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Natural Body Defense Mechanism

Natural Body Defence Mechanism

Nursing Notes - Asepsis & Investigations

Topic 3.10 / 3.11: Natural Body Defence Mechanism

The human body possesses a sophisticated array of natural defense mechanisms designed to protect against pathogens (e.g., bacteria, viruses, fungi) and foreign substances, as well as to repair damaged tissues. These defenses can be broadly categorized into non-specific (innate) defenses and specific (adaptive) defenses.

I. Non-Specific (Innate) Defenses:

These are the body's first line of defense, providing immediate, general protection against a wide range of threats without prior exposure. They do not differentiate between types of pathogens.

  • First Line of Defense (Physical & Chemical Barriers):
    • Skin: Intact skin acts as a formidable physical barrier, preventing pathogen entry. It also produces antimicrobial peptides and has a slightly acidic pH (acid mantle) which inhibits bacterial growth.
    • Mucous Membranes: Line all body cavities open to the exterior (respiratory, gastrointestinal, genitourinary tracts). They trap pathogens with sticky mucus and often contain antimicrobial substances.
    • Cilia: Hair-like projections in the respiratory tract that sweep mucus and trapped pathogens upwards for expulsion (e.g., coughing, sneezing).
    • Normal Flora (Microbiota): Non-pathogenic microorganisms colonizing various body surfaces (skin, gut, vagina) that compete with pathogens for nutrients and space, often producing inhibitory substances.
    • Body Secretions:
      • Tears & Saliva: Contain lysozyme, an enzyme that breaks down bacterial cell walls.
      • Gastric Acid: Highly acidic environment in the stomach destroys most ingested pathogens.
      • Urine: The acidic pH and flushing action help prevent bacterial colonization of the urinary tract.
      • Vaginal Secretions: Acidic pH inhibits the growth of many pathogens.
      • Cerumen (Earwax): Traps particles and contains antimicrobial properties.
  • Second Line of Defense (Internal Cellular & Chemical Defenses):

    If pathogens breach the first line, the second line of defense activates, involving cellular and chemical responses.

    • Phagocytes: Specialized white blood cells that engulf and digest foreign particles and pathogens.
      • Neutrophils: Abundant, early responders to infection, highly phagocytic.
      • Macrophages: Develop from monocytes, larger and longer-lived, act as "clean-up crews" and antigen-presenting cells.
    • Natural Killer (NK) Cells: Lymphocytes that non-specifically kill virus-infected cells and cancer cells by inducing apoptosis (programmed cell death).
    • Inflammatory Response: A localized tissue response to injury or infection, characterized by redness (rubor), heat (calor), swelling (tumor), and pain (dolor). Its purpose is to:
      1. Prevent spread of damaging agents.
      2. Dispose of cell debris and pathogens.
      3. Set the stage for repair.

      Key chemical mediators like histamine and prostaglandins cause vasodilation and increased capillary permeability.

    • Antimicrobial Proteins:
      • Interferons (IFNs): Proteins released by virus-infected cells that protect neighboring uninfected cells from viral replication.
      • Complement System: A group of plasma proteins that, when activated, enhances inflammation, promotes phagocytosis (opsonization), and directly lyses (bursts) bacterial cells.
    • Fever: Systemic response to infection, raising body temperature. Moderate fever can:
      • Inhibit the growth of some microorganisms.
      • Increase metabolic rate, speeding up repair processes.
      • Enhance phagocytic activity.

    • II. Specific (Adaptive) Defenses:

    This is the body's third line of defense, which is highly specific, systemic, and has memory. It targets specific pathogens and improves with each subsequent exposure.

  • Key Characteristics:
    • Specificity: Recognizes and targets specific antigens.
    • Memory: Remembers previous encounters with pathogens, allowing for a faster and stronger response upon re-exposure.
    • Systemic: Not restricted to the initial infection site.
  • Components:
    • Lymphocytes:
      • B Lymphocytes (B cells): Responsible for humoral immunity. They produce antibodies that circulate in bodily fluids and target extracellular pathogens (e.g., bacteria, toxins).
      • T Lymphocytes (T cells): Responsible for cellular immunity. They directly attack infected cells, cancer cells, or foreign cells. Types include:
        • Helper T cells (CD4+): Coordinate both humoral and cellular immunity.
        • Cytotoxic T cells (CD8+): Directly kill target cells.
        • Regulatory T cells: Suppress immune responses to prevent autoimmunity.
    • Antigen-Presenting Cells (APCs): Cells (e.g., macrophages, dendritic cells) that present antigens to T cells, initiating an adaptive immune response.
    • Antibodies (Immunoglobulins): Proteins produced by plasma cells (differentiated B cells) that bind specifically to antigens, marking them for destruction.
  • Types of Adaptive Immunity:
    • Active Immunity: Develops when the body produces its own antibodies or activated T cells in response to an antigen.
      • Naturally acquired active immunity: Infection (e.g., getting sick with measles).
      • Artificially acquired active immunity: Vaccination (e.g., MMR vaccine).
    • Passive Immunity: Occurs when antibodies are transferred from one individual to another. Provides immediate but temporary protection as the body does not produce its own memory cells.
      • Naturally acquired passive immunity: Antibodies passed from mother to fetus via placenta or to infant via breast milk.
      • Artificially acquired passive immunity: Injection of pre-formed antibodies (e.g., antivenom, rabies immunoglobulin).

    • Interrelationship of Defenses:

    It's crucial to understand that these defense mechanisms do not operate in isolation. Innate defenses provide immediate protection and also activate and guide the more specific adaptive immune responses. For example, inflammation helps to bring immune cells to the site of infection, and macrophages (innate) can act as APCs, linking to adaptive immunity. A healthy immune system relies on the coordinated action of all these components.

    INFLAMMATION

    Inflammation is part of the body's immune response to irritation, injury, or infection. Inflammation is a defensive mechanism in the body. Inflammation is a defensive reaction intended to neutralize, control or eliminate the offending agent and to prepare the site for repair.

    It can be beneficial when, for example, your knee sustains a blow and tissues need care and protection. However, sometimes, inflammation can persist longer than necessary, causing more harm than benefit.

    Cells or tissues of the body may be injured or killed by any of the agent (physical, chemical, infections) when this happens, an inflammatory response (inflammation) naturally occurs in healthy tissues adjacent to the site of injury.

    Note: inflammation is not the same as infection, an infectious agent is only one of several agents that may trigger an inflammatory response. An infection exist when the infectious agent is living, growing and multiplying in the tissues and is able to overcome the body’s normal defense.

    Inflammation differs from antibody mediated immunity and cell mediated immunity (AMI and CMI) in two important ways:

    • Inflammatory protection is immediate but short term. It does not provide true immunity on repeated exposure to the same organisms.
    • Inflammation is a non-specific body defense to invasion or injury and can be started quickly by almost any event, regardless of where it occurs or what causes it.
    Functions of inflammation
    • When something harmful or irritating affects a part of our body, there is a biological response to try to remove it. The signs and symptoms of inflammation can be uncomfortable but are a show that the body is trying to heal itself.
    • Cells of inflammation or tissues of the body may be injured or killed by any of the agents (physically chemical, infectious) when this happens an inflammatory response (inflammation) naturally occurs in the healthy tissues adjacent to the site of injury.
    • It provides immediate protection against the effects of tissue injury and invading foreign proteins.
    • Inflammation also helps start both antibodies mediated and cell mediated actions to activate full immunity.
    • It can be a barrier to prevent organisms from entering the body or can be an attacking force that eliminates organisms that have already entered the body.
    • This type of immunity cannot be transferred from one person to another and is not an adaptive response to exposure or invasion by foreign proteins.
    • The inflammatory response are part of innate immunity and other parts of innate immunity include;- This is the body’s ability to resist invading organisms and It is achieved through natural barriers, biologically functionally and chemically using:
      • The skin as a barrier,
      • Mucus to trap organisms,
      • mucus membranes as a barrier
      • Biological agents like normal flora
      • Functional like taking a lot of fluids to flash
      • Chemical secretions like tears to clear away
      • Cell mediated like lymphocytes or antibodies

    CELL TYPES INVOLVED IN INFLAMMATION

    The leukocytes (white blood cells) involved in inflammation are neutrophils, macrophages, eosinophil’s and basophils. An additional cell type important in inflammation is the tissue mast cell. Neutrophils and macrophages destroy and eliminate foreign invaders. Basophils, Eosinophil’s and mast cells release chemicals that act on blood vessels to cause tissue level responses that help neutrophil and microphage actions.

    NEUTROPHILS
    • Mature neutrophils make up between 55% and 70% of the normal total white blood cell count.
    • Neutrophils come from the stem cells and complete the maturation process in the bone marrow.
    • They are also called granulocytes because of the large number of granules present inside each cell; other names of neutrophils are based on their appearance and maturity.
    • Mature neutrophils are also called segmented neutrophils because of their nuclear shape.
    • Usually, growth of a stem cell into a mature neutrophil requires 12 to 14 days.
    • In a healthy person with full immunity, more than 100 billion fresh, mature neutrophils are released from the bone marrow into the circulation daily.
    • This huge production is needed because the life span of each neutrophil is short about 12 to 18 days.
    • Neutrophil function provides protection after invaders especially bacteria enter the body. This powerful army of small cells destroys invaders by phagocytosis and enzymatic digestion, although each cell is small and can take part in only one episode of phagocytosis.
    MACROPHAGE
    • Macrophage come from the committed myeloid stem cells in the marrow: and form the mono nuclear phagocyte system.
    • The stem cells first form monocytes which are released into the blood stream at this stage until they mature. Monocytes have limited activity.
    • Most monocytes move from the blood into the body tissues where they mature into macrophage.
    • Some macrophages become fixed in position within the tissues whereas others can move within and between tissues.
    • The liver, spleen and intestinal tract within large numbers of these cells.
    FUNCTIONS
    • Macrophage protects the body in several ways;-
    • These cells are important in immediate inflammatory responses and also stimulate the longer-lasting immune responses of antibody mediated immunity and cell mediated immunity.
    • Macrophage functions include phagocytosis, repair antigen presenting and secretion of cytokines for the immune system control.
    BASOPHILS
    • Basophils come from myeloid stem cells and make up only about 1% of the total circulating white blood cell count.
    • These cells cause the manifestation of inflammation.
    Functions
    • Basophils act on blood vessels and release chemicals which include;- heparin, histamine, serotonin, kinins and leukotriene’s.
    • Basophils have sites that bind the portion of immune-globulin E (IgE) molecules which binds to and is activated by allergens.
    • When allergens bind to the IgE on the basophils, the basophils membrane opens and releases the vaso-active amines into the blood, where most of them act on smooth muscle and blood vessel walls.
    • Heparin inhibits blood and proteins clotting.
    • Histamine constricts small veins inhibiting blood flow and decreasing venous return.
    • This effect causes blood to collect in capillaries and arterioles.
    • Kinins dilate arterioles and increase capillary permeability.
    • These actions cause blood plasma to leak into the interstial space.
    EOSINOPHILS
    • These come from the myeloid line and contain many vaso-active chemical.
    Functions
    • Eosinophil’s are very active against infestations on rurastic larvae and also limits inflammatory reaction.
    • The eosinophil granules contain many different substances; some are enzymes that degrade the vaso-active chemicals released by other leukocytes.
    TISSUE MAST CELLS
    • These cells have functions very similar to basophils and eosinophils. Although mast cells do originate in the bone marrow, they come from different parent cells than leukocytes and do not circulate as mature cells.
    • Instead they differentiate and mature in tissues especially those near blood vessels, nerves, lung tissues skin and mucous membranes.
    • Some mast cells also respond to the inflammatory products made and released by T. lymphocytes.

    The tissue mast cells have important roles in maintaining and prolonging inflammatory and hypersensitivity reactions.

    STAGES/ PHASES OF INFLAMMATION

    Injury
    • Any type of injury of exogenous (outside the body) or endogenous (inside the body) injury can initiate the inflammatory y response; heat cold, radiations, chemicals, trauma infections, immunological injuries, neoplasms etc.
    • Whatever the stimulus the response itself is the same but the degree of response varies with the type and severity of the injury.
    Vascular response
    • The vascular response consists of transitory vasoconstriction followed by immediate vasodilation. This reaction is due to chemical mediators such as histamine, serotonin or kinins being released at the site of infection or injury.
    • The mediator cause increase in blood flow to the area causing redness and heat.
    • They also cause increased permeability of the capillaries which increase blood flow to the interstitial space. The extra fluid dilutes toxins and microorganism the area and serves as a vehicle by which phagocytes and nutrients needed for healing to reach the injured site.
    Fluid exudation
    • Fluid exudation from the capillaries into the interstitial spaces begins immediately and is most active during the first 24hours after.
    • The exudate is serous fluid but the capillary walls become more permeable and proteins are lost into the interstitial spaces causing increased pressure in this space which encourages tissue swelling and oedema.
    Cellular exudation
    • It occurs when WBCS are summoned to the vessels in the affected area as a result of the release of chemostastic substance from injured cells and activation of complement.
    • WBCS adhere to the capillary walls and migrate through the walls. Neutrophils are the first to respond usually within first few hours.
    • Neutrophils ingest dead tissue cells and then die, releasing proteolytic enzyme that liquefy the dead neutrophils, dead bacteria and other dead cells forming pus.
    Healing

    The inflammatory response contains the spread of bacteria and prepares tissue for healing by two overlapping process: reconstruction and maturation. For repair to proceed, acute inflammation must subside and pus and dead tissue must be removed. Repair of wound involves three processes:

    • Filling in the wound
    • Sealing the wound
    • Shrinking the wound
    Reconstruction
    • Once the inflamed area is clean or debrided, reconstruction begins and new cells are produced to fill in the space left by the injury.
    • Fibroblast is attracted to the area which secret fibrin – a thread like structure that encircles the space.
    Maturation
    • Maturation follows reconstruction phase, during maturation which can last for months to years, scar is remodeled. Capillaries contract leaving a vascular scar and structure and function of damaged tissue are restored.

    Types of inflammation

    There are three main types of inflammation and its categorized by its duration and the type of exudate produced.

    • Acute inflammation
    • Chronic inflammation
    • Sub-acute inflammation
    ACUTE INFLAMMATION

    An acute inflammation is one that starts rapidly and becomes severe in a short space of time. Signs and symptoms are normally only present for a few days but may persist for a few weeks in some cases.

    The 5 Cardinal Signs (PRISH):
    • Pain: The inflamed area is likely to be painful, especially during and after touching.
    • Redness: This occurs because the capillaries in the area are filled with more blood than usual.
    • Immobility: There may be some loss of function in the region of the inflammation.
    • Swelling: This is caused by a buildup of fluid.
    • Heat: More blood flows to the affected area, and this makes it feel warm to the touch.
    Causes of Acute Inflammation
    • Burns
    • Chemical irritants
    • Frostbite
    • Toxins
    • Infection by pathogens
    • Physical injury, blunt or penetrating
    • Immune reactions due to hypersensitivity
    • Radiation
    • Foreign bodies, including splinters, dirt and debris
    • Trauma

    Examples of diseases, conditions, and situations that can result in acute inflammation include:

    • acute bronchitis
    • infected ingrown toenail
    • a sore throat from a cold or flu
    • a scratch or cut on the skin
    • high-intensity exercise
    • acute appendicitis
    • dermatitis
    • tonsillitis
    • infective meningitis
    • sinusitis
    • a physical trauma
    CHRONIC INFLAMMATION

    This refers to long-term inflammation and can last for several months and even years. It can result from:

    • Failure to eliminate whatever was causing an acute inflammation.
    • An autoimmune disorder that attacks normal healthy tissue.
    • Exposure to a low level of a particular irritant, such as an industrial chemical, over a long period.

    Examples of diseases and conditions that include chronic inflammation:

    • Rheumatoid arthritis
    • Asthma
    • Chronic peptic ulcer
    • Tuberculosis
    • Periodontitis
    • Ulcerative colitis and Crohn's disease
    • Sinusitis
    • Active hepatitis
    Acute Chronic
    Caused by Harmful bacteria or tissue injury Pathogens that the body cannot break down, including some types of virus, foreign bodies that remain in the system, or overactive immune responses
    Onset Rapid Slow
    Duration A few days From months to years
    Outcomes Inflammation improves, turns into an abscess, or becomes chronic Tissue death and the thickening and scarring of connective tissue

    Management of Inflammation

    Investigation
    • White blood cell count
    • Bacteriological examination of specimen got from the site of infection.
    • Serum tests for the presence of antibodies.
    Common treatments
    • Simple measures like fluid intake and rest can be considered to aid resolution.
    • Antibiotics may be given to combat infection.
    • Rest of the affected part.
    • Surgical interventions may be necessary if all fails, excision and removal of necrotic tissue can be done.
    • Incision and drainage may be done to drain pus.
    • Rehabilitation is done to restore the functions.
    Anti-inflammatory medications
    • Non-steroidal anti-inflammatory drugs (NSAIDs) can be taken to alleviate the pain caused by inflammation. Examples of NSAIDs include naproxen, ibuprofen, and aspirin.
    • Acetaminophen, such as paracetamol or Tylenol, can reduce pain without affecting the inflammation.
    • Corticosteroids, such as cortisol, are a class of steroid hormones that prevent a number of mechanisms involved in inflammation.
    Inflammation diet

    There are several foods that can have been shown to help reduce the risk of inflammation, including:

    • olive oil, tomatoes, nuts, leafy greens, fatty fish, fruit.

    Avoid eating foods that aggravate inflammation, including:

    • fried foods, white bread, soda and sugary drinks, red meat, Margarine.

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    Special investigations in surgical nursing (1)

    Aseptic technique & Special investigations in surgical nursing

    Nursing Notes - Asepsis & Investigations

    Topic 3.7: Aseptic Technique & Special Investigations

    Sub-topic 3.7.3: Aseptic Technique / Surgical Asepsis

    Introduction to Surgical Asepsis
    • It is defined as the absence of micro-organisms that can cause disease.
    • Surgical asepsis promotes tissue healing by determining pathogens from coming into contact with the surgical wound.
    • Practices that suppress, reduce and inhibit injection processes are known as aseptic technique.
    • Surgical asepsis prevents contamination of surgical wounds.
    • All members of the operating theatre (OR) team are responsible for strict adherence to aseptic techniques.
    • It is essential that OR nurses acquire a surgical conscience – vigilant adherence to aseptic technique throughout the entire peri-operative period.
    Operating Theatre Environment and Asepsis

    The purpose of maintaining asepsis in the operating theatre is paramount. The theatre environment should have the following:

    • Air conditioned ventilation.
    • Charnel enclosure for orthopedic work.
    • Easily cleanable fabric.
    • A one way traffic circulation from clean area to dirty area.
    • Adequate shower facilities for medical staff after finishing a day’s operation.

    Basic Rules of Surgical Asepsis in the OR

    1. Scrubbed persons function within sterile field

      Scrubbed personnel wear gloves and gowns at the surgical field. The gown of scrubbed team member is considered sterile in front, from the chest to the level of the sterile field and the sleeves are sterile front two inches above the elbow to the stockinette cuff. The non-sterile areas of the gowns include; stockinet cuff, neckline, shoulder, axillary region and back. Dressing in OR attire proceeds from head to toe.

    2. Sterile drapes are used to create a sterile field

      Sterile drapes are placed on the patient equipment and furniture used within the sterile field. Draped tables are sterile only at the table level; items extending over the table edge are contaminated. Handling of the drapes should be minimized.

    3. All items used in the sterile field are sterile

      If the sterility of an item is questioned, it must be considered unsterile. Packaging materials must guarantee that items will remain sterile until removed.

    4. Supplies introduced into the sterile field

      Are delivered in a manner that ensures the sterility of the item and maintains the integrity of the sterile field. The nurse opens a sterile package from the far side first and near side last and holds the wrapper tails when the item is presented to the sterile field. The nurse pours solutions carefully to avoid splashing liquids on to the field. After opening a bottle of a sterile solution, the nurse must present the entire contents to the sterile field or discard it.

    5. Maintenance and monitoring of sterile field

      The possibility for contamination increases with time, therefore the sterile field should be established as close to the time of use as possible. Un-attended sterile field is considered contaminated.

    6. The integrity of the sterile field must be maintained by individuals moving within or around the sterile field

      Only scrubbed personnel touch and reach over sterile areas. Sterile persons remain close to the sterile field and never turn their backs to it. Sterile individuals change positions by passing back to back or face to face. Un-scrubbed personnel only touch and reach over non-sterile areas, do not walk between sterile fields and approach sterile fields by facing them.

    SURGICAL ASEPSIS
    • It is defined as the absence of micro-organisms that can cause disease.
    • Surgical asepsis promotes tissue healing by determining pathogens from coming into contact with the surgical wound.
    • Practices that suppress, reduce and inhibit injection processes are known as aseptic technique.
    • Surgical asepsis prevents contamination of surgical wounds.
    • All members of the operating theatre (OR) team are responsible for strict adherence to aseptic techniques.
    • It is essential that OR nurses acquire a surgical conscience – vigilant adherence to aseptic technique throughout the entire peri-operative period.
    The purpose of maintaining asepsis, operating theatre. They should have the following;
    • Air conditioned ventilation.
    • Charnel enclosure for orthopedic work.
    • Easily cleanable fabric.
    • A one way traffic circulation from clean area to dirty area.
    • Adequate shower facilities for medical staff after finishing a day’s operation.

    Client Preparation for Surgery

    Although much preparation have taken place prior to clients transfer to the surgical department additional activities such as shaving and positioning may be performed.

    Skin preparation

    The goal of skin preparation is to reduce the risk of post-operative wound infection by;

    • Removing transient microbes from the skin
    • Reducing the resident microbes count to sub-pathogenic amounts
    • Inhibiting rapid rebound growth of microbes

    The skin is prepared by mechanically scrubbing or cleaning around the surgical site with anti-microbial agents. If the patient is very hairy or if the hair will interfere with the surgical procedure, the nurse removes it; usually either wet shaving, clippers or use of depilatory agent. The area is then scrubbed in a circular motion. The principal of scrubbing from the clean area (site of incision) to the dirty area (periphery) is observed at all times. A liberal area is cleansed to allow added protection and unexpected occurrences during the procedure. After preparation of the skin, the sterile members of the surgical team drape the area. Only the site to be incised is left exposed.

    Positioning the patient
    • It is a critical part of every procedure and usually follows administration of the anesthesia.
    • Anesthetist will indicate when to begin the positioning.
    • The circulating nurse ensures optimal positioning and continually assess the client.
    • The position of the patient should allow accessibility to the operative site, administration and monitoring of anesthetic agents and maintenance of the patient’s airway.
    • Improper positioning would potentially result into muscle strain, joint damage and other unwanted effects.
    • It is a nurse’s responsibility to secure the extremities provide adequate padding and support and obtain sufficient physical or mechanical help to avoid unnecessary straining of self or patient frequently.
    Positions used frequently include;
    • The surprise position: it is used for many abdominal surgeries, thoracic surgeries and some surgeries on the extremities
    • The semi-sitting up position: it is used for surgeries on the thyroid and neck areas
    • The prone position: it is used for spinal fusions and removal of hemorrhoids
    • The lateral chest position: it is used for gynecological, perinea or rectal surgeries
    • The jackknife: it is used for proctologic and some spinal surgeries
    • The Trendelenburg position: it is used for examinations and for performing abdominal surgeries
    • Lateral position: it is used for surgeries of the anal area

    NB: see positions in medical surgical nursing (patient centered collaborative care 8th edition)

    Anesthesia

    The term anesthesia is derived from the word anesthesis meaning “no sensation” therefore anesthesia is limited or total loss of feeling (normal sensation) with or without loss of consciousness. There are two broad classifications of anesthesia; general and local anesthesia.

    General Anesthesia

    Involves unconsciousness, complete insensitivity to pain, amnesia, motionless and muscle relaxation. It involves four overlapping stages i.e. induction (going to sleep), maintenance, emergence (waking up) and recovery.

    • Induction time period starting with pre-operative medication, initiation of appropriate IV access, application of monitors, initiation of sequence of medication that render the patient unconscious, securing airway, drugs used include; benzodiazepines, narcotics, hypnotics and volatile gases.
    • Maintenance-time period during which the surgical procedures is performed, patient remains in an unconscious state with appropriate measures to ensure safety of the airway. Drugs are the same as above.
    • Emergence-time – it is a period during which the surgical procedure is completed. Patient is prepared for return to return to consciousness and removal of airway assist devices. Drugs used; reversal agents – anticholinergic, sympathometics, narcotic, antagonists, benzodiazepines antagonist.
    • Recovery-time / period during which the patient regains his/her clear thinking ability. This often takes longer with some residual thinking difficulty persisting for several days or even weeks. Many anesthetic drugs are metabolized slowly. The speed of metabolism depends on amount of drug given, the length of surgery and how deeply the patient is breathing.
    Local Anesthesia

    Allows operative procedures to be performed on a particular part of the body without loss of consciousness or sedation. The duration of action of the local anesthetic frequently carries into the post-operative period providing continued analgesia.

