Pain on defecation suggests that the tip of the appendix is resting against the rectum; pain on urination suggests that the tip is near the bladder or impinges on the ureter arthritis in knee walking order voltaren 50mg visa. Laxatives administered in this instance may produce perforation of the inflamed appendix arthritis in the back and sciatica 100mg voltaren. In general arthritis in neck trouble swallowing 100 mg voltaren with mastercard, a laxative or cathartic should never be given while the person has fever arthritis in neck cracking purchase voltaren 50mg without a prescription, nausea rheumatoid arthritis diet gluten discount voltaren 50 mg without a prescription, or pain arthritis pain early pregnancy purchase voltaren 100mg on line. Assessment and Diagnostic Findings Diagnosis is based on results of a complete physical examination and on laboratory and x-ray findings. Gerontologic Considerations Acute appendicitis does not occur frequently in the elderly population. As a result, diagnosis and prompt treatment may be delayed, causing potential complications and mortality. The incidence of perforated appendix is higher in the elderly population because many of these patients do not seek health care as quickly as younger patients. To correct or prevent fluid and electrolyte imbalance and dehydration, antibiotics and intravenous fluids are administered until surgery is performed. Appendectomy (ie, surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. It may be performed under a general or spinal anesthetic with a low abdominal incision or by laparoscopy. Nursing Management Complications the major complication of appendicitis is perforation of the appendix, which can lead to peritonitis or an abscess. The nurse prepares the patient for surgery, which includes an intravenous infusion to replace fluid loss and promote adequate renal function and antibiotic therapy to prevent infection. If there is evidence or likelihood of paralytic ileus, a nasogastric tube is inserted. This position reduces the tension on the incision and abdominal organs, helping to reduce pain. The patient may be discharged on the day of surgery if the temperature is within normal limits, there is no undue discomfort in the operative area, and the appendectomy was uncomplicated. The nurse instructs the patient to make an appointment to have the surgeon remove the sutures between the fifth and seventh days after surgery. Incision care and activity guidelines are discussed; normal activity can usually be resumed within 2 to 4 weeks. If there is a possibility of peritonitis, a drain is left in place at the area of the incision. Patients at risk for this complication may be kept in the hospital for several days and are monitored carefully for signs of intestinal obstruction or secondary hemorrhage. Chapter 38 in the liver, elevating the temperature and pulse rate and increasing the leukocyte count. When the patient is ready for discharge, the nurse teaches the patient and family to care for the incision and perform dressing changes and irrigations as prescribed. A home care nurse may be needed to assist with this care and to monitor the patient for complications and wound healing. Management of Patients With Intestinal and Rectal Disorders 1037 tents can accumulate in the diverticulum and decompose, causing inflammation and infection. A diverticulum can become obstructed and then inflamed if the obstruction continues. The inflammation tends to spread to the surrounding bowel wall, giving rise to irritability and spasticity of the colon (ie, diverticulitis). Abscesses develop and may eventually perforate, leading to peritonitis and erosion of the blood vessels (arterial) with bleeding. Diverticulosis exists when multiple diverticula are present without inflammation or symptoms. Diverticular disease of the colon is very common in developed countries, and its prevalence increases with age. The incidence increases to 50% among those in the ninth decade of life (Keighley, 1999). Diverticulitis results when food and bacteria retained in a diverticulum produce infection and inflammation that can impede drainage and lead to perforation or abscess formation. Approximately 20% of patients with diverticulosis have diverticulitis at some point. A congenital predisposition is suspected when the disorder occurs in those younger than 40 years of age. A low intake of dietary fiber is considered a predisposing factor, but the exact cause is unknown. Diverticulitis may occur in acute attacks or may persist as a continuing, smoldering infection. The symptoms manifested generally result from its potential complications-abscesses, fistulas, obstruction, and hemorrhage. Clinical Manifestations Chronic constipation often precedes the development of diverticulosis by many years. Signs of acute diverticulosis are bowel irregularity and intervals of diarrhea, abrupt onset of crampy pain in the left lower quadrant of the abdomen, and a low-grade fever. The patient may have nausea and anorexia, and some bloating or abdominal distention may occur. With repeated local inflammation of the diverticula, the large bowel may narrow with fibrotic strictures, leading to cramps, narrow stools, and increased constipation. With acute diverticulosis, the patient reports mild to severe pain in the lower left quadrant. Abdominal x-ray findings may demonstrate free air under the diaphragm if a perforation has occurred from the diverticulitis. Diverticulosis may be diagnosed using barium enema, which shows narrowing of the colon and thickened muscle layers. If there are symptoms of peritoneal irritation and when the diagnosis is diverticulitis, barium enema is contraindicated because of the potential for perforation. A colonoscopy may be performed if there is no acute diverticulitis or after resolution of an acute episode to visualize the colon, determine the extent of the disease, and rule out other conditions. Laboratory tests that assist in diagnosis include a complete blood cell count, revealing an elevated leukocyte count, and elevated sedimentation rate. Pathophysiology A diverticulum forms when the mucosa and submucosal layers of the colon herniate through the muscular wall because of high intraluminal pressure, low volume in the colon (ie, fiber-deficient contents), and decreased muscle strength in the colon wall (ie, muscular hypertrophy from hardened fecal masses). If an abscess develops, the associated findings are tenderness, a palpable mass, fever, and leukocytosis. An inflamed diverticulum that perforates results in abdominal pain localized over the involved segment, usually the sigmoid; local abscess or peritonitis follows. Abdominal pain, a rigid boardlike abdomen, loss of bowel sounds, and signs and symptoms of shock occur with peritonitis. Noninflamed or slightly inflamed diverticula may erode areas adjacent to arterial branches, causing massive rectal bleeding. Gerontologic Considerations the incidence of diverticular disease increases with age because of degeneration and structural changes in the circular muscle layers of the colon and because of cellular hypertrophy. They may delay reporting symptoms because they fear surgery or are afraid that they may have cancer. Blood in the stool is overlooked frequently, especially in the elderly, because of a failure to examine the stool or the inability to see changes because of diminished vision. When possible, the area of diverticulitis is resected and the remaining bowel is joined end to end (ie, primary resection and end-to-end anastomosis). This is performed through traditional surgical or laparoscopically assisted colectomy. A two-stage resection may be performed in which the diseased colon is resected (as in a one-stage procedure) but no anastomosis is performed; both ends of the bowel are brought out onto the abdomen as stomas. The nurse reviews dietary habits to determine fiber intake and asks the patient about straining at stool, history of constipation with periods of diarrhea, tenesmus (ie, spasms of the anal sphincter with pain and persistent urge to defecate), abdominal bloating, and distention. Assessment includes auscultation for the presence and character of bowel sounds and palpation for lower left quadrant pain, tenderness, or firm mass. It is important to monitor temperature, pulse, and blood pressure for abnormal variations. Initially, the diet is clear liquid until the inflammation subsides; then, a high-fiber, low-fat diet is recommended. This type of diet helps to increase stool volume, decrease colonic transit time, and reduce intraluminal pressure. In acute cases of diverticulitis with significant symptoms, hospitalization is required. Hospitalization is often indicated for those who are elderly, immunocompromised, or taking corticosteroids. Withholding oral intake, administering intravenous fluids, and instituting nasogastric suctioning if vomiting or