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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)

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    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

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    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 »

    Thrombus and Embolus

    Thrombus and Embolus

    Nursing Notes - Thrombus and Embolus

    THROMBUS AND EMBOLUS

    Introduction

    The circulatory system is composed of blood vessels and the heart. Blood vessels (arteries and veins) facilitate the passage of blood throughout the body. Blood cells suspended in the plasma travel through blood vessels.

    Blood clots are solid masses that travels through the vessels along the blood. They are made up of either platelets, fibrin, fat, amniotic fluid, a tumor or air. Foreign substances such as iodine, cotton, talc or a piece of catheter tube can serve as blood clots. Thrombus and embolus are two terms used interchangeably to describe blood clots.

    The main difference between thrombus and embolus is that thrombus refers to a firm mass of blood clot developed within the circulatory system whereas embolus refers to a piece of thrombus that travels through the blood vessels. An embolus travels until it reaches the tiny blood vessels that are too small to pass through it.

    THROMBUS

    Definition

    Thrombus refers to a blood clot formed inside the circulatory system that can impede blood flow. It remains attached to the vessel wall at its site of formation.

    Pathophysiology & Virchow's Triad

    Generally, a thrombus stays attached to the site of the blood vessel where it is formed. A blood clot can be formed as a result of injury to a blood vessel or tissue. Aggregation of platelets forms a quick plug to prevent bleeding.

    The formation of a thrombus is classically explained by Virchow's Triad, which outlines the three broad categories of factors that contribute to thrombosis:

    1. Endothelial Injury: Damage to the inner lining (endothelium) of a blood vessel. This is often the most important factor, especially in arterial thrombosis. It exposes underlying collagen and tissue factor, which initiates platelet adhesion, activation, and the coagulation cascade.
      • Examples: Atherosclerosis (the most common cause in arteries), hypertension, physical trauma, surgery, indwelling catheters (e.g., IV lines, central lines), inflammation (vasculitis), toxins (e.g., from smoking).
    2. Stasis of Blood Flow (Abnormal Blood Flow): When blood flow is slow (stasis) or turbulent, platelets and clotting factors can accumulate in specific areas and become activated. Normal, laminar blood flow helps to keep clotting factors diluted and washes away activated clotting factors and platelets.
      • Examples of Stasis: Prolonged immobility (e.g., long-haul flights, bed rest, paralysis), heart failure, venous insufficiency, varicose veins, atrial fibrillation (in the heart's atria).
      • Examples of Turbulence: Atherosclerotic plaques, aneurysms, valvular heart disease, tortuous blood vessels.
    3. Hypercoagulability: An abnormal increase in the tendency of blood to clot, due to either an excess of pro-coagulant factors or a deficiency of anti-coagulant factors. This can be inherited (genetic) or acquired.
      • Examples of Inherited: Factor V Leiden mutation, Prothrombin gene mutation, deficiencies of Antithrombin, Protein C, or Protein S.
      • Examples of Acquired: Cancer (malignancy), pregnancy and postpartum period, oral contraceptives and hormone replacement therapy, dehydration, certain autoimmune diseases (e.g., antiphospholipid syndrome), severe infection (sepsis), major surgery, trauma, inflammatory conditions.
    Causes and Risk Factors of a Thrombus

    Beyond the elements of Virchow's Triad, specific conditions and lifestyle factors significantly increase the risk of thrombus formation:

    1. Atherosclerosis: The leading cause of arterial thrombosis. Plaque rupture exposes thrombogenic material, leading to clot formation.
    2. High Cholesterol (Hyperlipidemia): Contributes to atherosclerosis and endothelial damage.
    3. Hypertension (High Blood Pressure): Causes direct endothelial injury and promotes atherosclerosis.
    4. Diabetes Mellitus: Damages blood vessels (microvascular and macrovascular) and promotes a pro-thrombotic state.
    5. Tobacco Smoking: Directly damages endothelium, increases platelet aggregation, and promotes inflammation and hypercoagulability.
    6. Obesity and Overweight: Associated with chronic inflammation, insulin resistance, and a hypercoagulable state.
    7. Sedentary Lifestyle: Leads to blood stasis, especially in the lower extremities, increasing DVT risk.
    8. Cancer (Malignancy): Many cancers activate the coagulation system, leading to a significantly increased risk of thrombosis (e.g., Trousseau's syndrome).
    9. Surgery and Trauma: Endothelial injury during surgery and post-operative immobility are major risk factors.
    10. Prolonged Immobility: Whether due to bed rest, long travel, or paralysis, it promotes venous stasis.
    11. Atrial Fibrillation: Irregular and often rapid heart rate leads to blood pooling and stasis in the atria, increasing the risk of cardiac thrombus formation, which can then embolize.
    12. Heart Failure: Reduced cardiac output leads to blood stasis, especially in the venous system.
    13. Previous Thromboembolic Event: A history of DVT, PE, or stroke significantly increases the risk of recurrence.
    14. Age: Risk of thrombosis generally increases with age.
    15. Pregnancy and Postpartum Period: Hormonal changes and physical compression of veins lead to a hypercoagulable state and stasis.
    16. Certain Medications: Oral contraceptives, hormone replacement therapy, and some chemotherapy agents can increase clotting risk.
    17. Genetic Predisposition: Inherited thrombophilias (e.g., Factor V Leiden).
    18. Inflammatory Conditions: Systemic lupus erythematosus, inflammatory bowel disease, vasculitis.
    19. Dehydration: Can increase blood viscosity, contributing to stasis and hypercoagulability.
    Types of a Thrombus (Classification by Location and Composition)

    Depending on the location and primary composition, several types of thrombosis can be identified:

    1. Arterial Thrombus:
      • Formed in arteries, often associated with endothelial injury and turbulent flow due to atherosclerosis.
      • Typically "white thrombi" because they are rich in platelets, formed in areas of high blood flow.
      • Can lead to conditions like myocardial infarction (heart attack), ischemic stroke, or peripheral arterial occlusion.
      • Examples: Coronary artery thrombosis, cerebral artery thrombosis, peripheral artery thrombosis.
    2. Venous Thrombus:
      • Formed in veins, primarily associated with blood stasis and hypercoagulability.
      • Typically "red thrombi" because they are rich in fibrin and red blood cells, formed in areas of low blood flow.
      • Often results in Deep Vein Thrombosis (DVT), which can lead to pulmonary embolism (PE) if the clot embolizes.
      • Examples: Deep Vein Thrombosis (DVT) in legs, superficial thrombophlebitis.
    3. Cardiac Thrombus:
      • Formed within the chambers of the heart.
      • Often seen in conditions like atrial fibrillation (left atrial appendage thrombus), myocardial infarction (mural thrombus in left ventricle), or valvular heart disease.
      • Can embolize to systemic arteries (e.g., brain, kidneys, limbs).
    4. Microvascular Thrombus:
      • Formed in very small blood vessels (capillaries, arterioles, venules).
      • Often associated with systemic inflammatory states, sepsis, or disseminated intravascular coagulation (DIC).
      • Can lead to widespread organ damage.
    Clinical Manifestations (Signs and Symptoms)

    The symptoms of a thrombus occur when the clot restricts or completely blocks blood flow through the vessel, leading to ischemia (lack of oxygen) in the tissues supplied by that vessel. Symptoms vary widely depending on the location and size of the thrombus:

    A. Arterial Thrombosis:

    Due to sudden or significant reduction in blood flow, leading to tissue ischemia or infarction.

    1. Coronary Artery Thrombosis (leading to Myocardial Infarction / Heart Attack):
      • Severe chest pain, often described as crushing, pressure, or tightness, that may radiate to the arm (usually left), back, neck, jaw, or stomach.
      • Shortness of breath.
      • Sweating (diaphoresis).
      • Nausea and vomiting.
      • Lightheadedness or fainting.
      • Unstable angina (new onset, increasing, or rest angina).
    2. Cerebral Artery Thrombosis (leading to Ischemic Stroke):
      • Sudden weakness or numbness on one side of the body (face, arm, leg).
      • Difficulty speaking or understanding speech (aphasia, dysarthria).
      • Sudden vision changes in one or both eyes.
      • Sudden severe headache with no known cause.
      • Dizziness, loss of balance, or coordination.
    3. Peripheral Arterial Thrombosis (e.g., in legs/arms):
      • Sudden, severe pain in the affected limb.
      • Pallor (paleness) of the limb.
      • Pulselessness below the occlusion.
      • Paresthesia (numbness or tingling).
      • Paralysis (in severe cases).
      • Poikilothermia (coldness) of the affected limb.
      • (The "6 Ps": Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia).
    4. Mesenteric Artery Thrombosis (affecting intestines):
      • Severe, sudden abdominal pain, often disproportionate to physical findings.
      • Nausea, vomiting, diarrhea.
      • Abdominal distension.
      • Bloody stools (later stage).
    B. Venous Thrombosis:

    Primarily due to impaired venous return and inflammation.

    1. Deep Vein Thrombosis (DVT) (most commonly in lower extremities):
      • Swelling of the affected leg or arm.
      • Pain or tenderness in the calf or thigh (often described as a cramp or soreness), especially when standing or walking.
      • Warmth over the affected area.
      • Redness or discoloration of the skin.
      • Increased prominence of superficial veins.
      • Homan's sign (calf pain on dorsiflexion of the foot) is often cited but unreliable.
    2. Superficial Thrombophlebitis:
      • Red, tender, warm cord-like structure felt under the skin (usually along a varicose vein).
      • Less serious than DVT, but can sometimes extend into deep veins.
    Diagnosis of a Thrombus

    Diagnosing a thrombus involves a combination of clinical assessment, blood tests, and imaging studies:

    1. Clinical Assessment: Detailed medical history (including risk factors), physical examination for signs and symptoms (e.g., pain, swelling, discoloration, pulses).
    2. Blood Tests:
    • D-dimer: A blood test that measures a degradation product of fibrin. An elevated D-dimer can indicate the presence of a recent or ongoing clot, but it's not specific (can be elevated in many other conditions). A negative D-dimer can often rule out DVT or PE in low-risk patients.
    • Coagulation studies: Prothrombin Time (PT), Activated Partial Thromboplastin Time (aPTT), International Normalized Ratio (INR) to assess clotting function and monitor anticoagulant therapy.
    • Complete Blood Count (CBC): May show elevated white blood cells in inflammatory states or infection.
    • Thrombophilia Screen: If a genetic hypercoagulable state is suspected (e.g., Factor V Leiden, Protein C/S deficiency).
    3. Imaging Studies: The gold standard for confirming the presence and location of a thrombus.
    • Duplex Ultrasound: The most common and preferred non-invasive test for DVT. It uses sound waves to visualize blood flow and detect blockages in veins.
    • Venography: An invasive X-ray procedure where contrast dye is injected into a vein to visualize the venous system. Less common now due to ultrasound.
    • CT Angiography (CTA): Used for diagnosing arterial thrombi (e.g., coronary, cerebral, mesenteric, peripheral arteries) or for pulmonary embolism (CTPA - CT Pulmonary Angiogram). Involves injecting contrast dye and taking detailed X-ray images.
    • MR Angiography (MRA): Similar to CTA but uses magnetic fields and radio waves, avoiding radiation. Useful for arterial and venous thrombi.
    • Echocardiography: Used to detect thrombi within the heart chambers (e.g., in atrial fibrillation or after myocardial infarction) or to assess cardiac function.
    • Angiography (Conventional): An invasive procedure where a catheter is inserted into an artery and dye is injected to visualize the arterial system. Often performed when interventions (e.g., angioplasty, thrombectomy) are planned.
    Treatment of a Thrombus

    Treatment for a thrombus aims to prevent clot growth, dissolve existing clots, prevent new clots from forming, and manage symptoms. The approach depends on the type, size, and location of the thrombus, as well as the patient's overall health.

  • Anticoagulant Medications ("Blood Thinners"):
    • These medications prevent the clot from growing and help prevent new clots from forming. They do not typically dissolve existing clots but allow the body's natural fibrinolytic system to break down the clot over time.
    • Examples:
      • Heparin (unfractionated and low molecular weight heparin - LMWH): Often used for initial rapid anticoagulation, administered intravenously or subcutaneously.
      • Warfarin: An oral anticoagulant, requires regular INR monitoring.
      • Direct Oral Anticoagulants (DOACs) / Novel Oral Anticoagulants (NOACs): (e.g., rivaroxaban, apixaban, dabigatran, edoxaban). Do not require frequent monitoring, often preferred for convenience.
    • Nursing Considerations: Monitor for bleeding (e.g., bruising, petechiae, blood in urine/stools, epistaxis, gum bleeding), educate patient on bleeding precautions (e.g., soft toothbrush, electric razor, avoid contact sports), and importance of adherence.
  • Thrombolytic Medications ("Clot Busters"):
    • These potent medications actively dissolve existing clots by activating plasminogen to plasmin, an enzyme that breaks down fibrin.
    • Used in acute, severe cases where rapid clot dissolution is critical (e.g., massive pulmonary embolism, acute ischemic stroke, severe arterial occlusion).
    • Administered intravenously or directly into the clot via a catheter.
    • Nursing Considerations: High risk of bleeding. Close monitoring for signs of hemorrhage, frequent neurological checks if for stroke, and strict adherence to administration protocols. Contraindications (e.g., recent surgery, bleeding disorders, uncontrolled hypertension) must be carefully assessed.
  • Antiplatelet Medications:
    • Primarily used for arterial thrombosis. These medications prevent platelets from clumping together to form a clot.
    • Examples: Aspirin, Clopidogrel (Plavix), Ticagrelor (Brilinta), Prasugrel (Effient).
    • Nursing Considerations: Similar to anticoagulants regarding bleeding risk. Educate patient on the importance of adherence, especially after stenting or acute coronary syndromes.
  • Mechanical Thrombectomy/Embolectomy:
    • Surgical or endovascular procedures to physically remove the thrombus.
    • Thrombectomy: Often used for acute arterial occlusions (e.g., stroke, peripheral arterial occlusion) or massive DVT/PE in select cases. A catheter is guided to the clot, and it's mechanically extracted or aspirated.
    • Embolectomy: Surgical removal of an embolus (which originated as a thrombus elsewhere).
    • Nursing Considerations: Pre- and post-procedure care, monitoring for bleeding at access site, neurovascular checks of affected limb, pain management, and signs of reperfusion injury.
  • Inferior Vena Cava (IVC) Filters:
    • A small, retrievable filter is placed in the inferior vena cava (the large vein returning blood from the lower body to the heart) to catch blood clots traveling from the legs before they reach the lungs.
    • Used in patients with DVT who cannot take anticoagulants (due to high bleeding risk) or when anticoagulants fail.
    • Nursing Considerations: Monitor for complications related to insertion (e.g., bleeding, infection, filter migration, IVC perforation) and long-term complications (e.g., filter fracture, recurrent DVT above the filter).
  • Compression Therapy:
    • For DVT, graduated compression stockings are often used to reduce swelling and pain, and to help prevent post-thrombotic syndrome.
    • Nursing Considerations: Proper fitting and patient education on application and wearing schedule.
  • Lifestyle Modifications:
    • Early Ambulation: As soon as medically safe, to promote blood flow and prevent stasis.
    • Hydration: To prevent increased blood viscosity.
    • Smoking Cessation: Reduces endothelial damage and hypercoagulability.
    • Weight Management: Reduces overall cardiovascular risk.
    • Regular Exercise: Improves circulation.
    • Control of Underlying Conditions: Effective management of hypertension, diabetes, hyperlipidemia, and atrial fibrillation.

    • EMBOLUS

    Definition

    An embolus (plural: emboli) refers to any foreign material, such as a blood clot, fatty deposit, air bubble, or other debris, that travels through the bloodstream from one part of the body and lodges in a blood vessel, causing an obstruction. While most emboli are detached fragments of thrombi (thromboemboli), they can also originate from other substances.

    Pathophysiology of Embolism

    An embolus becomes clinically significant when it lodges in a blood vessel that is too narrow for it to pass through, thereby blocking blood flow to the downstream tissues or organs. This obstruction leads to a condition called embolism. The consequences of an embolism depend on the size of the embolus, the location of the occlusion, and the collateral blood supply to the affected area.

    When blood flow is cut off, the affected tissue experiences ischemia (lack of oxygen and nutrients). If the blood supply is not restored promptly, the cells in that tissue will begin to die, leading to infarction. The clinical presentation of an embolism is often sudden and severe, reflecting the acute deprivation of blood supply.

    Types of Embolism

    Embolism can be classified based on the composition of the embolus and its origin/destination:

    1. Thromboembolism:
    • The most common type of embolism. It occurs when a piece of a thrombus (blood clot) breaks off from its original site of formation and travels through the bloodstream.
    • Pulmonary Embolism (PE): A life-threatening condition where a piece of a thrombus, typically originating from a Deep Vein Thrombosis (DVT) in the legs or pelvis, travels through the right side of the heart and lodges in the pulmonary arteries of the lungs. This blocks blood flow to a portion of the lung, impairing gas exchange.
    • Systemic Arterial Embolism: An embolus (often originating from a cardiac thrombus due to atrial fibrillation, myocardial infarction, or valvular disease, or from an atherosclerotic plaque in the aorta) travels through the arterial system and lodges in an artery supplying an organ or limb. This can lead to:
      • Cerebral Embolism: When an embolus lodges in a blood vessel in the brain, causing an ischemic stroke.
      • Peripheral Arterial Embolism: Affecting arteries in the limbs (e.g., legs, arms), causing acute limb ischemia.
      • Mesenteric Embolism: Affecting arteries supplying the intestines, leading to intestinal ischemia/infarction.
      • Renal Embolism: Affecting arteries supplying the kidneys, potentially causing kidney injury or infarction.
      • Splenic Embolism: Affecting arteries supplying the spleen, potentially causing splenic infarction.
      • Retinal Embolism: An embolus lodges in an artery of the retina, causing sudden vision loss (amaurosis fugax or permanent vision loss).
    • Paradoxical Embolism: A rare type where a venous thrombus crosses from the right side of the heart to the left side through a patent foramen ovale (PFO) or atrial septal defect (ASD) and then enters the systemic circulation, causing an arterial embolism (e.g., stroke).
    2. Fat Embolism:
    • Occurs when fat globules enter the circulation and lodge in small blood vessels, most commonly in the lungs, brain, or skin.
    • Often seen after long bone fractures (e.g., femur, tibia), orthopedic surgery (e.g., joint replacement), severe burns, or pancreatitis.
    • Can lead to Fat Embolism Syndrome (FES), a constellation of symptoms including respiratory distress, neurological dysfunction, and petechial rash.
    3. Air Embolism (Gas Embolism):
    • Occurs when air bubbles enter the circulation and obstruct blood flow.
    • Can result from improper insertion or removal of central venous catheters, surgical procedures (especially neurosurgery, cardiac surgery), chest trauma, lung biopsy, or diving accidents (decompression sickness).
    • Can be venous (traveling to the heart and lungs, causing pulmonary obstruction) or arterial (if air crosses to the left side of the heart, causing stroke or myocardial ischemia).
    4. Septic Embolism:
    • A piece of infected material (containing bacteria, fungi, or other pathogens) breaks off from a site of infection (e.g., infective endocarditis, abscesses) and travels through the bloodstream.
    • Can lodge in various organs, causing new sites of infection, abscess formation, or infarction (e.g., septic pulmonary emboli in intravenous drug users with tricuspid endocarditis, septic arterial emboli causing brain abscesses).
    5. Amniotic Fluid Embolism (AFE):
    • A rare but catastrophic obstetric emergency where amniotic fluid, fetal cells, hair, or other debris enters the mother's bloodstream, typically during labor, delivery, or immediately postpartum.
    • Triggers a severe inflammatory and coagulopathic reaction, leading to acute respiratory distress, cardiovascular collapse, and disseminated intravascular coagulation (DIC).
    6. Tumor Embolism:
    • Occurs when malignant cancer cells or fragments of a tumor break off from the primary site and enter the bloodstream or lymphatic system.
    • These tumor emboli can then travel to distant sites and establish new tumors (metastasis).
    7. Foreign Body Embolism:
    • Rare, caused by accidental introduction of non-biological material into the bloodstream.
    • Examples include catheter fragments, talc (in intravenous drug users), or bullet fragments.

    Similarities and Differences Between Thrombus and Embolus

    Similarities

    While often used interchangeably in casual conversation, thrombus and embolus are distinct but related concepts in cardiovascular pathology. Their similarities highlight their shared role in obstructing blood flow:

    1. Both refer to blood clots or related occlusive masses: At their core, both terms describe a solid or semi-solid mass within the circulatory system. Although an embolus can be non-thrombotic (e.g., fat, air), the most common type of embolus is a thromboembolus.
    2. Both occur inside the circulatory system: Neither thrombi nor emboli are typically found outside blood vessels or the heart chambers.
    3. Both can be made up of various components: While thrombi are primarily composed of platelets, fibrin, and blood cells, emboli can also be formed from fat, air, amniotic fluid, tumor cells, infectious material, or foreign substances.
    4. Both can block the lumen of blood vessels: This is their primary pathological consequence – they physically obstruct the flow of blood, leading to ischemia and potential tissue damage.
    5. Both can lead to serious clinical complications: Both conditions can result in life-threatening events such as myocardial infarction, stroke, pulmonary embolism, and organ damage.
    6. Both are influenced by Virchow's Triad (indirectly for embolus): While Virchow's Triad directly explains thrombus formation, the embolus often originates from a thrombus, thus indirectly linking its formation to the principles of endothelial injury, stasis, and hypercoagulability.
    Comparison Table
    No. Variable Thrombus Embolus
    1. Definition A blood clot (solid mass of blood constituents) formed and remaining attached to the wall of a blood vessel or heart chamber at its site of origin. Any intravascular mass (most commonly a piece of a thrombus) that travels through the bloodstream from one site and lodges in a blood vessel at a distant site, causing occlusion.
    2. Mobility / State Stationary; attached to the vessel wall. It is a localized phenomenon. Mobile; freely floating in the bloodstream until it lodges. It is a migratory phenomenon.
    3. Location of Obstruction Obstructs blood flow at its site of formation. Obstructs blood flow at a site distant from its origin, typically where the vessel narrows or bifurcates.
    4. Origin Forms de novo within a blood vessel or heart chamber due to local factors (Virchow's Triad). Over 90% originate from a pre-existing thrombus (thromboembolus). Other origins include fat, air, amniotic fluid, tumor cells, bacteria, or foreign bodies.
    5. Primary Composition Primarily blood components: fibrin, platelets, red blood cells, white blood cells. Predominantly thrombotic material, but can also be non-thrombotic (e.g., fat, air, tumor, bacteria, amniotic fluid).
    6. Clinical Presentation Symptoms may be gradual or acute, depending on the degree and rate of obstruction at the site of formation (e.g., stable angina from coronary thrombus, DVT symptoms). Typically causes acute, sudden onset of symptoms due to abrupt occlusion of a distant vessel (e.g., sudden dyspnea in PE, sudden neurological deficit in stroke).
    7. Examples Arterial thrombus (e.g., in coronary artery causing MI), Venous thrombus (e.g., Deep Vein Thrombosis - DVT), Cardiac mural thrombus. Pulmonary Embolism (PE), Ischemic Stroke (cerebral embolism), Peripheral Arterial Embolism, Fat Embolism, Air Embolism.
    Clinical Manifestations of Embolism

    The signs and symptoms of an embolism are highly dependent on the location where the embolus lodges and the extent of blood flow obstruction. Symptoms typically have a sudden onset.

    1. Pulmonary Embolism (PE):
      • Sudden onset of shortness of breath (dyspnea).
      • Pleuritic chest pain (sharp, stabbing pain that worsens with deep breathing or coughing).
      • Tachypnea (rapid breathing) and Tachycardia (rapid heart rate).
      • Cough, sometimes with bloody sputum (hemoptysis).
      • Anxiety, restlessness, feeling of impending doom.
      • Dizziness or lightheadedness, syncope (fainting).
      • Signs of right heart strain in massive PE (e.g., jugular venous distension, hypotension, shock).
    2. Cerebral Embolism (Ischemic Stroke):
      • Sudden weakness or numbness, typically affecting one side of the body (face, arm, leg).
      • Sudden difficulty speaking (dysarthria) or understanding speech (aphasia).
      • Sudden vision changes in one or both eyes.
      • Sudden severe headache with no known cause.
      • Sudden dizziness, loss of balance, or coordination.
    3. Peripheral Arterial Embolism:
      • Sudden, severe pain in the affected limb.
      • Pallor (paleness) of the limb.
      • Pulselessness below the occlusion.
      • Paresthesia (numbness or tingling).
      • Paralysis (in severe cases, inability to move the limb).
      • Poikilothermia (coldness) of the affected limb.
      • (The classic "6 Ps": Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia).
    4. Mesenteric Embolism:
      • Severe, sudden abdominal pain, often disproportionate to physical findings (e.g., abdomen may not be very tender initially).
      • Nausea, vomiting, diarrhea.
      • Bloody stools (later stage as bowel infarction develops).
      • Abdominal distension.
    5. Retinal Embolism:
      • Sudden, painless loss of vision in one eye, often described as a "curtain" coming down or complete darkness.
      • Temporary vision loss (amaurosis fugax) if the embolus passes.
    6. Fat Embolism Syndrome (FES):
      • Onset 12-72 hours after initial injury.
      • Respiratory distress: Dyspnea, tachypnea, hypoxemia, diffuse pulmonary infiltrates on chest X-ray.
      • Neurological dysfunction: Confusion, agitation, stupor, seizures, coma.
      • Petechial rash: Small, non-blanching red spots typically on the upper torso, neck, axillae, and conjunctiva.
      • Fever, tachycardia.
    7. Air Embolism:
      • Symptoms depend on volume and location:
        • Venous Air Embolism: Sudden dyspnea, chest pain, hypotension, cyanosis, "millwheel murmur" (churning sound heard over the precordium).
        • Arterial Air Embolism: Neurological deficits (similar to stroke), myocardial ischemia/infarction symptoms, visual disturbances.
    8. Septic Embolism:
      • Signs of systemic infection (fever, chills, malaise).
      • Symptoms related to the organ where the embolus lodges (e.g., respiratory symptoms for septic PE, neurological symptoms for brain abscess).
    Diagnosis of an Embolism

    Diagnosis of an embolism relies on a combination of clinical suspicion, risk factor assessment, specific blood tests, and advanced imaging studies tailored to the suspected location.