    The disadvantages
    • Inadvertent IV administration producing hypotension and potential seizures
    • Inability to precisely match the duration of action of the agents administered to the duration of surgical procedure
    • Technique difficulty and discomfort that may be associated with infections
    Methods of administration
    • Topical application – application of the agent directly to the skin, mucous membranes or open surface
    • Local infiltration – injection of the agent into the tissues through which the surgical incision will pass
    • Regional nerve block – injection of the agent into or around a specific nerve or group of nerves. Examples of spinal anesthesia (injection of the agent into CSF found in the subarachnoid space, usually below L2 ) and epidural black (injection of agent epidural space via either a thoracic or lumber approach)
    Conscious sedation

    A minimally depressed level of consciousness with maintenance of patient’s protective airway, reflexes. Its primary goal is to reduce the patient’s anxiety and discomfort and to facilitate cooperation. Often a combination of sedative. The anesthetist determines the choice and method of administering the anesthesia according to;

    • Patient’s preferences, age, physical status and emotional status
    • Type and length of the surgical procedure
    • Patient’s positioning during surgery
    • Co-existing disease

    NB: operating theatre nurses do not administer anesthetic agents but they must understand the various anesthetics used in surgery and the potential side effects and complications (check pharmacology). This knowledge enables the nurse to plan intra-operative nursing care to assist the anesthesia team.

    Sub-topic 3.7.4: Special Investigations in Surgical Nursing

    Special investigations are diagnostic procedures used to confirm or rule out a surgical condition, determine the extent of disease, and plan for surgery. The nurse plays a vital role in patient preparation, education, and post-procedure care.

    X-ray & Contrast Studies

    The X-ray has been called one of the most significant advances in medical history. Routine X-rays involve exposing a body part to a small dose of radiation to produce an image of an internal organ. It is a fast and easy procedure. Patients will experience no discomfort or side effects from their examination and are allowed to leave immediately following their X-ray test.

    General Preparation of Patients for X-rays
    • Explain to the patient what is going to happen. This is especially necessary for x-rays which are done in a darkened room e.g. barium meal.
    • Remove jewellery e.g. necklaces for a chest X-rays.
    • Take the patient to the X-ray room, in a chair, or on a stretcher, or walking as ordered by the doctor, and bring with you the patient’s chart and previous x-rays, if any.
    • On arrival, remove the patient’s clothing and put on an X-rays gown.
    Contrast Studies
    • Esophagram (Barium Swallow): An examination of the pharynx and oesophagus using still and fluoroscopic X-ray images, after the patient drinks a barium solution.
    • Upper GI Series: A series of X-rays of the oesophagus, stomach, and small intestine taken after the patient drinks a barium solution.
    • Small Bowel or Small Intestine Series: A series of X-rays of the part of the digestive tract that extends from the stomach to the large intestine.
    • Barium Enema / Lower GI Series: A series of X-rays of the lower intestine (colon) and rectum taken after the patient is given an enema with a barium solution.
    • Intravenous Pyelogram (IVP): An X-ray examination of the kidneys, their drainage to the bladder, and the bladder, using an injected contrast dye.
    • Hysterosalpingogram: X-ray of the uterus and Fallopian tubes; usually done in diagnosing infertility.
    • Arthrogram: X-ray of a joint after the injection of a contrast medium.

    Advanced Imaging Techniques

    MRI (Magnetic Resonance Imaging)

    MRI is a method of obtaining detailed pictures of internal body structures without the use of radiation. It uses a magnetic field and radio waves. The patient will hear a repeated drum-like knocking sound as the scans are recorded. High quality images require the patient to lie still.

    How to Prepare For the MRI Exam
    • Patient wears loose, comfortable clothing without metal snaps or zippers.
    • Patient goes with a referral form from the doctor.
    • If the patient is having an MRI of the abdomen performed, advise the patient not to eat or drink anything after midnight the night before your procedure.
    CT (Computed Tomography)

    CT scanning is a rapid, painless diagnostic examination that combines X-rays and computers to see the location, nature, and extent of many different diseases or abnormalities.

    HOW to Prepare For the CT Exam
    • The meal prior to your CT examination should consist of CLEAR liquids ONLY.
    • If oral contrast (barium drink) is required, specific instructions on when to drink it will be given (e.g., TWO HOURS BEFORE and ONE HOUR BEFORE the appointment).

    Nuclear Imaging

    This provides information about both structure and function by using safe and painless techniques to image the body and treat disease. It involves introducing a small amount of a radioactive chemical (radionuclide or radiotracer) into the body.

    • PET/CT: Combines Positron Emission Tomography (PET) with CT to identify areas of abnormal metabolic activity, often used in cancer diagnosis and staging.
    • SPECT/CT: Combines Single-Photon Emission Computed Tomography (SPECT) with CT for similar purposes.
    Common Nuclear Scans
    • Bone Scan: A radionuclide collects in areas of high bone activity (fractures, infection, cancer), seen as 'hot spots'.
    • Cardiac Scan: Assesses blood flow to the heart muscle.
    • Renal Scan, Hepatobiliary Scan, etc.
    Preparation for Nuclear Medicine Exams

    Preparation varies. Some scans require no prep (Bone Scan), while others require fasting (Cardiac Scan, PET/CT). Patients must inform staff if they are diabetic or pregnant.

    Endoscopy

    Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope, an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ.

    Components of an Endoscope:
    • A rigid or flexible tube
    • A light delivery system
    • A lens system
    • An eyepiece
    • An additional channel to allow entry of medical instruments or manipulators
    Uses (Examples by Body System):
    • GI Tract: Esophagogastroduodenoscopy (EGD), Colonoscopy, ERCP.
    • Respiratory Tract: Rhinoscopy, Bronchoscopy.
    • Urinary Tract: Cystoscopy.
    • Joints: Arthroscopy.
    Preparation and Risks

    Preparation usually involves fasting to ensure the organ is empty. Risks, though infrequent, include infection, perforation (a tear) of the organ lining, and bleeding.

    Advanced Imaging Techniques

    MRI (Magnetic Resonance Imaging)

    Magnetic Resonance Imaging (MRI) is a method of obtaining detailed pictures of internal body structures without the use of radiation or radioactive substances of any kind.

    This is accomplished by placing the patient in a magnetic field while radio waves are turned on and off.

    This causes the body to emit its own weak radio signals which vary according to tissue characteristics.

    These signals are then picked up by a sensitive antenna and fed to a computer which produces detailed images of the body for interpretation by trained radiologists.

    During the examination the patient will not feel anything unusual. He/she will, however, hear a repeated drum-like knocking sound as the scans are recorded. The patient is free to bring a favourite CD or cassette tape to listen to during the scan to make her/himself comfortable. Hearing protection are provided to those patients who do not wish to listen to music.

    To produce high quality images, the patient has to lie still during the examination while breathing normally. The average scan takes 5 to 15 minutes—the complete examination about 30 to 45 minutes—during which time several dozen images will be produced.

    How to Prepare For the MRI Exam
    • Patient wears loose, comfortable clothing without metal snaps or zippers.
    • Patient goes with a referral form from the doctor.
    • If the patient is having an MRI of the abdomen performed, advise the patient not to eat or drink anything after midnight the night before your procedure.
    CT (Computed Tomography)

    Computed Tomography (CT) scanning is a rapid, painless diagnostic examination that combines X-rays and computers.

    A CT scan allows the radiologist to see the location, nature, and extent of many different diseases or abnormalities inside your body.

    HOW to Prepare For the CT Exam

    The meal prior to your CT examination should consist of CLEAR liquids ONLY. (You may have coffee/tea WITHOUT milk; broth; soda; and grape, cranberry or apple juice.)

    If you are having an out patient, provide the barium drink to the patient to take home. The patient SHOULD NOT REFRIGERATE the barium drink.

    TWO (2) HOURS BEFORE THE SCHEDULED APPOINTMENT

    • The patient removes cap and drinks the liquid within 30 minutes to the first designated line on the container.

    ONE (1) HOUR BEFORE THE SCHEDULED APPOINTMENT

    • Drink the liquid within 30 minutes to the 2nd designated line on the container.

    REMAINDER OF LIQUID

    • THE patient brings the remainder of the liquid to the hospital.
    • The patient will finish drinking the liquid when the study begins.
    • Prescription medications may be taken as usual.
    • EXCEPTION: Do not take Glucophage.

    Nuclear Imaging

    Nuclear Medicine provides doctors with information about both structure and function by using safe and painless techniques to image the body and treat disease. It is a superior way to gather medical information that would otherwise be unavailable or require surgery.

    Nuclear Imaging now offers two of the most advanced nuclear imaging modalities for the early detection of disease: PET/CT and SPECT/CT.

    PET/CT

    PET/CT is a state-of-the-art technique that combines Positron Emission Tomography (PET) with Computed Tomography (CT) to image tissue and organ function. This scan is designed to accurately identify even small areas of abnormal metabolic activity, which are associated with several disease processes. PET/CT’s major clinical impact to date is in cancer diagnosis and staging; however, PET/CT is also a useful modality for imaging the heart and brain. PET/CT can show more than just where tumours are located. PET/CT can reveal whether lesions are benign or malignant and can assess the effectiveness of treatment, whether surgery, chemotherapy, or radiation therapy.

    When the patient arrives at the Nuclear Imaging Suite, a technologist will discuss the PET/CT procedure with him/her and ask if s/he has any questions. When the patient is ready for the PET/CT scan, s/he will have the blood sugar tested. Next, most patients will receive an oral contrast (barium drink). An IV will then be started, and s/he will receive an injection of a small amount of safe, radioactive sugar (radiotracer). The patient will then be asked to wait very quietly in a seated area. Any activity, even talking or gum chewing, may affect the results of the test. Prior to the scan, the patient will be asked to empty his/her bladder.

    The patient will lie on a bed that passes slowly through the scanner. For scanning purposes, it is important that the patient lies quietly and remain still on the bed during the scan. The length of time between scans can vary depending on the body areas being studied, typically between 30 to 60 minutes. The patient should plan to spend approximately three hours total time at the Nuclear Imaging Suite for the entire PET/CT procedure.

    How to Prepare For the PET/CT Exam
    • Refrain from eating for at least six hours prior to the exam since the results of the test are affected by the blood sugar level.
    • It is important to be well hydrated for the test, so please make sure that the patient drinks plenty of water beginning the day before the exam up to the appointment time.
    • Do not perform any heavy lifting or exercising the day before or the day of the PET/CT scan.
    • If the patient is diabetic, please notify the technologist so that s/he may administer special instructions to you as necessary prior to the PET/CT scan.
    • It is also recommended that the patient wears comfortable clothing.
    SPECT/CT

    SPECT/CT is an advanced medical imaging technology that combines Single-Photon Emission Computed Tomography (SPECT) with Computed Tomography (CT) to enable physicians to detect heart disease, cancer and other diseases earlier and target treatments with greater precision.

    SPECT, like Positron Emission Tomography (PET), is a nuclear medicine exam that allows direct visualization of tissues, tumours and organs, such as the heart. SPECT/CT system allows physicians to obtain more detailed information and increased image clarity in a single, non-invasive procedure than is possible through separate procedures. The system detects changes in patients’ molecular activity – before structural changes become visible – and combines this information with precise anatomical detail obtained through CT technology to pinpoint the location of abnormal tissue.

    When the patient arrives at the Nuclear Imaging Suite, a technologist will discuss the SPECT/CT procedure with him/her and ask ifs/he has any questions. Then a small amount of radiopharmaceuticals will be introduced into the body by injection, swallowing or inhalation. The radiopharmaceuticals are attracted to specific organs, bones or tissues. The amount of radiopharmaceuticals used for the patient’s exam will be carefully determined to provide the least amount of radiation exposure and to ensure an accurate test.

    The scanner then creates images of the area being examined and identifies “hot spots” that indicate the location and extent of disease, such as the increased metabolic activity characteristic of cancer. The combination of high-resolution CT through the SPECT/CT allows physicians to accurately localize these hot spots and make a definitive diagnosis.

    How to Prepare For the Nuclear Medicine Exam
    • Bone Scan
      • The patient may eat and drink prior to his/her scan.
      • Please do not schedule an X-ray barium study on the same day as the patient’s Bone Scan.
      • You may schedule a CT exam on the day of the patient’s Bone Scan.
      • If the patient had a Barium Enema (BE) a day or two before the scheduled appointment time, an X-ray may be taken to make sure that the barium is all out of the system.
    • Cardiac Scan
      • Please do not eat or drink after midnight, the day before the Cardiac Scan.
      • At the time of scheduling your exam, the patient will be told whether or not s/he will receive Persantine during the exam. If the patient will be receiving Persantine, let him/her not ingest caffeine for 24 hours prior to the exam.
      • The doctor will advise the patient of which medications s/he may and may not take the morning of exam.
    • Hepatobiliary: Please do not eat or drink after midnight, the day before the scan.
    • Gastric Emptying: Please do not eat or drink after midnight, the day before your scan.
    • Brain: There is no preparation for this exam. The doctor will advise the patient of which medications s/he may and may not take the morning of exam.
    • Parathyroid: There is no preparation for this exam.
    • Renal Scan: There is no preparation for this exam.

    Ultrasound

    Ultrasound uses sound waves to obtain a medical image or picture of various organs and tissues in the body. It is a painless and safe procedure. Ultrasound produces very precise images of the soft tissues (heart, blood vessels, uterus, bladder, etc.) and reveals internal motion such as heart beat and blood flow. It can detect diseased or damaged tissues, locate abnormal growths and identify a wide variety of changing conditions, which enable the doctor to make a quick and accurate diagnosis.

    What will the exam be like?

    A technologist will assist the patient onto the examination table. At this time, a water-based transmission gel will be applied to the area of the body that will be examined. A transducer will be moved slowly over the body part being imaged. The transducer sends a signal to an on-board computer which processes the data and produces the ultrasound image. It is from this image that the diagnosis is made.

    The patient won’t feel a thing except for the slight pressure and movement of the transducer over the part of the body being imaged. It is important that the patient remains still and relaxed during the procedure. The ultrasound images will appear on a monitor similar to a TV screen and will be recorded either on paper or film for a detailed study.

    How to prepare for The Ultrasound exam of the pelvis

    Eat meals - DO NOT FAST! Drink 32 ounces of clear liquids (no soda) one hour and 15 minutes prior to the time of the appointment. (All of the liquid is to be in your system one hour before the appointment so that the bladder will be full.) DO NOT EMPTY the bladder until the study has been completed or the patient has spoken with a technologist.

    How to prepare for The Ultrasound exam for pregnancy, kidneys, and bladder
    • Eat meals - DO NOT FAST! Drink 20 ounces of water one hour and 15 minutes prior to the time of the appointment.
    • Continue as above
    How to Prepare For the Ultrasound Exam of the Abdomen
    • Do not eat or drink anything after midnight the night before the procedure.

    Bone Density (DEXA)

    Bone Densitometry is a fast, safe and painless test that uses advanced technology called DEXA (Dual Energy X-Ray Absorptiometry) to measure symptoms of osteoporosis -- such as low density and mineral content of bone -- that may have developed unnoticed over many years. Because osteoporosis can result in bone fractures that can cause chronic pain, disability and loss of independence, it is important to begin treating osteoporosis at an early stage. Bone densitometry can detect the early signs of osteoporosis so that patients can begin treating it before a debilitating fracture occurs.

    During a comprehensive DEXA bone evaluation, a patient lies comfortably on a padded table while the DEXA unit scans one or more areas of his/her body, usually the spine or hip because they are particularly prone to fracturing.

    When the exam is complete, the patient’s images are sent to a computer and analyzed. They are then given to a radiologist, a physician who specializes in the diagnostic interpretation of medical images. After the study has been reviewed, the doctor will receive a report of the findings. This report will include patient’s bone mineral density (BMD), along with the FRAX (Fracture Risk Assessment Tool) results. The radiologist will use the FRAX assessment tool, developed by the World Health Organization, to obtain two results, expressed as percentages. These numbers are a ten-year probability of hip fracture and ten-year probability of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).

    Digital Mammography

    A mammogram is a safe low-dose X-ray procedure that takes pictures of the internal tissues of the breasts. This simple exam is performed as a screening or diagnostic study, to determine the possibility of irregularities within the breast. It can reveal areas too small or deep to feel, which may or may not require further investigation. Digital Mammography is the most advanced diagnostic technology available for the early detection of breast cancer.

    What are the benefits of Digital Mammography?

    There are numerous benefits to digital mammography. For the patient, digital mammograms are faster. The test is "filmless," so nothing has to be developed. Images are read on a monitor and stored electronically in the PACS (Picture Archiving and Communications System). For the radiologist, digital mammograms provide more comprehensive visibility. Calcifications can be enhanced or magnified on the screen to aid the radiologist in interpreting whether or not the calcifications are suspicious. That is good news for younger women and those who have dense breasts. Digital mammography units are also able to accommodate women with larger breasts. This means fewer images and less radiation for these patients.

    Radionuclide (Isotope) Scan

    A radionuclide scan is a way of imaging bones, organs and other parts of the body by using a small dose of a radioactive chemical. A radionuclide (sometimes called a radioisotope or isotope) is a chemical which emits a type of radioactivity called gamma rays. A tiny amount of radionuclide is put into the body, usually by an injection into a vein. (Sometimes it is breathed in, or swallowed, depending on the test.)

    Gamma rays are detected by a device called a gamma camera. The computer builds a picture by converting the differing intensities of radioactivity emitted into different colours or shades of grey. Areas of the target organ or tissue which emit lots of gamma rays may be shown as red spots ('hot spots'). Areas which emit low levels of gamma rays may be shown as blue ('cold spots').

    Are there any risks with radioisotope scans?

    The term 'radioactivity' may sound alarming. But, the radioactive chemicals used in radionuclide scans are considered to be safe, and they leave the body quickly in the urine. The dose of radiation that your body receives is very small. However:

    • As with any other types of radiation (such as X-ray), there is a small risk that the gamma rays may affect an unborn child. So, tell your doctor if you are pregnant or if you may be pregnant.
    • Rarely, some people have an allergic reaction to the injected chemical. Tell your doctor if you are allergic to iodine.

    Endoscopy

    Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope, an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ.

    Risks
    • Infection
    • Punctured organs
    • Over-sedation

    The main risks are perforation, or a tear, of the stomach or oesophagus lining and bleeding. Although perforation generally requires surgery, certain cases may be treated with antibiotics and intravenous fluids. Bleeding may occur at the site of a biopsy or polyp removal. Seldom does surgery become necessary.

    After the Endoscopy

    After the procedure the patient will be observed and monitored by a qualified nurse in the endoscopy room or a recovery area until a significant portion of the medication has worn off. Occasionally the patient is left with a mild sore throat, which may respond to saline gargles, or chamomile tea. The patient may have a feeling of distention from the insufflate air that was used during the procedure. Both problems are mild and fleeting. When fully recovered, the patient will be instructed when to resume their usual diet.

    Aseptic technique & Special investigations in surgical nursing Read More »

    EMPHYSEMA PULMONARY EMPHYSEMA

    EMPHYSEMA / PULMONARY EMPHYSEMA

    Nursing Notes - Thrombus and Embolus

    EMPHYSEMA / PULMONARY EMPHYSEMA

    Introduction

    Definition: Emphysema is a chronic and progressive lung disease primarily characterized by the destruction and enlargement of the air sacs (alveoli) at the end of the smallest airways (bronchioles) in the lungs. This damage leads to a significant reduction in the surface area available for gas exchange, resulting in chronic and progressively worsening difficulty breathing.

    More specifically, emphysema is a pathological diagnosis that affects the air spaces distal to the terminal bronchiole. It is defined by an abnormal, permanent enlargement of the air spaces, accompanied by the destruction of their walls without obvious fibrosis. This destruction of the lung parenchyma leads to a loss of elastic recoil, increased air trapping, thoracic over-distention (hyperinflation), and often, a compromised function of the diaphragm. While sputum accumulation can be present, it is more characteristic of chronic bronchitis, which often coexists with emphysema.

    Pulmonary emphysema is a major component and a progressive form of Chronic Obstructive Pulmonary Disease (COPD). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines COPD as "a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases."

    NB: Emphysema, Chronic Bronchitis, and Asthma (when overlapping with persistent airflow limitation) are the primary disease entities that fall under the umbrella term of COPD.

    Pathology (Pathophysiology)

    The core pathological process in emphysema involves the irreversible breakdown of the elastic fibers and walls of the alveoli, which are the tiny air sacs responsible for gas exchange. This destruction leads to the coalescence of smaller air sacs into larger, irregularly shaped, and less efficient air spaces. The process unfolds as follows:

    • Alveolar Destruction and Enlargement: The delicate walls separating individual alveoli are progressively destroyed. This leads to the formation of fewer, but much larger, air-filled spaces. These enlarged spaces, often referred to as bullae if they are greater than 1 cm in diameter, have significantly reduced surface area for the efficient exchange of oxygen into the blood and carbon dioxide out of it.
    • Loss of Elastic Recoil: The lung tissue, particularly the elastic fibers that normally allow the lungs to recoil and expel air during exhalation, are damaged or lost. This loss of elasticity means that air becomes trapped within the enlarged air spaces, leading to hyperinflation of the lungs.
    • Air Trapping: Due to the loss of elastic recoil and the destruction of alveolar walls, air becomes trapped in the lungs, particularly during exhalation. This increases the residual volume and functional residual capacity, leading to a perpetually overinflated chest.
    • Bronchiolar Collapse: The small airways (bronchioles) that lead to the alveoli are also affected. Due to the loss of surrounding parenchymal support and elastic recoil, these airways tend to collapse prematurely during exhalation, further contributing to air trapping.
    • Inflammation and Protease-Antiprotease Imbalance: The primary trigger for this destructive process is chronic exposure to irritants, most notably cigarette smoke. These irritants activate an inflammatory response in the lungs. Inflammatory cells (e.g., neutrophils, macrophages) release proteolytic enzymes, particularly neutrophil elastase, which are capable of breaking down elastic fibers and connective tissue in the lung. Normally, the lungs are protected by anti-proteases, such as alpha-1 antitrypsin (AAT). However, in individuals exposed to smoke, the activity of these protective anti-proteases is overwhelmed or directly inhibited by components of cigarette smoke. This imbalance between proteases and anti-proteases leads to the unchecked destruction of the alveolar walls and the breakdown of elastic tissue and collagen.
    • Impaired Gas Exchange: The loss of alveolar tissue drastically reduces the surface area available for gas exchange. Additionally, the destruction of the capillary beds surrounding the alveoli (which are part of the alveolar wall) leads to reduced blood flow through the pulmonary capillary system. This combined effect severely impairs the transfer of oxygen into the blood and the removal of carbon dioxide.
    • Permanent Damage: The damage to the alveolar structures and elastic tissue is permanent and irreversible. While interventions can manage symptoms and slow progression, the ability to breathe properly cannot be fully restored once this destruction has occurred.

    Causes of Emphysema

    Emphysema is predominantly caused by long-term exposure to inhaled irritants, with genetic factors playing a significant role in susceptibility for some individuals.

  • Cigarette Smoking: This is by far the leading cause of emphysema, accounting for approximately 80-90% of cases. The chemicals and particulate matter in cigarette smoke directly initiate and perpetuate the inflammatory and destructive processes in the lungs. The duration and intensity of smoking are directly correlated with the risk of developing emphysema.
  • Passive Smoking (Secondhand Smoke): Chronic exposure to secondhand smoke can also increase the risk of developing emphysema, particularly in childhood and adolescence.
  • Alpha-1 Antitrypsin (AAT) Deficiency: This is a genetic (hereditary) condition where the body does not produce enough alpha-1 antitrypsin, a protein that protects the lungs from the destructive effects of enzymes (like elastase) released by inflammatory cells. Individuals with severe AAT deficiency can develop panacinar emphysema, often at a younger age and even without a history of smoking.
  • Inhaled Toxins and Air Pollutants: Long-term exposure to various occupational dusts, chemicals, and environmental pollutants can contribute to the development of emphysema. These include:
    • Occupational Dusts: Such as coal dust (in coal miners), grain dust, cotton dust, and silica.
    • Chemical Fumes: Exposure to cadmium, isocyanates, and other industrial chemicals.
    • Indoor Air Pollution: Smoke from biomass fuels (e.g., wood, animal dung) used for cooking and heating in poorly ventilated homes, particularly common in developing countries.
    • Outdoor Air Pollution: Chronic exposure to high levels of urban air pollution, including particulate matter and ozone.
  • Childhood Respiratory Disorders: Severe or recurrent respiratory infections during childhood, especially those that cause significant inflammation and damage to developing airways, may increase the susceptibility to developing emphysema later in life. While asthma itself is a distinct condition, severe, long-standing, or poorly controlled asthma can, in some cases, lead to irreversible airflow limitation similar to that seen in COPD, particularly if accompanied by structural changes in the airways.
  • Genetics (Other than AAT Deficiency): While AAT deficiency is the most well-understood genetic risk factor, other genetic predispositions may influence an individual's susceptibility to the harmful effects of inhaled irritants, explaining why some heavy smokers develop severe emphysema while others do not.
    • Contributory Risk Factors (can exacerbate or increase susceptibility)
    • Bronchial Asthma: While distinct, severe, chronic, or poorly controlled asthma can lead to airway remodeling and contribute to fixed airflow obstruction, sometimes blurring the lines with COPD, especially "asthma-COPD overlap syndrome."
    • Aging: As people age, natural changes occur in the lung structure, including a decrease in elastic recoil, which can make them more susceptible to emphysema.
    • Infections: Frequent respiratory infections can accelerate lung damage in susceptible individuals.

