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liver cirrhosis

Liver Cirrhosis

Nursing Notes - Biliary System and Liver

LIVER CIRRHOSIS

Cirrhosis is a chronic, irreversible disease characterized by the replacement of normal liver tissue with diffuse fibrosis (scar tissue). This scarring disrupts the normal structure and function of the liver, leading to necrosis of liver cells, nodule formation, and distortion of the liver's vascular network.

Types of Liver Cirrhosis

  • Alcoholic Cirrhosis (Laennec's Cirrhosis): The most common type, resulting from chronic alcohol ingestion and associated malnutrition. The scar tissue characteristically surrounds the portal areas.
  • Post-necrotic Cirrhosis: Characterized by broad bands of scar tissue, this type is often a late result of a previous acute viral hepatitis infection (especially Hepatitis B and C).
  • Biliary Cirrhosis: Scarring occurs around the bile ducts due to chronic biliary obstruction and infection (cholangitis). It is much less common.
  • Cardiac Cirrhosis: Results from long-standing, severe, right-sided heart failure, which causes chronic congestion and damage to the liver.

Causes of Liver Cirrhosis

  • Infections: Chronic viral hepatitis B and C are major causes.
  • Intoxication: Chronic, excessive alcohol consumption is the leading cause. Other toxins and drugs (e.g., methotrexate, isoniazid) can also cause cirrhosis.
  • Metabolic and Infiltrative Disorders: Non-alcoholic fatty liver disease (NAFLD), Wilson's disease (copper overload), and hemochromatosis (iron overload).
  • Biliary Obstruction: Chronic congestion with bile (e.g., primary biliary cirrhosis - PBC).
  • Vascular Congestion: Chronic congestion with blood (e.g., Budd-Chiari syndrome, cardiac failure).
  • Idiopathic: In some cases, the cause is unknown.

Clinical Features of Liver Cirrhosis

Signs and symptoms increase in severity as the disease progresses. Cirrhosis is often categorized as compensated or decompensated.

Compensated Cirrhosis

In this early stage, the liver is still able to perform most of its functions. Symptoms are often vague and may be discovered incidentally.

  • Intermittent mild fever.
  • Vascular spiders (spider angiomas) on the skin.
  • Palmar erythema (reddened palms).
  • Unexplained epistaxis (nosebleeds).
  • Ankle edema.
  • Vague morning indigestion and flatulent dyspepsia.
  • Abdominal pain.
  • A firm, enlarged liver (hepatomegaly) and splenomegaly.
Decompensated Cirrhosis

This is the late stage, where the liver is failing and signs of portal hypertension and liver insufficiency are prominent.

  • Ascites: Accumulation of fluid in the peritoneal cavity.
  • Jaundice: Yellowing of the skin and eyes.
  • Weakness and Muscle Wasting.
  • Weight Loss.
  • Endocrine Changes:
    • Loss of libido, testicular atrophy, gynecomastia (in males).
    • Amenorrhea, irregular menses, breast atrophy (in females).
  • Bleeding Tendencies: Spontaneous bruising, purpura (due to low platelet count), and epistaxis.
  • Hepatic Encephalopathy: Confusion, altered mental state, and asterixis ("liver flap") due to the accumulation of ammonia.
  • Other signs: Hair loss, finger clubbing, edema of the legs, and pain in the right upper abdominal quadrant.

Investigations for Liver Cirrhosis

  • Liver Function Tests (LFTs): To assess liver functional abnormalities. Shows elevated liver enzymes (AST, ALT), alkaline phosphatase, and bilirubin. Serum albumin will be low.
  • Complete Blood Count (CBC): To detect anemia and thrombocytopenia (low platelet count).
  • Serological Tests: Blood tests to rule out viral hepatitis (B, C) and HIV.
  • Coagulation Studies: Prothrombin Time (PT) will be prolonged due to decreased synthesis of clotting factors.
  • Serum Electrolytes: To check for imbalances, especially hyponatremia.
  • Abdominal Ultrasound: To reveal the size of the liver (can be enlarged or shrunken), assess for nodules, ascites, and other hepatic abnormalities.
  • CT Scan: To assess for lobe enlargement, vascular changes, and nodules in more detail.
  • Endoscopy (EGD): Crucial for identifying and assessing esophageal varices, a major complication of portal hypertension.
  • Liver Biopsy: The definitive test to confirm the diagnosis by revealing the destruction and fibrosis of liver tissues.

Management of a Patient with Liver Cirrhosis

Liver cirrhosis is a late-stage liver disease where healthy liver tissue is replaced by scar tissue, leading to irreversible liver damage and impaired liver function. Management is complex and aims to prevent further progression, manage complications, and improve the patient's quality of life.

Aims of Management

  • To remove or alleviate the underlying cause of cirrhosis (e.g., abstinence from alcohol for alcoholic liver disease, antiviral therapy for chronic viral hepatitis).
  • To prevent further liver damage and, where possible, promote regeneration of remaining healthy liver tissue.
  • To prevent and effectively treat complications arising from portal hypertension and liver dysfunction (e.g., ascites, variceal bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis).
  • To improve the patient's quality of life and functional status.

Nursing Care Plan for Patients with Liver Cirrhosis

Nursing care is pivotal in managing symptoms, preventing complications, educating patients and families, and providing comprehensive supportive care.

1. Admission and Initial Assessment
  • Placement: Admit the patient to a medical ward. Ensure a quiet, calm, well-ventilated environment conducive to rest.
  • Information Gathering: Obtain comprehensive patient particulars and medical history from the patient or their relatives. This quick history is crucial for establishing the likely cause of cirrhosis and guiding immediate medical management. Document all findings in the admission records.
  • Physician Notification: Immediately inform the attending physician of the patient's admission and preliminary findings to facilitate prompt medical assessment and orders.
  • Psychological Care:
    • Establish Therapeutic Rapport: Build trust and rapport with the patient and family.
    • Provide Counseling and Reassurance: Explain the condition, the management plan, and the importance of adherence to treatment in clear, understandable terms. Address anxieties and fears openly and empathetically. Encourage questions.
    • 2. Ongoing Monitoring and Observations
  • Positioning: Nurse the patient in a position of comfort that optimizes breathing and circulation. For patients with ascites and dyspnea, a semi-Fowler's or high-Fowler's position is often preferred to alleviate pressure on the diaphragm and improve lung expansion.
  • Vital Observations:
    • Monitor temperature, pulse, respiration, blood pressure, and oxygen saturation regularly (e.g., hourly, 2-hourly, or as ordered based on the patient's condition).
    • Maintain an accurate observation chart.
    • Report any abnormalities immediately (e.g., hypotension, tachycardia, fever, tachypnea), as these could indicate complications like bleeding, infection, or worsening liver failure.
  • Specific/Physical Observations: Continuously monitor for and document:
    • Skin: Jaundice (assess sclera, skin), severe pruritus, and skin integrity (assess for excoriations, pressure areas, edema, spider angiomas, palmar erythema).
    • Bleeding: Signs of internal or external bleeding (epistaxis, hematemesis, melena, hematochezia, petechiae, purpura, easy bruising, bleeding gums).
    • Neurological Status: Assess for signs of hepatic encephalopathy – confusion, disorientation, lethargy, slurred speech, asterixis (flapping tremors), changes in sleep-wake cycle, and ultimately coma. Use a grading scale (e.g., West Haven Criteria) if appropriate.
    • Abdominal Assessment: Abdominal girth measurements (daily, at the same level) and assessment for fluid wave to quantify ascites. Note any tenderness or guarding.
    • Edema: Peripheral edema (pitting vs. non-pitting, location, severity).
    • Gastrointestinal: Nausea, vomiting, indigestion, abdominal discomfort, changes in bowel habits.
    • Symptom Intensity: Note the intensity of all symptoms and report significant changes to the medical team.
    • 3. Diagnostic Investigations
  • Prepare the patient and assist with various investigations as ordered to confirm diagnosis, assess liver function, identify etiology, and monitor for complications:
    • Complete Blood Count (CBC): To check for anemia (due to chronic bleeding, malnutrition, or hemolysis), leukopenia, and thrombocytopenia (due to hypersplenism).
    • Liver Function Tests (LFTs): Bilirubin (total and direct), AST, ALT, ALP, GGT to monitor liver synthetic and excretory function.
    • Coagulation Profile: Prothrombin Time (PT), International Normalized Ratio (INR), Partial Thromboplastin Time (PTT) to assess clotting ability (impaired in liver dysfunction).
    • Kidney Function Tests: Urea, Creatinine, Electrolytes to monitor renal function, especially with diuretics or potential hepatorenal syndrome.
    • Serum Albumin: To assess liver synthetic function and risk of ascites/edema.
    • Serum Ammonia: To monitor for hepatic encephalopathy.
    • Serology: Blood tests for Hepatitis B (HBsAg, anti-HBc, HBeAg), Hepatitis C (anti-HCV, HCV RNA), Hepatitis D, and HIV to identify viral causes. Autoimmune markers if suspected.
    • Imaging Studies:
      • Abdominal Ultrasound: To assess liver size, texture, presence of ascites, portal vein patency, and rule out hepatocellular carcinoma.
      • CT Scan/MRI: Provides more detailed imaging of the liver and associated structures.
    • Liver Biopsy: The gold standard for confirming the diagnosis of cirrhosis, assessing its severity, and sometimes identifying the specific etiology (though often not required if clinical and imaging evidence is conclusive).
    • Esophagogastroduodenoscopy (EGD): To screen for and manage esophageal varices.
    • 4. Pharmacological Management
  • Administer all prescribed medications accurately and on time. Maintain an accurate treatment chart. Common medications include:
    • Diuretics: For ascites and edema. Spironolactone (a potassium-sparing diuretic) is often the first-line and is frequently combined with Furosemide (a loop diuretic) for synergistic effects. Monitor fluid balance and electrolytes carefully.
    • Antiviral Treatment: For chronic Hepatitis B or C to manage the underlying cause and prevent disease progression.
    • Lactulose: To reduce ammonia levels in patients with hepatic encephalopathy. It works as a laxative, promoting ammonia excretion in stool, and acidifies the colon, trapping ammonia.
    • Rifaximin: A non-absorbable antibiotic sometimes used in conjunction with lactulose to reduce ammonia-producing bacteria in the gut.
    • Vitamin Supplements:
      • Vitamin B complex (especially thiamine, folate, B12) for nutritional deficiencies and to prevent Wernicke-Korsakoff syndrome in alcoholic cirrhosis.
      • Vitamin K: May be given to correct clotting abnormalities due to impaired synthesis of clotting factors.
      • Fat-soluble vitamins (A, D, E) if cholestasis is significant.
    • Beta-blockers (e.g., Propranolol, Carvedilol): To reduce portal pressure and prevent variceal bleeding.
    • Proton Pump Inhibitors (PPIs) or H2 Blockers: To decrease gastric acid secretion and prevent stress ulcers.
    • Antibiotics: For infections (e.g., IV Ceftriaxone for spontaneous bacterial peritonitis).
    • Albumin: Intravenous albumin infusions may be given during large-volume paracentesis or for severe hypoalbuminemia.
    • Analgesics: Administer pain relief as prescribed (e.g., Tramadol). Avoid hepatotoxic drugs, especially NSAIDs and high doses of paracetamol, which can exacerbate liver damage or increase bleeding risk.
    • Antiemetics: (e.g., Metoclopramide) for nausea and vomiting.
    • 5. Non-Pharmacological Management & Lifestyle Modifications
  • Abstinence from Alcohol: Complete and lifelong avoidance of alcohol is the single most crucial intervention for alcoholic cirrhosis to halt disease progression and allow for potential liver recovery.
  • Appropriate Nutrition:
    • Provide a well-balanced diet adequate in calories and protein to promote liver regeneration and prevent malnutrition.
    • Protein Moderation/Restriction: While protein is essential, it must be restricted only if the patient shows signs of hepatic encephalopathy (as protein breakdown produces ammonia). Otherwise, adequate protein intake is encouraged.
    • Sodium Restriction: A strict low-sodium diet (< 2g/day) is essential to help manage and prevent ascites and peripheral edema.
  • Fluid Restriction: Usually only required if dilutional hyponatremia is present and severe.
  • Bed Rest and Moderate Exercise: During acute decompensation, bed rest reduces metabolic demands on the liver. As the patient improves, encourage and support active exercises to prevent deconditioning, respiratory complications, and deep vein thrombosis (DVT).
  • Avoidance of Hepatotoxic Agents: Educate the patient to avoid all known hepatotoxins, including certain over-the-counter medications (e.g., acetaminophen in high doses), herbal remedies, and illicit drugs, without consulting their physician.
    • 6. Surgical Treatment and Procedures
  • Paracentesis: A therapeutic procedure to remove excess ascitic fluid from the peritoneal cavity for symptom relief (dyspnea, abdominal discomfort). Often followed by infusions of salt-poor albumin, particularly after large volume paracentesis (>5L), to prevent post-paracentesis circulatory dysfunction.
  • Endoscopic Sclerotherapy or Band Ligation: Procedures performed via endoscopy to treat acute bleeding from esophageal varices or to prevent re-bleeding by obliterating the varices.
  • Transjugular Intrahepatic Portosystemic Shunt (TIPS): A radiological procedure that creates a shunt within the liver to relieve portal hypertension by diverting blood flow from the portal vein directly into the hepatic vein. Used for refractory ascites or recurrent variceal bleeding not controlled by endoscopic means.
  • Liver Transplantation: The definitive treatment for patients with advanced, end-stage liver disease who meet specific criteria. It offers the potential for long-term survival and improved quality of life.
    • 7. Elimination Management
  • Bladder Care: Offer a bedpan or urinal regularly. Monitor urine output meticulously for color and amount. Maintain an accurate fluid balance chart (strict intake and output) to assess hydration status and response to diuretics.
  • Bowel Care: Offer a bedpan or commode. Observe stool for color (checking for melena or hematochezia) and consistency. Administer medications like lactulose as prescribed to treat constipation and reduce ammonia levels by promoting regular bowel movements.
    • 8. Hygiene and Skin Care
  • Daily Hygiene: Provide daily bed baths or assist with showers to ensure comfort and cleanliness.
  • Meticulous Skin Care: Patients with cirrhosis are highly prone to skin breakdown due to edema, pruritus, malnutrition, and impaired clotting.
    • Inspect skin daily for signs of breakdown, excoriations, or infection.
    • Use mild soaps and moisturizers.
    • Implement 4-hourly repositioning and use pressure-relieving devices (e.g., special mattresses, cushions) to prevent pressure sores.
    • Manage pruritus effectively (see symptom management above).
  • Oral Care: Perform daily oral care to prevent oral complications (e.g., gum bleeding) and stimulate appetite.
    • 9. Activity and Mobility
  • Physiotherapy/Exercises: Provide passive range of motion exercises for patients on bed rest to prevent joint stiffness and muscle atrophy. As the patient's condition improves, encourage and support active exercises, deep breathing exercises, and progressive ambulation to prevent respiratory complications (e.g., hypostatic pneumonia) and circulatory complications (e.g., DVT).
  • Rest and Sleep: Ensure a quiet and restful environment by minimizing noise, dimming lights, and restricting non-essential visitors. Administer medications in a timely manner to manage symptoms (like pain, pruritus, or insomnia) that may interfere with sleep.
    • 10. Discharge Planning and Education

    When the patient's condition has stabilized and they are deemed fit for discharge, provide comprehensive education to the patient and their family to ensure continuity of care and prevent readmission:

  • Medication Adherence: Emphasize the importance of taking all prescribed medications exactly as ordered, understanding their purpose, and completing the full course. Educate on potential side effects.
  • Rest and Activity: Advise on the need for adequate rest at home to conserve energy and promote recovery, balanced with gentle, regular exercise as tolerated.
  • Dietary Guidelines: Reinforce adherence to a well-balanced, low-sodium diet. Reiterate the absolute avoidance of alcohol. Discuss protein intake guidelines based on whether hepatic encephalopathy is a concern.
  • Monitoring for Complications: Educate on signs and symptoms of worsening cirrhosis or complications (e.g., increased abdominal swelling, confusion, new bleeding, fever, worsening jaundice) and when to seek immediate medical attention.
  • Follow-up Appointments: Emphasize the importance of attending all scheduled follow-up appointments with physicians and other healthcare providers.
  • Medication Storage: Advise on proper storage of medications (dry, cool place, out of reach of children).
  • Lifestyle Adjustments: Discuss avoidance of illicit drugs, certain over-the-counter medications, and supplements without medical advice.