    1. Clinical Assessment:
      • Thorough patient history, including recent surgeries, trauma, prolonged immobility, cardiac conditions (e.g., atrial fibrillation), cancer, and family history of clotting disorders.
      • Physical examination: Vital signs, lung sounds, heart sounds, neurological exam, vascular exam (pulses, color, temperature of limbs), assessment for DVT signs if PE is suspected.
    2. Blood Tests:
      • D-dimer: Useful for ruling out DVT/PE in low-risk patients. A normal D-dimer makes PE/DVT very unlikely. An elevated D-dimer is non-specific and requires further investigation.
      • Arterial Blood Gas (ABG): To assess oxygenation and acid-base status, particularly in PE.
      • Cardiac Biomarkers (Troponin, BNP): May be elevated in PE due to right heart strain or in myocardial infarction.
      • Complete Blood Count (CBC) and Inflammatory Markers (ESR, CRP): May indicate infection or inflammation.
      • Coagulation studies (PT/INR, aPTT): To assess baseline clotting status and guide/monitor anticoagulant therapy.
      • Blood Cultures: If septic embolism is suspected.
    3. Imaging Studies:
      • For Pulmonary Embolism (PE):
        • CT Pulmonary Angiogram (CTPA): The gold standard. A CT scan with intravenous contrast that visualizes the pulmonary arteries to detect emboli.
        • Ventilation-Perfusion (V/Q) Scan: Used when CTPA is contraindicated (e.g., renal insufficiency, contrast allergy), assesses airflow and blood flow in the lungs.
        • Lower Extremity Duplex Ultrasound: To confirm the presence of DVT, which is the source of most PEs.
        • Echocardiography: May show signs of right heart strain or identify a cardiac source of emboli (e.g., thrombus in right atrium/ventricle, PFO).
      • For Cerebral Embolism (Stroke):
        • Non-contrast CT Head: Initial scan to rule out hemorrhagic stroke.
        • CT Angiography (CTA) or MR Angiography (MRA) of head and neck: To visualize cerebral blood vessels and identify occlusions.
        • Carotid Duplex Ultrasound: To assess for carotid artery stenosis as a potential source of emboli.
        • Echocardiography (Transthoracic or Transesophageal): To identify cardiac sources of emboli (e.g., atrial fibrillation, valvular disease, PFO).
      • For Peripheral Arterial Embolism:
        • Duplex Ultrasound: To visualize arterial flow and identify the occlusion.
        • CT Angiography (CTA) or MR Angiography (MRA) of the affected limb: Provides detailed anatomical information.
        • Conventional Angiography: Invasive, but can provide high-resolution images and allow for immediate intervention.
      • For Fat Embolism Syndrome: Diagnosis is primarily clinical, based on the classic triad (respiratory distress, neurological symptoms, petechial rash). Imaging (chest X-ray, CT chest) may show diffuse pulmonary infiltrates.
      • For Air Embolism: Clinical suspicion is key. Imaging may show air in vascular structures (e.g., CT, echocardiography).
    Treatment of an Embolism

    The treatment of an embolism is an urgent medical emergency aimed at restoring blood flow, preventing further embolization, and managing symptoms. The specific approach varies greatly depending on the type, location, and severity of the embolism.

    1. Anticoagulation:
      • The cornerstone of treatment for most thromboembolism (e.g., PE, DVT, some strokes) to prevent the existing clot from growing and to prevent new clots from forming.
      • Medications: Heparin (unfractionated or LMWH) for initial rapid anticoagulation, followed by oral anticoagulants (Warfarin or DOACs) for long-term therapy.
      • Nursing Considerations: Close monitoring for bleeding, regular lab checks (aPTT, PT/INR), patient education on medication adherence and bleeding precautions.
    2. Thrombolysis (Fibrinolysis):
      • "Clot-busting" medications (e.g., alteplase, tenecteplase) that actively dissolve the clot.
      • Used in severe, life-threatening cases where rapid clot dissolution is crucial (e.g., massive PE with hemodynamic instability, acute ischemic stroke within a specific time window, severe acute limb ischemia).
      • Can be administered systemically (intravenously) or directly into the clot via a catheter (catheter-directed thrombolysis).
      • Nursing Considerations: High risk of serious bleeding. Intensive monitoring for hemorrhage, neurological changes (for stroke), and strict adherence to protocols.
    3. Embolectomy (Surgical or Catheter-Based):
      • Physical removal of the embolus.
      • Surgical Embolectomy: Open surgical procedure to remove the clot, often used for large arterial emboli causing limb ischemia or massive PE unresponsive to thrombolysis.
      • Catheter-Based Embolectomy: Minimally invasive procedure where a catheter is threaded to the clot, and the embolus is aspirated, fragmented, or removed using specialized devices. Used for PE, stroke, and peripheral emboli.
      • Nursing Considerations: Pre- and post-procedure care, monitoring for bleeding at access sites, neurovascular checks of affected limb, pain management, and close monitoring of vital signs.
    4. Supportive Care:
      • Oxygen Therapy: To improve oxygenation, especially in PE or severe stroke.
      • Pain Management: To alleviate discomfort.
      • Hemodynamic Support: Vasopressors and fluids for hypotension in severe PE or shock.
      • Respiratory Support: Mechanical ventilation if respiratory failure occurs (e.g., in severe PE, Fat Embolism Syndrome).
      • Symptom-Specific Management: For cerebral embolism, may include blood pressure control, glucose management, and fever reduction.
    5. Inferior Vena Cava (IVC) Filters:
      • A small, retrievable filter placed in the IVC to catch clots traveling from the legs to the lungs.
      • Used in patients with DVT who have contraindications to anticoagulation or who experience recurrent PE despite adequate anticoagulation.
      • Nursing Considerations: Monitor for insertion site complications, filter migration, and long-term complications.
    6. Specific Treatments for Non-Thromboembolic Embolisms:
      • Fat Embolism Syndrome: Primarily supportive care, including oxygenation, ventilation, and hemodynamic support.
      • Air Embolism: Positioning the patient in a left lateral Trendelenburg position (Durant's maneuver) to trap air in the right ventricle, oxygen administration, and hyperbaric oxygen therapy for arterial air embolism.
      • Septic Embolism: Aggressive antibiotic therapy for the underlying infection, and potentially drainage of abscesses.
      • Amniotic Fluid Embolism: Immediate supportive care including respiratory and cardiovascular support, blood product transfusion for DIC, and uterine management.
    7. Prevention of Recurrence:
      • Long-term anticoagulation for thromboembolism.
      • Management of underlying risk factors (e.g., atrial fibrillation, atherosclerosis).
      • Lifestyle modifications (smoking cessation, weight management, regular exercise).

    Nursing Diagnoses and Interventions for Thromboembolic Disorders

    Nursing diagnoses provide a framework for nursing care, identifying patient problems that nurses can independently address. Below are common nursing diagnoses related to thromboembolic disorders, each with associated interventions.

    1. Ineffective Tissue Perfusion (Specify type: Pulmonary, Cerebral, Peripheral)

    Definition: Decrease in oxygen resulting in failure to nourish the tissues at the capillary level.

    Related to:
    • Interruption of arterial/venous blood flow by clot formation (thrombus or embolus).
    • Compromised oxygen transport due to ventilation-perfusion mismatch (in PE).
    • Increased vascular resistance.
    Assessment Cues:
    • Pulmonary: Dyspnea, tachypnea, chest pain, hypoxemia, apprehension, decreased breath sounds.
    • Cerebral: Altered mental status, motor/sensory deficits, speech disturbances, vision changes.
    • Peripheral: Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (coldness), swelling, diminished pulses.
    Nursing Interventions:
    • Monitor Vital Signs: Assess respiratory rate, heart rate, blood pressure, and oxygen saturation frequently. Note any changes suggestive of worsening perfusion (e.g., increased respiratory rate, decreased SpO2, hypotension).
    • Administer Oxygen Therapy: As prescribed, to maintain optimal oxygen saturation, especially in pulmonary embolism.
    • Position Patient: For PE, elevate the head of the bed to a semi-Fowler's or high-Fowler's position to facilitate lung expansion. For DVT, elevate the affected extremity to promote venous return and reduce edema.
    • Assess Affected Area:
      • Pulmonary: Auscultate lung sounds, monitor respiratory effort and depth.
      • Cerebral: Perform frequent neurological assessments (e.g., Glasgow Coma Scale, motor/sensory function, pupillary response).
      • Peripheral: Assess pulses (dorsalis pedis, posterior tibial, radial, etc.), skin color, temperature, capillary refill, sensation, and motor function of the affected limb. Measure limb circumference as indicated.
    • Administer Anticoagulants/Thrombolytics: As prescribed, carefully monitoring for therapeutic effects and potential complications (e.g., bleeding).
    • Maintain Hydration: Administer IV fluids as ordered to maintain adequate circulating volume, unless contraindicated.
    • Prepare for Procedures: Assist with preparation for diagnostic tests (e.g., CT angiogram, Doppler ultrasound) or interventional procedures (e.g., embolectomy, IVC filter placement).
    2. Acute Pain

    Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage, with sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end.

    Related to:
    • Tissue ischemia/infarction.
    • Inflammation secondary to vascular occlusion.
    • Pleuritic irritation (in PE).
    • Surgical incision/procedure (if applicable).
    Assessment Cues:
    • Verbal reports of pain (e.g., chest pain, calf pain, abdominal pain).
    • Non-verbal cues (e.g., grimacing, guarding, restlessness, moaning).
    • Increased heart rate, respiratory rate, blood pressure.
    • Facial pallor.
    Nursing Interventions:
    • Assess Pain: Use a standardized pain scale (e.g., 0-10) to assess pain intensity, location, quality, and aggravating/alleviating factors. Assess frequently.
    • Administer Analgesics: As prescribed, promptly and evaluate effectiveness.
    • Provide Non-Pharmacological Comfort Measures:
      • Repositioning for comfort.
      • Application of warm/cold compresses (use caution with anticoagulants and impaired circulation).
      • Distraction techniques (e.g., guided imagery, music).
      • Quiet environment and adequate rest.
    • Elevate Affected Limb: For DVT, elevation helps reduce swelling and discomfort.
    • Educate Patient: About pain management strategies and to report unrelieved pain.
    3. Risk for Bleeding

    Definition: Susceptible to a decrease in blood volume that may compromise health.

    Related to:
    • Administration of anticoagulants (heparin, warfarin, DOACs) or thrombolytics.
    • Disruption of clotting factors.
    • Invasive procedures or trauma.
    Assessment Cues:
    • Active bleeding (e.g., epistaxis, hematuria, melena, hematemesis, gingival bleeding).
    • Bruising, petechiae, purpura.
    • Changes in vital signs (e.g., tachycardia, hypotension) indicative of hypovolemia.
    • Decreased hemoglobin/hematocrit.
    • Prolonged PT/INR or aPTT.
    • Altered mental status (suggesting intracranial bleed).
    Nursing Interventions:
    • Monitor Coagulation Studies: Regularly check PT/INR for warfarin, aPTT for heparin, and monitor complete blood count (CBC) for hemoglobin and hematocrit.
    • Assess for Signs of Bleeding: Inspect skin, urine, stool, emesis, and any drainage for blood. Monitor for epistaxis, gingival bleeding, and signs of internal bleeding (e.g., abdominal distension, headache, altered mental status).
    • Implement Bleeding Precautions:
      • Avoid intramuscular injections.
      • Use smallest gauge needles for venipuncture.
      • Apply prolonged pressure to venipuncture sites.
      • Avoid vigorous toothbrushing; use a soft-bristle toothbrush.
      • Use an electric razor instead of a blade.
      • Avoid rectal temperatures, suppositories, and enemas.
      • Caution patient against vigorous nose blowing, coughing, or straining.
      • Prevent falls and injury.
    • Administer Antidotes: Be prepared to administer antidotes (e.g., protamine sulfate for heparin, vitamin K for warfarin) as ordered in case of severe bleeding or overdose.
    • Educate Patient: On signs of bleeding to report immediately, importance of medication adherence, and avoiding over-the-counter medications that can increase bleeding risk (e.g., NSAIDs, aspirin, herbal supplements).
    4. Impaired Physical Mobility

    Definition: Limitation in independent, purposeful physical movement of the body or one or more extremities.

    Related to:
    • Pain and discomfort.
    • Activity restrictions (e.g., bed rest for DVT, post-stroke deficits).
    • Neuromuscular impairment (in cerebral embolism).
    • Fatigue.
    Assessment Cues:
    • Reluctance to move.
    • Limited range of motion.
    • Decreased muscle strength.
    • Difficulty with gait or balance.
    • Pain with movement.
    Nursing Interventions:
    • Encourage Mobility within Restrictions: Assist with range of motion exercises (active or passive) to prevent joint stiffness and muscle atrophy, as tolerated and not contraindicated.
    • Assist with Ambulation: As appropriate and safe, using assistive devices if needed. Gradual increase in activity is key for DVT/PE patients once stable and on anticoagulation.
    • Position for Comfort and Function: Reposition patient frequently if on bed rest to prevent pressure injuries and promote circulation. Use pillows or wedges to support extremities.
    • Collaborate with PT/OT: Consult physical therapy (PT) and occupational therapy (OT) for specialized exercises, gait training, and adaptive equipment.
    • Educate Patient: On the importance of mobility, prescribed activity levels, and techniques to prevent complications of immobility.
    5. Deficient Knowledge (about condition, treatment, prevention)

    Definition: Absence or deficiency of cognitive information related to specific topic.

    Related to:
    • Lack of exposure/recall.
    • Information misinterpretation.
    • Unfamiliarity with information resources.
    Assessment Cues:
    • Questions about the disease process, medications, lifestyle changes.
    • Inaccurate statements about condition or treatment.
    • Lack of follow-through with instructions.
    Nursing Interventions:
    • Assess Learning Needs: Determine the patient's current knowledge level, preferred learning style, and readiness to learn.
    • Provide Education:
      • Disease Process: Explain what a thrombus/embolus is, its causes, and potential complications in clear, simple terms.
      • Medication Management: Explain the purpose, dose, schedule, side effects of anticoagulants, importance of strict adherence, and the need for regular lab monitoring (e.g., INR for warfarin).
      • Bleeding Precautions: Reinforce all bleeding precautions and signs to report.
      • Lifestyle Modifications: Discuss smoking cessation, healthy diet, regular exercise (as able), weight management.
      • Prevention of Recurrence: Emphasize avoiding prolonged sitting/standing, performing leg exercises during travel, adequate hydration, and wearing compression stockings (if prescribed).
      • Follow-up Care: Importance of follow-up appointments and continued monitoring.
      • Signs/Symptoms to Report: Educate on when to seek immediate medical attention (e.g., sudden shortness of breath, chest pain, signs of bleeding, neurological changes).
    • Use Various Teaching Methods: Provide written materials, visual aids, and utilize teach-back method to ensure understanding.
    • Involve Family/Caregivers: Educate significant others as appropriate to support the patient's care.
    • Provide Resources: Refer to support groups or reliable online resources.

    Thrombus and Embolus Read More »

    Arteriosclerosis and Atherosclerosis

    Arteriosclerosis and Atherosclerosis

    Nursing Notes - Arteriosclerosis & Atherosclerosis

    ARTERIOSCLEROSIS & ATHEROSCLEROSIS

    ARTERIOSCLEROSIS

    Introduction

    Arteriosclerosis is the thickening, hardening, and loss of elasticity of the walls of arteries. Arteriosclerosis is the most common disease of the arteries; the term means hardening of the arteries. It is a diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and arterioles become thickened. This process gradually restricts the blood flow to one's organs and tissues and can lead to severe health risks brought on by atherosclerosis, which is a specific form of arteriosclerosis caused by the buildup of fatty plaques, cholesterol, and some other substances in and on the artery walls.

    Pathophysiology

    The lesions of arteriosclerosis begin as the intima (innermost layer of blood vessel wall) of the arterial wall start to fill up with the deposition of cellular wastes. As these start to mature, they can take different forms of arteriosclerosis. All are linked through common features such as the stiffening of arterial vessels, thickening of arterial walls and degenerative nature of the disease. Arteriolosclerosis, unlike atherosclerosis, is a sclerosis that only affects small arteries and arterioles, which carry nutrients and blood to the cells.

    Types of Arteriosclerosis
    1. Monckeberg's arteriosclerosis or medial calcific sclerosis is seen mostly in the elderly, commonly in arteries of the extremities. This involves calcification of the media of muscular arteries, without obstruction of the vessel lumen.
    2. Hyperplastic: Hyperplastic arteriosclerosis refers to the type of arteriosclerosis that affects small arteries and arterioles, characterized by concentric thickening of the vessel walls (often described as "onion-skinning") due to smooth muscle cell proliferation, commonly seen in severe hypertension.
    3. Hyaline type: Hyaline arteriosclerosis, also referred to as arterial hyalinosis and arteriolar hyalinosis, refers to lesions that are caused by the deposition of homogenous hyaline (a proteinaceous material) in the small arteries and arterioles, leading to luminal narrowing. This is often associated with benign hypertension and diabetes mellitus.

    ATHEROSCLEROSIS

    Introduction

    Definition: Atherosclerosis is the buildup of fatty material called plaque or atheroma, in the lining of the artery walls. It is a specific type of arteriosclerosis.

    This buildup causes the narrowing of the affected arteries. When the arteries are narrowed, blood cannot go through it easily. This can lead to reduced delivery of oxygen and nutrients to the cells of the body.

    Causes of Atherosclerosis

    The exact cause of atherosclerosis isn’t known. However, studies show that atherosclerosis is a slow, complex disease that may start in childhood. It develops faster as you age. Atherosclerosis may start when certain factors damage the inner layers of the arteries.

    • Hypercholesterolemia (especially high levels of low-density lipoprotein (LDL)-cholesterol, often referred to as "bad" cholesterol)
    • Hypertension (High Blood Pressure)
    • Diabetes mellitus (High blood sugar levels can damage blood vessels over time)
    • Cigarette smoking (Damages the inner lining of blood vessels, promotes inflammation, and alters lipid profiles)
    • Age (Male older than 45 years and female older than 55 years; risk increases with age due to cumulative exposure to risk factors and natural aging processes)
    • Male gender (Men tend to develop atherosclerosis earlier than women, though risk for women increases after menopause)
    • Strong family history of early heart disease (suggests a genetic predisposition)
    • Also, a sedentary lifestyle (lack of physical activity contributes to obesity, hypertension, diabetes, and dyslipidemia)
    • Obesity (especially abdominal obesity, linked to metabolic syndrome and increased cardiovascular risk)
    • Diets high in saturated and trans-fatty acids, and certain genetic mutations contribute to risk.
    • While a low level of high-density lipoprotein (HDL)-cholesterol is considered a risk factor (HDL helps remove cholesterol from arteries, so low levels are detrimental)
    • High levels of C-reactive protein (CRP), a marker of inflammation (indicates systemic inflammation, which plays a role in atherosclerosis development)
    • Sleep apnea (can contribute to hypertension and other cardiovascular risks)
    • Chronic kidney disease
    • Inflammatory diseases (e.g., lupus, rheumatoid arthritis)
    Pathophysiology of Atherosclerosis

    Atherosclerosis is a chronic inflammatory response in the walls of arteries, primarily driven by endothelial dysfunction and lipid accumulation. The process typically unfolds over decades:

    1. Endothelial Damage/Dysfunction: The process begins with injury or dysfunction to the endothelium (the innermost lining of the artery). This damage can be caused by risk factors like hypertension, high cholesterol, smoking, and diabetes. Damaged endothelium becomes more permeable and allows LDL cholesterol to enter the arterial wall.
    2. Lipid Accumulation and Oxidation: LDL particles penetrate the intimal layer of the artery and become trapped. Within the arterial wall, these LDL particles undergo oxidation. Oxidized LDL is highly inflammatory and toxic.
    3. Immune Response and Foam Cell Formation: The oxidized LDL triggers an inflammatory response. Monocytes (a type of white blood cell) are recruited to the site, adhere to the dysfunctional endothelium, and migrate into the intima. Once in the intima, monocytes transform into macrophages. These macrophages engulf large amounts of oxidized LDL, becoming lipid-laden "foam cells."
    4. Fatty Streak Formation: An accumulation of foam cells forms visible yellowish lesions called "fatty streaks" on the arterial wall. These are the earliest macroscopic lesions of atherosclerosis and can be seen even in childhood.
    5. Smooth Muscle Cell Migration and Proliferation: In response to growth factors and cytokines released during the inflammatory process, smooth muscle cells (SMCs) from the media (middle layer of the artery) migrate into the intima. These SMCs proliferate and produce extracellular matrix components (collagen, elastin, proteoglycans), which contribute to the bulk of the plaque.
    6. Fibrous Plaque Formation: The proliferating SMCs, extracellular matrix, lipids (both intracellular and extracellular), and inflammatory cells form a "fibrous plaque." This plaque has a lipid-rich core (necrotic core) surrounded by a fibrous cap composed of SMCs and collagen.
    7. Plaque Progression and Complications:
      • Growth: Plaques grow over time, gradually narrowing the artery lumen and impeding blood flow. This can lead to symptoms of ischemia (e.g., angina, claudication).
      • Calcification: Over time, plaques often calcify, becoming harder and more rigid.
      • Rupture/Erosion: The fibrous cap can thin and become unstable, making it prone to rupture or erosion. When a plaque ruptures, the highly thrombogenic (clot-forming) contents of the lipid core are exposed to the blood.
      • Thrombosis: Exposure of the plaque contents triggers immediate platelet aggregation and activation of the coagulation cascade, leading to the formation of a thrombus (blood clot) on top of the ruptured plaque.
      • Acute Events: A thrombus can completely occlude the artery, leading to acute ischemic events like myocardial infarction (heart attack) or ischemic stroke. Even if it doesn't fully occlude, it can further narrow the artery or detach and travel downstream (embolism).
    Clinical manifestations

    Signs and symptoms will depend on which arteries are affected, and often only appear when an artery is significantly narrowed or blocked, or when an acute event (like plaque rupture) occurs.