distention occurs rests the bowel. An opioid is prescribed for pain relief; morphine is not used because it increases segmentation and intraluminal pressures. Antispasmodics such as propantheline bromide (Pro-Banthine) and oxyphencyclimine (Daricon) may be prescribed. Normal stools can be achieved by using bulk preparations (Metamucil) or stool softeners (Colace), by instilling warm oil into the rectum, or by inserting an evacuant suppository (Dulcolax). Such a prophylactic plan can reduce the bacterial flora of the bowel, diminish the bulk of the stool, and soften the fecal mass so that it moves more easily through the area of inflammatory obstruction. Alternatively, when the acute episode of diverticulitis resolves, surgery may be recommended to prevent repeated episodes. In a primary anastomosis, the proximal margin (dotted line) is transected and the bowel attached end-to-end. In a two-stage procedure, a colostomy is constructed at the proximal margin with the distal stump oversewn (Hartmann procedure, as shown) or brought to the outer surface as a mucous fistula. Has no blood in the stool · Peritonitis · Abscess formation · Bleeding Planning and Goals the major goals for the patient may include attainment and maintenance of normal elimination patterns, pain relief, and absence of complications. An individualized exercise program is encouraged to improve abdominal muscle tone. The nurse encourages daily intake of bulk laxatives such as Metamucil, which helps to propel feces through the colon. Stool softeners are administered as prescribed to decrease straining at stool, which decreases intestinal pressure. Oil retention enemas may be prescribed to soften the stool, making it easier to pass. The nurse records the intensity, duration, and location of pain to determine if the inflammatory process worsens or subsides. Peritonitis can also result from external sources such as injury or trauma (eg, gunshot wound, stab wound) or an inflammation that extends from an organ outside the peritoneal area, such as the kidney. The most common bacteria implicated are Escherichia coli, Klebsiella, Proteus, and Pseudomonas. Other common causes of peritonitis are appendicitis, perforated ulcer, diverticulitis, and bowel perforation. Peritonitis may also be associated with abdominal surgical procedures and peritoneal dialysis. The clinical manifestations of perforation and peritonitis and the care of the patient with peritonitis are presented in the next section. The nurse monitors vital signs and urine output and administers intravenous fluids to replace volume loss as needed. The nurse educates patients who have not been involved in these practices in the past about their importance and refers the patients to appropriate health care providers. Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, white blood cells, cellular debris, and blood. The immediate response of the intestinal tract is hypermotility, soon followed by paralytic ileus with an accumulation of air and fluid in the bowel. Clinical Manifestations Symptoms depend on the location and extent of the inflammation. The early clinical manifestations of peritonitis frequently are the symptoms of the disorder causing the condition. The pain tends to become constant, localized, and more intense near the site of the inflammation. The affected area of the abdomen becomes extremely tender and distended, and the muscles become rigid. The temperature and pulse rate increase, and there is almost always an elevation of the leukocyte count. Oxygen therapy by nasal cannula or mask can promote adequate oxygenation, but airway intubation and ventilatory assistance occasionally are required. Massive antibiotic therapy is usually initiated early in the treatment of peritonitis. Large doses of a broad-spectrum antibiotic are administered intravenously until the specific organism causing the infection is identified and the appropriate antibiotic therapy can be initiated. Surgical objectives include removing the infected material and correcting the cause. Surgical treatment is directed toward excision (ie, appendix), resection with or without anastomosis (ie, intestine), repair (ie, perforation), and drainage (ie, abscess). The nurse reports the nature of the pain, its location in the abdomen, and any shifts in location. Administering analgesic medication and positioning the patient for comfort are helpful in decreasing pain. The patient is placed on the side with knees flexed; this position decreases tension on the abdominal organs.
A systemic preparation may be used to gain rapid control of the disease; to manage severe arthritis early symptoms buy voltaren 50mg with amex, persistent asthma; to treat moderate to severe exacerbations; to accelerate recovery; and to prevent recurrence (Dhand rheumatoid arthritis scholarship discount voltaren 100mg on-line, 2000) arthritis treatment center torrance purchase voltaren 100 mg on-line. Cromolyn sodium (Intal) and nedocromil (Tilade) are mild to moderate anti-inflammatory agents that are used more commonly in children arthritis ear pain order voltaren 100 mg with amex. They also are effective on a prophylactic basis to prevent exercise-induced asthma or in unavoidable exposure to known triggers rheumatoid arthritis relieve home remedies voltaren 100mg discount. Long-acting beta2-adrenergic agonists are used with antiinflammatory medications to control asthma symptoms symptoms of arthritis in feet nhs buy generic voltaren 100 mg on line, particularly those that occur during the night. Long-acting beta2-adrenergic agonists are not indicated for immediate relief of symptoms. Possible causes are dust, dust mites, roaches, certain types of cloth, pets, horses, detergents, soaps, certain foods, molds, and pollens. Although national guidelines are available for the care of the asthma patient, unfortunately health care providers may not follow them. Failure to follow the guidelines in the following areas has been noted: lack of treatment of patients who have symptoms more than 2 days per week with a regular medication schedule, lack of patientspecific advice on improving the environment and an explanation about the importance of doing so, lack of encouragement for patients to monitor their peak flow measurements with a diary, and lack of written, up-to-date educational materials (Plaut, 2001). A 1998 survey by a group called "Asthma in America" found that 11% of physicians were unaware of the national asthma guidelines. Only 35% of patients with asthma who were surveyed reported having pulmonary function testing in the past year. Daily medication: · Anti-inflammatory: either inhaled corticosteroid (low doses) or cromolyn or nedocromil (children usually begin with a trial of cromolyn or nedocromil). Steps 2 and 3 actions plus: · Refer to individual education/ counseling Step 1 actions plus: · Teach selfmonitoring · Refer to group education if available · Review and update selfmanagement plan · Short-acting bronchodilator: inhaled beta2-agonists as needed for symptoms. Zafirlukast or zileuton may also be considered for patients 12 years of age, although their position in therapy is not fully established. Notes: · the stepwise approach presents general guidelines to assist clinical decision making; it is not intended to be a specific prescription. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients. Gaining control may be accomplished either by starting treatment at the step most appropriate to the initial severity of the condition or by starting at a higher level of therapy (eg, a course of systemic corticosteroids or higher dose of inhaled corticosteroids). First, review patient medication technique, adherence, and environmental control (avoidance of allergens or other factors that contribute to asthma severity). This may be especially common with exacerbations provoked by respiratory infections. An individual should be assigned to the most severe grade in which any feature occurs. The characteristics noted in this table are general and may overlap because asthma is highly variable. Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. Systemic corticosteroids may be necessary to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medications. Also, response to treatment may be monitored by serial measurements of lung function. This helps to guide the patient in self-management strategies regarding an exacerbation and also provides instructions regarding recognition of early warning signs of worsening asthma. Daily peak flow monitoring is recommended for all patients with moderate or severe asthma because it helps measure asthma severity and, when added to symptom monitoring, indicates the current degree of asthma control. The patient is instructed in the proper technique, particularly to give maximal effort. The "personal best" is determined after monitoring peak flows for 2 or 3 weeks after receiving optimal asthma therapy. Nursing Management the immediate nursing care of the patient with asthma depends on the severity of the symptoms. The patient may be treated successfully as an outpatient if asthma symptoms are relatively mild, or he or she may require hospitalization and intensive care for acute and severe asthma. Fluids may be administered if the patient is dehydrated, and antibiotic agents may be prescribed if the patient has an underlying respiratory infection. If the patient requires intubation because of acute respiratory failure, the nurse assists with the intubation procedure, continues close monitoring of the patient, and keeps the patient and family informed about procedures. A major challenge is to implement basic asthma management principles at the community level (Reinke, 2000). Key issues include education of health care providers, establishment of programs for asthma education (for patients and providers), use of outpatient follow-up care for patients, and a focus on chronic management versus acute episodic care. Methylxanthines (theophylline [Slo-bid, Theo-24, Theo-Dur]) are mild to moderate bronchodilators usually used in addition to inhaled corticosteroids, mainly for relief of nighttime asthma symptoms. Leukotriene modifiers (inhibitors) or antileukotrienes are a new class of medications. Leukotrienes are potent bronchoconstrictors that also dilate blood vessels and alter permeability. Leukotriene inhibitors act by either interfering with leukotriene synthesis or blocking the receptors where leukotrienes exert their action (Boushey, Fick, Lazarus & Martin, 2000). At this time, they may provide an alternative to inhaled corticosteroids for mild persistent asthma or may be added to a regimen of inhaled corticosteroids in more severe asthma to attain further control. In addition, combination products are also available (eg, albuterol/ipratropium [Combivent]) and offer ease of use for the patient. Short-acting beta-adrenergic agonists are the medications of choice for relieving acute symptoms and preventing exercise-induced asthma. From Facts about controlling asthma, National Asthma Education and Prevention Program, National Heart, Lung, and Blood Institute. Volume is measured in color-coded zones (right): the green zone signifies 80% to 100% of personal best; yellow, 60% to 80%; and red, less than 60%. If peak flow falls below the red zone, the patient should take the appropriate actions prescribed by his or her health care provider. Patient teaching is a critical component of care for the patient with asthma (Plaut, 2001). Multiple inhalers, different types of inhalers, antiallergy therapy, antireflux medications, and avoidance measures are all integral for long-term control. This complex therapy requires a patientprovider partnership to determine the desired outcomes and to formulate a plan to achieve those outcomes. The patient then carries out daily therapy as part of self-care management, with input and guidance by the health care provider. Patient Caregiver Chapter 24 Management of Patients With Chronic Obstructive Pulmonary Disease 595 Lung and Blood Institute. The nurse emphasizes adherence to the prescribed therapy, preventive measures, and the need to keep follow-up appointments with the primary health care provider. A home visit to assess the home environment for allergens may be indicated for the patient with recurrent exacerbations. In addition, the nurse reminds the patient and family about the importance of health promotion strategies and recommended health screening. Other criteria indicating the need for hospitalization include poor pulmonary function test results and deteriorating blood gas levels (respiratory acidosis), which may indicate that the patient is tiring and will require mechanical ventilation. Although most patients do not need mechanical ventilation, it is used for patients in respiratory failure, for those who tire and are too fatigued by the attempt to breathe, or for those whose conditions do not respond to initial treatment. Infection, anxiety, nebulizer abuse, dehydration, increased adrenergic blockage, and nonspecific irritants may contribute to these episodes. A ventilationperfusion abnormality results in hypoxemia and respiratory alkalosis initially, followed by respiratory acidosis. Nursing Management the nurse constantly monitors the patient for the first 12 to 24 hours, or until status asthmaticus is under control. Fluid intake is essential to combat dehydration, to loosen secretions, and to facilitate expectoration. The nurse administers intravenous fluids as prescribed, up to 3 to 4 L/day, unless contraindicated. Clinical Manifestations the clinical manifestations are the same as those seen in severe asthma: labored breathing, prolonged exhalation, engorged neck veins, and wheezing. As the obstruction worsens, the wheezing may disappear, and this is frequently a sign of impending respiratory failure. Assessment and Diagnostic Findings Pulmonary function studies are the most accurate means of assessing acute airway obstruction. Arterial blood gas measurements are obtained if the patient cannot perform pulmonary function maneuvers because of severe obstruction or fatigue, or if the patient does not respond to treatment. Cystic fibrosis is usually diagnosed in infancy or early childhood, but patients may be diagnosed later in life. For individuals diagnosed later in life, respiratory symptoms are frequently the major manifestation of the disease. Medical Management In the emergency setting, the patient is treated initially with a short-acting beta-adrenergic agonist and corticosteroids. Chloride transport problems lead to thick, viscous secretions in the lungs, pancreas, liver, intestine, and reproductive tract as well as increased salt content in sweat gland secretions. The ability to detect the common mutations of this gene allows for routine screening for this disease as well as the detection of carriers. This obstruction is due to bronchial plugging by purulent secretions, bronchial wall thickening due to inflammation, and, over time, airway destruction (Katkin, 2002). These chronic retained secretions in the airways set up an excellent reservoir for continued bronchial infections. Clinical Manifestations the pulmonary manifestations of this disease include a productive cough, wheezing, hyperinflation of the lung fields on chest x-ray, and pulmonary function test results consistent with obstructive airways disease (Katkin, 2002). Colonization of the airways with pathogenic bacteria usually occurs early in life. Staphylococcus aureus and Haemophilus influenzae are common organisms during early childhood. As the disease progresses, Pseudomonas aeruginosa is ultimately isolated from the sputum of most patients. Upper respiratory manifestations of the disease include sinusitis and nasal polyps. Nonpulmonary clinical manifestations include gastrointestinal problems (eg, pancreatic insufficiency, recurrent abdominal pain, biliary cirrhosis, vitamin deficiencies, recurrent pancreatitis, weight loss), genitourinary problems (male and female infertility), and clubbing of the extremities. Inhaled mucolytic agents such as dornase alfa (Pulmozyme) or N-acetylcysteine (Mucomyst) may also be used. These agents help to decrease the viscosity of the sputum and promote expectoration of secretions. To decrease the inflammation and ongoing destruction of the airways, anti-inflammatory agents may also be used. It helps to correct the hypoxemia and may minimize the complications seen with chronic hypoxemia (pulmonary hypertension). Because there is a long waiting list for lung transplant recipients, many patients die while awaiting a transplant. Gene therapy is a promising approach to management, with many clinical trials underway. Specific nursing measures include strategies that promote removal of pulmonary secretions; chest physiotherapy, including postural drainage, chest percussion, and vibration, and breathing exercises are implemented and are taught to the patient and to the family when the patient is very young. The patient is reminded of the need to reduce risk factors associated with respiratory infections (eg, exposure to crowds and to persons with known infections). The patient is taught the early signs and symptoms of respiratory infection and disease progression that indicate the need to notify the primary health care provider. The nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. Antibiotic medications are routinely prescribed for acute pulmonary exacerbations of the disease. Depending upon the severity of the exacerbation, aerosolized, oral, or intravenous antibiotic therapy may be used. Antibiotic agents are selected based upon the results of a sputum culture and sensitivity. Chapter 24 Management of Patients With Chronic Obstructive Pulmonary Disease 597 to be addressed in patients when warranted. For the patient whose disease is progressing and who is developing increasing hypoxemia, preferences for end-of-life care should be discussed, documented, and honored (see Chap. Patients and family members need support as they face a shortened life span and an uncertain future. She cannot lie flat in bed, she is extremely short of breath, and she has decreased breath sounds throughout the chest and crackles in the posterior basilar areas. What medical and nursing interventions might be used to decrease or alleviate these signs/symptoms? Your patient at an outpatient asthma clinic is a 35-yearold inner-city Mexican-American mother with asthma. Your 64-year-old patient has a history of bronchiectasis and heart failure following two myocardial infarctions. To promote removal of pulmonary secretions, his physician has prescribed chest physiotherapy and postural drainage. Describe how you would modify chest physiotherapy and postural drainage given his statement that he cannot breathe in a supine or prone position. Your 22-year-old patient is a college student with a history of cystic fibrosis; he has been admitted to your unit for intravenous antibiotic therapy.