    • Complications of Liver Cirrhosis

    The major complications of liver cirrhosis primarily stem from two pathological processes: portal hypertension and progressive liver cell failure. These complications are often life-threatening and require prompt and aggressive management.

    • Portal Hypertension: This is a key complication resulting from increased resistance to blood flow through the cirrhotic liver. The scar tissue obstructs the normal flow of blood from the portal vein (which collects blood from the GI tract and spleen) into the hepatic veins. This leads to an increase in blood pressure within the portal venous system, which then causes a cascade of other complications.
    • Variceal Hemorrhage: Due to portal hypertension, blood is shunted into collateral vessels, particularly in the esophagus and stomach (esophageal and gastric varices). These vessels are thin-walled, fragile, and not designed for high pressure. They are prone to rupture, leading to life-threatening gastrointestinal bleeding. Bleeding can be triggered by muscular exertion (e.g., straining during defecation, severe coughing), irritation from food, or gastric reflux. This is a medical emergency.
    • Ascites: The accumulation of large amounts of fluid in the peritoneal (abdominal) cavity. It is caused by a combination of high pressure in the portal system (forcing fluid out of vessels), low levels of serum albumin (due to impaired liver synthesis, reducing oncotic pressure and leading to fluid leakage from vessels), and renal retention of sodium and water.
    • Hepatic Encephalopathy: A complex, reversible neuropsychiatric syndrome resulting from the accumulation of toxic substances in the blood, primarily ammonia, which the damaged liver can no longer effectively detoxify. These toxins bypass the liver via shunts and reach the brain, leading to altered mental status, confusion, disorientation, changes in personality, asterixis (flapping tremors), and can progress to stupor and coma. Precipitating factors include GI bleeding, infection, constipation, high protein intake, and electrolyte imbalances.
    • Spontaneous Bacterial Peritonitis (SBP): A severe infection of the ascitic fluid that occurs in the absence of an obvious source of infection. It is a common and life-threatening complication in patients with ascites, believed to occur due to bacterial translocation from the gut into the ascitic fluid. Signs include fever, abdominal pain, and worsening encephalopathy.
    • Hepatorenal Syndrome (HRS): A severe and often fatal complication characterized by progressive kidney failure in people with advanced liver disease, particularly cirrhosis. It is a functional renal failure, meaning there is no intrinsic kidney disease; rather, it results from severe vasoconstriction of renal arteries due to complex circulatory abnormalities in liver failure, leading to reduced blood flow to the kidneys.
    • Hepatopulmonary Syndrome (HPS): A triad of liver disease, intrapulmonary vascular dilations, and arterial hypoxemia. It results from abnormal vasodilation of the pulmonary capillaries, leading to impaired gas exchange.
    • Portopulmonary Hypertension: Pulmonary hypertension that develops in patients with portal hypertension, not directly related to HPS, but due to pulmonary arterial vasoconstriction.
    • Hepatocellular Carcinoma (HCC): Cirrhosis, regardless of its cause, is the strongest risk factor for the development of primary liver cancer. Regular screening for HCC is crucial.
    • Coagulopathy: Impaired synthesis of clotting factors by the diseased liver leads to increased bleeding tendencies.
    • Malnutrition and Muscle Wasting: Common due to anorexia, malabsorption, and altered metabolism.
    • Infections: Patients with cirrhosis are immunocompromised and highly susceptible to various infections (e.g., pneumonia, UTIs, skin infections, SBP).

    Nursing Diagnoses and Interventions for Liver Cirrhosis

    Below are common nursing diagnoses for patients with liver cirrhosis, along with their associated nursing interventions.

    1. Excess Fluid Volume

  • Related to: Impaired regulatory mechanisms (e.g., renal sodium and water retention), portal hypertension, decreased plasma albumin.
  • Evidenced by: Edema (peripheral, sacral), ascites, weight gain, dyspnea, increased abdominal girth, altered electrolyte levels.
  • Nursing Interventions:
    • Monitor Fluid Balance: Accurately measure and record daily weight, strict intake and output.
    • Assess Edema and Ascites: Measure abdominal girth daily at the same level. Assess for peripheral and sacral edema (pitting vs. non-pitting).
    • Administer Diuretics: Give prescribed diuretics (e.g., Spironolactone, Furosemide) and monitor their effectiveness.
    • Monitor Electrolytes: Closely monitor serum sodium, potassium, and creatinine levels, reporting abnormalities.
    • Restrict Sodium: Implement and educate patient/family on a strict low-sodium diet as ordered.
    • Fluid Restriction: Implement fluid restriction only if ordered and necessary (e.g., severe dilutional hyponatremia).
    • Positioning: Elevate edematous extremities. Elevate the head of the bed (semi-Fowler's) to improve breathing if ascites is causing dyspnea.
    • Skin Care: Provide meticulous skin care to edematous areas to prevent breakdown.
    • Patient Education: Educate on rationale for sodium/fluid restriction, medication regimen, and reporting increased swelling or weight gain.

    • 2. Inadquate protein energy intake

  • Related to: Anorexia, nausea, impaired metabolism and absorption, altered fat and protein digestion/absorption (due to reduced bile production or portal hypertension affecting gut).
  • Evidenced by: Weight loss, muscle wasting, decreased albumin, electrolyte imbalances, fatigue.
  • Nursing Interventions:
    • Assess Nutritional Status: Monitor weight, evaluate dietary intake, assess for signs of malnutrition (muscle wasting, skin turgor).
    • Provide Nutritional Support: Collaborate with a dietitian to develop an individualized meal plan.
    • Offer Small, Frequent Meals: To improve tolerance and increase overall intake.
    • Encourage Calorie-Dense Foods: Unless contraindicated.
    • Protein Management: Provide adequate protein unless signs of hepatic encephalopathy are present. If encephalopathy, moderate protein intake as directed.
    • Administer Vitamin Supplements: As prescribed (e.g., B vitamins, fat-soluble vitamins, Vitamin K).
    • Manage Nausea: Administer antiemetics before meals as prescribed.
    • Oral Hygiene: Provide meticulous oral care before meals to enhance appetite.
    • Create Pleasant Environment: Ensure a comfortable and appealing environment for meals.
    • Patient Education: Educate on dietary modifications, avoidance of alcohol, and importance of nutrition.

    • 3. Risk for Bleeding

  • Related to: Impaired liver synthesis of clotting factors, portal hypertension leading to esophageal/gastric varices, thrombocytopenia (hypersplenism).
  • Evidenced by: (Potential for) Hematemesis, melena, epistaxis, petechiae, purpura, easy bruising, prolonged PT/INR.
  • Nursing Interventions:
    • Monitor for Bleeding: Routinely assess for signs of bleeding (check stool for melena, emesis for coffee grounds/bright blood, urine for hematuria, skin for petechiae/ecchymosis).
    • Monitor Coagulation Profile: Review PT/INR, PTT, and platelet count.
    • Administer Vitamin K: As prescribed to improve clotting factor synthesis.
    • Avoid Trauma: Use soft toothbrushes, electric razors. Avoid IM injections if possible; if given, use smallest gauge needle and apply prolonged pressure.
    • Prevent Constipation/Straining: Encourage high-fiber diet, fluids, and administer stool softeners/laxatives (like lactulose) to prevent straining, which can increase variceal pressure.
    • Administer Medications to Reduce Portal Pressure: Beta-blockers as prescribed.
    • Prepare for Endoscopic Procedures: If varices are known, prepare patient for EGD and band ligation/sclerotherapy.
    • Emergency Preparedness: Have emergency equipment (e.g., Sengstaken-Blakemore tube, IV access) readily available if variceal hemorrhage is suspected.
    • Patient Education: Educate on bleeding precautions, signs of bleeding to report, and medication adherence.

    • 4. Altered Thought Processes / Risk for Acute Confusion

  • Related to: Accumulation of toxins (especially ammonia) due to impaired liver detoxification.
  • Evidenced by: Changes in LOC (lethargy, disorientation), confusion, asterixis, personality changes, slurred speech, impaired judgment.
  • Nursing Interventions:
    • Assess Neurological Status: Perform frequent neurological assessments, including LOC, orientation, presence of asterixis, and appropriateness of behavior/speech. Use a standardized scale if applicable.
    • Monitor Ammonia Levels: Review serum ammonia levels.
    • Administer Medications: Give lactulose as prescribed to reduce ammonia (monitor for desired number of soft stools per day). Administer rifaximin if ordered.
    • Protein Restriction: If severe encephalopathy, ensure adherence to prescribed protein restriction (usually temporary).
    • Ensure Bowel Regularity: Encourage regular bowel movements to excrete ammonia.
    • Safety Precautions: Implement fall precautions (side rails up, bed in low position, assist with ambulation). Supervise activities.
    • Maintain Calm Environment: Minimize sensory overload. Provide reorientation as needed (calendar, clock).
    • Communicate Clearly: Use simple, direct commands. Allow time for response.
    • Family Education: Educate family on signs of encephalopathy and rationale for treatment.

    • 5. Impaired Skin Integrity / Risk for Impaired Skin Integrity

  • Related to: Edema, pruritus (scratching), malnutrition, altered clotting factors, jaundice.
  • Evidenced by: Excoriations, dryness, bruising, pressure ulcers.
  • Nursing Interventions:
    • Assess Skin Daily: Inspect skin for signs of breakdown, dryness, excoriations, color changes, and bruising.
    • Pressure Area Care: Turn patient every 2 hours or use pressure-relieving devices (e.g., air mattress, foam cushions).
    • Moisturize Skin: Apply emollients and lotions to dry skin.
    • Manage Pruritus: Administer anti-itch medications (e.g., cholestyramine, antihistamines) as prescribed. Keep nails short, suggest wearing soft cotton clothing. Provide cool baths.
    • Gentle Skin Care: Use mild soaps and avoid harsh scrubbing. Pat skin dry gently.
    • Nutrition: Promote good nutrition to support skin healing and integrity.
    • Protect from Injury: Pad side rails if patient is agitated or confused.

    • 6. Risk for Infection

  • Related to: Immunosuppression (impaired Kupffer cell function), ascites (risk of SBP), invasive procedures (paracentesis, endoscopy).
  • Evidenced by: (Potential for) Fever, chills, increased WBC, signs of peritonitis, worsening encephalopathy.
  • Nursing Interventions:
    • Monitor for Signs of Infection: Monitor temperature, WBC count. Assess for new onset or worsening abdominal pain, fever, or changes in mental status (suggesting SBP).
    • Aseptic Technique: Use strict aseptic technique for all invasive procedures (IV insertion, paracentesis, Foley catheterization).
    • Promote Pulmonary Hygiene: Encourage deep breathing and coughing to prevent pneumonia.
    • Administer Antibiotics: As prescribed for diagnosed infections (e.g., SBP prophylaxis or treatment).
    • Good Hand Hygiene: Educate patient, family, and staff on proper hand hygiene.
    • Avoid Crowds: Advise patient to avoid large crowds and sick individuals.
    • Vaccinations: Educate on importance of influenza and pneumococcal vaccines.

    • 7. Activity Intolerance

  • Related to: Fatigue, generalized weakness, muscle wasting, dyspnea (due to ascites), malnutrition, anemia.
  • Evidenced by: Reports of fatigue, weakness, dyspnea on exertion, inability to perform ADLs.
  • Nursing Interventions:
    • Assess Activity Level: Determine current activity tolerance and level of fatigue.
    • Promote Rest: Provide undisturbed periods of rest. Organize care to allow for rest.
    • Gradual Increase in Activity: Encourage progressive activity as tolerated. Collaborate with physical therapy for mobility plan.
    • Assist with ADLs: Provide assistance with self-care activities as needed to conserve energy.
    • Positioning: Elevate head of bed to ease breathing during activity.
    • Nutrition: Promote optimal nutrition to improve energy levels.
    • Patient Education: Educate on energy conservation techniques and importance of balancing rest and activity.

    • Liver Cirrhosis Read More »

    Nutrition in Children

    Nutrition in Children

    Nursing Notes - Child Growth and Development

    Nutrition in Children

    Balanced and sufficient nutritional intake is paramount for children. It serves multiple critical functions: promoting optimal growth and development, protecting and maintaining health, preventing nutritional deficiency conditions and various illnesses, and building reserves for periods of starvation or dietary stress. The term 'nutrition' itself is derived from 'nutricus', meaning 'to suckle at the breast', highlighting its fundamental connection to early life sustenance.

    Defining Key Terms

    • Nutrition: More broadly, nutrition is the intricate process by which consumed food is utilized for the nourishment and structural and functional efficacy of every cell in the body. In essence, it is the science that explores the relationship between food and health.
    • Food: Refers to anything that nourishes the body, encompassing solids, liquids, and semi-solids. Food provides the essential components for growth, energy, and bodily functions.

    Classification of Foods and Nutrients

    • Food Classification: Foods are typically classified based on their primary macronutrient content: proteins, fats, and carbohydrates. They also contain essential micronutrients like vitamins and minerals. Foods can be categorized by their origin, such as animal (e.g., meat, dairy) or vegetable (e.g., fruits, vegetables, grains).
    • Nutrients: These are the organic and inorganic complexes derived from food that the body requires for proper functioning. There are approximately 50 different essential nutrients that are normally supplied through the foods we eat.
    • Macronutrients vs. Micronutrients:
      • Macronutrients: Needed in larger quantities, these provide energy and building blocks for the body. This category includes carbohydrates, proteins, and fats.
      • Micronutrients: Required in much smaller amounts, these are vital for various metabolic processes, enzyme functions, and overall health. This category includes vitamins and minerals.

    Nutritional Requirements in Children

    Nutritional requirements vary significantly among individuals, influenced by metabolic differences, genetic predisposition, age, sex, and activity levels. It's crucial to understand that no single food, except for mother's milk (for infants), meets all the essential nutritional requirements for a baby.

    The primary components of a child's nutritional needs include:

    1. Water

    Water is arguably the most critical nutrient for the maintenance of life. It constitutes a significant portion of a child's body weight (around 70%), underscoring its importance. Water is essential for:

    • Digestion: Facilitates the breakdown of food and absorption of nutrients.
    • Metabolism: Involved in countless biochemical reactions within cells.
    • Renal Excretion: Helps the kidneys filter waste products from the blood and excrete them as urine.
    • Temperature Regulation: Helps maintain a stable body temperature through mechanisms like sweating.
    • Transportation: Acts as a medium for transporting nutrients, oxygen, hormones, and waste products throughout the body.
    • Maintenance of Fluid Volume: Crucial for maintaining blood volume and cellular turgor.
    • Growth: Essential for the formation of new cells and tissues.

    Water is absorbed throughout the intestinal tract. A critical note: Lack of water (dehydration) can lead to death far more rapidly than starvation, emphasizing its immediate necessity.

    2. Calories (Energy)

    The energy value of foods is measured in terms of calories (or kilocalories). The amount of energy produced varies depending on the type of food and how it's metabolized. Children require more calories per kilogram of body weight than adults, primarily due to their rapid growth and higher metabolic rates. Calorie requirements gradually decrease as a child approaches adulthood.

    Factors influencing calorie requirements in children include:

    • Body size and surface area.
    • Rate of growth.
    • Level of physical activity.
    • Individual food habits.
    • Climate (e.g., more energy needed in colder environments).

    Consequences of imbalanced calorie intake:

    • Deficiency: Inadequate calorie intake leads to weight loss, growth failure, and can result in protein-energy malnutrition (PEM).
    • Excess: An excessive intake of calories results in increased weight gain and can lead to obesity, posing significant long-term health risks.