    Coronary Arteries (Leading to Coronary Artery Disease - CAD)

    When atherosclerosis affects the arteries supplying blood to the heart, it leads to CAD, which can manifest as:

    1. Angina Pectoris: Chest pain or discomfort, often described as pressure, squeezing, fullness, or pain, typically triggered by exertion or stress and relieved by rest or nitroglycerin. This is due to insufficient blood flow to the heart muscle (ischemia).
    2. Shortness of Breath (Dyspnea): Especially with exertion, due to the heart's inability to pump enough blood efficiently.
    3. Tachycardia: Rapid heart rate, as the heart tries to compensate for reduced blood flow.
    4. Palpitations: Awareness of irregular or forceful heartbeats.
    5. Fatigue and Weakness: Due to reduced oxygen supply to the body.
    6. Myocardial Infarction (Heart Attack): Occurs when blood flow to a part of the heart is completely blocked, usually by a blood clot forming on a ruptured plaque, leading to heart muscle death. Symptoms include severe chest pain (often radiating to arm, back, neck, jaw, or stomach), shortness of breath, cold sweat, nausea, lightheadedness.
    7. Arrhythmias: Irregular heart rhythms.
    Carotid Arteries (Leading to Carotid Artery Disease)

    The carotid arteries supply oxygen-rich blood to the brain. If plaque narrows or blocks these arteries, one may have symptoms of a transient ischemic attack (TIA) or stroke. These symptoms may include:

    1. Sudden weakness, numbness, or paralysis of the face, arm, or leg, especially on one side of the body.
    2. Confusion or trouble understanding speech.
    3. Trouble speaking (aphasia) or slurred speech (dysarthria).
    4. Trouble seeing in one or both eyes (amaurosis fugax, often described as a curtain coming down over vision).
    5. Difficulty in swallowing (dysphagia).
    6. Dizziness, trouble walking, loss of balance or coordination, and unexplained falls.
    7. Loss of consciousness.
    8. Sudden and severe headache with no known cause.
    Peripheral Arteries (Leading to Peripheral Artery Disease - PAD)

    Plaque also can build up in the major arteries that supply oxygen-rich blood to the legs, arms, and pelvis. If these major arteries are narrowed or blocked, you may have:

    1. Intermittent Claudication: Pain, cramping, aching, or fatigue in the legs, calves, buttocks, or thighs during exercise (like walking) that disappears with rest. This is the hallmark symptom.
    2. Numbness or weakness in the legs or feet.
    3. Coldness in the lower leg or foot, especially compared with the other side.
    4. Sores on the toes, feet, or legs that heal slowly or not at all.
    5. A change in the color of the legs (pallor or bluish discoloration).
    6. Hair loss or slower hair growth on the legs and feet.
    7. Slower growth of toenails.
    8. Shiny skin on the legs.
    9. No or a weak pulse in the legs or feet.
    10. Erectile dysfunction in men.
    11. In severe cases, rest pain (pain in the feet or toes even at rest) and critical limb ischemia (leading to gangrene and potential amputation).
    Renal Arteries (Leading to Renal Artery Stenosis)

    The renal arteries supply oxygen-rich blood to the kidneys. If plaque builds up in these arteries, one may develop renal artery stenosis, which can lead to:

    1. Difficult-to-control high blood pressure (hypertension), especially if it develops suddenly or worsens rapidly.
    2. Worsening kidney function, particularly when taking certain medications for blood pressure.
    3. Fluid retention and generalized swelling.
    4. Early kidney disease often has no signs or symptoms. As the disease gets worse, it can cause tiredness, changes in how you urinate (more often or less often), loss of appetite, nausea (feeling sick to the stomach), swelling in the hands or feet, itchiness or numbness and trouble concentrating.
    5. Abdominal bruits (whooshing sounds heard with a stethoscope over the affected kidney artery).
    Mesenteric Arteries (Leading to Chronic Mesenteric Ischemia)

    Atherosclerosis in the arteries supplying the intestines can cause:

    1. Severe abdominal pain after eating (often called "abdominal angina"), as digestion requires increased blood flow.
    2. Weight loss due to fear of eating.
    3. Nausea, vomiting, diarrhea.
    Diagnosis of Atherosclerosis

    Diagnosis of atherosclerosis involves a combination of medical history, physical examination, and various diagnostic tests:

  • Medical History and Physical Exam: Assessment of risk factors, symptoms, blood pressure measurement, listening for bruits (abnormal whooshing sounds caused by turbulent blood flow through narrowed arteries) over arteries (e.g., carotid, renal, femoral), and checking pulses in the extremities.
  • Blood Tests:
    • Lipid Panel: Measures total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglycerides.
    • Blood Glucose/HbA1c: To check for diabetes.
    • High-sensitivity C-reactive protein (hs-CRP): A marker of inflammation that can indicate increased risk.
    • Kidney and Liver Function Tests: To assess organ health.
  • Electrocardiogram (ECG): Can show signs of past heart attacks or current ischemia.
  • Ankle-Brachial Index (ABI): Compares blood pressure in the ankle to blood pressure in the arm. A low ABI indicates PAD.
  • Doppler Ultrasound: Uses sound waves to create images of blood vessels and measure blood flow, helping to identify blockages or narrowing in arteries (e.g., carotid, renal, peripheral).
  • Echocardiogram: Used to assess the heart's function and structure, and can show evidence of heart muscle damage from CAD.
  • Stress Test: Involves exercising (or pharmacologically stimulating) the heart while monitoring ECG, blood pressure, and symptoms to detect blood flow problems during exertion.
  • Angiography (CT Angiography, MR Angiography, or Conventional Angiography):
    • CT Angiography (CTA): Uses X-rays and contrast dye to create detailed images of blood vessels.
    • MR Angiography (MRA): Uses magnetic fields and radio waves to create images of blood vessels, often without contrast or with a different type of contrast.
    • Conventional Angiography (Catheter Angiography): An invasive procedure where a catheter is inserted into an artery and guided to the area of interest, then contrast dye is injected to visualize the arteries on X-ray. Considered the gold standard for detailed arterial imaging.
  • Intravascular Ultrasound (IVUS) or Optical Coherence Tomography (OCT): Invasive techniques performed during catheterization that provide detailed cross-sectional images from inside the artery, offering more information about plaque composition and burden.
    • Medical Management / Treatment for Atherosclerosis

    Treatment for atherosclerosis focuses on slowing or reversing plaque buildup, managing symptoms, and preventing complications. It often involves a combination of lifestyle modifications, medications, and sometimes medical procedures.

    A. Lifestyle Modifications (Cornerstone of Management):
  • Healthy Diet:
    • Consume a diet rich in fruits, vegetables, whole grains, lean proteins (fish, poultry, legumes), and healthy fats (monounsaturated and polyunsaturated).
    • Limit saturated and trans fats, cholesterol, sodium, and added sugars.
    • Examples: Mediterranean diet, DASH diet.
  • Regular Physical Activity:
    • Aim for at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity exercise per week.
    • Helps control weight, lower blood pressure, improve cholesterol levels, and manage diabetes.
  • Maintain a Healthy Weight: Achieve and maintain a healthy Body Mass Index (BMI).
  • Quit Smoking: Smoking cessation is the single most important lifestyle change for preventing and managing atherosclerosis.
  • Manage Stress: Techniques like meditation, yoga, or spending time in nature can help reduce stress, which can impact cardiovascular health.
  • Limit Alcohol Consumption: If consumed, do so in moderation (up to one drink per day for women, up to two for men).
    • B. Medications:
  • Cholesterol-Lowering Medications:
    • Statins (e.g., atorvastatin, simvastatin): First-line therapy, highly effective at lowering LDL-cholesterol, stabilizing plaques, and reducing cardiovascular events.
    • Ezetimibe: Reduces cholesterol absorption in the intestine.
    • PCSK9 inhibitors (e.g., alirocumab, evolocumab): Powerful LDL-lowering drugs, typically used for patients with very high cholesterol or those intolerant to statins.
    • Other agents: Fibrates, Niacin (less commonly used due to side effects or less robust outcome data).
  • Antiplatelet Medications:
    • Aspirin: Often prescribed to prevent blood clots in patients with established cardiovascular disease or high risk.
    • P2Y12 inhibitors (e.g., clopidogrel, ticagrelor): Stronger antiplatelets, used in patients with recent heart attack, stroke, or after stent placement.
  • Blood Pressure Medications:
    • ACE Inhibitors (e.g., lisinopril, enalapril) or Angiotensin Receptor Blockers (ARBs) (e.g., valsartan, losartan): Protect the heart and kidneys, especially important in patients with diabetes or kidney disease.
    • Beta-Blockers (e.g., metoprolol, carvedilol): Lower heart rate and blood pressure, reduce oxygen demand of the heart, often used after heart attack or in heart failure.
    • Calcium Channel Blockers (e.g., amlodipine, diltiazem): Relax blood vessels, lower blood pressure.
    • Diuretics (e.g., hydrochlorothiazide, furosemide): Help the body eliminate excess fluid and sodium, lowering blood pressure.
  • Blood Sugar Control Medications: For patients with diabetes, strict control of blood sugar levels is crucial to prevent progression of atherosclerosis (e.g., metformin, SGLT2 inhibitors, GLP-1 receptor agonists).
    • C. Medical Procedures and Surgeries:

    These are typically reserved for cases where atherosclerosis is causing significant symptoms, severely narrowing arteries, or posing an immediate threat.

  • Angioplasty and Stenting:
    • A catheter with a balloon is inserted into the narrowed artery and inflated to widen it.
    • A stent (a small mesh tube) is often placed to keep the artery open. Commonly used in coronary arteries (Percutaneous Coronary Intervention - PCI), carotid arteries, and peripheral arteries.
  • Endarterectomy: Surgical removal of plaque from the inner lining of an artery. Commonly performed for carotid artery disease (carotid endarterectomy) to prevent stroke.
  • Bypass Surgery: A healthy blood vessel (from another part of the body, like a leg vein or chest artery) is used to create a new path around a blocked or narrowed artery.
    • Coronary Artery Bypass Grafting (CABG): For severe blockages in coronary arteries.
    • Peripheral Bypass Surgery: For blockages in leg arteries.
  • Atherectomy: A procedure that uses a catheter with a rotating blade or laser to remove plaque from the artery.
    • Medical and Surgical Management
    Medical Management
    1. Blood thinning agents such as Aspirin – to reduce the ability of the blood to clot, so that the blood flows easier through the narrowed arteries.
    2. Nitrates – to relax the blood vessels.
    3. Beta blockers – to decrease the cardiac demand for oxygen by means of lowering the heart rate and blood pressure levels
    4. Calcium channel blockers – used in combination with beta blockers
    5. Diuretics to reduce blood pressure
    6. Ranolazine – to treat angina
    Surgical Management
    1. Surgery. Surgical interventions are required if the medical team believes that an urgent, more aggressive treatment for the complications of atherosclerosis (such as CAD and PVD) is needed. These surgeries include:
    2. Coronary artery bypass surgery – creation of a graft to reroute the blood flow away from the diseased artery
    3. Fibrinolytic therapy – usage of a clot-dissolving drug to dissolve the atheroma
    4. Endarterectomy – surgical removal of atheroma from the narrowed arteries
    5. Angioplasty and stent placement: A catheter is first inserted into the blocked or narrowed part of the artery, followed by a second one with a deflated balloon that is passed through the catheter into the narrowed area. The balloon is then inflated, pushing the deposits back against the arterial walls, and then a mesh tube is usually left behind to prevent the artery from retightening.
    Lifestyle Changes

    A low cholesterol, low sugar diet to control cholesterol and blood glucose levels is needed for a patient with atherosclerosis. Foods rich in omega-3 fatty acids such as fish, soybeans, and flaxseeds are recommended. Smoking is another risk factor of atherosclerosis and CAD. Increased physical activity by doing at least 150 minutes of moderate aerobic exercises will help promote an active lifestyle.

    NURSING DIAGNOSES FOR ARTERIOSCLEROSIS AND ATHEROSCLEROSIS

    Nursing diagnoses provide a framework for nursing care, identifying patient problems that nurses can independently address. For patients with arteriosclerosis and atherosclerosis, common nursing diagnoses include:

    1. Ineffective Peripheral Tissue Perfusion related to decreased arterial blood flow secondary to narrowed or occluded vessels.
      • Defining Characteristics: Diminished or absent pulses, prolonged capillary refill, pallor on elevation, rubor on dependency, cool extremities, pain (claudication or rest pain), non-healing wounds, trophic changes (hair loss, brittle nails, shiny skin).
    2. Acute Pain / Chronic Pain related to myocardial ischemia (angina), peripheral ischemia (claudication), or cerebral ischemia.
      • Defining Characteristics: Verbalization of pain (chest, leg, abdominal, headache), guarding behavior, restlessness, changes in vital signs (tachycardia, hypertension during acute pain episodes), facial mask of pain.
    3. Activity Intolerance related to imbalance between oxygen supply and demand secondary to myocardial or peripheral ischemia.
      • Defining Characteristics: Dyspnea on exertion, chest pain with activity, leg pain with activity (claudication), weakness, fatigue, abnormal heart rate or blood pressure response to activity.
    4. Risk for Decreased Cardiac Output related to myocardial ischemia, left ventricular dysfunction, or arrhythmias.
      • Defining Characteristics (if actual): Tachycardia, dysrhythmias, decreased blood pressure, decreased peripheral pulses, crackles in lungs, S3 or S4 heart sounds, decreased urine output, altered mental status. (Note: "Risk for" implies potential, not actual, signs).
    5. Risk for Impaired Cerebral Tissue Perfusion related to interrupted blood flow secondary to carotid artery stenosis or emboli.
      • Defining Characteristics (if actual): Changes in mental status, neurological deficits (weakness, paralysis, aphasia, visual disturbances), dizziness, headache.
    6. Risk for Imbalanced Nutrition: More Than Body Requirements related to excessive intake of saturated fats, cholesterol, and calories, or sedentary lifestyle.
      • Defining Characteristics: BMI > 25, observed excessive food intake, sedentary activity level.
    7. Deficient Knowledge regarding disease process, risk factors, medications, diet, and lifestyle modifications.
      • Defining Characteristics: Verbalization of misconceptions, inaccurate follow-through of instructions, recurrence of preventable complications.
    8. Anxiety related to chest pain, fear of death, threat to health status, or perceived change in health status.
      • Defining Characteristics: Verbalization of anxiety, restlessness, apprehension, increased heart rate, shortness of breath.
    9. Ineffective Health Management related to complexity of therapeutic regimen, perceived barriers, or insufficient social support.
      • Defining Characteristics: Failure to take medications as prescribed, failure to follow diet/exercise recommendations, frequent exacerbations of chronic disease.
    Nursing Interventions for Arteriosclerosis and Atherosclerosis

    Nursing interventions are actions taken by nurses to achieve patient outcomes based on nursing diagnoses. These interventions aim to alleviate symptoms, prevent complications, and promote patient well-being.

    1. Assess the patient’s vital signs and characteristics of heart beat (rate, rhythm, strength) at least every 4 hours, and more frequently if unstable or during acute episodes. Auscultate heart sounds for murmurs, gallops (S3, S4), and rubs. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis (especially lips, nail beds), and cool, clammy skin. Document findings and report significant changes to the physician.
    2. Administer prescribed medications for atherosclerosis (e.g., antiplatelets, statins, antihypertensives, nitrates) as ordered, noting patient response and any adverse effects. Educate the patient about the purpose, dosage, frequency, and potential side effects of each medication. Emphasize adherence to the medication regimen.
    3. Administer supplemental oxygen, as prescribed, especially during episodes of chest pain or dyspnea, to improve myocardial oxygen supply and reduce demand. Monitor oxygen saturation (SpO2) closely. Discontinue if SpO2 level is above the target range (usually >92-94%), or as ordered by the physician, to prevent oxygen toxicity or hyperoxia.
    4. Educate patient on stress management techniques, deep breathing exercises, and relaxation techniques (e.g., guided imagery, progressive muscle relaxation) to help reduce sympathetic nervous system activation, which can exacerbate cardiovascular symptoms. Encourage participation in stress-reducing activities.
    5. Administer prescribed medications that alleviate the symptoms of pain (e.g., nitroglycerin for chest pain, analgesics for leg/limb pain) promptly. Assess the patient’s vital signs and characteristics of pain (location, intensity using a pain scale, quality, duration, precipitating and relieving factors) at least 30 minutes after administration of medication to evaluate effectiveness and identify need for further intervention.
    6. Elevate the head of the bed (semi-Fowler's or high-Fowler's position) if the patient is short of breath, to facilitate lung expansion and ease breathing. Administer supplemental oxygen, as prescribed, and monitor respiratory status (rate, depth, effort, breath sounds).
    7. Place the patient in complete bed rest when in severe pain (e.g., unstable angina, acute myocardial infarction) to decrease myocardial oxygen demand. Ensure a calm and quiet environment. Assist with all activities of daily living (ADLs).
    8. Promote gradual increase in activity as tolerated and indicated, following physician orders or cardiac rehabilitation guidelines. Monitor patient's response to activity (vital signs, SpO2, pain, dyspnea). Teach patient signs of activity intolerance to report.
    9. Monitor fluid balance (intake and output, daily weights, assess for edema) especially in patients with heart failure or renal involvement, to prevent fluid overload or dehydration. Administer diuretics as prescribed and monitor electrolyte levels.
    10. Implement a heart-healthy and low-sodium diet in collaboration with a dietitian. Educate the patient and family about dietary restrictions and food choices (e.g., lean proteins, whole grains, fruits, vegetables, low-fat dairy, limited processed foods, saturated/trans fats, and cholesterol).
    11. Encourage smoking cessation. Provide resources and support (e.g., nicotine replacement therapy, counseling, support groups). Educate on the detrimental effects of smoking on cardiovascular health.
    12. Promote regular exercise as appropriate for the patient's condition and tolerance. Refer to cardiac rehabilitation programs or provide guidance on safe exercise routines.
    13. Monitor blood glucose levels closely in diabetic patients and ensure adherence to antidiabetic medications and dietary recommendations to prevent micro- and macrovascular complications.
    14. Assess skin integrity regularly, especially on the extremities, for signs of impaired perfusion such as non-healing wounds, ulcers, or changes in skin color/temperature. Provide meticulous wound care if present.
    15. Educate patient and family about the disease process, risk factors, early signs and symptoms of complications (e.g., chest pain, stroke symptoms, worsening claudication), and when to seek emergency medical attention. Encourage active participation in self-management.
    16. Provide emotional support and address anxiety. Listen to patient concerns, provide clear explanations, and involve family in care. Refer to social work or counseling if needed.
    17. Prevent complications of immobility (e.g., deep vein thrombosis, pressure ulcers) through appropriate interventions such as repositioning, leg exercises, and ensuring adequate hydration and nutrition.
    Complications of Atherosclerosis

    The complications of atherosclerosis are varied and often severe, depending on which arteries are affected. They arise from the narrowing of blood vessels (ischemia) or the rupture of plaques leading to clot formation (thrombosis/embolism).

    • Coronary Artery Disease (CAD):
      • Angina (stable or unstable)
      • Myocardial Infarction (Heart Attack)
      • Heart Failure (due to chronic ischemia or damage from MIs)
      • Arrhythmias (e.g., sudden cardiac death)
    • Cerebrovascular Disease (leading to Stroke or TIA):
      • Transient Ischemic Attack (TIA - "mini-stroke")
      • Ischemic Stroke (due to blockages in brain arteries or emboli from carotid plaques)
      • Vascular Dementia (due to chronic reduced blood flow to the brain)
    • Peripheral Artery Disease (PAD):
      • Intermittent claudication
      • Non-healing ulcers/wounds in the extremities
      • Critical limb ischemia (severe rest pain, tissue loss)
      • Gangrene and limb amputation
    • Renal Artery Stenosis:
      • Refractory Hypertension (difficult to control)
      • Chronic Kidney Disease progressing to kidney failure
    • Mesenteric Ischemia:
      • Chronic mesenteric ischemia (abdominal pain after eating, weight loss)
      • Acute mesenteric ischemia (sudden, severe abdominal pain, bowel necrosis – a medical emergency)
    • Aneurysms: Atherosclerosis can weaken arterial walls, leading to the formation of aneurysms (bulges or balloons in the artery), most commonly in the aorta (abdominal aortic aneurysm - AAA). Aneurysms can rupture, causing life-threatening internal bleeding.

    Revision Questions:

    1. What is the fundamental difference between arteriosclerosis and atherosclerosis?
    2. A patient presents with sudden weakness on one side of their body and trouble speaking. Blockage in which arteries should be suspected?
    3. List five major modifiable risk factors for the development of atherosclerosis.
    4. What is the primary goal of surgical procedures like angioplasty or coronary artery bypass surgery in managing atherosclerosis?
    5. Describe three key nursing interventions for a patient with severe atherosclerosis experiencing chest pain.

    Arteriosclerosis and Atherosclerosis Read More »

    CONGESTIVE CARDIAC FAILURE

    CONGESTIVE CARDIAC FAILURE

    Nursing Notes - Congestive Cardiac Failure

    CONGESTIVE CARDIAC FAILURE (CCF), OR HEART FAILURE (HF)

    Introduction to Heart Failure

    Heart failure (HF), often referred to as congestive heart failure (CHF) particularly when fluid retention is prominent, is a complex clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Essentially, the heart cannot pump enough blood to meet the metabolic demands of the body's tissues for oxygen and nutrients.

    • It is not that the heart has "failed" or stopped working, but rather that it is not working as efficiently as it should.
    • HF is a progressive condition that can worsen over time.
    • The term "congestive" reflects the common symptom of fluid accumulation (congestion) in the lungs and/or other body tissues when the heart's pumping action is inefficient.
    • While "CCF" specifically points to the congestion, "Heart Failure" is the more encompassing and commonly used term in modern medical practice, as not all forms of heart failure present with overt congestion initially.
    • It is a syndrome, meaning it is a collection of signs and symptoms, rather than a single disease, often the end-stage of many cardiovascular diseases.

    Types of Heart Failure

    Heart failure can be classified based on which side of the heart is primarily affected, the ejection fraction, and its onset.

    I. Based on Affected Side:

    Heart failure can affect the left side, right side, or both.

    A. Left-Sided Heart Failure:

    Occurs when the left ventricle fails to pump blood effectively to the body. This leads to blood backing up into the lungs.

  • Mechanism: The left ventricle's inability to adequately pump blood leads to increased pressure in the left atrium and pulmonary veins, causing fluid to be pushed into the lung tissue (pulmonary congestion).
  • Subtypes:
    • Systolic Heart Failure (HFrEF - Heart Failure with reduced Ejection Fraction): The left ventricle loses its ability to contract normally. The heart muscle becomes weak and enlarged, and it can't pump enough blood into circulation. Characterized by an ejection fraction (EF) of <40-50%.
    • Diastolic Heart Failure (HFpEF - Heart Failure with preserved Ejection Fraction): The left ventricle becomes stiff and cannot relax or fill properly during diastole (the resting phase between beats). Although the pumping ability (ejection fraction) may be normal, the heart cannot fill with enough blood, leading to reduced cardiac output. Characterized by an EF of ≥50% but with evidence of diastolic dysfunction.
  • Key Symptom: Fluid in the lungs causing shortness of breath (dyspnea), cough, and crackles.
    • B. Right-Sided Heart Failure:

    Occurs when the right ventricle fails to pump blood effectively to the lungs. This causes blood to back up into the systemic circulation.

    • Mechanism: The right ventricle's inability to effectively pump blood into the pulmonary artery leads to increased pressure in the right atrium and systemic veins. This increased pressure causes fluid to accumulate in the body's tissues.
    • Causes: Most commonly caused by left-sided heart failure (as the increased pressure in the lungs eventually overworks and weakens the right ventricle). Other causes include chronic lung diseases (e.g., COPD leading to cor pulmonale), pulmonary hypertension, and specific right ventricular pathologies.
    • Key Symptom: Fluids may back up in the abdomen (ascites), liver (hepatomegaly), legs, and feet causing swelling (peripheral edema).
    C. Biventricular Heart Failure:

    Occurs when both the left and right ventricles are impaired. This is a common progression of heart failure, as failure of one side often places increased strain on the other. It presents with a combination of symptoms from both left and right-sided heart failure.

    II. Based on Onset:
    • Acute Heart Failure: Rapid onset or worsening of heart failure symptoms. Can be a first presentation or an acute decompensation of chronic HF. Often triggered by an acute event (e.g., myocardial infarction, arrhythmia, severe infection).
    • Chronic Heart Failure: A long-term condition with ongoing symptoms that may gradually worsen over time, often managed with medication and lifestyle changes. Patients may experience acute exacerbations (decompensations).

    Causes and Risk Factors of Heart Failure

    Heart failure is often the result of other chronic conditions that damage or overwork the heart. It's important to differentiate between primary causes and aggravating factors.

    A. Primary Causes (Conditions that directly damage the heart or increase its workload):
  • Coronary Artery Disease (CAD) and Myocardial Infarction (MI):
    • CAD: Narrowing of the arteries supplying the heart muscle reduces blood flow, leading to ischemia and chronic damage.
    • MI (Heart Attack): Sudden blockage of a coronary artery causes death of heart muscle tissue. The scarred tissue cannot pump effectively.
  • Hypertension (High Blood Pressure):
    • Sustained high blood pressure increases the workload on the heart, causing the heart muscle (especially the left ventricle) to thicken and become stiff (hypertrophy). Over time, this can lead to the heart becoming less efficient and eventually failing.
  • Valvular Heart Disease:
    • Stenosis (Narrowing): A valve doesn't open fully, forcing the heart to pump harder to push blood through (e.g., Aortic Stenosis).
    • Regurgitation (Leakage/Insufficiency): A valve doesn't close completely, allowing blood to flow backward, increasing the heart's workload (e.g., Mitral Regurgitation).
  • Cardiomyopathy:
    • Diseases of the heart muscle itself, often genetic or idiopathic. These can cause the heart muscle to become dilated (stretched and thin), hypertrophic (abnormally thick), or restrictive (stiff). HF due to cardiomyopathy is usually chronic and progressive.
  • Myocarditis: Inflammation of the heart muscle, often viral, which can weaken the heart's pumping ability.
  • Endocarditis: Infection of the heart valves or inner lining, leading to valve damage and impaired function.
  • Pericarditis: Inflammation of the sac surrounding the heart, which can restrict the heart's ability to fill properly.
  • Congenital Heart Defects: Structural problems with the heart present at birth (e.g., septal defects, patent ductus arteriosus) can lead to abnormal blood flow and increased workload on the heart chambers over time.
  • Arrhythmias (e.g., Chronic Atrial Fibrillation with uncontrolled ventricular rate): Persistent rapid or irregular heartbeats can overwork and weaken the heart muscle.
  • Chronic Lung Diseases (e.g., COPD, severe asthma): Can lead to pulmonary hypertension, which puts strain on the right side of the heart (cor pulmonale), eventually leading to right-sided heart failure.
  • Diabetes Mellitus (DM): Can damage blood vessels and nerves, contributing to CAD, hypertension, and direct damage to heart muscle (diabetic cardiomyopathy).
  • Thyroid Disorders:
    • Hyperthyroidism: Overactive thyroid can make the heart beat too fast and too hard.
    • Hypothyroidism: Underactive thyroid can slow metabolism and contribute to other risk factors.
  • Anemia: Severe or chronic anemia forces the heart to pump faster to deliver enough oxygen, which can overwork the heart.
  • Sleep Apnea: Repeated episodes of stopping breathing during sleep can lead to chronic oxygen deprivation and increased stress on the heart.
  • Certain Medications: Some cancer treatments (e.g., anthracyclines), NSAIDs, or specific antiarrhythmics can damage the heart or worsen HF.
    • B. Aggravating Factors (Can precipitate or worsen heart failure):
  • Lifestyle Factors:
    • Smoking (Tobacco Use): Damages blood vessels and contributes to CAD and hypertension.
    • Obesity: Increases the workload on the heart and is associated with hypertension, diabetes, and sleep apnea.
    • Excessive Alcohol Consumption: Can directly damage heart muscle (alcoholic cardiomyopathy).
    • High Sodium Diet: Leads to fluid retention, increasing blood volume and heart workload.
    • Lack of Physical Activity.
  • Infections: Any severe infection (e.g., pneumonia, sepsis) can increase metabolic demands and put strain on an already weakened heart.
  • Allergic Reactions: Severe systemic allergic reactions (anaphylaxis) can cause circulatory collapse and stress the heart.
  • Blood Clot (e.g., Pulmonary Embolism): Can acutely increase the workload on the right ventricle.
  • Ischemia: While a cause, acute ischemia (e.g., unstable angina) can also acutely decompensate chronic HF by depriving heart cells of oxygen and leading to acidosis from the accumulation of lactic acid.

