Adult Nursing I 2024-2025 Faculty of Nursing, South Valley University

Adult of Nursing I For Second Year Nursing Student First semester Faculty of Nursing, South Valley University- Qena 2024-2025 Adult of Nursing I: Unit Course content 1 Nursing management of patient with respiratory disorders: - Anatomy of respiratory system - Bronchitis - Pneumonia - Bronchial asthma 2 Nursing management of patients with cardiac disorders: - Hypertension - Rheumatic fever - Congestive heart failure 3 Nursing management of patient with GIT disorders: - Peptic ulcer - Ulcerative colitis - Liver cirrhosis 4 Nursing management of patient with endocrine disorders: - - Anatomy and physiology of endocrine system - Hyperthyroidisms - Hypothyroidisms - Diabetes mellitus 5 Nursing management of patients with oncology: - Cancer - Medical treatment of cancer. 1 Unit (1): Nursing management of patient with respiratory disorders: Anatomy of the respiratory system Figure(1):Respiratory System The respiratory system is divided into categories as the following: 1- The upper respiratory tract (upper air way): This includes; nose, nasal cavity, paranasal sinus as (Frontal sinuses, Maxillary sinus, Ethmoid and sphenoid), Turbinates bones, Larynx and Pharynx 2- The lower respiratory tract: This includes Trachea (windpipe), lungs, bronchi, bronchioles and alveoli. 3-Accessory structures: This includes The diaphragm, The mediastinum and Rib cage, sternum, spine, muscles and blood vessels. 2 Bronchitis Definition: It is inflammation of the mucous membranes that line the major bronchi and their branches. Types of bronchitis: 1- Acute bronchitis, which usually is self-limiting, lasts for several days. 2- Chronic bronchitis, it occurs for more than 2 months or recurs on 2 consequent years. Etiology of bronchitis: Acute bronchitis: Most commonly 90% caused by viral infection as (haemophilus influenza) and 10% is bacterial as (mycoplsma pneumonia and streptococcus pneumonia) or fungal infection. Fig(2)Acute bronchitis 3 Chronic bronchitis: 1- Can develop from repeated episodes of acute bronchitis or other repeated lung infections. 2- Other causes: A- Irritants which includes - Smoke. - Air pollution irritants as ozone and nitrogen dioxide. - Fumes from chemicals aas hydrogen sulfide, strong acids, ammonia and chlorine. - Dusts as coal dust or grain dust. B- Physical agents: which includes - Changes in temperature. - Humidity. - Cold drafts. Predisposing factors for chronic bronchitis: 1- Upper respiratory tract infection (URI). 2- Pulmonary congestion as in heart failure. 3- Bronchial obstruction due to excessive secretions. 4- Smoking (Goza). 5-Certain occupations (dusty jobs) 6- Allergy. Clinical manifestation of acute bronchitis: - Typically it begins as URI - Fever, chills, malaise and headache - Dry, irritating nonproductive cough. - Later, the cough produces mucopurulent sputum which may be blood- streaked if tracheobronchitis occurs. - Inspiratory crackles may be heard on chest auscultation. Clinical manifestation of chronic bronchitis: Usually insidious, developing over a period of years as 4 - Chronic cough that is productive rising in the morning and in the evening and lasting at 3 months a year for successive years. - Bronchospasm during sever bouts of coughing. - Sputum may become yellow, purulent, and copious. - Wheezing, cyanosis secondary to hypoxemia. - Dyspnea and haemoptysis. - Fever which may or may not be present. - Lack of energy, malaise and headache. Medical diagnosis for bronchitis: 1-Medical history. 2- Physical examination. 3-Chest X-ray. 4- Lung or pulmonary function test (spirometry). 5-Laboratory test: as CBC 6-Culture of sputum: Used to determine if symptoms are caused by a virus or bacteria. 7-Arterial blood gas test (ABG). 8-An electrocardiogram (ECG) to determine if symptoms are caused by or worsened by a heart problem. 9-Alpha 1- antitrypsin (AAT) test. - Is a protein that is made in the liver and released into blood. - It plays a role in protecting the lungs. - This test is done for patient who are around the age of 45 or younger, nonsmoker, or have a strong family history of COPD. Nursing management for chronic bronchitis: 1- Adequate rest and no smoking. 2- Relieve body aches by taking aspirin. 3- Humidifies assist to keep mucous membranes moist. 5 4- Drink fluids every one to two hours unless your doctor has restricted your fluid intake. 5- Follow doctor's instructions on ways to help clear mucus. 6- Note changes in the sputum production and cough. 7- If have a dry cough and cough up little to no mucus the doctor may prescribed antitussives (drugs used to prevent coughing). It may prescribe an expectorant to help loosen mucus to be more easily coughed up. 8- Facilitate removal of bronchial exudates (bronchodilators). 9- Antibiotics will not be useful because most episodes of bronchitis are viral except in case of bacterial infection. 10- Provide proper treatment for acute upper respiratory infections antimicrobial therapy and sensitivity study. 11- Provide for postual drainage and chest percussion. 12- Reduce the risk of getting bronchitis by life style change as the following: - Don't smoke and don't allow others to smoke in your home. - Stay away from or reduce your time around things that irritate your nose, throat, and lungs as dust or pets. - If you catch a cold, get plenty or rest. - Take your medication exactly, the way your doctor tells you. - Hand washing and eat a healthy diet. - Do not share food, cups and glasses. 6 Pneumonia Learning Objectives: At the end of the lecture, the student will be able to: 1. Define pneumonia. 2. Understand pathophysiology of pneumonia. 3. Enumerate classification, etiology, risk factors and clinical manifestations of pneumonia. 4. Describe diagnostic findings of pneumonia. 5. List complications of pneumonia. 6. Know prevention, nutritional therapy and prognosis of pneumonia. 7. Discuss treatment and nursing management of pneumonia. 7 Pneumonia Definition: Pneumonia is an inflammation of the lung parenchyma may be caused by either infectious or noninfectious agents. Examples of infectious agents are bacteria, mycobacteria, fungi, and nonspecific viruses. Noninfectious agents may include irritating fumes, dust, or chemicals that are inhaled or foreign matter that is aspirated. Fig (3) Pneumonia Classification: Pneumonias are classified as: - Community-acquired pneumonia (CAP): it is an acute infection of the lung occurring in patients who have not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms. - Hospital-acquired (nosocomial) pneumonia (HAP): it is pneumonia that occurs 48 hours or longer after hospital admission and was not incubating at the time of hospitalization. 8 - Pneumonia in the immunocompromised host or opportunistic Pneumonia: Individuals at risk for opportunistic pneumonia include those with altered immune responses. - Aspiration pneumonia: it results from the abnormal entry of material from the mouth or stomach into the trachea and lungs. Etiology: - When the defense mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents. - Decreased consciousness depresses the cough and epiglottal reflexes, which may allow aspiration of oropharyngeal contents into the lungs. - Tracheal intubation interferes with the normal cough reflex and the mucociliary escalator mechanism. - Air pollution. - Cigarette smoking. - Viral URIs. - Normal changes that occur with aging can impair the mucociliary mechanism. - Chronic diseases can suppress the immune system’s ability to inhibit bacterial growth. Methods by Which Organisms Can Reach the Lung: by 3 methods: - Aspiration of normal flora from the naso-pharynx or oropharynx. Many of the organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults. - Inhalation of microbes present in the air. Examples include Mycoplasma pneumonia and fungal pneumonias. - Hematogenous spread from a primary infection elsewhere in the body. An example is Staphylococcus aureus. 9 Pathophysiology: Pneumonia is an acute infection of the lungs that occurs when an infectious agent enters and multiplies in the lungs of a susceptible person. When the microorganisms multiply, they release toxins that induce inflammation in the lung tissue, causing damage to mucous and alveolar membranes. This leads to the development of edema and exudate, which fills the alveoli and reduces the surface area available for exchange of carbon dioxide and oxygen. Some bacteria also cause necrosis of lung tissue. Pneumonia may be confined to one lobe, or it may be scattered throughout the lungs. If it affects only one lobe, it is called lobar pneumonia. Generalized pneumonia is much more serious and is called bronchopneumonia. Bronchopneumonia occurs more often as a nosocomial (hospital acquired) infection in hospitalized patients, the very young, or the very old. Risk Factors: - Abdominal or thoracic surgery. - Age > 65 yrs. -Air pollution. - Altered consciousness: alcoholism, head injury, seizures, anesthesia, drug overdose and stroke. - Bed rest and prolonged immobility. - Chronic diseases: chronic lung and liver disease, diabetes mellitus, heart disease, cancer and chronic kidney disease. - Debilitating illness. - Exposure to bats, birds, rabbits, farm animals. 10 - Immunosuppressive disease and/or therapy (corticosteroids, cancer chemotherapy, human immunodeficiency virus [HIV] infection, immunosuppressive therapy after organ transplant). - Inhalation or aspiration of noxious substances. - Intestinal and gastric feedings via nasogastric or nasointestinal tubes. - IV drug use. - Malnutrition. - Recent antibiotic therapy. - Resident of a long-term care facility. - Smoking. - Tracheal intubation (endotracheal intubation, tracheostomy). - Upper respiratory tract infection. Clinical Manifestations: - Shortness of breath due to inflammation within the lungs, impairing gas exchange. - Difficulty breathing (dyspnea) due to inflammation and mucus within the lungs. - Fever due to infectious process. - Chills due to increased temperature. - Cough due to mucous production and irritation of the airways. - Crackles due to fluid within the alveolar space and smaller airways. - Rhonchi due to mucus in airways; wheezing due to inflammation within the larger airways. - Discolored, possibly blood-tinged, sputum due to irritation in the airways or microorganisms causing infection. - Tachycardia and tachypnea as the body attempts to meet the demand for oxygen. - Pain on respiration due to pleuritic inflammation, pleural effusion, or atelectasis development. 11 - Headache, muscle aches (myalgia), joint pains, or nausea may be present depending on the infecting organism. Complications: Potential complications include the following: - Pleurisy (inflammation of the pleura) is relatively common. - Pleural effusion (fluid in the pleural space) can occur. - Atelectasis (collapsed, airless alveoli) of one or part of one lobe may occur. - Bacteremia (bacterial infection in the blood) is more likely to occur in infections with Streptococcus pneumonia and Haemophilus influenzae. - Lung abscess (not common). - Empyema (the accumulation of purulent exudate in the pleural cavity). - Pericarditis. - Meningitis. - Pneumothorax. - Sepsis can occur when bacteria within alveoli enter the bloodstream. - Acute respiratory failure. Diagnostic Findings: - History: history (particularly of a recent respiratory tract infection). - Physical Examination: On physical examination, rhonchi and crackles may be auscultated over the affected region. If consolidation is present, bronchial breath sounds, and increased fremitus (vibration of the chest wall produced by vocalization) may be noted. Patients with pleural effusion may exhibit dullness to percussion over the affected area. - Chest X-Ray: Shadows on chest x-ray, indicating infiltration, may be in a lobar or segmental pattern or more scattered. 