Characterized by the need for increasing doses to maintain the same level of pain relief arthritis psoriatica diet voltaren 50 mg visa. Pain is significant in that it draws attention to its existence and teaches the person to avoid similar potentially painful situations arthritis in my neck what can i do best 50 mg voltaren. If no lasting damage occurs and no systemic disease exists symptoms of arthritis in feet nhs purchase voltaren 50 mg free shipping, acute pain usually decreases along with healing rheumatoid arthritis in feet and ankles 100mg voltaren fast delivery. For purposes of definition rheumatoid arthritis grants buy 50mg voltaren fast delivery, acute pain can be described as lasting from seconds to 6 months bichon frise arthritis relief discount voltaren 100 mg on line. However, the 6-month time frame has been criticized (Brookoff, 2000) as inaccurate since many acute injuries heal within a few weeks and most heal by 6 weeks. In a situation where healing is expected in 3 weeks and the patient continues to suffer pain, it should be considered chronic and treated with interventions used for chronic pain. Waiting for the full 6-month time frame in this example could cause needless suffering. For example, chest pain suggests angina or a myocardial infarction and indicates the need for treatment according to cardiac care standards. Burn pain and postherpetic neuralgia are examples of pain described by their etiology. Clinicians often can predict the course of pain and plan effective treatment using this categorization. Harmful Effects of Pain Regardless of its nature, pattern, or cause, pain that is inadequately treated has harmful effects beyond the suffering it causes. Zalon (1997) found that the most common response to severe pain in frail, elderly postoperative women was to lie absolutely still, a response likely to result in postoperative complications. It may have a poorly defined onset, and it is often difficult to treat because the cause or origin may be unclear. Although acute pain may be a useful signal that something is wrong, chronic pain usually becomes a problem in its own right. Chronic pain may be defined as pain that lasts for 6 months or longer, although 6 months is an arbitrary period for differentiating between acute and chronic pain. An episode of pain may assume the characteristics of chronic pain before 6 months have elapsed, or some types of pain may remain primarily acute in nature for longer than 6 months. Nevertheless, after 6 months, most pain experiences are accompanied by problems related to the pain itself. The nurse may come in contact with patients with chronic pain when they are admitted to the hospital for treatment or when they are seen out of the hospital for home care. Frequently the nurse is called on in community-based settings to assist patients in managing pain. The stress response ("neuroendocrine response to stress") that occurs with trauma also occurs with other causes of severe pain. The widespread endocrine, immunologic, and inflammatory changes that occur with stress can have significant negative effects. The stress response generally consists of increased metabolic rate and cardiac output, impaired insulin response, increased production of cortisol, and increased retention of fluids (see Chap. The patient with severe pain and associated stress may be unable to take a deep breath and may experience increased fatigue and decreased mobility. Although these effects may be tolerated by a young, healthy person, they may hamper recovery in an elderly, debilitated, or critically ill person. Pain resulting from cancer is so ubiquitous that after fear of dying, it is the second most common fear of newly diagnosed cancer patients (Lema, 1997). More than half of the 1,308 cancer patients included in a study conducted by Foley (1999) reported being in moderate to severe pain 50% of the time. Pain in the patient suffering from cancer can be directly associated with the cancer (eg, bony infiltration with tumor cells or nerve compression), a result of cancer treatment (eg, surgery or radiation), or not associated with the cancer (eg, trauma). Most pain associated with cancer, however, is a direct result of tumor involvement. This three-step approach illustrates the types of analgesic medications used for various levels of pain. A cancer pain algorithm developed as a set of analgesic guiding principles appears in Figure 13-2. Suppression of the immune function associated with chronic pain may promote tumor growth. Although health care providers express concern about the large quantities of opioid medications required to relieve chronic pain in some patients, it is safe to use large doses of these medications to control progressive chronic pain. In fact, failure to administer adequate pain relief may be unsafe because of the consequences of unrelieved pain (McCracken & Iverson, 2001). Regardless of how the patient copes with chronic pain, pain for an extended period can result in disability. Patients with a number of chronic pain syndromes report depression, anger, and fatigue (Meuser, Pietruck, Radruch et al. Tricyclic antidepressants may provide comfort in neuropathic and postherpetic pain. Burn Pain Possibly the most severe pain, burn pain tends to be underrated by health care professionals the longer they work with burn patients. Guillain-Barrй Syndrome and Pain A progressive, inflammatory disorder of the peripheral nervous system, Guillain-Barrй syndrome is characterized by flaccid paralysis accompanied by paresthesia and pain-muscle pain and severe, unrelenting, burning pain. Complaints of severe pain may be difficult to accept in the face of the characteristic flaccid facial response; therefore, the nurse must be sensitive and learn to disregard nonverbal cues that contradict the verbal report of pain. Causalgia and neurogenic pain may be relieved by systemic or epidural opioids or, possibly, antiseizure agents or tricyclic antidepressants. To relieve the burning, some patients beg to have windows opened and clothing removed, even in cold weather. Opioid Tolerance Opioid tolerance is common among patients treated for chronic pain, especially patients being treated by multiple health care providers. Opioid tolerance should be suspected when a patient (1) complains of significantly more pain than is usually associated with the condition, (2) requires unusually high doses of opioids to achieve pain relief, or (3) experiences an unusually low incidence and severity of side effects from opioids. Cancer patients also often develop a tolerance to opioids, requiring larger and larger doses of medication to obtain pain relief. In such cases, the nurse must recognize what is happening, seek additional information from the patient or family, and then procure additional prescriptions for analgesics or an alternative intervention. In patients undergoing surgery, epidural local anesthetic agents provide excellent postoperative analgesia, but the problem of opioid tolerance must be elicited from the patient preoperatively. Occasionally a recovering heroin addict is seen in an acute pain situation (surgery or trauma). This patient may be undergoing treatment with naltrexone (Trexan), a long-acting form of the opioid antagonist naloxone (Narcan). Both the short-acting naloxone and the longacting naltrexone act by binding to the opioid receptors, so opioids cannot be effective. If surgery is planned, the naltrexone should be discontinued a few days before the procedure. Should a patient receiving naltrexone be in immediate need of pain relief, very high doses of opioids are necessary. Complex regional pain syndrome describes a variety of painful conditions that often follow an injury. The magnitude