    • Clinical Manifestations / Signs and Symptoms of Heart Failure

    Symptoms vary depending on whether left or right-sided failure predominates, the severity, and the acuteness of the condition. They generally result from inadequate cardiac output and/or compensatory fluid retention.

    I. Symptoms of Left-Sided Heart Failure (Pulmonary Congestion):
    • Dyspnea (Shortness of Breath):
      • Exertional Dyspnea: Occurs with activity, initially mild, progresses to severe.
      • Orthopnea: Difficulty breathing when lying flat, relieved by sitting up (requires extra pillows to sleep).
      • Paroxysmal Nocturnal Dyspnea (PND): Sudden awakening at night with severe shortness of breath, relieved by sitting upright or standing.
      • Dyspnea at Rest: In advanced stages.
    • Cough: May be initially dry and irritating, later becoming productive of frothy, sometimes pink-tinged (blood-stained) sputum due to pulmonary edema. Worse at night or when lying down.
    • Crackles (Rales): Heard on auscultation of the lungs, indicative of fluid in the alveoli.
    • Wheezing: Can occur due to bronchial edema.
    • Tachypnea: Increased respiratory rate.
    • S3 Gallop: An extra heart sound heard on auscultation, indicative of rapid ventricular filling in a dilated ventricle.
    • Reduced Exercise Tolerance/Activity Intolerance: Due to insufficient oxygen delivery to muscles.
    • Fatigue and Weakness: Due to decreased cardiac output and poor tissue perfusion.
    • Nocturia: Increased urination at night, as supine position improves renal perfusion.
    • Pulmonary Edema: Severe accumulation of fluid in the lungs, leading to acute respiratory distress (medical emergency).
    • Cyanosis: Bluish discoloration of skin, lips, and nail beds in severe cases due to poor oxygenation.
    II. Symptoms of Right-Sided Heart Failure (Systemic Congestion):
    • Peripheral Edema: Swelling, mainly of the lower limbs (ankles, feet, sacrum if bedridden), often pitting. Worse at the end of the day.
    • Jugular Venous Distension (JVD): Visible swelling and pulsation of the jugular veins in the neck due to increased pressure in the right atrium.
    • Hepatomegaly: Enlargement of the liver due to venous congestion, leading to right upper quadrant pain or tenderness.
    • Ascites: Fluid accumulation in the peritoneal space, causing abdominal distension and discomfort.
    • Anorexia, Nausea, and Vomiting: Due to congestion of the gastrointestinal tract and liver, leading to feeling of fullness and impaired digestion.
    • Weight Gain: Due to fluid retention, despite potential muscle wasting.
    • Splenomegaly: Less common than hepatomegaly, but spleen can also enlarge due to congestion.
    • Heartburn and Feeling of Indigestion: Non-specific, but can be related to GI congestion.
    • Constipation: Can be related to reduced activity, dietary changes, or medication side effects.
    III. General Symptoms (Can occur in both or biventricular failure):
    • Fatigue and Weakness: As mentioned, common in all types due to reduced cardiac output.
    • Activity Intolerance: Difficulty performing daily activities like walking, climbing stairs, digging, carrying.
    • Anxiety and Restlessness: Often due to dyspnea or general discomfort.
    • Irritability: Can be a consequence of chronic illness and discomfort.
    • Rapid or Irregular Pulse Rate (Tachycardia/Arrhythmias): Heart tries to compensate by beating faster.
    • Palpitations: Awareness of heart beats.
    • Oliguria (Reduced Urine Output) / Anuria (Total Urine Absence): During the day due to decreased renal perfusion, but often followed by nocturia as renal perfusion improves at rest.
    • Confusion or Memory Impairment: In severe cases, due to reduced cerebral perfusion.
    • Weight Loss (Cardiac Cachexia): In advanced, chronic HF, despite fluid retention, due to metabolic derangements and protein-calorie malnutrition, leading to prominent ribs.
    • Anemia: Can be a co-morbidity or contribute to worsening HF.
    • Chest Pain: While more typical of ischemia, can occur with severe heart failure due to increased myocardial oxygen demand.

    Investigations and Diagnosis of Heart Failure

    Diagnosis of heart failure is a clinical diagnosis based on symptoms, physical examination, and confirmed by objective tests.

    A. Clinical Assessment:
  • History Taking: Detailed history of symptoms (onset, duration, aggravating/alleviating factors), past medical history (hypertension, CAD, MI, diabetes), medication history, social history (smoking, alcohol, diet).
  • General Physical Examination:
    • Assessment of vital signs (tachycardia, tachypnea, hypotension or hypertension).
    • Presence of edema (pitting, non-pitting).
    • JVD.
    • Lung auscultation (crackles, wheezes, diminished breath sounds if pleural effusion).
    • Heart auscultation (murmurs, S3 gallop, irregular rhythm).
    • Abdominal examination (hepatomegaly, ascites).
    • Skin turgor, color (pallor, cyanosis).
    • B. Laboratory Tests:
  • Blood Tests:
    • Complete Blood Count (CBC): To check for anemia, infection.
    • Serum Electrolytes (Na, K, Mg): To assess for imbalances, especially if on diuretics.
    • Renal Function Tests (Creatinine, BUN): To assess kidney function, which can be affected by HF or medications.
    • Liver Function Tests (LFTs): To assess for hepatic congestion.
    • Thyroid-Stimulating Hormone (TSH): To rule out thyroid dysfunction as a cause or contributing factor.
    • B-type Natriuretic Peptide (BNP) or N-terminal pro-BNP (NT-proBNP):
      • Purpose: Hormones released by the heart ventricles in response to stretching and increased pressure.
      • Significance: Elevated levels are highly suggestive of heart failure and correlate with its severity. Useful for diagnosis, prognosis, and monitoring treatment effectiveness.
    • Cardiac Biomarkers (Troponins): May be elevated in acute heart failure due to myocardial stress, or if underlying ischemic event.
    • Fasting Blood Glucose/HbA1c: To check for diabetes.
    • Lipid Profile: To assess for risk factors of CAD.
    • Blood for Culture and Sensitivity: If infection is suspected as a precipitating factor.
    • C. Imaging and Other Diagnostic Tests:
  • Electrocardiogram (ECG):
    • Purpose: To check heart rhythm, identify previous heart attacks, signs of chamber enlargement, or ischemia.
    • Findings: May show arrhythmias (e.g., atrial fibrillation), signs of past MI (Q waves), ventricular hypertrophy, conduction abnormalities. While not diagnostic of HF itself, it provides valuable information about underlying causes.
  • Chest X-ray (CXR):
    • Purpose: To visualize the size and shape of the heart and check for pulmonary congestion.
    • Findings: May reveal cardiomegaly (enlarged heart), pulmonary vascular congestion, interstitial edema, pleural effusions (fluid around the lungs). These images show the condition of the heart and lungs.
  • Echocardiogram (Echo):
    • Purpose: The most crucial diagnostic test for heart failure. It uses sound waves to create moving images of the heart.
    • Information Provided:
      • Ejection Fraction (EF): Measures the percentage of blood pumped out of the ventricle with each beat, differentiating HFrEF from HFpEF.
      • Chamber Size and Function: Assesses ventricular and atrial dimensions, wall thickness, and contractility.
      • Valvular Function: Identifies structural or functional abnormalities of heart valves (stenosis, regurgitation).
      • Pericardial Effusions.
      • Estimates Pulmonary Artery Pressure.
  • Stress Tests (Exercise or Pharmacologic):
    • Purpose: To evaluate for underlying ischemic heart disease, especially if the cause of HF is unclear. Determines how the heart responds to exertion.
  • Cardiac Magnetic Resonance Imaging (MRI):
    • Purpose: Provides highly detailed images of the heart's structure and function, particularly useful for evaluating cardiomyopathies, scar tissue, or complex congenital heart disease.
  • Cardiac Catheterization and Coronary Angiography:
    • Purpose: Invasive procedure to directly measure pressures within the heart chambers and identify blockages in the coronary arteries.
    • Indications: Considered if CAD is suspected as a cause, or before surgical interventions.
  • Biopsy: Rarely performed, but can be done to diagnose specific types of cardiomyopathy (e.g., amyloidosis, giant cell myocarditis).

    • Management:

    Aims:
    • To rest the patient- mentally and physically
    • To relieve symptoms
    • To prevent complications
    Nursing Interventions / Management
    • Admit patient on a medical ward in a well-ventilated room which is quiet near the nurse's station for close monitoring.
    • Give a complete bed rest to rest the heart.
    • Position the patient in a sitting up position to aid breathing, to relieve pressure of fluids in the lungs (fluid gravity).
    • Loosen anything of constrictive nature from the patient's body to aid breathing and promote comfort.
    • Use a bed cradle to lift the weight of beddings off the patient.
    • Observations - vital observations i.e. Pulse, respirations, temperature, and blood pressure must be measured 4 hourly and accurately recorded in the patient's file. Pulse may be done more frequently. Observe assess patient for oedema, respiratory status and signs of cyanosis. Continuous pulse oximetry is needed.
    • Provide a cardiac table to help the patient relax.
    • Administer oxygen 2-5 litres to support breathing and correct cyanosis.
    • Psychotherapy - patient and patient's relative are reassured to allay anxiety. This is started right from the time of admission up to discharge, always attend to patient's queries/questions and if possible stay with the patient.
    • Support the patient's feet with a foot rest (small pillows) to prevent foot drop.
    • Place a soft cushion beneath the oedematous sacral area to relieve pressure.
    • Daily weighing of the patient to assess oedema and Ascites improvement.
    • Provide a loose jacket or shawl to cover the patient in order to keep him/her warm.
    • Hygiene - in acute phase of CCF, everything is done for the patient like bed bath, mouth care regular pressure area treatment especially the oedematous areas. Provide a sputum mug with disinfectant for expectoration, which must be regularly emptied, cleaned and kept covered.
    • Diet - provide a highly nutritious diet with less sugar and carbohydrates (starch) which require a lot of energy metabolism. Provide a salt and fat free diet; give plenty of fruits, and vegetables/roughages to prevent constipation. Give little food at a time but frequently to avoid a distended stomach or abdomen.
    • Restrict fluids in oedema; however give adequate amount of fluids.
    • Drug therapy:
      • Digitalis group - like digoxin. Digitalis help to strengthens the heart and reduce on the contractility and conductivity of the heart. NB: digoxin should not be given when the pulse rate is < 60 b/m as it causes bradycardia.
      • Diuretics - to promote renal excretion of salt and water thus correcting oedema. These include: furosemide, Bendrofluazide, Potassium sparing diuretics.
      • Hypotensive - to normalize the blood pressure if high like: ACE inhibitors like captoprile, Beta blockers.
      • Sedatives – like diazepam or phenytoin to promote rest and sleep.
      • Supportive drugs like Haematenics e.g. Ferrous sulphate to prevent or treat anaemia, multivitamins to stimulate appetite.
    • Abdominal paracentesis to relieve abdominal pressure caused by Ascites.
    • Exercises – initially passive and when condition improves, active exercises can be commenced.
    • Bladder and bowel care - fluid balance chart must be strictly monitored and balanced every after 24 hours to assess kidney function. Provide roughages and fruits with just enough fluids to avoid constipation.
    • Health education: health educate patient and the patient's relative about:
      • The nature of the disease and how it's managed in the hospital and at home.
      • To adopt and comply with a cardiac diet- salt and fat free diet.
      • About the drugs, how to take them and then drug compliance.
      • To maintain a complete bed rest and the condition improves to carry out less strenuous exercises.
      • To reduce or stop all the predisposing factors to cardiac failure (CCF) like stopping smoking, reduce weight (obesity) control DM, stop/reduce high fat diet.
      • Vaccination of all patients against pneumococcal diseases, influenza, measles etc.
      • Return to the hospital for review on the appointed date.
      • NB: All mothers with cardiac failure (CCF) who want to conceive again must first consult their Cardiologists before conception.

    Complications of Heart Failure

    Heart failure is a progressive condition that can lead to various serious complications due to the body's compensatory mechanisms and the ongoing inability of the heart to pump effectively.

    • Acute Pulmonary Edema: A life-threatening condition where fluid rapidly accumulates in the lung alveoli, causing severe shortness of breath, hypoxia, and respiratory distress. Requires immediate medical intervention.
    • Kidney Damage or Failure: Chronic poor blood flow to the kidneys (due to low cardiac output) and the effects of medications (e.g., diuretics, ACE inhibitors) can impair kidney function, sometimes leading to cardiorenal syndrome.
    • Liver Damage: Chronic venous congestion in right-sided heart failure can lead to liver enlargement (hepatomegaly) and impaired liver function (cardiac cirrhosis in severe, long-standing cases).
    • Cardiac Arrhythmias: The stretched and damaged heart muscle is more prone to developing abnormal heart rhythms, including atrial fibrillation (very common), ventricular tachycardia, and ventricular fibrillation (life-threatening). These can further reduce cardiac output and increase the risk of sudden cardiac death.
    • Valvular Heart Disease: As the heart chambers enlarge, the valves (especially the mitral and tricuspid valves) may become stretched and unable to close properly, leading to regurgitation (functional mitral or tricuspid regurgitation), which can worsen the heart failure.
    • Stroke: Patients with heart failure, particularly those with atrial fibrillation, are at increased risk of blood clot formation within the heart chambers. These clots can dislodge and travel to the brain, causing an ischemic stroke.
    • Pulmonary Hypertension: Left-sided heart failure often leads to increased pressures in the pulmonary arteries, which can eventually cause pulmonary hypertension and further strain the right ventricle.
    • Anemia: Common in chronic heart failure due to various factors including chronic inflammation, kidney dysfunction, and nutritional deficiencies. Anemia can worsen HF symptoms.
    • Malnutrition/Cardiac Cachexia: In advanced stages, patients may experience significant weight loss and muscle wasting (cardiac cachexia) due to increased metabolic demands, malabsorption from gut edema, and anorexia.
    • Depression and Anxiety: The chronic and debilitating nature of heart failure can significantly impact a patient's mental health, leading to depression and anxiety, which can further affect self-care and quality of life.
    • Increased Risk of Infections: Patients with chronic conditions like HF may be more susceptible to infections, especially respiratory infections like pneumonia, which can trigger acute decompensation.

    Nursing Diagnoses for Heart Failure

    Nursing diagnoses provide a framework for nursing care, identifying patient problems that nurses can independently address. Here are common nursing diagnoses for patients with heart failure:

    • Decreased Cardiac Output related to altered contractility, altered preload, altered afterload, and/or altered heart rate/rhythm, as evidenced by dyspnea, fatigue, weakness, peripheral edema, S3 gallop, JVD, and altered blood pressure.
    • Excess Fluid Volume related to compromised regulatory mechanisms (e.g., decreased kidney perfusion, increased ADH) and increased sodium/water retention, as evidenced by peripheral edema, pulmonary congestion (crackles, dyspnea, orthopnea), weight gain, and JVD.
    • Impaired Gas Exchange related to alveolar-capillary membrane changes (fluid accumulation in lungs), as evidenced by dyspnea, tachypnea, abnormal blood gases, and crackles.
    • Activity Intolerance related to imbalance between oxygen supply and demand, generalized weakness, and deconditioning, as evidenced by dyspnea on exertion, fatigue, and inability to perform activities of daily living (ADLs).
    • Fatigue related to decreased cardiac output, inadequate tissue oxygenation, increased metabolic demands, and sleep disturbance (e.g., PND, nocturia), as evidenced by overwhelming sustained sense of exhaustion, decreased performance, and lethargy.
    • Imbalanced Nutrition: Less Than Body Requirements related to anorexia, nausea, early satiety (from GI congestion), and increased metabolic demands, as evidenced by weight loss, muscle wasting, and abnormal laboratory values.
    • Excessive Anxiety related to change in health status, perceived threat to self-concept, potential for death, and shortness of breath, as evidenced by restlessness, expressed concerns, and sympathetic nervous system manifestations.
    • Deficient Knowledge regarding disease process, dietary and fluid restrictions, medication regimen, signs and symptoms of worsening condition, and self-care activities, as evidenced by verbalized questions, inaccurate follow-through of instructions, or exacerbation of symptoms.
    • Risk for Impaired Skin Integrity related to edema, decreased tissue perfusion, and immobility, as evidenced by (potential for) skin breakdown in dependent areas.
    • Risk for Ineffective Self-Health Management related to complexity of therapeutic regimen, perceived barriers, lack of motivation, or insufficient social support.
    • Ineffective Breathing Pattern related to fluid shift into interstitial spaces/alveoli, as evidenced by dyspnea, orthopnea, tachypnea, and use of accessory muscles.

    CONGESTIVE CARDIAC FAILURE Read More »

    Self study questions for nurses and midwives

    Questions and Answers

    Questions and Answers

    Medicine

    Hyperglycemia
    1. Mrs. Loyce a thirty three year old female patient has been admitted with signs and symptoms of hyperglycemia.

                  (a). Manage Loyce from the time of her admission up to discharge.

                  (b) Differentiate between hyperglycemia and hypoglycemia.

                  (c) Explain how you can prevent a diabetic foot.

    SOLUTIONS

    a). Hyperglycemia– refers to chronically high blood glucose level .it is usually over 240mg/dl.

    Hypoglycemia– refers to dangerously low blood glucose levels that drop below 70mg/dl

    However the sign and symptoms of hyperglycemia includes:-

    • Blood glucose over 240mg/dl
    • More urine output than normal
    • Increased thirst (polydipsia)
    • Dry skin and mouth (dehydration)
    • Nausea and vomiting
    • Decreased appetite
    • Easy fatiquability ,drowsiness or no energy 

    Management of Loyce from the time of admission up to discharge

    Aims of management

    1. To reduce blood glucose level to normal 
    2. To prevent further complication 
    3. To provide basic nursing care  
    4. To alley anxiety

    ACTUAL MANAGEMENT

    • Mrs. Loyce is received in female medical ward given a seat and rapport created to alley anxiety
    • Brief history taking of the patient’s condition including the demographic data

    Admission

    •  The patient is admitted in female medical ward in a clean admission bed with clean linens in a well lit room free from dust and well ventilated

    Position

    • The patient adopts any comfortable position under nurse’s supervision

    Observations 

    1. Vital observations .temperature, pulse respiration and blood pressure of the patient are taken and recorded in the observation chart. So that incase of any deviation from normal, it can be managed appropriately.
    2. Specific observations .this includes observing the patient for jaundice, anemia ,cyanosis, clubbing, oedema, lymphadenitis, dehydration, urine colour and smell. Findings recorded and reported to the doctor.

    General observation 

    • This is done from head to toe to rule out any abnormalities.

    Inform the doctor: As soon as the observations are done the doctor is informed who will come and carry out his assessments (confirm the nurses findings) and may order for the following investigations

    Investigations

    1. Specific investigations
    • Haematology 

        -Blood for random blood sugar

        – Renal function test

       – Complete blood count

        – Blood electrolytes

    • Urinalysis to rule out presence of acetone & ketones, urine protein, blood in urine etc 
    1. b) General investigations

        – HIV serology

         – When results are out, the doctor makes a diagnosis and may prescribe the following supportive treatment

    • Intravenous fluids normal saline 3 liters while monitoring blood pressure until blood glucose level is lowered to normal
    • Insulin administered intradermal .it can be pre-breakfast or pre- supper depending on doctor’s prescription 
    • Antibiotics e.g. ceftriaxone 2g in case of any sign of infections 

    Specific nursing care

    • Diet. -The patient is given low sugar diet ,low fats diet and  diet rich in vitamins 
    • Elimination. – Bladder is monitored for urine output using the fluid balance chart (FBC) and recorded on the chart.
    • Bowel. Patient is encouraged to empty the bowel whenever necessary
    • Exercise:- passive exercise in acute state eg massaging the patients toes and fingers to aid circulation 
    • Active exercise e.g. deep breathing exercise to prevent hypostatic pneumonia, lower limbs to prevent DVT, the patient is encouraged to move around the ward 

    General nursing care

    • Rest and sleep by restricting number of visitors and noise in the room should be minimized
    •  Personal hygiene e.g. skin care, oral care and bed linens changed whenever it is soiled.
    • Environmental hygiene of the ward .the ward should be maintained clean and free  from horrible dour that may discomfort the patient 
    • Psychotherapy e.g. the nurse allows relatives to stay with the patient and also may invite religious leaders who may update the  patients spiritually 

    Investigations before discharge.

     When the patient’s condition has improved, the doctor may order for investigations like:-

    • Urinalysis
    • Blood  for blood sugar & CBC
    • Renal function test

    When the results are satisfactory, the doctor writes a discharge form and the patient is discharged

      Advice on discharge

    • Take medications as prescribed 
    • Come back for review on the schedule date
    • Avoid injuries that can cause damage to the skin
    • The patient is advised on diet as follows
    •  Food with reduced sugar 
    • Fatty food should be limited
    • Diet should contain vitamins
    • Improve on life style for example cessation of smoking ,alcoholism etc. 
    • Differences between hyperglycemia and hypoglycemia

    Hyperglycemia

    Hypoglycemia

    • High blood glucose level  more than 240mg/dl 
    • Low blood glucose level 
    • The onset is gradual over few days 
    • Onset is sudden over minutes 
    • Urine contains large amount of sugar and acetone 
    • Urine has no sugar and acetone 
    • Insulin is administered in most cases 
    • Glucose is given 
    • The skin is worm and dry 
    • The skin is pale, cold and sweaty 
    • Patients become gradually drowsy and lethargic 
    • Patient is confused ,restless and anxious 
    • Breath is deep and fast in most cases 
    • Shallow breath 
    • Fruity smell of the breath due to acetone
    • No fruity smell, acetone absent 
    • Rapid pulse rate 
    • Normal pulse rate 
     
     
     
     
    • Prevention of diabetic foot

    Diabetic foot is a neurological condition that occurs during diabetes. However, it can be prevented from occurring through the following ways:-

    • Maintain and keep the blood glucose level low in a target range to prevent  complications by administering insulin and advising on diet for example reduce on intake of sugar and fatty foods 
    • Examine and screen the patient’s feet daily for senses, colour, cuts, swelling, pain and temperature for early interventions incase of any.
    • Wash and dry feet paying much attention between the toes.
    • Turn the patient 2 hourly to prevent excessive pressure on the pressure areas of the foot to prevent pressure sores 
    • Wash and dry feet paying much attention between the toes.
    • Turn the patient 2 hourly to prevent excessive pressure on the pressure areas of the foot to prevent pressure sores 
    • Wear for the patient shoes and stockings to prevent injury to the feet .the shoes should be of appropriate size. Always check the shoes before wearing.
    • Trim the patients nail. This is done using the nail file to prevent under growing nails that can cause infections. 
    • Keep the skin soft and smooth by rubbing the skin with lotion over  the top and bottom to prevent cracks
    • Massage the feet to maintain blood circulation and the patient is encouraged not to cross the legs for long time because this can cut off circulation for the feet
    • Protect the feet from cold and hot water since this can impair the senses 
    • Exercise the foot by moving it for about  5 minutes and teach the patient how to do it (physiotherapy)
    •  

    Health educate the patient (Loyce) on the following;

    • Importance of wearing  a well fitting pair of shoes
    • Not to move bare foot 
    • Check her foot before putting on shoes
    • Seek medical assistance in case of any injury
    • Put on gumboots incase of farming activities
    Pulmonary Tuberculosis

    2. Joseph an adult patient has been diagnosed with pulmonary tuberculosis.

     (a) Outline ten signs and symptoms of PTB.

    (b) Describe his management using nursing process from the time of admission up to discharge.

     (c) List five complications of TB.

    SOLUTIONS

    Tuberculosis (TB)

    This is a chronic lung disease caused by a bacillus called mycobacterium of the genus mycobacterium tuberculosis.

    It can also occasionally be caused by other strains of mycobacteria including mycobacterium bovis which is found in animals.

    TB is of two types;

    1. Pulmonary TB
    2. Extra pulmonary TB

    PULMONARY TB:

    Type of TB that affects mainly the lungs and is the most common type of TB.

    SIGNS AND SYMPTOMS.

    • Fever and chills
    • Night sweats
    • Productive or non productive cough
    • Weight loss
    • Fatigue
    • Cough for more than 3 weeks.
    • Coughing up blood (Haemoptysis)
    • Chest pain
    • Significant figure clubbing may occur
    • Lymphdenopathy which is a sign of bacterial infection.
    • Aneroxia
    • Insomnia

    ASSESSMENT

    NURSING DIAGNOSIS

    PLAN/GOAL∕EXPECTED OUTCOME

    INTERVENTION OR IMPLEMENTATION

    RATIONALE

    EVALUATION

    Chest Pain

    A cute chest pain related to inflammatory response secondary to disease process as evidenced by patient coughing out blood and reporting pain.

    Relieve pain within 24 hours.

     

    Patient will be free from pain until discharge.

    Admit the patient on the medical ward specifically the TB unit.

     

    Take vital observations i.e. TPRIBP and weight.

     

    Position the patient in sit up position.

     

    Re-assure the patient.

    Inform doctor to prescribe drugs and order for investigations.

     

    Administer prescribed 

    analgesics like 1m diclofenac  

    75mg stat then later tabs paracetamol 1g tds x 3/7. 

    For proper management

     

    As baseline and for future reference.

     

    To relieve pressure of the abdominal organs onto the diaphragm.

     

    To allay the patient’s anxiety

     

    For proper assessment and management of the patient.

     

    To relieve pain.

    Goal met, patient was relieved from pain after 24 hours and patient was free from pain at discharge.

    Cough 

    Altered respiratory patterns related to disease process as evidenced by patient having cough for more than 3 weeks.