12 - Gram stain of sputum: to identify the organism is obtained before beginning antibiotic therapy. - Sputum culture and sensitivity test: (to identify the infective agent and the appropriate antibiotics). - Pulse oximetry (Low oxygen saturation) or ABGs (may show low oxygen and elevated carbon dioxide levels). - Complete blood count, WBC differential {Elevated WBC (leukocytosis) showing sign of infection}, and routine blood chemistries (if indicated) - Blood cultures (bloodstream invasion occurs frequently). - Auscultation of the chest reveals wheezing, crackles, and decreased breath sounds. The nail beds, lips, and oral mucosa may be cyanotic. - Bronchoscopy is often used in patients with acute severe infection, in patients with chronic or refractory infection, in immunocompromised patients when a diagnosis cannot be made from an expectorated or induced specimen, and in mechanically ventilated patients. Treatment: - Administer oxygen as needed. - Antibiotics are given for the most likely organism (empirically) until the sputum culture results are returned. - Administer antipyretics when fever >38 for patient comfort (as Acetaminophen, ibuprofen). - Administer brochodilators to keep airways open, enhance airflow if needed (as Albuterol, metaproterenol, levalbuterol via nebulizer or metered dose inhaler). 13 - Increase fluid intake to help loosen secretions and prevent dehydration. - Instruct the patient on how to use the incentive spirometer to encourage deep breathing; monitor progress. Nutritional Therapy: - Hydration is important in the supportive treatment of pneumonia to prevent dehydration and loosen secretions. - Individualize and carefully monitor fluid intake if the patient has heart failure. - If the patient cannot maintain adequate oral intake, IV administration of fluids and electrolytes may be necessary. - Weight loss often occurs in patients with pneumonia because of increased metabolic needs and difficulty eating due to shortness of breath and pleuritic pain. - Small, frequent meals are easier for dyspneic patients to tolerate. - Offer foods high in calories and nutrients. Prevention: - Promote coughing and expectoration of secretions if client experiences increased mucus production. - Change position frequently if client is immobilized for any reason. - Encourage deep-breathing and coughing exercises at least every 2 hours. - Administer chest physical therapy as indicated. - Suction client if he or she cannot expectorate. - Prevent aspiration in clients at risk. 14 - Prevent infections. - Cleanse respiratory equipment on a routine basis. - Promote frequent oral hygiene. - Administer sedatives and opioids carefully to avoid respiratory depression. - Encourage client to stop smoking and reduce alcohol intake. - Vaccination against pneumococcal infection. Nursing Management: Assessment: Nursing assessment is critical in detecting pneumonia. Respiratory assessment further identifies the clinical manifestations of pneumonia. The nurse monitors the patient for the following: changes in temperature and pulse; amount, odor, and color of secretions; frequency and severity of cough; degree of tachypnea or shortness of breath; changes in physical assessment findings and changes in the chest x-ray findings. Nursing Diagnoses: Nursing diagnoses for the patient with pneumonia may include, but are not limited to, the following: - Impaired gas exchange related to fluid and exudate accumulation at the capillary-alveolar membrane. - Ineffective breathing pattern related to inflammation and pain. - Acute pain related to inflammation and ineffective pain management and/or comfort measures. 15 Planning: The overall goals are that the patient with pneumonia will have: 1. Clear breath sounds. 2. Normal breathing patterns. 3. No signs of hypoxia. 4. Normal chest x-ray. 5. No complications related to pneumonia. Intervention: - Monitor respiration for rate, effort, use of accessory muscles, skin color, and breathing sounds. - Record fluid intake and output for differences, signsof dehydration. - Record sputum characteristics for changes in color, amount, and consistency. - Properly dispose of sputum. - Explain to the patient: - Take adequate fluids—3 liters per day—to prevent excess fluid loss through the respiratory system with exhalation. - Use of incentive spirometer. Evaluation: The expected outcomes are that the patient with pneumonia will: - Have effective respiratory rate, rhythm, and depth of respirations. - Lungs clear to auscultation. 16 Asthma Learning Objectives: At the end of the lecture, the student will be able to: 1. Define asthma. 2. Differentiates types of asthma. 3. Understand pathophysiology of asthma. 4. List risk factors for asthma and triggers of asthma attacks. 5. List signs and symptoms and complications of asthma. 6. Describe diagnostic test and drug therapy of asthma. 7. Know nutrition notes for the client with asthma. 8. Discuss nursing management of asthma. 17 Asthma Introduction: Asthma is a chronic inflammatory disorder of the airways. The chronic inflammation leads to recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night or in the early morning. These episodes are associated with widespread but variable airflow obstruction that is usually reversible, either spontaneously or with treatment. The clinical course of asthma is unpredictable, ranging from periods of adequate control to exacerbations with poor control of symptoms. Definition: Asthma is usually a reversible obstructive disease of the lower airway. It is Inflammation of the airway and hyper-responsiveness of the airway to internal or external stimuli. Or Asthma is a chronic inflammatory disease of the airways that causes airway hyper-responsiveness, mucosal edema, and mucus production. Types of asthma: There are two types of asthma: - Allergic asthma (extrinsic): occurs in response to allergens, such as pollen, dust, spores, and animal dander. - Non-allergic asthma (intrinsic): associated with factors such as upper respiratory infections, emotional upsets, and exercise. N.B: Many clients experience mixed asthma, which has characteristics of allergic and non-allergic asthma. 18 Pathophysiology: Mast cells and histamine are activated, initiating a local inflammatory response. Prostaglandins enhance the effect of histamine. Leukotrienes also respond, enhancing the inflammatory response. White blood cells responding to the area release inflammatory mediators. Astimulus causes an inflammatory reaction, increasing the size of the bronchial linings; this results in restriction of the airways. Fig (4): Asthma pathophysiology Risk Factors for Asthma and Triggers of Asthma Attacks:  Allergen inhalation: - Animal dander (e.g., cats, mice, guinea pigs). - House dust mite. - Cockroaches. - Pollens. - Molds. 19  Air pollutants: - Exhaust fumes. - Perfumes. - Oxidants. - Sulfur dioxides. - Cigarette smoke. - Aerosol sprays.  Inflammation and infection: - Viral upper respiratory tract infection. - Sinusitis, allergic rhinitis.  Drugs: - Aspirin. - Non-steroidal anti-inflammatory drugs. - β- Adrenergic blockers.  Occupational exposure: - Agriculture, farming. - Paints, solvents. - Laundry detergents. - Metal salts. -Wood and vegetable dusts. - Industrial chemicals and plastics. - Pharmaceutical agents.  Food additives: - Sulfites (bisulfites and metabisulfites). - Beer, wine, dried fruit, shrimp, processed potatoes. - Monosodium glutamate. Tartrazine.  Other factors: - Exercise and cold, dry air. - Stress. - Hormones, menses. - Gastroesophageal reflux disease (GERD). Signs and Symptoms: - Paroxysms of shortness of breath. - Wheezing. - Coughing and the production of thick. - Tenacious sputum. - Fear and anxiety. 20 Complications: - Status asthmatics. - Respiratory failure. - Pneumonia. - Atelectasis. - Airway obstruction, particularly during acute asthmatic episodes, often results in hypoxemia. - Severe and Life-Threatening Asthma Exacerbations. Diagnostic test: - History and physical examination. - Pulmonary function studies, including response to bronchodilator therapy. - Chest x-ray. - Measurement of oximetry. - Allergy skin testing (if indicated). - Blood level of eosinophils and IgE (if indicated). Drug Therapy:  Long-Term Control Medications: Anti-inflammatory Drugs: - Corticosteroids: o Inhaled ― Oral Bronchodilators: - Long-acting inhaled β2-adrenergic agonists. - Long-acting oral β2-adrenergic agonists.  Quick-Relief Medications: Bronchodilators: - Short-acting inhaled β2-adrenergic agonists. - Anti-cholinergic (inhaled). Nutrition Notes for the Client with Asthma: 1. Encourage clients with asthma to consume adequate calories and 21 protein to optimize health and resist infection. 2. Large meals may aggravate asthma by distending the stomach; small frequent meals may be better tolerated. 3. Certain vitamins and minerals are important for immune function, especially vitamins A, C, B6, and the mineral zinc, and should be liberally consumed. 4. Food allergens that may trigger asthma include milk, eggs, seafood, and fish should be avoided. Nursing Management: Nursing Assessment: If a patient can speak and is not in acute distress, take a detailed health history, including identification of any precipitating factors and what has helped alleviate attacks in the past. The patient may be using herbs and supplements to treat asthma. When doing the health history, ask about specific herbs or supplements that a patient may be using. Obtain all subjective and objective data from a patient with asthma. Nursing Diagnoses: - Impaired gas exchange. - Ineffective airway clearance. - Ineffective tissue perfusion. Planning: The overall goals are that the patient with asthma will have asthma control as evidenced by: 1. Minimal symptoms during the day and night. 2. Acceptable activity levels (including exercise and other physical activity). 22 3. Few or no adverse effects of therapy. 4. No recurrent exacerbations of asthma. 5. Adequate knowledge to participate in and carry out management. Interventions:  Obtains a history of allergic reactions to medications before administering medications.  Identifies medications the patient is currently taking.  Administers medications as prescribed and monitors the patient’s responses to those medications. These medications may include an antibiotic if the patient has an underlying respiratory infection.  Administers fluids if the patient is dehydrated.  Monitor respiration: patient’s respiratory status can continue to deteriorate; look at respiratory rate, effort, use of accessory muscles, skin color, breathing sounds.  Place patient in high Fowler’s position to ease respirations.  Monitor vital signs; look for changes in BP, tachycardia, tachypnea.  If the patient requires intubation because of acute respiratory failure, the nurse assists with the intubation procedure, continues close monitoring of the patient, and keeps the patient and family informed about procedures.  Explain to the patient: - How to use the metered dose inhaler or dry powder and in which order to take inhaled medication. - Avoid exposure to allergen. - How to recognize the early signs of asthma. 