    The average energy expenditure in children is distributed as follows:

    • Basal Metabolism: 50% (energy needed for basic bodily functions at rest).
    • Growth: 12% (energy used for tissue synthesis and development).
    • Physical Activity: 25% (energy expended during movement and play).
    • Fecal Loss: 8% (energy lost in undigested food).
    • Specific Dynamic Action (Thermic Effect of Food): 5-10% (energy expended in the digestion, absorption, and metabolism of food).
    3. Proteins

    Proteins are fundamental macronutrients, essential for a myriad of bodily functions, particularly in growing children. They are crucial for:

    • Synthesis of Body Tissues: Vital for the rapid growth and development of new cells, muscles, organs, and other tissues.
    • Body Repair: Involved in the repair and maintenance of existing tissues.
    • Formation of Vital Compounds: Essential for the production of digestive juices, hormones, plasma proteins, enzymes, hemoglobin (Hb), and immunoglobulins (antibodies, which are critical for the immune system).
    • Maintenance of Osmotic Pressure and Acid-Base Equilibrium: Proteins in the blood help regulate fluid balance and maintain the body's pH.
    • Source of Energy: While primarily building blocks, proteins can be used as an energy source when carbohydrate and fat intake is inadequate.

    Excess proteins, if consumed, are converted by the liver into fat and stored in body tissues. The human body requires 20 different amino acids (of which 9 are essential and must be obtained from the diet) to synthesize its own proteins. Protein requirements depend on age, sex, and physiological factors, gradually decreasing as age increases. Deficiency of protein intake can lead to growth failure and specific forms of protein-energy malnutrition, such as Kwashiorkor.

    4. Carbohydrates

    Carbohydrates are the body's primary and most readily available source of energy. They are essential for providing fuel for all bodily functions, including brain activity, muscle contraction, and maintaining body temperature. Beyond energy, they are also:

    • Essential for Digestion and Absorption: Aid in the proper digestion and absorption of other foods.
    • Protein-Sparing Effect: When sufficient carbohydrates are available, proteins can be spared from being used for energy and thus fully utilized for their primary roles in growth and various repair processes.

    Excess carbohydrates are converted into glycogen and stored in the liver and muscles for later use, or converted into fat if stores are full. While essential, excessive intake of carbohydrates, particularly refined ones, can contribute to obesity, increase the risk of ischemic heart disease, cataracts, and dental caries.

    5. Fats

    Fats are a concentrated source of energy, supplying a significant portion (40-50%) of the energy needed for infants due to their high caloric density. Besides providing energy, fats serve several other crucial roles:

    • Protection and Support: Provide cushioning and support for vital organs.
    • Insulation: Help insulate the body, regulating temperature.
    • Absorption of Fat-Soluble Vitamins: Necessary for the absorption of vitamins A, D, E, and K.

    Deficiency of essential fatty acids can lead to growth retardation, skin disorders, and increased susceptibility to infections. Recommended daily intake for young children is approximately 25g/day, and for older children, around 22g/day, though these can vary based on individual needs and dietary recommendations.

    6. Vitamins

    Vitamins are organic compounds required in minimal amounts for various metabolic processes and overall health. They are categorized into:

    • Fat-soluble vitamins: A, D, E, K (stored in the body's fatty tissues).
    • Water-soluble vitamins: B-complex vitamins and Vitamin C (not stored in the body and need to be replenished daily).

    Since water-soluble vitamins are not stored, a consistent, adequate daily dietary intake is crucial to prevent deficiency diseases.

    7. Minerals

    Minerals are inorganic elements essential for a wide range of physiological functions. They are required by the human body for growth, repair of tissues, and regulation of vital body functions. Minerals often act as catalysts in biochemical reactions, facilitating enzyme activity. More than 50 different minerals are found in the human body, all of which must be derived from the foods we eat (e.g., calcium for bones, iron for blood, zinc for immunity).

    Breastfeeding: The Optimal Infant Nutrition

    Breastfeeding is widely recognized as the safest, cheapest, and best natural feeding method for infants. It comprehensively meets the nutritional, emotional, and psychological needs of the infant. Tragically, many infants in vulnerable populations die from preventable illnesses like diarrhea and acute respiratory infections partly due to insufficient breastfeeding practices. Breastfeeding offers numerous advantages:

    Advantages for the Infant:
    • Nutritive Value: Breast milk contains all the essential nutrients in the right proportions needed for optimal growth and development of a baby up to 6 months of age. Its composition dynamically changes to meet the baby's evolving needs.
    • Digestibility: Breast milk is easily digestible because it contains unique proteins that form soft curds, which are gentle on an infant's immature digestive system. It also contains the enzyme lipase, which aids in the digestion of fats and provides easily absorbable free fatty acids.
    • Protective Value (Immunological Benefits): It is rich in critical immune factors, including IgA, IgM antibodies, macrophages, lymphocytes, lysozyme, and interferon. These components provide passive immunity, making a breastfed baby significantly less likely to develop infections, especially gastrointestinal and respiratory tract infections.
    • Psychological Benefits: Breastfeeding promotes a profound close physical and emotional bond between mother and infant through frequent skin-to-skin contact, eye contact, and interaction, fostering security and attachment.
    Maternal Benefits of Breastfeeding:
    • Uterine Involution: Helps reduce the chance of postpartum hemorrhage by stimulating uterine contractions and aids in better uterine involution (the process by which the uterus returns to its pre-pregnancy size).
    • Iron Stores Recovery: Promotes the recovery of maternal iron stores, reducing the risk of postpartum anemia.
    • Natural Contraception: Provides a natural, though not foolproof, form of contraception, protecting the mother from pregnancy for the first 6 months, particularly when breastfeeding is carried out exclusively (Lactational Amenorrhea Method - LAM).
    • Sense of Fulfillment: Provides a deep sense of satisfaction and fulfillment for the mother, contributing to maternal well-being.
    • Weight Loss: Improves maternal slimming by consuming extra fat accumulated during pregnancy, as lactation requires significant energy expenditure.
    • Convenience: It is highly convenient and time-saving, requiring no preparation, sterilization, or specific temperatures.
    Family and Community Benefits:
    • Economical: Breastfeeding is economical, saving families significant money that would otherwise be spent on formula, bottles, and sterilization equipment.
    • Environmental: Reduces environmental waste associated with formula production and packaging.
    • Public Health: Contributes to healthier communities by reducing infant morbidity and mortality rates.

    Preparation for Breastfeeding

    Successful breastfeeding begins long before delivery:

    • Antenatal Period: Preparation must begin during the antenatal period (pregnancy).
    • Education on Benefits: Mothers should be thoroughly educated about the extensive benefits of breastfeeding for both themselves and their babies.
    • Breast Examination: Examination of the breasts to identify any potential problems (e.g., inverted nipples) that might affect latch and provide solutions.
    • Maternal Health: Prevention of micronutrient deficiencies in the mother, along with advice on rest, regular exercise, and hygienic measures, contributes to successful lactation.
    • Counseling and Support: Antenatal counseling and strong family support are crucial for building the mother's confidence and preparing her for the breastfeeding journey.

    Initiation of Breastfeeding

    Early and proper initiation of breastfeeding is critical:

    • Immediate Initiation: Breastfeeding should be initiated within the first half an hour to one hour of birth, or as soon as possible after delivery, known as "immediate" or "early" initiation.
    • Benefits of Early Suckling: Early suckling provides warmth and security for the newborn and ensures they receive colostrum, the "first milk."
    • Exclusive Breastfeeding: Mothers should be strongly advised for exclusive breastfeeding up to 6 months. This means giving no food or drink other than breast milk to neonates.
    • Avoidance of Supplements: This includes no water, glucose water, animal milk, gripe water, indigenous medicines, or routine vitamin and mineral drops/syrups unless medically indicated.

    Indicators of Adequate Breastfeeding (Signs of Sufficient Milk Intake)

    Parents can look for several signs to confirm their baby is getting enough breast milk:

    • Audible Swallowing: Hearing the baby swallow during feeds.
    • Let-down Sensation: The mother may feel a tingling or fullness as milk is released from the breast.
    • Wet Nappies: 6 or more wet nappies (diapers) in 24 hours.
    • Breast Changes: Breasts feeling full before a feed and noticeably softer afterwards.
    • Bowel Movements: Frequent, soft bowel movements, typically 3-8 times in 24 hours (can decrease after the first few weeks).
    • Average Weight Gain: Consistent and appropriate weight gain as monitored by a healthcare professional.
    • Baby's Demeanor: Baby sleeps well, does not cry excessively, has good muscle tone, and healthy skin.

    Composition of Breast Milk

    Breast milk composition dynamically changes at different stages in the postnatal period to precisely fulfill the evolving needs of the baby:

    • Colostrum:
      • Secreted during the first 3 days after delivery.
      • Characterized by its thick, yellow appearance and small quantities.
      • Extremely rich in antibodies and immune cells, along with higher amounts of proteins and fat-soluble vitamins, providing crucial early protection.
    • Transitional Milk:
      • Secreted during the first 2 weeks of the postnatal period, following colostrum.
      • Bridge between colostrum and mature milk, with increased fat and sugar content as the milk volume increases.
    • Mature Milk:
      • Secreted from 10-12 days after delivery onwards.
      • Appears more watery but contains all the necessary nutrients in balanced proportions for optimal growth and development of the baby.
    • Preterm Milk:
      • Produced by mothers who deliver prematurely.
      • Contains specific nutrients and higher protein content tailored to the unique developmental needs and increased vulnerability of premature infants.
    • Foremilk:
      • The milk obtained at the beginning of a feed.
      • It is more watery and contains more proteins, sugar (lactose), vitamins, and minerals, primarily quenching the baby's thirst.
    • Hindmilk:
      • The milk obtained towards the end of a feed, after the foremilk.
      • Provides significantly more fat and thus more energy, crucial for the baby's growth and satiety. It's important for babies to get enough hindmilk.

    Techniques of Breastfeeding

    Proper technique ensures comfortable and effective breastfeeding for both mother and baby:

    1. Maternal Comfort: The mother should be comfortable and relaxed, both physically and mentally, before initiating a breastfeed.
    2. Correct Positioning: Ensure correct positioning of both the mother and the baby. The baby should be tummy-to-tummy with the mother, ear, shoulder, and hip in a straight line, and the head and body supported.
    3. Latching: Proper latching is crucial. The baby's chin should touch the breast, the cheek should touch the nipple, and the baby should open their mouth wide (rooting reflex). The nipple and most of the areola (the dark area around the nipple) should go into the baby's mouth, not just the nipple. This ensures effective milk transfer and prevents nipple soreness.
    4. Feeding Frequency: Breastfeeding can be offered at 1-2 hour intervals initially, and then on self-demand by the baby (feeding whenever the baby shows hunger cues).
    5. Duration of Feeding: The duration of a feed should be continued until the baby is satisfied and releases the breast on their own.
    6. Burping: Gently burp the baby after feeding to release swallowed air. However, if the baby has a good latch that prevents air entry, burping may not always be necessary.
    7. Post-Feeding Position: After feeding, the baby should be placed on their right side. Babies often fall asleep after feeding.
    8. Exclusive Breastfeeding Duration: Breastfeeding should be continued exclusively up to 6 months, as frequent suckling helps maintain an adequate milk supply for the baby.
    9. Complementary Feeding: At 6 months, complementary foods should be introduced, gradually and progressively, alongside continued breastfeeding up to 2 years or beyond. This is the process of transitioning the baby from solely breast milk to a varied family diet.
    10. Maternal Hygiene: The mother should maintain good hygienic measures, including daily bathing and washing breasts during baths, and wearing clean clothing to prevent contamination of breast milk.

    Assessment of Nutritional Status

    The nutritional status of an individual is a complex interplay of the adequacy of food intake (both in quality and quantity) and the individual's physical health. The purpose of nutritional assessment is to detect nutritional problems early and to develop a tailored plan to meet the child's specific nutritional needs. Common methods include:

    1. Dietary History:

      Involves collecting detailed information about the child's food intake, including types and quantities of cereals, pulses (legumes), vegetables, fruits, milk, meat, fish, eggs, oils, and sugar. This provides insight into dietary patterns and potential deficiencies or excesses.

    2. Clinical Examination:

      A thorough head-to-toe physical examination is performed to detect clinical signs of nutritional deficiency states. These can include hair changes (e.g., sparse, discolored hair in protein deficiency), anemia (pale conjunctiva), edema (swelling, often in severe protein deficiency), bleeding gums (Vitamin C deficiency), dental caries (poor oral hygiene/sugar intake), and enlarged thyroid gland (iodine deficiency).

    3. Anthropometry:

      A very valuable and widely used index for evaluating nutritional status. It involves taking precise body measurements, which are then compared to standardized growth charts. Key anthropometric measurements include:

      • Height/Length: For assessing linear growth and identifying stunting.
      • Weight: For assessing overall nutritional status and identifying underweight or overweight.
      • Skinfold Thickness: Measures subcutaneous fat, indicating body fat reserves.
      • Arm Circumference: Mid-upper arm circumference (MUAC) is a quick screening tool for acute malnutrition.
      • Head Circumference: Important for infants and toddlers as an indicator of brain growth.
      • Chest Circumference: Less commonly used alone but can be part of overall body proportion assessment.

    4. Biochemical Evaluation and Lab Tests:

      These involve the estimation of nutrient levels and their concentration in body fluids (e.g., blood tests for iron, vitamins). They can also assess enzyme levels or detect abnormal amounts of metabolites that indicate nutritional imbalances. While highly accurate, these tests are often time-consuming and expensive, usually performed in more complicated or ambiguous conditions.

    5. Functional Assessment:

      Emerging as an important aspect of diagnostic tools, functional assessments evaluate how nutritional status impacts the body's physiological functions. Examples include tests for nerve function (e.g., in thiamine deficiency) or assessing the working capacity of the heart (e.g., in severe malnutrition affecting cardiac muscle).

    6. Radiology:

      Radiological imaging can detect physical signs of nutritional deficiencies affecting skeletal health. Examples include:

      • Retardation of Bone Age: Indicates chronic malnutrition affecting skeletal maturation.
      • Osteoporosis: Can be seen in prolonged calcium or Vitamin D deficiency.
      • Classical Signs of Scurvy or Rickets: Specific bone changes indicative of severe Vitamin C or Vitamin D deficiency, respectively.

    Nutrition in Children Read More »

    Natural Body Defense Mechanism

    Natural Body Defence Mechanism

    Nursing Notes - Asepsis & Investigations

    Topic 3.10 / 3.11: Natural Body Defence Mechanism

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

    I. Non-Specific (Innate) Defenses:

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

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

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

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

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

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

    • II. Specific (Adaptive) Defenses:

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

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

    • Interrelationship of Defenses:

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

    INFLAMMATION

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

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

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

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

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

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

    CELL TYPES INVOLVED IN INFLAMMATION

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

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

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

    STAGES/ PHASES OF INFLAMMATION

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

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

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

    Types of inflammation

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

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

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

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

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

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

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

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

    Examples of diseases and conditions that include chronic inflammation:

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

    Management of Inflammation

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

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

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

    Avoid eating foods that aggravate inflammation, including:

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

    Natural Body Defence Mechanism Read More »

    Special investigations in surgical nursing (1)

    Aseptic technique & Special investigations in surgical nursing

    Nursing Notes - Asepsis & Investigations

    Topic 3.7: Aseptic Technique & Special Investigations

    Sub-topic 3.7.3: Aseptic Technique / Surgical Asepsis

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

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

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

    Basic Rules of Surgical Asepsis in the OR

    1. Scrubbed persons function within sterile field

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

    2. Sterile drapes are used to create a sterile field

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

    3. All items used in the sterile field are sterile

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

    4. Supplies introduced into the sterile field

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

    5. Maintenance and monitoring of sterile field

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

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

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

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

    Client Preparation for Surgery

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

    Skin preparation

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

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

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

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

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

    Anesthesia

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

    General Anesthesia

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

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

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

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

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

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

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

    Sub-topic 3.7.4: Special Investigations in Surgical Nursing

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

    X-ray & Contrast Studies

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

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

    Advanced Imaging Techniques

    MRI (Magnetic Resonance Imaging)

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

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

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

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

    Nuclear Imaging

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

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

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

    Endoscopy

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

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

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

    Advanced Imaging Techniques

    MRI (Magnetic Resonance Imaging)

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

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

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

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

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

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

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

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

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

    HOW to Prepare For the CT Exam

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

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

    TWO (2) HOURS BEFORE THE SCHEDULED APPOINTMENT

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

    ONE (1) HOUR BEFORE THE SCHEDULED APPOINTMENT

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

    REMAINDER OF LIQUID

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

    Nuclear Imaging

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

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

    PET/CT

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

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

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

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

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

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

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

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

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

    Ultrasound

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

    What will the exam be like?

