system creates antibodies against the parathyroid tissues, and
treats them as antigen. In the process, the parathyroid glands stop
manufacturing their hormone.
Extensive cancer radiation treatment
of face or neck, which can result in destruction of parathyroid glands
Low levels of magnesium in blood,
which can affect the function of parathyroid glands. Normal magnesium levels
are required for optimum secretion of parathyroid hormone.
RISK FACTORS
Recent neck surgery, particularly if
the thyroid was involved
A family history of
hypoparathyroidism
Having certain autoimmune or
endocrine conditions, such as Addison’s disease – a condition characterized by
a deficit in hormone production by the adrenal glands
DIAGNOSTIC EVALUATION
History: It begins with the
diagnostic process by taking a medical history and asking about symptoms, such
as muscle cramps or tingling of the extremities, recent surgeries, particularly
operations involving the thyroid or neck
Physical examination, looking for
signs that suggest hypoparathyroidism, such as facial muscle twitching
Blood tests will reveal low blood –
calcium level, low parathyroid hormone level, high blood – phosphorous level,
and low blood – magnesium level
Electrocardiogram (ECG): this test
involves taking electrical readings of heart’s activity. It can detect
arrhythmias associated with hypocalcemia, and in turn, hypoparathyroidism
Urine test: evaluation of a sample of urine can show whether body is
excreting too much calcium
X-rays and bone density tests these
can determine whether abnormal calcium levels have affected the strength of
bones
COMPLICATION
Tetany: these cramp-like spasms of
hands and fingers may be prolonged and painful. Tetany also may include muscle
discomfort and twitches or spasms of the muscles of face, throat or arms. When
these spasms occur in your throat, they can interfere with breathing, creating
a possible emergency.
Paresthesias: these are characterized
by sensory symptoms of odd, tingling sensations or pins and needles feelings in
your lips, tongue, fingers and feet
Loss of consciousness with
convulsions (grand mal seizures)
Malformation of the teeth
Impaired kidney function
Heart arrhythmias and fainting
Stunted growth (short stature)
Slow mental development (or mental
retardation) in children
Calcium deposits in the brain
Cataracts
MANAGEMENT
Treatments
and Drugs
Oral calcium
carbonate tablets
Vitamin D
can help your body absorb calcium and eliminate phosphorous. The forms of
vitamin D called ergocalciferol or calcitriol are recommended most often
because they have a longer duration of action or are more potent than are other
forms of this vitamin. Often, the required doses of vitamin D are much higher
than are those used for a typical daily vitamin supplement.
Diet
Rich in calcium. This includes dairy
products, green leafy vegetables, broccoli, kale, and fortified orange juice
and breakfast cereals.
Low in phosphorous-rich items. This
means avoiding carbonated soft drinks, which contain phosphorous I the form of
phosphoric acid. Eggs and meats also tend to be high in phosphorous.
Intravenous infusion: in some cases,
when immediate relief of symptoms are required, administer of calcium by
intravenous (IV) infusion
Regular monitoring, regularly
assessment of blood to monitor levels of calcium and phosphorous. Initially,
these tests will be weekly to monthly
Nutrition and supplements
Following these nutritional tips may
help reduce symptoms of hypoparathyroidism
Eliminate all potential food
allergens, including dairy, wheat (gluten), soy, corn, preservatives and food
additives
Eat calcium rich foods, including
beans, almonds, and dark green leafy vegetables (such as spinach)
Avoid refined foods, such as white
breads, pastas, and sugar
Eat fewer red meats and more lean
meats, cold water fish, tofu (soy), or beans for protein
Use healthy cooking oils, such as
olive oil or vegetable oil
Reduce or eliminate trans-fatty
acids, found in commercially baked goods such as cookies, crackers, cakes and
doughnuts. Also avoid French fries, onion rings, processed foods
Limit carbonated beverages. They are
high in phosphates, which can leach calcium from your bones
Avoid coffee and other stimulants,
alcohol and tobacco
Drink 6-8 glasses of filtered water
daily
Drink soy milk for bone health unless
allergic to soy
Exercise moderately at least 30
minutes daily, 5 days a week
A multivitamin daily, containing the
antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such
as magnesium, calcium, zinc and selenium
Ipriflavone (soy isoflavones)
standardized extract, 200 mg 3 times a day, for bone loss. Ipriflavone can
interfere with many different medications and may not be suitable for certain
people with immune deficiencies
Omega-3 fatty acids, such as fish
oils, 1-2 capsules or 1-2 tablespoonful of oil daily, to help decrease
inflammation and support healthy metabolism. Omega-3 fatty acids can have a
blood-thinning effect and may increase the effect of blood-thinning drugs, such
as warfarin (Coumadin) and aspirin.