and duration of the pain far exceeds the expected duration and often results in significant impairment of motor function. Pain, which worsens with movement, cutaneous stimulation, or stress, often occurs after surgery or trauma to the extremity but is not limited to the area of surgery or trauma. Post-traumatic headache disorder occurs after trauma to the head and is characterized by daily and persistent headache. It is more likely to follow mild head injury than moderate to severe injury (Uomoto & Esselman, 1993). Fibromyalgia (Fibrositis) Fibromyalgia, a chronic pain syndrome characterized by generalized musculoskeletal pain, trigger points, stiffness, fatigability, and sleep disturbances, is aggravated by stress and overexertion. Hemiplegia-Associated Shoulder Pain Hemiplegia-associated shoulder pain is a pain syndrome that affects as many as 80% of stroke patients. It may result from stretching of the shoulder joint due to the uncompensated pull of gravity on the impaired arm. It may be preventable with functional electrical stimulation of involved shoulder muscles. Pain Associated With Sickle Cell Disease Pain experienced by patients with sickle cell disease results from venous occlusion caused by the sickle shape of the blood cells, impaired circulation to a muscle or organ, ischemia, and infarction. Meperidine (Demerol) therapy is not recommended in patients with compromised renal function, nor is cold therapy. Some issues related to their history include tolerance, possible long-term dependence, racial prejudice, and inadequate pain treatment. These nerve fibers branch very near their origin in the skin and send fibers to local blood vessels, mast cells, hair follicles, and sweat glands. When these fibers are stimulated, histamine is released from the mast cells, causing vasodilation. Some receptors respond to only one type of stimuli; others, called polymodal nociceptors, respond to all three types of stimuli. These highly specialized neurons transfer the mechanical, thermal, or chemical stimulus into electrical activity or action potentials. The cutaneous fibers located more centrally further branch and communicate with the paravertebral sympathetic chain of the nervous system and with large internal organs. As a result of the connections between these nerve fibers, pain is often accompanied by vasomotor, autonomic, and visceral effects. In a patient with severe acute pain, for example, gastrointestinal peristalsis may decrease or stop. Analgesic regimens are based on pain reported as ranging from mild to moderate to severe. Various opioid (narcotic) and nonopioid medications may be combined with other medications to control pain. Peripheral Nervous System A number of algogenic (pain-causing) substances that affect the sensitivity of nociceptors are released into the extracellular tissue as a result of tissue damage. Histamine, bradykinin, acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain. Prostaglandins are chemical substances thought to increase the sensitivity of pain receptors by enhancing the painprovoking effect of bradykinin. These chemical mediators also cause vasodilation and increased vascular permeability, resulting in redness, warmth, and swelling of the injured area. Once nociception is initiated, the nociceptive action potentials are transmitted by the peripheral nervous system (Porth, 2002). The first-order neurons travel from the periphery (skin, cornea, visceral organs) to the spinal cord via the dorsal horn. Smaller, myelinated A (A delta) fibers transmit nociception rapidly, which produces the initial "fast pain. This type of pain has dull, aching, or burning qualities that last longer than the initial fast pain. If there is repeated C fiber input, a greater response is noted in dorsal horn neurons, causing the person to perceive more pain. In other words, the same noxious stimulus produces hyperalgesia, and the person reports greater pain than was felt at the first stimulus. For this reason, it is important to treat patients with analgesic agents when they first feel the pain. Patients require less medication and experience more effective pain relief if analgesia is administered before the patient becomes sensitized to the pain. Chemicals that reduce or inhibit the transmission or perception of pain include endorphins and enkephalins. They are examples of substances that reduce nociceptive transmission when applied to certain nerve fibers. Endorphins and enkephalins are found in heavy concentrations in the central nervous system, particularly the spinal and medullary dorsal horn, the periaqueductal gray matter, hypothalamus, and amygdala. Morphine and other opioid medications act at receptor sites to suppress the excitation initiated by noxious stimuli. The binding of opioids to receptor sites is responsible for the interpersonal relationships he or she engaged in before the pain began. Disabilities may range from curtailing participation in physical activities to being unable to take care of personal needs, such as dressing or eating. The nurse needs to understand the effects of chronic pain on the patient and family and needs to be knowledgeable about pain relief strategies and appropriate resources to assist effectively with pain management. Pathophysiology of Pain the sensory experience of pain depends on the interaction between the nervous system and the environment. The processing of noxious stimuli and the resulting perception of pain involve the peripheral and central nervous systems. Nociceptors are receptors that are preferentially sensitive to a noxious stimulus. Nociceptors Nociceptors are free nerve endings in the skin that respond only to intense, potentially damaging stimuli. The joints, skeletal muscle, fascia, tendons, and cornea also have nociceptors that have the potential to transmit stimuli that produce pain. However, the large internal organs (viscera) do not contain nerve endings that respond only to painful stimuli. Pain originating in these organs results from intense stimulation of receptors that have other purposes.
It is measured by the Strange Situation arthritis in neck treatment exercises voltaren 100mg cheap, in which observers note how much emotional security children derive from parents when under some stress due to the presence of strange people and objects arthritis thumb diet quality voltaren 50 mg. Malnourished children and those who receive less responsive warmth appear to be less emotionally secure than well-nourished and supported children (Cooper and others 2009; Isabella 1993; Valenzuela 1990) arthritis in lower back and pelvis buy 100 mg voltaren with amex. These factors include the preconception and pregnancy nutritional status of the mother arthritis strength tylenol purchase voltaren 50mg line, birth weight and linear growth of the infant arthritis pain relief advil buy cheap voltaren 50 mg on line, and conditions of labor and delivery; maternal mental health; and 242 Reproductive arthritis pain quiz order voltaren 50 mg without a prescription, Maternal, Newborn, and Child Health environmental conditions. However, we start with the condition most specific to mental development, namely, psychosocial stimulation. Psychosocial Stimulation Psychosocial stimulation refers to an external object or event that elicits a physiological and psychological response in the child. The infant and toddler version for children younger than age 24 months includes 45 items that are assessed through observation and interview. The caregiver is also questioned about activities that expose the child to places, people, and conversation. The focus is on opportunities to play and converse in ways that stretch thinking and understanding of speech. A brief version of the inventory called the Family Care Indicators is available for use in national surveys. Mothers (caregivers) were asked what they had done with their children under age five years in the past three days. Items largely focus on the variety of play materials available for the child (for example, things for making music, things for pretending, things for drawing) and play activities (for example, reading or looking at pictures, telling stories, singing songs). Only 25 percent of mothers said they had read to their children in the past three days, 25 percent had sung songs, and 35 percent had told stories. Thus, the presence of more children does not necessarily mean more of the right kind of stimulation. It is often mistakenly believed that older siblings provide sufficient stimulation and supervision. Many parents from countries in South Asia and SubSaharan Africa practiced only one or two. Although no threshold score is available to identify inadequate levels of stimulation, low levels such as these are unlikely to support expected levels of mental development (Bradley and Corwyn 2005). This interaction helps children translate their own thoughts and