    Patient will have normal respiratory patterns until discharge.

    Maintain the patient in the sit up position.

     

    Do investigations as ordered.

     

    Do sputum analysis and chest x – ray, erythrocyte sedimentation rate (ESR).

     

    Complete blood count  (CBC)

     

    Administer prescribed anti TB drugs and give the right regimen (6EHRZ + 2EH)

     

    Administer prescribed supportive drugs like multi-vitamins i.e. Folic acid

    For comfortibility.

     

    To confirm the causative agent and to rule out the involvement of other organs like the heart and complications.

     

    To help in the re-epithelialisation and boost the patient’s appetite.

     

    To destroy the causative organism

    Goal met, patient reports normal respiratory patterns until discharge.

    Fever 

    Altered thermoregulation / body temperature related to disease process as evidenced by the patient hot on touch also the patient reporting fevers for the last 3 weeks.

    To normalize the body temperatures wit in 24 hours and maintain within normal ranges until discharge.

    Expose the patient.

     

    Tepid sponge the patient.

     

    Maintain the already prescribed antipyretics.

     

    Take temperature 4 hourly until discharge.

    To allow cool air to reach the patient’s skin.

     

    To cool the external body.

     

    To act on the temperature regulating centres in the brain.

     

    As baseline and for future comparison.

    Goal met, patient’s temperatures normalized after 24 hours and the patient’s temperatures were maintained with in the normal ranges till discharge.

    Weight loss

    Altered nutrition less than body requirements related to loss of appetite as evidenced by the patient reporting having lost weight for the last 3 weeks or months.

    To nourish the patient throughout his stay on the ward.

    Encourage nourishing diet.

     

    Encourage oral care and continue with prescribed multi-vitamins.

    To nourish the patient.

     

    To boost the patient’s appetite.

    Goal met, patient was well nourished at discharge. 

    Fatigue 

    Activity intolerance related to disease process as evidenced by patient unable to perform activities of daily life.

    Patient will perform activities of daily living throughout his stay on the ward.

    Encourage patient to carryout activities of daily living such as bathing, eating, toileting, oral care and going to the urinals by himself  

    To improve on patient’s general hygiene and improve on the appetite 

     

    To avoid complications that may arise as a result of over staying in bed. 

    Goal met, patient is able to perform activities of daily living at discharge.

    Insomnia 

    Altered sleeping patterns related to night sweats and irritating cough secondary to disease process as evidenced by the patient reporting not sleeping well.

    Patient will have normal sleeping patterns during his stay on the ward.

    Minimize noise and visitors on the ward.

     

    Switch off light (bright lights)

     

    Administer prescribed sedatives like tabs diazepam 5mg OD or PRN 

     

    Continue re-assuring the patient.

    To enable the patient have enough rest.

    To induce sleep.

    To alley patient anxiety

    		 

    COMPLICATIONS ARE;

    • Plueral effusion
    • Pericardial effusion
    • Empyema (pus in the pleural cavity)
    • Pneumothorax
    • Lung fibrosis
    • Lung collapse (Atelectasis)
    • Extra TB due to spread of the infection to other organs.
    Nephrotic Syndrome

    3. An adult male patient has been brought to medical ward with features of nephrotic syndrome

               (a) List five cardinal signs and symptoms of nephrotic syndrome

                (b) Describe his management from admission up to discharge.

                (c) Mention five likely complications of this condition.

    SOLUTIONS

     (a) NEPHROTIC SYNDROME.

    Is a syndrome caused by many diseases that affect the kidney characterized by severe and prolonged loss of protein in urine especially albumen, retention of excessive salts and water, increased levels of fats.

    FIVE CARDINAL SIGNS AND SYMPTOMS.

    • Massive protenuria.
    • Generalized edema.
    • Hyperlipidemia.
    • Hypoalbuminemia.
    • Hypertension.

    (b) MANAGEMENT.

    Aims of management

    • To prevent protein loss in urine.
    • To prevent and control edema.
    • To prevent complications.

     ACTUAL MANAGEMENT.

    • Admit the patient in medical ward male side in a warm clean bed in a well ventilated room and take the patients particulars such as name, age, sex, religion, status.
    • General physical examination is done to rule out the degree of oedema and other medical conditions that may need immediate attention.
    • Vital observations are taken such as pulse, temperature, blood pressure recorded and any abnormality detected and reported for action to be taken.
    • Inform the ward doctor about the patient’s conditions and mean while the following should be done.
    • Position the patient in half sitting to ease and maintain breathing as the patient may present with dyspnoea due to presence of fluids in the pleural cavity.
    • Weigh the patient to obtain the baseline weight and daily weighing of the patient should be done to ascertain whether edema is increasing or reducing which is evidenced by weight gain or loss.
    • Monitor the fluid intake and output using a fluid balance chart to ascertain the state of the kidney.
    • Encourage the patient to do deep breathing exercises to prevent lung complications such as atelectasis.
    • Provide skin care particularly over edematous area to prevent skin breakdown.
    • On doctor’s arrival, he may order for the following investigations.
    • Urine for culture and sensitivity to identify the causative agent.
    • Urine analysis for proteinuria and specific gravity.     
    • blood for; 
    • Renal function test, it will show us the state of the kidney function.
    • Cholesterol levels; this will show us the level of cholesterol in blood.
    • Serum albumen; this will show us the level of protein or albumen in blood.
    • The doctor may prescribe the following drugs to be administered;
    • Diuretics, such as spirinolactone 100-200mg o.d to reduce edema by increasing the fluid output by the kidney.
    • Antihypertensives such as captoril to control the blood pressure.
    • Infusion albumen 1g/kg in case of massive edema ascites and this will help to shift fluid from interstitial spaces back to the vascular system.
    • Plasma blood transfusion to treat hypoalbuminemia.
    • Cholesterol reducing medication to have the cholesterol levels in blood such as lovastatin.
    • Anticoagulants to reduce the blood ability to clot and reduce the risk of blood clot formation e.g. Hepanine. 
    • Immune suppressing medications are given to control the immune system such as prednisolone if the cause is autoimmune. 
    • Antibiotics such as ceftriaxone to treat secondary bacterial infections.
    • The doctor may order for renal transplant if the chemotherapy fails.

          

      Routine nursing care.

     

    • Continuous urine testing is done to see whether proteinuria is reducing or increasing.
    • Encourage the patient to take a deity rich in carbohydrates and vitamins but low in protein and salts.
    • Ensure enough rest for the patient as this will reduce on body demand for oxygen and hence prevent fatigue.
    • Promote physical comfort by ensuring daily bed bath, change of position, oral care and change of bed linen. 
    • Re-assure the patient to alley anxiety and hence promote healing.
    • Ensure bladder and bowel care for the patient.

    ADVICE ON DISCHARGE 

    The patient is advised on the following:

    • To take a deity low in salt and protein.
    • Drug compliance.
    • Personal hygiene. 
    • Stop using drugs like heroin, NSAID’s.
    • Screening and treating of diseases predisposing or causing the disease.
    • To come back for review on the appointment given.

     COMPLICATIONS.

    • Acute kidney failure.
    • Kidney necrosis.
    • Ascites.
    • Pyelonephrosis.
    • Cardiac failure
    • Pulmonary embolism.
    • Atherosclerosis.
    • Deep venous thrombosis.

    Surgical Nursing

    Fractures

    Josephine a thirty year old female patient has been involved in a road traffic accident and sustained a compound fracture.

    (a) Outline ten signs and symptoms of fracture.

    (b) Discuss the negative factors that can influence healing of a bone.

    (c) Describe the healing of a bone.

    (d) Mention ten complications of fractures.

    SOLUTIONS

    1. a) History from the patient or the on lookers.
    • Pain aggravated by movement
    • Tenderness over the fractured limb
    • Loss of function of the affected part or the whole limb
    • Deformity
    • Shortening of the limb
    • Abnormal mobility at the affected area
    • Creepers or grating of the bone ends as they move each other
    • Swelling of the affected part
    • Shock may occur
    • The bone may be seen out if it’s a compound fracture

    b)

    • Tissue fragments between bone ends; Splinters of dead bone (sequestrate) and soft tissue fragments not removed by phagocytosis delay healing.
    • Deficient blood supply; this delays growth of granulation tissue and new blood vessels. Hypoxia also reduces the number of osteoblasts and increases the number of chondrocytes that develop from there common parent cells. This may lead to cartilaginous union of fracture which results in a weaker repair.
    • Poor alignment of bone ends: This may result in the formation of a callus that heals slowly and often results in permanent disability
    • Continued mobility of bone ends; Continuous movement results in fibrosis of the granulation tissue followed fibrous union of the fracture.
    • Miscellaneous; this include
    • Infection; pathogens enter through broken skin, although they occasionally be blood borne, healing will not occur until infection resolves
    • System illness 
    • Malnutrition
    • Drugs e.g. Corticosteroids
    • Aging

    c)

    • Following a fracture the broken ends of a bone a joined by the deposition of a new bone. This occurs in several stages
    • Hematoma forms between the ends of the bone and in the surrounding soft tissues.
    • There follows development of acute inflammation and accumulation of inflammatory exudates, continuing microphages that phagocytosis the hematoma and small fragments of a bone without blood supply(this takes place about five days). Fibroblasts migrate to the site, granulation tissue and the new capillaries develop.
    • New bone forms as large numbers of osteoblasts secretes spongy bone, which unit the broken ends, and is protected by the outer layer of the bone and cartilage, this new deposits of bone and cartilage are called callus.
    • Over the next few weeks, the callus matures and the cartilage is gradually replaced by new bone
    • Reshaping of the bone continues and gradually the medullary canal is re –opened through the callus (in weeks or month). In time the bone heals completely with callus tissue replaced with mature compact bone. Often the bone is thicker and stronger at the repair site that originally, and the second is more likely to occur at a different site.
    1. d) Complications of fractures are divided in to two.

    General complications.

    • Local complications
    • General complications are;
    • Hemorrhage which may lead in to shock.
    • Fat embolism
    • Infections
    • Hypostatic Pneumonia
    • Damage to the nearby structures

    Local complications

    • Keloids
    • Loss of function
    • Damage to the nerves
    • Necrosis
    • Delayed union of bones; this may be as a result of incomplete reduction, inadequate immobilization, lack of blood supply to areas, infection which disrupt formation
    • Malunion of the bones; this when there’s failure of bone fragments to unit. This as a result of a big gap between the fragment
    Hyperthyroidism

    1.Define:

    (a) Hyperthyroidism:

    (b)Hypothyroidism

    (c) Thyrotoxicosis

    2. Outline the differences between hyperthyroidism and hypothyroidism

    3. Describe the management of a patient with hyperthyroidism.

    4. Mention seven complications which are likely to occur following a thyroidectomy.

    SOLUTIONS

    The hub of excellence 

    a)  Hyperthyroidism:  this is a condition in which there is high circulating thyroid hormone in blood.
    b) Hypothyroidism-this a condition in which there are low circulating thyroxin hormone in blood.
    c) Thyrotoxicosis– it is a state of hyper secretion of  thyroxin by the thyroid gland.

    2. Differences between hyperthyroidism and hypothyroidism

    Hyperthyroidism 

    Hypothyroidism 

    It is characterized  by  excessive thyroxin production. 

    Characterized by  insufficient thyroxin production. 

    Characterized by weight loss with increased appetite and diarrhea 

    Characterized by weight gain 

    More commonly caused by  an auto immune response to specific anti bodies 

    Can be of congenital cause 

    T4( thyronine ) levels are elevated 

    The serum Thyroid stimulating hormone is elevated  in an attempt to produce more thyroxin 

    Commonly occurs in women than men, usually at age of 20 to 40 years 

    Common in women of ages 30 to 60 years 

    Surgery is always indicated incase medication  and radio therapy has failed 

    Primarily managed by hormonal replacement therapy 

      

    3. Management

    • Patient is admitted on a medical ward for complete bed rest. 
    • Reassure patient and relatives.
    • Vitals are taken and doctor informed
    • Thorough physical assessment is done 

      Pre operative tests are ordered by the doctor and blood taken for the following tests;

    •  Serum thyroxin estimation- which levels are elevated in hyperthyroidism
    • Serum tri-thyroxin(T3) 
    • TSH estimation –to rule out hypothyroidism
    • Thyroid antibody measurement in cases of autoimmune thyroidism 
    • Radio active iodine uptake and scan for both diagnosis and treament.
    • FNAC- for cytology to rule out any malignancy
    • Fibre optic laryngoscopy-to view the vocal cords

    Pre operative preparation(immediate)

    • Patent’s HB is checked
    • Cross match  and book 2 units of blood
    • x-ray chest thoracic inlet
    • Shaving of the neck skin, upper part of the chest, the axilla and the upper arms

    Pre operative drugs are also given as ordered by the doctor  to  bring patient to euthyroid state including;

    • Carbimazole 10-20mg start 8hourly,several weeks then stopped 10days to surgery
    • Propranolol 120-160 mg daily in divided doses. this is continued up to operation day 
    • Lugol’s iodine 0.3-0.9mls T.D.S. for 10 days-to reduce vascularity 
    • Diazepam 5mg 12 hourly to sedate the patient 
    • Digitalis incase of atrial fibrilation

     Meanwhile, specific  pre operative nursing care  includes;

    • Daily measuring of the neck circumference to monitor progression of thyroid enlargement
    • Monitor serum electrolyte levels and check for hyperglycaemia
    • Monitor for signs of heart failure e.g date dyspnoea
    • Ensure nutritious diet with adequate calorie, proteins
    • Minimize physical and emotional stress
    • Re assure patient and family that mood swings will disappear with Rx.
    • Monitor frequency and characteristic of stool and give anti diarrhaels as ordered

    Post operative management

    • Post operative bed is prepared and patient put in lateral position till recovery, then propped up supported by back rest.
    • Monitor vitals including BP, Respirations. Give oxygen incase respirations are fast, shallow
    • Report any respiratory difficulty for prompt management
    • Ensure little fluid intake to clean the mouth.  

    Specific nursing care

    • Ensure constant drainage in a drainage bottle or dressing
    • Intubation if there is respiratory edema.
    • Closely observe for hemorrhage.
    • Ensure a calm environment, and possibly give drugs to encourage sleep.
    • Care of drain and sutures; change drainage 24 hourly and sutures removed on third day or fourth day.
    • Minimize patient’s neck movement to minimize neck pain.
    • Give analgesics 1g start to reduce pain.
    • 2 hourly vitals’ taking including temperature, respiration and blood pressure to monitor for any complications like thyroid storm or infections.
    • Give antibiotics; ceftriaxone 2g 24 hourly

    4. Complications of thyroidectomy

    • Hemorrhage due  to hyper ventilation of the thyroid gland
    • Thyroid crisis (thyroid storm); characterized by rapid pulse, raised temperature, profuse,      sweating, and confusion.
    • Tetany; due to removal or trauma to parathyroid glands- it’s characterized by tingling and numbness of the face, lips and hands.
    • Soreness of the throat. 
    • Hoarseness –due to damage to the recurrent laryngeal nerve
    • Hypothyroidism due to thyroid removal
    • Recurrent thyrotoxicosis
    • Respiratory obstruction –due to laryngeal edema.
    • Wound  infection
    Shock

    1.An adult male patient has been brought to S.O.P.D with featured of shock.

    (a)Define shock

    (b) Explain seven types of shock that you know.

    (c) Describe how you would manage a patient with hypovolemic shock.

    SOLUTIONS

    a). shock.

    Is the failure of the circulatory system to maintain adequate tissue perfusion of the vital organs like the heart and kidney, brain?

    PATHOPHYSIOLOGY

    • Heart:-due to the reduced fluid volume in the body(blood) caused by vaso constriction leads to inadequate blood supply to the heart which decreases cardiac output hence less amount of blood reach the brain leading to hypoxia eventually shock occurs.
    1. B) . seven types of shock.
    • Hemorrhagic shock.

    It occurs due to severe blood loss causes are as follows:- Obstetric emergencies e.g. post partum heamorrhage, abortion etc, Trauma i.e. RTA, gun shot

    • Septic shock

    It occurs as result of bacteria multiplying in the blood and releasing toxins in the circulation leading to pooling of blood in the capillaries and blood vessels. It occurs in diabetic wounds, crutch wounds, burns.

    • Carcinogenic shock ; this is when the heart fails to maintain tissue perfusion leading to shock. It results from the following; Heart attack, Myocardial infarction
    • Neurogenic shock. 

    This is generalized vasodilatation due to stimulation of Vegas nerve e.g. due to strong pain.

    • Anaphylactic shock.

    This is due to hypersensitivity reaction which results from exposer to allergens leading to sudden cardiac arrest or respiratory distress. It can be due to reaction to drugs, foods.

    • Hypovolemic shock.

    This is due to loss of body fluids through diarrhea, vomiting, burns etc.

    • Ologenic shock.

    This is due to either receiving of good or bad news: – emotional upset

    C). management

    • It’s a surgical emergency that requires immediate intervention 

    Aims of management 

    • To maintain functions of the vital organs like the brain and heart
    • To improve circulation 
    • To prevent complications 
    • To promote patients comfort 

    Admission 

    • The patient is received and quickly admitted in surgical ward in warm well ventilated room  
    • The relatives of the patient are reassured 
    • Patient is put in semi porn Position with the head turned to one side for easy drainage of secretions and to prevent the tongue from falling back 
    • The foot of the bed is elevated to aid return of blood to the circulatory center
    • Quick assessment done

    Assess the consciousness of the patient using Glasgow coma scale. This is performed as follows .

    PARAMETERS

    SCORE

    Eye opening 

    • Spontaneously
    • To speech
    • To pain 
    • None

    4

    3

    2

    1

    Best verbal response

    • Oriented
    • Disoriented
    • Inappropriate
    • Incompressible
    • No response

    5

    4

    3

    2

    1

    Best motor response

    • Obeys command
    • Localized pain
    • With draw or flexion
    • Extension with rigidity
    • None response

    6

    5

    4

    3

    2

    1

    Total response for 3 is 15

    		 

    Observations i.e.

    • Vital observations like temperature, pulse, respiration and BP (blood pressure).
    • General observations such as level of dehydration, skin color for cyanosis.
    • Doctor is informed 

    Specific management

    Air way:-

    • Artificial air way is put in position and sanction is done whenever necessary to avoid blockage of the air way with secretion and falling back tongue
    • Air way piece is insitu to prevent back flow of the tongue.

    Breathing:–

    • Patient is administered oxygen 5-8 liters per minute in order to ventilate the lungs and increase tissue perfusion.

    Circulation:-

    • Plan c of management of dehydration applies
    • An intravenous line is established to re hydrate patient with intravenous fluids like normal saline  0.9% and ringers lactate(se) allows it to run faster at a drop /rate of 40drops per minute
    • Continue monitoring the patient’s condition for over flow 

    Investigations 

    Doctor orders for the following investigations below.

    Blood 

    • Hb, grouping and cross matching
    • CBC (complete blood count, Ph of the blood showing decreased Ph (acidic Ph)

    ECG (Electrocardiogram)

    • To check for the activities of the heart.

    EEG (.electro encephalogram):- 

    • To check for the activities of the brain.

    Urinalysis: –

    • To determine kidney function

    Specific nursing care

    • Patient is provided with warmth by adding additional blanket but not to overheated transfuse the patient incase patient is anemic with whole blood and to improve blood volume in the circulation
    • Foot of the bed is elevated to aid return of blood into the circulatory center.
    • Continue monitoring vitals that is TPR/BP, to detect deviation from the normal.

    General nursing care

    Hygiene:-

    • Ensure patient s hygiene by daily oral care, care of the skin , finger nails, patients hair, daily bathing of patient if able and if patient unable to bath by self carry out bed bath for patient as well much attention is on the pressure areas.

    Diet:-

    • The patient is feed on well balanced diet and light diet which can digest easily. Feeding is done using naso gastric tube, when patients condition improves give patient food orally.

    Rest and sleep:-

    • Adequate rest is ensured by limiting visitors; minimize noise in the room or ward etc.

    Psychotherapy:-

    • This includes care of mind by counseling, give adequate information about the illness to the patient and the relatives or family members

    Physiotherapy: – 

    • This is done by helping and encouraging the patient to carry out some light exercise that is passive and active exercise such as deep breathing exercise. 

    Elimination 

    • Care of the bladder and bowel check if patient is passing urine out normally and avoid constipation by encouraging plenty of fluids and light diet is suitable 
    • Pass catheter incase of incontinence to prevent wetting of the bed or soiling of the bed linen
    • Give bed pan to the patient if passing out stool normally.
    • Establish fluid balance chart in order to monitor fluid input and output.
    Tracheostomy

    A male patient aged 40 yrs has been brought to S.O.P.D with features of an airway obstruction, upon assessment the surgeon recommended for a tracheotomy.

    1. Define tracheotomy.
    2. Mention 10 indications of a tracheotomy.
    3. Describe the pre and post operative management of the patient up to discharge.
    4. Mention 5 likely complications which may occur following a tracheotomy.

    SOLUTIONS

    Tracheotomy is the artificial opening through the neck into the trachea to relieve sudden airway obstruction

    Indications of a tracheotomy

    These are divided into two i.e. obstructive conditions of the larynx and paralysis or spasm of the respiratory muscles or respiratory failure.

    • Obstructive conditions of the larynx
    • Acute laryngitis e.g. in diphtheria
    • Carcinoma of the larynx
    • A cute oedema of the glottis
    • Foreign body in the airway
    • Trauma to the trachea
    • Severe burns of the mouth or involving the larynx
    • Severe neck or mouth injuries
    • Paralysis or spasms of the respiratory muscles failure
    • Paralysis of the respiratory muscles
    • Respiratory failure
    • Tetanus
    • Following thyroidectomy
    • Surgery around the box (larynx) that prevents normal breathing and swallowing

    Pre-operative management of the patient for tracheostomy

    Aims

    • To relieve sudden airway obstruction
    • To alley patient’s anxiety
    • To prevent likely complications to occur .

    Admission:  The patient is admitted to the surgical ward in a well ventilated room and all procedures are done within this time.

    Nurse patient relationship / rapport: A positive nurse patient relationship is created to alley patients, anxiety; explain the nature of condition is having to the patient and what is going to be done.

    Observation: Both general and vital observations are done to know the state of condition in which the patient is in starting with general observations then vital observations that is temperature, tube, respiration and pressure monitor patients conditions 

    Investigation: The doctor will order for investigation i.e. Hb, biopsy 

    Consent form: It’s obtained from the patient after through explanation towards what is going to be done in theatre to relieve airway obstruction

    Shaving: This is done immediately before the patient being taken to theatre for operation

    Theatre gown: The patient is offered with a theatre gown before going in for operation, all other items like bangle and dentures are removed there and then 

    Premedication: Will be administered to the patient if any was prescribed by the doctor

    Informing of theatre staffs: They are informed before the patient is taken for theater for the operation

    Patient taken of theatre: The patient will then be taken to theatre for operation by two nurses who will handle the patient to theatre staff

    Post – operative bed: After the nurses have handled over the patient in theatre they will come and make a postoperative bed and all its accompaniments

    In theatre : A patient well be positioned in a supine position with the neck hyper extended over the shoulder which brings the tracheal orifice closer to the surface. An incision is made on the trachea and the tracheal tube inserted into the opening and secured in position with tapes tied around the neck

    Post operative management 

    Prepare an emergency tray at the bed side with tapes tied around the neck

    • Sterile tracheal dilators, 
    • Sterile suction catheters
    • Sterile gloves
    • Suction machine with half an inch of savlon in the suction bottle
    • Bowl of savlon
    • Gallipot with saline to act as a lubricant

    After completion of the operation, the theatre team will inform ward nurse s to come all collect the [patent taken to the ward

    On the ward

    Position: The patient should lie flat in bed had turned on one side hourly for easy drainage, when patient a wakens he should be probed up and kept in this position for 48 hours

    Observations: Vital observations are done ½  hourly for ½ hourly for 2 hours , 1 hourly , 2 hourly for 6b hours then when the patient stabilizers they are done twice a day , much emphasis is put on the respiration rates , observe the tube to see if its not blocked.

    Medication: Drugs like antibiotics to treat or prevent any infections like – IV ceftriaxone1-2 gms o.d for 5-7 days 

    Analgesics e.g. in diclofenac 75 mg IM 8hry for 24 hours then  paracetamol tablets 1gm tds for 3 days 

    Oxygen may be administered via the tracheotomy mask or tube 

    Care of the tubes: Frequent suction is very important at least 2 hourly then later PRN , it’s done by anesthetist and a nurse , the inner tube is washed with sodium bicarbonate , sterilized and replaced as required a supply of sterile tubes be readily available

    Keep the tube covered loosely with gauze to prevent entry of cockroaches and other insects especially at night

    Care of the incision wound: It should be cleaned daily using a suitable antiseptic and new dressings replaced, key hole dressing is used

    Exercises: Deep breathing exercises are carried out under the direction by a physiotherapist, suction must be readily available for the nurse to suck the secretions

    Provide a bell, book and pen for easy communication in acute phase

    Diet: Swallowing may be very difficult especially in the  acute phase but small amounts of fluids can usually be taken and if the patient fails to tolerate intravenous fluids are given , when the condition improves they are stopped

    Hygiene : Is should be observed throughout to prevent respiratory infections, hands scrubbed and worn to prevent cross infection. Tubes must be stylized before re use

    Psychological care: This is maintained throughout the patient’s stays on the ward to alley anxiety

    Bowel and bladder care: By taking of plenty of oral sips and roughages to prevent constipation

    Rest and sleep: Ensure that the patient facts enough reset a sleep by minimizing noise, dimming lights during the night and covering the tube to prevent entry of insects into the tube 

    Discharge : When the patient’s condition is satisfaction will be discharged home and follow up date given

    N.B 

    In case the tracheostomy is permanent like in cases of career ,  the patient will be returning for reviews and increase where its temporarily when the obstruction has resolved the tube is removed and the wound left to close

    Advice on discharge

    • Take drugs as prescribed
    • Maintain proper hygiene
    • Maintain / keep follow up dates

    Complications

    • Haemorrhage 
    • Shock 
    • Infections
    • Respiratory failure
    • Emphysema
    • Nerve injury including paralysis
    • Scarring
    • Damage to the thyroid gland

    Pharmacology

    Malaria

    Opio aged 10 years with a body weight of 18 kg was diagnosed with severe malaria. The doctor prescribed IV artesunate and requested the nurse to calculate the right dose.