NURSING MANAGEMENT
Activity intolerance related to fatigue and decreased cognitive process
Constipation related to decreased gastrointestinal function
Knowledge deficit related to exposure to information about treatment program for lifelong thyroid replacement therapy
Ineffective breathing pattern related to depression of ventilation
Disturbed thought process related to metabolic disorder and cardiovascular and respiratory status changes
HYPOPARATHYROIDISM – Etiology, Risk Factors, Diagnostic Evaluation, Complication and Management
HEMOTHORAX – Etiology,
Pathophysiology, Signs and Symptoms, Diagnostic Evaluation and Management
A hemothorax
is a condition that results from blood accumulating in the pleural cavity.
ETIOLOGY
Penetrating trauma
Blunt trauma
Broken ribs
Shearing forces
Violet compression of pleural cavity
PATHOPHYSIOLOGY
Due to
trauma (blunt or penetrating injury) to the thorax (resulting in) —- rupture
of the serious membrane or covering the lungs (this rupture allows) —- blood
to spill into the pleural space (leading to) —- hemothorax
SIGNS AND SYMPTOMS
Tachypnea
Dyspnea
Cyanosis
Decreased or absent breath sounds on
affected side
Tracheal deviation to unaffected side
Dull resonance on percussion
Unequal chest rise
Tachycardia
Hypotension
Pale, cool, clammy skin
Possibly subcutaneous emphysema
Narrowing pulse pressure
DIAGNOSTIC EVALUATIONS
Chest X-ray
CT scan
Pleural fluid analysis
Thoracentesis
MANAGEMENT
Thoracostomy: a hemothorax is managed
by removing the source of bleeding and by draining the blood already in the
thoracic cavity. Blood in the cavity can be removed by inserting a drain (chest
tube) in a procedure called tube thoracostomy
Thrombolytic agents have been used to
break up clot in tubes or when the clot becomes organized in the pleural space.
However, this is risky as it can lead to increased bleeding and the need for
reoperation
COMPLICATIONS
Collapsed lung, leading to
respiratory failure
Death
Fibrosis or scarring of the pleural
membranes
Infection of the pleural fluid
(empyema)
Pneumothorax
Shock
HEMOTHORAX – Etiology, Pathophysiology, Signs and Symptoms, Diagnostic Evaluation and Management
GASTRIC CANCER – Causes and Risk
Factors, Pathophysiology, Signs and Symptoms, Stages, Diagnosis and Management
INTRODUCTION
Gastric
cancer was once the second most common cancer in the world. In most developed
countries, however, rates of stomach cancer have declined dramatically over the
past half century. Men have higher incidence of gastric cancer than women. Most
of these deaths occur in people older than 40 years of age.
Gastric
cancer: tumors in the stomach can be benign or malignant. Gastric cancer is a
disease in which tumors are found in the stomach. Stomach cancer is common
throughout the world and affects all races, it is more common in men than
women, and has its peak age range between 40 and 60 years old. If it is not
diagnosed quickly, it may spread to other parts of your stomach as well as to
other organs. There are twice as many males with this disease than females.
Stomach
cancer usually begins in cells in the inner layer of the stomach. Overtime, the
cancer may invade more deeply into the stomach wall. A stomach tumor can grow
through the stomach’s outer layer into nearby organs, such as the liver,
pancreas, esophagus, or intestine.
Causes/Risk Factors of gastric Cancer
Helicobacter pylori infection:
H.pylori is a bacterium that commonly infects the inner lining (the mucosa) of
the stomach. Infection with H.pylori can cause stomach inflammation and peptic
ulcers.