actions into speech and later into writing and reading. Play materials that children enjoy manipulating and combining in multiple ways help them learn about mass Very Early Childhood Development Br Co azil sta Ri ca Ch ile 243 da Et 1 hio pia Ug an da 2 es h Vi et na m Th ail an d lad ng Ug an Figure 13. Communication that linear growth may be a proxy for other critical nutrition processes related to brain and behavioral development. A model of how nutrition contributes to mental development is presented in figure 13. One pathway is direct in the sense that nutrients support the structure and activity of brain sites responsible for mental development. Other pathways are indirect in that nutrition enhances health and engagement with the environment, which promote mental development. Evidence from nutrition interventions showing effects on growth and health are described here. Macronutrients Sufficient macronutrients, such as carbohydrates, proteins, and fats, are important to linear growth and mental development. In the first six months, exclusive breastfeeding provides sufficient nutrients to support healthy rates of growth and immunity (Kramer and others 2001) (see chapter 5 in this volume, Stevens, Finucane, and Paciorek 2016). After age six months, the quality of diet is captured by the term dietary diversity and measured as the number of seven different food categories in a daily diet (Daelmans, Dewey, and Arimond 2009). Dietary diversity was positively related to linear growth in five of the nine countries for which these data were analyzed (Jones and others 2014). Improving dietary diversity, especially with animal-source foods, is a critical message in nutrition education interventions (Neumann and others 2007). In eight studies, nutrition education alone for mothers of children ages 624 months, usually about foods to feed and number of meals, led to gains in length, with an effect size of d = 0. Agricultural improvements at the household level are also being implemented and evaluated (Iannotti and others 2014). Micronutrients Micronutrients such as iron and iodine are considered to be important for mental development in the first 24 months (see chapter 11 in this volume, Lenters, Wazny, and Bhutta 2016; and chapter 12, Das and others 2016). Numerous studies have demonstrated high levels of anemia in young children, especially in South Asia and Sub-Saharan Africa, where 20 percent of children younger than age five years are anemic (Black and others 2013). Both an iron-deficient diet and hookworm in contaminated soil are responsible for low Figure 13. The material must be challenging so that children have opportunities to construct the material in new ways. Child Nutrition One of the strongest risk factors for poor mental development is short length- or height-for-age (for crosssectional studies, see Olney and others 2009; Servili and others 2010; for longitudinal studies, see GranthamMcGregor and others 2007). It is not clear why length and height are so strongly related to cognitive and language development, except 244 Reproductive, Maternal, Newborn, and Child Health levels of hemoglobin. Anemic children are consistently found to have lower levels of mental development than non-anemic children in case-control studies, and differences persist over the long term (Lozoff and others 2006). Anemic children also show a number of socially isolating behaviors, such as wariness and lethargy. However, the nutritional and mental consequences of providing young children with iron are mixed and generally weak (Pasricha and others 2013). Alternative explanations are being sought for the longitudinal findings, such as low levels of stimulation in the home environment, where the mother may be anemic. Brain functioning, such as speed of processing auditory and visual information, may be a more sensitive measure of the mental effects, especially if iron is an important element in the myelin sheath around neuronal axons (Lozoff and others 2006). Iodine deficiency is consistently associated with poor school achievement, but much less is known about its effect on the mental development of children younger than age 24 months (Zimmermann 2012; Zimmermann, Jooste, and Pandav 2008). Many countries lack naturally occurring iodine in the soil and water and therefore must fortify a product such as salt. Most of the data on prevalence has been collected from children ages 612 years whose urinary iodine levels tend to match that of their parents. Based on these data, an estimated 40 percent of the Sub-Saharan African population and 31. Four prospective studies find that mental development scores of children with inadequate iodine levels at birth were half a standard deviation less than those with healthy levels (Bougma and others 2013); this finding translates into a development quotient difference of 8 points on a standard mental test-a meaningful difference. Multiple Vitamin and Mineral Supplements Multiple micronutrients constitute the common nutritional supplement provided to young children. Children are often deficient in many minerals, such as iron and zinc, as well as vitamins. All are critical for health and growth, and their effects on mental development are becoming clear. The rationale for studying multiple micronutrients is that they work together to improve health, they appear to be necessary for linear growth, and they are found in many sites in the brain. Most of what is known about the effects of combining multiple micronutrients comes from evaluations of trials in which various combinations are provided in a powder sprinkled on the food daily at mealtime. Alternatively, researchers weigh meal foods and calculate quantities of different nutrients in each food item. The section on Interventions for Mental Development reports effects on cognitive and language outcomes. Systematic reviews have consistently shown that the effect sizes of nutrition interventions on linear growth gains were lowest for micronutrient fortification (about 0. Although nutrition education is insufficient on its own, especially in food-insecure sites, it is necessary if benefits from short-term supplementation and fortification are to be sustained, and in some cases leads to better mental development (Vazir and others 2013). Despite a resurgence in some places, deaths due to neonatal tetanus, and sensory-motor disabilities due to polio and measles, are being reduced with the help of vaccines. However, trachoma, diarrhea, and cerebral malaria continue to have major impacts on early mental development. It is endemic in 57 countries, but 80 percent of the cases are in 15 countries, most in Sub-Saharan Africa. One study of southern Sudan found that 64 percent of children ages 19 years had active trachoma; 46. The condition begins in early childhood when the Chlamydia trachomitis, passed by hand or flies, leads to inflammation of the conjunctiva of the upper eyelid. Although surgery is needed for cases of blindness Very Early Childhood Development 245 among adults, the more common approach has been mass azithromycin antibiotic treatment as a primary and secondary prevention (Ogden and Emerson 2012). Diarrhea Diarrhea becomes most prevalent between 6 and 24 months of age; children have on average four to five episodes a year (Kosek, Bern, and Guerrant 2003). The most common cause of severe diarrhea is rotavirus, for which vaccines are being given to infants in many countries in East Asia and Pacific and South Asia and Sub-Saharan Africa (Armah and others 2010). The main route of transmission is fecal-oral, so the risk is high if families do not use a latrine or improved sources of water. Children become exposed to contaminated soil and water, typically after age six months when they start to crawl and share family meals. Hookworm, one of the geohelminths found in contaminated soil, is responsible for half of the anemia in children, and diarrhea is a common cause of malnutrition and stunting (Checkley and others 2008). Although there is little evidence that worms and diarrhea directly impede mental development, they may diminish important determinants, such as growth and activity (Fischer Walker and others 2012; Taylor-Robinson, Jones, and Garner 2007) (see chapter 9 in this volume, Keusch and others 2016). Enteropathy Recent attention has focused on tropical or environmental enteropathy, which results from constantly ingested fecal bacteria, as a subclinical condition. Constantly high levels of pathogenic bacteria lead to chronic changes in the villi of the small intestines (Humphrey 2009; McKay and others 2010; Weisz and others 2012). The effect of enteropathy is to increase absorption of bacterial products, such as endotoxins, into the system and allow for leakage of nutrients, such as proteins. Consequently, young children experience recurrent infections, with associated loss of appetite and diversion of nutrients