23 - How to perform coughing and deep-breathing exercises. Evaluation: If interventions have been effective, the patient will - Learn techniques to make breathing as comfortable as possible. - Be able to cough up secretions and maintain a clear airway. - Be able to manage anxiety symptoms. - Complete activities of daily living (ADLs) or other desired activity without dyspnea. - The patient’s intake should be adequate to maintain a stable weight. - If any of the patient’s goals have not been met, the plan of care should be revised. 24 Unit (2): Nursing management of patients with cardiac disorders: Hypertension Learning Objectives: At the end of this lecture the student will be able to: 1. Define hypertension. 2. Mention etiology and risk factors of hypertension. 3. Mention classification of blood pressure reading. 4. Discuss pathophysiology of hypertension. 5. Describe clinical manifestations and complications of hypertension. 6. Specify diagnostic tests used for hypertension. 7. Discuses management of hypertension. 8. Prioritize the nursing management of the patient with primary hypertension. 25 Hypertension Introduction: Blood pressure (BP) is the force the heart exerts against the walls of arteries as it pumps the blood out to the body. BP is measured using two numbers; the first number, called systolic blood pressure, measures the pressure in blood vessels when heart beats. The second number, called diastolic blood pressure, measures the pressure in blood vessels when the heart rests between beats. Definition: - Hypertension is defined as a systolic blood pressure (SBP) equal or more than 140 mmHg and/or diastolic blood pressure (DBP) equal or more than 90 mmHg based on the mean of 2 or more properly measured seated blood pressure readings on each of 2 or more office visits. Etiology of hypertension: Hypertension can be classified as either primary or secondary. 1- Primary hypertension (essential or idiopathic) is elevated BP without an identified cause, and it accounts for 90% to 95% of all cases of hypertension. The exact cause of primary hypertension is unknown. 2-Secondary hypertension is elevated BP with a specific cause that often can be identified and corrected. This type of hypertension accounts for 5% to 10% of hypertension in adults. Etiology of secondary hypertension; - 1- Diabetes complications (diabetic nephropathy). Diabetes can damage kidneys' filtering system, which can lead to high blood 26 pressure. 2- Renal diseases e.g., (Polycystic kidney disease, glomerular disease, renal artery stenosis). 3- Endocrinal disease e.g., (Cushing syndrome, a pituitary tumor or other factors that cause the adrenal glands to produce too much of the hormone cortisol, thyroid problems e.g., hypothyroidism and hyperthyroidism). 4- Coarctation of the aorta. 5- Sleep apnea. 6- Pregnancy-induced hypertension or pre-eclampsia. 7- Drug-related: estrogen replacement therapy, oral contraceptives, corticosteroids, sympathetic stimulants (e.g., cocaine). Classifications of blood pressure readings: Category SBP (mm Hg) DBP (mm Hg) Normal 90 mm Hg, orthostatic changes in BP and pulse; abnormal heart sounds; laterally displaced, apical pulse; carotid, renal, or femoral bruits; peripheral edema, gastrointestinal; obesity (BMI ≥ 30 kg/m2, neurological; mental status changes and possible diagnostic findings; abnormal serum electrolytes (especially potassium); blood urea nitrogen (BUN), creatinine, glucose, cholesterol, and triglyceride levels; proteinuria, microalbuminuria, microscopic hematuria Nursing Intervention: Nursing diagnosis: - 1- Deficient Knowledge related to unfamiliarity with the need for frequent blood pressure (BP) checks, adherence to antihypertensive therapy, and lifestyle changes. 34 Goal; - Increasing patient’s knowledge. Interventions: - Assess the patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs. - Teach the importance of assessing BP at frequent intervals and adhering to the prescribed medication therapy. - Provide teaching guidelines on the importance of exercise, stress reduction, weight loss (if appropriate), decreased alcohol intake, and a less than 2 g/day sodium diet. Review how to read food labels and choose low sodium foods. Refer to a nutritionist and exercise program, if appropriate. - Teach medication actions, administration times, side effects, adverse effects, and the importance of taking as prescribed. - Teach the importance of seeking medical evaluation if BP reading is greater than 200/100 mm Hg or less than 90/60 mm Hg, or if headache, dizziness, lightheadedness, or blurred vision occurs. 2- Risk for Injury related to syncope and dizziness secondary to side effect of antihypertensive drugs. Goal: Maintaining patient’s safety. Interventions: - Monitor postural changes in BP by assessing client while he or she is lying, sitting, and standing. A 20 mm Hg fall in systolic blood pressure or a 10 mm Hg fall in diastolic blood pressure within 3 minutes of assuming an upright position indicates postural hypotension. 35 - Encourage client to rise slowly from a sitting or lying position. Gradual changes in position provide time for the heart to increase its rate of contraction to re supply oxygen to the brain. - Help client to sit or lie down if he or she is dizzy. The support of a chair or bed reduces the potential for falling. 3- Risk for Decreased Cardiac Output related to excessive or prolonged systemic vascular resistance. Goal: Maintaining adequate cardiac output. - Promote physical rest. Rest decreases BP and reduces the resistance that the heart must overcome to eject blood. - Relieve emotional stress. Reduced stress decreases production of neurotransmitters that constrict peripheral arterioles. - Encourage compliance with salt/sodium restrictions. Doing so decreases blood volume and improves the potential for greater cardiac output. - Recommend smoking cessation. Nicotine raises heart rate, constricts arterioles, and reduces the heart’s ability to ejectblood. - Enforce prescribed fluid restrictions. Reduced oral fluid ultimately decreases circulating blood volume and systemic vascular resistance. - Help client reduce or eliminate caffeine and tobacco. Caffeine and nicotine increase heart rate and causes vasoconstriction. - Administer prescribed antihypertensive. 36 Heart failure Learning Objectives On completion of this chapter, student will be able to: 1. Discuss the pathophysiology and etiology of heart failure. 2. Identify differences between left-sided and right-sided heart failure. 3. Describe the symptoms, diagnosis, and treatment of heart failure. 4. Discuss the nursing management of patient with heart failure. 37 Heart Failure Introduction: - Heart failure (HF) is a common condition associated with significant mortality, morbidity, reduction in quality of life, and health care costs. Nurses play an important role in the care of patients with HF. Well- informed nurses, skilled in the care of patients with HF, make significant contributions to the health and well-being of these patients. Definition: - the inability of the heart to pump sufﬁcient blood to meet the needs of the tissues for oxygen and nutrients; signs and symptoms of pulmonary and systemic congestion may or may not be present. Fig (5): Pathophysiology of HF 38 The pathophysiology of heart failure:- A decrease in cardiac output activates multiple neuro hormonal mechanisms that ultimately result in the signs and symptoms of heart failure. Primary causes of heart failure: - 1. Coronary artery disease, including myocardial infarction. 2. Hypertension, including hypertensive crisis. 3. Rheumatic heart disease. 4. Congenital heart defects (e.g.,ventricular septal defect). 5. Pulmonary hypertension. 6- Cardiomyopathy. 7- Valvular disorders (e.g., mitral stenosis). 8- Myocarditis. Factors That Can Precipitate Heart Failure: - 1- Anemia: - ↓ oxygen (O2)-carrying capacity of the blood stimulating ↑ in cardiac output (CO) to meet tissue demands, leading to increase in cardiac workload and increase in size of left ventricle (LV). 2- Infection e.g. (Rheumatic activity, Chest infection): - ↑ O2 demand of tissues, stimulating ↑CO. 3- Thyrotoxicosis: -Changes the tissue metabolic rate, ↑HR andworkload of the heart. 4- Hypothyroidism: -Indirectly predisposes to ↑atherosclerosis; severe hypothyroidism decreases myocardial contractility. 5- Dysrhythmias (marked tachycardia or bradycardia): - May CO and ↑ workload and O2 requirements of myocardial tissue. 6- Bacterial endocarditis: - Infection: ↑ metabolic demands and O2 requirements. 39 7- Pulmonary embolism: - ↑ pulmonary pressure resulting from obstruction leads to pulmonary hypertension, ↓CO. 8- Nutritional deficiencies: - May ↓cardiac function by ↑myocardial muscle mass and myocardial contractility. 9- Hypervolemia: - Preload causing volume overload on the right ventricle (RV). 10- Physical and emotional stress. 11- Excessive dietary salt. Types of Heart Failure: - HF is usually manifested by biventricular failure, although one ventricle may precede the other in dysfunction. 1- Left-Sided Heart Failure: - Left-sided HF results from left ventricular dysfunction. This prevents normal, forward blood flow and causes blood to back up into the left atrium and pulmonary veins. The increased pulmonary pressure causes fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli. This manifests as pulmonary congestion and edema. 2- Right-Sided Heart Failure: - Right-sided HF occurs when the right ventricle (RV) fails to contract effectively. It causes a backup of blood into the right atrium and venous circulation. Venous congestion in the systemic circulation. Clinical Manifestations of heart failure: -1-Left-Side Heart Failure: - A) Forward (low cardiac output) manifestations: - 40 1. Cerebral: dizziness, blurred vision, anxiety, restlessness, confusion and syncope. 2. Coronaries: angina pain in severe cases. 3. Kidney: Oliguria. However, when the patient is sleeping, the cardiac workload is decreased, improving renal perfusion, which in some patients leads to frequent urination at night (nocturia). 4. Muscles: fatigue and intermittent claudication. 5. Skin: Cold, pale and may be cyanotic extremities. 6. Pulse: weak and thread. 7. Blood pressure: low systolic. B) Backward (pulmonary congestion) manifestations: - 1. Dyspnea; exertional, orthopnea, paroxysmal nocturnal dyspnea. Fluid that accumulates in the dependent extremities during the day may be reabsorbed into the circulating blood volume when the patient lies down. 2. Exertional cough: is initially dry and nonproductive. The cough may become moist over time. Large quantities of frothy sputum, which is sometimes pink (blood-tinged), may be produced, usually indicating severe pulmonary congestion. 3. Recurrent chest infection. 4. Hemoptysis. 5. Hydrothorax may occur. C) Cardiovascular signs: - 1. Tachycardia. 2. Left ventricular enlargement: The apex is shifted down and out. 3. Pulse alternans: Alternating weak and strong beats. 41 2- Right Side Heart Failure: - A) Forward (low cardiac output) manifestations: - as left side. B) Backward (Systemic congestion) manifestations: - 1. Edema of the lower extremities (dependent edema). 2. Anorexia (loss of appetite) and nausea or abdominal pain results from the venous engorgement and venous stasis within the abdominal organs. 3. Congested pulsating neck vein. 4. Hepatomegaly and tenderness in the right upper quadrant of the abdomen result from venous engorgement of the liver. 5. Lately, as hepatic dysfunction progresses, increased pressure within the portal vessels may force ﬂuid into the abdominal cavity, causing ascites. 6. Gastrointestinal distress due to increase pressure on the stomach and intestines caused by ascites. 