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

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

    How to prepare for The Ultrasound exam of the pelvis

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

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

    Bone Density (DEXA)

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

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

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

    Digital Mammography

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

    What are the benefits of Digital Mammography?

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

    Radionuclide (Isotope) Scan

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

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

    Are there any risks with radioisotope scans?

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

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

    Endoscopy

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

    Risks
    • Infection
    • Punctured organs
    • Over-sedation

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

    After the Endoscopy

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

    Aseptic technique & Special investigations in surgical nursing Read More »

    INFECTIVE ENDOCARDITIS, Causes, Investigations, Management, and Nursing Interventions

    INFECTIVE ENDOCARDITIS: Causes, Investigations, Management, and Nursing Interventions

    Nursing Notes - Inflammatory Diseases of the Heart

    INFECTIVE ENDOCARDITIS: Causes, Investigations, Management, and Nursing Interventions

    Infective Endocarditis (IE) is a severe and potentially life-threatening infection of the inner lining of the heart (the endocardium) and heart valves. It occurs when microorganisms, typically bacteria, enter the bloodstream and attach to damaged or abnormal heart valves or to areas of the endocardium, forming vegetations. These vegetations are composed of platelets, fibrin, inflammatory cells, and microorganisms, and can lead to valve destruction, embolization to other organs, and systemic infection.

    I. Causes and Risk Factors of Infective Endocarditis (Etiology)

    IE typically develops in individuals with pre-existing cardiac conditions or those with routes for bacteremia. The causative microorganisms are predominantly bacteria, but fungi can also be responsible, especially in immunocompromised individuals or those with indwelling catheters.

    A. Microorganisms (Pathogens):

    The type of pathogen often correlates with the route of infection and patient characteristics.

    Staphylococci:
    • Staphylococcus aureus: The most common cause of acute IE, particularly in intravenous drug users (IVDUs), patients with prosthetic valves, and those with healthcare-associated infections. Known for rapid valve destruction and severe complications.
    • Coagulase-negative Staphylococci (e.g., Staphylococcus epidermidis): Common cause of prosthetic valve endocarditis (PVE), especially early PVE, as they are part of normal skin flora and can contaminate surgical sites.
    Streptococci:
    • Viridans group Streptococci (e.g., S. mutans, S. sanguinis, S. mitis): The most common cause of subacute IE, typically originating from the oral cavity (e.g., dental procedures, poor oral hygiene). Affects previously damaged native valves.
    • Streptococcus gallolyticus (formerly S. bovis): Associated with gastrointestinal malignancies.
    • Enterococci (e.g., Enterococcus faecalis, E. faecium): Common in older males with genitourinary or gastrointestinal tract procedures, often resistant to multiple antibiotics.
    HACEK Group:
    • Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella: Fastidious Gram-negative bacteria that are part of normal oral flora. Can cause large vegetations and embolic events, typically subacute.
    Fungi:
    • Candida species, Aspergillus species: Rare but highly lethal, seen in IVDUs, immunocompromised patients, or those with prolonged antibiotic use/central venous catheters. Often causes large vegetations.
    Other Rare Pathogens:
    • Gram-negative Bacilli: Pseudomonas aeruginosa, E. coli (rare).
    • Culture-negative Endocarditis: Occurs when standard blood cultures fail to identify the pathogen, often due to prior antibiotic use, fastidious organisms (e.g., Coxiella burnetii, Bartonella spp., Tropheryma whipplei), or fungal infections.
    B. Risk Factors:

    Conditions that predispose individuals to bacteremia or provide a suitable surface for bacterial attachment.

    Pre-existing Cardiac Conditions:
    • Prosthetic Heart Valves: Mechanical or bioprosthetic, highest risk due to foreign material.
    • Previous Infective Endocarditis: Strongest risk factor for recurrence.
    • Congenital Heart Disease: Unrepaired cyanotic heart disease, surgically repaired defects with residual shunts/regurgitation, bicuspid aortic valve (most common congenital lesion).
    • Valvular Heart Disease: Rheumatic heart disease, degenerative valve disease (e.g., calcific aortic stenosis, mitral valve prolapse with regurgitation and thickened leaflets).
    • Hypertrophic Obstructive Cardiomyopathy (HOCM).
    • Intracardiac Devices: Pacemakers, implantable cardioverter-defibrillators (ICDs).
    Routes for Bacteremia:
    • Intravenous Drug Use (IVDU): Especially with unsterile injection practices; often affects the tricuspid valve.
    • Intravascular Catheters: Central venous lines, PICCs, hemodialysis catheters.
    • Dental Procedures: With gingival manipulation (high-risk procedures in patients with predisposing cardiac conditions). Poor oral hygiene is an ongoing risk.
    • Other Invasive Procedures: Gastrointestinal, genitourinary, respiratory tract procedures, skin infections.
    • Chronic Hemodialysis.
    Immunocompromised State:
    • HIV infection, malignancy, chemotherapy, immunosuppressive medications (e.g., post-transplant).
    II. Clinical Manifestations (Signs and Symptoms) of Endocarditis

    The clinical presentation of IE is diverse and can range from acute, rapidly progressing illness to a subacute, indolent course. Symptoms are often non-specific, making diagnosis challenging.

    A. General and Constitutional Symptoms:

    Common in both acute and subacute forms, reflecting systemic inflammation and infection.

    • Fever: Present in >90% of cases, though may be absent in elderly, immunocompromised, or those with renal failure. May be intermittent.
    • Chills, Sweats (especially night sweats).
    • Fatigue, Malaise, Weakness.
    • Anorexia and Weight Loss.
    • Arthralgia (joint pain), Myalgia (muscle pain).
    • Headache.
    B. Cardiac Signs:

    Reflect involvement of heart valves and potential heart failure.

    • New or Changing Heart Murmur: The most important physical sign, occurring in up to 85% of cases. Due to valve destruction or altered blood flow.
    • Signs of Heart Failure: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, crackles in lungs, S3 gallop. Due to severe valvular regurgitation (e.g., aortic or mitral).
    • Pericarditis/Myocarditis: Less common, but inflammation can extend to adjacent structures.
    C. Embolic Phenomena (Systemic and Pulmonary):

    Result from fragments of vegetations breaking off and traveling through the bloodstream.

    • Systemic Embolism (Left-sided IE):
      • Cerebral Emboli: Stroke (most common and serious), transient ischemic attack (TIA).
      • Splenic Infarcts: Left upper quadrant pain, tenderness.
      • Renal Infarcts: Flank pain, hematuria.
      • Peripheral Arterial Emboli: Ischemia of limbs (pain, pallor, pulselessness, paresthesias, paralysis).
      • Mycotic Aneurysms: Weakening of arterial walls due to infection, can rupture.
    • Pulmonary Embolism (Right-sided IE, common in IVDUs):
      • Recurrent pneumonia-like symptoms, pleuritic chest pain, dyspnea, hemoptysis.
      • Septic pulmonary emboli can lead to lung abscesses.
    D. Immunologic Phenomena:

    Less specific but classic signs of IE, thought to be due to immune complex deposition or vasculitis.

    • Osler's Nodes: Painful, tender, red or purplish nodules on finger or toe pads.
    • Janeway Lesions: Non-tender, erythematous or hemorrhagic macules on palms and soles.
    • Roth Spots: Retinal hemorrhages with pale centers on fundoscopic exam.
    • Glomerulonephritis: Microscopic hematuria, proteinuria, renal dysfunction.
    • Clubbing of Fingers and Toes: In chronic IE.
    III. Investigations for Infective Endocarditis (Diagnosis)

    Diagnosis of IE relies on a combination of clinical features, microbiological evidence, and echocardiographic findings, typically guided by the modified Duke Criteria.

    A. Laboratory Tests:
  • Blood Cultures:
    • Gold Standard: At least three sets of blood cultures from different venipuncture sites, drawn at different times, before initiating antibiotic therapy.
    • Yield: Positive in 90-95% of cases. Culture-negative IE requires specialized testing (e.g., serology for Coxiella burnetii, Bartonella, fungal cultures).
  • Inflammatory Markers:
    • ESR and CRP: Almost always elevated in active IE, but non-specific.
  • Complete Blood Count (CBC):
    • Anemia: Common in chronic IE (anemia of chronic disease).
    • Leukocytosis: May or may not be present.
  • Renal Function Tests:
    • Monitor for glomerulonephritis or renal infarcts.
  • Urinalysis:
    • May show microscopic hematuria (due to renal infarcts or glomerulonephritis).
    • B. Echocardiography:

    Crucial for visualizing vegetations, assessing valvular damage, and evaluating cardiac function.

  • Transthoracic Echocardiogram (TTE):
    • Initial Imaging: Non-invasive, widely available. Good for visualizing large vegetations (>2-3 mm) on native valves, and assessing ventricular function.
    • Limitations: Limited sensitivity for small vegetations, prosthetic valves, or in patients with poor acoustic windows.
  • Transesophageal Echocardiogram (TEE):
    • More Sensitive: Offers superior visualization of all four heart valves, prosthetic valves, perivalvular extensions (abscesses, fistulae), and smaller vegetations (<2-3 mm).
    • Indications: Suspected IE with negative TTE, prosthetic valves, intracardiac devices, complicated IE, or when surgical intervention is contemplated.
    • C. Other Imaging:
    1. CT Scans (Chest, Abdomen, Brain):
      • Purpose: To detect embolic events (e.g., splenic, renal, cerebral infarcts, mycotic aneurysms) or extracardiac infection.
    2. PET/CT (Positron Emission Tomography/Computed Tomography):
      • Emerging Role: Particularly useful for diagnosing PVE and culture-negative IE by identifying areas of increased metabolic activity consistent with infection.
    D. Modified Duke Criteria:

    A set of clinical criteria used to classify the likelihood of IE (definite, possible, or rejected) based on major and minor criteria. Requires clinical judgment.

    • Major Criteria:
      • Positive blood cultures for IE-typical microorganisms (e.g., S. aureus, Viridans strep) or persistently positive cultures.
      • Evidence of endocardial involvement by echocardiography (vegetation, abscess, new partial dehiscence of prosthetic valve, new regurgitation).
    • Minor Criteria:
      • Predisposition (predisposing heart condition or IVDU).
      • Fever (temperature >38°C).
      • Vascular phenomena (e.g., arterial emboli, septic pulmonary infarcts, mycotic aneurysm, conjunctival hemorrhages, Janeway lesions).
      • Immunologic phenomena (e.g., glomerulonephritis, Osler's nodes, Roth spots, rheumatoid factor).
      • Microbiological evidence (positive blood culture not meeting major criteria or serologic evidence of active infection with organism consistent with IE).
    IV. Management and Treatment of Infective Endocarditis

    Treatment of IE involves prolonged courses of high-dose intravenous antibiotics and, in many cases, surgical intervention. The goals are to eradicate the infection, prevent complications, and restore valvular function.

    A. Antibiotic Therapy:

    The cornerstone of IE treatment. Therapy is empiric initially, then tailored based on blood culture results and antibiotic sensitivities.

    1. Empiric Therapy:
      • Choice: Broad-spectrum antibiotics covering likely pathogens (e.g., Staphylococci, Streptococci, Enterococci). Often involves combination therapy (e.g., Vancomycin + Ceftriaxone or Gentamicin).
      • Initiation: Started after obtaining adequate blood cultures.
    2. Targeted Therapy:
      • Adjustment: Based on identification of the pathogen and its antibiotic sensitivities.
      • Duration: Typically 2-6 weeks of intravenous antibiotics. Longer courses are common for prosthetic valve endocarditis, fungal endocarditis, or difficult-to-treat organisms.
      • Route: Primarily IV, often requiring PICC line insertion for outpatient management.
    3. Monitoring Antibiotic Levels:
      • For certain antibiotics (e.g., Vancomycin, Gentamicin) to ensure therapeutic levels and minimize toxicity (e.g., nephrotoxicity, ototoxicity).
    B. Surgical Intervention:

    Up to 50% of patients with IE may require surgery. Timing of surgery is crucial and can be emergent, urgent, or elective.

    1. Indications for Surgery:
      • Heart Failure: Due to severe valvular regurgitation (e.g., aortic or mitral valve destruction) refractory to medical therapy. This is the most common indication.
      • Uncontrolled Infection: Persistent bacteremia despite appropriate antibiotic therapy (typically >7-10 days), perivalvular extension (abscess, fistula, pseudoaneurysm), or infection by resistant organisms (e.g., fungi, multidrug-resistant bacteria).
      • Prevention of Embolism: Large vegetations (>10-15 mm, especially mobile vegetations on the anterior mitral leaflet), or recurrent embolic events despite appropriate antibiotics.
      • Prosthetic Valve Dysfunction or Dehiscence.
    2. Surgical Procedures:
      • Valve Repair: Whenever possible, especially for mitral valve.
      • Valve Replacement: With mechanical or bioprosthetic valves.
      • Debridement of Infected Tissue: Removal of vegetations and abscesses.
    C. Management of Complications:
    1. Embolic Stroke: Medical management, potential anticoagulation (controversial in active IE due to risk of hemorrhagic transformation).
    2. Mycotic Aneurysm: May require surgical or endovascular repair.
    3. Renal Failure: Supportive care, dialysis if needed.
    4. Heart Block: Temporary or permanent pacemaker insertion.
    D. Prophylaxis:

    Antibiotic prophylaxis is recommended only for very specific high-risk cardiac conditions undergoing high-risk dental procedures.

    • High-Risk Cardiac Conditions: Prosthetic heart valves, previous IE, unrepaired cyanotic congenital heart disease, repaired congenital heart disease with residual defects, cardiac transplant recipients who develop valvulopathy.
    • High-Risk Dental Procedures: Involving manipulation of gingival tissue or periapical region of teeth, or perforation of the oral mucosa.
    • Not Recommended: For routine dental cleanings in low-risk individuals, or for GI/GU procedures unless there is an active infection.
    V. Nursing Interventions for Infective Endocarditis

    Nursing care for patients with IE is complex, requiring vigilant monitoring, meticulous infection control, comprehensive medication management, and extensive patient education.