    Signs and Symptoms of Emphysema

    The symptoms of emphysema typically develop gradually over many years and progressively worsen. They reflect the impaired gas exchange and increased work of breathing.

    • Dyspnea (Shortness of Breath): This is the hallmark symptom and is typically progressive. Initially, it may only occur during physical exertion, but as the disease advances, it becomes noticeable even with minimal activity or at rest. Patients often report feeling "air hungry."
    • Chronic Cough: While more characteristic of chronic bronchitis, a persistent cough, which may or may not be productive of sputum, can also be present in emphysema, particularly if bronchitis coexists.
    • Wheezing: A whistling sound during breathing, caused by narrowed airways.
    • Frequent Lung Infections: Due to impaired mucociliary clearance and damaged lung tissue, individuals with emphysema are more susceptible to recurrent respiratory infections (e.g., bronchitis, pneumonia).
    • Weight Loss: Significant weight loss can occur due to the increased energy expenditure associated with the constant work of breathing, reduced appetite, and systemic inflammation.
    • Fatigue: Chronic dyspnea, increased work of breathing, hypoxemia, and sleep disturbances contribute to profound fatigue.
    • Cyanosis: Bluish discoloration of the skin, lips, or nail beds, indicating insufficient oxygen in the blood. This is a sign of advanced disease.
    • Anxiety and Depression: The chronic, debilitating nature of the disease, coupled with the constant struggle for breath and fear of suffocation, often leads to significant psychological distress.
    • Sleep Problems: Dyspnea, coughing, and hypoxemia can disrupt sleep patterns, leading to insomnia or frequent awakenings.
    • Morning Headaches: Can be a sign of hypercapnia (high carbon dioxide levels) during sleep due to hypoventilation.
    • Barrel Chest: Due to chronic air trapping and hyperinflation, the chest wall may expand, giving it a rounded, barrel-like appearance.
    • Pursed-Lip Breathing: A compensatory breathing technique used to create back pressure in the airways, helping to keep them open during exhalation and reduce air trapping.
    • Use of Accessory Muscles of Respiration: As the diaphragm's efficiency decreases, patients may rely on neck and shoulder muscles (e.g., sternocleidomastoid, scalenes) to assist with breathing.

    Management of a Patient with Emphysema

    The management of emphysema is focused on relieving symptoms, slowing disease progression, preventing and treating complications, and improving the patient's quality of life. As emphysema is irreversible, the goal is not a cure but effective disease management.

    Aims of Management
    • To optimize respiratory function and restore the best possible breathing pattern.
    • To prevent or minimize the frequency and severity of acute exacerbations.
    • To alleviate symptoms such as dyspnea and cough.
    • To improve exercise tolerance and overall physical functioning.
    • To prevent and manage complications, including infections and heart problems.
    • To enhance the patient's quality of life and reduce anxiety/depression associated with the disease.
    • To provide education and support for self-management.
    General Management and Nursing Interventions

    A multi-faceted approach involving medical, nursing, and rehabilitative interventions is crucial.

    1. Assessment and Monitoring:

    • Admission of the patient to a medical ward, ideally quiet and well-ventilated, to promote rest and reduce environmental irritants.
    • Thorough initial assessment of respiratory status: rate, rhythm, depth, use of accessory muscles, breath sounds (e.g., diminished, wheezes, rhonchi), and oxygen saturation (SpO2).
    • Regular monitoring of vital observations: temperature, pulse, respiration, and blood pressure. These must be meticulously recorded on the patient's file and trended to identify changes or signs of deterioration (e.g., fever indicating infection, increased respiratory rate, tachycardia).
    • Assess for signs of hypoxemia (cyanosis, confusion) and hypercapnia (morning headaches, somnolence, confusion).
    • Monitor fluid balance, especially if there is increased insensible loss from tachypnea or if diuretics are used for cor pulmonale.
    • Assess nutritional status and provide dietary support if needed.

    2. Positioning and Comfort:

    • Position the patient in a sitting-up position (e.g., High Fowler's, orthopneic position) to maximize lung expansion and aid breathing by reducing pressure on the diaphragm.
    • Provide emotional support and reassurance to allay anxiety, which can worsen dyspnea. Teach relaxation techniques.

    3. Oxygen Therapy:

    • Administration of supplemental oxygen therapy as prescribed, guided by SpO2 levels and arterial blood gases (ABGs). The goal is to maintain adequate oxygenation (e.g., SpO2 > 90%) while carefully monitoring for CO2 retention, especially in advanced stages (start with low flow rates, e.g., 1-2 L/min, and titrate based on patient response and ABGs). Oxygen therapy helps improve oxygen delivery to the lungs and tissues.

    4. Pharmacological Management (Drug Therapy):

    • Bronchodilators: These medications relax the smooth muscles of the airways, helping to open them up and reduce bronchospasm. They are typically given via inhalers (nebulizers or metered-dose inhalers with spacers).
      • Short-acting beta-agonists (SABAs) e.g., Albuterol (Salbutamol): For quick relief of acute dyspnea.
      • Long-acting beta-agonists (LABAs) e.g., Salmeterol, Formoterol: For long-term maintenance.
      • Short-acting anticholinergics e.g., Ipratropium: For quick relief.
      • Long-acting anticholinergics (LAMAs) e.g., Tiotropium: For long-term maintenance.
      • Methylxanthines e.g., Theophylline: Less commonly used due to side effects and narrow therapeutic window, but may be used in some cases.
    • Corticosteroids:
      • Inhaled Corticosteroids (ICS): Often used in combination with LABAs for patients with frequent exacerbations or significant symptoms, particularly if they have an "asthma-like" component. E.g., Fluticasone, Budesonide.
      • Oral Corticosteroids: Used for acute exacerbations to reduce inflammation and improve airflow. E.g., Prednisone. Long-term use is generally avoided due to significant side effects.
    • Antibiotics: Prescribed for acute exacerbations if there is evidence of bacterial infection (e.g., increased sputum purulence, fever).
    • Diuretics: May be used if the patient develops cor pulmonale with peripheral edema.
    • Mucolytics: (e.g., acetylcysteine) May be considered in some patients with very thick, tenacious sputum, although their routine use is debated.
    • Alpha-1 Antitrypsin Augmentation Therapy: For patients with documented severe AAT deficiency, intravenous infusion of pooled human alpha-1 antitrypsin can help slow the progression of emphysema.

    5. Pulmonary Rehabilitation:

    • A comprehensive program that includes exercise training, nutritional counseling, education on lung disease, and psychological support. This significantly improves exercise tolerance, reduces symptoms, and enhances quality of life.
      • Physical exercises: Encouraged within the patient's tolerance, such as walking, cycling (stationary bikes). These help the body use oxygen more efficiently, improve muscle strength, and reduce breathlessness.
      • Breathing Techniques: Teaching pursed-lip breathing and diaphragmatic breathing can help control dyspnea and improve exhalation.

    6. Nutritional Support:

    • Patients with advanced emphysema often have increased caloric needs due to the work of breathing but may experience reduced appetite. Nutritional counseling and calorie-dense, small, frequent meals can help prevent weight loss and maintain muscle mass.

    7. Surgical Interventions (for select cases):

    • Lung Volume Reduction Surgery (LVRS): In highly selected patients with upper lobe emphysema and low exercise capacity, surgical removal of the most diseased parts of the lung can reduce hyperinflation and improve lung function.
    • Bullectomy: Surgical removal of large bullae that are not contributing to gas exchange and are compressing healthy lung tissue.
    • Lung Transplantation: A last-resort option for very severe emphysema in carefully selected candidates.

    Health Education on Emphysema

    Comprehensive health education is fundamental to empowering patients to manage their condition effectively, prevent complications, and maintain the best possible quality of life.

    • Smoking Cessation: This is the single most important intervention. Emphasize that quitting cigarette smoking (and avoiding all other tobacco products) is crucial to slow the progression of the disease and prevent further lung damage. Provide resources for smoking cessation programs, nicotine replacement therapy, or medications.
    • Vaccination: Highly recommended to prevent respiratory infections that can trigger acute exacerbations.
      • Annual influenza (flu) immunization.
      • Pneumococcal vaccination: Typically, a series of two vaccinations (PCV13 and PPSV23) for adults with chronic lung disease, with specific intervals. (Note: "5 yearly one against pneumonia" is a simplified guideline, and current recommendations for pneumococcal vaccines should be followed).
      • COVID-19 vaccination and boosters.
      • Pertussis (whooping cough) vaccine.
    • Nutritional Guidance: A healthful diet with plenty of fresh fruits, vegetables, whole grains, lean proteins, and a low intake of processed foods, unhealthy fats, and added sugars is necessary. Advise on strategies to manage appetite and maintain weight, such as smaller, more frequent meals.
    • Physical Activity and Exercise: Encourage regular, gentle physical exercises within the patient's tolerance (e.g., walking, using stationary bikes, light resistance training). Explain that these help the body use oxygen more efficiently, improve muscle strength, and hence improve breathing and overall well-being. Emphasize the importance of pulmonary rehabilitation.
    • Breathing Techniques: Teach and reinforce effective breathing techniques such as pursed-lip breathing (to control breathlessness and prevent airway collapse) and diaphragmatic (abdominal) breathing (to maximize diaphragm efficiency).
    • Medication Adherence: Educate on the purpose, correct administration (especially for inhalers), dosage, and potential side effects of all prescribed medications. Emphasize the importance of consistent use of maintenance medications.
    • Symptom Recognition and Action Plan: Teach patients to recognize early signs of worsening symptoms or acute exacerbations (e.g., increased dyspnea, increased cough, change in sputum color/volume, fever) and provide a clear action plan on when to contact their healthcare provider or seek emergency care.
    • Avoidance of Irritants: Advise avoiding exposure to environmental lung irritants such as secondhand smoke, air pollution, chemical fumes, and strong odors.
    • Infection Control: Practice good hand hygiene, avoid crowds during flu season, and manage underlying conditions that increase infection risk.
    • Psychological Support: Address anxiety and depression. Encourage open communication, support groups, and professional counseling if needed.
    • Follow-up Care: Emphasize that regular follow-up visits with healthcare providers are crucial for ongoing assessment, adjustment of treatment plans, and early detection of complications.
    • Energy Conservation Techniques: Advise on strategies to conserve energy and manage daily activities, such as pacing oneself, taking breaks, and using assistive devices if necessary.

    Complications of Emphysema

    The complications of emphysema range from direct respiratory issues to systemic effects, often progressing in severity as the disease advances.

    • Acute Exacerbations of COPD (AECOPD): Emphysema patients are highly susceptible to acute worsening of their symptoms, often triggered by respiratory infections (viral or bacterial) or increased exposure to irritants. These exacerbations can be severe, requiring hospitalization and significantly impacting lung function and quality of life.
    • Pneumonia: Due to impaired lung defenses and altered lung architecture, individuals with emphysema are at increased risk of developing bacterial or viral pneumonia, which can be life-threatening.
    • Pneumothorax (Collapsed Lung): The destruction of alveolar walls can lead to the formation of large air-filled sacs (bullae). These bullae can sometimes rupture, allowing air to escape into the space between the lung and the chest wall (pleural space), leading to a collapsed lung (spontaneous pneumothorax). This is a medical emergency.
    • Bullae: While bullae themselves are part of the emphysematous process, very large bullae can compress healthy lung tissue, further impairing function. They also carry the risk of rupture.
    • Pulmonary Hypertension: The chronic hypoxemia (low blood oxygen) in emphysema causes the blood vessels in the lungs to constrict (pulmonary vasoconstriction). This leads to increased pressure in the arteries of the lungs, a condition known as pulmonary hypertension.
    • Cor Pulmonale (Right-Sided Heart Failure): Persistent pulmonary hypertension places increased strain on the right side of the heart, which is responsible for pumping blood to the lungs. Over time, this increased workload can cause the right ventricle to enlarge and weaken, leading to right-sided heart failure (cor pulmonale). Symptoms include swelling in the ankles and legs (peripheral edema), jugular venous distension, and liver enlargement.
    • Respiratory Failure: In advanced stages or during severe exacerbations, the lungs' ability to adequately oxygenate the blood and remove carbon dioxide becomes severely compromised, leading to acute or chronic respiratory failure. This may necessitate mechanical ventilation or long-term oxygen therapy.
    • Polycythemia: Chronic hypoxemia can stimulate the bone marrow to produce more red blood cells (erythrocytosis or polycythemia) as the body attempts to compensate for low oxygen levels. This increases the viscosity (thickness) of the blood, raising the risk of blood clots (e.g., deep vein thrombosis, pulmonary embolism).
    • Weight Loss and Malnutrition: The increased metabolic demands from the work of breathing, reduced appetite, and systemic inflammation often lead to unintentional weight loss and muscle wasting.
    • Osteoporosis: Patients with emphysema are at higher risk of developing osteoporosis due to chronic inflammation, corticosteroid use, and reduced physical activity.
    • Muscle Weakness and Dysfunction: Systemic inflammation and deconditioning contribute to weakness and atrophy of skeletal muscles, further impacting exercise capacity and quality of life.
    • Depression and Anxiety: The chronic and debilitating nature of emphysema significantly impacts mental health, often leading to depression and anxiety.

    EMPHYSEMA / PULMONARY EMPHYSEMA Read More »

    BRONCHITIS

    BRONCHITIS

    Nursing Notes - Thrombus and Embolus

    BRONCHITIS

    Introduction

    Bronchitis is a common respiratory condition characterized by an inflammation of the mucous membranes lining the bronchi. These are the larger and medium-sized airways that serve as critical conduits for airflow, transporting air from the trachea (windpipe) into the more distal and delicate lung parenchyma, where gas exchange occurs. This inflammation leads to a cascade of physiological changes, including swelling, increased mucus production, and irritation of the airways, which collectively impair normal respiratory function.

    Types of Bronchitis

    Bronchitis is broadly classified based on its duration and clinical presentation into two main categories: acute and chronic.

    1. Acute Bronchitis:

      This form of bronchitis represents a transient inflammation of the large airways of the lung, typically characterized by a sudden and rapid onset of symptoms. It is usually self-limiting, meaning it resolves spontaneously, often within a period of 10 days to 3 weeks, although the associated cough can sometimes persist for several weeks longer. Acute bronchitis is commonly a sequela of an upper respiratory tract infection.

    2. Chronic Bronchitis:

      In contrast, chronic bronchitis is defined by a persistent and recurrent inflammation of the large airways of the lung. Its development is often gradual, and the defining characteristic is a chronic productive cough that lasts for at least 3 months in a year for two consecutive years, in the absence of other underlying lung diseases that could explain the cough. This condition is often a component of Chronic Obstructive Pulmonary Disease (COPD) and is typically associated with long-term exposure to irritants, most notably cigarette smoke.

    Classification of bronchitis according to cause

    Beyond duration, bronchitis can also be classified based on its etiology, distinguishing between infectious and non-infectious triggers.

    1. Infectious/Contagious Bronchitis:

    This type of bronchitis occurs when the inflammation of the bronchi is caused by a living biological agent, or pathogen. These pathogens are transmitted from person to person or from the environment. Common infectious causes include:

    • Viral Bronchitis: By far the most common cause, accounting for approximately 90-95% of acute bronchitis cases in healthy adults. Viruses such as Influenza A and B, Parainfluenza, Adenovirus, Respiratory Syncytial Virus (RSV), Rhinovirus, and Coronavirus are frequent culprits.
    • Bacterial Bronchitis: Less common in acute settings, but can occur, often as a secondary infection following a viral illness. Common bacterial agents include Mycoplasma pneumoniae, Chlamydophila pneumoniae, Bordetella pertussis (whooping cough), Streptococcus pneumoniae, and Haemophilus influenzae. Bacterial bronchitis may also be seen in chronic bronchitis exacerbations.
    • Fungal Bronchitis: Rarer, typically affecting individuals with compromised immune systems (e.g., those with HIV/AIDS, organ transplant recipients, or those on immunosuppressive therapy). Examples include Aspergillus species or Candida species.

    2. Non-infectious/Non-contagious Bronchitis:

    This form of bronchitis is not caused by a pathogen and therefore is not transmissible. Instead, it results from exposure to various irritants or other underlying conditions. Common non-infectious causes include:

    • Chemical Irritants: Inhalation of toxic fumes, industrial pollutants, strong chemicals (e.g., ammonia, chlorine, sulfur dioxide), or particulate matter can directly irritate and inflame the bronchial lining.
    • Environmental Factors: Exposure to high levels of air pollution, smog, dust, or allergens (e.g., pollen, pet dander, mold spores) can trigger an inflammatory response in the airways.
    • Allergic Reactions: In susceptible individuals, exposure to specific allergens can induce an allergic bronchial inflammation, sometimes referred to as allergic bronchitis.
    • Gastric Reflux: Chronic gastroesophageal reflux disease (GERD) can lead to micro-aspiration of stomach acid into the airways, causing irritation and inflammation, particularly contributing to chronic cough and sometimes chronic bronchitis.
    • Drug Side Effects: Certain medications, though less common, can rarely induce a form of bronchitis as a side effect.
    • Mechanical Irritation: Prolonged exposure to very cold or very dry air can sometimes cause irritation, particularly in sensitive airways.

    Pathophysiology

    The pathophysiological processes underlying acute and chronic bronchitis differ significantly, reflecting their distinct etiologies and clinical courses.

    Acute Bronchitis

    Acute bronchitis is fundamentally the result of acute inflammation of the bronchi, triggered predominantly by various factors, with viral infections being the most common. Other triggers can include bacterial infections, allergens, environmental pollutants, or even aspiration. The inflammatory process unfolds as follows:

    1. Initial Irritation and Viral Entry: Typically, a viral upper respiratory infection (URI) precedes acute bronchitis. Viruses replicate in the epithelial cells lining the upper airways and can then spread downwards to the larger bronchi.
    2. Inflammatory Response: The body's immune system mounts an inflammatory response to the invading pathogen or irritant. This leads to the release of inflammatory mediators (e.g., histamine, prostaglandins, bradykinin).
    3. Mucosal Changes: The inflammation of the bronchial wall results in:
      • Mucosal Thickening and Edema: The lining of the airways swells and becomes thicker due to fluid accumulation, narrowing the bronchial lumen.
      • Epithelial-Cell Desquamation: The protective epithelial cells that line the airways are damaged and shed.
      • Denudation of the Basement Membrane: In some areas, the underlying basement membrane, which supports the epithelial cells, may become exposed, making the airway more vulnerable to further irritation and infection.
      • Increased Mucus Production: Goblet cells within the bronchial lining, and submucosal glands, respond to inflammation by overproducing mucus. This mucus often becomes thicker and stickier.
    4. Airway Obstruction and Symptoms: The combination of mucosal edema, increased and tenacious mucus, and damaged cilia (tiny hair-like structures that help move mucus) leads to partial airway obstruction. This obstruction and irritation trigger the characteristic symptoms of acute bronchitis:
      • Cough: The primary symptom, initially non-productive, but often becoming productive as mucus accumulates.
      • Wheezing: Due to narrowed airways.
      • Shortness of Breath: In more severe cases.
    5. Resolution: As the immune system clears the infection and the inflammation subsides, the bronchial mucosa heals, and symptoms resolve. The cough may linger due to persistent airway hyperresponsiveness even after the acute inflammation has resolved.
    Chronic Bronchitis

    Chronic bronchitis is a progressive inflammatory condition primarily characterized by chronic mucus hypersecretion and structural changes in the airways. It is often a key component of Chronic Obstructive Pulmonary Disease (COPD) and is distinct from acute bronchitis in its chronic, often irreversible nature. The pathophysiology involves:

    1. Chronic Irritant Exposure: The primary trigger is prolonged and repeated exposure to inhaled irritants, with cigarette smoke being the most significant. Other irritants include industrial dusts, air pollution, and occupational chemicals.
    2. Goblet Cell Hyperplasia and Hypersecretion: In response to chronic irritation, the number and size of mucus-producing goblet cells in the bronchial lining increase (hyperplasia), and they produce excessive amounts of mucus (hypersecretion). Submucosal glands also enlarge and overproduce mucus.
    3. Impaired Mucociliary Clearance: The cilia, which are responsible for sweeping mucus and trapped particles out of the airways, become damaged, dysfunctional, or are destroyed by the chronic inflammation and irritant exposure. This impairment leads to mucus stasis, further promoting irritation and susceptibility to infection.
    4. Inflammatory Cell Infiltration and Mediator Release: The chronic irritation triggers a persistent inflammatory response in the bronchial walls. Various inflammatory cells, including macrophages, neutrophils, and lymphocytes, infiltrate the airway. These cells release a range of pro-inflammatory mediators, such as interleukin-8 (IL-8), tumor necrosis factor-alpha (TNF-α), leukotrienes, and proteases (e.g., elastase from neutrophils). These mediators contribute to ongoing inflammation, tissue damage, and mucus production.
    5. Imbalance of Regulatory Substances: There is often an associated decrease in the release of regulatory substances that normally protect the airway, such as angiotensin-converting enzyme (ACE) and neutral endopeptidase. This imbalance can exacerbate inflammation and bronchoconstriction.
    6. Airway Remodeling: Over time, chronic inflammation and irritation lead to structural changes in the airways, known as airway remodeling. This includes:
      • Thickening of the bronchial walls due to fibrosis and smooth muscle hypertrophy.
      • Narrowing of the small airways, leading to increased airway resistance.
      • Loss of elastic recoil in the lungs (if emphysema is also present), further impairing airflow.
    7. Acute Exacerbations: During an acute exacerbation of chronic bronchitis (AECB), typically triggered by viral or bacterial infections, the bronchial mucous membrane becomes acutely hyperemic (engorged with blood) and edematous. Bronchial mucociliary function is further diminished. This, in turn, leads to a significant increase in airflow impediment because of luminal obstruction to small airways by even more copious and tenacious mucus. The airways become further clogged by cellular debris, inflammatory exudates, and thickened mucus, significantly increasing irritation and worsening symptoms.
    8. Characteristic Cough: The most characteristic symptom of chronic bronchitis, the persistent productive cough, is directly caused by the copious secretion of mucus that the body attempts to clear from the airways.

    Causes of Bronchitis

    The causes of bronchitis vary significantly depending on whether it is acute or chronic.

    Acute Bronchitis

    Acute bronchitis is predominantly caused by infections, usually viral, and is generally self-limiting.

  • Infectious Agents (Most Common):
    • Approximately 90-95% of acute bronchitis cases in healthy adults are secondary to viral infections. The predominant viruses that are causative include:
      • Influenza viruses (Type A and B): Commonly cause seasonal epidemics.
      • Parainfluenza viruses: Often cause croup in children but can cause bronchitis in adults.
      • Adenoviruses: Can cause a range of respiratory illnesses.
      • Respiratory Syncytial Virus (RSV): A common cause of bronchiolitis in infants but can affect adults.
      • Rhinoviruses: The most common cause of the common cold.
      • Coronaviruses: Including those that cause the common cold and SARS-CoV-2 (COVID-19).
    • Bacterial infections are less common primary causes but can occur, often as a secondary infection following a viral illness. Dominant bacterial agents include:
      • *Mycoplasma pneumoniae*: Often associated with "walking pneumonia" but can cause bronchitis.
      • *Chlamydophila pneumoniae*: Another atypical bacterium causing respiratory infections.
      • *Bordetella pertussis* (Whooping Cough): Causes a characteristic paroxysmal cough.
      • Less commonly, *Streptococcus pneumoniae* or *Staphylococcus aureus*.
  • Non-Infectious Irritants and Allergens: Acute bronchitis can sometimes be triggered or exacerbated by the inhalation of various non-infectious irritants or allergens. This can lead to an inflammatory response without an underlying infection. Examples include:
    • Smoke Inhalation: From fires, strong chemical fumes, or even very heavy tobacco smoke exposure.
    • Polluted Air Inhalation: Exposure to high levels of urban air pollution, smog, or particulate matter.
    • Dust: Exposure to occupational dusts (e.g., silica, coal dust) or environmental dust.
    • Chemical Fumes: Such as those from cleaning products, industrial chemicals, or solvents.
    • Allergens: In individuals with allergic sensitivities, exposure to pollen, pet dander, mold spores, or dust mites can trigger an acute asthmatic bronchitis-like reaction.
  • Other Factors: Factors like cold air or extreme humidity can sometimes irritate the airways and contribute to acute bronchitis symptoms.
    • Chronic Bronchitis

    Chronic bronchitis is primarily caused by long-term exposure to respiratory irritants, leading to persistent inflammation and structural changes in the airways.