    1. State any four cardinal symptoms of severe malaria.
    2. Calculate the dose of IV artesunate you would give to Opio.
    3. Outline the steps you would take as you administer IV artesunate.
    4. Mention any 3 drugs used in the prevention of malaria.

    SOLUTIONS

    Malaria: Is an acute illness characterized by fever and other clinical features which is caused by infection with the malaria parasites of the genus anopheles mosquito.

    TRANSMISSION: Malaria is transmitted from one person to another through the bite of an infected anopheles mosquito.

    Plasmodium species

    • P. Falciparum
    • P. Malarie
    • P. Vivax
    • P. Ovale 

    No.1

    • Altered mental state / confusion.
    • Convulsions.
    • Severe anemia.
    • Prostration.
    • Difficulty in breathing.

    No.2

    Artesunate dosage   =3.0mg × body weight

      =3mg ×18

      = 54mg

    Therefore: The dosage of Artesunate to be given to Opio is 54mg.

    No. 3

    • Identify the patient.
    • Create a rapport and weigh the patient.
    • Identify the drug and check for the expiry date.
    • Reconstitute the drug by mixing Sodium bicarbonate with Artesunate powder.
    • Shake approximately for 2 minutes until the dissolved solution will be cloudy.
    • The reconstituted solution will be clear in about 1 minute. Discard if not clear.
    • Insert the needle to remove air.
    • Inject the required volume of saline in to the reconstituted solution.
    • Artesunate solution is now ready for use.
    • With draw the required dose in m/s according to the route of administration.
    • Give slow IV injection 3-4 minutes per minute or injection in the appropriate site by deep IM.

    No.4

    • Chloroquine
    • Sulphurdoxine.
    • Doxycycline.
    • Mefloquine.
    Hypertension

    MN, a 44 year old truck driver was diagnosed with hypertension by his doctor after registering a BP of 160/ 95 mmhg on 3 separate clinic visits. MN weighs 107 kgs and his height is 1.7 M tall. He smokes an average of 16 cigarettes per day and drinks 4 bottles of beer every evening. The doctor prescribed Nifedipine 20mg 12 hourly for 30 days.

    1. To which class of anti hypertensive does Nifedipine belong?
    2. Name any other 3 drugs that belong to the same class as Nifedipine.
    3. Give 4 common side effects associated with the use of Nifedipine.
    4. Besides drug treatment, give any 5 advices you would give to Opio in order to effectively control his blood pressure.
    5. Mention any 4 complications associated with poorly managed hypertension.

    SOLUTIONS

    1.  Nifedipine belongs to a group of antihypertensive called calcium channel blockers

    Calcium channel blockers act by decreasing calcium uptake into cardiac and smooth muscles by blocking slow calcium channels which reduces on the vascular tone that results into reduction in peripheral resistance thus controlling blood pressure

           2. Examples of other calcium channel blockers

    • Amlodipine   Tablets 10mg, 5mg
    • Nicardipine   Capsules 20mg, 30mg
    • Felodipine     Tablets 2.5mg, 5mg, 10mg
    • Nimodipine   Tablets 30mg

         3. Side effects associated with the use of Nifedipine

    • Peripheral edema
    • Flushing
    • Hypotension
    • Visual disturbances
    • Headache
    • Dizziness
    • Fatigue 
    • Fast heart rate 

         4.  Advises which can be given to Mr. Opio to effectively control his blood pressure

    • Health educating Opio about dangers of smoking
    • Health educating him about the dangers of excessive alcohol consumption
    • Eating much less than usual to reduce the weight 
    • Eating fat free foods
    • Doing enough exercises
    • Visiting the clinic regularly for blood pressure checking
    • Teaching him about the warning signs of elevated blood pressure 

         5. Complications of poorly managed hypertension

    • Renal failure
    • Glomeronephritis
    • Heart failure
    • Retinopathy 
    • Un explained abortions
    • Intra uterine growth retardation  i.e. in pregnant mothers
    • Cerebral vascular accident
    • Hypertensive encephalopathy
    • Impotence
    • Brain damage

    Mental Health

    Causes of Mental Illnesses
    1. Mental illness is very common in Uganda, Write down the general causes of mental illness.

    SOLUTIONS

    CAUSES OF MENTAL ILLNESS.

    The chief cause of mental illness is unknown i.e. it is idiopathic.

    However research states a number of factors responsible for causing mental illness.

    These factors are either;

    • Predisposing factors
    • Precipitating factors
    • Perpetuating factors.

    PREDISPOSING FACTORS 

    • These factors determine an individual’s susceptibility to mental illness. They interact with triggering factors resulting into mental illness. Examples include; Genetic risk factor, physical damage to the central nervous system (the brain and spinal cord).

    PRECIPITATING FACTORS.

    • These are events that occur shortly before the onset of the disorder. I.e. they trigger the onset of the disease. Examples include; physical stress and psychosocial stress.

    PERPETUATING FACTORS.

    • These factors are responsible for aggravating or prolonging the disease already existing in an individual. Examples include; psychosocial stress.

    Thus, etiological factors of mental illness can be;

    • Biological factors
    • Physiological factors
    • Psychological factors
    • Social factors

    BIOLOGICAL FACTORS

      • Genetic risk factor; According to research individuals born in families with parents and relatives who have suffered from mental illness, are susceptible to developing mental illness once exposed stressful conditions. This is because the predisposition gene is passed on from the parents to the offspring.
      •   Biochemical; This regards the neurotransmitters (provide medium for transmission of impulses). Any imbalances in the levels of the neurotransmitters in the brain may result into mental illness as shown below.

    Neurotransmitter related state

    Mental disorder

    Increased in dopamine level

    Schizophrenia

    Decrease in nor epinephrine level

    Depression

    Decrease in serotonin level

    Alzheimer’s disease

    Decrease in gamma amino butyric acid

    Anxiety

    Decrease in glutamate level

    Psychotic thinking

    Brain damage; This may be as a result of;

    • Infections e.g. HIV infection, neurosphilis, encephalitis etc.
    • Injury that involves loss of the brain tissue.
    • Intoxication; toxins that can damage the brain tissue e.g. alcohol.
    • Vascular damage; damage to blood vessels leading to poor blood supply to the brain, subdural hemorrhage, intracranial hemorrhage, etc.
    • Tumors; brain tumors
    • Degenerative diseases; dementia.

    Physiological factors; The functioning of the body changes at certain critical periods in life i.e., puberty, pregnancy, menstruation, peurperium and delivery. Coupling these physiological changes with maladaptive psychological capacity makes an individual susceptible to mental ill health.
    Psychological factors; 

    • Personality; It has been observed that specific personality types are more prone to certain psychological disorders, e.g. Schizoid personality (unsocial and reserved) are vulnerable to schizophrenia under stressful situations.
    • Strained interpersonal relationships at home, school and work.
    • Childhood insecurity due to parent’s over strictness, rejection and unhealthy comparisons.
    • Social and recreational deprivation; which may result into boredom, isolation and alienation.
    • Marriage problems e.g. forced bachelorhood, childlessness and many children.
    • Sexual difficulties.
    • Stress and frustrations.

    Social factors;

    • Poverty.
    • Unemployment.
    • Injustice.
    • Insecurity.
    • Migration.
    • Urbanization.
    • Gambling.
    • Alcoholism.
    • Prostitution.
    • Divorce.
    • Religions.
    • Traditions.
    Psychiatric Emergencies

    Psychiatric emergencies are very common in the community.

    1. Mention all the psychiatric emergencies.
    2. How can we prevent psychiatric emergencies?
    3. Nakimbugwe, a psychiatric patient has completely refused to eat food and she wants to starve herself to death, How can you manage such a patient?

    SOLUTIONS

    • The psychiatric emergencies.
      1. Aggression and violence; Aggression is an intended behavior that can cause pain, harm directly to one self or others either physically or verbally whereas violence is an intention to use physical force/power to threatened action against one’s self, other person or group resulting into injury.
      2. Suicidal attempts; This is a type of deliberate self-harm and is defined as an intentional human act of killing oneself.
      3. Delirium tremens; A type of delirium caused by abrupt withdraw from excessive taking of alcohol or substance of abuse
      4. Status Epilepticus; This is said to occur when a seizure lasts too long or when seizures occur close together and the person doesn’t recover between seizures.
      5. Catatonic stupor; This refers to decreased motor activity or being emotionless or being unresponsive to the environment stimuli although he or she is conscious
      6. Hysterical attacks; This personality disorder due to the upbringing. Individual of this category present with exaggeration, attention seeking, want over protection, very sensitive to pain and also want to be cared about
      7. Furor Epilepticus; The sudden unprovoked attacks of intense anger and violence to which individuals with psychomotor epilepsy are occasionally subject.
      8. Panic attacks; This is a psychiatric emergency characterized by periods of intensive fear, which occurs suddenly without accompanying danger but person thinks or perceives that there is danger
      9. Total insomnia; Sleeping disorder characterized by loss of sleep of an individual
      10. Food refusal; Psychiatric eating disorder characterized by abandoning of oneself to eat food
      11. Severe depression; Excessive type of depression characterized by persisted low mood or sadness

       2. How we can prevent psychiatric emergencies. 

    Psychiatric emergencies are life threatening and therefore they should be attended to urgently to prevent complications and save life. I.e. the ways include;

    • Proper counseling and guidance of patients with stress disorders 
    • Proper management of psychiatric conditions
    • Early diagnosis and treatment of psychiatric conditions
    • Health education of the people about the predisposing factors to severe mental illness
    • Equipping heath skilled workers on how to manage the psychiatric conditions by regular CME’s.
    • Ensuring drug compliance to prevent relapses and progression to severity

    3. Management of food refusal

    On admission

    Patient is hospitalized in a psychiatric unit and a rapport is created in order to gain confidence of the patient in the health unit and the healthy worker

    Assessment

    • Subjective data; Here history is obtained of any chronic illness, and any history about mental illness in the family
    • Objective data; physical examination from head to toe and general appearance of the patient to rule out any underlining conditions
    • Mental data; This involves the emotional response, concentration, orientation , memory and perception.

    Investigation

    • Do an FBC to rule out any infection
    • VDL test to rule out syphilis
    • Do an RBS  to check the amount of sugar levels of the patient
    • Do a urinalysis for ketones

    Nursing care

    • Daily weighing of the patient is paramount
    • Monitor status of skin and mucous membranes 
    • Encourage the patient to verbalize feelings of not wanting food.
    • Maintenance of a strict output and input chart
    •  Avoid discussions that focus on food and weight gain
    • Allow patient to take packed foods and fluids
    • Encourage family to participate in education regarding connection between family process and the patient’s disorders
    • Control vomiting by making the bathroom inaccessible for at least 2hours
    • Eating must be supervised by the nurse and a balanced diet of atleast 3000 calories should be provided in 24hours

    Drugs

    • Give appetite stimulants like multivitamins
    • Give antidepressants like Amitriptyline 25mg-75mgs

    Family therapy; Educate and counsel the family to accept the patient

    Psychotherapy; If the patient’s condition improves, assist the patient to sit and move around and encourage her by respecting her suggestions

    Individual therapy; Talk politely to the patient and make him aware that she is important by respecting her decisions

    Bi-Polar

    Bipolar Affective Disorder is one of the common conditions patients present with.

    1. What is bipolar affective disorder?
    2. Mention the signs and symptoms of Bipolar Affective Disorder?
    3. How would you manage a patient with bipolar affective disorder?

    SOLUTIONS

      1. Bipolar affective disorder– is an affective/ mood disorder characterized by alternating attacks of Mania and Depression separated by episodes of normal mood
    2. Signs and symptoms of Bipolar affective disorder

    Manic episode

    • Persistently elevated mood
    • Increased psychomotor activity
    • Flight of ideas
    • Poor judgement
    • Pressure of speech
    • Lack of insight
    • Delusions of grandeur and persecution
    • Decreased food intake due to over activity
    • Dressed in flamboyant clothes. In severe cases, there is poor self care
    • Decreased need for sleep (less than 3hrs)
    • Increased libido
    • Decreased attention and concentration
    • High risk activity
    • Irritability
    • Increased sociabilities
    • Impulsive behavior
    • High risk activities e.g. reckless driving, foolish business investment, distributing money or articles to unknown people

    Depressive episode

    • Decreased psychomotor activity
    • Persistent low mood/ sadness
    • Social withdrawal
    • Loss of energy
    • Hopelessness, unworthlessness and powerlessness
    • Fatigue
    • Delusion of persecution, sin, control, unworthiness, hypochondriasis
    • Decreased food intake due to lack of appetite
    • Auditory hallucinations
    • Avolition i.e. lack of will to act
    • Ambivalence i.e. two opposing ideas
    • Anhedonia i.e. inability to experience pleasure
    • Insomnia
    • Physiological symptoms e.g. headache, backache, chest pain, amenorrhea, decreased libido, abdominal pain
    • Tearfulness
    • Pessimistic
    • Recurrent thoughts of death
    • Slow speech/ poverty of ideas
    • Negativism

        3. Management of Bipolar affective disorder

    Manic phase

    Aims of management

    1. To alleviate delusions and hallucination
    2. To alleviate hyperactivity
    3. To prevent possible injury and aggression
    4. To calm down the patient
    5. To restore normal food intake
    6. To restore normal sleep pattern

    Management

    • Assessment to obtain baseline data and the basis for evaluation. It focuses on the severity of the disorder, causes, patients’ resources, mood and affect, thinking, perceptual ability, sleep disturbance, changes in energy level. 

    Obtain both objective and subjective data from the patient

    Objective data

    • Disturbed speech
    • Rapid speech
    • Loud pressured speech
    • Over activity
    • Mood lability
    • Weight changes

        Subjective data

    • Feelings of joy
    • Rapid mood swing
    • Sleep disturbance 
    • Delusions and hallucinations
    1. Admit the patient on an acute non-storeyed psychiatric ward with minimum furniture, free from harmful objects with reduced environmental stimuli to prevent possible harm to self or others.
    2. Form a positive nurse-patient relationship to win the patients’ trust and confidence
    3. Encourage patient to verbally express his feelings to relieve tension and hostility
    4. Have sufficient staff to show strength to the patient and convey contrl over the situation
    5. Reassure patients and relatives to allay anxiety
    6. Encourage performance of planned activities to channel excess energy into socially acceptable behaviours
    7. Formulate a contract and set limits on manipulative behavior, explain the consequences if limits are violated
    8. Stay with the patient as hyperactivity increases to offer support and provide a feeling of security
    9. Keep the patient occupied most of the time during day, discourage day sleep eliminate uncomfortable stimuli at bed time, avoid caffeine containing drinks  at bed time, administer prescribed hypnotics to promote sleep and rest of the patient
    10. Teach the patient relaxation techniques e.g. deep breathing exercise, diversion techniques e.g. listening to music to cope with anxiety
    11. To restore normal food intake:
    • Serve the patient meals on time
    • Involve patient in food preparation
    • Serve meals in clean and attractive dishes
    • Fruits should be provided unpeeled
    • Provide patients with foods that the patient can eat while moving
    • Encourage patient to sit down and eat
    • Provide a balanced diet
    • Ensure adequate fluid intake
    • Monitor fluid intake and output
    • Weigh the patient regularly

          12. Encourage the patient to interact with others to promote communication

          13. Positive reinforcement for desired behaviours

          14. Involve family members in the management of this patient

          15. Administer prescribed drugs i.e.

    • Major tranquilizers such as Chlorpromazine 100-600mg daily in divided doses, Haloperidol 5-60mg daily
    • Mood stabilizers such as carbomazepine200-1000mg daily, Lithium carbonate300-1500mg daily in divided doses, Sodium valporate600-2600mg daily
    • Anxiolytics and sedatives such as Diazepam 5-20mg daily in divided doses

           16. Monitor side effects of drugs 

            17. ECT

            18. Health educate patient and family members about side effects and how to manage them, increased fluid intake, drug compliance 

            19. Advice on discharge

     

    Depressive episode

    Aims of management

    • To promote possible harm self and others
    • To restore normal nutritional status
    • To restore normal sleep pattern
    • To restore normal communication

           Interventions

    • Assessment to obtain baseline information and determine the basis for evaluation. It focuses on severity, risk for suicide, causes, resources available, Mood, affect, thinking, somatic complaints. Obtain both objective and subjective data

    Objective data

    • Alteration of activity
    • Poor personal hygiene
    • Apathy
    • Altered social interaction
    • Impaired cognition
    • Delusions

    Subjective data

    • Anhedonia
    • Worthlessness, hopelessness, helplessness
    • Suicidal idea
    1. Admit the patient on a non-stored  open psychiatric ward with limited furniture, free from dangerous objects to prevent possible harm to self
    2. Form a therapeutic nurse- patient relationship to win patients’ trust and confidence
    3. Closely supervise the patient during meals and medication time
    4. Form a contract with the patient not to harm self. This gives a degree of responsibility of his safety
    5. Explore feelings of anger and help the client direct them towards intended object
    6. Accept the clients’ feelings, spend time with the patient, focus on the strengths and accomplishments and minimize failures to build patients’ self esteem
    7. Teach patient assertive and communication skills to promote self esteem
    8. Allow the patient to participate in goal setting and decision making regarding own core to increase his or her feelings of control
    9. Positive reinforcement for desired behavior
    10. Close supervision is always required when recovering from the disease
    11. Involve patient in groups as he improves to promote communication
    12. Ensure quiet and peaceful environment, give warm bath to the patient, do not allow patient to sleep during day, sedatives, plan day activities basing on patients’ interest to improve night sleep
    13. Closely monitor food and fluid intake, maintain input and output chart, record patients’ weight regularly, serve patient with the food he likes, feed the patient on small but frequent meals, encourage more fluid intake to restore normal nutrition. Feed patient on roughage diet and green vegetables to prevent constipation
    14. Administer prescribed drugs i.e.
    • Antidepressants such as
    • SSRI’s  e.g. Fluoxetine 20-60mg daily, Paroxetine, Sertraline, Citalopram
    • Tricyclic antidepressants e.g. Amitriptyline 25-75mg Nocte, Imipramine 25-150mg
    • MAOIs’ e.g. Phenelzine
    • Others e.g. Maprotiline
    Mania

    Nakibirye, a mentally ill is presenting with a provisional diagnosis of mania.

    1. Define the term mania.
    2. What are the causes of mania?
    3. Mention the signs and symptoms of mania.
    4. What medical treatment will be given to this patient with mania?

    SOLUTIONS

    1. Mania is a mood disorder characterized by self important ideas, mood changes consisting of elation, irritability and over activity sustained over a long period of time

          2. Causes of mania

    The actual cause is idiopathic but however there are factors that are believed to contribute to its occurrence.

    They include:

    1. Predisposing factors
    2. Precipitating factors
    3. Perpetuating factors/ maintaining factors

    (I) PREDISPORSING FACTORS

    These are factors that may operate from early life or people are born with them. 

    • Hereditary: Mania is believed to have been passed on from the parents/ relatives who suffered from it to children
    • Uterine environment: This includes factors like maternal drug abuse while pregnant which can be transplacental and causes effect to the fetus
    • Personality: People with difficult personalities like the paranoid are predisposed to mania due to their irritative mood
    • Biochemical factor: This includes the abnormal secretion of neuro transmitters and hormones like over secretion of serotonin, dopamine, acetylcholine, adrenaline hormone stimulates the hyperactivity of the body.

    (II) PRECIPITATING FACTOR

    These are factors which occur shortly before the onset of the illness and appear to have induced the disorder for example: 

    • Physical and social factors like upbringing of children: Which can be due to too much freedom/ permissiveness given to children by parents when growing up?
    • Maternal deprivation: This creates a depressive mood at early childhood due to inadequate maternal love provided to the child but later mania may be developed as denial to the depression.
    • Anxious parents: For example parents who expect much from the child and hence drive child’s mind to go for bigger positions (like in leadership if at school) in order to sustain the parents. 
    • Physical stressors: These include changes that which occur for example during adolescents
    • Psychological situations: Financial achievements like acquiring a job, winning money/prizes. Fulfilled goals in life like education at higher levels like masters degree, PHD.
    • Marriage and partnership: Being wedded/ introduced especially among women by their husbands. Becoming pregnant for example among women once pronounced infertile by community.
    • Drug abuse like alcohol abuse marijuana, khaki etc: Trauma to the brain for example through accidents involving the head. Brain tumor like brain cancer can precipitate mania. Infections like syphilis, meningitis that affect the brain tissues may precipitate mania .

    (iii) PERPECUATING FACTOR

    1. Continuous drug abuse during the illness.
    2. Poor drug compliance during the illness.
    3. Loss of a job due to the disorder.
    4. Difficulty personality maintaince for example psyclothemic who have mood swing

      4. What medical treatment will be given to this patient with mania? 

    • Mania can be managed with/ without treatment depending on the cause.
    • The patient is admitted on psychiatric ward in a side room with no furniture’s, open sealing or an y other metals to avoid injuries to the patient.
    • She is given the following medical treatment as prescribed by the psychiatric doctor.
    • Anti-psychotic drugs-  to control psychotic features like hallucination for example chlorpromazine initially 100-200mg 8hourly,then daily doses of up to 300mg are given as a single dose at night.

    OR.

    • Iv sterazine 5-10mg every 12hours;then adjust according to the response up to 40mg or more daily may be required in severe or persistent cases..

    OR.

    • IV haloperidol 5-10mg for every 12 hours; then assessment is made according to response.
    • An additional dose of diazepam 5-20mg 12hourly for 3/7 its given with chlorpromazine (above)
    • If patients condition improves is given tablets diazepam 10mg once at night to allow patient rest.
    • She can also be given a mood stabilizer for example. 
    • Carbamezapine 200mg once a day until a condition stabilizers

    OR

    • Tabs: sodium valporate 200-500mg 12 hourly

    OR

    • Tabs: lithium carbonate 300mg once a day till condition stabilizers.
    • In case of extra pyramidal side effects, tablets artane is given 2mg-5mg once daily.

    Supportive treatment

    • Family planning is initiated for example IM depoprouera 150mg for every 3 months since she has a high libido.
    • I.V fluids like normal saline/ dextrose 10% for rehydrating the patient.
    • A nutritious diet is provided to the patient to boast the immunity.
    • Psychotherapy like counseling incase patient gains insight.
    • And investigations are carried out to find out the underlying cause for example rapid plasma reagent (RPR) to R/O for syphilis , serology to R/O HIV/AIDS , and a CT-scan to R/O brain tumors.

    Pediatrics

    Immunisation, Cold chain
    1. Define the term immunization.
    2. Outline the current immunization schedule.
    3. Describe the cold chain system.

    SOLUTIONS

    Definition.

    Immunization is the process of introducing a weakened or killed vaccine into the body in an attempt to increase the body’s ability to fight against immunizable diseases.

    UGANDA NATIONAL EXPANDED PROGRAMME ON IMMUNIZATION (UNEPI)

    Vaccine

    Doses

    No of dosage

    Interval between dosage

    Minimum age to start.

    Route of administration.

    Site of administration.

    Storage temperature.

    Remark

    BCG

    -0.05mls up to 11months

    -0.1mls after 11months.

    1

    None

    -At birth 

    -At 1st contact.

    I M

    -Right upper arm.

    +2-+8

    -Use diluents provided for BCG ONLY.

    Not to be given to children with symptomatic HIV/AIDS.

    -Discard reconstituted vaccine after 6 hrs.

    Use sponge method.

    DPT+ Hep B – Hip


    0.5mls

    3

    1 month

    At 6 weeks.

    I M

    -Outer aspect of the left thigh.

    +2-+8

    -Don’t freeze

    -Don’t place directly on ice.

    Use sponge method.

    PCV

    0.5mls

    3

    1 month

    At 6 weeks.

    I M

    -Outer aspect of the thigh.

    +2-+8

    -Don’t freeze

    Use sponge method.

    Polio O.P.V


    3 drops

    0+3

    1 month

    -At birth OPV

    -First contact.

    Orally

    Mouth

    +2-+8

    -Use diluents provided.

    -Discard used vial.

    Use sponge method.

    Measles

    0.5mls

    1

    None

    At 9 months

    1st contact.

    S/C

    -Left upper aspect of the arm.

    -Outer aspect of the thigh.

    +2-+8

    -Use diluents provided.

    Use sponge method.

    Tetanus toxoid

    0.5mls

    5

    TT1-TT2=1mnth

    TT2-TT3=6mnth

    TT3-TT4=1yr

    TT4-TT5=1yr. 

    -At child bearing age 1st contact

    Pregnant mother

    I M

    -Upper arm or 

    -Outer aspect of the thigh.

    +2-+8

    -Don’t freeze

    -Don’t place vial directly on the ice pack.

    Use sponge method.

    HPV

    0.5mls

    2

    HPV 1:At first contact with a girl in primary 4 or aged 10 years for those in the community

    HPV2; 6 months after HPV1.

    Girls in primary 4 or 10 years old girls who are out of school.

    IM

    Left upper arm.