    1. Infection Control and Prevention:
      • Aseptic Technique: Maintain strict aseptic technique during IV line insertion, dressing changes, and medication administration to prevent secondary infections.
      • Catheter Care: Meticulous care for central venous catheters (PICC lines, CVCs) used for prolonged antibiotic therapy. Monitor insertion sites for signs of infection (redness, swelling, drainage, pain).
      • Oral Hygiene: Encourage and assist with regular and thorough oral hygiene to reduce bacterial load.
      • Skin Care: Assess and maintain skin integrity, especially in IV drug users, to prevent skin breakdown and source of infection.
    2. Medication Administration and Monitoring:
      • Accurate IV Antibiotic Administration: Administer high-dose IV antibiotics on time, ensuring correct dilution and infusion rates.
      • Monitor for Adverse Drug Reactions: Assess for common side effects (e.g., rash, nausea, diarrhea) and specific toxicities (e.g., nephrotoxicity, ototoxicity with aminoglycosides/vancomycin; monitor peak and trough levels as ordered).
      • Anticoagulation Management: If on anticoagulants (e.g., for mechanical prosthetic valves), monitor INR/PTT and assess for bleeding.
      • Pain Management: Administer analgesics as needed, assess pain effectiveness.
    3. Cardiac Monitoring and Assessment:
      • Continuous Cardiac Monitoring: Observe for arrhythmias (e.g., new heart blocks due to perivalvular abscess) and signs of worsening heart failure.
      • Frequent Vital Signs: Monitor temperature (fever patterns), heart rate, blood pressure, and respiratory rate for signs of infection progression or sepsis.
      • Assess Heart Sounds: Auscultate regularly for new or changing heart murmurs, S3 gallop.
      • Monitor for Signs of Heart Failure: Assess for dyspnea, orthopnea, crackles, JVD, peripheral edema, daily weights.
    4. Monitoring for Embolic and Immunologic Phenomena:
      • Neurological Assessment: Frequent assessment for changes in mental status, new neurological deficits (e.g., weakness, numbness, speech changes) indicative of cerebral emboli.
      • Peripheral Vascular Assessment: Check pulses, color, temperature, and sensation in all extremities for signs of peripheral emboli.
      • Abdominal Assessment: Palpate for tenderness (splenic or renal infarcts).
      • Skin and Eye Assessment: Inspect skin for Janeway lesions, Osler's nodes, petechiae. Fundoscopic exam for Roth spots if indicated.
      • Urine Output: Monitor for hematuria or signs of renal impairment.
    5. Patient Education:
      • Disease Process: Educate the patient and family about IE, its causes, complications, and the importance of prolonged antibiotic therapy.
      • Medication Adherence: Emphasize the critical importance of completing the entire course of antibiotics, even if feeling better, to prevent relapse. Teach proper PICC line care if antibiotics are given at home.
      • Oral Hygiene: Stress the importance of meticulous lifelong oral hygiene and regular dental check-ups.
      • Prophylaxis: Educate high-risk patients about the need for antibiotic prophylaxis before specific dental procedures and provide them with an endocarditis prophylaxis card/information.
      • Warning Signs: Instruct on signs and symptoms of recurrent IE (e.g., fever, new murmur) and when to seek immediate medical attention.
      • Avoidance of IV Drug Use: For IVDU patients, provide counseling and referral to addiction treatment programs.
    6. Nutritional Support:
      • Assess nutritional status; encourage a high-protein, high-calorie diet to support recovery and combat weight loss associated with chronic infection.
      • Provide small, frequent meals if anorexia is an issue.
    7. Psychosocial Support:
      • Address anxiety, fear, and depression associated with a serious illness, prolonged hospitalization, and potential surgical intervention.
      • Encourage verbalization of feelings and provide emotional support.
      • Facilitate communication between the patient/family and the healthcare team.
      • Refer to social work or support groups if needed.
    8. Pre- and Post-Operative Care (if surgery is indicated):
      • Standard cardiac surgical nursing care, including close hemodynamic monitoring, pain management, wound care, and early mobilization.

    INFECTIVE ENDOCARDITIS: Causes, Investigations, Management, and Nursing Interventions Read More »

    MYOCARDITIS: Causes, Investigations, Management, and Nursing Interventions

    MYOCARDITIS: Causes, Investigations, Management, and Nursing Interventions

    Nursing Notes - Inflammatory Diseases of the Heart

    MYOCARDITIS: Causes, Investigations, Management, and Nursing Interventions

    Myocarditis is an inflammatory disease of the heart muscle (myocardium) that can be caused by various factors, most commonly viral infections. It can affect people of any age, from infants to adults, and its clinical presentation can range from asymptomatic to severe heart failure, arrhythmias, or sudden cardiac death. The inflammation can lead to damage of the heart muscle cells, impairing the heart's ability to pump blood effectively.

    I. Causes of Myocarditis (Etiology)

    Myocarditis can stem from a wide array of sources, often categorized as infectious or non-infectious.

    A. Infectious Causes:

    These are the most common triggers for myocarditis, with viruses being the predominant culprits.

    Viral Infections:
    • Enteroviruses: Coxsackievirus B (most common cause globally), Echovirus.
    • Adenoviruses: Often associated with respiratory infections.
    • Herpesviruses: Cytomegalovirus (CMV), Epstein-Barr Virus (EBV), Human Herpesvirus 6 (HHV-6).
    • Influenza Virus: Types A and B.
    • Parvovirus B19: Can cause persistent infection.
    • HIV: Direct viral effect or opportunistic infections in immunocompromised individuals.
    • SARS-CoV-2 (COVID-19): Myocarditis has been recognized as a complication of COVID-19 infection.
    Bacterial Infections:
    • Spirochetes: Lyme disease (Borrelia burgdorferi), Syphilis (Treponema pallidum).
    • Streptococcus: Post-streptococcal acute rheumatic fever can lead to myocarditis.
    • Staphylococcus, Corynebacterium diphtheriae (Diphtheria): Diphtheria toxin can directly damage myocardial cells.
    • Mycoplasma pneumoniae, Chlamydia pneumoniae.
    Fungal Infections:
    • Rare, typically seen in immunocompromised individuals.
    • Examples: Candida, Aspergillus, Histoplasma, Coccidioides.
    Parasitic Infections:
    • Trypanosoma cruzi (Chagas Disease): Endemic in Central and South America, causes chronic cardiomyopathy.
    • Toxoplasma gondii.
    B. Non-Infectious Causes:

    These include autoimmune conditions, toxins, and drug reactions.

  • Autoimmune and Systemic Diseases:
    • Systemic Lupus Erythematosus (SLE): Can cause inflammation of various organs, including the heart.
    • Rheumatoid Arthritis.
    • Scleroderma, Sarcoidosis: Granulomatous inflammation in the myocardium.
    • Inflammatory Bowel Disease (IBD): (Crohn's disease, Ulcerative colitis).
    • Giant Cell Myocarditis: A rare but aggressive form of myocarditis requiring prompt immunosuppression.
    • Eosinophilic Myocarditis: Associated with hypereosinophilic syndromes, parasitic infections, or drug reactions.
    Toxins and Drugs:
    • Alcohol: Chronic abuse can lead to alcoholic cardiomyopathy, which has an inflammatory component.
    • Chemotherapeutic Agents: Anthracyclines (e.g., Doxorubicin), Cyclophosphamide, Trastuzumab.
    • Illicit Drugs: Cocaine, Amphetamines.
    • Environmental Toxins: Heavy metals (e.g., lead), carbon monoxide.
    • Hypersensitivity Reactions: Penicillins, Sulfonamides, Phenytoin, Methyldopa, Clozapine.
    Physical Agents:
    • Radiation Therapy: To the chest for cancer treatment.
    • Heatstroke, Electric Shock.
    Idiopathic Myocarditis:
    • When no specific cause can be identified despite thorough investigation. Many cases presumed viral fall into this category retrospectively.
    • II. Clinical Manifestations (Signs and Symptoms) of Myocarditis

    The presentation of myocarditis is highly variable, depending on the severity of inflammation, extent of myocardial damage, and the patient's immune response. Symptoms can mimic other cardiac or non-cardiac conditions.

    Cardiac Symptoms:
    • Chest Pain: Can be sharp, stabbing, or dull, often mimicking myocardial infarction or pericarditis. May be pleuritic.
    • Dyspnea (Shortness of Breath): On exertion or at rest, due to impaired cardiac function and potential heart failure.
    • Fatigue and Weakness: Common, often profound, resulting from reduced cardiac output.
    • Palpitations or Arrhythmias: Due to inflammation affecting the heart's electrical conduction system (e.g., premature beats, atrial fibrillation, ventricular tachycardia).
    • Signs of Heart Failure: Peripheral edema, jugular venous distension (JVD), crackles in lungs, S3 gallop.
    • Syncope or Near-Syncope: Due to arrhythmias or severely reduced cardiac output.
    • Sudden Cardiac Death: In severe cases, due to malignant arrhythmias.
    Non-Cardiac (Constitutional/Systemic) Symptoms:
    • Fever, Chills, Body Aches, Headache: Often preceding or accompanying viral infections.
    • Myalgia (Muscle Pain), Arthralgia (Joint Pain): Common with systemic inflammatory responses.
    • Upper Respiratory or Gastrointestinal Symptoms: Sore throat, cough, nausea, vomiting, diarrhea (often preceding viral myocarditis).
    • Rash: Seen in some systemic or drug-induced causes.
    Asymptomatic:
    • Many cases of myocarditis may be subclinical and resolve spontaneously without causing noticeable symptoms or long-term damage.
    III. Investigations for Myocarditis (Diagnosis)

    Diagnosing myocarditis can be challenging due to its varied presentation and the lack of a single definitive non-invasive test. A combination of clinical assessment, laboratory tests, imaging, and sometimes biopsy is required.

  • Medical History and Physical Examination:
    • History: Recent viral illness, exposure to toxins/drugs, autoimmune conditions, family history of cardiomyopathy. Detailed description of symptoms.
    • Physical Exam: Auscultation for heart murmurs, S3 gallop, pericardial rub (if myopericarditis), signs of heart failure (rales, edema, JVD).
    Laboratory Tests:
    • Cardiac Biomarkers:
      • Troponin I or T: Elevated in acute myocardial injury/inflammation. High sensitivity troponins are very sensitive.
      • Creatine Kinase (CK) and CK-MB: May be elevated but less specific than troponin.
    • Inflammatory Markers:
      • C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR): Non-specific indicators of inflammation, often elevated.
    • Complete Blood Count (CBC): Leukocytosis (elevated white blood cells) or eosinophilia (in eosinophilic myocarditis).
    • Viral Serology/PCR: For specific viruses (e.g., Coxsackievirus, Adenovirus, HIV). May help identify the underlying cause but not always diagnostic of active cardiac involvement.
    • Autoimmune Panel: Antinuclear antibodies (ANA), rheumatoid factor (RF), anti-dsDNA, ANCA if autoimmune etiology suspected.
    • Renal and Liver Function Tests: To assess systemic effects or rule out other causes.
    Electrocardiography (ECG):
    • Findings: Highly variable and non-specific. Can include:
      • Sinus tachycardia (most common).
      • Non-specific ST-T wave changes (ST elevation or depression, T wave inversion).
      • Conduction abnormalities (bundle branch blocks, AV blocks).
      • Arrhythmias (atrial fibrillation, premature ventricular contractions, ventricular tachycardia).
      • Q waves (suggesting myocardial damage, but can be non-ischemic).
    Echocardiography (Echo):
    • Purpose: Assesses cardiac function, chamber size, wall motion abnormalities, and valvular function.
    • Findings: Often shows left ventricular dysfunction (reduced ejection fraction), regional or global wall motion abnormalities, ventricular dilatation, and occasionally pericardial effusion (in myopericarditis).
    Cardiac Magnetic Resonance Imaging (CMR):
    • Purpose: Considered the gold standard non-invasive imaging technique for diagnosing myocarditis.
    • Findings: Can detect myocardial edema (swelling), hyperemia (increased blood flow), and late gadolinium enhancement (LGE), which indicates myocardial fibrosis or necrosis. Uses "Lake Louise Criteria" for diagnosis.
    Endomyocardial Biopsy (EMB):
    • Purpose: The definitive diagnostic test, but rarely performed due to its invasive nature, patchy nature of the disease (sampling error), and risk of complications.
    • Indications: Reserved for patients with rapidly progressive heart failure, life-threatening arrhythmias, or when specific etiologies (e.g., giant cell myocarditis, eosinophilic myocarditis) require specific immunosuppressive therapy.
    • Findings: Histological examination shows inflammatory infiltrates with myocyte necrosis. Immunohistochemistry can identify specific inflammatory cell types.
    IV. Management and Treatment of Myocarditis

    Treatment is primarily supportive, aiming to manage symptoms, improve cardiac function, and prevent complications. Specific therapies are employed for identifiable causes.

    A. General Supportive Care:
    1. Rest: Physical rest is crucial to reduce myocardial workload and promote healing. Strenuous exercise should be avoided during the acute phase and for several months.
    2. Management of Heart Failure:
      • Diuretics: To reduce fluid overload and pulmonary congestion.
      • ACE Inhibitors/ARBs: To reduce afterload and improve ventricular function.
      • Beta-blockers: Once stable, to improve left ventricular function and control heart rate.
      • Digoxin: May be used in specific cases to improve contractility.
    3. Arrhythmia Management:
      • Antiarrhythmic Drugs: To control symptomatic arrhythmias.
      • Temporary Pacing: For severe bradyarrhythmias or heart blocks.
      • Implantable Cardioverter-Defibrillator (ICD): For persistent risk of malignant ventricular arrhythmias.
    4. Pain Management:
      • NSAIDs: Generally avoided in pure myocarditis due to potential for worsening inflammation or renal effects, but may be used cautiously if there's a strong pericarditis component (myopericarditis) and no significant heart failure.
      • Acetaminophen: Preferred for pain and fever control in pure myocarditis.
    5. Mechanical Circulatory Support:
      • For severe, refractory heart failure or cardiogenic shock (e.g., Intra-aortic balloon pump (IABP), Extracorporeal membrane oxygenation (ECMO), Ventricular assist devices (VADs)).
    6. Cardiac Transplantation:
      • In cases of irreversible, end-stage heart failure despite maximal medical therapy.
    B. Specific Therapies (Targeted Treatment):
    1. Immunosuppressive Therapy:
      • Corticosteroids: May be used in certain forms of myocarditis (e.g., giant cell myocarditis, eosinophilic myocarditis, sarcoidosis, lupus myocarditis) where there's an active inflammatory or autoimmune process. Generally not recommended for viral myocarditis.
      • Other Immunosuppressants: Azathioprine, Cyclosporine, Mycophenolate mofetil in specific autoimmune cases.
    2. Antiviral Therapy:
      • Not routinely used for acute viral myocarditis, as most cases resolve spontaneously. May be considered for specific viruses like HIV or CMV in certain contexts.
    3. Antibiotic/Antiparasitic/Antifungal Therapy:
      • For bacterial, parasitic (e.g., Chagas disease), or fungal causes.
    4. Intravenous Immunoglobulin (IVIG):
      • Some studies suggest a benefit in certain viral-induced myocarditis, but evidence is not conclusive and not routinely recommended.
    V. Nursing Interventions for Myocarditis

    Nursing care for patients with myocarditis is multifaceted, focusing on symptomatic relief, monitoring for complications, optimizing cardiac function, and providing emotional support and education.

    1. Cardiac Monitoring and Assessment:
      • Continuous ECG Monitoring: To detect arrhythmias (tachycardia, bradycardia, blocks) and ST-T wave changes. Report any significant changes immediately.
      • Frequent Vital Signs: Monitor heart rate, blood pressure, respiratory rate, and oxygen saturation regularly.
      • Assess for Signs of Worsening Heart Failure: Monitor for increasing dyspnea, orthopnea, crackles in lungs, S3 gallop, peripheral edema, weight gain, and JVD.
      • Auscultate Heart Sounds: Listen for muffled heart sounds, new murmurs, or pericardial friction rubs (if myopericarditis).
      • Assess Peripheral Perfusion: Check skin temperature, color, capillary refill, and peripheral pulses.
    2. Activity Management and Rest Promotion:
      • Strict Bed Rest: During the acute phase to reduce myocardial workload. Progress activity slowly as tolerated and as per physician orders.
      • Assist with ADLs: Help with personal care to conserve patient energy and reduce cardiac demand.
      • Provide a Quiet Environment: Minimize disturbances to promote rest and reduce anxiety.
      • Educate on Activity Restrictions: Explain the importance of avoiding strenuous physical activity for several months (typically 3-6 months or more, depending on recovery) to allow for myocardial healing.
    3. Pain and Symptom Management:
      • Assess Pain: Regularly assess chest pain characteristics (location, quality, severity, precipitating/alleviating factors).
      • Administer Analgesics: As prescribed, typically acetaminophen, avoiding NSAIDs if possible unless specifically ordered for a pericarditis component.
      • Positioning: Elevate the head of the bed to ease breathing and reduce cardiac workload.
      • Manage Fever: Administer antipyretics as ordered.
    4. Fluid Balance and Nutrition:
      • Monitor I&O: Accurately record all fluid intake and output.
      • Daily Weights: Monitor for fluid retention (suggesting worsening heart failure) or dehydration.
      • Administer Diuretics: As prescribed, and monitor for effectiveness and electrolyte imbalances (e.g., hypokalemia).
      • Sodium and Fluid Restriction: If signs of fluid overload or heart failure are present, educate the patient on dietary restrictions.
    5. Medication Administration and Monitoring:
      • Administer prescribed medications (e.g., ACE inhibitors, beta-blockers, antiarrhythmics, immunosuppressants) and monitor for their therapeutic effects and adverse reactions.
      • Educate the patient about each medication, its purpose, dosage, and side effects.
    6. Psychosocial Support and Education:
      • Address Anxiety and Fear: Acknowledge the patient's concerns regarding their cardiac condition. Provide reassurance and clear, concise information.
      • Education on Disease Process: Explain myocarditis, its potential causes, symptoms, and the importance of adhering to the treatment plan.
      • Risk Factor Modification: If applicable (e.g., abstinence from alcohol, illicit drugs).
      • Warning Signs: Educate patient and family on signs and symptoms that require immediate medical attention (e.g., worsening dyspnea, chest pain, syncope, significant swelling).
      • Coping Strategies: Help the patient develop coping strategies for managing chronic fatigue or activity limitations.
      • Referrals: Consider referrals to cardiac rehabilitation, social work, or support groups as appropriate.
    7. Prevention of Complications:
      • Infection Control: Practice strict aseptic technique for any invasive procedures.
      • Skin Integrity: Reposition frequently and provide skin care, especially if on prolonged bed rest.
      • Deep Vein Thrombosis (DVT) Prophylaxis: Implement measures such as sequential compression devices (SCDs) or anticoagulant therapy as ordered, given reduced mobility.