  • Tobacco Smoke Exposure (Most Significant Factor): The most important and prevalent causative factor for chronic bronchitis is exposure to cigarette smoke, whether due to active smoking (first-hand smoke) or passive inhalation (second-hand smoke). The chemicals and particles in tobacco smoke directly irritate the bronchial lining, leading to chronic inflammation, mucus hypersecretion, and ciliary dysfunction.
  • Inhaled Environmental and Occupational Irritants: Many other inhaled irritants to the respiratory tract can cause or contribute to chronic bronchitis. These include:
    • Smog and Air Pollution: Chronic exposure to urban air pollutants, ozone, and particulate matter.
    • Industrial Pollutants: Fumes, gases, and dusts encountered in various occupations (e.g., mining, construction, manufacturing). Examples include silica, coal dust, grain dust, cotton dust, and chemical vapors.
    • Toxic Chemicals: Repeated exposure to irritant gases such as ammonia, sulfur dioxide, chlorine, or acid fumes.
  • Recurrent Respiratory Infections: Although bacterial and viral infections usually cause acute bronchitis, repeated or severe respiratory infections, particularly during childhood, can contribute to chronic airway damage and increase the susceptibility to developing chronic bronchitis later in life. In patients with established chronic bronchitis, infections frequently trigger acute exacerbations.
  • Underlying Respiratory Diseases: People who have an associated background in certain chronic respiratory diseases have a higher predisposition to develop or exacerbate chronic bronchitis. These include:
    • Asthma: Chronic inflammation and airway hyperresponsiveness in asthma can contribute to symptoms overlapping with chronic bronchitis.
    • Cystic Fibrosis: A genetic disorder leading to thick, sticky mucus production and recurrent infections, causing chronic bronchial inflammation.
    • Bronchiectasis: A condition characterized by permanent enlargement of parts of the airways, leading to chronic mucus accumulation and recurrent infections.
    • Alpha-1 Antitrypsin Deficiency: A genetic condition that predisposes individuals to early-onset emphysema and chronic bronchitis.
  • Chronic Gastroesophageal Reflux Disease (GERD): Chronic gastroesophageal reflux, with repeated micro-aspiration of gastric contents into the lower airways, is a well-documented but less frequent cause of chronic cough and can contribute to chronic bronchitis, particularly if other causes are absent.
  • Genetic Predisposition: While not a direct cause, genetic factors may play a role in individual susceptibility to the effects of environmental irritants and the development of chronic bronchitis.

    • Clinical manifestations of Bronchitis

    Acute Bronchitis

    Patients with acute bronchitis present with:

  • Productive cough:
    • a. Usually, their cough is the predominant complaint and the sputum is clear or yellowish, although sometimes it can be purulent. It's important to note that purulent sputum does not inherently correlate with bacterial infection or necessitate antibiotic use.
    • b. The cough after acute bronchitis typically persists for 10 to 20 days but occasionally may last for 4 or more weeks. The median duration of cough after acute bronchitis is 18 days. Paroxysms of cough, especially if accompanied by an inspiratory "whoop" (a high-pitched gasp) or post-tussive emesis (vomiting after coughing), should raise concerns for pertussis (whooping cough).
    • c. The cough may be worsened by cold air, smoke, or irritants.
  • Malaise: A general feeling of discomfort, illness, or unease whose exact cause is difficult to identify. This can include fatigue and body aches.
  • Difficulty breathing (dyspnea): Often described as shortness of breath, especially with exertion, due to inflammation and narrowing of the bronchial tubes.
  • Wheezing: A high-pitched, whistling sound produced by air flowing through narrowed airways, commonly heard during exhalation. This indicates bronchospasm or inflammation.
  • A prodrome of upper respiratory infection (URI) symptoms like:
    • Runny nose (rhinorrhea)
    • Nasal congestion
    • Sore throat (pharyngitis)
    • Headache
    • Muscle aches (myalgia)
  • Fever: A low-grade fever (typically < 101°F or 38.3°C) may be present. However, high-grade fevers in the setting of acute bronchitis are unusual and warrant further diagnostic workup to rule out other infections like pneumonia.
  • Chest discomfort or tightness: A dull ache or pressure in the chest due to persistent coughing and inflammation of the bronchial tubes.
  • Slight hoarseness: Due to irritation of the vocal cords from coughing.
    • Chronic bronchitis
  • Cough:
    • a. The most common and defining symptom of patients with chronic bronchitis is a persistent cough.
    • b. The history of a cough typical of chronic bronchitis is characterized by its presence for most days in a month, lasting for at least 3 months, with at least 2 such consecutive episodes occurring for 2 years in a row.
    • c. A productive cough with sputum is present in about 50% of patients. The sputum color may vary from clear, white, yellow, green or at times blood-tinged. The color of sputum may change due to the presence of secondary bacterial infection, but it's important to note that color alone is not a definitive indicator.
    • d. Very often, changes in sputum color can be due to peroxidase released by leukocytes in the sputum, giving it a greenish or yellowish hue without a bacterial cause. Therefore, sputum color alone is not a definite indication of bacterial infection and should be interpreted with other clinical signs.
    • e. The cough is typically worse in the mornings and in damp or cold weather.
  • History of possible exposure to inhaled irritants or chemicals, such as industrial fumes, air pollution, or dust, as well as full details regarding smoking habits (pack-years, current status). Occupational exposure is a significant risk factor.
  • Fever is uncommon in chronic bronchitis and when present, can be suggestive of associated acute exacerbation, influenza, or pneumonia.
  • Generalised malaise: A common associated symptom, contributing to overall fatigue and reduced energy levels.
  • Chest pain or abdominal muscle pain caused by continuous forceful coughing, leading to muscle strain or even rib fractures in severe cases.
  • Shortness of breath (dyspnea): Initially occurs with exertion, but as the disease progresses, it can become present at rest. This is a key differentiating factor from uncomplicated chronic bronchitis.
  • Wheezing and crackles: May be heard on auscultation, indicating airflow obstruction and the presence of secretions.
  • Cyanosis: Bluish discoloration of the skin and mucous membranes, especially in the lips and nail beds, due to chronic hypoxemia ("blue bloater" appearance in advanced stages).
  • Peripheral edema: Swelling in the ankles and legs due to right-sided heart failure (cor pulmonale) which can develop as a complication of long-standing chronic bronchitis and pulmonary hypertension.

    • NB: Uncomplicated chronic bronchitis presents primarily with a cough, and there is no evidence of significant airway obstruction physiologically. When airway obstruction is present, it is often indicative of Chronic Obstructive Pulmonary Disease (COPD) with a chronic bronchitis phenotype.

    Investigations

    1. History taking: The diagnosis of bronchitis is primarily made through a detailed history taking, focusing on the onset, duration, and characteristics of symptoms (especially cough), any recent respiratory tract infections, recent or chronic exposure to inhaled irritants (e.g., smoking, occupational hazards, environmental pollutants), and patient's chief complaints.
    2. Physical examination: This involves a thorough assessment of vital signs, respiratory rate, and oxygen saturation. Key findings during physical examination include:
      • Auscultation of lung sounds: May reveal wheezing, rhonchi (coarse rattling sounds), or crackles, indicating inflammation, mucus, or narrowed airways.
      • Observation of breathing patterns: Assessment for signs of respiratory distress, such as accessory muscle use, pursed-lip breathing, or tachypnea.
      • Palpation of chest: May reveal tenderness due to muscle strain from coughing.
      • Inspection: Assessment for cyanosis or clubbing of fingers (in chronic cases).
    3. Chest X-ray (CXR):
      • For acute bronchitis, a chest X-ray is typically normal and is primarily performed to rule out pneumonia or other lung pathologies, especially if symptoms are severe, atypical, or persistent, or if there is a concern for consolidation.
      • For chronic bronchitis, a CXR may show increased bronchovascular markings, cardiomegaly (if cor pulmonale is present), or evidence of hyperinflation in advanced cases of COPD. It helps exclude other causes of chronic cough.
    4. Fiberoptic bronchoscopy: May be both diagnostic (allowing for direct visualization of the airways, collection of qualitative cultures, and biopsy of suspicious lesions) and therapeutic (e.g., for mucus plug removal or re-expansion of lung segments). This is usually reserved for complex or atypical cases, or to rule out other conditions.
    5. Arterial Blood Gases (ABGs) / Pulse Oximetry:
      • Pulse oximetry provides a non-invasive measurement of oxygen saturation (SpO2). Abnormalities may be present, depending on the extent of lung involvement and underlying lung disease.
      • ABGs provide a more detailed assessment of oxygenation (PaO2), ventilation (PaCO2), and acid-base balance. In chronic bronchitis, chronic hypoxemia and hypercapnia may be present, especially during exacerbations.
    6. Gram stain/cultures:
      • Sputum collection: Can be done for Gram stain and culture to identify bacterial pathogens and determine antibiotic sensitivity, especially if bacterial infection is suspected (e.g., purulent sputum with fever and worsening symptoms).
      • Other samples: Needle aspiration of empyema, pleural fluid, transtracheal or transthoracic fluids, lung biopsies, and blood cultures may be done to recover causative organisms in severe cases or when pneumonia is suspected. More than one type of organism may be present; common bacteria include *Streptococcus pneumoniae*, *Staphylococcus aureus*, alpha-hemolytic streptococcus, *Haemophilus influenzae*; also viral pathogens like Cytomegalovirus (CMV). Note: Sputum cultures may not identify all offending organisms, and blood cultures may show transient bacteremia.
    7. Complete Blood Count (CBC):
      • Leukocytosis (elevated white blood cell count) is usually present in bacterial infections, although a low white blood cell (WBC) count may be present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia.
      • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are non-specific inflammatory markers that may be elevated.
    8. Serologic studies: E.g., viral titers (for influenza, adenovirus, RSV), *Legionella* titers, or cold agglutinins (for *Mycoplasma pneumoniae*). These assist in the differential diagnosis of specific organisms, especially in atypical presentations or outbreaks.
    9. Pulmonary Function Studies (PFTs):
      • These tests measure lung volumes, capacities, and airflow. In acute bronchitis, PFTs are typically normal or show mild, transient obstruction.
      • In chronic bronchitis, especially when progressing to COPD, volumes may be decreased (due to congestion and alveolar collapse), airway pressure may be increased, and compliance decreased. Obstructive patterns with reduced FEV1/FVC ratio are characteristic. Shunting may be present, leading to hypoxemia.
    10. Electrolytes: Sodium and chloride levels may be low, particularly in cases of severe illness or syndrome of inappropriate antidiuretic hormone secretion (SIADH) which can sometimes complicate severe respiratory infections.
    11. Alpha-1 Antitrypsin Deficiency Screening: Recommended in patients with early-onset emphysema or a family history of lung disease, as it is an inherited risk factor for COPD.

    Management

    Medical Management
    Acute Bronchitis

    Acute bronchitis is predominantly self-limiting, and treatment is typically symptomatic and supportive, focusing on relieving discomfort and promoting recovery.

    1. For cough relief, both non-pharmacological and pharmacological therapy should be offered:
      • a. Non-pharmacological therapy includes:
        • Drinking plenty of fluids (warm water, herbal tea, clear broths) to thin secretions and keep the throat moist.
        • Consuming soothing agents like honey (not for infants under 1 year due to botulism risk), ginger, or using throat lozenges or hard candies to relieve throat irritation.
        • Using a cool-mist humidifier in the bedroom to moisten the air and help loosen mucus.
        • Avoiding irritants such as cigarette smoke (including secondhand smoke), air pollution, and chemical fumes.
      • b. Pharmacological antitussive agents:
        • Dextromethorphan: An over-the-counter cough suppressant.
        • Codeine: A narcotic cough suppressant, sometimes prescribed for severe cough, but its use is generally discouraged due to its addictive potential and side effects.
        • Guaifenesin: An expectorant that helps to thin mucus, making it easier to cough up. Often found in combination with antitussives.
        • It's important to use these agents judiciously as suppressing a productive cough excessively can hinder clearance of secretions.
    2. For treatment of wheezing or bronchospasm: Inhaled bronchodilators (e.g., short-acting beta-agonists like albuterol) may be prescribed to reduce bronchospasm, open airways, and promote sputum expectoration, especially if the patient has underlying reactive airway disease or significant wheezing.
    3. Analgesic and antipyretic agents: Over-the-counter medications like acetaminophen (paracetamol) or ibuprofen can be used to treat associated malaise, myalgia (muscle aches), headache, and fever.
    4. Corticosteroids: Oral corticosteroids (e.g., prednisone) or inhaled corticosteroids may be considered in cases with significant inflammation or bronchospasm that is unresponsive to bronchodilators, to help with the inflammation. However, their routine use in acute bronchitis is not recommended.
    5. Lifestyle modification: Smoking cessation is paramount for preventing chronic bronchitis and recurrent acute episodes. The avoidance of allergens and environmental pollutants (e.g., industrial dust, chemicals) also plays an important role in the avoidance of recurrence and complications.
    6. Vaccinations:
      • Influenza vaccine: Especially recommended annually for special groups including adults older than 65, children younger than two years (older than six months), pregnant women, and residents of nursing homes and long-term care facilities.
      • Pneumococcal vaccine: Recommended for individuals at higher risk of developing complications (e.g., pneumonia), including people with chronic lung diseases (asthma, COPD), immunocompromised adults, and adults older than 65.
    7. Antibiotics: A course of oral antibiotics (e.g., a macrolide, doxycycline, or trimethoprim-sulfamethoxazole) may be instituted in specific situations, but their routine use for acute bronchitis is highly controversial and generally not recommended because most cases are viral. Antibiotics are considered only if:
      • Bacterial infection is strongly suspected (e.g., high fever, severe purulent sputum, signs of pneumonia on X-ray, or prolonged symptoms).
      • The patient is immunocompromised.
      • There's a concern for pertussis (treated with macrolides).
    Chronic bronchitis

    The primary aim of treatment for chronic bronchitis is to relieve symptoms, prevent complications (such as exacerbations and progression to COPD), and slow the progression of the disease. The primary goals of therapy are aimed at reducing the overproduction of mucus, controlling inflammation, managing cough, and improving airflow.

    Pharmacological interventions are the following:

    1. Bronchodilators: These are cornerstone medications for symptomatic relief by opening the airways.
      • Short-acting β-Adrenergic receptor Agonists (SABAs) like albuterol (salbutamol): Used as rescue inhalers for quick relief of acute shortness of breath or wheezing.
      • Long-acting β-Adrenergic receptor Agonists (LABAs) like salmeterol, formoterol: Used for maintenance therapy to provide sustained bronchodilation.
      • Anticholinergic agents (Short-acting: ipratropium; Long-acting: tiotropium, aclidinium): Help by blocking acetylcholine, which leads to bronchodilation, increasing the airway lumen, and reducing mucus production. They also aid in increasing ciliary function and by increasing mucous hydration. Often used in combination with beta-agonists.
    2. Glucocorticoids: These powerful anti-inflammatory medications reduce inflammation and mucus production.
      • Inhaled corticosteroids (ICS) like fluticasone, budesonide: Often used in combination with LABAs (e.g., in COPD exacerbations) to reduce exacerbations and improve quality of life. However, their long-term use can induce systemic side effects (e.g., osteoporosis, diabetes, hypertension, increased risk of pneumonia) and should be administered under medical supervision and for the shortest effective periods.
      • Oral corticosteroids: Used for acute exacerbations of chronic bronchitis to reduce severe inflammation, but not for long-term daily use due to significant side effects.
    3. Antibiotic therapy: Generally not indicated in the stable treatment of chronic bronchitis, as it is a chronic inflammatory condition, not an infection. However:
      • Acute exacerbations of chronic bronchitis (AECB) with signs of bacterial infection (e.g., increased sputum purulence, volume, or dyspnea) often warrant antibiotic treatment.
      • Long-term macrolide therapy (e.g., azithromycin) has been shown to have anti-inflammatory and immunomodulatory properties and can reduce the frequency of exacerbations in some patients with severe COPD and chronic bronchitis, hence it may have a role in the treatment of chronic bronchitis, but this is typically reserved for severe cases and involves careful risk-benefit assessment.
    4. Phosphodiesterase-4 (PDE4) inhibitors: Roflumilast is an example of this class. These oral medications decrease inflammation and promote airway smooth muscle relaxation by preventing the hydrolysis of cyclic adenosine monophosphate (cAMP), a substance whose degradation leads to the release of inflammatory mediators. They are used in severe COPD associated with chronic bronchitis and a history of exacerbations.
    5. Mucolytics: Medications like N-acetylcysteine or carbocysteine may be used to thin mucus, making it easier to clear, though their benefit is often modest.
    6. Oxygen therapy: For patients with chronic hypoxemia, supplemental oxygen therapy can improve survival and quality of life.

    Non Pharmacological Measures

    1. The most critical non-pharmacological intervention is smoking cessation. Smoking cessation significantly improves mucociliary function, decreases goblet cell hyperplasia (which contributes to mucus overproduction), and has been shown to reduce airway injury resulting in lower levels of exfoliated mucus in tracheobronchial cells. It is the single most effective intervention to slow disease progression.
    2. Pulmonary rehabilitation: An important and comprehensive part of treatment for chronic bronchitis and COPD, which consists of:
      • Education: On disease management, medications, self-care, and warning signs of exacerbations.
      • Lifestyle modification: Including nutrition, stress management, and avoidance of triggers.
      • Regular physical activity: Tailored exercise programs to improve exercise tolerance, muscle strength, and reduce dyspnea.
      • Breathing techniques: Such as pursed-lip breathing and diaphragmatic breathing to optimize lung function.
      • Avoidance of exposure to known pollutants: Either at work or in the living environment (e.g., air pollution, secondhand smoke, occupational dusts).
    3. Nutritional support: Patients with chronic bronchitis/COPD may experience weight loss or malnutrition due to increased energy expenditure for breathing or difficulty eating, so nutritional counseling is important.
    4. Psychological support: Addressing anxiety and depression, which are common in chronic respiratory conditions.

    Nursing management

    Nursing management for bronchitis involves a holistic approach, focusing on assessment, symptom management, patient education, and prevention of complications. While some interventions refer to general principles, specific applications for bronchitis are highlighted below.

  • Assessment:
    • a. Refer to the notes of general assessment nursing interventions, but specifically for bronchitis:
      • Respiratory Assessment: Auscultate lung fields for adventitious sounds (wheezing, rhonchi, crackles), assess respiratory rate, depth, and effort. Note presence of dyspnea, use of accessory muscles, pursed-lip breathing. Monitor oxygen saturation via pulse oximetry.
      • Cough Assessment: Characterize the cough (productive/non-productive, frequency, severity, timing). Assess sputum characteristics (color, consistency, amount, odor). Inquire about any triggers for the cough.
      • Vital Signs: Monitor temperature for fever, pulse for tachycardia, and blood pressure.
      • Pain Assessment: Evaluate for chest pain or abdominal muscle pain related to coughing, using a pain scale.
      • Hydration Status: Assess skin turgor, mucous membranes, and urine output to determine hydration levels.
      • Activity Tolerance: Assess the patient's ability to perform activities of daily living (ADLs) and any limitations due to dyspnea or fatigue.
      • History: Detailed history of smoking, exposure to irritants, vaccination status, and any underlying lung conditions (e.g., asthma, COPD).
  • Management of fevers:
    • a. Refer to the notes of general fever nursing interventions, but specifically for bronchitis:
      • Administer antipyretics (e.g., acetaminophen, ibuprofen) as prescribed.
      • Provide comfort measures: cool compresses, light clothing, and ensuring a comfortable room temperature.
      • Encourage increased oral fluid intake to prevent dehydration associated with fever.
      • Monitor temperature regularly and assess for signs of worsening infection.
  • Prevention of infection:
    • a. Refer to the nursing interventions of influenza under infection prevention, but specifically for bronchitis:
      • Educate on good hand hygiene practices for both the patient and caregivers.
      • Advise avoiding close contact with individuals who are sick.
      • Encourage annual influenza vaccination and pneumococcal vaccination as recommended, especially for at-risk groups.
      • Instruct on proper disposal of tissues and respiratory etiquette (coughing/sneezing into elbow).
      • For chronic bronchitis, reinforce adherence to prescribed medications to prevent exacerbations, which can be triggered by infections.
  • To improve airway clearance (managing wheezing and secretions):
    • a. Position head midline with flexion appropriate for age/condition to gain or maintain an open airway. For adults, semi-Fowler's or high-Fowler's position is generally preferred to maximize lung expansion.
    • b. Elevate the head of the bed (HOB) to decrease pressure on the diaphragm, promote lung expansion, and facilitate drainage of secretions.
    • c. Observe signs of worsening infection or increased secretions to identify an infectious process or exacerbation.
    • d. Auscultate breath sounds and assess air movement frequently to ascertain status and note progress or deterioration. Document changes.
    • e. Instruct the patient to increase fluid intake (2-3 liters/day unless contraindicated by co-morbidities like heart failure or renal disease) to help liquefy secretions, making them easier to expectorate.
    • f. Demonstrate and encourage effective coughing and deep-breathing techniques (e.g., huff cough, diaphragmatic breathing) to maximize effort and facilitate clearance of secretions. Assist with chest physiotherapy (postural drainage, percussion, vibration) if indicated and prescribed.
    • g. Keep the patient's back dry and linen clean to prevent skin breakdown and further complications, especially if there is excessive sweating or sputum production.
    • h. Turn the patient every 2 hours (for bedridden patients) to prevent pooling of secretions, promote lung expansion, and prevent possible aspirations.
    • i. Administer bronchodilators (e.g., nebulizers, metered-dose inhalers) as prescribed, monitoring for effectiveness and side effects (e.g., tachycardia, tremors).
    • j. Encourage ambulation and mobilization as tolerated to promote lung expansion and secretion clearance.
  • To ensure effective breathing pattern (managing difficulty in breathing):
    • a. Place patient in semi-Fowler's or high-Fowler's position to allow for maximum lung expansion and ease of breathing.
    • b. Increase fluid intake as applicable and tolerated to liquefy secretions and improve mucociliary clearance.
    • c. Keep patient's back dry and provide frequent linen changes to maintain comfort and prevent skin issues.
    • d. Place a pillow when the client is sleeping to provide adequate lung expansion while sleeping, possibly by elevating the head slightly.
    • e. Instruct how to splint the chest wall with a pillow or hands for comfort during coughing and to reduce pain. Elevate the head over the body as appropriate to promote physiological ease of maximal inspiration.
    • f. Maintain a patent airway; suctioning of secretions may be done as ordered to remove secretions that obstruct the airway, especially in patients with impaired cough reflex or thick secretions.
    • g. Provide respiratory support: Oxygen inhalation is provided per doctor’s order to aid in relieving patient from dyspnea and to maintain adequate oxygen saturation levels (e.g., SpO2 >90%). Monitor oxygen flow rate and effectiveness.
    • h. Administer prescribed cough suppressants and analgesics. Be cautious, however, because opioids may depress respirations more than desired. Use judiciously to promote patient comfort without compromising respiratory drive.
    • i. Educate on pursed-lip breathing and diaphragmatic breathing techniques to improve ventilation and reduce air trapping.
    • j. Provide periods of rest between activities to conserve energy and reduce dyspnea.
    • k. Monitor for signs of respiratory distress and immediately report any worsening symptoms to the physician.
  • Patient Education and Self-Management:
    • Educate patients about their condition, medication regimen (purpose, dose, side effects, proper inhaler technique), and when to seek medical attention (e.g., worsening cough, increased sputum, fever, increased dyspnea).
    • Counsel on smoking cessation strategies and provide resources.
    • Discuss avoidance of environmental triggers and irritants.
    • Teach energy conservation techniques for chronic bronchitis patients.
    • Encourage regular exercise within tolerance limits.

    • Nursing Diagnoses

    Nursing diagnoses provide a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. For bronchitis, common nursing diagnoses, based on NANDA International (NANDA-I) classifications, might include:

    1. Ineffective Airway Clearance related to increased mucus production, thick tenacious secretions, impaired ciliary function, and/or bronchospasm, as evidenced by abnormal breath sounds (e.g., rhonchi, wheezes), ineffective cough, dyspnea, and/or changes in respiratory rate/rhythm.
    2. Impaired Gas Exchange related to altered oxygen supply (e.g., narrowed airways, mucus plugging) and/or ventilation-perfusion imbalance, as evidenced by dyspnea, abnormal arterial blood gases (e.g., decreased PaO2, increased PaCO2), cyanosis, and/or abnormal breath sounds. (More prevalent in chronic bronchitis/COPD exacerbations).
    3. Ineffective Breathing Pattern related to inflammatory process, mucus obstruction, anxiety, and/or pain (e.g., from coughing), as evidenced by dyspnea, tachypnea, use of accessory muscles, pursed-lip breathing, and/or altered chest excursion.
    4. Acute Pain related to persistent coughing, muscle strain (e.g., intercostal, abdominal), and/or chest discomfort secondary to inflammation, as evidenced by patient reports of pain, grimacing, guarding behavior, and/or restlessness.
    5. Fatigue related to increased work of breathing, persistent coughing, sleep disturbance, and/or systemic infection, as evidenced by patient reports of overwhelming lack of energy, lethargy, decreased activity level, and/or difficulty performing ADLs.
    6. Activity Intolerance related to imbalance between oxygen supply and demand, dyspnea, and/or fatigue, as evidenced by verbal reports of fatigue/weakness, exertional dyspnea, abnormal heart rate or blood pressure response to activity, and/or decreased ability to perform ADLs. (More common in chronic bronchitis).
    7. Deficient Knowledge regarding disease process, treatment regimen, symptom management, and/or prevention of recurrence/exacerbations, as evidenced by patient questions, inaccurate follow-through of instructions, and/or development of preventable complications.
    8. Risk for Infection related to stasis of secretions, impaired ciliary action, and/or compromised immune response. (Applies to both acute bronchitis progressing to pneumonia or chronic bronchitis with increased susceptibility to exacerbations).
    9. Excessive Anxiety related to dyspnea, fear of suffocation, change in health status, and/or uncertainty about the future, as evidenced by patient reports of nervousness, restlessness, increased respiratory rate, and/or apprehension.