Long-term inflammation of the
stomach: people who have conditions associated with long-term stomach
inflammation (such as the blood disease pernicious anemia) are at increased
risk of stomach cancer
Smoking: smokers are more likely than
nonsmokers to develop stomach cancer. Heavy smokers are most at risk
Family history: close relatives
(parents, brothers, sisters, or children) of a person with a history of stomach
cancer are somewhat more likely to develop the disease themselves. If many
close relatives have a history of stomach cancer, the risk is even greater
Poor diet, lack of physical activity
Obesity people who eat a diet high in
foods that are smoked, salted, or pickled have an increased risk for stomach
cancer
A lack of physical activity may increase
the risk of stomach cancer
PATHOPHYSIOLOGY
Most gastric
cancer is adenocarcinomas and occurs in portion of stomach —- the tumors
infiltrate the surrounding mucosa —- penetrating the wall of the stomach and
adjacent organs and structures —- the liver, pancreas esophagus and duodenum
are often affected —- metastasis through lymph to the peritoneal cavity
occurs later in disease
SIGNS AND SYMPTOMS
Stomach
cancer is often asymptomatic or it may cause only nonspecific symptoms. By the
time symptoms occur, the cancer has often reached an advanced stage and may
have also metastasized. Stomach cancer can cause the following signs and
symptoms.
STAGE 1 (Early)
Indigestion or a burning sensation
(heartburn)
Loss of appetite, especially for meat
Abdominal discomfort or irritation
Stage 2
(Middle)
Weakness and fatigue
Bloating of the stomach, usually
after meals
Stage 3
(Late)
Abdominal pain in the upper abdomen
Nausea and occasional vomiting
Diarrhea and constipation
Weight loss
Bleeding (vomiting blood or having
blood in the stool) which will appear as black. This can lead to anemia.
Dysphagia this feature suggests a
tumor in the cardiac or extension of the gastric tumor into the esophagus
DIAGNOSIS
Physical examination: abdomen for
fluid, swelling, or other changes. Also will check for swollen lymph nodes
Endoscopy: uses a thin, lighted tube
(endoscope) to look into your stomach
Biopsy: an endoscope has a tool for
removing tissue
Computed tomography or CT scanning of
the abdomen may reveal gastric cancer, but is more useful to determine invasion
into adjacent tissues, or the presence of spread to local lymph nodes
Gastroscopic examination: this
involves insertion of a fiber optic camera into the stomach to visualize it
MANAGEMENT
Treatment
for stomach cancer may include surgery, chemotherapy, and radiation therapy
Surgery:
surgery is the most common treatment. The surgeon removes part or all of the
stomach, as well as surrounding lymph nodes, with the basic goal of removing
all cancer and a margin of normal tissue.
Endoscopic mucosal resection (EMR) is
a treatment for early gastric cancer (tumor only involves the mucosa. In this
procedure, the tumor, together with the inner lining of stomach (mucosa), is
removed from the wall of the stomach using an electrical wire loop through the
endoscope. The advantage is that it is a much smaller operation than removing
the stomach
Endoscopic submucosal dissection
(ESD) is a similar technique used to resect a large area of mucosa in one
piece. If the pathologic examination of the resected specimen shows incomplete
resection or deep invasion by tumor, the patient would need a formal stomach
resection
Surgery to remove stomach cancer the
types of operation have to remove stomach cancer will depend on which part of
the stomach the cancer is in. if cancer is near the area where stomach joins
food pipe (esophagus) may need part of food pipe removed as well.
Gastric bypass procedures (GBP) – in
this stomach is divided into a small upper pouch and a much larger lower ‘remnant’ pouch
and then re-arranges the small intestine to connect to both
Radiation therapy is the use of
high-energy rays to damage cancer cells and stop them from growing. When used,
it is generally in combination with surgery and chemotherapy, or used only with
chemotherapy in cases where the individual is unable to undergo surgery
COMPLICATIONS
OF ABDOMINAL SURGERY
Infection: infection of the incisions
or of the inside of the abdomen (peritonitis, abscess) may occur due to release
of bacteria from the bowel during the operation
Venous thromboembolism: any injury,
such as a surgical operation, causes the body to increase the coagulation of
the blood
Hemorrhage: many blood vessels must
be cut in order to divide the stomach and to move the bowel. Any of these may
later begin bleeding, either into the abdomen (intra-abdominal hemorrhage), or
into the bowel itself (gastrointestinal hemorrhage)
Hernia: a hernia is an abnormal
opening, either within the abdomen or through the abdominal wall muscles. An
internal hernia may result from surgery and re-arrangement abdominal of the bowel,
and is a cause of bowel obstruction
Bowel obstruction: abdominal surgery
always results in some scarring of the bowel, called adhesions. A hernia,
either internal or through the abdominal wall, may also result
Preoperative
Management
Preoperative assessment: the
patient’s preoperative physiological status is a major factor in determining
outcome after major surgery. Although scoring systems including a variety of
parameters have been evaluated, the previous medical history and concurrent
morbidity remain the strongest predictors
Past medical history: a detailed
medical history and physical examination is a prerequisite to the assessment of
any anesthetic and operative risk. Cardiorespiratory disease has been
identified as the commonest coexisting disease in patient presenting for
esophagectomy. Pre-existing ischemic heart disease, poorly controlled
hypertension, and pulmonary dysfunction are all associated with increased
operative morbidity, particularly in the elderly and following upper abdominal
and thoracic surgery. The efficacy of any medication prescribed for
cardiorespiratory conditions should be evaluated at an early stage
Social habits: smoking is a
significant etiological factor in preoperative morbidity. All patients must be
encouraged to stop smoking preoperatively
Preoperative investigations: the
minimum preoperative investigations for all patients undergoing gastric or
esophageal surgery should include baseline hematological and biochemical
profiles, arterial blood gases on air, pulmonary functions tests, a resting
electrocardiogram, and a chest X-ray
Nutritional status: obesity is
associated with increased operative risk
Psychological
Preparation
All patients
should be counseled about treatment options, paying particular attention to the
results and limitations of surgery. A clear description of the preoperative
period should be given. An assessment of pretreatment symptoms on quality of
life of the patient should be carefully undertaken as there is accumulating
evidence of quality of life scores having an independent effect on outcome
Thromboembolic
Prophylaxis
Appropriate
measures should be taken against the risk of thromboembolic complications.