    • MYOCARDITIS: Causes, Investigations, Management, and Nursing Interventions Read More »

    Inflammatory disorders of the Heart and Blood Vessels

    Inflammatory disorders of the Heart and Blood Vessels

    Nursing Notes - Inflammatory Diseases of the Heart

    Topic 3.4.3: Inflammatory Disorders of the Heart and Blood Vessels

    INFLAMMATORY DISEASES OF THE HEART

    Introduction

    Inflammatory diseases of the heart refer to a diverse group of conditions characterized by inflammation affecting different layers of the heart. This inflammation can impact the heart's ability to pump blood effectively, leading to a range of symptoms and potential complications. The specific location and extent of inflammation determine the clinical presentation and management strategies.

    The three primary types of inflammatory heart diseases are:

    • Myocarditis: Inflammation of the myocardium (heart muscle).
    • Pericarditis: Inflammation of the pericardium (the protective sac surrounding the heart).
    • Endocarditis: Inflammation of the endocardium (the inner lining of the heart chambers and valves).
    Causes of Inflammatory Diseases of the Heart

    Inflammation in the heart can be triggered by a variety of factors, including:

  • Infections:
    • Viral: Common culprits include coxsackievirus B, adenovirus, influenza virus, parvovirus B19, and herpesviruses.
    • Bacterial: Such as streptococcus (leading to rheumatic fever), Staphylococcus aureus, and other bacteria causing infective endocarditis.
    • Fungal: Less common, but can occur in immunocompromised individuals.
    • Parasitic: For example, Chagas disease (Trypanosoma cruzi) can cause severe myocarditis.
  • Autoimmune Diseases: Conditions where the body's immune system mistakenly attacks its own tissues, including the heart. Examples include systemic lupus erythematosus (SLE), rheumatoid arthritis, and scleroderma.
  • Toxins and Drugs: Certain medications (e.g., some chemotherapy drugs, clozapine) or illicit drugs (e.g., cocaine) can cause cardiac inflammation.
  • Systemic Inflammatory Conditions: Conditions like sepsis or inflammatory bowel disease can sometimes lead to cardiac involvement.
  • Radiation Therapy: Can cause chronic inflammation and fibrosis in the heart, particularly after chest radiation for cancer.
  • Idiopathic: In many cases, especially for myocarditis, the exact cause remains unknown.
    • General Clinical Manifestations of Inflammatory Diseases of the Heart

    While specific symptoms vary depending on the affected part of the heart, some general signs and symptoms can be present across different inflammatory heart conditions:

    1. Chest Pain: Varies in character and location depending on the specific inflammatory condition (e.g., sharp and pleuritic in pericarditis, more diffuse in myocarditis).
    2. Dyspnoea (Shortness of Breath): Can occur at rest or with exertion, and may worsen when lying flat (orthopnea) due to fluid accumulation or impaired heart function.
    3. Fatigue and Weakness: Generalized tiredness and lack of energy are common due to the body's inflammatory response and reduced cardiac output.
    4. Palpitations: Sensations of a rapid, irregular, or pounding heartbeat, often due to arrhythmias triggered by inflammation.
    5. Fever: A low-grade fever is frequently present, especially in acute inflammatory processes.
    6. Malaise: A general feeling of discomfort, uneasiness, or illness.
    7. Flu-like Symptoms: May precede or accompany the cardiac symptoms, including muscle aches, joint pain, and headache, particularly in viral infections.
    8. Edema (Swelling): Swelling in the ankles, feet, or abdomen can occur due to fluid retention caused by impaired heart function, especially in chronic or severe cases.
    9. Syncope or Near-Syncope: Fainting or feeling faint due to transient reduction in blood flow to the brain, possibly from arrhythmias or severe heart dysfunction.
    10. Cough: Can be present, especially if there is pulmonary congestion due to heart failure.
    11. Changes in Voice (Hoarseness, Aphonia): Less common, but can occur if inflammation affects nerves near the heart (e.g., recurrent laryngeal nerve).
    12. Dysphagia (Difficulty Swallowing): Rare, but possible if severe inflammation or effusion puts pressure on the esophagus.
    13. Cyanosis: Bluish discoloration of the skin or mucous membranes, indicating poor oxygenation, typically seen in severe cases of heart failure.
    14. Distended Neck Veins (Jugular Venous Distension): Visible bulging of the neck veins, indicating increased pressure in the right side of the heart.
    15. Anxiety: Can be a direct symptom or a psychological response to the discomfort and uncertainty of the illness.
    16. Differences in Pulse and Blood Pressure in Upper Extremities: May suggest specific conditions like aortic dissection or certain types of vasculitis, which can sometimes be associated with inflammatory heart disease.
    Nursing Notes - Inflammatory Diseases of the Heart

    PERICARDITIS

    Inflammatory disorders of the Heart and Blood Vessels Read More »

    General signs and symptoms of Cardiovascular disorders

    General signs and symptoms of Cardiovascular disorders

    Nursing Notes - Circulatory System Conditions

    Sub-topic 3.4.1: Review of Anatomy and Physiology of the Circulatory system

    Anatomy of the Heart and Circulatory System
  • Heart: A muscular organ located slightly left of the center of the chest, responsible for pumping blood throughout the body. It has four chambers: two atria (upper chambers) and two ventricles (lower chambers).
  • Blood Vessels:
    • Arteries: Carry oxygenated blood away from the heart to the rest of the body. The largest artery is the aorta.
    • Veins: Carry deoxygenated blood back to the heart. The largest veins are the vena cavae.
    • Capillaries: Tiny blood vessels that connect arteries and veins, where the exchange of oxygen, nutrients, and waste products occurs between blood and tissues.
  • Blood: Composed of plasma, red blood cells (carry oxygen), white blood cells (fight infection), and platelets (involved in clotting).
  • Pulmonary Circulation: Carries deoxygenated blood from the heart to the lungs and returns oxygenated blood back to the heart.
  • Systemic Circulation: Carries oxygenated blood from the heart to the rest of the body and returns deoxygenated blood back to the heart.
    • Physiology of the Circulatory System
    • Cardiac Cycle: The sequence of events that occurs when the heart beats, including systole (contraction) and diastole (relaxation).
    • Blood Pressure: The force of blood against the walls of the arteries. Measured as systolic pressure (during heart contraction) over diastolic pressure (during heart relaxation).
    • Heart Rate: The number of times the heart beats per minute.
    • Cardiac Output: The volume of blood pumped by the heart per minute (Heart Rate x Stroke Volume).
    • Regulation of Blood Flow: Regulated by various mechanisms, including nervous system control, hormonal control, and local factors.
    • Gas Exchange: Occurs in the lungs (oxygen into blood, carbon dioxide out) and in the tissues (oxygen out of blood, carbon dioxide into blood).
    • Nutrient and Waste Transport: Blood delivers nutrients and hormones to cells and removes waste products.

    Sub-topic 3.4.2: General Signs and Symptoms of Cardiovascular Disorders

    Signs and symptoms of heart disease
    • Chest pain (Angina Pectoris): Often described as a heavy, squeezing, or burning sensation, typically in the center or left side of the chest. It may radiate to the left arm, neck, jaw, back, or stomach. Often provoked by exertion or stress and relieved by rest or nitroglycerin. Different types include stable angina, unstable angina, and Prinzmetal's angina.
    • Dyspnoea (Shortness of Breath): Difficulty breathing, which can be exertional (occurs with activity), orthopnea (occurs when lying flat), or paroxysmal nocturnal dyspnoea (occurs at night, waking the person from sleep). It results from pulmonary congestion due to inefficient heart pumping.
    • Palpitations: A sensation of a rapid, strong, irregular, or fluttering heartbeat. Can be caused by various arrhythmias (abnormal heart rhythms).
    • Syncope (Fainting): Temporary loss of consciousness due to a sudden decrease in blood flow to the brain, often caused by arrhythmias, severe valve disease, or significant drop in blood pressure.
    • Fatigue: Persistent and unexplained tiredness, often due to the heart's inability to pump enough oxygenated blood to meet the body's demands (inadequate systemic perfusion).
    • Peripheral Oedema: Swelling, typically in the ankles, feet, and legs, due to fluid retention. This occurs when the heart's pumping action is inefficient, leading to increased pressure in the veins and fluid leakage into surrounding tissues, exacerbated by renal underperfusion and activation of the Renin-Angiotensin-Aldosterone System (RAAS).
    • Cyanosis: Bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. Can be central (lips, tongue) or peripheral (fingertips, toes).
    • Clubbing of the Fingers: Enlargement of the fingertips and curving of the nails, often associated with chronic oxygen deprivation.
    • Irregular or Thread Pulse: An abnormal heart rhythm or a weak and rapid pulse, indicating issues with heart function or blood volume.
    • Raised Jugular Venous Pressure (JVP) and Extended Jugular Veins: Visible distension of the jugular veins in the neck, indicating increased pressure in the right side of the heart.
    • Restlessness and Irritability: Non-specific symptoms that can be associated with reduced cerebral perfusion or overall systemic illness related to heart conditions.
    • Heart Murmurs: Abnormal sounds heard during auscultation of the heart, caused by turbulent blood flow through damaged or narrowed heart valves, or other structural abnormalities.
    Investigations done in heart disease
  • Blood work:
    • Complete Blood Count (CBC): To assess for anemia (which can exacerbate heart conditions) and signs of infection.
    • Haemoglobin level estimation: Specific measurement of oxygen-carrying capacity.
    • Cardiac Enzymes/Biomarkers: Such as troponin (I and T), creatine kinase-MB (CK-MB), and B-type natriuretic peptide (BNP). These are released into the bloodstream when the heart muscle is damaged.
    • Blood Urea Nitrogen (BUN) and Creatinine: To assess kidney function, which can be affected by heart disease and impact treatment.
    • Serum Electrolytes: (Sodium, Potassium, Chloride, Magnesium, Calcium) to check for imbalances that can affect heart rhythm and function.
    • Liver Function Tests (LFTs): To assess liver health, as liver congestion can occur in severe heart failure.
    • Thyroid Function Tests: To rule out thyroid disorders, which can mimic or exacerbate heart conditions.
    • Lipid Profile: (Total cholesterol, LDL, HDL, triglycerides) to assess risk factors for atherosclerosis and coronary artery disease.
    • Blood for Culture and Sensitivity: If an infection (e.g., endocarditis) is suspected.
    • C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR): Markers of inflammation, which can be elevated in various cardiac conditions.
  • Chest X-ray: Provides an image of the heart, lungs, and blood vessels. Can help to determine heart size, detect fluid in the lungs (pulmonary edema), identify calcifications, or exclude conditions like pericardial effusion.
  • Electrocardiography (ECG/EKG): Records the electrical activity of the heart. Used to detect arrhythmias, signs of heart attack, and other electrical abnormalities.
  • Echocardiography (Echo): An ultrasound of the heart that provides detailed images of the heart's structure and function, including valve function, chamber size, and pumping ability. Types include transthoracic (TTE) and transesophageal (TEE).
  • Cardiac Computed Tomography (CT): Uses X-rays and computer processing to create detailed cross-sectional images of the heart and blood vessels. Can detect coronary artery calcification, blockages, and structural abnormalities.
  • Cardiovascular Magnetic Resonance Imaging (MRI): Uses magnetic fields and radio waves to create detailed images of the heart. Provides excellent soft tissue contrast for assessing heart muscle, blood flow, and identifying areas of scar tissue or inflammation.
  • Cardiac Catheterization and Coronary Angiography: An invasive procedure where a thin, flexible tube (catheter) is inserted into a blood vessel and guided to the heart. Dye is injected to visualize the coronary arteries and detect blockages (angiography). Can also measure pressures within the heart chambers and assess valve function. Interventions like angioplasty and stenting can be performed during this procedure.
  • Stress Tests:
    • Exercise Stress Test: Monitors heart function during physical exertion (treadmill or stationary bike) to detect coronary artery disease.
    • Pharmacological Stress Test: Uses medication to simulate the effects of exercise on the heart for patients unable to exercise.
    • Stress Echocardiography or Nuclear Stress Test: Combines stress testing with imaging to assess blood flow to the heart muscle.
  • Holter Monitor/Event Monitor: Portable devices that record the heart's electrical activity over an extended period (24-48 hours for Holter, longer for event monitors) to detect intermittent arrhythmias.

    • Revision Questions:

    1. What is the difference between a diagnosis and a differential diagnosis?
    2. List five general causes of disease and provide one specific example for each.
    3. Describe the three levels of disease prevention and give a nursing activity that falls under each level.
    4. What is Cor-pulmonale?
    5. A patient presents with breathlessness that worsens when they lie flat. What is the medical term for this symptom?

    General signs and symptoms of Cardiovascular disorders Read More »

    Levels of disease prevention

    Nursing Notes - Introduction to Medical Nursing

    Levels of disease prevention

    Primary (1°) prevention

    1. Is prevention that proceeds disease or days function and is applied to patients considered physically and emotionally healthy.
    2. It is aimed at intervention before pathological diseases have begun during the stage of susceptibility.
    3. It includes activities that are directed at using the probability of specific illness or body function.
    4. 1° prevention includes both general health promotions and specific protection.

    General health promotions include e.g.

    • Health education
    • Good standard of nutrition adjusted to developmental stages of life.
    • Attention to personality development.
    • Provision of adequate housing and recreation and agreeable working conditions.
    • Genetic screening
    • Marriage and sex education
    • Periodic selective examination.

    Specific Protection refers to measures aimed at protecting individual against specific agents e.g. immunization,

    • Vaccination
    • Attention to personal hygiene for self-care.
    • Use of environment sanitation e.g. chlorination of well
    • Protection from accidents e.g. Wearing helmets.
    • Use of specific nutrients
    • Protection or avoidance of allergens
    • Protection from carcinogens.

    Any particular disease or health problem is a result of intervention between a number of specific or associated risks that can be classified as Agent; Host and Environmental factors.

    The interaction can be understood by visualizing the concepts or positive health and disease.

    Secondary prevention (2°)

    Focuses on the individuals who are experiencing health problems or illness and who are at risk for developing conditions or worsening conditions.

    Its efforts seek to detect disease early and treat if promptly.

    The goal is to cure the disease at the earliest stage when cure is impossible to slow its progression as well as prevent conditions of limit disability.

    The activities directed at:-

  • Early Diagnosis and Treatment:-
    • Case finding measures, individual and mass
    • screening surveys
    • Selective Exam
    • Cure and prevention of disease process to prevent spread of communicable disease, prevent conditions and short the period of disability.
  • Disability Limitations
    • Adequate TX to arrest disease process with prevents conditions.
    • Provision of facilities to limit disability and prevent death.

    • Tertiary (3°) prevention

    Occurs when the defect or disability is permanent.

    It includes limitations of rehabilitation for those persons who have already experienced residual damage.

    Tertiary prevention activities focus on the middle to latter phases of clinical disease.

    When irreversible pathological damage produces disability (e.g. smoke exercise). Here the activities of restoration and rehabilitation will include:-

    • Provision of hospital and community facilities for training and education to maximize use of remaining capacities.
    • Education of the public and industries to use rehabilitated –
    • Mother and father Meoble extent.
    • Selective placement
    • Work therapy and hospital

    In 3° prevention, mainly the activities are directed at rehabilitation rather than diagnoses and treatment. Case at this level aims to help the patient to achieve a high level of functioning as possible despite the limitation caused by illness or impaired functions.