    Complications of Bronchitis

    While acute bronchitis is usually self-limiting and resolves without complications, chronic bronchitis can lead to significant and often debilitating complications. Complications can also arise from acute bronchitis, especially in vulnerable populations (e.g., very young, elderly, immunocompromised).

    Complications of Acute Bronchitis
    1. Pneumonia: The most common and serious complication. The inflammation and impaired mucociliary clearance can allow bacterial or viral infections to spread from the bronchi to the lung parenchyma, leading to pneumonia. This risk is higher in individuals with weakened immune systems, underlying lung disease, or the very young/elderly.
    2. Acute Exacerbation of Underlying Chronic Lung Disease: In individuals with pre-existing conditions like asthma or COPD, acute bronchitis can trigger a severe exacerbation of their underlying disease, leading to worsening symptoms, increased airway obstruction, and potentially respiratory failure.
    3. Persistent Cough: While most coughs resolve within 2-3 weeks, post-infectious cough can linger for several weeks (e.g., 4-8 weeks) due to airway hypersensitivity, even after the infection has cleared. This is often bothersome but not usually serious.
    4. Bronchiolitis: More common in infants and young children, severe inflammation can extend to the smaller airways (bronchioles), causing significant respiratory distress.
    5. Dehydration: Especially in infants and elderly, fever and increased respiratory rate can lead to fluid loss if fluid intake is not maintained.
    6. Ear Infections (Otitis Media) and Sinusitis: Upper respiratory tract infections that lead to bronchitis can also predispose to complications in adjacent structures.
    Complications of Chronic Bronchitis

    Chronic bronchitis, particularly as part of COPD, can lead to a range of severe and progressive complications affecting various body systems.

    1. Recurrent Acute Exacerbations of Chronic Bronchitis (AECB): These are acute events characterized by a worsening of respiratory symptoms (increased dyspnea, cough, sputum volume, and/or purulence) beyond day-to-day variations. AECBs are often triggered by bacterial or viral infections, air pollution, or other irritants and can lead to significant morbidity, hospitalizations, and accelerate lung function decline.
    2. Chronic Obstructive Pulmonary Disease (COPD): Chronic bronchitis is a major component and a clinical diagnosis of COPD. Over time, the persistent inflammation and airway remodeling lead to irreversible airflow limitation, reduced lung function, and progressive dyspnea.
    3. Emphysema: Often coexists with chronic bronchitis in COPD. Emphysema involves the destruction of the alveolar walls, leading to enlarged air spaces and loss of elastic recoil, further contributing to airflow obstruction and impaired gas exchange.
    4. Respiratory Failure: As the disease progresses, the lungs become unable to adequately oxygenate the blood and/or remove carbon dioxide, leading to chronic hypoxemia (low oxygen) and hypercapnia (high CO2). This can necessitate supplemental oxygen therapy and, in severe exacerbations, mechanical ventilation.
    5. Cor Pulmonale (Right-Sided Heart Failure): Chronic hypoxemia leads to pulmonary vasoconstriction, increasing pulmonary artery pressure (pulmonary hypertension). This increased workload on the right ventricle of the heart can eventually lead to its enlargement and failure, resulting in peripheral edema (swelling in the ankles, legs), jugular venous distension, and hepatomegaly.
    6. Pulmonary Hypertension: Persistently elevated blood pressure in the arteries of the lungs, often a precursor to cor pulmonale.
    7. Pneumothorax: In severe cases of COPD with emphysema, ruptured bullae (enlarged air sacs) can lead to a collapsed lung.
    8. Polycythemia: Chronic hypoxemia can stimulate the kidneys to produce erythropoietin, leading to an increase in red blood cell production. This thickens the blood, increasing the risk of blood clots.
    9. Weight Loss and Malnutrition: Increased energy expenditure for breathing, reduced appetite (due to dyspnea, fatigue, or depression), and systemic inflammation can lead to unintended weight loss and malnutrition.
    10. Osteoporosis: Chronic inflammation, corticosteroid use, and reduced physical activity in COPD/chronic bronchitis patients contribute to bone density loss and increased fracture risk.
    11. Muscle Wasting and Dysfunction: Systemic inflammation, hypoxemia, and reduced activity can lead to skeletal muscle weakness and atrophy, further impacting exercise tolerance and quality of life.
    12. Depression and Anxiety: The chronic nature of the disease, debilitating symptoms, and impact on quality of life often lead to significant psychological distress.
    13. Increased Susceptibility to Infections: Impaired mucociliary clearance and chronic inflammation make individuals with chronic bronchitis more vulnerable to recurrent respiratory infections.
    14. Respiratory Acidosis: In advanced stages or during exacerbations, the body's inability to effectively clear CO2 can lead to a build-up of acid in the blood.

    BRONCHITIS Read More »

    LARYNGITIS

    LARYNGITIS

    Nursing Notes - Thrombus and Embolus

    LARYNGITIS

    Introduction

    Laryngitis refers to inflammation of the larynx, commonly known as the voice box. The larynx contains the vocal cords, which vibrate to produce sound. When the vocal cords become inflamed or irritated, they swell, leading to a distorted voice or a complete loss of voice. It can present in both acute and chronic forms.

    Types of Laryngitis

    Laryngitis can be classified according to its duration:

    1. Acute Laryngitis: This is a common, often mild, and self-limiting condition that typically lasts for a period of 3 to 7 days, rarely exceeding two weeks. It usually has a sudden onset.
    2. Chronic Laryngitis: If laryngitis lasts for over 3 weeks, it is termed chronic laryngitis. This form of laryngitis is usually less severe but can be persistent and may indicate an underlying, ongoing irritant or medical condition.

    Classification of Laryngitis according to cause

    1. Infectious Laryngitis: The cause is a pathogen, most commonly viruses, but sometimes bacteria or fungi.
    2. Non-infectious Laryngitis: Caused by non-pathogens such as vocal overuse, irritants (smoke, allergens), or conditions like gastroesophageal reflux disease (GERD).

    Pathophysiology

    The pathophysiology of laryngitis involves the inflammatory response of the laryngeal tissues, particularly the vocal cords.

    1. Acute laryngitis is characterized by inflammation and congestion of the larynx in the early stages. This inflammation can encompass the supra-glottic (above the vocal cords), glottic (vocal cords themselves), or subglottic (below the vocal cords) larynx, or any combination thereof, depending on the inciting agent.
    2. The inflammation leads to increased vascular permeability and fluid accumulation (edema) in the vocal cord tissues.
    3. As the inflammatory process progresses, white blood cells and other immune components arrive at the site of infection or irritation to remove pathogens or clear debris.
    4. This process enhances vocal cord edema, which adversely affects the normal vibration of the vocal folds, changing the amplitude, magnitude, and frequency of their dynamic movement.
    5. As the edema progresses, the phonation threshold pressure (the minimum subglottal pressure required to initiate vocal fold vibration) can increase. This means it becomes more difficult to generate adequate vocal fold vibration and produce clear sound.
    6. The patient develops phonatory changes (dysphonia or hoarseness) both as a result of the changing fluid-wave dynamics of the inflamed and edematous tissue, and as a result of both conscious and unconscious adaptation to attempt to mitigate these altered tissue dynamics (e.g., trying to push more air through).
    7. Sometimes edema is so marked that it becomes impossible to generate adequate phonation pressure, leading to frank aphonia (complete loss of voice). Such maladaptations (e.g., vocal strain) may result in prolonged vocal symptoms after an episode of acute laryngitis that can persist long after the inciting event has resolved.
    8. Acute laryngitis typically resolves within 2 weeks. Persistent symptoms beyond this timeframe may indicate a super-infection or a transition to chronic laryngitis, suggesting ongoing irritation or an underlying pathology.

    Causes of Laryngitis

    Acute Laryngitis
    Infectious causes
    1. Viral agents: The most common cause of acute laryngitis. Viruses such as rhinovirus (common cold), parainfluenza virus, respiratory syncytial virus (RSV), coronavirus, adenovirus, and influenza virus are all potential etiologic agents (listed in roughly descending order of frequency). It is possible for bacterial super-infection to occur in the setting of viral laryngitis, which classically occurs approximately seven days after symptoms begin, leading to worsening symptoms.
    2. Bacterial organisms: Less common as primary causes but can be involved in superinfections. Common bacterial culprits include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Certain exanthematous febrile illnesses such as measles, chickenpox, and pertussis (whooping cough) are also associated with acute laryngitis symptoms, so it is prudent to obtain an accurate immunization history.
    3. Fungal infection: Laryngitis caused by fungal infections like Candida albicans is very rare in immunocompetent individuals. It is more often seen as chronic laryngitis in immunocompromised patients (e.g., those with HIV/AIDS, cancer patients undergoing chemotherapy) or in patients using inhaled steroid medications (e.g., for asthma or COPD) without proper rinsing of the mouth after use.
    Non-infectious causes

    Acute non-infectious laryngitis can be due to:

    • Vocal trauma/abuse/misuse: Such as excessive shouting, singing, or prolonged talking.
    • Allergies: Inhalation of allergens can cause inflammation of the laryngeal mucosa.
    • Gastro-esophageal reflux disease (GERD) or Laryngopharyngeal Reflux (LPR): Stomach acid irritating the larynx.
    • Asthma: Can sometimes cause irritation or inflammation in the larynx.
    • Environmental irritants: Exposure to pollutants, chemical fumes, or dry air.
    • Smoking: Direct irritation from tobacco smoke.
    • Inhalational injuries: Such as inhaling smoke from fires.
    • Functional/conversion disorders: Psychogenic causes where no organic pathology is found.
    Chronic Laryngitis

    A variety of factors can cause chronic laryngitis, often involving prolonged irritation or damage to the vocal cords:

    1. Long-term cigarette smoking: A major cause, as smoke directly irritates the vocal cords and can lead to swelling and changes in the laryngeal lining.
    2. Gastroesophageal reflux (GERD) or Laryngopharyngeal Reflux (LPR): Stomach acid moving up into the esophagus and irritating the larynx over time, often without typical heartburn symptoms.
    3. Excessive alcohol consumption: Can irritate the vocal cords.
    4. Chronic exposure to environmental irritants: Such as chemical fumes, dust, or allergens.
    5. Vocal abuse or overuse: Chronic strain on the voice due to professional use (singers, teachers) or habitual shouting.
    6. Chronic sinusitis or bronchitis: Postnasal drip can continuously irritate the larynx.
    7. Vocal cord lesions: Such as polyps, nodules (singer's nodes), cysts, or granulomas that form on the vocal cords due to chronic irritation or overuse.
    8. Neurological conditions: Affecting vocal cord movement (e.g., vocal cord paralysis).
    9. Allergies: Persistent allergic reactions.
    10. Pneumonia: Can sometimes be associated with persistent cough and laryngeal irritation.
    11. Thyroid dysfunction: Hypothyroidism can sometimes affect vocal cord function.
    12. Rare causes: Autoimmune diseases (e.g., rheumatoid arthritis affecting laryngeal joints), granulomatous diseases (e.g., sarcoidosis), or even early laryngeal cancer.

    Clinical manifestations

    Acute Laryngitis

    In addition to symptoms of an upper respiratory tract infection (i.e., fever, cough, rhinitis), the patient primarily experiences dysphonia or a hoarse voice. The individual may also experience the following:

    1. Hoarseness of the voice: The hallmark symptom, ranging from mild to severe.
    2. Weakened voice or loss of voice (aphonia): Due to the vocal cords being too swollen to vibrate effectively.
    3. Rough or raspy voice quality.
    4. Constant tickling sensation or minor throat irritation.
    5. Dry cough: Often irritating and persistent.
    6. Odynophonia: Pain when speaking.
    7. Dysphagia: Difficulty swallowing.
    8. Odynophagia: Painful swallowing (less common than in pharyngitis).
    9. Dyspnea: Shortness of breath, especially if there is significant laryngeal swelling (more common in children with croup).
    10. Rhinorrhea: Runny nose (if associated with a common cold).
    11. Postnasal discharge: Mucus dripping down the back of the throat.
    12. Sore throat: May accompany other URI symptoms.
    13. Congestion: Nasal or chest congestion.
    14. Fatigue and malaise: General feeling of being unwell.
    15. Fever: Usually low-grade, if present.
    Chronic Laryngitis

    Symptoms are usually less acute but persistent:

    1. Persistent hoarseness: The primary and most common symptom, lasting for weeks or months.
    2. Loss of voice: May occur intermittently or be constant in severe cases.
    3. A raw or irritated throat sensation.
    4. A persistent dry cough.
    5. Frequent throat clearing.
    6. Feeling of a lump in the throat (globus sensation).
    7. Reduced vocal range or fatigue when speaking.
    8. Difficulty swallowing: Less common, but can occur if there's significant inflammation or associated conditions like GERD.
    9. Swelling of the lymph nodes in your neck: Not common in isolated chronic laryngitis, but may indicate an underlying infection or more serious condition.
    10. Fever: Generally absent in non-infectious chronic laryngitis.

    Test and Diagnosis

    Acute Laryngitis

    Diagnosis is primarily clinical, based on patient history and physical examination.

    1. History: Presence of typical symptoms like hoarseness, often following an upper respiratory infection, and duration of symptoms usually less than 3 weeks.
    2. Physical examination: Examination of the throat may reveal redness or inflammation. Direct visualization of the larynx is usually not necessary for uncomplicated acute laryngitis.
    3. Laryngoscopy: Direct visualization of the larynx using a laryngoscope is generally reserved for cases of persistent symptoms, severe symptoms, or if there is concern for a more serious underlying condition. This allows the clinician to see inflamed and edematous vocal cords, sometimes with mucus or slight redness.
    Chronic Laryngitis

    Diagnosis requires a more thorough investigation to identify the underlying cause, as the symptoms persist for more than 3 weeks.

    1. History: Detailed history of chronic hoarseness, vocal habits, exposure to irritants (smoking, chemicals), symptoms of GERD, allergies, and any associated systemic conditions.
    2. Laryngoscopy: This is a crucial diagnostic tool for chronic laryngitis. It allows direct visualization of the vocal cords and surrounding structures. Findings may include:
      • Redness and swelling of vocal cords.
      • Presence of vocal cord nodules, polyps, cysts, granulomas.
      • Changes suggestive of chronic reflux (e.g., posterior laryngeal erythema).
      • Signs of Reinke's edema (swelling of the vocal cords due to smoking).
      • Suspicious lesions that may indicate malignancy.
    3. Imaging studies:
      • CT scan or MRI of the neck and throat: May be performed to rule out tumors, anatomical abnormalities, or spread of disease, especially if malignancy is suspected or if a mass is palpated.
    4. Laboratory tests:
      • High throat swab for culture and sensitivity: If bacterial or fungal infection is suspected and visualized, a swab can be taken for culture to identify the pathogen and determine appropriate antibiotic/antifungal treatment.
      • Full blood count (CBC): Can indicate signs of infection or other systemic issues.
      • Allergy testing: If allergies are suspected as a contributing factor.
      • pH monitoring: Esophageal pH monitoring (24-hour pH impedance study) can be done to confirm GERD or LPR, especially if symptoms are atypical or unresponsive to treatment.
    5. Biopsy: If any suspicious lesions are found during laryngoscopy, a biopsy may be taken for histopathological examination to rule out malignancy.

    Management

    Medical Management

    Treatment is often supportive in nature and depends on the severity and underlying cause of laryngitis. The primary goals are to reduce inflammation, alleviate symptoms, and identify/address the root cause.

    1. Voice rest: This is the single most important factor for acute laryngitis. Use of the voice during laryngitis results in incomplete or delayed recovery and can worsen vocal cord damage. Complete voice rest is recommended, although it is almost impossible to achieve. If the patient needs to speak, they should be instructed to use a "confidential voice" – a normal phonatory voice at low volume without whispering or projecting, as whispering can strain the vocal cords more than soft speaking.
    2. Humidification: Inhaling humidified air (e.g., from a cool-mist humidifier, steam inhalation from a bowl of hot water, or a steamy shower) enhances moisture of the upper airway and vocal cords, which helps to soothe irritation, reduce swelling, and facilitate the removal of secretions and exudates.
    3. Avoidance of irritants: Smoking and alcohol should be strictly avoided as they significantly irritate the laryngeal mucosa and delay prompt resolution of the disease process. Exposure to environmental pollutants, dust, and allergens should also be minimized.
    4. Dietary modification: Dietary restrictions are recommended for patients with gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR). This includes avoiding caffeinated drinks, spicy food items, fatty food, chocolate, peppermint, citrus fruits, and carbonated beverages. Another important lifestyle modification is the avoidance of late meals; the patient should have meals at least 3 hours before sleeping to prevent nocturnal reflux. The patient should drink plenty of water to maintain hydration. While the efficacy of these dietary measures is well-established for classic GERD, their effectiveness in LPR is debated, but they are often still employed.
    5. Medications:
      • Antibiotics: Antibiotic prescription for an otherwise healthy patient with acute viral laryngitis is currently unsupported and ineffective. However, for high-risk patients (e.g., immunocompromised) or patients with severe symptoms and confirmed bacterial infection (e.g., with signs of bacterial superinfection), antibiotics may be given. Some authors recommend narrow-spectrum antibiotics only in the presence of identifiable gram stain and culture.
      • Antivirals: Rarely used for laryngitis unless a specific viral cause (e.g., severe influenza or herpes simplex) is identified and treatment is indicated.
      • Antifungals: Fungal laryngitis can be treated with the use of oral antifungal agents such as fluconazole. Treatment is usually required for a three-week period and may be repeated if needed. This should be reserved for patients with confirmed fungal infection via laryngeal examination and/or culture.
      • Mucolytics: Like guaifenesin, may be used for clearing thick secretions.
      • Corticosteroids: May be prescribed in severe cases of acute laryngitis with significant vocal cord swelling causing severe hoarseness or mild airway compromise (e.g., croup in children) to rapidly reduce inflammation. Long-term use is generally avoided due to side effects.
      • Anti-reflux medications: In addition to lifestyle and dietary modifications, LPR-related laryngitis is treated with anti-reflux medications. Medications that suppress acid production, such as H2 receptor blockers (e.g., ranitidine, famotidine) and proton pump inhibitors (PPIs) (e.g., omeprazole, lansoprazole, esomeprazole), are effective against gastroesophageal reflux. PPIs are generally found to be most effective for LPR. These may require higher doses or a twice-daily dosing schedule to be effective in this setting, and treatment often needs to be long-term.
      • Analgesics/Antipyretics: Over-the-counter pain relievers like acetaminophen or ibuprofen can help manage associated pain and fever.
    6. Voice Therapy: For chronic laryngitis, particularly that related to vocal abuse/misuse or vocal cord lesions, referral to a speech-language pathologist for voice therapy is crucial. Therapy teaches proper vocal hygiene, efficient voice production techniques, and strategies to prevent further vocal cord injury.
    7. Surgical Intervention: For chronic laryngitis caused by vocal cord polyps, nodules, cysts, or other lesions that do not resolve with conservative management, surgical removal may be necessary.

    Nursing Interventions/Management

    1. Assessment of the Patient
    • a. Obtain a comprehensive history including the onset, duration, and nature of hoarseness or voice changes. Inquire about associated symptoms like cough, sore throat, difficulty swallowing, fever, and symptoms of upper respiratory infection or reflux.
    • b. Assess for potential causes: recent illness, vocal overuse/abuse (e.g., shouting, singing), exposure to irritants (smoking, chemicals), allergies, and history of GERD.
    • c. Perform vital sign assessment (Temperature, Pulse, Respiration, Blood Pressure) and a general physical examination. Note any signs of respiratory distress, stridor, or changes in voice quality.
    • d. Document the patient's vocal habits, profession (if voice-demanding), and lifestyle (smoking, alcohol use).
    • e. Inquire about any past medical history, current medications, and allergies.
    2. Promoting Voice Rest and Vocal Hygiene
    • a. Educate the patient on the critical importance of absolute voice rest during acute laryngitis. Explain that talking, whispering, and throat clearing can further irritate and damage vocal cords.
    • b. Instruct the patient to use non-vocal communication methods (e.g., writing, gestures) as much as possible.
    • c. Teach "confidential voice" if speaking is unavoidable: speak softly but not whisper, use natural pitch.
    • d. Emphasize avoidance of vocal strain, shouting, screaming, and prolonged singing.
    3. Managing Symptoms and Promoting Comfort
    • a. Encourage increased fluid intake to keep vocal cords hydrated and thin secretions. Warm fluids (e.g., herbal tea with honey) or cool liquids may be soothing.
    • b. Advise the use of a cool-mist humidifier in the patient's room, especially at night, to humidify the air and soothe the larynx.
    • c. Instruct on proper steam inhalation techniques (e.g., leaning over a bowl of hot water with a towel over the head for 5-10 minutes, several times a day), ensuring safety to prevent burns.
    • d. Administer prescribed analgesics (e.g., acetaminophen, ibuprofen) for pain relief and antipyretics for fever.
    • e. Encourage throat lozenges or sprays to relieve irritation and dryness, if appropriate.
    • f. Instruct on gargling with warm salt water to reduce throat discomfort.
    • g. Advise avoiding irritants such as tobacco smoke (including secondhand smoke), alcohol, and caffeine, which can dry out and irritate the vocal cords.
    4. Preventing and Managing Complications
    • a. Monitor for signs of respiratory distress (e.g., increased respiratory rate, shortness of breath, stridor, retractions, cyanosis), especially in children, as laryngeal swelling can compromise the airway. Report immediately to the physician.
    • b. For chronic laryngitis, educate the patient about the potential long-term effects of persistent inflammation (e.g., vocal cord nodules, polyps, or changes that could mask malignancy).
    • c. Ensure the patient completes the full course of antibiotics if prescribed for bacterial laryngitis to prevent recurrence or resistance.
    • d. For patients with GERD/LPR, reinforce adherence to dietary and lifestyle modifications (e.g., elevating the head of the bed, avoiding late meals, dietary triggers) and consistent use of anti-reflux medications.
    5. Health Education and Patient Teaching
    • a. Educate the patient and family about the causes, symptoms, and treatment of laryngitis, distinguishing between acute and chronic forms.
    • b. Provide detailed instructions on proper vocal hygiene, including the importance of hydration, avoiding shouting/whispering, and resting the voice.
    • c. Teach patients about identifying and avoiding personal triggers for laryngitis (e.g., allergens, irritants, vocal abuse).
    • d. For patients with chronic laryngitis due to GERD, provide comprehensive education on anti-reflux measures.
    • e. Emphasize the importance of follow-up care, especially if symptoms persist or worsen, or if there is concern for chronic conditions or malignancy.
    • f. Advise seeking medical attention immediately for severe symptoms such as difficulty breathing, severe pain, or inability to swallow.
    6. Referral and Collaboration
    • a. Collaborate with the healthcare team, including physicians, speech-language pathologists (for voice therapy in chronic cases), and allergists or gastroenterologists if underlying conditions like allergies or GERD are present.
    • b. Facilitate referrals to specialists as needed (e.g., otolaryngologist for laryngoscopy in chronic or atypical cases).

    Complications

    While acute laryngitis is usually benign and self-limiting, complications can arise, especially if the underlying cause is not addressed or in specific populations. Chronic laryngitis, due to persistent irritation, can lead to more significant issues.