7. Hydrothorax may occur. 8. weight gain due to retention of ﬂuid. C) Cardiovascular signs: - as left side except right ventricular enlargement instead of left. Complications of heart failure: - 1. Renal failure: decrease cardiac output lead to decrease renal perfusion. 2. Hypokalemia: due to potassium losing diuretics and secondary hyperaldosteronism. 3. Hyponatremia: due to salt restriction, diuretics. 4. Impaired liver functions: The hepatic congestion and decrease 42 arterial blood supply leads to impaired liver function. Eventually liver cells die, fibrosis occurs, and cirrhosis can develop 5. Thromboembolism: due to decrease cardiac output and immobility. 6. Pleural Effusion: It results from increasing pressure in the pleural capillaries. A transudation of fluid occurs from these capillaries into the pleural space. 7. Dysrhythmias: Chronic HF causes enlargement of the chambers of the heart. This enlargement can cause changes in the normal electrical Pathways. Investigations:- 1- Electrocardiogram (ECG): It will show chamber enlargement. (Tachycardia, arrhythmia) and diagnose myocardial infarction and ischemia. 2- Chest X-ray: - will show chamber enlargement and may show pulmonary congestion and pleural effusion. 3- Echocardiography: will show chamber enlargement, may show causes of e.g., valvular lesions. It also can measure ejection fraction to assess contractility. - Cardiac catheterization and angiography. - Laboratory studies usually performed during the initial workup include serum electrolytes, blood urea nitrogen (BUN), and creatinine, thyroid-stimulating Hormone, complete blood cell count, serum B-type natriuretic peptide (BNP), and routine urinalysis. The BNP level is a key diagnostic indicator of HF. 43 Medical management: -1- Nutritional Therapy: 1- A low-sodium (2 to 3 g/day) diet. 2- Avoidance of drinking excessive amounts of ﬂuid is usually recommended. 3- Examine labels to determine sodium content. 4- Examine the label of over-the-counter drugs such as laxatives, coughmedicines, and antacids for sodium content. 5- Avoid using salt when preparing foods or adding salt to foods. 6- Eat smaller, more frequent meals. 2- Pharmacologic Therapy: - a. Angiotensin-Converting Enzyme (ACE) Inhibitors. b. Angiotensin II Receptor Blockers. c. Beta-Blockers. d. Diuretics: Loop diuretics, Thiazide diuretics, Potassium-sparing diuretics. e. Positive Inotropes e.g., Digitalis digoxin (Lanoxin): - It increases the force of myocardial contraction and slows conduction through the atrio ventricular node. It improves contractility, increasing left ventricular output, which also enhances diuresis. Digoxin Toxicity: - signs and symptoms Anorexia, nausea, vomiting, fatigue, depression, and malaise (early effects of digitalis toxicity).Changes in heart rate or rhythm; onset of irregular rhythm. Nursing considerations and actions: 1. Assess the patient’s clinical response to digoxin therapy by 44 evaluating relief of symptoms such as dyspnea, orthopnea, crackles, hepatomegaly, and peripheral edema. 2. Monitor the patient for factors that increase the risk of toxicity: Decreased potassium level (hypokalemia), which may be caused by diuretics. Hypokalemia increases the action of digoxin and predisposes patients to digoxin toxicity and dysrhythmias. Impaired renal function, particularly in patients age 65 and older. Because digoxin is eliminated by the kidneys, renal function (serum creatinine) is monitored and doses of digoxin are adjusted accordingly. 3. Before administering digoxin, it is standard nursing practice to assess apical heart rate. When the heart rate is less than 60 bm, or the rhythm becomes regular, the nurse may withhold the medication and notify the physician. 4. Monitor for neurologic side effects: headache, malaise, nightmares, forgetfulness, social withdrawal, depression, agitation, confusion, hallucinations, decreased visual acuity, yellow or green halo around objects. f. Vasodilators e.g., nitroglycerin. g. Morphine. It dilates both the pulmonary and systemic blood vessels. h. Other Medications: Anticoagulants: may be prescribed, especially if the patient has a history of atrial ﬁbrillation or a thromboembolic even, medications that manage hyperlipidemia (e.g, statins) , antidysrhythmic drugs to prevent or treatment dysrhythmias. 45 Additional Therapy: 1- Supplemental Oxygen Oxygen therapy may become necessary as HF progresses. The need is based on the degree of pulmonary congestion and resulting hypoxia. Some patients require supplemental oxygen only during periods of activity. 2- Other Interventions A number of procedures and surgical approaches may beneﬁt patients with HF. If the patient has underlying coronary artery disease, coronary artery revascularization with percutaneous coronary intervention or coronary artery bypass surgery may be considered. In patients with severe left ventricular dysfunction and the possibility of life- threatening dysrhythmias, placement of an implantable cardioverter deﬁbrillator (ICD) can prevent sudden cardiac death and extend survival. -Cardiac Resynchronization Therapy: - It is used primarily for clients whose heart failure is caused by dilated cardiomyopathy. - Intra-Aortic Balloon Pump - Cardiac transplantation is the only option for long-term survival. Nursing management: Assessment: - A- Subjective Data: Respiratory system, Cardiovascular, Fluid retention, GIT ,Neurological, Medications, Knowledge of Condition, and Coping Skills. B- Objective Data: Integumentary: Cool, diaphoretic skin; cyanosis or pallor; 46 peripheral edema (right-sided heart failure). Respiratory: Tachypnea, crackles, wheezes; frothy,blood-tinged sputum. Cardiovascular: Tachycardia, S3, S4, murmurs; pulsus alternans, jugular venous distention. Gastrointestinal: Abdominal distention, hepato- splenomegaly, ascites. Neurologic: Restlessness, confusion, decreased attention or memory Possible Diagnostic Findings: Altered serum electrolytes (especially Na+ and K+), ↑BUN, and creatinine. Impaired liver function tests; ↑BNP; chest x-ray demonstrating cardiomegaly, echocardiogram showing increased chamber size decreased wall motion, decreased EF or normal EF with evidence of diastolic failure, ECG; ↓ O2 saturation. Nursing diagnosis: - 1- Decreased Cardiac Output related to ineffective ventricular contraction, tachycardia, reduced stroke volume, hypertension. Expected Outcome: Client will have increased cardiac output as evidenced by heart rate between 60 to 100 beats/minute, urinary output between 1500 to 3000 mL/day, systolic BP below 120 mm Hg, diastolic BP below 80 mm Hg, and no mental confusion. Intervention: 1- Assess apical heart rate before administering a cardiac glycoside (digitalis) or other drug that slows heart rate. Withhold a cardiac glycoside until the physician is consulted when the heart rate is less than 60 or more than 120 beats/minute. 47 2- Administer prescribed medications such as cardiac glycosides (digitalis), diuretics, and antihypertensive. 3- Promote rest. It decreases metabolic needs of the body and work of the heart. 4- Continuously monitor cardiac rhythm to detect dysrhythmias. 2- Risk for Impaired Gas Exchange related to pulmonary congestion secondary to left ventricular dysfunction. Expected Outcome: Client will maintain adequate gas exchange as evidenced by clear lung sounds, decreased work of breathing, pulse oximeter reading above 90%, partial pressure of arterial oxygen (PaO2) between 80- and 100-mm Hg, partial pressure of arterial CO2 (PaCO2) between 35- and 45-mm Hg, and blood pH between 7.35 and 7.45. Intervention: - 1- Maintain client in a high Fowler’s or semi-Fowler. Elevating the upper body maximizes lung expansion by decreasing pressure on the diaphragm. 2- Administer supplemental oxygen therapy. 3- Avoid gas-forming foods. Gas that accumulates in the intestine increases the volume in the abdominal cavity. Expansion of the intestine can crowd the diaphragm and interfere with inspired volumes of air. 4- Offer small, frequent feedings. Preventing stomach distention increases the space in the thoracic cavity for lung expansion. 5- Limit physical activity. Activity requires increased oxygen for cellular metabolism. 48 3- Excess Fluid Volume related to reduced renal function secondary to increased antidiuretic hormone and aldosterone production and reduced cardiac output. Expected Outcome: Fluid volume will be reduced as evidenced by reduced weight and peripheral edema, normal BP measurements, increased urine output. Interventions: - 1- Monitor for edema, weight gain, jugular venous distention (JVD), lung crackles. 2- Monitor intake and output (I&O). 3- Administer prescribed diuretic. Diuretics promote the excretion of sodium and water. 4- Provide sodium-restricted diet as prescribed. 5- Maintain fluid restriction as ordered 4- Activity Intolerance related to hypoxemia secondary to decreased cardiac output. Expected Outcome: The patient will show increased activity tolerance. Interventions: - 1- Provide rest and space activities. 2- Keep personal items within easy reach. Reduced exertion decreases oxygen expenditure. 3- Teach use of assistive devices and lifestyle changes. 4- Assist as needed with activities of daily living (ADLs). 49 Rheumatic fever Learning objectives: At the end of this lecture the student will be able to:  Define rheumatic fever.  Describe pathophysiology of rheumatic fever  Mention predisposing factors for rheumatic fever.  List clinical manifestations fever  List diagnostic criteria of rheumatic fever.  Describe the medical and nursing management of the patient with rheumatic fever. 50 Definition: - Rheumatic fever (RF) is an acute inflammatory disease of the heart potentially involving all layers (endo cardium, myocardium, and pericardium). Rheumatic heart disease is a chronic condition resulting from RF that is characterized by scarring and deformity of the heart valves. Patho physiology: - RF is the result of an auto immunological sequel to a virulent Streptococcus pyogenes infection in a patient who was immunologic ally sensitized from prior infection. During a streptococcal infection activated antigen-presenting cells such as macrophages, present the bacterial antigen to helper T cells. Helper T cells subsequently activate B cells and induce the production of antibodies against the cell wall of streptococcus. The antibodies may act against the myocardium and joints, producing the symptoms of rheumatic fever. Predisposing factors: 1- Age: 5 - 15 years, (it is rare below age of 4 years or more than 25 years. 2- Low socioeconomic status. 3- Overcrowding. Clinical Manifestations: - The presence of two major criteria or one major and two minor criteria plus evidence of a preceding group A streptococcal infection indicate a high probability of RF. 51 A) Major Criteria: - 1- Carditis is the most important manifestation of RF. 2- Mono arthritis or poly arthritis: - is the most common finding in RF. The inflammatory process affects the synovial membranes of the joints, causing swelling, heat, redness, tenderness, and limitation of motion. The larger joints particularly the knees, ankles, elbows, and wrists, are most frequently affected. 3- Sydenham’s chorea: - is the major CNS manifestation of RF. It is often a delayed sign occurring several months after the initial infection. It is characterized by involuntary movements, especially of the face and limbs; muscle weakness; and disturbances of speech and gait. 4- Erythema marginatum: - lesions are a less common feature of RF. The bright pink, non-pruritic, map like macular lesions occur mainly on the trunk and proximal extremities, and may be exacerbated by heat (e.g., warm bath). 