    +2 to 8

    Don’t freeze 

    Use conditioned ice packs

    Use sponge method


    IPV

    0.5mls

    1

    None

    At 14 weeks (or first contact after that age)

    IM

    Outer upper aspect of right thigh2.5cm from PCV injection site.

    +20c to +80c

    -Do not freeze

    -Use conditioned ice packs.

    -Use sponge method.

    		 

     

     

    b).       Cold chain – Refers to the set of equipments or containers in which vaccines are stored at specified temperatures and transported from the moment of manufacture to the time of administration. It is essential to ensure an unbroken cold chain for vaccines right from the manufacturer (producer) to the person being vaccinated. The specified temperature range is 35° F (2°C) to 45°F (8°C),the system involves personnels, equipments, vaccines, supplies and procedures.

    If the vaccines get warm, their potency (effectiveness) is lost, especially those containing live organisms such as polio and measles. On the other hand, vaccines made from toxoids such as Tetanus and diphtheria, and suspended dead organisms such as whooping cough (pertussis) must not be frozen as this will make them loose potency. Vaccines must be stored at their own correct temperatures all the time. The cold chain must not be broken. If the cold chain is broken, Vaccines may loose potency and become useless.

    DIAGRAMATIC REPRESENTATION OF THE COLD CHAIN.


    Manufacturer of vaccines

     

    Airport

       

    Central vaccine store

     

    Regional or District store

     

    Mobile or Outreach post

     

    Health centre

     

    Immunization post

     

    Recipient (Mothers, children)

    The chain travels in this way;

    1. From the manufacturer to the airport, vaccines are carried in deep freezers in the aeroplane.
    2. From the airport, to the general medical vaccines stores and they are carried in freezers or cold boxes.
    3. From the general medical vaccines stores to the regional (Districts). They are carried in a refrigerated van, in a refrigerator, cold boxes or vaccine carriers.
    4. From the district to the health units, they are carried in the vaccine carriers or cold boxes.
    5. From the health unit to the outreach site, the vaccine should be wrapped in black polythene bags and carried in a well packed vaccine carrier with ice packs.

       In the chain vaccines should be separated into those that can be frozen and those that must not be frozen.

    The temperature monitoring devices used in the cold chain are; Thermometers and vaccine vial monitors (VVMS).

    The equipments used in the cold chain are;

    1. Cold rooms
    2. Freezers and Refrigerators 
    3. Vaccine carriers
    4. Ice packs.
    5. Thermometers.

    COLD ROOMS

    Cold rooms are large, specially constructed rooms or self- contained buildings located at national and in some cases regional levels for storage of large quantities of vaccines that last for 12 months or more.

    They have a 24-hour temperature monitoring system with an alarm, a recorder, and a back up generation that will turn on automatically when the regular power is interrupted.

    FREEZERS AND REFRIGERATORS

    Freezers and refrigerators are used at the district, regional and central stores.

    Freezers are used for freezing icepacks and storing some vaccines, particularly OPV that need to be kept at temperatures below 0°c. Other vaccines are stored in refrigerators, which are also used for chilling diluents before mixing with freeze- drained Ice lined refrigerations, which are used at the central and regional levels, are capable of maintaining temperatures below =8°c even when electricity fails as many as 16 of every 24 hours, day after day.

    HOW TO CARE FOR REFRIGERATORS.

    COLD BOXES

    Cold boxes are insulated containers that are lined with icepacks to keep vaccines and diluents cold. They are normally used to transport vaccines from the central level to the regions, regions to districts, and sometimes from districts to the service delivery levels (immunization posts). In some developing countries, Refrigerated vehicles are used instead of cold boxes.

    However, these vehicles are expensive to buy, and are subject to frequent mechanical breakdowns, a good cold box works as well, or even better.

    Cold boxes are used for temporary storage of vaccines when a refrigerator is out of order, or being defrosted.

    VACCINE CARRIERS

    These are insulated containers that are lined with icepacks to keep vaccines and diluents cold. They are more portable, are commonly used to transport vaccines from distinct stores to smaller health facilities and to outreach sessions (immunization posts).

    ICE PACKS

    An icepack is a flat rectangular plastic container designed to be filled with clean water, frozen and then used to keep vaccine. Icepacks must be placed in a cold box or vaccine carrier in a precise way, So their size is important. One extra set of ice packs should be available so that while one set is being frozen at a temperature of (-) 25°C, the other is being used. Freezing icepacks is a process that usually takes at least 24 hours. The icepacks are different from vaccine carriers and should be as per the guide of the manufacturer.

    THERMOMETERS

    Health unit staffs use alcohol thermometers to monitor the temperature of vaccines in refrigerators, cold boxes and vaccine carriers.

    VACCINES

    • It is stored at a temperature of +2°C to+8°C.
    • Restricted BCG and Measles vaccine should not be used beyond 6 hours.

            Only use the diluents supplied and packaged by the manufacturer with the vaccine since the diluents is specifically designed for the needs of that vaccine, with respect to volume, HP level and chemical properties.

    The diluents may be stored outside the cold chain as it may occupy the space of the fridge but keep diluents for at least 24 hours before use in the fridge to ensure that the vaccine and diluents are at +2°C to 8°C when being reconstituted. Otherwise, it can lead to thermal shock that is, the death of some or all the essential live organisms in the vaccine. Store all the diluents and droppers with the vaccine in the vaccine carrier during transportation. Diluents should not come in contact with the ice packs.

          Any vials that are expired or frozen or with VVMS beyond the discard point, should not be kept in the cold chain.

    Questions and Answers Read More »

    nursing exam Nursing Management nursing exam

    Nursing Exam Question Approach

    Click Here for Question Approach for Nursing Concerns, Interventions, Considerations, e.t.c

    Nursing Exam Question Approach.

    In this comprehensive guide, we will explore and provide examples of the Question Approach for nurses preparing for their nursing exams. We will cover question types such as EXPLAIN, OUTLINE, DESCRIBE, MENTION, IDENTIFY, STATE, LIST, WHAT, and GIVE. 

    Also, we will dive into question approaches specifically related to Nursing Management questions, including specific nursing interventions, considerations, concerns, issues, and interventions.

    The EXPLAIN Question Approach

    In Simple Terms: "Explain" means to give details and reasons. You need to show *how* or *why* something happens, not just what it is.

    The EXPLAIN question requires nurses to provide a detailed explanation of a particular concept, process, or condition. When approaching an EXPLAIN question, follow these steps:

    Step 1: Understand the question

    Carefully read the question and identify the main topic or concept that needs to be explained. Pay attention to any specific instructions or requirements.

    Step 2: Organize your response

    Create an outline or mental map of the key points you want to include in your explanation. Start with a concise introduction that provides context and a clear thesis statement. Then, present your main points in a logical order, supporting them with relevant evidence or examples.

    Step 3: Provide a thorough explanation

    Elaborate on each key point using clear and concise language. Use appropriate nursing terminology and provide examples or case studies to enhance your explanation. Aim to cover all relevant aspects of the topic while maintaining a coherent and structured response.

    Example EXPLAIN question:

    “Explain the pathophysiology of diabetes mellitus and its effects on the body.”

    Sample response:

    Diabetes mellitus is a chronic metabolic disorder characterized by high blood glucose levels due to impaired insulin secretion, insulin action, or both. The pathophysiology of diabetes involves multiple factors that contribute to the development and progression of the disease.

    Firstly, in type 1 diabetes, an autoimmune process leads to the destruction of insulin-producing beta cells in the pancreas. This results in a deficiency of insulin and requires external insulin administration. On the other hand, type 2 diabetes is primarily characterized by insulin resistance, where the body’s cells become less responsive to insulin.

    Insulin is a hormone produced by the beta cells of the pancreas, and its main function is to regulate glucose metabolism. In diabetes, the lack of insulin or the body’s inability to use it effectively leads to hyperglycemia. Persistently high blood glucose levels can have detrimental effects on various organs and systems in the body.

    The effects of diabetes on the body are many. It can lead to macrovascular complications, such as cardiovascular disease, stroke, and peripheral vascular disease. Also, microvascular complications may arise, affecting small blood vessels in the eyes, kidneys, and nerves. Diabetes can also increase the risk of infections, slow wound healing, and cause diabetic neuropathy and nephropathy.

    The OUTLINE Question Approach

    In Simple Terms: "Outline" means to create a structured summary. Use main headings and sub-points to show the main parts of a topic in a clear, organized way.

    The OUTLINE question requires nurses to present a structured overview of a particular topic, process, or care plan. When approaching an OUTLINE question, follow these steps:

    Step 1: Analyze the question

    Carefully read the question and identify the main components or aspects that need to be outlined. Pay attention to any specific instructions or requirements.

    Step 2: Organize your response

    Create a clear and logical outline for your response. Identify the main headings or sections that you will include and arrange them in a coherent order. Each section should address a specific aspect of the topic or process.

    Step 3: Provide detailed information

    Under each heading or section, provide detailed information, explanations, or examples related to that particular aspect. Use concise and informative language, ensuring that your outline is well-structured and easy to follow.

    Example OUTLINE question

    “Outline the steps involved in the nursing process.”

    Sample response:
    The nursing process is a systematic framework that guides nurses in delivering patient-centered care. It consists of five essential steps: assessment, diagnosis, planning, implementation, and evaluation.

  • Assessment: Gather relevant patient data, including physical, psychological, social, and cultural aspects. Perform a comprehensive health history and physical examination. Utilize assessment tools and techniques to collect objective and subjective data. Document and organize the collected data systematically.
  • Diagnosis: Analyze the assessment data to identify health problems, risks, or potential complications. Formulate nursing diagnoses based on the identified issues. Ensure that the diagnoses are accurate, concise, and specific.
    • Collaborate with other healthcare professionals when necessary.
  • Planning: Establish patient-centered goals and outcomes in collaboration with the patient.
    • Develop a nursing care plan that includes evidence-based interventions and strategies. Prioritize nursing actions based on the urgency and importance of each goal. Ensure that the care plan is feasible, realistic, and adaptable.
  • Implementation: Execute the planned nursing interventions effectively and efficiently.
    • Provide safe and compassionate care while considering the patient’s preferences. Document the implementation process and any modifications made. Collaborate with the interdisciplinary healthcare team to deliver comprehensive care.
  • Evaluation: Assess the patient’s response to the nursing interventions and the achievement of goals. Compare the actual outcomes with the expected outcomes. Modify the care plan if needed based on the evaluation findings. Document the evaluation results and communicate them to the healthcare team.

    • The DESCRIBE Question Approach

    In Simple Terms: "Describe" means to paint a picture with words. You need to give a detailed account of the characteristics or features of something.

    The DESCRIBE question requires nurses to provide a detailed account or characterization of a particular topic, condition, or intervention. When approaching a DESCRIBE question, follow these steps:

    Step 1: Understand the question

    Carefully read the question and identify the main topic or subject that needs to be described. Pay attention to any specific instructions or requirements.

    Step 2: Provide a comprehensive description

    Offer a thorough and comprehensive description of the topic or subject. Include relevant details, characteristics, features, or components. Use clear and concise language to ensure clarity and understanding.

    Step 3: Use appropriate terminology

    Utilize appropriate nursing terminology to accurately describe the topic or subject. This will demonstrate your knowledge and understanding of the nursing concepts related to the question.

    Step 4: Provide examples (if applicable)

    Enhance your description by providing relevant examples. These real-life scenarios will help illustrate the topic or subject and provide a practical way for understanding.

    Example DESCRIBE question:

    “Describe the stages of wound healing.”

    Sample response:
    Wound healing is a complex process that involves several distinct stages. Understanding these stages is essential for nurses to provide appropriate wound care and promote optimal healing.

  • Hemostasis: This initial stage begins immediately after the injury occurs.
    • Blood vessels constrict to reduce blood flow and prevent excessive bleeding. Platelets aggregate to form a temporary clot. The clotting process releases various growth factors and cytokines, initiating the subsequent stages of healing.
  • Inflammatory phase: This phase typically lasts for 2-3 days.
    • Inflammation occurs as a response to tissue injury. Vasodilation and increased vascular permeability allow immune cells to migrate to the wound site. Neutrophils arrive first to eliminate debris and prevent infection. Macrophages then remove dead tissue and release additional growth factors to stimulate healing.
  • Proliferative phase: This phase generally occurs between days 3 and 20.
    • New blood vessels form to supply oxygen and nutrients to the wound. Fibroblasts produce collagen, which provides structural support for wound healing. Epithelial cells migrate from the wound edges to resurface the wound. Granulation tissue forms, consisting of new blood vessels, fibroblasts, and extracellular matrix.
  • Maturation phase: This final phase can last for several months to years.
    • Collagen fibers reorganize and remodel, increasing the wound’s tensile strength. Scar tissue forms, but it may not possess the same strength and flexibility as the original tissue. The scar gradually becomes more refined and fades over time.

    The MENTION / IDENTIFY / STATE Question Approach

    In Simple Terms: These words mean "give a short, direct answer." Just name the specific facts or points asked for, without extra explanation.

    The MENTION/IDENTIFY/STATE question requires nurses to highlight or state specific information or facts related to a particular topic or condition. When approaching such a question, follow these steps:

    Step 1: Understand the question

    Carefully read the question and identify the specific information or facts that need to be mentioned, identified, or stated. Pay attention to any specific instructions.

    Step 2: Provide a direct response

    Offer a direct and concise response to the question. Avoid unnecessary elaboration or providing excessive details beyond what is asked.

    Step 3: Use precise language

    Use precise and accurate language to give the required information. Ensure that your response aligns with the question and provides the requested details.

    Step 4: Provide examples if applicable

    If the question allows for it or if it helps clarify the information, you can provide relevant examples or scenarios to support your response.

    Example MENTION / IDENTIFY / STATE question:

    “Mention/ Identify/ State the types of delusions.”

    Sample response:

  • Grandiose delusions; the patient believes s/he is somebody great /important ,knowledgeable or powerful contrary to the social cultural ,religious background and experiences.
  • Delusion of guilty and worthlessness; the patient believes s/he is not worth to live even though there’s nothing to justify this belief.
  • Delusions of jealousy; the patient believes that spouse/partner is being unfaithful even when there is no evidence to suggest so.
  • Delusion of persecution: the patient believes they’re being deliberately wronged, conspired or harmed by another person or agency even when there’s no evidence to suggest so.
  • Religious delusions; the individual believes he or she has a special link with God that is out keeping with people of the same religious belief.
  • Delusions of control, influence or phenomenon; these are three types; belief that the person performs activities as a result of an extreme force.

    • The LIST Question Approach

    In Simple Terms: "List" means to present points one after another, usually with a short description for each one.

    The LIST question requires nurses to present a series of items, factors, or elements related to a specific topic or condition. When approaching a LIST question, follow these steps:

    Step 1: Understand the question

    Carefully read the question and identify the specific items or factors that need to be listed. Pay attention to any specific instructions or requirements.

    Step 2: Organize your response

    Create a well-structured list that presents the items or factors in a logical and coherent order. Consider using bullet points or numbered lists for clarity.

    Step 3: Provide concise descriptions

    Under each item or factor, provide a concise description or explanation. Keep your descriptions clear, informative, and relevant to the question.

    Example LIST question:

    “List the risk factors for cardiovascular disease.”

    Sample response:

  • Hypertension: High blood pressure increases the strain on the heart and blood vessels, leading to an increased risk of cardiovascular problems.
  • High cholesterol levels: Elevated levels of LDL (low-density lipoprotein) cholesterol, also known as “bad” cholesterol, can lead to the formation of plaque in the arteries, restricting blood flow and increasing the risk of cardiovascular events.
  • Smoking: Tobacco smoke contains harmful chemicals that can damage blood vessels and promote the development of atherosclerosis.
  • Obesity: Excess body weight, especially when concentrated around the abdomen, increases the risk of hypertension, high cholesterol, and diabetes, all of which contribute to cardiovascular disease.
  • Sedentary lifestyle: Lack of regular physical activity can contribute to obesity, hypertension, and other risk factors for cardiovascular disease.
  • Diabetes mellitus: Individuals with diabetes have a higher risk of developing cardiovascular disease due to the impact of chronically elevated blood glucose levels on blood vessels and the heart.
  • Family history: Having a close relative, such as a parent or sibling, with a history of cardiovascular disease increases an individual’s risk.
  • Age and gender: Advancing age and being male are additional risk factors for cardiovascular disease.

    • The WHAT Question Approach

    In Simple Terms: "What" asks for a definition. Give a clear, simple explanation of the term or concept.

    The WHAT question requires nurses to provide an explanation or definition of a specific term, concept, or procedure. When approaching a WHAT question, follow these steps:

    Step 1: Understand the question

    Carefully read the question and identify the specific term, concept, or procedure that needs to be explained or defined. Pay attention to any specific instructions.

    Step 2: Provide a clear explanation or definition

    Offer a clear and concise explanation or definition of the term, concept, or procedure. Use simple language and avoid unnecessary words.

    Step 3: Provide examples if applicable

    If the term, concept, or procedure can be further elucidated with examples or scenarios, provide relevant and practical illustrations to enhance understanding.

    Example WHAT question:

    “What is sepsis?”

    Sample response:

    Sepsis is a potentially life-threatening condition that occurs when the body’s response to an infection becomes unregulated, leading to widespread inflammation and organ dysfunction. It is often triggered by bacterial, fungal, or viral infections, but can also result from other sources of inflammation.

    Nursing Exam Question Approach Read More »

    Hypertension high blood pressure

    Hypertension

    Nursing Notes - Thrombus and Embolus

    HYPERTENSION

    Introduction

    Definition: Hypertension, or high blood pressure (BP), is defined as a persistent systolic blood pressure (SBP) greater than or equal to 140 mm Hg, diastolic blood pressure (DBP) greater than or equal to 90 mm Hg. High blood pressure means that the heart is working harder than normal thus putting the heart and the blood vessels on a high pressure.

    This is based on the average of two or more accurate blood pressure measurements during two or more consultations with the healthcare provider. The definition is taken from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

    1. Blood pressure: This is the pressure exerted when blood flows into the arteries. It is measured in mmHg using a sphygmomanometer (blood pressure machine).
    2. Diastolic pressure: This is the pressure exerted on the arteries when the heart relaxes.
    3. Systolic pressure: This the pressure exerted on the arteries when the heart contracts.

    Types of Hypertension

    1. Primary (essential or idiopathic) hypertension: elevated BP without an identified cause; accounts for 90% to 95% of all cases of hypertension.
    2. Secondary hypertension: elevated BP with a specific cause; accounts for 5% to 10% of hypertension in adults.

    Stages of Hypertension

    Blood pressure is classified to guide treatment and assess risk.

    Category Systolic BP (mmHg) Diastolic BP (mmHg)
    Normal less than 120 and less than 80
    Elevated 120 – 129 and less than 80
    Stage 1 hypertension 130 – 139 or 80 – 89
    Stage 2 hypertension 140 or higher or 90 or higher
    Hypertensive crisis higher than 180 and/or higher than 120

    Proper Measurement of Blood Pressure

    In order to obtain appropriate results, the following must be followed:

    • Right Blood Pressure Machine: The cuff should not be too small or too large for the patient.
    • Rest Period: Allow the patient to rest for at least 5 to 10 minutes before measuring the blood pressure, as exercise increases blood pressure.
    • Avoid Talking: The patient should not be talking while the blood pressure is being measured, as wrong results (higher) may be obtained when the patient talks.
    • Arm Position: The arm of the patient should be positioned at the level of the heart.
    • Multiple Measurements: At least 2-3 measurements should be made at different visits for those with pre-hypertension and stage 1 hypertension before the patient is confirmed to be having hypertension.
    • Inform Patient: Inform the patient of his or her blood pressure results and what they mean.
    • Record and Provide Copy: Record the patient’s blood pressure on the medical form, and a copy of results should be given to the patient.

    Pathophysiology

    There are various mechanisms described for the development of hypertension which includes increased salt absorption resulting in volume expansion, an impaired response of the renin-angiotensin-aldosterone system (RAAS), increased activation of the sympathetic nervous system. These changes lead to the development of increased total peripheral resistance and increased afterload which in turn leads to the development of hypertension.

    Causes of Hypertension

    Hypertension has a lot of causes just like how fever has many causes. The factors that are implicated as causes of hypertension are:

    1. Increased sympathetic nervous system activity: Sympathetic nervous system activity increases because there is dysfunction in the autonomic nervous system.
    2. Increase renal reabsorption: There is an increase reabsorption of sodium, chloride, and water which is related to a genetic variation in the pathways by which the kidneys handle sodium.
    3. Increased RAAS activity: The renin-angiotensin-aldosterone system increases its activity leading to the expansion of extracellular fluid volume and increased systemic vascular resistance.
    4. Decreased vasodilation of the arterioles: The vascular endothelium is damaged because of the decrease in the vasodilation of the arterioles.

    Risk factors of Hypertension

    1. Age: Increasing age increases the risk of development of hypertension
    2. Family History of the disease increases the risk
    3. Lack of exercise
    4. Obesity
    5. Stress and depression
    6. Vitamin D deficiency
    7. Smoking
    8. Drug abuse and alcoholism
    9. Cushing syndrome
    10. Diabetes
    11. Sedentary lifestyle
    12. Intake of extra salt
    13. Insufficient calcium, magnesium, and potassium intake
    14. Chronic kidney disease
    15. Adrenal and thyroid problems
    16. Adrenal gland tumors
    17. Thyroid problems
    18. Certain medications such as birth control pills, cough, and cold remedies and over-the-counter pain relievers( NSAIDs)
    19. Obstructive sleep apnea

    Clinical manifestations

    Often called the “silent killer” because it is frequently asymptomatic until it becomes severe and target organ disease occurs.

    • Headache: The red blood cells carrying oxygen is having a hard time reaching the brain because of constricted vessels, causing headache.
    • Dizziness occurs due to the low concentration of oxygen that reaches the brain.
    • Chest pain: Chest pain occurs also due to decreased oxygen levels.
    • Blurred vision: Blurred vision may occur later on because of too much constriction in the blood vessels of the eye that red blood cells carrying oxygen cannot pass through.
    • Fatigue or confusion,
    • Lightheadedness,
    • Vertigo,
    • Tinnitus,
    • Fainting,
    • Irregular heartbeat,
    • Blood in the urine.

    Test and Diagnosis for Hypertension

    1. History exam
    2. Physical exam: Manual checking of blood pressure by a sphygmomanometer.
    3. Urinalysis is performed to check the concentration of sodium in the urine though the specific gravity.
    4. Blood chemistry (e.g. analysis of sodium, potassium, creatinine, fasting glucose, and total and high density lipoprotein cholesterol levels). These tests are done to determine the level of sodium and fat in the body.
    5. Renin level. Renin level should be assessed to determine how RAAS is coping.
    6. Urinalysis: May show blood, protein, or white blood cells; or glucose suggests renal dysfunction and/or presence of diabetes.
    7. Renin: Elevated in renovascular and malignant hypertension, salt-wasting disorders.
    8. Urine steroids: Elevation may indicate hyperadrenalism, pheochromocytoma, pituitary dysfunction, Cushing’s syndrome.
    9. Intravenous pyelogram (IVP): May identify cause of secondary hypertension, e.g., renal parenchymal disease, renal/ureteral -calculi.
    10. Kidney and renography nuclear scan: Evaluates renal status (TOD).
    11. Excretory urography: May reveal renal atrophy, indicating chronic renal disease.

    Management

    Medical Management

    The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction.

    • For uncomplicated hypertension, the initial medications recommended are diuretics and beta blockers.
    • Only low doses are given, but if blood pressure still exceeds 140/90 mmHg, the dose is increased gradually.
    • Thiazide diuretics decrease blood volume, renal blood flow, and cardiac output.
    • ARBs (Angiotensin II Receptor Blockers) are competitive inhibitors of aldosterone binding.
    • Beta blockers block the sympathetic nervous system to produce a slower heart rate and a lower blood pressure.
    • ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II and lowers peripheral resistance.
    Drug therapy
    1. ACE Inhibitors (Captopril, Enalapril, Perindopril, Quinapril). an ACE inhibitor is particularly. Useful if heart failure and diabetes present.
    2. Beta-blockers (Acebutolol, Atenolol, Bisoprolol, Propranolol, Timolol). Slowing the heart rate and reducing the force of the heart.
    3. Calcium channel blockers (Amlodipine, DIltiazem, Felodipine, Nifedipine, Verapamil). Relaxing blood vessels and control blood pressure.
    4. Diuretics (Bendroflumethiazide, Chlortalidone, Cyclopenthiazide and Indapamide).
    Lifestyle modification

    Lifestyle modifications are indicated for all patients with prehypertension and hypertension and include the following:

    1. Weight reduction: A weight loss of 10 kg (22 lb) may decrease SBP by approximately 5 to 20 mm Hg.
    2. Dietary Approaches to Stop Hypertension (DASH) eating plan. Involves eating several servings of fish each week, eating plenty of fruits and vegetables, increasing fiber intake, and drinking a lot of water. The DASH diet significantly lowers BP.
    3. Restriction of dietary sodium to less than 6 g of salt (NaCl) or less than 2.4 g of sodium per day. This involves avoiding foods known to be high in sodium (e.g., canned soups) and not adding salt in the preparation of foods or at meals.
    4. Restriction of alcohol
    5. Regular aerobic physical activity (e.g., brisk walking) at least 30 minutes a day most days of the week. Moderately intense activity such as brisk walking, jogging, and swimming can lower BP, promote relaxation, and decrease or control body weight.
    6. It is strongly recommended that tobacco use be avoided.
    7. Stress management. Stress can raise BP on a short-term basis and has been implicated in the development of hypertension. Relaxation therapy, guided imagery, and biofeedback may be useful in helping patients manage stress, thus decreasing BP.