    Management of diseases

    Clinical diagnostic principles and treatment:

    1. History taking and recording
    2. Physical examination
    3. Tests and studies
    4. Treatment which involves first aid, nursing care, medical treatment, surgical treatment, preventive treatment/health education/discharge advice.

    History taking and recording

    This is the process of gathering information concerning the patient’s health problem as he arrives from home to the hospital.

    Factors to be considered before history taking are commenced:

    1. The clinician/nurse taking history should be understood by the patient in order for a good problem account to be taken and recorded.
    2. The language to be used in history taking should be simple, clear and understandable to the patient.
    3. Where the interpreter is involved, the patient should be given time to express him or herself.
    4. The interviewer should not as far as possible ask questions which do not have definite answers and the questions should be related to the suspected disease which may lead to the diagnosis but not off topic questions.
    5. The interviewer should not just stop at presenting complaint and assumes that that is all for the history but should go deeper than that since the presenting complaint may just be only a small part of the problem.
    6. The history should be taken from the right source, i.e., the patient her self, close family member who has been with the patient since the illness started or a mother in case of a child, or from the incident report from the first aider/health centre/ those who found the patient and helped him to reach the hospital.
    7. Allow the patient to present the complaints in the way he/she feels it and only fill in the necessary information which should include whatever has been disclosed concerning the patient and his/her attitudes.
    8. There must be privacy during history collection to avoid concealing more otherwise vital information that could have helped in the diagnosis.
    9. The history should be detailed, clear and chronological with significant information. It should include the interpretation of the present situation and should indicate the result they expect from consultation.
    10. History taking should be done is such a way that the patient/attendant learns from the interview so that he is made to discover what could have gone wrong such that the illness has occurred.

    Physical examination

    Introduction

    Physical examination can be done through inspection, palpation, percussion and auscultation and this may need a stretcher or just the laps of the mother for the case of a small child/a baby.

    1. Inspection: this is the act of visually observing the patient to note any significant physical change.
    2. Palpation: this is the use of sense of touch to assess factors such as texture, crepitance, temperature, moisture, vibration or pulsation, swelling, rigidity or spasticity, organ location and size, presence of lumps or masses, and presence of tenderness or pain. Different parts of the hands are used for palpation.
    3. Percussion: this is striking the patient’s skin to determine the density, size and location of the underlying structure. A tap on the skin sets the body wall in motion: and the quality of sound produced describes the organ below, i.e. the density of air versus solid matter of the different structures. The sounds of the different notes on the percussed areas may either be of normal clear, hollow quality, low pitched one, or much lower & louder in the lung areas where there is much air, or it may be dull: soft, high-pitched, muffled thud over the spleen and liver. The sound may be absolutely dull/flat sound where there is no air especially over the thigh muscles or large tumors.
    4. Auscultation: this is used to assess sounds produced by the heart, lungs, and bowel. Abnormalities can be detected as different sounds are interpreted and compared to the normal sounds produced by the above organs.

    General principles of Inspection

    1. Approaching the patient: whenever possible, ample time is allowed for the examiner and the patient to become acquainted. Patient should be treated as an individual with respect and dignity. The beliefs and other values should be considered. Encourage a good examiner-client relationship.
    2. Observations/inspection: this starts at the time the patient is entering the examination room/screen/hospital ward. The purpose is to note any significant physical characteristics. It is the point-specific scrutiny of the patient as a whole/system by system. It must be purposeful, focused, and unhurried.
    3. First observe the movement/gait and the way he/she is coming or being brought in, i.e., walking straight/limping/supported/rolled on a wheel chair/or on a stretcher. This tells you about how weak the patient is/how severe his condition is and the type of treatment/action he/she needs.
    4. Observe general appearance: is the face sad/sick looking, crying in deep pain/grimacing or vise versa.
    5. Carry out ABC plan of assessment: but you should be careful for your own safety before starting the assessment.
    6. Respiration: check if the breathing is normal/dyspnoiec and respiratory characteristics
    7. Dehydration, malnutrition and anemia: skin turgor/wrinkles, hollow cheek and jutting prominences, thirst, presence of secretions-saliva, urine, history of vomiting/diarrhea/bleeding/not eating and drinking for sometimes?
    8. Check for mental outlook: consciousness, confusion and hallucinations, alertness, orientation or unconsciousness. Observe the head for injuries, bleeding, and swelling. Do the same for the eyes, nose and ears, also the pupils for the size and their reaction to light.
    9. Smell for: breathe in case of alcohol/poisonous intake/acetone smell especially in patients who are unconscious.
    10. Take the vital signs: temperature, pulse, respiration, blood pressure and weight
    11. Look for muscle: for weakness, paralysis and spasms.

    Process of examination

    1. Undressing: the majority of patients resent the removal of clothes even for examination purposes, i.e., the bras, pants and knickers. Most females look shy. The reason for clothe removal must be explained to the patient and confidentiality be ensured. The patient should then be told to lie on the stretcher in an anatomical position.
    2. Examination: usually it is better to start with an area unlikely to be having pain or a site of a patient’s complaints. The ears, eyes throat should be last in children. Before performing a disagreeable painful or embarrassing examination, tell the patient what is likely to happen and how the patient can assist, tell him that the examination is necessary and it will be performed as fast as possible and that during examination, some specimen has to be taken like vaginal smears.

    Order of examination

    Head

    1. Check the hair for quantity, thickness, texture, distribution, infestation. The texture is very important when conditions like hyper/hypothyroidism, or HIV/AIDS/chronic wasting diseases that cause protein loss, drugs, or alopecia are implicated.
    2. Check the scalp for scaliness, parasites, lumps, lesions, and nits. Note also the skin color, cyanosis, pallor in the face, jaundice, and mucous membrane, and edema.
    3. Observe the general size and contour of the skull and note any deformity, lumps and tenderness especially when checking for hydrocephalus, microcephalus or acromegally. Check for facial expression, symmetry of the facial structures (stroke and hypertension).
    4. Eyes: ask if patient is able to see/has blurred vision esp. in hypertension and diabetes mellitus. Also look for photophobia, visual acuity (for long/short sightedness), any swelling, discharge, wounds, eye size, check pupil size and their reaction to light esp. in unconscious patients or those with injuries on the head.
    5. Ears: for size, skin lesions, swelling, tenderness and pain on the pinna. Look for redness, wounds in the middle ear and discharge (note the color whether bloody, purulent, serous, etc) for they have different indications.
    6. Nose: check for any deformity, asymmetry, inflammation, wounds, discharge, patency of each nostril, smelling test.
    7. Mouth and throat: inspect the lips for color, moisture, lumps, ulcers, cracking. Certain diseases affect the lips including dehydration. Note the color of the mucous membrane in the tongue, smoothness (for the dorsal surface of the tongue is normally roughened from the presence of papillae), check for rashes and fungal infections, sores and wounds. Check the gum for swelling; bleeding, discoloration, retraction, etc. check the throat for the swellings of thyroid glands, salivary glands, range of movement and strength of cervical bones and muscles.

    Thoracic cavity

    1. On inspection, look for shape (barrel chest-horizontal ribs+ large antero-posterior diameter or scoliosis-an S-shaped curvature, lordosis/sway-back=an anterior curvature of the lumbar spine, and kyphosis-an exaggerated posterior curvature of the thoracic spine= hump back).
    2. Observe the skin and muscles to determine the level of nutrition.
    3. Check for any respiratory movement, wounds and penetrations.
    4. Note respiratory abnormalities such as dyspnoea, tachypnoeic, bradypnea, irregular, shallow, slow breathing, apnea, cheyne stoke’s breathing.
    5. Look for chest sounds by use of percussion and auscultation ( decreased and absent sounds occur in bronchial obstruction by foreign bodies, secretions, mucus plug), and percussion notes( resonance = normal, hyperresonace = emphysema, dull = abnormal density in the lungs caused by pneumonia, pleural effusion, Atelectasis or tumor).
    6. Do breast examination for size, dimples, nodules, sores, swelling, etc. Do also cardiovascular examination.

    Abdomen by use of inspection, auscultation, percussion and palpation:

    1. Check the abdomen for distension, scars, rigidity, tenderness and pain, enlargement of the organs, ascites, skin turgor and folding. Nb: the abdomen is auscultated first after inspection and before percussion and palpation so that the auscultatory findings are not altered by increased or decreased peristalsis
    2. Pelvis: check it for position, size and proportion to detect any abnormality.
    3. Extremities (both lower and upper extremities): note the color, presence of clubbing of the fingers and toes in chronic illnesses, hair distribution, venous pattern, swellings, ulcers, temperature, palpate the blood supply to the extremities, check for range of movement abilities at the joints and observe for muscle strength, any deformity and inequality.
    4. Skin: check for color, texture, rashes, scales, desquamation, scars, swollen nodes, edema, sensation, temperature, wounds, etc.

    Neurological examination

    This involves assessing for the level of consciousness by calling him/her, shaking, shouting in the ears, pressing a nail bed for pain stimuli and see how he/she is responding, checking for papillary reaction to light and size, or by use of Glasgow coma scale, check for the senses of smell, taste, site, touch, muscle weakness, paralysis, reflexes, etc.

    Investigations/tests & studies

    Tests are procedures carried out from the laboratory to identify the pathogenic microbes while studies are investigations which need interpretation.

    The types of tests that can be done in the laboratory include:

    1. Urine: this may be collected either in a sterile way to identify the microbes such as; E.coli, enterococci, staphylococci, hemolytic streptococci, mycobacterium tubercle, parasites such as schistosoma haematobium, trichomonas vaginalis, urea, Creatinine, etc. clean urine may also be collected to check for amount, color, consistency, specific gravity, glucose, albumin, pH, acetone, etc.
    2. Blood: this may be removed for various tests such as complete blood count, erythro-sedimentation rate, Hb, grouping and cross-match, smears, urea, renal and liver function tests, glucose, etc.
    3. Stool: this is removed to identify the ova, cysts, occult blood, mucus, microbes, worms, etc.
    4. Discharges: vaginal, urethral, cervical, pus, sputum, skin smears are taken for gram staining, etc.
    5. Punctures: this is when cavities are gone into and their secretions are aspirated and taken to the laboratories for analysis; e.g. thoracentesis, paracentesis, lumbar punctures, knee aspirations, etc.

    Studies done to diagnose diseases include:

    1. Biopsies: this depends on the disease suspected and pieces of affected tissues are removed and taken for histological studies to identify the different cell types found in the tissue questioned especially if cancerous cells are suspected.
    2. Radiography: use of x-rays to detect any deformity/breakage in the bones; find abnormal lungs, distended loops of the gut, to show the size and shape of the heart.
    3. Ultra sound scan: use of sound waves emitted by the machine to produce an image of an anatomical structure which may either be normal/abnormal in size or structure.
    4. Endoscopies: this involves the insertion of tubes with light source at their tips and a viewing lens at the other side, into the tubular structures to view their walls for wounds, swellings, inflammations. These include: bronchoscopy, cystoscopy, endoscopy, etc.
    5. Use of radiopaque dyes: this is when radiopaque substances are injected into the tubular structures to coat up the walls of these organs so that when their radiograph is taken, blocked tubes, narrow ones are identified and actions are taken appropriately. These include: angiography, urography, venography, etc.
    6. Computerized tomography: a much more expensive method of imaging than the ultra sound scanning that can be used for more finely and diagnostic procedures for tumors especially in the brain where ultra sound scanning may not give any information that may be of help.
    7. Magnetic resonance imaging (MRI): use of magnetic waves to provide information about kidney masses that can not be obtained by other methods. Here solid masses look different from cystic/hollow masses which contain fluid in them.

    Treatment of diseases

    Principles of treatment of diseases

    1. First aid treatment: this is the kind of treatment offered especially for the patients who come to the hospital/health centers when they are badly off and their condition is deteriorating to the dying point within minutes. Assess for your own safety, carry out ABCDE plan of resuscitation and assessment, and refer the patient for further management.
    2. Nursing care: This care given to the patient without the use of drugs and it depends on the condition of the patient on arrival. Airway care is catered for first, then circulation (shock, anaemia, dehydration), and then others may follow. Nursing care involves preparing the patient, your self and equipment, doing the procedure, clearing and making the patient comfortable including records and patient follow up and continuous assessment and monitoring of the patient.
    3. Medical treatment: is the treatment of diseases using drugs. This may have been given during emergency before the doctor’s arrival and those that the doctor may prescribe before or after laboratory results.
    4. Surgical treatment: the use of mechanical means of operation to cure diseases in situations that drugs may not cure the patient.
    5. Preventive treatment: this involves prevention of infections through notification, isolation, health education and giving prophylactic drugs. Screening of contacts may be done and drugs given to the infected ones and you protect the health workers and other contacts.

    Levels of disease prevention Read More »

    Medicines Acting on Specific Body Systems

    Medicine Introduction and General Causes of Disease

    Nursing Notes - Introduction to Medical Nursing

    Module Unit: CN-2102 - Medical Nursing (I)

    Module Unit Description

    This module unit is intended for students to acquire competencies in providing high quality evidence-based nursing care in traditional as well as innovative healthcare settings. This will mainly cover introduction to medical nursing, study of conditions of circulating, respiratory systems and conditions of hematology.

    Learning Outcomes

    By the end of this module unit, students shall be able to;

  • Identify the common medical conditions affecting circulatory, blood and respiratory systems
  • Identify patients with circulatory, haematologic and respiratory conditions for referral
  • Identify cases in the above category of medical conditions for referral.

    • INTRODUCTION TO MEDICINE

    DEFINITION OF MEDICINE

    This is the study or science of treating diseases especially by means of internal remedies (drugs) as distinct from mechanical and operative procedures which is the domain of surgery.

    TERMS USED IN MEDICINE

    1. Health: is a state of complete physical, social, mental and spiritual wellbeing of an individual and not merely the absence of diseases or infirmity.
    2. Aetiology: is the study of the causes of diseases and the facts that influence their occurrence. The causes are divided into 2; the exciting cause (the micro-organism responsible for that particular disease) and predisposing causes/factors (these are factors encouraging/promoting/influencing/aggravating/precipitating the occurrence of that particular disease.
    3. Pathology: is the study of the disease process/developing or study of changes which occur in the diseased organs so as to produce signs and symptoms.
    4. Signs: are the abnormal things that we can see in a patient with our naked eyes, e.g. a rash, swelling, diarrhea, ulcer, scar, etc.
    5. Symptom: the abnormal things that we can not see in a patient with our naked eyes, e.g. pain, nausea, musclé ache, etc.
    6. Physical sign: is what is found on examination of the patient, e.g. an enlarged spleen, liver, full urinary bladder, a pregnant uterus, anaemia seen from the pale tongue and mucous membrane, fracture, sore, etc.
    7. Inspection: is the general observation of the patient by use of eyes only and this reveals many abnormalities such as deformity, diminished movements on the affected side of the body, etc.
    8. Palpation: this is feeling a patient by use of the palms of the hands for swellings (whether painful, hot, cold, smooth, fluctuant, fixed/mobile, round/irregular). It is a manual examination of the patient by placing the hands on the chest/abdomen and trying to feel the nature of underlying organs.
    9. Percussion: this is the tapping of the chest or abdominal wall using flat hands and fingers, then striking over them with fingers from the opposite hands. This is to detect normal sounds and abnormal ones from the underlying cavities or hollow organs as the tapping sounds are transmitted through the skin, muscles and into the cavities/organs. A dull sound in the chest indicates fluid filled cavities or consolidated hollow organ (filled and without any space), and a loud sound is heard over the normal area where the air is freely entering into the free space. The same to the abdomen and the organs contained there in.
    10. Auscultation: this is listening with the stethoscope on the chest wall/abdominal wall to enable the clinician/doctor/nurse to hear the normal breathe/abdominal sounds and the abnormal ones or for peristaltic movements in the abdomen in post-operative abdominally operated patients. Those with intestinal obstruction or abdominal post-operative patients who have taken 2 days may have no sounds at all.
    11. Complications: this is a lesion/damage/symptom which results from the original disease and not necessarily part of that disease, e.g., a complication of gonorrhea is urethral stricture, or meningitis results in paralysis if the brain was involved.
    12. Sequeale: is a symptom persisting after the original disease has subsided. It is a permanent complication that remains with the patient for life. The sequale of meningitis is permanent mental retardation.
    13. Diagnosis: is the recognition of a particular disease. It is arrived at through good history taking, physical examination and laboratory findings.
    14. Laboratory diagnosis: this is through identification of micro-organisms under the microscope in the laboratory to confirm the clinical diagnosis. In urgent situations, the patient should be treated according to the clinical diagnosis and not to wait for confirmation from the laboratory.
    15. Differential diagnosis: this is the knowledge of other diseases which resemble the disease in question and it points the difference which will help in performing a final diagnosis, e.g. malaria +meningitis are all fever causing diseases unless blood slide and lumbar puncture are done to differentiate btn the 2.
    16. Prognosis: is the act of foretelling how the disease will end judging from the course/progress/worsening reduction in the progress of the disease. E.g. the disease started like this, it later changed like this and it might end this way.
    17. Prophylaxis: this is the prevention of a disease by vaccination, giving treatment before the disease starts. It may be for an individual, or for the whole community.
    18. Path gnomic sign: this is a sign occurring in one disease only and not found in any other condition. When present, it affords the establishment of a certain disease. E.g., koplick’s spots in measles, polyarthritis in rheumatic fever which is shifting in nature.
    19. Syndrome: is a collection of signs and symptoms which constitute a special disease, e.g. Aids.
    20. Epidemiology: is the study of the diseases by reference to its incidence in the population, e.g., during which season, in which geographical areas, which group of people are more affected.
    21. Geriatric: is a branch of medicine which is concerned with the prevention of social neglect in the elderly. It is the health care given to the elderly.
    22. Infection: is a successful invasion of the body tissues by micro-organisms without showing any sign and symptoms.
    23. Inflammation: is the body’s reaction/response to infection (by developing fever in order to make the temperature unsuitable for the survival of microbes; swelling to take more cells-soldiers to the invaded area in much blood supply; pain is caused by the overstretching of a part due to swelling, due to destruction of tissues and nerves; loss of function in order for the affected part to rest and to heal without being disturbed. The inflammation can be acute or chronic.