5- Subcutaneous nodules; -, usually associated with severe carditis, are firm, small, hard, painless swellings located over extensor surfaces of joints, particularly the knees, wrists, and elbows. B) Minor Criteria: - Clinical findings: Fever, polyarthralgia Laboratory findings: ↑ ESR, ↑ WBC count, ↑ CRP ECG findings: Prolonged PR interval C) Evidence of Group A Streptococcal Infection: - 52 Laboratory findings: ↑ Antistreptolysin-O titer, positive throat culture, positive rapid antigen test for group A streptococci. Complication of rheumatic fever: - Serious heart damage can occur. This may include: -1- Abnormal heart rhythms (arrhythmias). 2- Damage to the heart valves (mitral stenosis or aortic stenosis). 3- Inflammation of the heart tissues (endocarditis or pericarditis). 4- Heart failure. Diagnostic tests: - - Throat culture (identifies streptococcal infection). - Antistreptolysin O titer level greater than 250 IU/mL. - Elevated ESR and WBC. - Chest x-ray. - Echocardiogram. - Electrocardiogram. Medical management: - a-General measures: - Rest till -- S&S, - ESR, - CRP, Diet-- Carbohydrate, salt, also avoid heavy meals. b-Prophylaxis of rheumatic fever: - a. Primary prevention: Proper hygiene, avoidance of overcrowding, good nutrition to' prevent streptococcal throat infection. Early detection and treatment of streptococcal throat infection. 53 b. Secondary Prevention: Long acting penicillin till age 25 years or for 5 years after the last attack in adults. Recurrences are more common when cardiac lesion is present and if so, prophylaxis may be required until age 30 years or for life?. c- Active treatment: - 1. Penicillins: (to eliminate any residual streptococcal infection) 2. Salicylates (e.g.Aspirin). 3. Steroids Nursing management: -A- Subjective Data: - Important Health Information: Past health history: Recent streptococcal infection, previous history of rheumatic fever or rheumatic heart disease. Functional Health Patterns: Health perception–health management : Family history of rheumatic fever; malaise, Nutritional-metabolic: Anorexia, weight loss, Activity-exercise: Palpitations; generalized weakness, fatigue; ataxia, Cognitive- Perceptual: Chest pain; widespread joint pain and tenderness (especially large joints). B- Objective Data: -General: Fever Integumentary: Subcutaneous nodules and erythema marginatum. Cardiovascular: Tachycardia, pericardial friction rub, muffled heart sounds; murmurs; peripheral edema. Neurologic: Chorea (involuntary, , rapid motions; facial grimaces) 54 Musculoskeletal: Signs of mono arthritis or poly arthritis, including swelling, heat, redness, limitation of motion (especially of knees, ankles, elbows, shoulders, wrists). Possible Diagnostic Findings: - Cardiomegaly on chest x-ray; prolonged PR interval on ECG; valve abnormalities, chamber dilation, and pericardial effusion on echocardiogram; ↑ antistreptolysin-O titer, positive throat culture, positive rapid antigen test for group A streptococci; ↑ ESR, ↑ CRP, leukocytosis. Nursing diagnosis: - Decreased cardiac output related to impaired valvular function or heart failure. Goal: - Patient has adequate cardiac output as evidenced by vital signs within normal limits, no dyspnea or fatigue. Nursing intervention: - 1-Assess vital signs, murmurs, dyspnea, and fatigue. 2- Give oxygen as ordered. 3- Provide rest as ordered. 4- Elevate head of bed 45 degrees. Nursing diagnosis: - Activity intolerance related to arthralgia or arthritis secondary to joint pain, pain from pericarditis, and HF. Goal: Patient will state less fatigue in response to activity. 55 Nursing intervention: 1- Assess patient’s preferred activities and hobbies. 2-Plan patient’s schedule around relaxing and fun activities 3-Use pet therapy. 4-Provide a mix of physical, mental, and social activities on a rotating schedule. 5- Encourage adequate nutrition, including source of iron from food and supplements. Nursing diagnosis: - Acute and chronic pain related to inflammation and increased disease activity, tissue damage. Goal: Relieve pain Nursing intervention: 1- Provide variety of comfort measures: - a. Massage, position changes, rest. b. Foam mattress, supportive pillow, splints. c. Relaxation techniques, diversional activities. 2. Administer anti-inflammatory, analgesic, and slow- ant rheumatic medications as prescribed. 3. Individualize medication schedule to meet patient’s need for pain management. 4. Encourage verbalization of feelings about pain and chronicity of disease. 56 Unit (3): Nursing management of patient with gastrointestinal disorder Peptic ulcer Learning objectives: At the end of this lecture the student will be able to: 1- Define peptic ulcer. 2- Describe the etiology and incidence of peptic ulcer. 3- Discuss pathophysiology of peptic ulcer. 4- List the clinical manifestations of peptic ulcer. 5- Describe the diagnostic evaluation of peptic ulcer. 6- Discuss the general management of peptic ulcer. 7- Discuss the surgical intervention of peptic ulcer. 8- Discuss the nursing process for patient with peptic ulcer. 57 Definition: A peptic ulcer is an excavation formed in the mucosal wall of the stomach, the pylorus, the duodenum or the lower end of the esophagus. - Peptic ulcer tends to be loss in an area of the GI tract that is in contact with hydrochloric acid and pepsin. - On the physiologic function the stomach is divided into two main portions as: The proximal two third, the fundus gland area which acts as a receptacle for ingested food and secrete acid and pepsin. Also, the distal third, the pyloric gland area which mixes and propels food into the duodenum and produces the hormone gastrin. - Peptic ulcer sites are common inflammatory sites in the previous. Fig (6) Layers of the stomach Etiology and incidence: - Gram-negative bacteria (H. pyloric), is present in the gastric or duodenal mucosa of 80%-90% of patient with PUD. 58 - Increase incidence with family history with PUD. - Incidence in men is two increased than in but equal after menopause. Predisposing factors: 1- Stress or anger. 2- Familial tendency. 3- The persons with blood type O and more susceptible than persons with blood type A, B, or AB. 4- Chronic use of non-steroidal anti-inflammatory drugs, alcohol ingestion and excessive smoking. 5- Bacterial infection with agents as H. pyloric. 6- Also, peptic ulcers accrue due to amount of hormone gastrein produced by tumors. 7- Zollinger-Ellison syndrome (gastrinoma): is suspected when a patient presents with several peptic ulcers that resistant to slandered medication therapy. Pathophysiology of peptic ulcer: - Peptic ulcer diseases (PUD) occurs when the normal balance between factors that promote mucosal injury (gastric acid, pepsin, bile acid, ingested substances) and factors that protect the mucosa (intact epithelium, mucus, and bicarbonate secretion) is disrupted. - Ulcers develop when there is prolonged hyperacidity or chronic reduction in mucus. Once gastric acid has penetrated the mucosal layer, the acid begins to digest the stomach wall. - Histamine released from the injured cells, aggravates the condition by triggering hyper secretion of more hydrochloric acid and pepsin. 59 - The body responds with the inflammatory process in which the mucosa swells and easily bleeds. - Unless the process is controlled the erosion can lead to an obstruction from scar formation or penetrate the entire thickness of the stomach wall, spilling gastric contents into the peritoneal cavity. - Chronic gastric inflammation inhibits the production of intrinsic factors leading to poor absorption of vitamin B12 and high risk for Pernicious anemia. Fig (7): Peptic ulcer areas Clinical manifestations of peptic ulcer: 1-Pain burning sensation in the mid-epigastrium or in the back occurs due to acid content of the stomach and duodenum. 2-Pyrosis (Heartburn) some patients experience a burning sensation in the esophagus and stomach, which moves to the mouth. 3-Vomiting may be a symptom of peptic ulcer it is due to obstruction of the gastric outlet. 4- Constipation or diarrhea. 5- Hemorrhage, haematemesis or melena. 6- Weight loss. 60 Diagnostic evaluation of peptic ulcer: 1- Assess signs and symptoms on (pain epigastric tenderness or abdominal distention, bowel sounds may be absent). 2- Endoscopy: upper gastrointestinal endoscopy is used to identify inflammatory changes, ulcers and lesions. Through endoscopy the mucus can directly visualized and a biopsy obtained. 3- Gastric secretory studies to diagnosis a chlorhydria (the absence of hydrochloric acid in gastric juice). Comparison between gastric and duodenal ulcer: Comparison Duodenal ulcer Gastric ulcer Incidence Age (30-60 years). Usually 50 and over Male: female 3-1 occurs moreMale: female 2:1 frequently than gastric ulcer. Signs and -Hyper secretion of -Normal secretion of symptoms stomach acid and weight stomach acid and weight loss may occur. gain. -Pain occurs 1/2 to in -Pain occurs 2-3 hours our after a meal, rarely after a meal. occurs at night, may -Ingestion of food relieves be relieved by pain. vomiting. -Vomiting is uncommon. -Ingestion of food -Melena more common does not help relieves than hematemesis. pain. -Vomiting common. -Haematemes is more common than melena. 61 Malignancy Rare Occasionally possibility Risk factors Blood group o, chronic Gastritis, alcohol, renal failure, alcohol, smoking and stress. smoking and stress General management of peptic ulcer: 1- Stress reduction and rest. 2- Stop smoking. 3- Dietary modification. 4- Medication. Specific pharmacotherapy: - Most of clients with PUD, have H.pylori thus, the goals of treatment are to eradication of the bacteria, reduce the acid levels and promote healing, as the following: 1- Antibiotics: most common antibiotics are amoxicillin and clarithromycin. 2- Amebicides: metronidazole (flagyl) assists in eradication of bacteria. 3- Histamine2- receptor (H2) antagonists: ranitisine (zantac). Which block H2 receptors and decrease hydrochloric acid secretion so relieving pain. 4- Antacids: to neutralize existing stomach acid. 5- Proton pump inhibitors: which block the final step in acid production at the surface of parietal cells and promote healing as omeprazole, lansoprazole. 6- Cytoprotective agents: as carafate which forms a seal over the ulcer. Protecting it from irritation or cytotec which is synthetic prostaglandin used to sustain the mucosal layer especially among client who require 62 large doeses or longoterm treatment with aspirin or NSAIDs. Dietary measures; 1- Well-balanced diet, high fiber content, meals at regular intervals (6 meals/day). 2- Avoid caffeine, colas and alcohol. 3- Avoid smoking which decrease healing and increase recurrence. Surgery indicated: In emergency situations for uncontrolled bleeding or bleeding that developed despite chronic drug maintenance therapy. 1- Vagotomy: cutting of vagus nerve to eliminate the stimulus that triggers gastric acid secretion by the gastric cells, can choose to cut all or portions. 2- Subtotal gastrectomy: a- The resected portion includes a small cuff of the duodenum, pylorus and from two thirds to three quarters of the stomach. b- The duodenum or side of the jejunum is anastomosed to the remaining portion of the stomach. Fig (8): Subtotal gastrectomy 63 3- Total gastrectomy: esophagus is anastomosed to jejunum. Fig(9): Total gastrectomy Complications of peptic ulcer: 1- GI hemorrhage. 2- Ulcer perforation. 