    1. Airway Obstruction (especially in children): In infants and young children, significant swelling of the subglottic area (below the vocal cords) can lead to a condition called croup (laryngotracheobronchitis). This causes a characteristic "barking" cough, stridor (a high-pitched crowing sound during inhalation), and difficulty breathing, which can be life-threatening and require immediate medical attention. In adults, severe laryngeal edema can also rarely lead to airway compromise.
    2. Vocal Cord Lesions: Chronic inflammation, vocal abuse, or irritation can lead to the development of benign lesions on the vocal cords:
      • Vocal Nodules (Singer's Nodes): Callus-like growths that result from chronic vocal cord abuse, leading to persistent hoarseness.
      • Vocal Polyps: Softer, blister-like growths, often unilateral, that can result from a single traumatic vocal event or chronic irritation.
      • Vocal Cysts: Fluid-filled sacs within the vocal cord.
      • Granulomas: Inflammatory lesions, often associated with intubation trauma or LPR.
      • Reinke's Edema: A severe swelling of the vocal cords, almost exclusively seen in heavy smokers, leading to a deep, husky voice.
      These lesions often require voice therapy and sometimes surgical removal to restore vocal quality.
    3. Chronic Hoarseness/Dysphonia: Persistent voice changes that significantly impact communication and quality of life, leading to vocal fatigue, pain, or professional limitations.
    4. Psychological Impact: Chronic voice problems can lead to frustration, social isolation, anxiety, or depression, especially in individuals whose profession relies on their voice.
    5. Misdiagnosis of Serious Conditions: Persistent hoarseness, especially in smokers or heavy drinkers, can be a symptom of laryngeal cancer. Untreated chronic laryngitis can delay the diagnosis of malignancy, which is a critical concern.
    6. Spread of Infection: If infectious laryngitis is not properly managed, especially bacterial cases, the infection can spread to other parts of the respiratory tract, leading to bronchitis, pneumonia, or other more systemic infections.
    7. Laryngeal Stenosis: In rare cases, chronic inflammation or repeated trauma can lead to scarring and narrowing of the larynx (stenosis), which can severely restrict airflow and may require surgical intervention.

    It is crucial for persistent hoarseness (lasting more than 2-3 weeks), especially in adults, to be evaluated by an otolaryngologist (ENT specialist) to rule out serious underlying conditions, including malignancy.

    Nursing management

    1. Assessment of the patient
    • a. Carrying out history of the presenting signs and symptoms e.g. fever, fatigue, throat pain and hoarseness of the voice among others.
    • b. Taking vital observation e.g. TPR/BP and general examination to exclude other diseases
    • c. Alerting the doctor who will order for investigations and admission, there the nurse will assist the patient throughout the process.
    2. Managing fever (patient has 37.6 and above temperature, chills)
    • a. Assess the patient’s vital signs at least every 4 hours.
    • b. Remove excessive clothing, blankets, and linens. Adjust the room temperature.
    • c. Administer and monitor the prescribed antibiotics and anti-pyretics.
    • d. Assess the mental status of the patient because elevated temperatures can alter the function of the mind.
    • e. Offer a tepid sponge bath.
    • f. Elevate the head of the bed
    3. To alleviate pain
    • a. Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.
    • b. Elevate the head of the bed and position the patient in semi Fowler’s.
    • c. Administer prescribed analgesics
    4. Ensuring clear airway
    • a. Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. Assess for signs of hypoxia.
    • b. Place the patient on a side-lying or prone position.
    • c. Suction secretions.
    • d. Administer the prescribed medications (e.g. corticosteroids) and antibiotic medications.
    5. To prevent infection
    • a. Assess vital signs and observe for any signs of infection as well as for any signs of respiratory distress.
    • b. Perform a focused assessment on the oropharyngeal region, particularly checking for any collection of abscess.
    • c. Teach the patient how to perform proper hand hygiene.
    • d. Administer antibiotics as prescribed.
    6. Educate the patient about self-management
    • a. Use a humidifier or inhale steam to alleviate dryness.
    • b. Get vocal therapy to analyze and correct the way you use your voice and any abnormal speech patterns that place stress on your vocal cords and voice box.
    • c. Drink lots of fluids.
    • d. Gargle with 1/2 tsp. of salt and 1/2 tsp. of baking soda in 8 oz. of warm water.
    • e. Rest your voice.
    • f. Avoid screaming or talking loudly for long periods of time.
    • g. Avoid decongestants, which can dry your throat.
    • h. Suck on lozenges to keep your throat lubricated.
    • i. Refrain from whispering, which can strain the voice.

    Complications

    1. Epiglositis
    2. Pneumonia
    3. Chronic irritation of throat
    4. Throat cancer
    5. Chronic hoarseness of the voice

    LARYNGITIS Read More »

    PHARYNGITIS

    PHARYNGITIS

    Nursing Notes - Thrombus and Embolus

    PHARYNGITIS

    Introduction

    Pharyngitis is the inflammation of the mucous membranes of the pharynx. In most cases, the cause is an infection, either bacterial or viral. Other less common causes of pharyngitis include allergies, trauma, cancer, reflux, and certain toxins.

    Types of Pharyngitis

    Pharyngitis can be classified according to the duration i.e. as acute or chronic.

    1. Acute pharyngitis: has a sudden onset, and it resolves within less than 3 months. It may settle completely and recur in the future.
    2. Chronic pharyngitis: can last up to more than 3 months or having more than 5 episodes of tonsillitis in a year.
    Classification of pharyngitis according to cause
    1. Infectious Pharyngitis: the cause is a pathogen e.g., commonly viruses, bacteria.
    2. Non-infectious pharyngitis: Caused by non-pathogens e.g., GERD.

    Pathophysiology

    Bacteria and viruses can cause direct invasion of the pharyngeal mucosa. Certain viruses like rhinovirus can cause irritation secondary to nasal secretions. In almost all cases, there is a local invasion of the pharyngeal mucosa which also results in excess secretion and edema. The inflammatory response leads to the characteristic symptoms of sore throat, redness, and swelling.

    Causes of pharyngitis

    1. Viral causes: About 50% to 80% of pharyngitis, or sore throat, symptoms are viral in origin and include a variety of viral pathogens. These pathogens are predominantly rhinovirus, influenza, adenovirus, coronavirus, and parainfluenza. Less common viral pathogens include herpes simplex virus (HSV), Epstein-Barr virus (EBV) which causes infectious mononucleosis, human immunodeficiency virus (HIV), and coxsackievirus (causing Hand, Foot, and Mouth Disease). More severe cases tend to be bacterial and may develop after an initial viral infection.
    2. Bacterial causes: The most common bacterial infection is Group A beta-hemolytic streptococci (GAS), which causes 5% to 36% of cases of acute pharyngitis, particularly in children. Other bacterial etiologies include Group C and G streptococci, Chlamydia pneumoniae, Mycoplasma pneumoniae, Haemophilus influenzae, Candida albicans (fungal infection, often in immunocompromised individuals), Neisseria meningitidis, Neisseria gonorrhoeae (gonococcal pharyngitis), Arcanobacterium haemolyticum, Fusobacterium necrophorum (associated with Lemierre's syndrome), and Corynebacterium diphtheriae (diphtheria, rare due to vaccination).
    3. Non-infectious causes: Environmental allergies and chemical exposures (e.g., smoke, pollutants, dry air), gastroesophageal reflux disease (GERD) where stomach acid irritates the throat, excessive voice use, and mouth breathing can also cause acute or chronic pharyngitis.
    4. Pharyngitis symptoms may also be part of the symptom complexes of other serious illnesses, including peritonsillar abscess, retropharyngeal abscess, epiglottitis (a life-threatening emergency), and Kawasaki disease (in children).

    Clinical manifestations

    The signs and symptoms of pharyngitis can vary depending on the underlying cause, but common manifestations include:

    1. Sore throat/Throat pain: Often described as scratchy, burning, or painful, especially when swallowing.
    2. Dysphagia: Difficulty or pain when swallowing.
    3. Fever: Common, especially with bacterial or severe viral infections.
    4. Tonsillar exudates: White patches or streaks of pus on the tonsils (more common in bacterial infections like strep throat).
    5. Pharyngeal erythema: Redness and inflammation of the throat.
    6. Fatigue/Malaise: General feeling of being unwell.
    7. Nasal congestion and rhinorrhea: Runny nose, sneezing (more common in viral pharyngitis).
    8. Postnasal drip: Mucus dripping down the back of the throat, causing irritation and cough.
    9. Headache.
    10. Painful cervical adenopathy: Swollen and tender lymph nodes in the neck.
    11. Cough: Can be dry or productive.
    12. Myalgia and arthralgia: Muscle and joint aches (especially with viral infections like influenza).
    13. Ear pain: Referred pain from the throat.
    14. Rash: Can occur with certain infections, e.g., scarlatiniform rash with strep throat (scarlet fever), or maculopapular rash with infectious mononucleosis.

    NB: Uncomplicated infectious pharyngitis, both viral and bacterial, typically is self-limited to 5 to 7 days, is not progressive, is bilateral, does not have trismus (difficulty opening the mouth), and does not have evidence of airway obstruction (stridor or severe difficulty breathing).

    Diagnosis & Differential Diagnosis

    Diagnosis

    Diagnosis of pharyngitis typically involves a combination of clinical assessment and diagnostic tests.

  • History taking: Detailed inquiry about symptoms (onset, duration, severity, associated symptoms like fever, cough, nasal discharge, rash), exposure to sick individuals, recent travel, allergies, and vaccination history.
  • Physical examination:
    • Inspection of the throat: Using a light source and tongue depressor to visualize the pharynx and tonsils for redness, swelling, exudates, ulcers, or vesicles.
    • Palpation of the neck: To check for swollen and tender lymph nodes (cervical adenopathy).
    • Examination of the ears and nose: To check for other possible sites of infection or signs of allergies.
    • Skin examination: To check for any rashes (e.g., scarlatiniform rash of scarlet fever).
    • Auscultation of lung and heart sounds: To rule out respiratory or cardiac involvement.
  • Diagnostic tests:
    • Rapid Antigen Detection Test (RADT): A quick test performed in the clinic to detect Group A Streptococcus (GAS) bacteria. If positive, it suggests strep throat. If negative, a throat culture may still be performed, especially in children, to confirm.
    • Throat culture: A sterile swab rubbed over the tonsils and posterior pharynx is sent to the lab to grow and identify bacteria. This is considered the gold standard for diagnosing strep throat.
    • Molecular tests (PCR): Highly sensitive and specific tests that detect bacterial or viral DNA/RNA directly from a throat swab, providing rapid and accurate results for various pathogens.
    • Complete Blood Count (CBC): May show elevated white blood cell count (leukocytosis) in bacterial infections, or atypical lymphocytes in viral infections like mononucleosis.
    • Monospot test (Heterophile Antibody Test): Used to diagnose infectious mononucleosis, especially if EBV is suspected.
    • Blood cultures: Rarely needed, but may be considered in severe cases or immunocompromised patients to rule out bloodstream infection.
    • Differential Diagnosis

    It is important to differentiate pharyngitis from other conditions that can present with similar symptoms:

    • Common cold: Usually presents with prominent nasal symptoms (runny nose, sneezing) and milder sore throat.
    • Influenza: Characterized by abrupt onset of high fever, severe body aches, headache, fatigue, and respiratory symptoms including sore throat.
    • Laryngitis: Primarily affects the voice box, leading to hoarseness or loss of voice, with less prominent throat pain.
    • Tonsillitis: Often occurs with pharyngitis, but specifically refers to inflammation of the tonsils, which may be swollen, red, and have exudates.
    • Allergic rhinitis: Chronic nasal congestion, sneezing, itching, and often clear nasal discharge, but typically without fever or significant throat pain unless due to postnasal drip.
    • Gastroesophageal Reflux Disease (GERD): Can cause chronic sore throat, hoarseness, and a sensation of a lump in the throat, especially if untreated.
    • Peritonsillar abscess: A collection of pus behind the tonsil, characterized by severe unilateral throat pain, trismus, muffled voice ("hot potato voice"), and deviation of the uvula. This is an emergency.
    • Retropharyngeal abscess: A deep neck space infection, presenting with severe sore throat, fever, difficulty swallowing, stiff neck, and sometimes airway compromise. Also an emergency.
    • Epiglottitis: Inflammation of the epiglottis, a life-threatening emergency, characterized by rapid onset of severe sore throat, dysphagia, drooling, muffled voice, and inspiratory stridor.
    • Oral candidiasis (Thrush): Fungal infection causing white patches on the tongue and oral mucosa, which can extend to the throat, often seen in immunocompromised individuals.
    • Sexually transmitted infections (STIs): Gonococcal pharyngitis or primary HIV infection can present with sore throat.
    • Kawasaki disease: A rare childhood illness causing inflammation of blood vessels, with symptoms including fever, rash, conjunctivitis, swollen lymph nodes, and red throat.

    Management

    Treatment goals:
    • Relieve symptoms (pain, fever).
    • Eradicate infection (if bacterial).
    • Prevent complications.
    Medical Management

    Treatment of pharyngitis is largely supportive for viral cases and focuses on maintaining adequate hydration and caloric intake and controlling pain and fever. For bacterial cases, antibiotics are crucial.

    1. Hydration: Maintaining adequate oral fluid intake is essential to prevent dehydration, especially with fever and difficulty swallowing. If oral intake is insufficient, intravenous (IV) hydration may be necessary.
    2. Diet: Soft, easily swallowed foods and cool liquids are often preferred. Avoid irritating foods (acidic, spicy).
    3. Rest: Adequate rest is important for recovery, especially for children.
    4. Pharmacologic Management:
      • Antibiotics: Prescribed only for bacterial pharyngitis, most commonly for Group A Streptococcus. Penicillin or amoxicillin are first-line agents. For penicillin-allergic patients, azithromycin, cephalexin, or clindamycin may be used. The full course of antibiotics must be completed to prevent complications like rheumatic fever.
      • Analgesics and Antipyretics:
        • Acetaminophen (paracetamol): For pain and fever relief.
        • Nonsteroidal Anti-inflammatory Drugs (NSAIDs): (e.g., ibuprofen, naproxen) also reduce pain and inflammation.
      • Topical Anesthetics: Throat lozenges, sprays (e.g., benzocaine, phenol), or gargles can provide temporary local pain relief.
      • Corticosteroids: (e.g., dexamethasone) may be administered in severe cases of pharyngitis (e.g., with significant swelling or in infectious mononucleosis) to reduce inflammation, improve swallowing, and potentially reduce pain.
      • Antivirals: Rarely used for viral pharyngitis, except in specific cases like severe influenza (oseltamivir) or herpes simplex virus (acyclovir).
    Nursing interventions/management
    1. Assessment of the patients
    • a. Carrying out a comprehensive history of the presenting signs and symptoms (e.g., fever, ear pain, sore throat, difficulty swallowing, cough, nasal discharge, rash, muscle aches, exposure history).
    • b. Taking vital observations (e.g., Temperature, Pulse, Respirations, Blood Pressure) and performing a general physical examination to assess the patient's overall condition and to exclude other serious conditions (e.g., signs of airway compromise, severe dehydration).
    • c. Alerting the doctor if signs of severe infection or complications are present, for further investigations and management. The nurse will assist the patient throughout this process.
    2. Managing fever
    • a. Assess the patient’s vital signs, especially temperature, at least every 4 hours, and more frequently if fever is high.
    • b. Remove excessive clothing and blankets. Adjust the room temperature to a comfortable level.
    • c. Administer prescribed antipyretics (e.g., acetaminophen, ibuprofen) as ordered.
    • d. Offer a tepid sponge bath or cool compresses to the forehead and axillae, if tolerated and effective.
    • e. Encourage increased fluid intake to prevent dehydration associated with fever.
    • f. Encourage rest.
    3. To relieve pain and discomfort
    • a. Assess the patient’s pain level using a pain scale and characteristics of pain (location, quality, duration) before and at least 30 minutes after administration of medication to evaluate effectiveness.
    • b. Administer prescribed analgesics (e.g., acetaminophen, NSAIDs).
    • c. Encourage warm or cool liquids (e.g., warm tea with honey, cold water, popsicles) as preferred by the patient to soothe the throat.
    • d. Offer throat lozenges or sprays as ordered or as appropriate.
    • e. Encourage gargling with warm salt water several times a day to reduce inflammation and discomfort.
    • f. Advise the patient to minimize talking or rest the voice to reduce strain on the throat.
    • g. Encourage the patient to verbalize feelings of pain and discomfort.
    • h. Elevate the head of the bed or position the patient in semi-Fowler’s to promote comfort and ease breathing.
    4. Prevention of complications
    • a. Continuously assess the patient’s vital signs and respiratory status (rate, depth, effort, presence of stridor, retractions, oxygen saturation) at least every 4 hours, and more frequently if signs of respiratory distress are noted. Assess for signs of hypoxia (e.g., restlessness, cyanosis).
    • b. Monitor for signs of worsening infection or development of complications (e.g., peritonsillar abscess: severe unilateral pain, trismus, muffled voice; rheumatic fever: joint pain, rash, cardiac murmurs; glomerulonephritis: dark urine, swelling).
    • c. Ensure completion of the full course of antibiotics for bacterial pharyngitis to prevent complications like acute rheumatic fever and post-streptococcal glomerulonephritis.
    • d. Position the patient in a side-lying or prone position if secretions are excessive to prevent aspiration, or elevate the head of the bed.
    • e. Suction oral secretions as needed to maintain airway patency.
    • f. Advise cessation of smoking or avoiding exposure to secondhand smoke, and minimizing alcohol intake, as these can irritate the throat and impede healing.
    • g. Administer prescribed medications (e.g., corticosteroids to reduce swelling, antibiotics for bacterial infections).
    5. To prevent infection and to promote good nutrition
    • a. Assess vital signs and observe for any signs of worsening infection or secondary infections.
    • b. Perform a focused assessment on the oropharyngeal region, particularly checking for any collection of abscess or spreading inflammation.
    • c. Teach the patient and family how to perform proper hand hygiene to prevent the spread of infection.
    • d. Encourage the patient to take a lot of warm fluids (at least 2-3 liters a day, unless contraindicated) to thin secretions and prevent dehydration.
    • e. Encourage the patient to consume soft, easy-to-swallow foods rich in vitamins and nutrients to support the immune system. Avoid foods that may irritate the throat (e.g., very hot, cold, spicy, acidic, crunchy foods).
    • f. Administer antibiotics as prescribed and ensure adherence.
    6. To relieve the patient’s anxiety and Health educate the patient
    • a. Reassure the patient and family, providing clear and honest information about the condition and treatment plan.
    • b. Assess the patient’s fears and concerns, and provide emotional support and counselling as needed.
    • c. Health educate the patient and family about the disease process, its causes, modes of transmission, and expected course.
    • d. Teach the patient and family about proper hand hygiene, cough etiquette, and avoiding close contact with others to prevent the spread of infection.
    • e. Explain the importance of completing the full course of antibiotics and the signs of complications that require immediate medical attention.
    7. Advice on discharge
    • a. Encourage the patient to maintain good hydration by taking plenty of warm fluids.
    • b. Emphasize the importance of adhering to prescribed medications, especially completing the full course of antibiotics.
    • c. Advise on when to return for follow-up appointments with the healthcare provider.
    • d. Educate on lifestyle modifications, such as avoiding irritants (smoking, pollutants), managing underlying conditions like GERD or allergies.
    • e. Provide clear instructions on warning signs or symptoms that necessitate seeking immediate medical attention (e.g., difficulty breathing, severe worsening pain, persistent high fever, rash, swelling, inability to swallow).

    Complications

    If left untreated or inadequately managed, pharyngitis, especially bacterial pharyngitis caused by Group A Streptococcus, can lead to several complications:

  • Local complications:
    • Peritonsillar abscess (Quinsy): A collection of pus behind the tonsil, requiring drainage.
    • Retropharyngeal abscess: A deep neck space infection behind the pharynx, a life-threatening emergency.
    • Epiglottitis: Inflammation of the epiglottis, which can rapidly lead to airway obstruction.
    • Cervical lymphadenitis: Inflammation and enlargement of neck lymph nodes.
    • Otitis media: Middle ear infection.
    • Sinusitis: Inflammation of the sinuses.
    • Mastoiditis: Infection of the mastoid bone behind the ear (rare).
  • Systemic complications (Non-suppurative complications, primarily associated with untreated GAS infection):
    • Acute Rheumatic Fever (ARF): A serious inflammatory disease that can affect the heart (rheumatic heart disease), joints, brain, and skin. It is a preventable complication with appropriate antibiotic treatment of strep throat.
    • Post-streptococcal Glomerulonephritis (PSGN): A kidney disorder that can develop after a strep infection, characterized by inflammation of the kidney's filtering units.
    • Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS): A controversial condition where strep infections are thought to trigger or exacerbate certain neuropsychiatric disorders in children (e.g., OCD, Tourette's syndrome).

    • PHARYNGITIS Read More »

    SINUSITIS RHINOSINUSITIS

    SINUSITIS/RHINOSINUSITIS

    Nursing Notes - Thrombus and Embolus

    SINUSITIS/RHINOSINUSITIS

    Introduction

    Sinusitis is the inflammation and swelling of the lining of the sinuses, which blocks the openings into the nose, prevents normal drainage and creates a breeding ground for further infection. Possible causes are a viral, bacterial or fungal infection, or an allergy. This condition is currently known as Rhinosinusitis. It's the inflammation of the paranasal sinuses and the nasal cavity. It is recommended to use the word rhinosinusitis because usually sinusitis is accompanied by inflammation of the nasal mucosa.

    Types of sinusitis

    CLASSIFICATION (according to duration) of symptoms:

    1. Acute sinusitis: is diagnosed when symptoms last up to four weeks (Brook et al, 2000). It often develops from a common cold or allergic rhinitis.
    2. Sub-acute (or relapsing) sinusitis: is diagnosed when symptoms persist or recur after four weeks, but for less than three months.
    3. Chronic sinusitis: is diagnosed when symptoms persist for more than three months. It is also diagnosed when people have more than three or four significant episodes annually, or repeatedly fail to respond to medical treatment. Chronic sinusitis can be further classified into chronic sinusitis with nasal polyps (CRSwNP) and chronic sinusitis without nasal polyps (CRSsNP).
    4. Recurrent acute rhinosinusitis: Characterized by four or more episodes of acute rhinosinusitis per year, with complete resolution of symptoms between episodes.

    Pathophysiology

    Most commonly a viral upper respiratory infection causes sinusitis secondary to edema and inflammation of the nasal lining and production of thick mucus that obstructs the paranasal sinuses and allows a secondary bacterial overgrowth. There are frontal, maxillary, sphenoid, and ethmoid sinuses. Allergic rhinitis can lead to sinusitis also due to ostial obstruction. Ciliary immobility can lead to increased mucus viscosity, further blocking drainage. Bacteria are introduced into the sinuses by coughing and nose blowing. Bacterial sinusitis usually occurs after a viral upper respiratory infection and worsening symptoms after 5 days, or persistent symptoms after 10 days. The impaired mucociliary clearance and obstruction of the ostia (openings of the sinuses) are key factors in the development of sinusitis. This creates an environment conducive to bacterial or fungal proliferation.

    Causes of sinusitis

    • Bacterial: Common causative organisms include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Less commonly, Staphylococcus aureus and anaerobic bacteria may be involved, especially in chronic cases.
    • Viral: Rhinovirus, influenza virus, parainfluenza virus, adenovirus, and respiratory syncytial virus are common viral culprits, often preceding bacterial infections.
    • Fungal: Fungal sinusitis is less common but can be severe, especially in immunocompromised individuals. It can be invasive (e.g., mucormycosis, aspergillosis) or non-invasive (e.g., fungal ball, allergic fungal rhinosinusitis).
    • Allergic: Allergic reactions can lead to inflammation and swelling of the nasal and sinus lining, obstructing drainage and predisposing to infection.
    • Environmental irritants: Exposure to pollutants, smoke, and chemical irritants can irritate the sinus lining and contribute to inflammation.

    Risk factors for sinusitis

    These include any condition that interferes with proper drainage and ventilation of the sinuses due to stasis of secretion and mucosal swelling e.g.

  • Upper Respiratory Tract Infections (URTIs): Viral URTIs are the most common predisposing factor.
  • Allergic Rhinitis: Chronic inflammation and swelling of the nasal passages due to allergies.
  • Structural abnormalities:
    • Deviated nasal septum: A displacement of the wall that divides the nostrils, impeding drainage.
    • Nasal polyps: Benign growths in the nasal passages or sinuses that can obstruct airflow and drainage.
    • Adenoid hypertrophy: Enlarged adenoids, especially in children, can block the Eustachian tubes and contribute to sinus issues.
    • Turbinate hypertrophy: Enlarged turbinates (structures inside the nose) can obstruct drainage.
  • Immunodeficiency: Conditions like HIV/AIDS, chemotherapy, or immunosuppressive medications can weaken the immune system, making individuals more susceptible to infections.
  • Cystic Fibrosis: A genetic disorder that causes thick, sticky mucus, leading to blockages in the respiratory system, including the sinuses.
  • Ciliary Dyskinesia: Disorders affecting the cilia (tiny hair-like structures that help move mucus) can impair mucociliary clearance.
  • Smoking: Irritates the nasal and sinus lining, impairs ciliary function, and increases susceptibility to infections.
  • Environmental irritants: Exposure to air pollution, dust, and certain chemicals.
  • Dental infections: Infections in the upper teeth can spread to the maxillary sinuses.
  • Trauma to the face or nose: Can lead to structural changes that impair sinus drainage.
  • Swimming and diving: Can force water into the sinuses, leading to irritation or infection.
  • Foreign body in the nose: Especially in children, can cause localized inflammation and obstruction.
  • Barotrauma: Changes in air pressure (e.g., during flying or diving) can affect sinus pressure and lead to inflammation.