    INTRODUCTION TO DISEASES

    Disease: is any alteration in the structure and function of an organ.

    Types of diseases

    • Communicable/infectious diseases
    • Non-communicable/non-infectious diseases

    Communicable/infectious diseases

    Definition: Communicable disease is an illness due to specific infectious agents in its toxic products, which under certain conditions tends to spread among individuals in a community.

    Period of communicability or communicable period: refers to the time during which an infectious agent may be transferred directly or indirectly from an infected person to a susceptible person. This period is usually equal to the maximum known incubation period for that disease.

    Examples of Communicable / infectious Diseases

    • Tuberculosis
    • Cholera
    • Malaria
    • Meningococcal meningitis and Viral meningitis
    • Plague
    • HIV
    • Ebola virus and Marburg virus
    • Hepatitis A, B, C and E

    Modes of Transmission of communicable diseases

    The modes of transmission may be classified into two broad categories: direct and indirect.

    Direct Transmission
    1. Direct contact: e.g., sexual contact, kissing, etc., and continued close contact. Diseases transmitted here include STI/HIV, Leprosy, and Scabies.
    2. Droplet infection: Through coughs, sneezes. Diseases include common cold, TB, measles, whooping cough, meningitis, etc.
    3. Contact with infected soil: e.g., Tetanus, infective hookworm larvae.
    4. Inoculation into skin or mucosa: e.g., animal bites (dog bites - rabies) and HIV or Hepatitis B virus from contaminated needle pricks.
    5. Trans-placental or vertical transmission: e.g., toxoplasmosis, HIV, rubella virus, syphilis.
    Indirect Transmission
    1. Vehicle-borne transmission: The common vehicle of transmission is water, milk, or food; other vehicles may be blood, serum, plasma, and other biological products. This group includes water-borne, milk-borne, food-borne, and blood-borne infections. Examples: enteric fever, cholera, dysentery, diarrhea, hepatitis A, B, E, food poisoning.
    2. Vector-borne transmission: e.g., malaria, filarial, kala-azar, and plague are transmitted by insects. The mode of transmission is vector transmission.
    3. Air-borne transmission: e.g., Droplet nuclei - (very small infective particles which float in the air, e.g., TB), infected dust (due to sweeping or dusty infected settled droplets on the ground).
    4. Fomite-borne transmission: Fomites are articles that convey infection to others because they have been contaminated, e.g., handkerchiefs, drinking glasses, door handles, clothing, etc. Highly infectious diseases, e.g., Ebola, can be easily transmitted by fomites.

    Other terms used in communicable diseases

    1. Zoonoses: An infectious disease transmissible under natural conditions from vertebrate animals to man is called a zoonoses. There are over 150 diseases common to man and animals. Examples include anthrax, liver fluke, bovine TB, salmonellosis, brucellosis, rabies, plague, typhus, and yellow fever.
    2. Nosocomial infections: An infection occurring in a patient in a hospital or other healthcare facility and in whom it was not present or incubating at the time of admission or arrival at a healthcare facility is called a nosocomial infection. It refers to diseases transmitted from a hospital. Usually such infections are more difficult to manage as they are generally resistant to most of the common antibiotics. Nosocomial infections also include those infections, which were contacted in the hospital but manifested after discharge, and also infections suffered by staff members if they contacted the infection from the hospitalized patients.
    3. Herd Immunity: The immune status of a group of people/community is called herd immunity as it is the immune status of the 'herd' of people. For many communicable diseases, an outbreak of disease is only possible if the level of immunity is sufficiently low and there are a large number of susceptible individuals in the population. In diseases like poliomyelitis, diphtheria, measles, etc., herd immunity plays an important role. However, in a disease like tetanus or rabies where every individual is at risk unless specifically protected, herd immunity plays no role.

    Factors responsible for the increased risk of infectious diseases are;

    • Failure to control vectors especially mosquitoes
    • Break down of the water and sanitation system.
    • Failure to detect the disease early.
    • Lack of immunization programmes
    • High risk human behavior.

    When the immune system is compromised especially in children and elderly, various conditions or diseases set in.

    Control of communicable diseases

    This refers to the reduction of the incidence and prevalence of communicable diseases to a level where it cannot be a major public health problem.

    There are three main methods of controlling communicable diseases:

    • Eliminating the reservoir (attacking the source)
    • Interrupting transmission
    • Primordial prevention

    Eliminating the reservoir (attacking the source)

    1. Detection and adequate treatment of cases: This arrests the communicability of the disease, e.g., control of tuberculosis and leprosy and most sexually transmitted diseases.
    2. Isolation: This means that the person with the disease is not allowed to come into close contact with other people except those who are providing care; therefore, the organism cannot spread. It is used to control highly infectious diseases such as hemorrhagic viral fevers.
    3. Quarantine: Limitation of the movement of apparently well person or animal who has been exposed to the infectious disease for the duration of the maximum incubation period of the disease.
    4. Reservoir control: In those diseases that have their main reservoir in animals, mass treatment or chemoprophylaxis or immunization of the animals can be carried out, e.g., in brucellosis. Other ways include separating humans from animals or killing the animals and so destroying the reservoir, e.g., plague, rabies, and hydatid disease.
    5. Notification: Means immediately informing the local health authorities (e.g., the District Medical Officer) that you suspect a patient is suffering from an infectious disease.

    Interrupting transmission

    This involves the control of the modes of transmission from the reservoir to the potential new host through:

    • Environmental sanitation
    • Personal hygiene and behavior change.
    • Vector control, e.g., mosquitoes
    • Disinfection and sterilization
    • Protection of susceptible host
    1. Immunization: This increases host resistance by strengthening internal defenses. It is one of the most effective controls of communicable diseases in Africa. To be more effective, immunization has to be given to a high proportion of the people (at least 80%).
    2. Chemoprophylaxis: Drugs that protect the host may be used for suppressing malaria and for preventing infection with such diseases as plague, meningitis, and tuberculosis.
    3. Personal protection: The spread of some diseases may be limited by the use of barriers against infection, e.g., shoes to prevent entry of hookworms from the soil, bed nets, and insect repellents to prevent mosquitoes.
    4. Better nutrition: Malnourished children get infections more easily and suffer more severe complications. Prevention and actions aimed at eradicating, eliminating, or minimizing the impact of disease and disability.

    Primordial prevention

    This consists of actions and measures that inhibit the emergence of risk factors in a country or population. It begins with the change in the social and environmental conditions. Examples of primordial prevention actions:

    • National policies and programs on nutrition involving agricultural sector, the food industry.
    • Comprehensive policies to discourage smoking
    • Programs to promote regular physical activity
    1. Primary prevention: This is action prior to the onset of disease which removes the possibility that the disease will occur. Its objectives are to promote health, prevent exposure, and prevent disease.
    2. Secondary prevention: This is the action which halts the progress of a disease and limits permanent damage through early detection and treatment of disease.
    3. Tertiary prevention: This is to limit disabilities and to promote the patients' adjustments to irremediable conditions. Interventions include disability limitation and rehabilitation.

    Non-communicable diseases

    These are types of diseases which cannot be transmitted from one person to another.

    Types of non-communicable diseases

    1. Congenital disease: It is a disease or an abnormality somebody is born with, e.g., syphilis, AIDS, extra digits, or an imperforate anus. These abnormalities may be caused by drugs, viral infections, radiations, and genetic factors like sickle cell disease (the passage of a gene of abnormal red blood cell shape to the offspring from the parents).
    2. Inherited disease: This is a disease which is hereditary and runs in families, such as SCD, diabetes mellitus (type one), or hemophilia, a condition of blood clotting abnormalities.
    3. Traumatic disease: Is a disease due to injury by mechanical means, e.g., fractures, burns, wounds, ruptured organs, etc.
    4. Inflammatory disease: Is a disease caused by an infection with pathogenic organisms. This can be acute or chronic. Acute disease occurs suddenly but chronic disease occurs slowly.
    5. Circulatory disease: This is a disease which affects the circulatory system like blood vessels; blood itself, the heart, and so on.
    6. Neoplasm/new growths: These are swellings or ulcers which result from overgrowth of new tissues from abnormal cells.
    7. Degenerative diseases/miscellaneous diseases: Degeneration means wearing out of cells and the gradual replacement of tissues by fats, fibrous tissues, or some other material. It may occur as a result of action of toxic metabolic changes or diminished blood supply. The diseases of degeneration may occur because of disease or old age. Examples of these diseases are diabetic and other metabolic disorders, blood vessel diseases, or brain deterioration due to old age.
    8. Allergic diseases: Allergy means an abnormal reaction or response of an individual to a normal allergen which would not cause any reaction to another individual. These abnormal allergens lead to the formation of antibodies (immunoglobulin Igb) and a high concentration of these in blood suggests an allergic reaction. The examples of allergic diseases are bronchial asthma, anaphylactic shock, and other minor ones which provoke characteristic symptoms whenever they are consequently encountered.

    Etiology of diseases

    Introduction

    • There are 3 elements that determine the etiology of health problems in population; these are: Agent, the Host, and Environment.
    • They are referred to as an epidemiological triad.
    • Epidemiology is a study of distribution and determinants of the diseases and health related events in human population.
    • Disease or disorder occurs when the agent is more powerful than the host and causes the host to become weaker and the environment becomes favorable for growth, multiplication, and survival of the agent.
    • This is possible when the host becomes stronger and the agent is moved and the environment becomes unfavorable to the agent.

    Agent

    It is a factor whose presence or absence causes a disease.

    It is a specific factor without that a disease cannot occur.

    A disease agent is defined as a substance living or non-living or a force; tangible or non-tangible, the excessive presence or relative lack of that is the immediate cause of a particular disease.

    The disease agent is classified as follows:

    1. Physical Agents: Various mechanical forces of frictions that may produce injury as well as atmospheric abnormalities such as extremes of heat, cold, humidity, pressure, radiation, electricity, sound, etc.
    2. Biological Agent: Include all living organisms, e.g., Viruses, Bacteria, Rickettsia, Chlamydia, Protozoa, Fungi, Helminthes, among others.
    3. Chemical Agents:
  • Endogenous: Some of the chemicals may be produced in the body as a result of decayed function, e.g., Urea (uremia), Ketones (Ketosis), Sodium, Bilirubin (Jaundice), uric acid (Gout), CaCo3 (Kidney stones), among others.
  • Exogenous Agents: These arise from outside of the human host, allergens, Metals, fumes, insecticides, etc. They may be acquired by inhalation, ingestion, or inoculation.
    • 4. Genetic Agents: Transmitted from parent to a child through the genes.
    5. Mechanical Agent: Chronic friction and other mechanical forces resulting in injuries, trauma, fractures, sprain, dislocation, and even death
    6. Nutrient Agents: Dietary components we need to survive, e.g., proteins, fats, Carbohydrates, vitamins, minerals, and H2O.
  • The excessive or deficient intake of nutrients leads to Malnutrition, etc., which in turn leads to susceptibility to disease.
  • Absence, Insufficiency or Excess of factor:
  • Chemical hormones, e.g., insulin, estrogen, etc.
  • Nutrients
  • Lack of structure, e.g., congenital defects of the heart.
  • Chromosomes, e.g., Mongolism, Mental retardation.

    • Host

    This refers to humans or animals that come in contact with the agent.

    Host factors influence the interaction with the agent and the environment as follows:

    1. Age: Certain diseases are more frequent in certain age groups than others, e.g.,
      • Childhood age; Measles, whooping cough
      • Advanced age, e.g., diabetes, hypertension, cardiovascular
    2. Sex: There are certain anatomical and hormonal differences between the two sexes, e.g., disorders associated with pregnancy in females; Prostatic hypertrophy in males.
    3. Race: Some races also suffer from particular diseases, e.g., Negroes suffer from sickle cell Anemia (SCA).
    4. Genetical factors: Behavioral disorders and diseases of blood run in the family due to chromosomal factors.
    5. Habits: Living habits or lifestyles such as dietary patterns, use of tobacco, alcohol, narcotics, and drugs are the factors that influence the susceptibility of disease, e.g., Malnutrition, drug dependence, sexual excesses.
    6. Nutrition: The effects of poor nutrition lead to susceptibility to various infections.
    7. Customs: Certain traditional systems like superstition lead to diseases, e.g., fixed belief in gods of disease in Hindu society makes people not to believe in immunization that leads to childhood diseases.
    8. Human Mobility: Frequent diseases in place may cause, e.g., malaria, cholera, AIDS, syphilis, etc.
    9. Immunity: The reaction of the human host to infection depends upon his previous immunological experience, e.g., infection, immunization. Those who acquired natural immunity will not be easily susceptible to disease.
    10. Social Status: Certain diseases occur according to social class, e.g., low social classes are susceptible to Bronchitis, TB. Usually, upper classes have lower mortality and morbidity than lower classes.
    11. Economic status: Person’s occupation itself may be the cause of certain occupational hazards and infections, e.g., Brucellosis, Dermatitis, etc., and unemployment also leads to diseases.
    12. Educational status: Diseases can be easily controlled and managed in the educated class whereas it will be difficult in the case of the uneducated class.

    Environment

    This refers to the aggregate of all external conditions and influences affecting the life and development of organisms, human behavior, and society.

    1. Physical Environment: It includes non-living things and physical factors like H2O, Air, Soil, Heat, Light, Radiation, Noise, Housing, Climate, etc. Alteration or disease in this environment due to various causes leads to H2O pollution, Air pollution, soil pollution, Noise pollution that is too may cause diseases, e.g., heavy flooding in the village or town can cause the likelihood that the area H2O sources will be contaminated with waste products.
    2. Biological Environment: Includes all the living things created in the world. Man lives around the living things that include bacteria, Viruses, and other various Microorganisms which may cause diseases and mal-adjustment in the ecological system leading to the causative factor of the disease.
    3. Social Environment: Man has to live in society and should follow the accepted patterns of particular society such as cultural values, customs, habits, beliefs, attitudes, and morals, religion, and other psychological factors. Any alteration in these factors may lead to conflicts and tensions that may cause behavioral diseases. Habits like smoking, alcohol, drug dependence are well known to cause diseases.

    Medicine Introduction and General Causes of Disease Read More »

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