3- Gastric outlet obstruction. Post-operative complications: 1- Dumping syndrome: - The term used for a group of unpleased vasomotor and gastrointestinal symptoms includes reducing the reservoir capacity of the stomach, associated with meal having a hyperosmolar composition. - Occur after gastric surgery in approximately one third to one half of patients. - The stomach no longer has control over the amount of gastric chime entering the small intestine. 64 Consequently: - A large bolus of a hypertonic fluid enters the intestine and result in fluid being drawn into the bowel lumen; this creates a decrease in plasma volume. - Distension of the bowel lumen (as a result of this bowel shift) which stimulate intestinal motility and the urge to defecate. - The onset of symptoms occurs at the end of the meal or within 15-30 min after eating, lasts for no longer than an hour after meals. The patient usually describes: - Feeling of generalized weakness, sweating, palpations, tachycardia and dizziness (these symptoms attributed to the sudden decreases in plasma volume) - Abdominal cramp, borborygmi and the urge to defecate. 2- Postprandial hypoglycemia: - As a bolus of fluid high in carbohydrate get into the small intestine results in hyperglycemia and the release of excessive amounts of insulin into the circulation. - A secondary hypoglycemia then occurs 2 hours after meals. - The immediate ingestion of sugared fluid or candy relieves the hypoglycemic symptoms. - To avoid similar occurrence: the patient should be instructed to limit the amount of sugar consumed with each meal, and to eat small frequent meals with moderate amount of proteins and fat. 65 Nursing process for patient with peptic ulcer: Assessment: - History: Ask patient to describe the pain and the methods used to relieve it (food, antacids). - Ask about: any bloody stools. - Assess the patient smoke cigarettes. - Assess the patient level of tension or nervousness. - Assess the patient occupational stress or are there problems within the family history of ulcer disease. - Vital signs are assessed for indicators of anemia. - The stool is examined for occult blood. - A physical examination is performed and the abdomen is palpated for localized tenderness. Nursing Diagnoses: 1- Pain related to the effect of gastric acid secretion on damaged tissue Goal: Relief of pain. Nursing interventions: 1- Administer medication therapy as prescribed as (histamine antagonists, antibiotics). 2- Advise patient to avoid foods that are irritating to the stomach as caffeine and alcohol. 3- Advise patient to space meals and snacks at regular interval help to neutral at regular help to neutralize the acidity of gastric secretions. 4- Advise patient to stop smoking 66 Expected outcome: experiences less pain. 2- Knowledge deficit regarding the preventing of symptoms and management of the condition. Goal: Acquisition of knowledge about prevention and management. Nursing interventions: 1- Assess the patient's level of knowledge and readiness to learn. 2- Teach necessary information. 3- Reassure the patient that the disease can be managed. 3- Anxiety related to nature of the disease and the long- term management. Goal: Reduction of anxiety. Nursing intervention: 1- Encourage the patient to express concerns and fear and ask question as needed help to reduce anxiety. 2- Explain the reasons for adhering to plan treatment schedule. 3- Assist the patient to identify situation producing anxiety. 4- Teach stress management strategies. 4- Altered nutrition to pain associated with eating. Goal: Attainment a fan optimal level of nutrition. Nursing intervention: 1- Recommended nonirritating foods. 2- Suggest that meals bedtime at regularly scheduled time: avoid smacks before bedtime. 3- Encourage eating meals in a relaxed atmosphere. 67 Ulcerative colitis Learning objectives: At the end of the lecture the student will be able to: 1- Define ulcerative colitis. 2- List the etiology of ulcerative colitis. 3- Discuss path physiology of ulcerative colitis. 4- List clinical manifestations of ulcerative colitis. 5- Identify the diagnostic evaluation for ulcerative colitis. 6- List complications of ulcerative colitis. 7- Identify the management of ulcerative colitis. 8- Describe and apply the nursing management for ulcerative colitis. 68 Ulcerative colitis Definition: It is chronic idiopathic inflammatory disease characterized by diffuse friability and ulceration without skip areas in the mucosal and submucosal layers of the colon and rectum. - Usually affect lower 1/3 of the large intestine, rectum and anus. - The deferent between ulcerative colitis and corhn's disease that the last ulceration affects all the GIT. Fig (10) Ulcerative colitis and corhn's disease Etiology and incidence: - The disease is most common in young and middle-aged adults but can occur at any age. The exact cause is unknown, but multiple factors trigger the disease as: - Genetic predisposition, infection, allergy and abnormal immune response. 69 Clinical picture: the onset of the disease usually is abrupt. 1- Severe diarrhea and expel blood and mucus along with fecal matter. 2- Intermittent rectal bleeding (the bleeding may be mild or severe). 3- Anorexia, weight loss. 4- Fever, vomiting and dehydration. 5- Cramping and abdominal pain in the lower left quadrant (LLQ) accompany diarrhea 6- Intermittent tenesmus [the feeling of an urgent need to defecate (the patient may report passing 10-20 liquid stools/day)]. 7- Hypocalcaemia and anemia. 8- Skin lesions. 9- Eye lesion, joint abnormalities arthritis as (ankylosing spondylitis) and liver diseases. Complications: 1- Colon dilates and atonic (lacks motility). 2- Perforation fistula and abscess formation 3- Peritonitis, bleeding and septicemia. Diagnostic evaluation: 1- Stool examination and CBC. 2- Proctosigmoidoscopy or colonoscopy with biopsy. 3- Barium enema X-ray. Medical management: 1- Diet management: - High-protein, high calorie diet with supplemental vitamin therapy and iron replacements. - Correction of fluid and electrolyte by intravenous therapy as necessary. 70 - Cold foods are avoided, along with smoking to not increase intestinal motility. 2- Pharmacotherapy management: - Sedative and Antidiarrheal. - Antiperistatic medication is used to decrease peristalsis to a minimum to rest the inflamed bowel as opiate-related antidiarrheal. - Anti-inflammatory: Acetylsalicylic acid - Antibiotics. - Parenteral adrenocorticotrophic and corticosteroids treat inflammatory bowel disease by inhibit inflammatory immune response - Immune-modulating agents. - Nursing management for the patient with ulcerative colitis: Nursing assessment: - Take a health history to identify the onset, duration and characteristics of abdominal pain, the presence of diarrhea or fecal urgency and tenseness, nausea, anorexia or weight loss. - Family history of inflammatory bowel disease. - Diet history about amount of alcohol, caffeine and nicotine used daily and weekly. - Assess bowel elimination ask about stool characterized as present pus, fat or mucus. - Ask about allergies and food intolerance especially milk intolerance. - Identify the patients sleep pattern disturbance when present diarrhea or pain at night. - Auscultate the abdomen for bowel sounds and their characteristics. - Palpate the abdomen for distention, tenderness or pain. 71 - Inspect the skin of the abdomen for evidence of fistula tracts or symptoms of dehydration. Nursing diagnoses: 1- Diarrhea related to inflammatory process. Goal: attainment of normal bowel elimination patterns. Nursing intervention: - Activity as well as the frequency of bowel movements and the identified precipitating factors as emotional stress, certain food and character, consistency and amount of stool passed. - Give antidiarrheal medications as prescribed. - Encouraged bed rest to decrease peristalsis. 2- Pain related to peristalsis and GI inflammation. Goal: relief of abdominal pain and cramping. Nursing intervention: - Identify the character of pain is described as dull, burning or cramp. - Ask about pain occur after or before meals or during the night or before elimination. - Give anticholinergic medication as prescribed 30 min before to decrease intestinal motility. - Local application of heat. 3- Anxiety related to impending surgery. Goal: reducing anxiety. Nursing intervention: - Ask patient questions to express feelings. - Help patient to understand this condition. 72 - Give medication as prescribed. - Ask patient to use relaxation technique. 4- Altered nutrition, less than body requirements related to dietary restrictions, nausea and mal absorption. Goal: reducing anxiety. Nursing intervention: - Ask patient questions to express feeling: - Help patient to understand this condition. - Give medication as prescribed. - Ask patient to use relaxation technique. 5- Altered nutrition, less than body requirements related to dietary restrictions, nausea and mal absorption. Goal: maintaining optimal nutrition. Nursing intervention: - Provide parenteral nutrition used when disease is severe. - Make chart of intake and output as well as the patient's daily weight. - The blood glucose is monitored every 6 hours. - Feeding high in protein and low in fat. - Observe any signs of intolerance as nausea, vomiting, diarrhea or abdominal distention. - Restricted activities to conserve energy. 6- Fluid volume deficit related to anorexia, nausea and diarrhea. Goal: maintaining fluid intake and balance. 73 Nursing intervention: - Chart of intake and output. - Monitored daily weight. - Assess patient for fluid volume deficit (dehydration) dry skin and mucous membranes decreased skin turgor, oliguria, exhaustion, decreased temperature, haematocrit and hypotension. Potential complications: 1- Electrolyte imbalance. 2- Perforation of the bowel. 3- GI bleeding with fluid volume loss. 4- Cardiac dysarrhythmia related to electrolyte depletion. Nursing management for potential complication: - Monitored serum electrolyte level. - Assess any change in the level of consciousness. - Give electrolyte replacement as prescribed. - Monitored any rectal bleeding. - Take vital signs especially BP. - Administer vitamin K. - Observe signs of perforation as in abdominal pain, rigid abdomen, vomiting or hypotension. - Observe any signs of toxic mega colon as abdominal distention, fever, and tachycardia and electrolyte imbalance. 74 Liver cirrhosis Learning objectives: At the end of the lecture, the student will able to: 1-Define liver cirrhosis. 2-The effect of liver disease. 3- Incidence. 4-List the types of liver cirrhosis. 5-Discuss pathophysiology of liver cirrhosis. 6-List clinical manifestations of liver cirrhosis. 7-Identify the diagnostic evaluation of liver cirrhosis 8- Describe the progress of liver cirrhosis. 9- List complications of liver cirrhosis. 10- Identify the medical management of liver cirrhosis. 11- Describe and apply the nursing management for liver cirrhosis. 