to fight infections and inflammation, resulting in inactivity and growth faltering. Jiang and others (2014) find a direct association between mental development scores and the number of days during which an infant experienced fever and elevated levels of pro-inflammatory cytokines. Although preliminary, the work suggests a connection between inflammation and mental development. Cerebral Malaria Cerebral malaria has clear but variable consequences for early childhood mental development. There are 104 malaria-endemic countries in the world; most are in Sub-Saharan Africa. The parasite Plasmodium falciparum, in particular, is most strongly associated with cerebral malaria leading to high fever, coma, and organ failure. Contracted by pregnant women or young children, malaria is a serious cause of death and disability among children. In one Ugandan study, approximately 10 percent of survivors had severe neurological deficits; the majority had moderate problems that were detected only with psychological testing when the children were older (Bangirana and others 2006). Disabilities are evident in auditory or visual processing, as well as in memory and attention; language problems were not as severely affected. Because impairments vary, many researchers report the number of subtests on which cerebral malaria survivors show deficits compared with controls. For example, a prospective study with children ages 59 years in Kampala, Uganda, finds that on several tests of attention, working memory, and learning, 36. Deficits in attention and memory were most common and were related to the number of seizures and duration of coma. Most of this research has been conducted in urban hospitals, although the larger burden of malaria is likely found in rural sites. Consequently, the evidence is strong that a large proportion of children with cerebral malaria and its associated brain complications will show longterm cognitive and perceptual problems. The failure to meet the benchmark indicates increased risk of difficult deliveries for mothers and children; short maternal stature, defined as less than 246 Reproductive, Maternal, Newborn, and Child Health 145 centimeters, is also problematic. Consequently, birth injuries, such as asphyxia, are untreated and leave lasting effects on mental development. These issues include cognitive impairment, hearing and vision problems, and motor and behavioral problems. One hospitalbased assessment of surviving preterm Bangladeshi infants with gestational age of less than 33 weeks finds that 73 percent had mild or serious impairments when tested at younger than age two years; 66 percent were reported as having impairments between ages two and four years (Khan and others 2009); most of the impairments were cognitive. More research is needed to identify the range of disabilities they may experience related to sensory development, learning, mental health, and executive function. Accordingly, although prematurity was the stronger determinant of neonatal mortality, weight-for-gestational-age had more lasting effects on linear growth. Maternal Mental Health Maternal depression is increasingly recognized as an important risk factor for poor child development (Tomlinson and others 2014; Walker and others 2011) (see chapter 3 in this volume, Filippi and others 2016). A systematic review reports that the prevalence of maternal depression among pregnant women in low-income and lower-middle-income countries was 15. Prevalence is higher in many South Asian countries, for example, in Pakistan, where one study reports a 25 percent prevalence of maternal depression in the antenatal period and 28 percent in the postnatal period (Rahman, Iqbal, and Harrington 2003). Important determinants of maternal mental health include intimate partner violence (Ludermir and others 2008); social support (Rahman and Creed 2007); the quality of her relationships with her husband (Oweye, Aina, and Morakinyo 2006) and other close relatives, such as in-laws (Chandran and others 2002); and her coping strategies (Faisal-Cury and others 2003). Evidence suggests that iron-deficiency anemia contributes to a depressed mood at levels lower than required for a diagnosis of depression, as might iodine deficiency (Beard and others 2005). Infants with special needs requiring higher levels of care have been linked to higher levels of maternal distress (Yousafzai, Lynch, and Gladstone 2014). Studies from South Asia have shown that young children of depressed mothers are at risk of poor health, growth, and development outcomes. Rural Pakistani children of depressed mothers were twice as likely to have five or more episodes of diarrhea per year than children of nondepressed mothers (Rahman, Bunn, and others 2007). Studies from India and Pakistan have shown that infants born to depressed mothers are 2. Some hospital samples show a link (for example, Hamadani and others 2012), but in rural Ethiopia, maternal depression was not associated with poor mental development in children (Servili and others 2010).
Continued education and encouragement are usually needed to enable patients to formulate an acceptable plan that helps them live with their hypertension and adhere to the treatment plan arthritis stiff fingers order voltaren 50 mg otc. Compromises may have to be made about some aspects of therapy to achieve success in higher-priority goals arthritis in knee vitamins buy 50 mg voltaren with visa. The nurse can assist with behavior change by supporting patients in making small changes with each visit that move them toward their goals arthritis treatment vital101 voltaren 100 mg with visa. Another important factor is following up at each visit to see how the patient has progressed with the plans made at the prior visit rheumatoid arthritis toes buy 100 mg voltaren with visa. If the patient has had difficulty with a particular aspect of the plan rheumatoid arthritis neuropathy discount voltaren 50 mg line, the patient and nurse can work together to develop an alternative or modification to the plan that the patient believes will be more successful arthritis cold feet buy generic voltaren 100mg line. When the patient returns for follow-up care, all body systems must be assessed to detect any evidence of vascular damage. Examining the eyes with an ophthalmoscope is particularly important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system. The patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. Any significant findings are promptly reported to determine whether additional diagnostic studies are required. Based on the findings, medications may be changed to improve blood pressure control. Gerontologic Considerations Compliance with the therapeutic program may be more difficult for elderly people. The medication regimen can be difficult to remember, and the expense can be a problem. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive. Special care must be taken to ensure that the elderly patient understands the regimen and can see and read instructions, open the medication container, and get the prescription refilled. Because elderly people have impaired cardiovascular reflexes, they are often more sensitive than younger people to the extracellular volume depletion caused by diuretic therapy and to the sympathetic inhibition caused by adrenergic antagonists. The nurse teaches patients to change positions slowly when moving from a lying or sitting position to a standing position. The nurse also counsels elderly patients to use supportive devices such as hand rails and walkers when necessary to prevent falls that could result from dizziness. Maintains blood pressure at less than 140/90 mm Hg (or less than 130/85 mm Hg for persons with diabetes mellitus or proteinuria greater than 1 g per 24 hours) with lifestyle modifications, medications, or both b. Adheres to the dietary regimen as prescribed: reduces calorie, sodium, and fat intake; increases fruit and vegetable intake b. The nurse may think that taking vital signs every 5 minutes is appropriate if the blood pressure is changing rapidly or may check vital signs at 15 or 30 minutes intervals if the situation is more stable. A precipitous drop in blood pressure can occur, which would require immediate action to restore blood pressure to an acceptable level. Critical Thinking Exercises Hypertensive Crises There are two hypertensive crises that require nursing intervention: hypertensive emergency and hypertensive urgency. Hypertensive emergencies and urgencies may occur in patients whose hypertension has been poorly controlled or in those who have abruptly discontinued their medications. During the physical assessment, the patient, who is 5 feet 6 inches tall and weighs 180 lb, asks you what he can do to reduce his blood pressure. How would your assessment and plan change if the patient also had degenerative arthritis of his knees? Conditions associated with hypertensive emergency include acute myocardial infarction, dissecting aortic aneurysm, and intracranial hemorrhage. Hypertensive emergencies are acute, lifethreatening blood pressure elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The medications of choice in hypertensive emergencies are those that have an immediate effect. Intravenous vasodilators, including sodium nitroprusside (Nipride, Nitropress), nicardipine hydrochloride (Cardene), fenoldopam mesylate (Corlopam), enalaprilat (Vasotec I. One of your patients is an elderly man who lives alone and who has hypertension along with other health problems, including heart failure and atrial fibrillation. During a home visit, you learn that he has difficulty taking his medications as directed. How will you direct your assessment to identify factors contributing to this problem? Using the factors identified, develop a sample follow-up home care teaching plan for this patient. Recommendations for routine blood pressure measurement by indirect cuff sphygmomanometry. Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Genes and hypertension: From gene mapping in experimental models to vascular gene transfer strategies. Behavior of ambulatory blood pressure surrounding episodes of headache in mildly hypertensive patients. Compare the leukemias, their incidence, physiologic alterations, clinical manifestations, management, and prognosis. Use the nursing process as a framework for care of patients with lymphoma or multiple myeloma. Use the nursing process as a framework for care of patients with bleeding disorders. Identify therapies for blood disorders, including the nursing implications for the administration of blood and blood components. Patients with hematologic disorders can be quite challenging to nurses because they often have significant abnormalities in blood tests but few or no symptoms. It is equally important for the nurse to anticipate potential patient needs and to target nursing interventions accordingly. Because it is so important to the under- standing of most hematologic diseases, a basic appreciation of blood cells and bone marrow function is necessary. Blood is a specialized organ that differs from other organs in that it exists in a fluid state. Plasma is the fluid portion of blood; it contains various proteins, such as albumin, globulin, fibrinogen, and other factors necessary for clotting, as well as electrolytes, waste products, and nutrients. These cellular components of blood normally make up 40% to 45% of the blood volume. Because most blood cells have a short life span, the need for the body to replenish its supply of cells is continuous; this process is termed hematopoiesis. During embryonic development and in other conditions, the liver and spleen may also be involved. Thus, under normal conditions, the marrow responds to increased demand and releases adequate numbers of cells into the circulation. The volume of blood in humans is approximately 7% to 10% of the normal body weight and amounts to 5 to 6 L. Circulating through the vascular system and serving as a link between body organs, the blood carries oxygen absorbed from the lungs and nutri- ents absorbed from the gastrointestinal tract to the body cells for cellular metabolism. Blood also carries waste products produced by cellular metabolism to the lungs, skin, liver, and kidneys, where they are transformed and eliminated from the body. Blood also carries hormones, antibodies, and other substances to their sites of action or use. Because blood is fluid, the danger always exists that trauma can lead to loss of blood from the vascular system. To prevent this, an intricate clotting mechanism is activated when necessary to seal any leak in the blood vessels. Excessive clotting is equally dangerous, because it can obstruct blood flow to vital tissues. To prevent this, the body has a fibrinolytic mechanism that eventually dissolves clots (thrombi) formed within blood vessels. The balance between these two systems, clot (thrombus) formation and clot (thrombus) dissolution or fibrinolysis, is called hemostasis. In a child all skeletal bones are involved, but as the child ages marrow activity decreases. By adulthood, marrow activity is usually limited to the pelvis, ribs, vertebrae, and sternum. Marrow is one of the largest organs of the body, making up 4% to 5% of total body weight. It consists of islands of cellular components (red marrow) separated by fat (yellow marrow). As the adult ages, the proportion of active marrow is gradually replaced by fat; however, in the healthy person, the fat can again be replaced by active marrow when more blood cell production is required. In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also resume production of blood cells by a process known as extramedullary hematopoiesis. The stem cells have the ability to self-replicate, thereby ensuring a continuous supply of stem cells throughout the life cycle. When stimulated to do so, stem cells can begin a process of differentiation into either myeloid or lymphoid stem cells. Thus, with the exception of lymphocytes, all blood cells are derived from the myeloid stem cell. Research has identified many of the complex mechanisms involved, often at the molecular level. A thorough description of these processes is beyond the scope of this textbook; however, some mechanisms against which a specific treatment is targeted are briefly described in the relevant disease-specific sections of this chapter. It has a diameter of about 8 µm and is so flexible that it can pass easily through capillaries that may be as small as 2. Uncommitted (pluripotent) stem cells can differentiate into myeloid or lymphoid stem cells. These stem cells then undergo a complex process of differentiation and maturation into normal cells that are released into the circulation. Each step of the differentiation process depends in part on the presence of specific growth factors for each cell type. When the stem cells are dysfunctional, they may respond inadequately to the need for more cells, or they may respond excessively, sometimes uncontrollably, as in leukemia. The oxygen-carrying hemoglobin molecule is made up of four subunits, each containing a heme portion attached to a globin chain. An important property of heme is its ability to bind to oxygen loosely and reversibly. Oxygen readily binds to hemoglobin in the lungs and is carried as oxyhemoglobin in arterial blood. Oxyhemoglobin is a brighter red than hemoglobin that does not contain oxygen (reduced hemoglobin), which is why arterial blood is a brighter red than venous blood. The oxygen readily dissociates (detaches) from hemoglobin in the tissues, where the oxygen is needed for cellular metabolism. In venous blood, hemoglobin combines with hydrogen ions produced by cellular metabolism and thus buffers excessive acid. The erythroblast is a nucleated cell that, in the process of maturing within the bone marrow, accumulates hemoglobin and gradually loses its nucleus. Differentiation of the primitive myeloid stem cell of the marrow into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. The average daily diet in the United States contains 10 to 15 mg of elemental iron; normally 0. Additional amounts of iron, up to 2 mg daily, must be absorbed by women to replace blood lost during menstruation. Iron is stored in the small intestine as ferritin and in reticuloendothelial cells. Iron is lost in the feces, either in bile, blood, or mucosal cells from the intestine. The concentration of iron in blood is normally about 75 to 175 µg/dL (13 to 31 µmol/L) for men and 65 to 165 µg/dL (11 to 29 µmol/L) for women. Iron deficiency in the adult generally indicates that blood has been lost from the body (eg, from bleeding in the gastrointestinal tract or heavy menstrual flow). In the adult, lack of dietary iron is rarely the sole cause of iron deficiency anemia. The source of iron deficiency should be investigated promptly, because iron deficiency in an adult may be a sign of bleeding in the gastrointestinal tract or colon cancer. Folic acid is absorbed in the proximal small intestine, but only small amounts are stored within the body. If the diet is deficient in folic acid, stores within the body quickly become depleted. Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little B12. People who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of B12 may be diminished. The effects of either decreased absorption or decreased intake of B12 are not apparent for 2 to 4 years. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. They are removed from the blood by the reticuloendothelial cells, particularly in the liver and the spleen. Most of the iron is recycled to form new hemoglobin molecules within the bone marrow; small amounts are lost daily in the feces and urine and monthly in menstrual flow.
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