    • CLINICAL MANIFESTATION

    Symptoms can vary depending on the affected sinus and the severity of the inflammation.

    • Facial pain and pressure: Often described as a dull, throbbing pain or pressure over the affected sinus (e.g., forehead for frontal, cheeks/upper teeth for maxillary, behind eyes for ethmoid/sphenoid). Pain worsens when bending forward, straining, or coughing.
    • Nasal congestion/blockage: Difficulty breathing through the nose due to swollen nasal passages.
    • Purulent nasal discharge (rhinorrhea): Thick, discolored (yellowish, greenish) discharge from the nose, which may be offensive in bacterial cases. Postnasal drip can also occur, leading to throat irritation and cough.
    • Headache: Continuous frontal throbbing headache is common, especially with frontal sinusitis.
    • Cough: Often worse at night due to postnasal drip.
    • Fever: More common in acute bacterial sinusitis.
    • Fatigue and malaise: General feeling of unwellness.
    • Halitosis (bad breath): Due to bacterial overgrowth and drainage.
    • Decreased sense of smell (hyposmia) or complete loss of smell (anosmia): Due to inflammation affecting the olfactory receptors.
    • Ear pain or pressure: Can occur due to Eustachian tube dysfunction.
    • Sore throat: From postnasal drip.
    • Dental pain: Maxillary sinusitis can mimic toothache.
    • Tenderness to palpation: Over the affected sinus areas.

    NB: Bending and coughing or straining increases the pain. It can be confused with a lot of conditions like migraine, trigeminal neurological disorder or cranial arteritis.

    DIAGNOSIS & DIFFERENTIAL DIAGNOSIS

    DIAGNOSIS

    Diagnosis of sinusitis involves a combination of clinical assessment and diagnostic tests.

  • Clinical examination:
    • History taking: Detailed information about symptoms, their duration, severity, and associated factors.
    • Physical examination:
      • Anterior rhinoscopy: Examination of the nasal passages using a speculum to visualize inflammation, discharge, and any structural abnormalities.
      • Palpation: Tenderness to palpation over the frontal and maxillary sinuses.
      • Transillumination: Shining a light through the sinuses to check for opacity (cloudiness), though this is less reliable than imaging.
      • Pharyngeal examination: To assess for postnasal drip.
  • Imaging studies:
    • Plain sinus X-rays: May show mucosal thickening, air-fluid levels, or opacification (cloudiness) of the sinuses, but less sensitive than CT.
    • Computed Tomography (CT) scan of the sinuses: The gold standard for diagnosing sinusitis, providing detailed images of bony and soft tissue structures, demonstrating mucosal thickening, fluid levels, polyps, and anatomical variations. It helps in planning surgical interventions.
    • Magnetic Resonance Imaging (MRI): Useful for differentiating between inflammatory fluid, tumors, and fungal infections, especially when intracranial complications are suspected.
  • Endoscopic examination:
    • Nasal endoscopy: A thin, flexible or rigid endoscope is inserted into the nose to directly visualize the nasal passages and sinus openings, assess for inflammation, polyps, and discharge, and obtain samples for culture.
  • Microbiological studies:
    • Nasal or throat swab: Less reliable for diagnosing bacterial sinusitis as it may reflect colonization rather than true infection.
    • Sinus culture: Obtained directly from the sinus cavity (e.g., during endoscopy or aspiration) is the most accurate way to identify causative bacteria or fungi and determine antibiotic susceptibility.
  • Blood tests:
    • Complete Blood Count (CBC): May show an elevated white blood cell count in bacterial infections, but often non-specific.
    • Inflammatory markers: Elevated C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) may indicate inflammation but are not specific to sinusitis.
    • Differential diagnosis

    It is important to differentiate sinusitis from other conditions that present with similar symptoms:

    • Common cold: Usually self-limiting with symptoms resolving within 7-10 days, without significant facial pain or purulent discharge.
    • Allergic rhinitis: Characterized by sneezing, itching, watery eyes, clear nasal discharge, and often triggered by allergens. No fever or purulent discharge.
    • Migraine or other headaches: Can cause severe head pain, but usually lack nasal symptoms, fever, or purulent discharge.
    • Trigeminal neuralgia: Causes severe, sharp facial pain, but typically without nasal symptoms or signs of infection.
    • Cranial arteritis (Giant cell arteritis): Inflammatory condition affecting arteries, causing headache and scalp tenderness, but usually in older adults and without typical sinus symptoms.
    • Dental infections: Can cause pain in the upper jaw, mimicking maxillary sinusitis. Dental examination can differentiate.
    • Nasal polyps: Can cause nasal obstruction and decreased sense of smell, but may not always be associated with acute inflammatory signs.
    • Adenoids (especially in children): Enlarged adenoids can cause nasal obstruction and mouth breathing, leading to recurrent sinus infections.
    • Foreign body in the nose: Especially in children, can cause unilateral foul-smelling nasal discharge.
    • Temporomandibular joint (TMJ) dysfunction: Can cause facial pain around the jaw and ear.

    Management

    Treatment goals:
    • Relieve symptoms (pain, congestion).
    • Eradicate infection (if bacterial or fungal).
    • Restore normal sinus drainage and ventilation.
    • Prevent complications and recurrence.
    Pharmacological Management:
    • Antibiotics: For bacterial sinusitis, a course of antibiotics is typically prescribed. Common choices include Amoxicillin, Amoxicillin-clavulanate (co-amoxiclav), Doxycycline, or Fluoroquinolones (e.g., Levofloxacin, Moxifloxacin) for penicillin-allergic patients or resistant cases. The duration of treatment varies but is often 10-14 days for acute cases.
    • Nasal Decongestants:
      • Topical decongestants: (e.g., oxymetazoline, xylometazoline) can provide rapid relief of nasal congestion by constricting blood vessels. Use should be limited to 3-5 days to prevent rebound congestion (rhinitis medicamentosa).
      • Oral decongestants: (e.g., pseudoephedrine, phenylephrine) can also reduce congestion, but may have systemic side effects like increased heart rate and blood pressure.
    • Corticosteroids:
      • Topical intranasal corticosteroids: (e.g., fluticasone propionate, mometasone furoate, budesonide) are highly effective in reducing mucosal inflammation and swelling, improving sinus drainage. They are a cornerstone of treatment for both acute and chronic rhinosinusitis, and particularly useful in allergic rhinitis.
      • Oral corticosteroids: (e.g., prednisone) may be prescribed for severe cases of acute sinusitis or chronic sinusitis with significant inflammation or polyps, for a short course to reduce inflammation rapidly.
    • Mucolytics: (e.g., guaifenesin) can help thin mucus, making it easier to drain.
    • Antihistamines: May be used if allergic rhinitis is a contributing factor, but generally not recommended for non-allergic sinusitis as they can dry out nasal secretions.
    • Pain relievers: Over-the-counter analgesics like acetaminophen (paracetamol) or NSAIDs (e.g., ibuprofen, naproxen) can manage pain and fever.
    Non-Pharmacological and Supportive Measures:
    • Nasal saline irrigation: Using a neti pot or saline spray to rinse nasal passages helps clear mucus, irritants, and allergens, and can reduce inflammation. This is highly recommended for both acute and chronic sinusitis.
    • Steam inhalation: Inhaling steam from a bowl of hot water or a shower can help moisten nasal passages and loosen mucus.
    • Warm compresses: Applying warm, moist towels to the face (over the affected sinuses) can help relieve pain and promote drainage.
    • Adequate hydration: Drinking plenty of fluids (water, clear broths) helps thin mucus.
    • Rest: Important for recovery, especially during acute phases.
    • Humidifier: Using a humidifier in the bedroom can keep nasal passages moist.
    • Avoid irritants: Steer clear of smoke, strong odors, and allergens that can worsen symptoms.
    Surgical Management:
    • Functional Endoscopic Sinus Surgery (FESS): This is the most common surgical procedure for chronic sinusitis that does not respond to medical treatment, or in cases of recurrent acute sinusitis, or complications. FESS aims to restore natural drainage pathways by removing obstructions (e.g., polyps, diseased tissue, bone) and enlarging sinus openings, while preserving healthy tissue.
    • Balloon Sinuplasty: A less invasive procedure where a balloon catheter is used to dilate the sinus openings.
    • Septoplasty: Surgical correction of a deviated nasal septum if it is contributing significantly to obstruction.
    • Polypectomy: Surgical removal of nasal polyps.

    Complication of sinusitis

    If left untreated or inadequately managed, sinusitis can lead to several complications, some of which can be serious:

  • Orbital complications:
    • Periorbital cellulitis: Infection of the soft tissues around the eye.
    • Orbital cellulitis: More serious infection involving the tissues within the orbit, potentially leading to vision loss or blindness.
    • Orbital abscess: Collection of pus within the orbit.
  • Intracranial complications: (rare but life-threatening)
    • Meningitis: Inflammation of the membranes surrounding the brain and spinal cord.
    • Brain abscess: Collection of pus within the brain tissue.
    • Epidural or subdural abscess: Collections of pus between the dura mater and the skull, or between the dura and arachnoid membranes, respectively.
    • Cavernous sinus thrombosis: Formation of a blood clot in the cavernous sinus, a large venous channel at the base of the brain, which can lead to severe neurological deficits or death.
  • Bone complications:
    • Osteomyelitis: Infection of the bone (e.g., frontal bone osteomyelitis, also known as Pott's puffy tumor if associated with a swelling on the forehead).
  • Chronic symptoms and impact on quality of life: Persistent pain, nasal obstruction, postnasal drip, fatigue, and decreased sense of smell can significantly impact a person's daily life, productivity, and overall well-being.
  • Lower respiratory tract infections: Chronic postnasal drip can contribute to pharyngitis, laryngitis, or even exacerbate asthma.
  • Decreased sense of smell (hyposmia) or complete loss of smell (anosmia): Can be temporary or permanent due to damage to the olfactory epithelium.
  • Mucocele/Pyocele: A mucocele is a mucus-filled cyst that can expand and erode surrounding bone. A pyocele is an infected mucocele.

    • Nursing Interventions for Sinusitis/Rhinosinusitis

    Nursing care for patients with sinusitis focuses on symptom management, promoting drainage, preventing complications, and patient education.

    1. Assessment:
    • Gather comprehensive history:
      • Onset, duration, and characteristics of symptoms (pain, discharge, congestion, fever, cough).
      • Aggravating and alleviating factors.
      • Presence of allergies, asthma, or other respiratory conditions.
      • Previous episodes of sinusitis or respiratory infections.
      • Medications being taken (prescription and over-the-counter).
      • Risk factors (smoking, exposure to irritants, immune status).
    • Perform thorough physical assessment:
      • Assess vital signs (temperature, pulse, respiration, blood pressure).
      • Inspect nasal mucosa for swelling, redness, and character of discharge.
      • Palpate over sinus areas for tenderness.
      • Assess for facial swelling or redness.
      • Auscultate lung sounds to identify any signs of lower respiratory involvement.
      • Assess sense of smell.
    • Evaluate pain: Use a pain scale to assess severity, location, and quality of pain.
    • Monitor for complications: Observe for signs of orbital or intracranial complications (e.g., changes in vision, eye swelling, severe headache, altered mental status, stiff neck).
    2. Symptom Management:
    • Pain management:
      • Administer prescribed analgesics (acetaminophen, NSAIDs) as ordered.
      • Educate patient on proper use of over-the-counter pain relievers.
      • Encourage warm compresses to the face to reduce pain and discomfort.
    • Promote sinus drainage and reduce congestion:
      • Instruct and assist with nasal saline irrigation (e.g., neti pot, saline sprays) several times a day. Emphasize using distilled, sterile, or previously boiled and cooled water.
      • Encourage steam inhalation (e.g., warm shower, humidifier, bowl of hot water with towel over head) for 10-15 minutes, several times a day.
      • Administer prescribed nasal decongestants and corticosteroids, educating on proper technique and limiting use of topical decongestants.
      • Encourage increased fluid intake (water, juices, clear broths) to thin secretions and prevent dehydration.
      • Advise elevation of the head of the bed to promote drainage.
    • Fever reduction: Administer antipyretics as ordered.
    • Cough management: Encourage increased fluid intake and possibly cough suppressants if cough is disruptive.
    3. Medication Administration and Education:
    • Administer antibiotics as prescribed, ensuring completion of the full course even if symptoms improve, to prevent recurrence and antibiotic resistance. Educate on potential side effects.
    • Educate on the correct use of nasal sprays (corticosteroids, decongestants), emphasizing proper head position and avoiding swallowing.
    • Explain the purpose and potential side effects of all prescribed medications.
    4. Patient Education:
    • Disease process: Explain what sinusitis is, its causes, and expected course.
    • Importance of adherence: Emphasize the importance of completing the full course of antibiotics and consistently using other prescribed medications.
    • Self-care measures: Reinforce nasal saline irrigation, steam inhalation, hydration, and rest.
    • Prevention strategies:
      • Avoid irritants (smoke, allergens, strong chemicals).
      • Practice good hand hygiene.
      • Avoid close contact with sick individuals.
      • Manage underlying conditions like allergies effectively.
      • Consider humidifier use, especially in dry environments.
    • Warning signs: Educate on signs and symptoms that warrant immediate medical attention (e.g., worsening pain, high fever, vision changes, severe headache, swelling around the eyes, stiff neck, altered mental status).
    • Follow-up care: Explain the importance of follow-up appointments with the healthcare provider.
    5. Promote Rest and Comfort:
    • Encourage adequate rest to facilitate recovery.
    • Provide a quiet and comfortable environment.
    6. Nutritional Support:
    • Encourage a balanced diet to support the immune system.
    • Ensure adequate fluid intake.
    7. Pre- and Post-operative Care (if surgery is indicated):
    • Pre-operative:
      • Provide clear explanations of the surgical procedure (e.g., FESS), expected outcomes, and potential risks.
      • Educate on pre-operative instructions (e.g., NPO status, medication adjustments).
      • Address patient anxieties and concerns.
    • Post-operative:
      • Monitor vital signs, level of consciousness, and pain.
      • Assess for nasal bleeding or excessive drainage.
      • Provide pain management.
      • Educate on post-operative care: nasal packing care (if applicable), nasal saline rinses, activity restrictions, avoiding nose blowing, and signs of complications.
      • Emphasize follow-up appointments for nasal endoscopy and cleaning.

    SINUSITIS/RHINOSINUSITIS Read More »

    COMMON COLD/CORYZA

    Nursing Notes - Thrombus and Embolus

    COMMON COLD/CORYZA

    Introduction

    It is the acute inflammation of the upper respiratory tract; rhinitis (nasal mucosa) and rhinopharyngitis (nasal and pharyngitis).

    Causes of common cold
    1. The most common virus is rhinovirus. Other viruses include the influenza virus, adenovirus, enterovirus, and respiratory syncytial virus.
    2. Bacteria may cause roughly 15% of sudden onset pharyngitis presentations. The most common is S. pyogenes, a Group A streptococcus.

    Clinical manifestations

    Manifestations of common cold infection typically appear after an incubation period of 12-72 hours and last 7-11 days, but may persist for longer.

    Signs and symptoms include the following:
    1. Nasal dryness or irritation - May be first symptom
    2. Sore throat or throat irritation – Common and bothersome initial symptom
    3. Nasal discharge, nasal congestion, and sneezing – Intensify over 2-3 days
    4. Headache
    5. Facial and ear pressure
    6. Loss of sense of smell and taste
    7. Cough (30% of infected individuals)
    8. Hoarseness (20%)
    9. Irritability or restlessness
    10. Fever (unusual; when present, typically low grade)
    11. Tiredness with slight pyrexia
    12. General malaise
    13. Mild conjunctivitis
    14. Anorexia
    15. Loss of or swollen enlarged lymph nodes

    Test and Diagnosis

    History taking and physical examination – include the following:
    1. Inspection of the nose and ears to check for any other possible sites of infection.
    2. Inspection of the skin for any rash related to scarlet fever to rule out the condition.
    3. Palpation of the lymph nodes around the neck.
    4. Auscultation to listen to the patient’s breathing and heart sounds.
    5. In some cases, mononucleosis may be ruled out as it can also cause inflammation of the tonsils.
    Other diagnostic tests may be performed as follow:
    1. Throat swab – a sterile swab rubbed over the throat will be sent to the lab to check for streptococcal bacteria and the need for antibiotics.
    2. Complete blood count – to show the presence of either a viral or bacterial infection depending on what blood cell is elevated.
    3. Because of the prolonged time to obtain positive culture findings, rhinovirus culture has rarely been found useful in clinical settings.
    4. PCR testing of respiratory specimens may be useful in evaluating severely immunocompromised patients.
    DIFFERENTIAL DIAGNOSIS
    • Rhinitis
    • Early signs of measles
    • An allergy
    • Whooping cough

    Management of Common Cold

    The common cold is primarily a self-limiting viral infection, and treatment is mainly supportive, focusing on relieving symptoms.

    Aims of management
  • To promote quick recovery
  • To prevent further complication
    • Symptomatic Relief:
  • Rest: Adequate rest helps the body recover.
  • Hydration: Drink plenty of fluids like water, juice, clear broth, and warm lemon water with honey to prevent dehydration and soothe sore throats.
  • Pain relievers and fever reducers: Over-the-counter medications like acetaminophen (paracetamol) or ibuprofen can help relieve aches, pains, and fever.
  • Decongestants: Oral decongestants (e.g., pseudoephedrine, phenylephrine) or nasal sprays (e.g., oxymetazoline, xylometazoline) can help relieve nasal congestion. Nasal sprays should not be used for more than a few days to avoid rebound congestion.
  • Cough suppressants: For a dry cough, dextromethorphan may be used. For a cough with mucus, expectorants like guaifenesin can help loosen phlegm.
  • Antihistamines: First-generation antihistamines (e.g., diphenhydramine, chlorpheniramine) can help with sneezing, runny nose, and watery eyes, but may cause drowsiness.
  • Sore throat remedies: Warm salt water gargles, throat lozenges, and medicated sprays can provide relief for a sore throat.
  • Nasal saline sprays: Can help moisten nasal passages and loosen mucus.
    • When to Seek Medical Attention:

    While most common colds resolve on their own, it's important to seek medical advice if you experience any of the following:

    • Symptoms that worsen or do not improve after 7-10 days.
    • High fever (above 103°F or 39.4°C).
    • Severe sore throat, especially if it's sudden and without other cold symptoms.
    • Swollen glands in the neck or jaw.
    • Significant sinus pain.
    • Shortness of breath, wheezing, or difficulty breathing.
    • Chest pain.
    • Earache.
    • New or worsening headache.
    • Symptoms in infants (e.g., difficulty breathing, unusual drowsiness, refusal to feed).
    • Weakened immune system due to other conditions (e.g., HIV, cancer treatment).
    Medical Management

    Common cold is a viral disease which needs only symptomatic treatment and no antibiotics are needed.

    Antibiotics:

    Antibiotics are ineffective against viral infections, including the common cold. They are only prescribed if a bacterial complication, such as a bacterial sinus infection or strep throat, is diagnosed.

    Drug therapy
    1. NSAIDS
    2. Antihistamines
    3. Corticosteroids
    4. Nasal decongestants
    Nursing interventions/management
    1. Assessment of the patient
    • a. Carrying out history of the presenting signs and symptoms e.g. fever, flue among others.
    • b. Taking vital observation e.g. TPR/BP and general examination to exclude other diseases.
    • c. Alerting the doctor who will order for investigations and admission, there the nurse will assist the patient throughout the process.
    2. Managing fever
    • a. Assess the patient’s vital signs at least every 4 hours.
    • b. Remove excessive clothing, blankets, and linens. Adjust the room temperature.
    • c. Administer the prescribed antibiotic and anti-pyretic.
    • d. Offer a tepid sponge bath.
    • e. Elevate the head of the bed.
    3. To relieve headache, joint pains, flue and cough
    • a. Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.
    • b. Elevate the head of the bed and position the patient in semi Fowler’s.
    • c. Encouraging patient to sneeze into the elbow not in the hand.
    • d. Must were a mask most time.
    • e. Should be isolated until he improves.
    • f. Encouraging patients to take soothing fluids like warm water and honey or lemon.
    • g. Administer cough suppressants, antibiotics and analgesics as prescribed.
    • h. Encourage patients to verbalise feeling of pain.
    • i. Measure the pain compliants of patients using a pain scale.
    • j. Encourage patients to take more fluids at least 3 liters.
    4. Prevention of complication
    • a. Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. Assess for signs of hypoxia.
    • b. Place the patient on a side-lying or prone position.
    • c. Suction secretions.
    • d. Positioning the mattress at a 45° angle.
    • e. Discontinuing smoking or using alcohol.
    • f. Administer the prescribed medications (e.g. corticosteroids) and antibiotic medications.
    5. To prevent infection
    • a. Teach the patient
      • i. Self isolation
      • ii. Wearing masks while in public
      • iii. Maintain social distance
    • b. Assess vital signs and observe for any signs of infection as well as for any signs of respiratory distress.
    • c. Perform a focused assessment on the oropharyngeal region, particularly checking for any collection of abscess.
    • d. Teach the patient how to perform proper hand hygiene.
    • e. Administer antibiotics as prescribed.
    • f. Disinfecting the environment using phenol-alcohol–based compounds.
    • g. Washing hands.
    6. Health education of the patients
    • a. Educating the patient about wearing mask, maintaining hand hygiene.
    • b. Educating the patients about the disease.
    7. Discharge advice
    • a. Encourage proper hand hygiene, wearing masks.
    • b. Encourage proper adherence to drugs.
    • c. Inform the patient about the follow up date and encourage the patient to attend.

    Prevention of Common Cold

    While there is no vaccine for the common cold, certain measures can help prevent its spread:

    • Frequent handwashing: Wash hands thoroughly with soap and water for at least 20 seconds, especially after coughing, sneezing, or blowing your nose, and before eating. Hand sanitizers with at least 60% alcohol can be used when soap and water are not available.
    • Avoid touching face: Try to avoid touching your eyes, nose, and mouth, as viruses can enter the body through these routes.
    • Stay away from sick people: Maintain distance from individuals who are ill with a cold.
    • Clean and disinfect surfaces: Regularly clean and disinfect frequently touched surfaces, such as doorknobs, phones, and keyboards, especially when someone in the household is sick.
    • Boost your immune system: A healthy lifestyle, including a balanced diet, regular exercise, adequate sleep, and stress management, can help strengthen your immune system.
    • Use tissues: Cover your mouth and nose with a tissue when you cough or sneeze, then dispose of the tissue immediately. If a tissue isn't available, cough or sneeze into your elbow.

    COMPLICATION

    • Sinusitis
    • Lower respiratory tract infection (LRTI) e.g pneumonia
    • Deafness
    • Otitis media
    • Headache
    • Acute tonsillitis
    • Chronic bronchitis
    • Exacerbations of reactive airway disease (e.g. asthma)

    COMMON COLD/CORYZA Read More »

    COAGULATION DISORDERS

    COAGULATION DISORDERS

    Nursing Notes - Thrombus and Embolus

    COAGULATION DISORDERS

    A coagulation disorder is a medical condition characterised by excessive bleeding occurring as a result of deficiency of any of the essential clotting factors. Coagulations disorders are conditions that affect the blood’s clotting activities. Hemophilia, Von Willebrand disease, clotting factor deficiencies, hypercoagulable states and deep venous thrombosis are all coagulations disorders. Hemophilia and Von Willebrand disease are among the best known.

    Normal mechanism of blood clotting
    1. Damage or injury to the endothelium will initiate a cascade of events in an attempt to control bleeding.
    2. Disruption of the endothelium will first cause local vasoconstriction to occur, limiting blood flow to the area.
    3. Primary hemostasis initiates by platelets with the release of von Willebrand factor (vWF), a large plasma glycoprotein made and stored in endothelial cells and megakaryocytes.
    4. Platelets and vWF will combine to form a plug at the site of injury. Circulating vWF continues to bind with collagen and Factor VIII as well as other endothelial substances, allowing the platelet plug to adhere to the area of injury.
    5. Through activation of the clotting cascade and secondary hemostasis, this initial platelet plug will get reinforced to a sturdy fibrin clot.
    6. The clotting cascade operates through a dual process system in which the various clotting factors become activated with the result being the formation of a fibrin strand or clot at the site of tissue injury.

    NB: A deficiency of any of the essential clotting factors will result in difficulty forming a fibrin clot, and excessive bleeding can occur.