75 Liver cirrhosis Definition: Chronic progressive disease characterized by degeneration and destruction of liver cells which replaced the normal tissue with diffuse fibrosis that disrupts the structure and function of the liver. Incidence: It affects people between 40-60 years, more common in men than in women. It may be related to excessive alcohol intake. Pathophysiology: - Once liver cells are irreversibly damaged, nonfunctional fibrous connective scar tissue replaces them, which leads to: - Distortion and partial or complete occlusion of blood channels in the liver and the liver becomes unable to carry out its many functions which lead to: - Disturbance in digestion and metabolism, defects in blood coagulation, fluid and electrolyte imbalances and impaired ability to metabolize hormones and detoxify chemicals. - Fat malabsorption and inability to absorb fat soluble vitamins due to bile begins to drain into the intestine. Fig (11): Liver cirrhosis 76 Types of cirrhosis: Liver cirrhosis 1- Lannec's cirrhosis: which caused by - Nutritional deficiencies. - Exposure to alcohol. - Exposure to toxins. - The liver enlarges (knobby) than shrinking, it can be reversed if the case is corrected early. 2- Post necrotic cirrhosis: which caused by - Destruction of the liver cells secondary to infection as hepatitis. - Metabolic liver disease related to massive liver cell necrosis. - Exposure to hepatotoxins or industrial chemicals. - Genetic (haemochromatosis α 1, antitrypsin deficiency Wilson's disease) - Cryptogenic (unknown) 3- Biliary cirrhosis: called obstructive or idiopathic cirrhosis. - Because usually is related to chronic biliary obstruction and infection in which scarring occurs around the bile ducts (cystic fibrosis). - Primary biliary cirrhosis refers to a progressive autoimmune disease of the liver. Clinical manifestation 1- Mild symptoms (compensated) as: - Intermittent mild fever. - Vascular spiders. - Palmar erythema (reddened palms). 77 - Unexplained epistaxis. - Ankle edema. - Vague morning indigestion. - Flatulent dyspepsia. - Abdominal pain. - Firm, enlarged liver, splenomegaly. Diagnostic evaluation: - Blood studies usually show: increased level of bilirubin, increased enzyme level of SGOT, SGPT and GGT, low RBC count with cells appear large, decreased leukocytes and thrombocytes, low fibrinogen level, prolonged PT, decreased platelet count, low serum albumin level, increased globulin level and hypokalemia. - Ultrasound scanning. - CT scan, MRI and radio isotopic liver scans. - Arterial blood gases. Progress of disease: 1- GIT disturbances: anorexia, vomiting, diarrhea or constipation, flatulence and dyspepsia. This is due to impaired of carbohydrate, fat, and protein metabolism. 2- Bulged dilate veins in the esophagus (esophageal varices) and in the rectum (hemorrhoids). 3- Visible prominent veins in the abdomen. 4- Hematological disorders in the form of: a- Anemia, leucko-cytopenia, thrombocytopenia caused: - Splenomegaly which result from back up of blood from the portal vein into the spleen. 78 - Over activity of the enlarged spleen result in increased removal of blood cells from circulation. - Inadequate red blood cells production and survival. - Poor diet, poor absorption of folic acid and bleeding from varices. b- Coagulation problems result from the liver's inability to produce prothrombin and other factors essential for blood clot. c- The patient becomes easily tried and more liable to get infection, they may bleed extensively from minor trauma as epistaxis. Late signs and symptoms (decompensated): - Ascites, jaundice, weakness. - Muscle wasting, weight loss, continuous mild fever. - Clubbing of fingers. - Purpura, spontaneous bruising. - Epistaxis, hypotension, sparse body hair. - White nails, gonadal atrophy (in men: gynecomastis, impotence, testicular atrophy. In women: amenorrhea). - Confusion and disturbance in conscious level due to accumulation of ammonia. - Skin lesions: as spider angiomas or spider nevi which are small dilated blood vessels with a bright-red center point and spider-like branches in the nose, cheeks, upper trunk, neck and shoulders. - Dilated abdominal veins called caput medusa. - Peripheral neuropathy due to vit. B12 and folic acid deficiencies. Complications: 1- Portal hypertension: 79 The diseased liver changes obstruct the flow of incoming blood to back up in the portal system. It causes collateral vessels to develop (in an attempt to reduce this high pressure, reduce plasma volume and lymphatic flow) in the esophagus, anterior abdominal wall and rectum. Fig (12): Portal hypertension 2- Peripheral edema: result from: 1- Decreased colloidal osmotic pressure from impaired liver synthesis of albumin. 2- Increase porto caval pressure from portal hypertension. 3- Esophageal varices: They are distended, engorged tortuous vessels in the esophagus. They are fragile and bleed easily. 80 Fig (13): Esophageal varices 4- Ascites: It is an accumulation of fluid in the peritoneal cavity. Fig (14): Ascites 1- Liver Encephalopathy (liver coma): Inability of the liver to toxify ammonia leads to accumulation of ammonia in the blood. 6- Hepatorenal syndrome: it is renal failure to the cirrhotic patient with advanced azotemia, and oliguria. 81 Medical management for patient with liver cirrhosis: Goals: 1- To limit deterioration of the liver function. 2- To prevent complications. 3- To promote rest for liver regeneration. Drug therapy: 1- Collaborative care: a- Bed rest: is significant in reducing metabolic demands of the liver and allowing for recovery of liver cells. b- Diet characteristics must be: - High in carbohydrate (with controlled blood sugar level), vitamins. - Moderate protein if ammonia level is normal. - Restricted protein if ammonia level is high. - Small frequent semisolid liquid meals to prevent anorexia. - Give supplement iron and vitamins. - Intravenous fluid to correct fluid and electrolyte imbalance. - Restrict water and sodium in case of fluid retention. - Anemia may require blood transfusion. Management for ascites: 1- Maintain blood volume. 2- Increase urinary output with diuretic therapy, plasma or IV albumin. If it is not responding with drugs fluid can be removed by paracentesis as the following: Paracentesis: it is the removal of ascetic fluid from the peritoneal cavity. 82 Side effects: 1- Remove essential proteins and electrolytes. 2- Potential entry of pathogens. Management of Encephalopathy: Definition: it is result from accumulation of ammonia and other toxic metabolites in the blood. Management: The goal of management is the reduction of ammonia formation this consists of: 1- Protein restriction (determined by the degree of mental changes). 2- Reduction of ammonia formation from the intestines by: a- Sterilization of the intestines with antibiotics as neomycin sulfate orally or rectally 1-4gm/ 6hours. This reduces the bacterial flora of the colon, bacterial action on protein in the feces results in ammonia production. b- Enemas by Mg sulfate 3 times /day can also be used to decrease bacterial action. c- Constipation should be prevented. d- Lactulose (15-30ml/8hours orally) the dose increased gradually until the bowel are moving twice daily. It is frequently the preferred drug rather than neomycin because it causes renal toxicity and hearing impairments. Management of esophageal varices: When esophageal varices bleeding occurs: 1- Stabilize the patient and manage air way. 83 2- The IV therapy is initiated and may include blood product (fresh frozen plasma and packed RBCs). 3- Vit. K supplementation. 4- Iced saline gastric lavage to remove blood from the GI tract, to produce vasoconstriction of the esophageal and gastric blood vessels, and to enhance visualization for Endoscopic. 5- Intravenous administration of vasopressin to produce vasoconstriction. Line of treatment: 1- Endoscopic sclerotherapy. 2- Surgical legation (esophageal banding therapy). 3- Esophageal gastric balloon tube. Fig (15): Endoscopic sclerotherapy 84 Complications: includes esophageal ulceration, stricture and perforation. Fig (16): Variceal band ligation Fig (17): Esophageal gastric balloon tube 85 Assessment and Management of Patients with Endocrine Disorders Learning objectives: On completion of this chapter, the student will be able to: 1. Describe the functions of each of the endocrine glands and their hormones. 2. Identify the diagnostic tests used to determine alterations in function of each of the endocrine glands. 3. Compare hypothyroidism and hyperthyroidism: theircauses, clinical manifestations, management, and nursing interventions 4. Develop a plan of nursing care for the patient undergoing thyroidectomy. 5. Differentiate between type I and type 2. 6. Describe etiologic factors associated with diabetes. 7. Relate the clinical manifestations of diabetes to the associated pathophysiologic alterations. 8. Explain the dietary modifications used for management of people with diabetes. 9. Describe the relationships among diet, exercise, and medication. 10. Differentiate between hyperglycemia with DKA and HHNS. 11. Describe management strategies for a person with diabetes to use during ―sick days‖. 12. Describe the major macrovascular, microvascular, and neuropathic complications of diabetes. 13. Use the nursing process as a framework for care of patients with diabetes. 86 Unit (4): Assessment and Management of Patients with Endocrine Disorders Endocrine glands and hormones: Fig (18): The endocrine system Pituitary gland: - The pituitary gland is called the master gland because it regulates the function of other endocrine glands; however it connected by a stalk to the hypothalamus in the brain which influence the pituitary gland. - The pituitary gland is divided into three lobes: the anterior, intermediate and posterior. - The anterior lobe secrets: growth hormone, prolactin, thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), luteinizing hormone (LH), and follicle stimulating hormone (FSH). - The posterior lobe secrets: antidiuretic hormone (ADH) and oxytocin. Hypothalamus: - It creates a pathway for neuro hormones (releasing hormones or 87 factors) that stimulate and inhibit secretions from the anterior and posterior lobes of the pituitary gland. Thyroid gland: It located in the lower neck anterior to the trachea and divided into two later lobes joined by isthmus. - Concentrates iodine from food and uses to synthesize thyroxine (T4) which is converted to (T3) and triiodothyronine (T3). These two hormones regulate the body's metabolic rate. - Secretes calcitonin which inhibits the release of calcium from bone into the extracellular fluid. The function of the thyroid hormones: - Regulate carbohydrate and lipid metabolism. - Stimulating oxygen consumption by cells. - Controlling growth and development. Parathyroid glands: Are four small, bean shaped bodies embedded within the lateral lobes of the thyroid. - They secrete parathyroid hormone, which increase the level of calcium in the blood when there is a decrease in the serum level. This through release calcium and phosphorus from the bones, interfering urinary excretion of calcium and activating vit. D which increase calcium absorption within the intestine. Thymus gland: - It located in the upper part of the chest above or near the heart. It lare during childhood but usually shrinks by adulthood - Secretes thymosin and thymopoietin which aid in developing T lymphocytes. 88 Pineal gland: It attached to the thalamus in the brain and secretes melatonin which aids in regulating sleep cycles and mood. Adrenal glands: It located above the kidneys the outer portion is called the cortex and the inner portion is the medulla. 1- The adrenal cortex: secretes corticosteroids which divided into: a- Glucocorticoids (as cortisol which affect body metabolism, suppress inflammation and stand stress) and mineralocorticoids (as aldosterone which maintain water and electrolyte) are essential to life and influence many organs and structures of the body. b- Androgenic hormones which convert to testosterone and estrogens. c- Anabolic steroids which promote the development of the muscle mass and other masculinizing characteristics. 