    Nursing management

    1. Assessment of the patient
    • a. Carrying out history of the presenting signs and symptoms e.g. fever, headaches 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. To prevent the heart failure as a result of BP > 140 systolic
    • a. Monitor bp. Measure in both arms/thighs three times, 3–5 min apart while patient is at rest, then sitting, then standing for initial evaluation. Use correct cuff size and accurate technique.
    • b. Note presence, quality of central and peripheral pulses because pulses in the legs/feet may be diminished, reflecting effects of vasoconstriction increased systemic vascular resistance and venous congestion.
    • c. Auscultate heart tones and breath sounds to detect pulmonary congestion secondary to developing or chronic heart failure.
    • d. Observe skin color, moisture, temperature, and capillary refill time to detect or exclude peripheral vasoconstriction.
    3. To relieve pain (head ache among others)
    • a. Determine specifics of pain, e.g., location, characteristics, intensity (0–10 scale), onset/duration and note nonverbal cues to identify the pain
    • b. Encourage/maintain bed rest during acute phase to minimizes stimulation/promotes relaxation.
    • c. Provide/recommend non-pharmacological measures for relief of headache, e.g., cool cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation techniques (guided imagery, distraction); and diversional activities to reduce cerebral vascular pressure.
    4. Diet
    • a. Establish a realistic weight reduction plan with the patient, e.g., 1 lb weight loss/wk.
    • b. Instruct and assist in appropriate food selections, such as a (DASH diet) diet rich in fruits, vegetables, and low-fat dairy foods referred to as the dash dietary approaches to stop hypertension) diet and avoiding foods high in saturated fat (butter, cheese, eggs, ice cream, meat) and cholesterol (fatty meat, egg yolks, whole dairy products, shrimp, organ meats).
    5. To promote patient’s knowledge:
    • a. Instruct patient and family about the cause, management of symptoms, signs, and symptoms, and the need for follow-up.
    • b. Instruct patient about the factors that may have contributed to the development of the disease.
    6. Discharge and Home Care Guidelines
    • a. The nurse can help the patient achieve blood pressure control through education about managing blood pressure.
    • b. Assist the patient in setting goal blood pressures.
    • c. Encourage the involvement of family members in the education program to support the patient’s efforts to control hypertension.
    • d. Encourage and teach patients to measure their blood pressures at home.
    • e. Emphasize strict compliance of follow-up checkup.

    Complications of Hypertension

    • Heart attack or stroke,
    • Aneurysm,
    • Weakened and narrowed blood vessels of the kidney,
    • Heart failure,
    • Thickened narrowed or torn blood vessels of eyes (Blindness),
    • Metabolic syndrome.

    Drug Therapy for Hypertension

    Drug treatment is recommended for those patients who have not responded to non-drug measures and for those who report when the blood pressure is already very high. One drug (monotherapy) is recommended initially for patients with mild hypertension.

    In case of poor response, another drug may be added or substituted.

    Patients who present when already in stage 2 hypertension may be started on two drugs at once in lower doses, then adjusted depending on the response.

    Choice of Antihypertensive

    When choosing a drug for treating hypertension, consider the following in order to safely use the drugs and effectively control blood pressure:

    • Co-existing Diseases/Conditions: Patients with other existing diseases or conditions such as pregnancy, asthma, diabetes, heart failure, and angina pectoris. This is because some antihypertensives are not recommended to be used in some of the above conditions.
    • Affordability and Accessibility: Ensure affordability and accessibility of the medicine by the patients.
    • Allergies: Establish whether the patient is allergic to the drug or not.
    • Target Organ Damage: Establish the presence of target organ damage.
    Choice of Antihypertensive in Different Conditions
    Condition 1st Choice 2nd Choice
    Pregnancy Methyldopa (Aldomet) Atenolol, Nifedipine
    Diabetes Mellitus Captopril, Lisinopril Nifedipine, Amlodipine
    Asthma Amlodipine, Nifedipine
    Preeclampsia or Eclampsia of Pregnancy Hydralazine (Apresoline) Labetalol
    Angina Pectoris Nifedipine, Amlodipine Atenolol, Propranolol
    Heart Failure Frusemide, Lisinopril, Captopril Carvedilol

    Resistant Hypertension

    This is the persistent elevation of blood pressure above 140/90mmHg despite the use of 3 or more appropriate drug combinations including a diuretic at full doses.

    Causes:
    • Patients above 60 years
    • Poor drug compliance (taking the drugs wrongly)
    • Continuous presence of risk factors such as smoking, excessive alcohol intake, and obesity
    • Concurrent use of drugs that elevate blood pressure, for example, flu (common cold) preparations (decongestants), painkillers like diclofenac
    • Presence of secondary causes of hypertension, for example, kidney failure

    Malignant Hypertension, Hypertensive Emergency, Hypertensive Urgency

    Malignant Hypertension

    Malignant hypertension is a condition characterized by a sudden severe rise in blood pressure resulting in small vessel damages.

    Clinical Presentation:
    • Confusion
    • Headache
    • Visual loss
    • Coma

    It is a medical emergency that requires hospital admission and rapid control of blood pressure over 12 to 24 hours to a normal level.

    Hypertensive Emergency

    This is a severe elevation of blood pressure (more than 180/120mmHg) with signs of damage to target organs such as the brain and kidney.

    The patient must be admitted to the hospital, if possible in an intensive care unit, and pressure must be lowered immediately to prevent damage to the kidney, heart, and brain.

    Blood pressure should be gradually lowered since cerebral hypoperfusion can occur if the blood pressure is lowered by more than 40% in the initial 24 hours.

    Drugs used to treat hypertensive emergencies in Uganda include intravenous hydralazine or Labetalol.

    Hypertensive Urgency

    This is a situation in which blood pressure is very elevated but there is no potential organ damage.

    The blood pressure must be reduced within 1-2 days, and oral medications are recommended, for example, Nifedipine (Sublingual), Captopril, Labetalol tablet, etc.

    Drugs Used in the Treatment of Hypertension

    Drugs used in the treatment of hypertension in Uganda include:

    • Beta blockers
    • Calcium channel blockers
    • Diuretics
    • Angiotensin converting enzyme inhibitor (ACE inhibitors)
    • Angiotensin II antagonist
    • Centrally acting antihypertensive
    • Direct acting vasodilators
    1. Beta Blockers

    Beta blockers are the most commonly used drugs in the treatment of hypertension in Uganda because they are affordable and available in most places countrywide.

    Examples:
    • Propranolol (Inderal)
    • Atenolol (Totamol)
    • Carvedilol
    • Labetalol
    Mechanism of Action:

    Beta blockers block beta 1 receptors in the heart, which results in slowing of the heart rate and reduction in the force of heart contraction. This action results in lowering of blood pressure.

    Indications:
    • Hypertension
    • Angina pectoris
    • Migraine headache
    • Congestive heart failure (Carvedilol)
    • Post myocardial infarction
    Side Effects:
    • Impotence
    • Wheezing
    • Cold extremities
    • Bradycardia
    • Reduced exercise tolerance
    • Tiredness
    • Heart failure
    Contraindications:
    • Patients with asthma
    • Patients with acute heart failure
    • Heart block
    • Chronic obstructive airway disease
    • Patients with diabetes mellitus (since they mask signs of hypoglycemia)
    • Depression
    • Pregnancy and breast feeding

    Generally, common beta blockers are recommended for use in pregnant mothers, though prolonged use may lead to growth retardation in fetuses. Beta blockers may be used in breast feeding mothers.

    2. Calcium Channel Blockers

    Calcium channel blockers are among the first-line drugs used in the treatment of hypertension. They can be used alone or in combination with other antihypertensives such as beta blockers, Angiotensin converting enzyme inhibitors, or diuretics. These drugs can be used safely in patients who also have other co-existing conditions such as asthma, hyperlipidemia, diabetes mellitus, and renal dysfunction.

    Examples:
    • Nifedipine
    • Amlodipine
    • Felodipine
    Mechanism of Action:

    Calcium channel blockers decrease the entry of calcium ions into the smooth muscles, causing vasodilation and lowering of the blood pressure.

    Indications:
    • Hypertension
    • Angina pectoris
    Side Effects:
    • Flushing
    • Oedema
    • Headache
    • Postural hypotension
    • Dizziness
    • Weakness
    • Heart burn
    • Tachycardia
    Contraindications:
    • 2nd or 3rd degree heart block
    • Known hypersensitivity to any of the members
    • Severe heart failure
    • Severe hypotension
    • Pregnancy and breast feeding

    Calcium channel blockers, especially Nifedipine, are used in the treatment of hypertension in pregnant mothers.

    3. Diuretics

    Diuretics are among the first-line drugs used in the treatment of hypertension. Diuretics, for example Bendrofluazide, are safe, cheap, and effective in the treatment of hypertension. These drugs may be used alone or in combination with ACE inhibitors, beta blockers, etc., in the treatment of hypertension.

    Classification of Diuretics:
    Class Example
    Thiazide Diuretics Bendrofluazide (Aprinox), Metolazone
    Loop Diuretics Frusemide (Lasix)
    Potassium Sparing Diuretics Spironolactone
    Mechanism of Action:

    Diuretics work by promoting the excretion of large amounts of water in the form of urine, thereby reducing the blood volume and lowering of blood pressure.

    Indications:
    • Hypertension
    • Heart failure

    Note: Thiazide diuretics are mainly used in the treatment of hypertension but may be used in mild cases of heart failure. Loop diuretics are commonly used in the treatment of heart failure and rarely in the treatment of hypertension unless associated with fluid overload (oedema).

    Side Effects:
    Class Common Side Effects
    Thiazide Diuretics Hypokalaemia, Hyperuricaemia (elevated level of uric acid), Glucose intolerance, Sexual dysfunction (impotence), Weakness, Dehydration
    Loop Diuretics Dehydration, Dry mouth, Muscle aches, Hypokalaemia, Elevation of blood sugar, Postural hypotension
    Contraindications:

    Thiazide diuretics are not recommended in patients with:

    • Gout
    • Diabetes
    • Hypokalaemia
    • Hyperlipidemia
    • Known hypersensitivity
    Pregnancy and Breastfeeding:

    Generally, diuretics should be used with caution during pregnancy and breastfeeding.

    4. Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors)

    ACE inhibitors are drugs of first choice in the treatment of hypertension and also hypertension in diabetic patients. They may be used alone or in combination with diuretics or beta blockers.

    Examples:
    • Captopril
    • Ramipril
    • Lisinopril
    • Enalapril
    Mechanism of Action:

    These drugs interfere with the conversion of Angiotensin I (vasodilator) to Angiotensin II (vasoconstrictor) by inhibiting the Angiotensin converting enzyme. This leads to a reduction of peripheral resistance and lowering of blood pressure.

    Indications:
    • Hypertension
    • Heart failure
    • Diabetic nephropathy
    Side Effects:

    The common side effects associated with the use of ACE inhibitors include:

    • Dry irritating cough
    • Skin rash
    • Taste disturbance
    • Angioedema
    Contraindications:
    • Pregnant mothers
    • Patients with renal impairment
    • Previous history of angioedema
    • Known hypersensitivity to any of the drugs in this group
    • Breastfeeding
    5. Centrally Acting Antihypertensives

    These drugs were among the first to be used in the treatment of hypertension in Uganda. They are no longer used so much in the general management of hypertension because of associated side effects and presence of effective drugs with less side effects.

    Examples:
    • Methyldopa
    • Clonidine

    Methyldopa, the only member currently registered in Uganda, is used as a drug of 1st choice in the treatment of hypertension in pregnant mothers because of its safety in this category of patients.

    Mechanism of Action:

    These drugs inhibit sympathetic outflow from the brain, thereby decreasing total peripheral resistance and lowering of blood pressure.

    Indications:
    • Hypertension during pregnancy
    • Severe hypertension as a 3rd line drug
    Side Effects:
    • Tiredness
    • Headache
    • Impotence
    • Dizziness
    • Mental depression
    • Sedation
    • Rebound hypertension on withdrawal
    Contraindications:
    • Severe liver disease
    • Known hypersensitivity to methyldopa
    6. Angiotensin II Antagonists

    These drugs are among the new ones used in the treatment of hypertension. They are as effective as ACE inhibitors but are usually recommended in patients who cannot tolerate ACE inhibitors because of side effects such as cough.

    Examples:
    • Losartan
    • Telmisartan
    • Valsartan
    • Candesartan
    Mechanism of Action:

    Angiotensin II antagonists bind tightly at Angiotensin II receptors, preventing the action of Angiotensin II. This action reduces peripheral resistance, resulting in vasodilation and lowering of blood pressure.

    Indications:
    • Hypertension
    • Heart failure
    Side Effects:

    The most common side effects associated with the use of these drugs include:

    • Hypotension
    • Dizziness
    • Hyperkalaemia
    Contraindications:

    These drugs should be avoided during pregnancy, especially during the 2nd and 3rd trimester, since they are associated with fetal malformation.

    • Breastfeeding mothers
    7. Direct Acting Vasodilators

    Drugs that belong to this group include:

    • Hydralazine
    • Minoxidil

    Hydralazine is the only member registered in Uganda and is only recommended in the treatment of hypertension that has not responded to other antihypertensives.

    The use of hydralazine in the long-term treatment of hypertension is associated with fluid retention and reflex tachycardia, which can be offset by combining it with beta blockers (to prevent reflex tachycardia) or diuretics (to reduce fluid retention).

    Mechanism of Action:

    Direct acting vasodilators work directly on the blood vessels causing relaxation (widening of the blood vessel) leading to a reduction in the blood pressure.

    Indications:
    • Severe hypertension
    • Hypertensive emergencies
    • Hypertension in pregnancy associated with pre-eclampsia and eclampsia
    Side Effects:

    The following side effects are commonly seen when hydralazine is used:

    • Headache
    • Tachycardia
    • Flushing
    • Dyspnoea
    • Oedema
    • Postural hypotension
    Contraindications:
    • Angina pectoris
    • Patients with heart failure
    • Known hypersensitivity

    Hypertension Read More »

    Transverse Myelitis

    Transverse Myelitis

    Transverse Myelitis (TM)

    Transverse myelitis (TM) is a rare but serious neurological condition caused by inflammation of the spinal cord. 

    This inflammation leads to the formation of scars or lesions that disrupt communication between the nerves of the spinal cord and the rest of the body.

    The term “transverse“ refers to the fact that the inflammation can spread across the width of the spinal cord. However, in some cases, the swelling may only affect a portion of the spinal cord’s width. TM can occur at any age and affects both children and adults.

    signs and symptoms of transverse myelitis

    Signs and Symptoms of Transverse Myelitis

    Symptoms of transverse myelitis typically develop over a few hours to several weeks. They can vary depending on the severity and location of the inflammation. Common signs and symptoms include:

    1. Motor Symptoms (Affecting Movement)

    • Muscle weakness in the legs, and sometimes the arms
    • Mobility problems, including difficulty walking or paralysis (paraplegia or quadriplegia)
    • Muscle spasms or involuntary muscle contractions (spasticity)

    2. Sensory Symptoms (Affecting Sensation)

    • Tingling, numbness, or unusual sensations (burning, prickling, or coldness) in the legs, arms, or torso
    • Loss of sensation in affected areas
    • Heightened sensitivity to touch, temperature, or pain.

    3. Autonomic Dysfunction (Affecting Involuntary Functions)

    • Bladder dysfunction (incontinence, urinary retention, or frequent urination)
    • Bowel dysfunction (constipation or incontinence)
    • Sexual dysfunction (erectile dysfunction in men, loss of sensation in women)

    4. Pain Symptoms

    • Sharp or shooting pain in the lower back, chest, or limbs
    • Chronic neuropathic pain, which can persist even after inflammation subsides

    In severe cases, TM can lead to complete paralysis and loss of all sensory functions below the affected area of the spinal cord.

    Types of Transverse Myelitis

    Transverse myelitis can be classified into different types based on how quickly symptoms develop and their duration:

    1. Acute Transverse Myelitis (ATM)

    • The most common form of TM.
    • Symptoms develop suddenly, often within a few hours or days.
    • Can lead to rapid deterioration and may require urgent medical intervention.

    2. Subacute Transverse Myelitis (STM)

    • Symptoms develop gradually over several weeks to months.
    • Less aggressive than ATM but still causes significant neurological issues.

    3. Chronic Transverse Myelitis (CTM)

    • Symptoms persist for six months or longer.
    • Can lead to long-term disability due to persistent nerve damage.

    Causes of Transverse Myelitis

    Transverse myelitis can result from autoimmune disorders, infections, or other underlying conditions. In many cases, the exact cause remains unknown (idiopathic transverse myelitis).

    1. Autoimmune Disorders

    In some cases, TM is caused by an autoimmune reaction, where the immune system mistakenly attacks the body’s own nerve tissues. Autoimmune diseases that can trigger TM include:

    • Neuromyelitis optica (NMO) – A condition that affects both the spinal cord and optic nerves.
    • Myelin oligodendrocyte glycoprotein (MOG)-associated myelitis – A demyelinating disorder affecting the central nervous system.
    • Sarcoidosis – An inflammatory disease that can affect multiple organs, including the nervous system.
    • Sjögren’s syndrome – A chronic autoimmune disease affecting moisture-producing glands and sometimes the nervous system.
    • Systemic lupus erythematosus (lupus) – An autoimmune disease that can cause inflammation throughout the body, including the spinal cord.

    2. Viral Infections

    Certain viral infections can lead to TM, either directly attacking the nervous system or triggering an immune response that causes spinal cord inflammation. These include:

    • Enteroviruses (e.g., echovirus
    • Epstein-Barr virus (EBV)
    • Hepatitis A
    • Herpes simplex virus (HSV)
    • Human immunodeficiency virus (HIV)
    • Influenza virus (flu)
    • Rubella virus
    • Varicella-zoster virus (causes chickenpox and shingles)

    3. Bacterial Infections

    Some bacterial infections can also contribute to transverse myelitis, including:

    • Syphilis – A sexually transmitted infection that can affect the nervous system in its later stages.
    • Lyme disease – Caused by Borrelia burgdorferi bacteria transmitted through tick bites.
    • Tuberculosis – A bacterial infection that primarily affects the lungs but can also involve the nervous system.

    4. Cancer (Paraneoplastic Syndrome)

    Certain cancers may trigger an abnormal immune response, leading to inflammation of the spinal cord. This is known as paraneoplastic transverse myelitis and can occur in cancers such as:

    • Lung cancer
    • Breast cancer
    • Lymphomas

    Diagnosing Transverse Myelitis

    Diagnosis of transverse myelitis requires a combination of clinical evaluation and diagnostic tests to confirm spinal cord inflammation and rule out other conditions.

    1. Neurological Examination: Assess reflexes, muscle strength, coordination, and sensory responses to determine the extent of spinal cord dysfunction.

    2. Magnetic Resonance Imaging (MRI) Scan : MRI scans of the spine help identify lesions, swelling, and inflammation in the spinal cord.

    • MRI of the brain may be done to check for conditions like multiple sclerosis (MS) or neuromyelitis optica (NMO).

    3. Lumbar Puncture (Spinal Tap): Cerebrospinal fluid (CSF) analysis can detect inflammation, infections, or autoimmune activity. 

    • Elevated white blood cell counts or abnormal proteins may indicate infection or immune system dysfunction.

    4. Blood Tests: Blood tests help detect infections, autoimmune markers, and vitamin deficiencies that might contribute to TM. 

    • Specific antibody tests can help identify conditions like neuromyelitis optica (NMO-IgG antibody test) or MOG-associated myelitis.

    5. Additional Imaging and Tests

    • Computed Tomography (CT) Scan – Used if MRI is unavailable or to rule out other spinal conditions.
    • Evoked Potential Tests – Measures how quickly nerves respond to stimulation.

    Management of Transverse Myelitis (TM)

    The management of transverse myelitis involves a multidisciplinary approach aimed at reducing inflammation, managing symptoms, preventing complications, and promoting functional recovery. 

    Aims of Management

    The main objectives in managing transverse myelitis include:

    1. Reducing inflammation in the spinal cord to minimize nerve damage.
    2. Alleviating symptoms such as pain, muscle weakness, and bowel/bladder dysfunction.
    3. Restoring mobility and function through rehabilitation therapies.
    4. Preventing complications such as pressure sores, infections, and contractures.
    5. Addressing underlying causes such as autoimmune disorders or infections.
    1. Acute Phase Management (Hospital Admission and Initial Treatment)

    A. Admission and Monitoring

    Patients with suspected transverse myelitis are typically admitted to a hospital for close monitoring. Initial care includes:

    • Vital signs monitoring, especially respiratory function and cardiovascular status.
    • Neurological assessment to evaluate the severity and progression of symptoms.
    • Bladder and bowel assessment to manage dysfunctions early.

    B. Medical Treatment

    1. Corticosteroids (First-line Treatment)

    • High-dose intravenous corticosteroids (e.g., methylprednisolone) are administered to reduce inflammation and prevent further spinal cord damage.
    • If effective, an oral steroid taper may be given over weeks to prevent recurrence.
    • Side effects include increased infection risk, mood changes, stomach irritation, and weight gain.

    2. Plasma Exchange Therapy (Plasmapheresis)

    • Used for patients who do not respond to corticosteroids.
    • Helps remove harmful autoantibodies from the blood.
    • Typically done over 5-7 sessions.

    3. Immunomodulatory Therapy

    • For autoimmune-related TM, immunosuppressants such as azathioprine, rituximab, or cyclophosphamide may be required.

    4. Antiviral or Antibiotic Therapy

    • If an infection (viral or bacterial) is suspected, appropriate antiviral (e.g., acyclovir) or antibiotic (e.g., ceftriaxone) treatment is given.

    5. Symptomatic Treatment (Pain and Spasticity Management)

    • Neuropathic pain is managed with gabapentin, pregabalin, or amitriptyline.
    • Muscle spasms and stiffness are treated with baclofen, tizanidine, or diazepam.
    2. Symptom Management and Rehabilitation

    A. Managing Muscle Weakness and Mobility Issues

    Muscle weakness and paralysis significantly impact mobility and independence. Treatment includes:

    • Physical therapy to improve muscle strength, coordination, and endurance.
    • Stretching and strengthening exercises to prevent contractures.
    • Use of mobility aids (e.g., walkers, canes, wheelchairs) for movement support.
    • Occupational therapy to enhance daily activities and recommend home modifications (e.g., stair lifts, grab bars).

    B. Bladder Dysfunction Management

    1. Overactive bladder treatment: Anticholinergic medications like oxybutynin or tolterodine.

    2. Urinary retention treatment:

    • Intermittent self-catheterization (ISC) to empty the bladder as needed.
    • Indwelling catheterization for patients with severe dysfunction.
    • Hand-held external stimulators may help initiate urination.

    C. Bowel Dysfunction Management

    • Constipation: High-fiber diet, increased fluid intake, and laxatives (e.g., lactulose, bisacodyl).

    • Severe constipation: May require suppositories or enemas.

    • Bowel incontinence: Pelvic floor exercises and medications like loperamide for diarrhea control.

    D. Pain Management

    1. Neuropathic Pain (Nerve-Related Pain) Treatment

    • Anticonvulsants: Gabapentin, pregabalin.
    • Tricyclic antidepressants: Amitriptyline, nortriptyline.

    2. Musculoskeletal Pain Management

    • Physical therapy: Exercises, proper seating posture.
    • Pain relievers: NSAIDs (e.g., ibuprofen) or stronger analgesics if needed.
    • Transcutaneous Electrical Nerve Stimulation (TENS): May help alleviate chronic pain.

    E. Sexual Dysfunction Management

    • Men with erectile dysfunction: PDE-5 inhibitors (e.g., sildenafil).
    • Women with decreased libido: Psychological counseling and sexual therapy.
    • Relationship counseling: Helps couples adjust to changes in intimacy.
    3. Nursing Management of Transverse Myelitis

    Nursing care focuses on supportive management, preventing complications, and assisting with rehabilitation.

    A. Nursing Diagnoses and Interventions

    Nursing Diagnosis

    Interventions

    Impaired physical mobility (related to muscle weakness/spasticity)

    – Assist with physical therapy.

    – Provide mobility aids.

    – Prevent contractures with passive ROM exercises.

    Risk for skin breakdown (due to immobility and pressure ulcers)

    – Reposition every 2 hours.

    – Use pressure-relieving mattresses.

    – Keep skin dry and moisturized.

    Urinary retention/incontinence

    – Assist with catheterization.

    – Monitor fluid intake.

    – Teach bladder training techniques.

    Bowel incontinence or constipation

    – Encourage high-fiber diet and hydration.

    – Assist with bowel training.

    Chronic pain (related to nerve damage)

    – Administer prescribed analgesics.

    – Provide warm compresses or TENS therapy.

    Risk for infection (due to catheterization, immunosuppressants)

    – Follow aseptic techniques.

    – Monitor for fever and signs of infection.

    B. Psychological and Emotional Support

    • Patients with TM may experience anxiety, depression, and frustration due to mobility loss.
    • Counseling and mental health support can help cope with emotional challenges.
    • Support groups allow patients to connect with others facing similar challenges.
    4. Preventing Complications

    Complications of transverse myelitis can be serious and life-threatening. Preventative strategies include:

    Complication

    Prevention Strategies

    Pressure ulcers

    Regular repositioning, skin assessments, pressure-relieving mattresses.

    Deep vein thrombosis (DVT)

    Compression stockings, anticoagulants, leg exercises.

    Urinary tract infections (UTIs)

    Proper catheter care, increased hydration, bladder training.

    Respiratory failure

    Respiratory exercises, mechanical ventilation if needed.

    Chronic pain

    Early pain management, physiotherapy, psychological counseling.

    Transverse Myelitis Read More »

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