Antithromboembolic stockings, low molecular weight heparin, and preoperative
calf compression should be employed
Antibiotic prophylaxis: broad
spectrum antibiotic prophylaxis should
be administered preoperatively
Blood cross match: four units of
blood should be cross matched prior to surgery. Transfusion however should be
avoided if at all possible as the immunological suppressive effect can
adversely affect survival
Postoperative
Management
Meticulous attention to the
maintenance of fluid balance and respiratory care are essential in the
immediate postoperative period
Pain control
Pulmonary physiotherapy
Early mobilization is important in
the prevention of venous thrombosis and pulmonary embolism
Promote pulmonary ventilation
Provide adequate analgesic during few
days
Encourage ambulation
Promote nutrition and family
education
Add food in small amount at frequent
interval until well tolerated
Monitor weight regularly
STOMACH
CANCER (GASTRIC) PREVENTION
Gastric
cancer can sometimes be associated with known risk factors for the disease.
Many risk factors are modifiable though not all can be avoided
Diet and lifestyle: excessive salt
intake has been identified as a possible risk factor for gastric cancer. Having
a high intake of fresh fruits and vegetables may be associated with a decreased
risk of gastric cancer. Studies have suggested that eating foods that contain
beta-carotene and vitamin C may decrease the risk of gastric cancer, especially
if intake of micronutrients is inadequate
Pre-existing conditions: infection
with a certain bacteria, Helicobacter pylori, is associated with an increased
risk of gastric cancer. Long standing reflux of gastric contents and the
development of an abnormal cellular lining is also associated with an increased
risk of cancer at the junction of the stomach and esophagus
Cancer-fighting foods
Citrus fruits: it is no secret that
oranges, tangerines and clementines bring us vitamin C; they are among the
richest sources of this critical vitamin
NURSING MANAGEMENT
Nursing
assessment: careful selection of the varying therapeutic modalities is
essential. Such selection should consider not only the nature of the symptoms
to be relieved but also the general medical and psychological status of the
patient. Decisions should be taken in the context of the predicted prognosis
and the effect of any treatment intervention on quality of life
Nursing
Diagnosis
Preoperative
Acute pain related to the growth of
cancer cells
Anxiety related to plan surgery
Imbalanced nutrition less than body
requirements related to nausea, vomiting and no appetite
Activity intolerance related to
physical weakness
Postoperative
Ineffective breathing pattern related
to the influence of anesthesia
Acute pain related to interruption of
the body secondary to invasive procedures or surgical intervention
Imbalanced nutrition less than body
requirements related to fasting status
Risk for infection related to an
increased susceptibility secondary to the procedure
Intervention
Encourage the patient to eat small
and frequent portions of nonirritating foods to decrease gastric irritation
Food supplements should be high in
calories as well as vitamin A and C and iron to enhance tissue repair
The nurse administers analgesic as
prescribed
A continuous infusion of an Opioid
may be necessary for severe pain
The nurse help the patient express
fears, concern grief and diagnosis
Encourage the patient to participate
in treatment decisions
GASTRIC CANCER – Causes and Risk Factors, Pathophysiology, Signs and Symptoms, Stages, Diagnosis and Management