2- The adrenal medulla: secretes epinephrine and norepinephrine. Pancreas: - It lies below the stomach, which the head of the gland close to the duodenum. It is both an exocrine and an endocrine gland. - The exocrine portion: secretes digestive enzymes that the common bile duct carries to the small intestine. - The hormone secreting cells of the pancreas called the islets of Langerhans which release insulin, glucagon, somatostatin and pancreatic polypeptide as the following: - Insulin: released by beta islet cells, lowers the level of blood glucose when it rises beyond normal limits. 89 Hyperthyroidism Overview on thyroid gland The thyroid gland is a butterfly-shaped endocrine gland that is normally located in the lower front of the neck. It Produces 3 hormones when stimulated by TSH: Thyroxin (T4) & Triiodothreonine (T3): - Regulates body metabolism - Thermal regulation - Regulation of physical/mental development Calcitonin: - Release is triggered by an increase in blood calcium levels; - Targets bone cells (inhibits osteoclast activity) & kidney tubules (causes secretion of calcium into urine); - Therefore, causes a decrease in blood calcium and phosphate levels to normal. Definition of hyperthyroidism: An increase in release of thyroid hormone. Severe hyperthyroidism can precipitate a thyroid storm or crisis, which is a life-threatening emergency The two types of spontaneous hyperthyroidism are: 1. Graves’ disease: - Commonly occurs in the third or fourth decade of life - More common in women - Familial predisposition, - May cause extra thyroidal symptoms, goiter, and symptoms of hyper metabolism and sympathetic nervous system hyperactivity. 90 2. Toxic nodular goiter: signs and symptoms vary with the type and severity - Occurs in elderly people - Its slow onset causes less severe symptoms than Graves’ disease Causes 1. Thyroid Nodule (over-secretion by tumor). 2. Thyroiditis (infection). 3. Exogenous hyperthyroidism: overdose of thyroid hormone medication. 4. Graves’ disease (autoimmune antibodies result in hyper secretion of thyroid hormones). Clinical Manifestations: 1. Heat intolerance. 2. Palpitations elevated systolic BP. 3. Weight changes. 4. Menstrual irregularities 5. Increased serum T4, T3. 6. Exophthalmos (bulging eyes) 7. Goiter. enlarged thyroid gland 8. Insomnia. 9. Muscle weakness. 10. Heat intolerance. 11. Diarrhea. Diagnostic Studies: - History -Physical examination - Ophthalmologic examination - ECG to evaluate the effects on the heart 91 - Radioactive iodine uptake (RAIU): Indicated to differentiate Graves’ disease from other forms of thyroiditis. Treatment Goals: - Block adverse effects of thyroid hormones. - Stop hormone over secretion and prevent thyroid storm. - The treatment depends on the cause and severity, patient's age, & goiter size. Three primary treatment options: - Anti-thyroid medications - Radioactive iodine therapy (RAI) - Subtotal thyroidectomy (A) Pharmacological management: 1. Anti-thyroid: are anti-thyroid agents that inhibit the synthesis of thyroid hormones 2. β-Adrenergic blockers: Helps to control nervousness, tachycardia, tremor, anxiety, and heat tolerance. Example: Propranolol (Inderal) administered with other antithyroid agents Nursing consideration: - Monitor blood pressure, heart rate, and ECG. - Monitor for hypoglycemia. (B) Iodine & Radioactive iodine therapy Uses: -Used with other antithyroid drugs in preparation for thyroidectomy or treatment of thyrotoxic crisis. -Given several weeks preoperatively. -Decrease the vascularity of thyroid gland decreasing bleeding making surgery safer. 92 Action: Inhibit synthesis of T3 & T4 and block release into circulation to slow metabolism (C) Surgical Interventions: Several surgical options exist for treating thyroid disease and the choice of procedure depends on two main factors: The first is the type and extent of thyroid disease present. The second is the anatomy of the thyroid gland itself. The most commonly performed procedures include: lobectomy, lobectomy with isthmectomy, subtotal thyroidectomy, and total thyroidectomy. Nursing care plan for the patient with hyperthyroidism: Nursing diagnosis: Hyperthermia related to hypermetabolic state Goal: Body temperature will be within normal limits. 1. Monitor temperature. 2. Administer acetaminophen as ordered 3. Apply cooling blanket as ordered. 4. If a cooling blanket is necessary, set to one to two degrees below current temperature, and wrap extremities with towels. Nursing diagnosis: Diarrhea related to increase in peristalsis Goal: Patient will maintain fluid and electrolyte balance. 1. Provide a low-fiber diet. 93 2. Provide small frequent meals of bland foods (bananas, rice, applesauce) that are less likely to worsen diarrhea. 3. Monitor electrolytes, especially sodium and potassium. 4. Monitor for dehydration. 5. Keep skin clean and dry; apply barrier cream Nursing diagnosis: Imbalanced nutrition, less than requirements, related to increased metabolism Goal: The patient will maintain weight in proportion to height. 1. Determine healthy weight for height. 2. Monitor weight weekly 3. Consult dietician for high-calorie diet with six meals to meet caloric requirements. Nursing diagnosis: Disturbed sleep pattern related to sympathetic stimulation. Goal: The patient will state feeling rested upon awakening. 1. Provide a quiet, restful environment to assist the patient to fall asleep. 2. Ask the patient if music or earplugs are desired 3. Administer propranolol or sedative as ordered Nursing diagnosis: Anxiety related to sympathetic stimulation Goal: Patient will state anxiety is controlled. 1. Provide the patient with accurate information about the disorder and treatment, and that proper treatment will correct symptoms. 2. Administer propranolol or antianxiety agent as ordered. 3. Offer massage, music, or other relaxation techniques preferred by the patient. 94 Nursing diagnosis: Risk for injury related to hypermetabolic state and eye involvement Goal: Patient will remain safe and without injury. Report changes in vital signs to the physician. 1. Administer lubricating saline eyedrops as ordered 2. Advise use of dark, tight fitting glasses 3. Gently tape eyes shut with nonallergic tape for sleeping. 4. Elevate the head of the bed 5. Provide a low-sodium diet. 6. Teach patient to notify physician immediately if eye pain or vision changes occur. Patient education: Teach the patient about the disease and symptoms of hyperthyroidism or hypothyroidism to report. Also teach the patient how to take medications and the importance of routine follow-up laboratory testing. 95 Hypothyroidism Definition of hypothyroidism: A diminished production of thyroid hormone, leading to thyroid insufficiency Primary hypothyroidism: is caused by thyroid gland dysfunction. Secondary hypothyroidism: from insufficient secretion of TSH by the pituitary gland. Myxedema: The most severe form of hypothyroidism occurs when hypothyroidism is untreated or suddenly stopped the medication. It is characterized by swelling of the hands, face, feet, and periorbital tissues. Causes 1. Cells damaged 2. Use of medications (lithium, amiodarone) 3. Inadequate intake of iodine 4. insufficient thyroid hormone replacement therapy for hyperthyroidism 5. pituitary gland dysfunction due to infection, surgery, trauma, or tumor Clinical Manifestations Early findings - Fatigue, lethargy, irritability - Intolerance to cold - Constipation - Weight gain without an increase in caloric intake - Pale skin - Thin, brittle fingernails - Depression - Thinning hair - Joint and/or muscle pain 96 Late findings - Bradycardia, hypotension, dysrhythmias - Slow thought process and speech - Dry, flaky skin - Hypoventilation, pleural effusion - Thickening of the skin - Thinning of hair on the eyebrows - Swelling in face, hands, and feet (myxedema [non-pitting, mucinous edema]) - Decreased acuity of taste and smell. -Hoarse, raspy speech - Abnormal menstrual periods (menorrhagia/amenorrhea) Diagnostic test:- - Measurement of serum TSH, T3, and T4, and free T4 levels; T3 resin uptake test; and radioisotope thyroid uptake test. - History and physical examination Treatment of hypothyroidism - Thyroid hormone replacement, synthetic levothyroxine sodium is the preferred thyroid hormone replacement and typically relieves symptoms in 2 to 3 days Nursing care plan for patient with hypothyroidism: Nursing Diagnosis: Activity intolerance related to fatigue and depressed cognitive process Goal: Increased participation in activities and increased independence Intervention: 1. Assist patient with self-care activities. 2. Allow for rest between activities. 3. Slowly increase patient’s activities as medication begins to be effective. 97 4. Provide stimulation through conversation and non-stressful activities. 5. Monitor patient’s response to increasing activities. Nursing Diagnosis: Constipation related to depressed gastrointestinal function Goal: Return of normal bowel function 1. Encourage increased ﬂuid intake within limits of ﬂuid restriction. 2. Provide foods high in ﬁber. 3. Instruct patient about foods with high water content. 4. Monitor bowel function. 5. Encourage increased mobility within patient’s exercise tolerance. 6. Encourage patient to use laxatives and enemas sparingly. Nursing Diagnosis: Impaired skin integrity related to dry skin, inactivity. Goal: Skin remains intact. Interventions 1. Assess skin daily for breakdown. 2. Avoid use of soap on dry areas. 3. Try bath oil. 4. Use nondrying lotion following bath. 5. Encourage/assist with position changes at least every 2 hours. Nursing Diagnosis: Imbalanced nutrition, more than requirements, related to decrease metabolic rate. Goal: Patient will return to pre-illness weight. Intervention: 1. Weigh weekly and record. 2. Consult dietitian for therapeutic diet until hypothyroidism is controlled. 98 3. Encourage regular exercise within limits of fatigue. 4. Counsel patient that weight should normalize once hypothyroidism is controlled. 5. Allow patient to help determine acceptable diet modifications. Nursing Diagnosis: Risk for imbalanced body temperature. Goal: Maintenance of normal body temperature. Intervention: 1. Provide extra layer of clothing or extra blanket. 2. Avoid and discourage use of external heat source (eg, heating pads, electric or warming blankets). 3. Monitor patient’s body temperature and report decreases from patient’s baseline value. 4. Protect from exposure to cold and drafts. Nursing Diagnosis: Deﬁcient knowledge about the therapeutic regimen for lifelong thyroid replacement therapy Goal: Knowledge and acceptance of the prescribed therapeutic regimen Intervention: 1. Explain rationale for thyroid hormone replacement.Describe desired effects of medication to patient. 2. Assist patient to develop schedule and checklist to ensure self- administration of thyroid replacement. 3. Describe signs and symptoms of over- and underdoes of medication. 4. Explain the necessity for long-term follow-up to patient and family. 99 Diabetes Mellitus Definition of diabetes mellitus: Metabolic disorder characterized by hyperglycemia due to an absolute or relative lack of insulin or to a cellular resistance to insulin. Or Is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both. Classification of diabetes mellitus (1)Type 1 Diabetes Mellitus: - Formerly known as juvenile onset or insulin dependent diabetes (IDDM).

Adult Nursing I 2024-2025 Faculty of Nursing, South Valley University

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