    Types of coagulation disorders

    Bleeding disorders fall into two main categories:

    1. Inherited coagulation disorders: Hereditary bleeding disorders are due to the absence or deficiency of specific clotting proteins which act as pro-coagulants through precise interactions in the clotting cascade. The three most common are:
    • a. Hemophilia A (Factor VIII deficiency): Hemophilia A is an X-linked recessive genetic disorder affecting 1 in 5000 males making it the most common congenital coagulopathy.
    • b. Hemophilia B (Factor IX deficiency): Hemophilia B is an X-linked genetic coagulopathy affecting 1 in 30000 male births.
    • c. Von Willebrand disease: It is characterised by excessive bleeding as a result of deficiency of von-Willebrand factor hence causing failure of platelet plug formation.
    2. Acquired coagulation disorders: Acquired bleeding disorders can be caused by conditions that an individual may develop at any point during their lifetime. These can be broader in range and dependent on comorbid conditions.
    • a. Liver disease
    • b. Vitamin k deficiency
    • c. Disseminated intravascular coagulation

    Causes of Coagulation disorders

    The major causes of acquired coagulation disorders are:

    1. Vitamin K deficiency
    2. Liver disease
    3. Disseminated intravascular coagulation (DIC)
    4. Development of circulating anticoagulants
    5. Severe liver disease (e.g. cirrhosis, fulminant hepatitis, acute fatty liver of pregnancy) may disturb hemostasis by impairing clotting factor synthesis. Because all coagulation factors are made in the liver (by hepatocytes and endothelial cells), both the prothrombin time (PT) and partial thromboplastin time (PTT) are prolonged in severe liver disorders. (PT results are typically reported as INR [international normalized ratio].)

    The most common hereditary disorder of hemostasis is:

    • a. Von Willebrand disease (VWD)
    • b. The hemophilias

    Clinical manifestations

    Hemophilia:
    1. While mild hemophilia may only present after a traumatic injury or surgery.
    2. Those with a moderate to severe form of the disease may exhibit hallmark characteristics such as:
      • a) Mucosal or gingival bleeding
      • b) Easy bruising
      • c) Hematoma formation
      • d) Hemarthrosis: is bleeding into joints, particularly in the ankles.
      • e) Bleeding into muscle tissue from minor traumas can result in anemia and
      • f) Compression of vital structures and nerves leading to compartment syndrome.
      • g) Intracranial bleeds
    3. Hemophilia can present in infancy with cephalohematoma formation after vaginal birth and with significant bleeding after circumcisions.
    Von Willebrand Disease
    1. Von Willebrand disease can exhibit clinical signs and symptoms starting in childhood with a history of easy bruising and bleeding.
    2. While patients with a very mild version of the disease may not have clinical symptoms at all, patients with vWF that is qualitative or quantitatively low may present with a predisposition to mucosal bleeding and episodic epistaxis.
    3. Women with von Willebrand disease may have significant menorrhagia which is often a presenting sign of the illness, precipitating a workup and eventual diagnosis.
    4. These patients can also go unrecognized until undergoing major surgery or experiencing a traumatic injury.

    Test and Diagnosis for coagulation disorders

    Hemophilia
    1. Chromogenic assay: This assay is considered by some to be more accurate, as it measures the level of plasma factor VIII activity but it is less widely available in clinical laboratories in the United States.
    2. Laboratory studies: Laboratory studies for suspected hemophilia include a complete blood cell count, coagulation studies, and a factor VIII (FVIII) assay.
    3. CT scans: Head CT scans without contrast are used to assess for spontaneous or traumatic intracranial hemorrhage.
    4. MRI: Perform magnetic resonance imaging (MRI) on the head and spinal column for further assessment of spontaneous or traumatic hemorrhage; MRI is also useful in the evaluation of the cartilage, synovium, and joint space.
    5. Ultrasonography: Ultrasonography is useful in the evaluation of joints affected by acute or chronic effusions.
    6. Testing for inhibitors: Laboratory confirmation of a FVIII inhibitor is clinically important when a bleeding episode is not controlled despite infusion of adequate amounts of factor concentrate.
    7. Carrier testing: Screening for carrier status can be performed by measuring the ratio of FVIII coagulant activity to the concentration of von Willebrand factor (vWF) antigen; a ratio that is less than 0.7 suggests carrier status.
    8. Radiography: Radiography for joint assessment is of limited value in acute hemarthrosis; evidence of chronic degenerative joint disease may be visible on radiographs in patients who have been untreated or inadequately treated or in those with recurrent joint hemorrhages.

    Management

    Medical Management - Hemophilia

    The treatment of hemophilia may involve prophylaxis, management of bleeding episodes, treatment of factor VIII (FVIII) inhibitors, and treatment and rehabilitation of hemophilia synovitis.

    Pre-hospital care
    1. Rapid transport to definitive care is the mainstay of prehospital care; prehospital care providers should apply aggressive hemostatic techniques, assist patients capable of self-administered factor therapy, and gather focused historical data if the patient is unable to communicate.
    2. Emergency department care. Use aggressive hemostatic techniques; correct coagulopathy immediately; include a diagnostic workup for hemorrhage, but never delay indicated coagulation correction pending diagnostic testing; acute joint bleeding and expanding, large hematomas require adequate factor replacement for a prolonged period until the bleed begins to resolve, as evidenced by clinical and/or objective methods; life-threatening bleeding episodes are generally initially treated with FVIII levels of approximately 100%, until the clinical situation warrants a gradual reduction in dosage.
    3. Factor VIII and FIX concentrates. Various FVIII and FIX concentrates are available to treat hemophilia A and B; besides improved hemostasis, continuous infusion decreases the amount of factor used, which can result in significant savings; obtain factor level assays daily before each infusion to establish a stable pattern of replacement regarding the dose and frequency of administration.
    4. Desmopressin. Desmopressin vasopressin analog, or 1-deamino-8-D-arginine vasopressin (DDAVP), is considered the treatment of choice for mild and moderate hemophilia A; DDAVP stimulates a transient increase in plasma FVIII levels; DDAVP may result in sufficient hemostasis to stop a bleeding episode or to prepare patients for dental and minor surgical procedures.
    5. Management of bleeding. Immobilization of the affected limb and the application of ice packs are helpful in diminishing swelling and pain; early infusion upon the recognition of initial symptoms of a joint bleed may often eliminate the need for a second infusion by preventing the inflammatory reaction in the joint; prompt and adequate replacement therapy is the key to preventing long-term complications.
    6. Treatment of patients with inhibitors. Inhibitors are antibodies that neutralize factor VIII (FVIII) and can render replacement therapy ineffective; the treatment of patients with inhibitors of FVIII is difficult; assuming no anamnestic response, low-titer inhibitors (ie, concentrations below 5 Bethesda units [BU]) occasionally can be overcome with high doses of factor VIII; there is no established treatment for bleeding episodes in patients with high-titer inhibitors.
    7. Prophylactic factor infusions. The main goal of prophylactic treatment is to prevent bleeding symptoms and organ damage, in particular to joints; in December 2013, the US Food and Drug Administration (FDA) expanded the indication for anti-inhibitor coagulant complex (Feiba NF) to include routine prophylaxis in patients with hemophilia A or B who have developed inhibitors; approval was based on data from a pivotal phase III study in which a prophylactic regimen resulted in a 72% reduction in median annual bleed rate compared with on-demand treatment.
    8. Pain management. Hemophilic chronic arthropathy is associated with pain; narcotic agents have been used, but frequent use of these drugs may result in addiction; nonsteroidal anti-inflammatory drugs may be used instead because their effects on platelet function are reversible and because these drugs can be effective in managing acute and chronic arthritic pain; avoid aspirin because of its irreversible effect on platelet function.
    9. Activity. Generally, individuals with severe hemophilia should avoid high-impact contact sports and other activities with a significant risk of trauma; however, mounting evidence suggests that appropriate physical activity improves overall conditioning, reduces injury rate and severity, and improves psychosocial functioning.
    10. Gene therapy. With the cloning of FVIII and advances in molecular technologies, the possibility of a cure for hemophilia with gene therapy was conceived; ex vivo gene therapy, in which cells to be transplanted are genetically modified to secrete factor VIII and then are reimplanted into the recipient; in vivo gene therapy, in which a vector (typically a virus altered to include FVIII DNA) is directly injected into the patient; and nonautologous gene therapy, in which cells modified to secrete FVIII are packaged in immunoprotected devices and implanted into recipients.
    11. Radio-synovectomy. In patients who develop synovitis from joint bleeds, intra-articular injection of radioisotopes to ablate the synovium (radiosynovectomy) can be used to decrease bleeding, slow progression of cartilage and bone damage, and prevent arthropathy.
    Pharmacologic Management - Hemophilia

    Medications of choice for patients with hemophilia are:

    1. Factor VIII. Factor VIII (FVIII) is the treatment of choice for acute or potential hemorrhage in hemophilia A; recombinant FVIII concentrate is generally the preferred source of factor VIII; prophylactic administration of FVIII is often recommended for pediatric patients with severe disease.
    2. Anti-fibrinolytic agents. Antifibrinolytic agents, such as aminocaproic acid and tranexamic acid, are especially useful for oral mucosal bleeds but are contraindicated as initial therapies for hemophilia-related hematuria originating from the upper urinary tract because they can cause obstructive uropathy or anuria.
    3. Factor IX. Factor IX is the treatment of choice for acute hemorrhage or presumed acute hemorrhage in hemophilia B. Recombinant factor IX is the preferred source for replacement therapy.
    4. Coagulation factor VIIa. These agents can activate coagulation factor X to factor Xa as well as coagulation factor IX to IXa.
    5. Coagulation factors. FVIII concentrates replace deficient FVIII in patients with hemophilia A, with the goal of achieving a normal hematologic response to hemorrhage or preventing hemorrhage; recombinant products should be used initially and subsequently in all newly diagnosed cases of hemophilia that require factor replacement; agents that bypass FVIII activity in the clotting cascade (eg, activated FVII) are used in patients with FVIII inhibitors.
    6. Anti-hemophilic agents. These agents are used to control bleeding in hemophilia B or FIX deficiency and to prevent and/or control bleeding in patients with hemophilia A and inhibitors to FVIII.
    7. Monoclonal antibodies. Monoclonal antibodies are used to bind to one specific substance in the body (eg, molecules, antigens); this binding is very versatile and can mimic, block, or cause changes to enact precise mechanisms (eg, bridging molecules, replacing or activating enzymes or cofactors, immune system stimulation).
    8. Vasopressin-related. Desmopressin transiently increases the FVIII plasma level in patients with mild hemophilia A.
    Management - Von Willebrand disease

    Treatment depends on the type of VWD and should be decided by a hematologist. Options include the following:

    1. Hormonal treatments such as oral contraceptives and some intrauterine devices are highly effective in controlling menorrhagia. In fact, 88% of women with VWD report improvement in bleeding symptoms when treated only with oral contraceptives.
    2. Desmopressin (DDAVP) is effective in most patients with type 1 VWD and some patients with type 2. Recovery testing must be done to determine its effectiveness. During a recovery test, a blood sample is obtained before the medication is given and 30 to 60 minutes after administration. This test helps determine if the medication increases the patient’s factor levels enough to prevent or stop bleeding.
    3. Replacement factor made from plasma-derived concentrates can be used in any patient with VWD, but must be used in all patients with type 3 and in some patients with type 2. Replacement factor is also used when patients don’t respond to DDAVP.
    4. Anti-fibrinolytics such as aminocaproic acid and tranexamic acid are used in conjunction with factor or DDAVP to treat bleeding. Anti-fibrinolytics stabilize a clot by preventing it from breaking down too early, which would cause bleeding. Without anti-fibrinolytics, bleeding may occur several days or weeks after a procedure involving mucosal tissue. Antifibrinolytics are effective in treating mucosal bleeding such as with dental surgery, menstrual bleeding, nosebleeds, and gastrointestinal bleeding.
    Nursing intervention/management
    1. Relieve pain. Immobilize joints and apply elastic bandages to the affected joint if indicated; elevate affected and apply a cold compress to active bleeding sites, but must be used cautiously in young children to prevent skin breakdown.
    2. Maintain optimal physical mobility. Provide gentle, passive ROM exercise when the child’s condition is stable; educate on preventive measures, such as the application of protective gear and the administration of factor products; and refer for physical therapy, occupational therapy, and orthopedic consultations, as required.
    3. Assist in the coping of the family. Encourage family members to verbalize problem areas and develop solutions on their own; encourage family members to express feelings, such as how they deal with the chronic needs of a family member and coping patterns that help or hinder adjustment to the problems.
    4. Prevent bleeding. Monitor hemoglobin and hematocrit levels; assess for inhibitor antibody to factor VIII; anticipate or instruct in the need for prophylactic treatment before high-risk situations, such as invasive diagnostic or surgical procedures, or dental work; and provide replacement therapy of deficient clotting factors.
    5. Prevent injury. Utilize appropriate toys (soft, not pointed or small sharp objects); for infants, may need to use padded bed rail sides on crib; avoid rectal temperatures; provide appropriate oral hygiene (use of a water irrigating device; use of a soft toothbrush or softening the toothbrush with warm water before brushing; use of sponge-tipped toothbrush); and avoid contact sports such as football, soccer, ice hockey, karate.
    Complications
    1. Anemia
    2. Arthritis

    COAGULATION DISORDERS Read More »

    LEUKEMIA

    LEUKEMIA

    Nursing Notes - Thrombus and Embolus

    LEUKEMIA

    Definition: Leukemias are a group of hematologic disorders characterized by the dysfunctional proliferation and development of leukocytes. Leukemias are cancers of white blood cells or of cells that develop into white blood cells.

    White blood cells develop from stem cells in the bone marrow. Sometimes the development goes awry, and pieces of chromosomes get rearranged. The resulting abnormal chromosomes interfere with normal control of cell division, so that affected cells multiply uncontrollably or are resistant to normal cell death, resulting in leukemia.

    Types of Leukemia

    As such, the four major subtypes of leukemia are:

    1. Acute lymphoblastic leukemia (ALL): ALL occurs when primitive white blood cells of lymphoid origin reproduce without developing into normal B and T cells. It is the most common leukemia in pediatrics, accounting for up to 80% of cases in this group vs. 20% of cases in adults.
    2. Acute myelogenous leukemia (AML): AML is also characterized by the hyperplasia of blasts, but in this case, of myeloid origin. It accounts for half of the leukemia cases diagnosed in teenagers and people in their 20s. It is the most common acute leukemia in adults.
    3. Chronic lymphocytic leukemia (CLL): CLL occurs when mature but abnormal white blood cells of lymphoid origin undergo hyperplasia, leading to a monoclonal population of dysfunctional lymphocytes. Most cases occur in people between ages 60 and 70.
    4. Chronic myelogenous leukemia (CML): A monoclonal population of self-renewing, dysfunctional myeloid cells (e.g., neutrophils, basophils, eosinophils, macrophages) characterizes CML. Most cases occur in people between ages 25 and 60.
    Note
    1. Acute vs. chronic: Acute leukemias are characterized by abnormal cells that are less mature, develop quickly, and leave the bone marrow as dysfunctional cells called “blasts.” These blasts crowd out healthy cells in the bone marrow, causing the rapid onset of symptoms. Blasts normally make up 1% to 5% of marrow cells, and having more than 20% blasts in the bone marrow is required for a diagnosis of acute leukemia. In contrast, chronic leukemias develop slowly and may take years to develop symptoms. They are composed primarily of more mature and functional cells, and there are generally not elevated numbers of blasts.
    2. Myeloid vs. lymphoid: Hematopoietic stem cells give rise to two types of blood cells: myeloid and lymphoid. Myeloid cells include monocytes, macrophages, neutrophils, basophils, eosinophils, erythrocytes, and megakaryocytes. Lymphoid cells include T cells, B cells, and natural killer cells. So myeloid leukemia affects myeloid cells and lymphoid leukemia affects lymphoid cells.

    Causes of Leukemia

    Several risk factors are associated with a higher risk of developing leukemia:

    1. Exposure to ionizing radiation is associated with an increased risk of multiple subtypes of leukemia.
    2. Exposure to benzene is a risk factor for leukemia in adults, particularly AML.
    3. Previous exposure to chemotherapy, especially alkylating agents and topoisomerase inhibitors, increases the risk for acute leukemia later in life.
    4. A history of any hematologic malignancy is a risk factor for subsequently developing another subtype of leukemia.
    5. Viral infections (e.g., human T-cell leukemia virus, Epstein Barr virus) are linked with subtypes of ALL.
    6. Several genetic syndromes (e.g., Down syndrome, Fanconi anemia, Bloom syndrome, Li-Fraumeni syndrome) are associated with an increased risk of AML and ALL.

    Clinical manifestations

    1. Fever
    2. Lethargy
    3. Bone pain or tenderness
    4. Myalgia
    5. Malaise or generalised body weakness
    6. Moderate to severe infections which may be recurrent
    7. Unexplained or unintentional weight loss
    8. Recurrent nosebleeds
    9. Tendency to bleed or bruise easily
    10. Petechiae – tiny red spots on the skin
    11. Excessive sweating, especially at night (nocturnal hyperhidrosis)
    12. Chronic Fatigue
    13. On palpation, you may feel lymph node swelling and enlargement of the liver and spleen i.e. Hepatosplenomegaly
    14. When you auscultate the patient’s lungs, you may hear decreased breath sounds, shallow and rapid respirations, a rapid heart rate, and a systolic ejection murmur.
    15. Musculoskeletal symptoms (especially in the spine and long bones) can also be clues to the diagnosis.
    16. Shortness of breath,
    17. Symptoms related to thrombocytopenia, such as excessive bruising or heavy menstrual cycles.

    NB: Chronic leukemia subtypes occur almost exclusively in adults. Many patients are asymptomatic at the time of diagnosis, identified only incidentally after:

    • a) Marked leukocytosis is discovered on a CBC performed for another reason.
    • b) Hepatosplenomegaly and lymphadenopathy can be appreciated in some cases while bleeding and bruising are less common, presenting features relative to acute leukemia subtypes.

    Test and Diagnosis

    1. Medical history and physical exam,
    2. CBC and blood smear – peripheral WBC count varies widely from 1,000 to 100,000/mm3 and may include significant numbers of abnormal immature (blast) cells, anemia may be profound; platelet count may be abnormal and coagulopathies may exist.
    3. Bone marrow aspiration and biopsy – cells also studied for chromosomal abnormalities (cytogenetics) and immunologic markers to classify type of leukemia further.
    4. Lymph node biopsy – to detect the spread.
    5. Lumbar puncture and examination of cerebrospinal fluid for leukemic cells (especially ALL).

    Management

    Medical Management
    1. Chemotherapy – uses drugs to kill cancer cells. The most common chemotherapy protocols for leukemia may include combinations of anti-tumor antibiotics, vinca alkaloids, and other systemic anti-cancer therapy (SACT) medications.
    2. Targeted Therapy – uses drugs that attack specific abnormalities in the cancer cell
    3. Immunotherapy – utilizes the immune system to attack the leukemia cells; examples include immune system modulators and checkpoint inhibitors
    4. Radiotherapy. Radiotherapy uses radiation or high-powered energy beams such as protons and X-rays to kill the cancer cells. This can last from 3 days to 6 weeks.
    5. External beam radiation – aims the energy beams at the affected body area
    6. Brachytherapy – places radioactive material inside the body in order to perform radiation therapy
    7. Chimeric antigen receptor (CAR)-T Cell Therapy. This is a specialized treatment which involves the harvesting of the patient’s T-cells, engineering them to fight the leukemia cells, and infusing them back to the patient’s body.
    8. Bone Marrow Transplant. BMT is a procedure wherein the unhealthy bone marrow of the leukemia patient is removed and replaced by healthy stem cells which will cause a regeneration of healthy bone marrow to produce normal blood cells. It is also known as stem cell transplant.

    Nursing interventions/management

    1. Assessment of the patient
    • a. Carrying out history of the presenting signs and symptoms e.g. fever, chronic fatigue, bleeding disorders among others.
    • b. Taking vital observation e.g. TPR/BP and general examination to exclude other diseases
    • c. Alerting the doctor who will order for investigations and admission, there the nurse will assist the patient throughout the process.
    2. Managing fever (patient has 37.6 and above temperature, chills)
    • a. Assess the patient’s vital signs at least every 4 hours.
    • b. Remove excessive clothing, blankets, and linens. Adjust the room temperature.
    • c. Administer and monitor the prescribed antibiotics and anti-pyretics.
    • d. Assess the mental status of the patient because elevated temperatures can alter the function of the mind.
    • e. Offer a tepid sponge bath.
    • f. Elevate the head of the bed
    3. To relieve acute pain
    • a. Assess pain.
    • b. Place patient at complete rest pain episode.
    • c. Instruct patient to notify nurse immediately when pain occurs.
    • d. Assess and document patient response to medication to provides information about disease progression and also aids in evaluating effectiveness of interventions, and may indicate need for change in therapeutic regimen.
    • e. Identify precipitating event, if any: frequency, duration, intensity, and location of pain which will helps differentiate this chest pain, and aids in evaluating possible progression to unstable angina.
    • f. Stay with patient who is experiencing pain or appears anxious to allay anxiety
    • g. Maintain quiet, comfortable environment and also restrict visitors as necessary to prevent mental stress.
    4. To manage fatigue
    • a. Ask the patient to rate fatigue level (mild, moderate, or severe fatigue) to assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity inorder to create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
    • b. For patients with grade 3 fatigue (severe fatigue), consider discussing having a treatment break with the oncology team because anti-cancer therapies such as chemotherapy treatments may increase the fatigue levels in a cancer patient, disabling them to perform even the most basic daily activities such as eating and bathing. Having a treatment break may be needed to allow the patient to recuperate before receiving further doses.
    • c. Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep to gradually increase the patient’s tolerance to physical activity.
    • d. Teach deep breathing exercises and relaxation to allow the patient to relax while at rest. To allow enough
    5. To maintain healthy normal weight (patients complains of anorexia, unexplained weight loss)
    • a. Explore the patient’s daily nutritional intake and food habits (e.g., meal times, duration of each meal session, snacking, etc.) inorder to create a baseline of the patient’s nutritional status and preferences.
    • b. Create a daily weight chart and a food and fluid chart. Discuss with the patient the short term and long-term nutrition and weight goals.
    • c. Help the patient to select appropriate dietary choices to increase dietary fiber, caloric intake and alcohol and coffee intake inorder to promote nutrition and healthy food habits, as well as to boost the energy levels of the patient. Dietary fiber can help reduce stool transit time, thus promoting regular bowel movement.
    • d. Refer the patient to the hematology/oncology dietitian to provide a more specialized care for the patient in terms of nutrition and diet in relation to newly diagnosed leukemia.
    • e. Symptom control: Administer the prescribed medications for abdominal cramping and pain, such as anti spasmodics. Promote bowel emptying using laxatives as prescribed for constipation. On the other hand, provide advice on taking anti-diarrheal medications for diarrhea.
    6. Preventing and Managing bleeding:
    • a. Watch for signs of minor bleeding, such as petechiae, ecchymosis, conjunctival hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites, vaginal spotting, and heavy menses.
    • b. Be alert for signs of serious bleeding, such as headache with change in responsiveness, blurred vision, hemoptysis, hematemesis, melena, hypotension, tachycardia, dizziness.
    • c. Test all urine, stool, emesis for gross and occult blood.
    • d. Monitor platelet counts daily.
    • e. Administer blood components as directed.
    • f. Keep patient on bed rest during bleeding episodes.
    7. Patient Education and Health Maintenance:
    • a. Teach signs and symptoms of infection and advise whom to notify.
    • b. Encourage adequate nutrition to prevent emaciation from chemotherapy.
    • c. Teach avoidance of constipation with increased fluid and fiber, and good perineal care.
    • d. Teach bleeding precautions.
    • e. Encourage regular dental visits to detect and treat dental infections and disease.
    8. Preventing infection: (due to lowered immunity)
    • a. Frequently monitor the client for pneumonia, pharyngitis, esophagitis, perianal cellulitis, urinary tract infection, and cellulitis, which are common in leukemia and which carry significant morbidity and mortality.
    • b. Monitor for fever, flushed appearance, chills, tachycardia; appearance of white patches in the mouth; redness, swelling, heat or pain in the eyes, ears, throat, skin, joints, abdomen, rectal and perineal areas; cough, changes in sputum; skin rash.
    • c. Check results of granulocyte counts. Concentrations less than 500/mm3 put the patient at serious risk for infection.
    • d. Avoid invasive procedures and trauma to skin or mucous membrane to prevent entry of microorganisms.
    • e. Use the following rectal precautions to prevent infections: Avoid diarrhea and constipation, which can irritate the rectal mucosa, avoid the use of rectal thermometers, and keep perineal are clean.
    • f. Care for the patient in private room with strict hand washing practice.
    • g. Encourage and assist patient with personal hygiene, bathing, and oral care.
    • h. Obtain cultures and administer antimicrobials promptly as directed.

    Complications

    Leukemia may cause several complications, which may include:

    1. Recurrent infections due to low levels of immunity
    2. Unintentional weight loss
    3. Anemia
    4. Bleeding problems
    5. Metabolic abnormalities – may lead to organ failure, particularly in the kidneys
    6. Central nervous system impairment
    7. Cataracts
    8. Infertility
    9. Increased risk of other types of cancer
    10. Mental health problems
    11. Poor quality of life
    12. Renal dysfunction
    13. Tumor lysis syndrome
    14. Nutritional depletion
    15. Mucositis

    LEUKEMIA Read More »

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